January 2018

The Health Consequences of Libya’s Long War

By Dr. Issam Hajjaji, Former Head of the Libyan Diabetes & Endocrinology Association

A month before the uprising that would lead to his downfall and death in 2011, Col Muammar Gaddafi did something compassionate. A young girl with diabetes, under my care, had a rare type that required massive doses of daily insulin injections. She spends most of the year in hospital, away from her family and friends in her hometown 80km away. One day, I took a group of medical students to see her. This group happened to include Gaddafi’s daughter. I told them that this patient needs further investigations & treatment in the US and that this would cost at least $100,000. A week later, I got a call from Gaddafi’s secretary, asking what they can they do to organize and pay for her treatment abroad. While we started organizing this, the revolution started and matters came to a standstill. I later heard that on hearing about the case from his daughter, he banged the table in anger & instructed his secretary to transfer $1 million to the embassy in Washington specifically for her care, accompanied by a family member.

It used to amaze me that whenever Gaddafi, members of his family, cronies, or senior government officials heard of the poor standard of health services in Libya or, in the rare occasion, had to use them, they would express shock. In what universe were these people living?

Following the steep rise in oil prices in 1974, much was spent on new hospitals, foreign staff, medical schools and training of Libyan doctors abroad. In the 1980s, however, Libya closed in on itself and there was a steady in decline in healthcare that is to continue until the regime’s fall.

I was guardedly optimistic when I wrote an opinion in the British Medical Journal shortly after the whole country finally shook off the old regime. Sadly, subsequent governments have fared no better, and the decline continued, but at a swifter pace. The following short appraisal is reminiscent of other third world countries post-independence or revolution. The difference is that Libya is rich enough to absorb the corruption and nepotism and can still be able to provide high quality healthcare to its citizens.

Following the end of the revolution, $400m were allocated to treat the injured fighters abroad. This was to be managed by Global Health Program (GHP). However, the file was taken from them a few months later and given to a committee in the transitional government. The funding was doubled to $800m. The number sent for treatment subsequently exceeded the total number of fighters (injured and healthy). Women went for tummy tucks, nose jobs, removal of tattoos, and breast implants, men for hair transplants. They were put up in 4 or 5 star hotels along with 3-4 family members and given a daily stipend. By March of 2015, $9 billion has gone to this fund (see the piece in libya-al-mostakbal). According to a deputy PM on BBC, a mere 10-15% of those treated had war injuries. Suddenly, it seemed every young man was a revolutionary fighter, and around 200,000 drew the salary set up for fighters. Were Gaddafi  and his sons the only enemy combatants in the seven months’ long conflict?

In a space of 4 years, Libya has had 9 governments, some replaced while ministers were still being picked, whilst the last 2 coexist. During all this, little of significance was done to address the long list of problems in the health sector. As usual in third world countries, endless meetings, grandiose plans and goals are agreed upon. These are rarely realized when the next government comes along. All past work is shelved and a new round of meetings begins to consider yet other proposals. The Peter Principle* is frequently seen in operation: it is assumed that doctors who are successful in their field will do just as well at running a hospital or ministry. The practice of giving the Hospital Director virtual dictatorial powers, carried from the previous regime, also serves to make the institution operate at the level of that director.

Currently, we are blessed with 2 ministers of health in 2 governments that are geographically 1,000 km, but politically 1,000,000 km apart. So what is happening on the ground? Provision of medical supplies and drugs to small towns has dropped appreciably. Countryside roads are blocked or insecure, with flare ups of intertribal/inter-town conflicts, and carjackings in plain daylight. Indeed, even the carjackers have lost their decorum of late: in the past they allowed you to take your valuables before driving away with your car. A patient of mine, living in a town 300 km southwest of Tripoli, came to her clinic appointment via Tunisia, as all other connecting routes were blocked or too insecure. Perim Associates in partnership with the University of California at Berkeley, UCSF and EyePACS, has worked for two years to create emergency medicine training facility, and a program to  diagnose and treat diabetic eye disease.  The project was suspended in 2012, and then again in 2014 due to security concerns (the group is currently working to restart operations in Benghazi).   These are projects are eminently workable, and would have a noticeable impact on the quality of medical care, given a modicum of security and local assistance.

