Millions of civilians in Syria’s last rebel-held province have been living in fear of an all-out assault by the government and its allies.
An agreement between Russia and Turkey to create a demilitarised zone appears to have forestalled an imminent attack, but medical workers remain fearful that the deal will collapse and trigger a humanitarian catastrophe.
When Dr Adnan Ali moved his wife and children across the Syrian border to Turkey six years ago, he hoped that the rest of his family would follow. He tried to convince his mother it would be safer than her three-bedroom house south of Idlib city, but she flatly refused to leave.
“My mother said: ‘I was born here and I will die here’. She said if her home is still standing then she will stay,” he says. “They live with attacks and bombardments all around them. I worry about their safety all the time.”
Dr Ali has been worrying more in recent days. He has just returned from Idlib province – the last remaining stronghold of the rebels and jihadists seeking to overthrow Syrian President Bashar al-Assad – and describes the situation there as “critical”.
For weeks there have been fears that the Syrian government, with support from its ally Russia, would launch a full-scale operation to retake Idlib. It says it wants to liberate the province from Hayat Tahrir al-Sham, an al-Qaeda-linked jihadist alliance, which controls large parts of the region.
But concerns over a looming attack were quietened after Russia and Turkey, which backs the rebels, agreed to create a demilitarised zone from which HTS and other “radical” fighters must withdraw by the middle of October.
The move has been tentatively welcomed the government, opposition and aid groups.
“I am cautious,” Dr Ali says. “If the [government] and Russia keep this agreement then it will be good for the people and may save lives. If they break it then it will be a catastrophe.”
He says a broken agreement, and a major offensive, will prove disastrous because the health service in Idlib is already at breaking point.
“The medical supplies were enough for the local community, but after the displacement from Eastern Ghouta and other places there is not enough,” he says.
“We really fear for the future if [the government] attacks medical facilities and puts them out of service. This will mean the other hospitals will receive more and more people and the supplies of drugs will not be enough.”
Ambulances, hospitals, and rescue workers in Idlib have already been bombed. Officials say four hospitals were struck in less than a week earlier this month and the Syria Civil Defence says its volunteer rescue workers, who are commonly known as the White Helmets, have come under fire multiple times in recent days.
A spokeswoman for the International Committee of the Red Cross (ICRC) told the BBC that a quarter of health facilities in the area were now completely out of service.
The organisation says damage to a single hospital last year deprived 500,000 people of access to lifesaving medical care. Another hospital has had 90% of its medical equipment destroyed.
“Some hospitals are carrying on, despite the odds, but function only partially… with reduced levels of staff, medicine and equipment,” the spokeswoman said.
This is the case for the facilities Dr Ali manages in Idlib. He works for the Union of Medical Care and Relied Organizations (UOSSM), a charity which operates a number of hospitals in the region – hospitals which are already struggling to get by.
“They are operating to a minimum level,” he says. “But it will be a disaster if [pro-government forces] target the hospitals directly.”
The ICRC says that the dire state of Idlib’s health services means that – even if the latest agreement puts a stop to military action – there is still much work to be done.
“If the guns fall silent and there are no further attacks… health structures and water pumps need repairs and medical equipment and medicines are in short supply,” the spokeswoman said.
Aid groups are also concerned about the huge number of displaced people who are living in dire, overcrowded, conditions.
As Syria’s civil war has raged on, the province has been inundated with an estimated 1.4 million Syrians who have already been displaced from other parts of the country. That has increased the population to 2.9 million, including one million children.
If there is an escalation in violence further down the line hundreds of thousands of people will be forced to flee – but where?
Turkey has shut its border, fearing another mass influx of refugees, while nearby rebel-held areas that Turkey controls are already overwhelmed by large numbers of displaced people. Many opposition supporters fear imprisonment or worse if they enter government territory.
Put simply, there is no easy route out of Idlib.
Those who do stay have to contend with other dangers. “Displaced people are at increased risk of infectious diseases due to limited access to safe water and sanitation and overcrowding,” a World Health Organization spokesman says.
According to Abdel Kareem, a humanitarian aid worker from Idlib, there is a “severe state of displacement” in the area and aid organisations are already struggling to cope.
“There’s concern about what will happen now, especially because of the bombing that many areas of the province have witnessed,” he says.
Abdel Kareem says his organisation – the charity Syria Relief, which works throughout Idlib province monitoring the displacement of people – cannot cope with what has happened in the past two weeks alone.
“It – like other organisations – needs to completely distribute aid, and there needs to be international support to deal with the displacement,” he adds.
Other organisations agree that there needs to be an increase in aid coming into the area if its health service is to recover and conditions are to improve.
“Improvement of the humanitarian situation, including of course the very fragile healthcare situation, can only come with increased, regular, and safe humanitarian access,” the ICRC spokeswoman says. “We now have to wait and see how the [agreement between Turkey and Russia] is implemented.”
But Dr Ali says medical staff are prepared to face the challenges posed by the area’s decimated health system. “We are doctors and medical staff, and there are millions of civilians in Idlib,” he says.
“We’re ready to keep our medical facilities going. We will do what we can.”
Some names have been changed to protect individuals’ safety.