A brutal stretch of winter has just passed, but Syrian refugees living in Lebanon’s Bekaa Valley are still struggling amidst the deplorable living conditions they’ve endured for years now.

The season is almost irrelevant at this point. If it’s winter, they must contend with frigid nights and heavy snowfalls that often collapse their flimsy tents. In summer, they’re exposed to extreme, arid heat. Rains at any time bring floods and mud as well. And regardless of the month, they have little access to the sort of health care so many of them urgently need.

Staff at the four clinics Médecins Sans Frontiers (MSF) runs in the Bekaa regularly see patient numbers rise when the elements get particularly harsh, their ailments a reflection of the situation the war in their country drove them into.

Regrettably, the circumstances are as dire as they were predictable. "Almost four years have passed since the beginning of the conflict in Syria,” says Thierry Coppens, MSF Head of mission in Lebanon. “Families are living in despicable conditions in informal tented settlements spread all over the country”— settlements hastily set up in vacant lots, abandoned buildings, garages, and sheds on farmlands. “Support and assistance to this vulnerable population should remain constant,” Coppens adds. This crisis cannot be forgotten.”

Of particular concern is the lack of access to free, high-quality health care. The needs are evident. In December 2014, MSF teams in the Bekaa provided some 5,000 consultations; the count for January will easily surpass that number. “Respiratory infections are on the rise among Syrian refugees at the moment,” says Dr. Bilal Kassem, an MSF doctor in Baalbek. “It’s a direct consequence of the harsh winter combined with extremely poor living conditions. People living in these settings suffer from very limited access to water and hygiene, so the risks of communicable diseases are very high as well. And that’s not even mentioning the struggle they face to find food, which also leads to health complications.”

MSF staff not only receives patients in their clinics but also goes out into the settlements to find people who need assistance. One MSF social worker, Khaled Osman, recently visited Khoder Hawash, where eight Syrian families are huddled together in one of the smallest and most isolated settlements in the Bekaa.

“Have you seen how it snowed last week?” asked an 8-year-old girl named Asma. “Now the snow is melting and we are living in the midst of mud. I feel cold.”

She was sharing a blanket with her cousin Sara, staying as close as they could to a burning stove that will keep them warm for no more than an hour. “The worst is at night,” Asma continued. “Sometimes I do not feel my feet and I am scared. Blankets are humid and we do not have wood to light a fire.”

Both Sara and Asma, who were struggling with respiratory issues and recurrent fevers, were treated at MSF’s clinic in Baalbek. Even as temperatures rise in the Valley, however, they will still be vulnerable to the illnesses so many refugees regularly contract—and the threat of burns that come with having stoves in such cramped quarters.

“I wonder how they cope with this level of misery,” Khaled said later. His job entails continuously visiting the most vulnerable families to report on the needs and refer patients to the MSF clinics. “People boil snow to make drinking water and they use cardboards or plastic garbage to warm up. Most of them have a stove but no wood or proper fuel. It is freezing inside their tents and they barely have enough blankets for the whole family. These situations are unbearable and the most vulnerable are children and the elderly, who we see in high numbers in our facilities.”

Further north, MSF teams this week also distributed urgently needed winter essentials to Syrian refugees in Akkar district, where few aid groups are active and the fear of being deported back to Syria is widespread. The distributions focused on villages up in the mountains where the winter temperatures have been bitterly cold. Around 900 families—4,700 people in all—have received stoves, fuel, and blankets.

In Lebanon, MSF is assisting refugees including Palestinians and Syrian and vulnerable host community including Lebanese returnees from Syria through primary health care such as treatment of acute and chronic diseases, immunization, reproductive health care and mental health care, as well as distributing relief items. In 2014, MSF teams provided more than 260,000 primary healthcare consultations to Lebanese, Syrian and Palestinian patients in Lebanon.