After tending to the war-wounded for more than a year, Libya’s doctors and nurses are facing a new battle in COVID-19. It’s a fight they are suiting up for despite the fact their salaries often go unpaid, their hospitals are regularly shelled, and the country at large is woefully underprepared for the global pandemic.
Since last April, eastern forces allied with general Khalifa Haftar have been fighting groups loyal to the Tripoli-based and UN-backed Government of National Accord (GNA), forcing around 200,000 people to flee their homes, including 18,500 over the past weekend alone. The UN documented at least 64 civilian deaths and 67 injuries from the violence in the first four months of this year, and many more fighters have been filling up the country’s hospitals.
There are reports a ceasefire may be in the works, but peace talks have so far brought no respite for either the Libyans or the hundreds of thousands of migrants and refugees who often find themselves caught in the crossfire. It has been especially difficult for doctors, nurses, and paramedics: the UN says that since the start of this 2020, at least 15 separate attacks have hit health facilities or ambulances and injured healthcare workers, who were already working in a system short on staff, medication, and supplies.
Libya announced its first COVID-19 case on 24 March, and as of 8 June there were 332 confirmed cases, and five deaths. Around 200 of those infections are in the southern city of Sabha. But, with testing extremely limited, many fear the real numbers are much higher. And the virus is putting new pressure on an already stressed public healthcare network that can’t ensure its workers are safe and is struggling to coordinate a coherent response to COVID-19 between different warring authorities across the country.
“Doctors are afraid to go to work, because the hospital could be attacked at any time.”
“Our healthcare system is collapsing,” one Libyan maternity nurse, who works in Tripoli’s al-Khadra General Hospital – hit three times by shelling in five days in early April – told The New Humanitarian. “Hospitals are not safe, either for us or for our patients. But we keep working to serve our country.”
Hospitals under fire
Since Haftar’s forces began their assault on Tripoli 14 months ago, the capital and its surroundings have been the focal point of fierce clashes and shelling, although there have been battles in other parts of the country. Several facilities have had to close down, exacerbating long-standing problems Libyans have had in accessing healthcare.
Mohammed, a doctor who has worked for four years at al-Khadra General Hospital, said he feels “at risk everyday, and overwhelmed by the situation”.
Like many of the health professionals who spoke to TNH – by phone in late May – Mohammed asked that his real name not be published because he didn’t want to risk his job and feared for his personal safety.
The 400-bed al-Khadra had been designated as a hospital that could treat COVID-19 patients, but the obstetrics, gynaecology, and intensive care units have all had to shut their doors because of damage from the April shelling. The hospital is still open for emergencies, but Mohammed told TNH that doctors like him “are afraid to go to work, because [the hospital] could be attacked at any time. But we are still on duty”.
Even before Libya’s first COVID-19 case, most hospitals did not have sufficient medication or personnel, with many medical professionals leaving the country in the violence that followed dictator Muammar Gaddafi’s 2011 ouster.
“There is a shortage of medical supplies like anaesthetic, a lack of qualified medical staff, and our hospitals are damaged and need maintenance,” said a Libyan anaesthetist who works on two hospitals on Tripoli’s front lines, earning the equivalent of less than $200 a month overall.
Several humanitarian sources, who asked to remain anonymous, told TNH that doctors are often at risk of assault or death if they don’t prioritise soldiers’ needs over those of the general population, and, according to a 2018 UN report, armed groups – including those formally allied with the Tripoli government – have often assaulted and threatened health workers.
One doctor who works in an intensive care unit in Tripoli told TNH that, as a doctor, “you can lose your life at any time, armed groups can intimidate you, or enter the hospital with their weapons, asking you to resuscitate their members while they hold a gun to your head.”
Pandemic pile on
The pandemic has only added to the stress of healthcare workers, as they try to prepare and treat people in the midst of the fighting. Before COVID-19, those who could afford it – including fighters – often sought treatment at private facilities across the border in Tunisia. With borders closed to stem the spread of the coronavirus, there are now even more patients for Libya’s already overburdened facilities to treat.
Preparation and organisation has been delayed by the fact that Libya is roughly divided into two zones of control: the west, run by Tripoli’s GNA; and the east, run by forces loyal to Haftar. Within the west and east, there are even smaller divisions, between factions and tribes that are nominally on the same side.
The National Centre for Disease Control (NCDC), located in Tripoli, is largely considered a neutral body. But it has still struggled to coordinate the COVID-19 response between health authorities in the west and east, as well as with other national agencies.
Tom Garofalo, Libya country director for the International Rescue Committee, said that getting a COVID-19 plan in place had been a complex and slow process.
“It has been very challenging for the NCDC to implement a plan because there are so many different centres of power,” he told TNH. “Communities, municipalities, and militias can and do refuse to allow, for example, an isolation ward to be established in their areas”.
Staffers at the Misrata Medical Centre, the northwestern city’s biggest and best-equipped public hospital, saw this first hand. In late March, they were supposed to be planning for the coronavirus, but instead were deluged by more than 140 injured fighters in less than 24 hours.
