Syria’s civil war has created large volumes of human displacement. In 2013, Dr. Ihlas Altinci was among those who fled the devastating conflict – leaving Aleppo for Turkey.  

Eight years on, however, she is a sexual and reproductive health advisor for CARE in Gaziantep, Turkey, where she also manages projects and health facilities involving refugees and other populations in Syria. 

Dr. Ihlas (as she prefers to be called) has just the background to succeed in such a vital mission. After graduating from medical school in Romania in 1996, she returned to Syria, earned a master’s degree in family medicine in Damascus and conducted the country’s first study on violence against women while working as a general practitioner in Aleppo.

After fleeing Aleppo, Dr. Ihlas’s journey has been both challenging and productive, wreaking havoc on her family, but allowing her to deepen her commitment to providing reproductive health services for women who have been displaced by conflict.   

Dr. Ihlas says she started to put more emphasis on reproductive health because, “I observed that it was a bit neglected. Everybody was talking about primary health care, secondary health care, trauma care. We had many casualties because of the war, and shelling, and so on. So maternal and pediatric health was not really at the center of attention.”

She adds that she was lucky in 2015 to have “a manager who shared my view, and thought that there should be a person who was dedicated only to reproductive health issues. And I was that person, luckily for me.”

Sarah B. Barnes, Director of the Wilson Center’s Maternal Health Initiative, interviewed Dr. Ihlas, about the impact that human displacement has on women and girls and their reproductive and maternal healthcare, and the need for women’s leadership.

Taking Flight

Dr. Ihlas recalls her life in Aleppo before Syria’s civil war – and the factors that compelled her to flee the country with her family.

In Aleppo, I had everything any doctor could dream of – our house, our summer house, my clinic. I used to work when I wanted to, and in the way I wanted to, because I was controlling my own issues.

In Aleppo, I had everything any doctor could dream of – our house, our summer house, my clinic. I used to work when I wanted to, and in the way I wanted to, because I was controlling my own issues.

I had a clinic in one of the poorest neighborhoods of Aleppo. No one understood the notion of family medicine in Syria. Not then, not now. So, I used to tell people: “I'm a general practitioner.” My patients were mainly women and girls.

Since I was young, I knew that I could do whatever I wanted. I could travel, I could study, I could have my own dreams, my own plans. My mother and my father supported that. 

But to go into this neighborhood and practice medicine there, and see little girls brought to me because I needed to test their virginity, or because they were subject to sexual harassment or attempted rape, and that I needed to do something… That was very difficult for me…. Practicing in this poor neighborhood put me face to face with [parts of] my society that I knew nothing about.

Dr. Ihlas says a case of mistaken identity in 2013 was her catalyst to leaving Syria. 

One day, I went to one of the government buildings to register my daughter’s birth, who was only two months old. A person stopped me and told me: “Come with me.” He took me to a room and let me wait there. Then four or five men came to interrogate me. They [accused me of being a suicide bomber]. They had received intelligence saying that a woman wearing sport shoes and sports clothes would come to this area and blow herself up. 

I told them: “I'm a doctor. These are the papers of my daughter. I just gave birth to her.” I was wearing sporting clothes because I lived very far away from the governmental building. There was no transportation. I had no fuel to use my car. So, I walked. This is why I was wearing sporting shoes. 

I remember the four or five of them just standing in front of me in a dark room, in a basement somewhere. And they said: “We have arrested you because of the shoes you are wearing.” 

I was very, very lucky that one of them was convinced that I was not lying. And he let me go. 

I was sure that next time I was arrested for any reason, and I didn’t find a person who believed me, I would just disappear. So, two weeks later, I took my husband, my children, and we left. I left everything: the house, the summer house, the money, the furniture, everything. I just took my clothes…my children, and my husband – and that's it.

I threw away those shoes, by the way. I really liked those shoes…. I didn’t want to disappear just because someone thinks that I'm a terrorist.

Trouble In Turkey 

Dr. Ihlas’ problems intensified when her family arrived in Turkey after leaving Aleppo. They did not cross the border officially because they were “terrified” and snuck out, she recalls. Her extended family stayed in Syria, but pledged to support her, her children, and her husband when they fled.  

Turkey was supposed to be just a station in our journey. We were supposed to go to Germany. My family members were supposed to support me in that. 

But the moment we arrived in Turkey, the persons who were supposed to help us said: “You know what? We changed our minds. We cannot support you anymore.” I needed €5,000 to travel to Germany. I had only €500.

We spent those €500 in the first two days renting a house of 18 square meters. My house in Aleppo was 250 square meters. The six of us were packed in those 18 meters in inhuman conditions. We had no heater…. So, for four months, I don't know how we managed by ourselves. I was lucky to find a job as a translator.

One of the first significant challenges in Dr. Ihlas’ experience as a refugee was the breakup of her marriage. 

