REYHANLI, Turkey — The Syrian opposition fighter arrived unexpectedly at Dr. Mazen Kewara's office at the Syrian American Medical Assn., desperately seeking help.
Humanitarian aid was not reaching enough armed rebels and civilians in Syria's Idlib province, an exasperated Abdullatif "Abu Salah" Halaq told the doctor in this Turkish border town. The association could not wait for the needy to ask for assistance, Halaq said; it must try harder to locate those needing medical aid.
"Your work here is good, but there are shortages," he said recently, looking at Kewara through bloodshot eyes. "Why are you waiting for people to come to you?"
Kewara, a vascular surgeon from Damascus, the Syrian capital, explained that there was great awareness of the needs in Syria, but not enough supplies. His answer sent a disappointed Halaq away without what he wanted most — to secure more field hospitals.
"They don't understand the realities on the outside," Kewara said.
Despite receiving some humanitarian assistance, millions of Syrians face severe conditions after two years of war between forces loyal to President Bashar Assad and fighters seeking his ouster. Many have been displaced from their homes as the country's infrastructure and services have crumbled and basic needs such as heating fuel, bread and clean water have become unavailable.
Early this month, the United Nations reported that the number of refugees who had fled Syria during the war had reached 1 million. The number hints at the greater humanitarian crisis in Syria, where experts estimate that between 2 million and 6 million people have been displaced.
U.N. humanitarian chief Valerie Amos said last month that the opposition-held north remained mostly out of reach to aid operations. Activists report that in parts of the Old City of Homs in central Syria, neighborhoods have been cut off from help for months.
"We are watching a humanitarian tragedy unfold before our eyes," Amos said.
Relief efforts have included those controlled or influenced by the United Nations, Turkey or the Syrian community working from outside the country, but each has encountered roadblocks — sometimes literally — and limitations.
A $519-million Syria relief program announced by the U.N. in December is being criticized in part because it will run in consultation with the Assad government, a condition denounced by opposition groups. In addition, aid from other countries that had been making its way directly to Syria reportedly is being diverted to the U.N. program, raising concerns that less will make it to opposition-controlled areas.
Jens Laerke, spokesman for the U.N. Office for the Coordination of Humanitarian Affairs, said assistance was not reaching all the opposition-controlled areas where it was needed in part because of "logistical constraints crossing conflict lines." The World Food Program in Syria, however, reported that between 40% and 45% of the food assistance it distributed went to opposition-held or disputed areas, he said.
Opposition leaders say the aid is needed most in these areas because they are under regular attack by Assad's forces.
"How is it possible that the United Nations is giving humanitarian aid to a regime that has committed massacres, that has killed upward of 70,000 people?" said Khalid Omar, a pharmacist in Aleppo, Syria's largest city, and a liaison between the Union of Free Medicine and other agencies or donors. "He is the one who is killing me; how is he going to be the one to feed me?"
Omar said that by distributing aid through the government the international community was strengthening Assad and giving his government legitimacy.
When the Union of Syrian Medical Relief Organizations, an umbrella group, recently requested help to vaccinate an estimated 2 million to 3 million children in opposition-controlled areas, it was told by representatives of foreign governments that the vaccinations could be provided by UNICEF, but only through the Syrian Red Crescent.
"The world is either ignorant or ignoring the issue that the Red Crescent in our country is political and has an agenda," said Abdulrahman Omar, a pediatrician from Hama who oversees the primary health centers for the union. "The Red Crescent in Syria is the government."
Laerke said the U.N. humanitarian affairs office operates under the mandate given it by the United Nations General Assembly. Syria's sovereignty cannot be violated, and that includes crossing borders that are under opposition control without the government's consent, he said.
"We have been accused of giving aid money to the Syrian government. That is incorrect. We need to work with the Syrian government," Laerke said. "From the United Nations perspective the government is still the government."
Syrian humanitarian groups said that although Turkey's government has been accommodating in many ways, requiring provincial approval on each shipment of aid or the partnering with registered Turkish aid groups has slowed the flow of supplies. At times, they said, shipments aren't allowed through the official border crossing between Turkey and Syria at Bab Hawa because of pressure exerted by a strong Alawite community in Turkey, which still supports Assad.
The Turkish government, however, has allowed regular aid through the border crossing or through an informal crossing into Atmeh, Syria, a few miles away.
A significant amount of the aid goes into Syria through the unofficial crossing, a long dirt road manned by Turkish soldiers. The supplies at times skirt Turkish law in some way, by lacking documentation or receipts or including expired medicine, but some doctors say even expired medicine may still be helpful for people facing urgent needs. Doctors' groups estimate that more than 90% of the medical laboratories in Syria have shut down.
More than a month ago, the Syrian American Medical Assn., which is U.S.-based, brought into Syria a 40-foot shipping container full of medicine, medical equipment and other supplies for field hospitals. It took more than two months for the group to get Turkish approval for the container to be sent from the U.S., through Turkey in partnership with the Red Crescent and then to Syria. Kewara said two more shipping containers are on their way from the U.S. to Syria.
Saeed Suleiman, a director with the nongovernmental organization Sanad, based in Gaziantep, Turkey, said efforts were underway to transport donated diesel from an oil-producing Arab country through Turkey and into Syria to power field hospitals and other facilities. Diesel in Turkey costs more than twice what it does in Syria and the group does not have the money to buy Turkish fuel, he said.
Abdulrahman Omar said the relief organizations did not have issues with Turkey, but that "our problem is with the Western world."
Last month, representatives of the European Parliament were in Turkey to meet with aid groups. When Omar and others asked the representatives what help the European Union could offer, they were told the representatives were only there to listen and report what they had learned.
"So I told him," Omar said, "'After 23 months of conflict that even the children of Africa have heard of, all you are doing is listening and reporting?'"