“We were overwhelmed. Surgical spaces were crowded, and all operating theatres were very busy,” recalled Dr Khalid Abufalgha, head physician and radiologist at the hospital.
“We had limited resources, but we managed to deal with the injured and plan for COVID-19,” he told TNH. “It wasn’t easy.”
Since then, with the funds donated by a local businessman, Misrata has set up a new 100-bed facility just for COVID-19.
In Tripoli, there is a 44-bed isolation facility for critical cases at the Mitiga International Airport, but the location is a frequent target of shelling. “Mitiga is absolutely not safe,” said Garofalo. “But there are very few places in Tripoli that are completely safe these days.”
Another floating isolation centre has been prepared on board a navy ship docked at Tripoli’s port.
Refusal to work
For some Libyan health workers, COVID-19 is the last straw after more than a year of increasing war casualties. They are opting not to go to work – what they see as their only option to protect themselves and their families, especially given an ongoing shortage of personal protective equipment (PPE).
“Often health workers don’t come to work,” IRC’s Garofalo confirmed. “They are displaced; they are scared of the virus; they’re helping someone in their family with a health issue that can’t be addressed because of a breakdown somewhere else.”
One hospital, in the southwestern city of Ghad, had to close because its doctors refused to show up, and a clinic in Misrata that deals with respiratory illnesses was forced to shut by locals, who feared it would attract people with COVID-19.
“At the beginning of the crisis, people were really afraid, and we didn't have proper measures in place,” explained a medic working in Tripoli.
Frustrations over safety are compounded by a lack of regular payment. Several sources told TNH that hundreds of doctors and nurses working in the public sector have not received their salaries in several months.
The GNA has said that doctors, nurses, and other healthcare workers working on the COVID-19 response will receive a monthly bonus but, according to several sources at the Ministry of Health – all of whom asked to remain anonymous because they weren’t authorised to speak to the media – tensions between the prime minister and the governor of the Central Bank have prevented these payments from going out.
There is particular concern about people who live in the southeast of Libya, which is home to several ethnic minority groups and on a well-travelled migrant smuggling route.
The area was already underserved by Libya’s healthcare system. A doctor in al-Qatrun, a village of around 10,000 people on the road to Chad and Niger, said he had very little to work with, citing low levels of anaesthetic, sutures, sterile solution, and surgical dressings. “We lack everything here, and people cannot get the healthcare they need, coronavirus or not,” he said.
Right groups have warned that the Libyan south as a whole is woefully unprepared for the pandemic, as it lacks adequate testing facilities, protective equipment, and qualified health workers. Pre-existing discrimination against ethnic minority groups such as the Tebu and Tuareg can also create additional barriers to access to healthcare, they say. Migrants are also likely to struggle with similar problems.
“We lack everything here, and people cannot get the healthcare they need, coronavirus or not.”
Sabha, a southern migrant hub of around 210,000 people, has seen a severe uptick in COVID-19 cases in the past two weeks. It has set up a municipal committee to deal with the outbreak, along with an isolation centre. But organising a coordinated response in the largely lawless city, which is divided between tribal factions loyal to the GNA and Haftar, is particularly sensitive as tensions grow on a national local level.
This makes for growing confusion in terms of who is in charge of hospitals and clinics as well as the possibility that clashes could kick off in the strategic town at any time, and several aid workers and doctors said the Sabha centre would not likely be sufficient for people elsewhere in the south who may struggle to travel long distances. Many Tebu and Tuareg people also lack ID documents despite the long history of their ethnic groups in Libya, adding yet another obstacle to getting help.
A sliver of hope?
While Libyan doctors labour in a disorganised and dangerous system, they have had some help from colleagues abroad pitching in, not only in responding to COVID-19, but also to help better allocate resources and centralise medical information.
Dr Mohamed Aburawi, a US-based Libyan surgeon turned tech entrepreneur, helped develop an app called Speetar, “hospital” in Libyan Arabic. The app was developed before the pandemic to help Libyan doctors triage patients. It is now available to Libyans who have internet access to self-check symptoms: it tells them if they should go to a clinic or self-isolate at home. The NCDC released it nationwide on 20 May, and it has already been downloaded more than 5,000 times.
“There are a lot of challenges, like lack of trust and social stigma associated with COVID-19,” said Aburawi, currently in Boston for a fellowship at Harvard University. “We hope that the application will help local health authorities to respond securely and privately, get an initial assessment of the patients, and effectively direct resources.”
With testing capacity limited and health facilities susceptible to attack, some Libyan doctors believe telemedicine and other digital solutions like Speetar might be the best way forward for healthcare in the country, even after COVID-19 passes.
“Telemedicine is urgently needed in Libya,” said Dr Enas Engab, head of medical digital training for the NCDC Libya COVID-19 Task Force. “It could help in many situations, like if people cannot leave their house due to the conflict, or when specialised physicians are not available.”