Hospitals in large cities are expectedly better off, though not by much. 2 out of the 3 large government hospitals in Benghazi are closed. A colleague, an orthopedic surgeon in one of the better off general hospitals in Tripoli, tells me that in operations that need insertion of a metal plate or screws, the patient has to provide them. Those operating theatres that are not closed operate at 20% capacity.  Recurrent acute shortages of cancer drugs, dialysis disposables and childhood vaccines occur. The consequence with regard to the latter caused a measles outbreak in the south in 2012. In 2009, 17.6% of the total health sector workforce was foreign, comprising mainly Filipina nurses. They tend to be highly experienced and industrious: it is universally agreed that hospitals in Libya have grown to be highly dependent on them. Pre-revolution, 1,300 and 600 were working at the main hospitals in Tripoli and Benghazi respectively. About 4,000 stayed after evacuations during the conflict. However, in July 2014 a Filipino construction worker was beheaded and a Filipina nurse was gang raped in Tripoli. This has caused a further flight and the Philippine government to issue a ban on travel to Libya on its nationals (strangely, North Korean nurses were banned from returning home by their government). Before these hideous crimes, a nurse that has been working in my hospital for 20 years told me that she would only leave Libya after nationals like me emigrate. She has since left without waiting for us to make up our minds. Many health (and other) establishments have taken to using paid militias for maintaining security, a job previously done by the police and internal security. These militias are composed of armed and inexperienced youth. Some are vain and trigger happy. There has been many incidents of them threatening and assaulting staff at the very hospitals they are supposed to be guarding. Gunfights between members have occurred on hospital grounds. A neurosurgeon was kidnapped for allegedly allowing a more junior surgeon to operate on a militiaman’s relative. It was known by the authorities where he was held, but they were unable to secure his release. This finally occurred, but after imprisonment and torture for over a year. Lately, kidnapping of senior consultants have occurred on several occasions, where ransom money of up to one million dinars was paid for their release.

The volume of health tourism to neighboring Tunisia, a 160 km drive from Tripoli, already high during the old regime, has increased markedly in the new. During 2009, 100,000 medical tourists went there, in 2013, 155,000. Estimates for the 2014 & 2015 would not tell the whole story: frequent suspensions of flights from/to Libya, security concerns on the coastal road to the border and stricter passport control on the Tunisian side have served to slow down the deluge. Current debts to private clinics in Tunisia amount to $60m.  Up to 2m Libyans (⅓ of the population) are thought to be currently residing abroad, half of these in Tunisia. Reliable figures for the current leading causes of morbidity and mortality are unattainable at present. Those for rape and mental illness more so, as these are considered taboo. A rape victim would only seek help if a significant physical injury occurred. A survey conducted by the Danish human rights organization, Dignity, 2 years post revolution on mental illness found that 30% of Libyans suffered from clinical depression and 29% from anxiety. Again, these are likely underestimates. The other issues that contribute to the decline of the health of Libyans are the unchecked flow of migrant workers from Africa through the unmanned borders, the lack of quality control on drugs in private pharmacies and on foodstuffs and a Libyan dinar on a downward spiral. Alternative therapists are going strong: an innovative one treats diabetes by adding the tablets the patient is already on in his secret mixture whilst telling the patient stop ‘these synthetic chemicals’. Unexploded mines have left many children dead or maimed. After clearing over 100,000 mines in 2013, MAG (Mines Advisory Group) suspended its operations citing the deteriorating security situation.

The expected reversal of the brain drain with the new Libya did not, unsurprisingly, occur. Published original medical research from Libya continues to be paltry compared with its neighbours (25 papers per million population in 2015/16, cf Tunisia with 10 times as many).

I feel that in trying to solve major problems we seem to add to them. An example is the introduction of machine-readable passports. The applicant is required to come in person to the passport office to be photographed and a 10-finger print taken.  Sick people on hospital trolleys are regularly seen in the waiting room, brought by their relatives from the hospital by ambulance, seeking to travel abroad for treatment. At the border crossing checks there aren’t even the machines that read these passports.

With such rapid turnover of governments, there is a scramble for ministerial and other posts with plenty of perks. The late British novelist Douglas Adams said “It is a well-known fact that those people who want to rule people are, ipso facto, those least suited to do it… anyone who is capable of getting themselves made President should on no account be allowed to do the job”.

On the media and social networking sites, virtually every Libyan seems to have the solution to these and other problems. Many are saying that the public healthcare system is moribund. Even during Gaddafi’s time, throwing money at the more chronic problems ceased to make any difference (other than lining the pockets of ministers). The private health sector is doing comparatively well and extending health insurance to encompass all government employees seems a possible, though not perfect solution. Bank and oil sector employees are already covered, and recently judges were added. Any resolution of the more pressing problems will not restore the lost faith in medical care in Libya by the multitude that seeks it elsewhere for a long time to come.

My young patient has still not been able to get government funding for her treatment and is now living in the hospital where she passes the time as a nurses’ aid.

*’A manager is promoted to his or her level of incompetence’