By Caelainn Hogan

ON a hazy morning this spring, at the entrance of the Al-Bayrouni cancer center in northeast Damascus, a wall of tires teetered atop a long mound of dirt. Where there were no tires, jagged sheets of metal or rusting barrels had been propped up to create a makeshift shield. The edges of the flat roof were lined with barrels and sandbags. The 500-bed facility, the biggest oncology hospital in Syria, stands on the edge of an old highway, near the Al-Assad and Harasta suburbs, overlooking an active front line between government and opposition forces. As the engines of passing warplanes sucked at the air overhead, soldiers patrolled the grounds. For the government, the highway is a direct supply line to the police hospital and barracks beside the cancer center. For the opposition, controlling the road would provide them a chance to break a siege that has left most medical facilities destroyed or empty.

From the guard’s bunker, the face of Bashar Al-Assad surveyed those arriving through dark aviator glasses. Throughout the hospital, too, Assad’s face beamed down from framed portraits hung on nearly every ward. In the front lobby, Syrian and Palestinian flag bunting was draped from wall to wall. On the side of the building that faced the front line, many wards lay empty, scattered with unplugged monitoring machines, unwound bandages and creased bedsheets. Divots in corridors marked where shrapnel had knocked chunks of plaster from the walls. A wad of chewing gum had been stuck across a crack in a pane of glass. The army had soldiers stationed on the hospital’s top floor; young men with guns slung over their shoulders paced the halls there, while a gaggle of white-uniformed nurses sat in a room nearby. One made a heart shape with her hands and blew a kiss at a rose-framed picture of the president. With the medical staff now outnumbering the patients, her days at the hospital were boring, she complained.

That day, like most days in recent months, the rainbow row of colored seats leading to the ward for children with cancer were almost all empty. Most of the mothers and fathers who did make it to this waiting area had faced a harrowing choice: Travel with their children along a road they knew had been the target of mortar fire, to a hospital that overlooked a front line; or stay put and pray the conflict would soon end, knowing that the disease could be spreading through the bodies of their children. Some of the parents had to leave their other children behind in cities being bombed, unable to see them for months, living alone in shelters and cheap hotels so their sick children could get treatment. One woman from Raqqa told me she paid thousands of Syrian pounds to a smuggler to walk by foot with her months-old baby, across terrain strewn with mines — afraid that if they were caught she would be beheaded, but knowing that if they stayed, her newborn son would die from the cancer.

In one room, the lighter-fluid stench of chemotherapy clung to a girl’s spindly body like a cloud. The shaking of the walls, as airstrikes found their mark nearby, couldn’t shift the smell; it left a rusty taste in the mouth, stung the eyes. The 9-year-old was sitting up in bed, a blue blanket pulled over her legs. Her eyes were set intensely on the pen in her hand, drawing the round outline of a smiley face, next to shaky letters that spelled out her name: Shahd.

Shahd had grown accustomed to the sound of bombings. In east Damascus, the front line of the battle between government forces and the opposition had fluctuated since she arrived two months earlier. Her head was fuzzy bald, though her eyebrows remained. When she smiled — mouth wide open, like the face she’d drawn on the page — her teeth glinted a translucent gray, blackened by the intensity of the treatment. Shahd knew she was sick, but her mother had never spoken the word ‘‘cancer’’ to her. The diagnosis was Ewing’s sarcoma, a rare form of cancer occurring in bones and soft tissue. A tumor on the eighth vertebrae of her spine restricted the movement of her legs. By the time she reached the hospital, Shahd’s cancer had spread throughout her body. But over more than five journeys back and forth between the hospital and her home for chemo, some of the cancer had retreated and shrunk. She even regained some sensation in her legs. As long as they could still reach the hospital, her mother felt she still had control over her daughter’s disease.

