IDLIB — Since September, COVID-19 cases have dramatically increased in northwest Syria. As of January 25, the number of cases in the region controlled by the Syrian opposition and Hayat Tahrir al-Sham (HTS) reached 20,939, including 380 deaths, according to the Idlib Health Directorate, exceeding the total registered cases in areas controlled by the Assad regime and the Kurdish-dominated Autonomous Administration of North and East Syria (AA). Furthermore, “54 hospitals, medical centers and clinics have been destroyed since April 2019 in the Hama, Aleppo and Idlib countrysides due to the Syrian regime and its Russian backer’s military operations,” a member of the Idlib Health Directorate’s media office told Syria Direct. “This has contributed to the deteriorating medical situation in the area.”
But while attention in the northwest – which hosts some four million people, half of whom are internally displaced persons (IDPs) – is focused on the number of people infected with the virus and the region’s capacity to deal with the outbreak, other related issues go unnoticed. This includes disposing of the medical waste produced by isolation centers and health facilities receiving COVID-19 patients, as well as the belongings of the infected and those who have died due to the pandemic.
There are no statistics about the amount of pandemic-related medical waste in northwest Syria “due to the discrepancy in the number of people infected daily and the number of those quarantined in [medical] centers and being treated in the hospitals,” Hussam Kara Muhammad, the doctor responsible for the Idlib Health Directorate’s COVID-19 response, told Syria Direct.
A man pushes two empty medical waste bins at the incinerator of the maternity and pediatric hospital in the city of Harem in Syria’s northwestern province of Idlib, 4/1/2021 (Syria Direct)
Nevertheless, the amount of waste remains “very large,” according to Kara Muhammad, and includes “non-medical waste, which is taken to landfills through the local councils’ mechanisms, and non-hazardous medical waste, which largely resembles household garbage and makes up 80 percent of the total amount.”
Hazardous medical waste, which includes “chemical and infectious substances, such as autopsy equipment, pharmaceutical waste, radioactive material and those that include the patient’s bodily fluids and blood,” Kara Muhammad added, “is put outside medical buildings, provided it is not there longer than 48 hours in the summer and 72 hours in the winter, and it is then taken to be incinerated.” However, “the absence of a central medical incinerator or dedicated incinerators in coronavirus centers to dispose of waste is among the most important challenges facing the medical sector.”
“The directorate’s incinerator in [the village of] Basanqoul [in the Ariha region of the Idlib countryside] has been out of service for six months due to a lack of support. The other incinerator, in the Harem region, is for regular medical waste and may be used in an emergency to get rid of coronavirus waste,” Kara Muhammad said. The Syrian American Medical Society (SAMS) has also set up an incinerator in one of the Harem area hospitals in Idlib northern countryside, but “its capacity is no more than 20 percent of the total medical waste [in Idlib], at most.”
The medical sector in the western countryside of Aleppo is also suffering from an inability to dispose of COVID-19 waste. “In Darat Izza, there is an incinerator supported by the Syria Relief and Development Organization (SRD), which only has a capacity of 20 kilograms per hour,” Dr. Hassan Darwish of SRD told Syria Direct.
With the increase in COVID-19 waste, which affects the ability of medical centers and hospitals to dispose of it, “SRD has turned to training personnel to separate the waste according to its hazardousness,” Darwish added. “The waste is divided into ordinary trash placed in black bags, hazardous waste placed in sealed red bags and extremely hazardous waste placed in safety boxes.” Next, “the hazardous and extremely hazardous wastes are taken to the incinerator in specialized vehicles, while ordinary waste is taken to landfills.”
The volume of waste generated by the SRD-managed hospitals and centers in the west Aleppo countryside also varies according to their work and the number of people in quarantine. Darwish estimates that “the volume of waste from the Siraj centers is around 400 liters per week, and around 1,000 liters per week in the Kafr Koumin center, while the waste from al-Amal Hospital and Kafr Koumin Hospital is about 6,000 liters per week.”
Rashid Abu Ali (a pseudonym), a displaced person from the northern countryside of Hama, lives with his family of seven in a single tent in Idlib’s Atama camps. When he was infected with COVID-19 in November 2020, he could not isolate himself from his family.
“Two of my sons stayed over with their friends while I was sick to make a little room inside the tent,” Abu Ali told Syria Direct. His financial situation also didn’t allow him to “get single-use dishes. I would eat next to the members of my family, using a separate dish and spoon, which were washed after I used them.”