Because of the pressure and so on, me and my husband got divorced. We arrived in February. We were separated in September or October.

Because of the pressure and so on, me and my husband got divorced. We arrived in February. We were separated in September or October. I don't remember because the pressure was very, very high. He didn't expect that my family would just dump me, that no one wanted to talk to us anymore because we didn’t stay. They kept asking us: “Why did you leave?”

For three years, I was a single mother with four children. It was a very good experience for me [although] I lived some very bad days. As a single mother and a refugee, I’ve been subject to all the kinds of harassment you can think of. So have my children. 

But it was very good that I went through this because it helped me understand life. As I told you, I always thought that my life would be brilliant. I'm brilliant. I will have the best children, future, and everything. I have the money; I have the knowledge.

But then life taught me very nicely that I should be better. And I should, I should fight harder. Because in the same way life gives to you, it takes from you. Now, life needs to know what kind of person you are. And I'm still, still trying to reveal what kind of person I am. We are not safely on shore yet.

Luckily for me, I did reunite with my husband after three years. It's lucky also for the children, because living as a single mother as a refugee was terrible. But I survived it. My children also survived it. And we will keep doing it until we figure out what will happen with our country. 

Gendered Roles During Crises

Eventually, Dr. Ihlas was able to put her skills into practice in a new environment as a sexual and reproductive health and rights advisor for CARE-Turkey. She says it can be difficult work – both in a rapidly shifting landscape of displacement, as well as in the gender politics surrounding health care. 

Even if it is very difficult to provide health services here, I see hope in what we are doing – specifically in providing sexual and reproductive health care services to our beneficiaries.

My job with CARE is the source of joy and inspiration and hope for the future. Even if it is very difficult to provide health services here, I see hope in what we are doing – specifically in providing sexual and reproductive health care services to our beneficiaries. I believe that change has begun in the Syrian society. I saw it in myself. I saw it in many midwives working inside Syria, and also in [those receiving services and their families]. 

The war revealed a clear picture of male dominance in Syrian society. As Syrian females, no matter where we are with our own eyes, we also see that the amplification of the male role in society is not that real. Men used to tell us: “We take the decisions. We do this. We are able to do everything. We handle calamities. We handle situations. You just sit at home and take care of your children.”

But when a real calamity or a real disaster happened, we saw men perplexed, crying, running away, and not able to manage the situation. The one who actually managed it was the woman. Maybe I'm a bit biased when I say this. But, I say it because I lived it. I saw it in myself, in my sister’s life, in my relatives’ lives, in our beneficiaries, and female health care providers. They are the ones who are up to the challenge.

They were solution oriented. They looked for solutions and they forced the solutions. Whereas men in our crisis, I'm sorry to say, are still running after ego, after power, and after how to hurt the other side. 

What Do Displaced Women and Girls Need? 

In her present role, Dr. Ihlas manages several projects for CARE – including a maternity and pediatric hospital. Seeing the range of operations in play gives her a unique perspective on how day-to-day operations play out regionally, and indirect consequences of the conflict, like malnutrition and poor maternal health outcomes. 

Our hospital is a safe place of secondary health care where women can deliver their babies safely. They can be operated on if they need to be – if it is a minor or major gynecology surgical procedure, or a C-section. They can receive family planning counseling and services. Also, there's a pediatric ward where a newborn can be examined by a pediatrician. Mothers can receive counseling about breastfeeding, family planning, and how to plan for future pregnancies. Attached to the hospital are outpatient clinics where women can come if they have infections, or for family planning counseling, or for general complaints and consultation about their children. 

We also have teams of community health workers working in the hospital and in the surrounding areas, spreading information about general health and hygiene – personal hygiene, child feeding, nutrition during pregnancy.

Previously, we never had malnutrition in Syria. But due to the conflict and forced displacement happening in Syria, now we have it. We never had malnutrition among pregnant and lactating woman, or anemia. Now we do. 

Previously, we never had malnutrition in Syria. But due to the conflict and forced displacement happening in Syria, now we have it. We never had malnutrition among pregnant and lactating woman, or anemia. Now we do. 

And the percentages are high. It's not something easy to talk about. The percentage of C-sections is very, very high. The percentage of early marriages. We had early marriages prior to the conflict. Now the rates are again very high. Estimates gleaned from community interactions reveal that about 30 to 40 percent of marriages are early child or forced marriages. And these are the official numbers. So, I cannot imagine what's happening in reality, you know? 

We still see that very young girls are forced to receive hormonal medication, so they [arrive at] puberty quickly and can be put into the marriage market. Parents cannot afford to feed those girls, and it’s an honor issue in our society, so it’s easier for some parents just to marry off their girls. 

