Health and Nutrition Cluster Bulletin Crisis in Libyan Arab Jamahiriya

No: 11 Date: 30 September 2011

Highlights

• The number of war wounded is currently estimated by the Ministry of Health to be at least 50 000, including some 20 000 people with serious injuries.

• Conflict‐related injuries remain a public health priority, followed by noncommunicable diseases, due to difficulties in accessing to health care resulting from shortages in manpower, medicines and medical supplies.

• The biggest unmet need is the provision of mental health and psychosocial support services. It is estimated that one third of the Libyan population have been directly or indirectly subject to conflict stressors.

Situation

• Health and living conditions are gradually improving in areas where the fighting has ceased. Most humanitarian health needs are being met by the Ministry of Health and Health and Nutrition Cluster partners. The number of war wounded is currently estimated by the Ministry of Health to be at least 50 000, including some 20 000 with serious injuries and these numbers are expected to rise. At a meeting on 21 September at the United Nations in New York, the chairman of the National Transitional Council Mustafa Abdel Jalil, confirmed the high number of casualties and said that 25 000 people had been killed.

1 • After the capture of Tripoli by the National Transitional Council in late August, the fighting is now concentrated around the cities of Sirte and Bani Walid, which are the last strongholds of the pro‐Qaddafi troops. The total population living in Sirte, Bani Walid and Sabha is 500 000 people. As of 22 September, up to 40 000 were thought to be displaced as a result of the fighting in Bani Walid. The main public health issues in this area are:

– treating conflict‐related injuries; – ensuring equitable access to essential health services by all wounded and conflict‐affected populations; ensuring security of health facilities, especially hospitals, and health staff; and – ensuring functionality of health facilities (water and sanitation, electricity, medicines, safe blood and consumables).

• Actions being taken in liberated areas include:

– ensuring that shortages of medical staff and irregularity of supplies are mitigated to enable provision of basic health services and sustainment of public health programmes (vaccinations); – ensuring availability of mental health and psychosocial support services; – treating conflict‐related injuries and injuries causing complications (infections, maladaptation of fractures and pains). There is the possibility of a second wave of injuries due to unexploded ordance that has reportedly been causing injuries in several cities; – ensuring rehabilitation of conflict‐related injuries. There is an increase in the demand for physical therapy, rehabilitation and possibly prosthetics due to the large number of wounded. This is a concern as many of Libya's 25 physiotherapy centres, which are mostly attached to major hospitals, are not functioning; and – conducting post‐conflict early recovery planning for the health system.

Health response

Partners are continuing to respond to the crisis with medical teams during the month of September. Some of the activities are detailed below.

• International Medical Corps’ (IMC) surgical team provided support to a field hospital set up outside Sirte. The medical team is working together with Libyan volunteer doctors to provide life‐saving care to a high number of wounded. IMC is providing medical staff to Tripoli Medical Centre, Al Khadra and Mitiga hospitals in Tripoli and support to hospitals in Nalut, Kabaw, Jadu and Zintan, and is positioned to respond to injuries resulting from the fighting in remaining loyalist towns.

• In Bani Walid, IMC is preparing a medical team to be deployed to the field hospital as needed. In Misrata, IMC is continuing to provide nursing support to the Al Hilal hospital. In Tripoli, IMC’s teams are providing support to three hospitals, Al Khadra, Tripoli Medical Centre and the Tripoli Central Hospital. In eastern Libya, IMC are providing primary health care in the Al Marj and Ajdabiya region, 30 nurses continue to provide support to three hospitals with reduced nursing capacity. As of 27 September, IMC withdrew mobile medical teams that supported eight primary health care centres in eastern Libya, due to lack of funding. There is still a need for support to these centres as national health staff have not returned to work.

• A number of ambulances, operated by the Misurata Emergency Ambulance Centre, are serving the frontlines and transport casualties to the field hospital, and if needed, to Misrata. IMC is also assisting in coordinating medivac by helicopter to Misrata.

• A surgical team from Médecins Sans Frontières (MSF) is working alongside local health personnel at the Ben Ashour clinic in central Tripoli as of 1 September. MSF is also providing surgical support in two hospitals in

2 Misrata – Qasr Ahmed hospital and Abbad hospital, and in hospitals in Yefren and Zintan in western Libya.

• Save the Children is providing mobile health teams at two internally‐displaced persons camps in eastern Libya.

• Arab Medical Union (AMU) are providing teams of specialists to the Benghazi Medical Centre.

• International Development and Relief Board (IDRB) has a team in Benghazi Medical Centre and Hawari Jala hospital.

• A Tunisian medical team of 14 persons, including a neurosurgeon, orthopaedic surgeon, general surgeon, urologist, internists, nurses and an anaesthetist supported by the Gherian hospital (Nafusa mountains) from 9 to 14 September. The team provided consultation and services to more than 70 patients, in addition to a thorough assessment of the hospital and its capacity and made recommendations for the future. Two medical and surgical teams, including orthopaedic and general surgeons, anaesthetists, neurosurgeons and gynaecologists, are taking turns supporting the hospital in El Khums. The teams are bringing a substantial quantity of medicines and medical supplies to the hospitals and are part of an agreement between the ministries of health of Tunisia and Libya, facilitated by WHO.