Abu Ali is among approximately one million displaced Syrians living in camps in northwest Syria.In the camps, the virus can spread easily due to the dense population and inability for the infected to quarantine. There is also a lack of awareness about health practices, including how to deal with the belongings of a person infected with the virus.
In addition to staying with his family in a single tent, Abu Ali and his family faced a hidden danger. Abu Ali did not know “the best way to dispose of the belongings and tools I used while I was sick.” But he disposed of his mask daily “by putting it in a plastic bag, which my son put in a garbage bin near our tent.”
According to Rami al-Alawi, from the city of al-Dana in the northern countryside of Idlib, the region’s residents did not receive “any advice or instructions about how to dispose of the possessions of a person infected with the coronavirus.”
“We had not heard about safe disposal methods,” al-Alawi, whose child contracted COVID-19, told Syria Direct, and he would throw out “the masks, including my infected son’s mask, in a dumpster in front of the house.”
By personal initiative, Samia al-Suleiman, who works in an Idlib health center and lives in the Deir Hassan camps, took it upon herself to quarantine after being infected with COVID-19. While ill, she used “disposable paper dishes,” she told Syria Direct. “After I recovered, I gathered my dishes and clothes and burned them in the yard.”
Several organizations working in northwest Syria have implemented awareness-raising programs to confront the coronavirus since March 2020, Dr. Muhammad Sultan, Community Health Supervisor at the Relief Experts Association (UDER) in the Jisr a-Shughour countryside, told Syria Direct. While UDER has targeted “2.5 million people in the area through home and workplace visits, distributed cloth and multi-use masks to 1.4 million people, in addition to personal hygiene items to 170,500 families,” Sultan admitted that “we did not discuss how civilians should deal with waste outside the home.”
Warning that “the community is not currently qualified to deal with the large increase in waste from treatment centers dealing with COVID-19 patients,” Sultan expressed his belief that if advice and recommendations are provided on prevention mechanisms and COVID-19 waste disposal, “a large portion of the community would be able to comply.”
In the same context, Ahmed al-Yousef, the General Director of Local Councils in the HTS-backed Salvation Government, said that “the directorate launched an awareness-raising campaign for people about putting garbage in sealed plastic bags to ensure that infection is not transmitted. We have emphasized that people quarantined in their homes must put their waste in special bags to be transported and dealt with alongside medical waste from hospitals and health centers.”
On the outskirts of northwest Syria’s camps and near residential areas in big cities, there are dumping sites that also constitute a source of livelihood for hundreds of families in the region who rely upon collecting garbage that can be recycled and sold to meet their needs.
An informal garbage dump near a residential neighborhood in the Idlib countryside city of Salqin, 4/1/2021 (Syria Direct)
In the wake of the military campaign launched by the Assad regime and its allied militias in late 2019, the number of IDPs, as well as poverty and unemployment rates among them, have increased, forcing more families to work collecting garbage. But the increase in numbers of COVID-19 infections could mean an increase in garbage-pickers catching infectious diseases, especially given the possibility of residents throwing out the personal waste of coronavirus patients in public garbage dumps.
Muneer al-Asmar, originally from the south Idlib countryside, now lives in the northern Syrian camps and collects garbage with two of his children, “searching for something that can be sold to get food.” Al-Asmar is aware of “the danger of working in this profession, especially with the spread of the coronavirus,” and said they “have encountered medical waste, such as masks and syringes.” He added, “However, dying of the virus is better than dying of starvation.”
According to Darwish of SRD, “the period the virus is active on medical waste and surfaces depends on a number of conditions, including the temperature, humidity and type of surface.” He pointed out that “the virus is weak in an external environment, and does not survive for a long period.” He believes that “there is no need to take different measures from how other medical waste is dealt with since the World Health Organization recommendations do not distinguish between virus waste and other kinds of medical waste.”
Even so, Darwish emphasized that this “does not negate the need to make people aware of the possibility of transmitting the virus by touch.” Therefore, “the greatest responsibility in the awareness-raising process, especially in the camps, lies with health and community awareness workers.” Darwish also emphasized the need to inform camp residents of how to dispose of COVID-19 waste, such as “collecting it in sealed bags and putting them in closed containers to avoid the possibility of children digging into them or animals getting at them.”
This report was originally published in Arabic and translated into English by Mateo Nelson.