BEIRUT Alongside guns, pirated DVDs and foreign currency, a new type of product has appeared on war-torn Syria's thriving black market: stolen medical supplies.
The country's vast and under-funded public health system was already struggling when protesters took the streets to demand democratic rights in March 2011. President Bashar al-Assad - a trained eye doctor - sent forces to crush the revolt and 20 months later a civil war has left 40,000 dead.
The government says more than half of Syria's hospitals have now been damaged and a quarter are non-operational.
Rebels and pro-Assad militia have looted medical supplies from hospitals to use on the battlefield and opportunist criminals have stolen equipment to sell, doctors say.
"Many times, myself and other doctors have had to put our money together to buy hospital equipment because it was stolen," said a 30-year-old nurse from the Damascus suburb of Sayida Zeinab. She, like all the healthcare workers interviewed for this article, asked to remain anonymous to protect herself.
Sayida Zeinab is ostensibly controlled by the government, the nurse said, but security forces have been stretched by battles with rebels elsewhere and armed groups have exploited the light security presence to rob the hospital several times.
"We can't buy the medicine ourselves forever," she said.
Many pharmacies only supply limited goods such as over-the-counter pain killers and basic first aid -- the war has made travel around the country precarious so it is hard to resupply.
For more specific needs, residents say, a black market dealer can provide.
BRING YOUR OWN MEDICINE
Doctors interviewed in Aleppo, Deir al-Zor and in the suburbs of Damascus - all areas where battles rage - told Reuters some patients had bought their own supplies such as anesthetic and oxygen cylinders.
Anything from plastic gloves to X-ray machines to dialysis machines can be bought at inflated prices on the black market by desperate patients, they say.
Access to healthcare in central Damascus, an area that government forces have so far blocked off from rebel advances, is better than in districts controlled by the rebels or contested areas, like Sayida Zeinab.
A doctor at a government hospital in the central suburb of Mezzeh said there were shortages but they were manageable.
"The two areas where there are shortages are in antibiotics and medicines for chronic conditions," he told Reuters, adding that medicines that expire are sometimes hard to restock.
"Of course, I'm worried about the situation, because it is unpredictable. You don't know what you may be missing from one month to the next," he said, adding that the hospital has just been able to cover its monthly needs.
Whether the situation will deteriorate or not, he says, depends on whether Syrian pharmaceutical companies - which produce 90 percent of its medicines and drugs - can stay open.
It is not looking good. Seventy percent of pharmaceutical production stopped in Aleppo after rebels stormed into the city in July, prompting fierce fighting, he said. In August, the World Health Organization said most Syrian drug makers had closed down.
Syrian state media regularly accuse rebels of kidnap, murder and now, stealing medicine.
One state news report this week said armed forces in Aleppo province had seized 100 million Syria pounds ($14,000) of medicine from what it called "dens of armed terrorist groups".
Reuters was not able to independently confirm such reports due to government restrictions on media access to the country.
A doctor from Aleppo told Reuters the lack of supplies had been so dire in some hospitals that doctors had at times been forced to conduct operations without the necessary equipment.
"Some equipment is too expensive to buy again. We can't find an affordable replacement for the X-ray," he said.
ACCESS TO HEALTHCARE
Elizabeth Hoff, head of World Health Organization in Syria, said Syria's ministry of health frequently asks for help to supply and distribute medicines and other medical supplies.
"Local pharmacies are increasingly unable to provide regular medicines such as simple pain killers and insulin," Hoff said, adding that health centers around the country are not receiving sufficient supplies from the central authorities.
She said the WHO has no first-hand information on the black market but that during a recent visit to a maternity hospital in Damascus, the director had said he had to buy oxytocin, routinely given during birth, from the private sector because it had not been supplied by the government.
Alexia Jade, an opposition activist who helps supply medical aid to residents in areas of Damascus where there is little government presence, said she was finding it increasingly difficult to get supplies.
"The government does not want the opposition to get medical supplies," she said. "I have a friend who was caught trying to smuggle some antibiotics into an opposition area. She was detained for 43 days."
Jade says her reserves are depleting. Activists in areas that are getting shelled and bombed by aerial attacks will call her to ask if she can get certain medical supplies.
"Normally they ask for pain killers and blood bags. But the other day I got an odd request. They wanted body bags," she said. "You can't bury bodies when you are being shelled and they have nowhere to store them."
(Additional reporting by Erika Solomon in Beirut and Stephanie Nebehay in Geneva; editing by Philippa Fletcher)