Our hospital covers the basic health needs of women and girls. But we also have an initiative called the AMAL Initiative or Adolescent Mothers Against All Odds. It specifically targets adolescent girls who are first-time mothers or new mothers, or married between ages 10 and 19. In Arabic, “amal” means hope, by the way. The acronym is very nice. I like it. 

Through this project, adolescent girls participate in eight sessions, where they receive information about their reproductive health, about their sexual health, about some life skills, so they can manage their lives.

Through this project, adolescent girls participate in eight sessions, where they receive information about their reproductive health, about their sexual health, about some life skills, so they can manage their lives. They are children raising children, living in big families, taking on very, very big responsibilities yet without any ability to make decisions.

So, we try to help them gain access to health services and provide them with some life skills, negotiation skills, and some self-esteem elevation, so they can manage their lives. 

At the beginning, this project was called “Young Mothers Club.” But after implementing it for some period, we observed that we need to make the circle bigger and include more people in the initiative or project. The adolescent and her entourage are included. She's a child. She cannot make any decisions and she cannot fight for herself alone. We also need the support of society and healthcare providers. The “Young Mothers Club” became the “AMAL Initiative” to target all three components. With society members and health care providers, we ask them to think critically – and encourage them to see what social and gender norms exist in the family and in society. How to challenge them. How to change them.

The Costs of Care

As Dr. Ihlas experienced in her own flight from Syria, money is one of the rarest resources for refugees – and the monies required to support health care are significant.

Money comes from donors. And all services should be free in humanitarian emergency settings.  

We even provide patients with means to access services. For example, last year we observed that people from the camps didn't have the money to visit our facilities and access the services. So, we asked our donors to support us by running a shuttle bus back and forth between the facility and the camps – with a specific route and timetable.

It's also the case with [those coming to] safe spaces for awareness raising sessions in specific centers. Some beneficiaries – adolescents, specifically – don't have the money to come or are not allowed to walk in the streets by themselves to access services. But a husband or a father will allow her to go by bus because it takes her directly from her house to the facility. For some women who need protection from gender-based violence, we have this transportation service as well. Or, if she’s a grown woman and can walk by herself, but she needs the fee of the transportation, we also give cash. 

A Need for Women Leaders

Dr. Ihlas observes that even with issues as basic as feminine hygiene, women refugees face a tide of gender bias and lack of understanding. For instance, she describes a landscape in which even well-intended donations of underwear and sanitary napkins do not meet women’s basic needs. One particular frustration was occasioned by donations of polyester underwear. 

Displaced women need suitable and fitted cotton underwear. They are displaced. They cannot have polyester ones – sexy, narrow – because it itches. It can create infections. It does not fit the purpose of this underwear.

You are not serving our women and girls by giving them leaking, bad quality sanitary pads. Because they will not go to school. They will not go out. They will not receive any services. They will be locked for at least one week at home, every month.

Dr. Ihlas says that her work in maternal care has left her concluding that more women need to take on leadership roles, not just in that sector, but across the entire health care sector to ensure that women and girls receive the services and supplies that they need and deserve.

In 2019, I was creating a strategy for the health sector in Northwest Syria, where we were setting the priorities. We had a workshop with around 30 men working in Syrian health response. All of them were Syrians who occupied very important positions in different organizations. 

I was the only woman in the room, and I was the facilitator of the workshop. One of my priorities was maternal and pediatric health. And we had a long debate about it. A Syrian humanitarian worker, who's also a neurosurgeon, approached me at the break. He told me: “You are totally wrong. Maternal and pediatric health shouldn't be a priority in this strategy.”

When I asked him why, he said we have other many more important issues happening in the health sector.

“Give me one example,” I replied.

“Addiction,” he said. “People are addicted to different substances. We should fight this, and not make maternal and pediatric health services as a priority in this strategy.”

So, I told him: “Dear colleague, you are talking to a woman who had four C-sections in order to have her four children. So do not come here and tell me to my face that maternal and pediatric health services are totally irrelevant to a strategy for the health sector and Northwest Syria. I'm sorry, but you are talking to the wrong person. This is 2019, not 1910.”

This is the sort of conversation we still have after years and years of donors’ money for trainings, gender protection, and capacity building for persons – Syrians and expats – who are working in the health sector. This is what we get. 

This is the main reason why I keep saying women should be involved in higher positions of decision-making in the health sector.

Dr. Ihlas Altinci is a Sexual and Reproductive Health Technical Advisor for CARE Turkey and leads CARE’s sexual and reproductive health and rights work in Northwest Syria. Sarah B. Barnes is the Project Director for the Maternal Health Initiative at the Woodrow Wilson International Center for Scholars.

Cover art: The incubator section in Al-Amal hospital provides full care to newborn and preterm babies including health care, hospitalization, and medical services. The section contains seven incubators, a phototherapy unit, and a children's hospitalization system, in addition to receiving emergency cases and medical referrals around the clock. Copyright: CARE/Violet* Name changed to protect identity.