Seven-year-old Fatima Hadeed, a leukemia patient, had come from Raqqa, the city held by Daesh (the so-called IS); she sat on her bed in a swaddle of pink duvet, quietly watching everything around her as the orange chemo liquid flowed steadily from an IV bag. Damaged veins ran like strikes of lightning along the tops of her hands and up the soft fleshy skin of her inner arms. Just over a month earlier, she shared the room with 9-year-old Samar Hatabi, who grew up in Aleppo, in one of the now-gutted neighborhoods on the eastern side of the city. Samar also had leukemia. When she wasn’t wearing the heavy-fringed wig that she put on to go outside, the short hairs sprouting from her bald head heralded the return of a widow’s peak. The girls’ parents would sometimes chat about the treatments their children were undergoing. They avoided speaking of what was happening in the cities they had left behind.

Throughout the ward, mothers sat sentry beside each bed. They had come from all over Syria to the front line just for this, to hold the hands of their children and stay with them, sleeping on pullout armchairs. At Children’s University Hospital, in the Mezze neighborhood of Damascus, parents were not allowed to stay in the rooms. There was no space.

The children receiving treatment at Al-Bayrouni no longer reacted to the rattling windows and walls after each strike. Instead they talked about the things that young kids usually do: The last time they were in school. Their favorite hobbies. What they wanted to be when they grew up. The parents showed me photos from when their children still had hair. The eyes and the corners of the mouth matched up, but there was a vast distance between then and now. The cancer had worn down the children and claimed parts for itself.

The country where they have grown up has also been stripped of what their parents used to cherish. It is barely recognizable but still theirs. When airstrikes hit nearby, a woman reassured Shahd and the other children that it was the government. ‘‘It is us,’’ she stressed. ‘‘It’s normal, it’s us.’’ I wondered what that ‘‘us’’ meant to these families, who had come from both sides of the front lines.

In Syria these days, people talk about a ‘‘cancer of fears.’’ They blame the tumors in the bodies of their children on the traumas of war: on the daily fear of government airstrikes and opposition attacks; on the fumes breathed in from the use of dirty fuel since the oil fields were taken over by Daesh; on bodies weakened and warped from shortages of food. Many fear that even if the war ends, the conflict will mark the health of future generations. The effects of the carcinogenic materials used in the war will most likely only be reflected in Syrian cancer rates years down the line. An oncologist working in a clinic in besieged Eastern Ghouta, the site of chemical attacks, already reported significantly rising rates of cancer in her patients.

The fear of the parents at Al-Bayrouni — that the war was the cause of their children’s cancers — is hard to prove or disprove. But the effects of the war on treatment and survival rates are clear. Delays in treatment can quicken progression and worsen outcomes. With cancer, after all, timing can be everything. If caught early, roughly 70 percent of patients with Ewing’s sarcoma, the rare cancer Shahd was fighting, are alive five years later; but after the disease has spread, that figure drops to around 30 percent. For the most common form of childhood leukemia, five-year remission rates can reach 85 percent, but this can depend on its stage at diagnosis and how rapidly the cancer responds to treatment. The six-year conflict has claimed the lives of more than 300,000 Syrians, but as of 2014, 200,000 more have died from chronic diseases, including cancer. Of the millions who have fled the country, an estimated 27,000 were skilled physicians, more than half the total number of medical doctors who worked in the country before the conflict. Half the nation’s hospitals and health centers have been destroyed, in many cases deliberately.

In Gaziantep, a sprawling Turkish city, I visited a hostel that has been set up specifically for Syrians battling cancer in exile. A 35-year-old tailor named Jaber Abu Ali described the journey he took across the border every 20 days from opposition-held Idlib for chemo. He was not able to bring his pregnant wife and two young children across, so he had to go back and forth for treatment. Both he and his friend at the hostel, a 25-year-old named Ehsan Barakat, said it was impossible to seek treatment in Damascus. Ehsan traveled all the way from Dara’a, the birthplace of the revolution, to Turkey for treatment. On the way, he was captured by Daesh for one day. He had to pay a smuggler $200 to take him around government-held areas. Ehsan was hopeful that his thyroid cancer would be cured, but Ali was facing what seemed like an impossible battle. When I asked where his cancer had spread, Ali’s hand rested on his abdomen, his side, his chest, his rib cage: The cancer was in his colon, his kidneys, his lungs. There was never cancer in his family before, he said. He blamed the war.