• The International Organization for Migration (IOM) continued to provide pre‐departure fitness‐to‐travel health checks for migrants scheduled for repatriation to Tunisia, Egypt, Chad, Niger, Sudan and other sub‐ Saharan countries. IOM facilitated care, treatment and follow up in local hospitals for those with significant medical conditions. Medical escorts were arranged to final destinations for third country nationals with anticipated needs during travel, and handed over to family members or a health facility to ensure continuity of health care upon arrival back home.

Medicines, vaccines and medical supplies

• Partners continue to fill gaps in medicines, vaccines and medical supplies. There are still shortages of supplies but as most of the country is under the control of the interim Government of Libya, the flow of supplies is improving. WHO, on behalf of the interim Government, is procuring medicines for € 100 million. On 18 September, the first shipment was delivered to the Medical Supply Organization in Tripoli as part of the main procurement exercise.

• On 2 September, seven interagency kits were delivered by WHO to the Ministry of Health’s central warehouse in Tripoli. On 17 September, WHO delivered 10 trauma kits, together with other requested supplies to the Ministry of Health’s Medical Supply Organization.

• The International Committee of the Red Cross (ICRC) provided 24 000 doses of Penta and 18 000 doses of MMR vaccines. It is anticipated that this will be enough for eastern Libya for 1 month. UNICEF is also planning to provide more vaccines shortly.

• After the fall of Tripoli, IMC delivered 1331 boxes of medications and consumables to Tripoli to respond to identified needs, in addition to providing oxygen cylinders and orthopaedic equipment.

• WHO has provided surgical kits to hospitals in Tripoli and more equipment is on route.

• WHO facilitated a shipment of medicines procured by the health authorities in Libya to Tripoli, the shipment also contains blood donations from Tunisia. The central blood bank in Tripoli is functioning but experiencing a shortage of consumables and reagents for testing and cross checking.

• Save the Children have ordered two emergency health kits for shipping to, and distribution in, Tripoli – these will provide medicines and medical supplies to 20 000 people for 3 months. 3 Assessments

• As the security situation improves and more areas become accessible a number of assessments have been carried out to assess health service availability, health facility status, and make recommendations for improvement. Conclusions from many assessments have highlighted weak reporting, lack of medicines and consumables, lack of nurses and specialized physicians and hospitals that were not operating at its full capacity due to refurbishment or damaged due to the conflict.

• On 26 August the UN conducted an assessment of the different sector needs in the city of Zlitan. According to reports the pre‐conflict health care system was poor and the only hospital in the city ‐ Zlitan General Hospital, is still under construction. The hospital has a current capacity of 276 beds. Severe medical cases have been transferred to Tripoli and Misrata. The hospital is lacking supplies and medicines for chronic diseases. The Cluster should advocate for resource allocation to cover medical supplies for the hospital.

• IMC has conducted a mission to assess the health situation in Rasnaouf and Benjawad in the second week of September. It was found that at both locations there were enough medical supplies but there is a shortage of medical staff. IMC is ready to support medical staff, but this needs to be confirmed by the Ministry of Health. The oil company based there is also ready to provide support in the form of accommodation and salaries.

• Mercy Corps and IMC carried out rapid assessments of hospitals in the Tripoli area in early September. Both assessments indicated that the public hospitals and major clinics in Tripoli are functioning despite the difficult situation, including fuel shortages, insecurity, lack of water and human resource constraints. There was a need for medical supplies across the city, in particular orthopaedic equipment, oxygen and narcotic pain medications. Human resource needs includes doctors, operating theatre nurses and hospital management. These needs may decline when the security situation improves and staff feels secure to return to work. Access to water has been a major problem but reports of restored tap water and incoming bottled water will ensure the supply. Unverified rumours about missing patients have been reported. At the beginning of the conflict there were reports of some coordination between hospitals to coordinate supplies and medicines, however, there has been polarization between hospitals perceived to be pro‐Qadaffi or pro‐ NTC.

• WHO carried out an assessment of the pharmaceutical supply chain in the city of Ajdabya on the first week of September. The city has two storage facilities – the central pharmacy warehouse and the main hospital’s own storage, both facilities are receiving pharmaceuticals directly from the Benghazi Medical Warehouse. The central pharmacy warehouse serves 17 health facilities in the city. It was badly damaged during the fighting and needs rapid repair and refurbishment. The assessment team recommended: a rapid repair of the central pharmacy and maintenance of the warehouse and refrigerator; centralization of stock – all pharmaceuticals should be sent to the central pharmacy and from there be distributed to the hospital and health facilities; and ensuring a more efficient distribution of work between staff members.

• On 26 September, WHO, the Ministry of Health and the UK Department for International Development carried out an assessment mission to AlKhums hospital (282 beds) and a nearby health centre. The hospital has stopped doing elective interventions and is only performing life‐saving surgery. In most cases, patients were referred to hospitals in Tripoli after stabilizing interventions to receive further care. About 20 deliveries are managed per day. The health centres provide outpatient services, including surgery, paediatric and vaccination services. Reporting is weak. The main polyclinic of the city is closed for “reconstruction”. The rural hospital is believed to be non‐functional.

• On 28 September, WHO participated in an interagency mission which managed to reach as far as Nesma village, some 70 km from Bani Walid city. The health centre in Nesma receives 125–200 patients a day. The majority of consultations were for seasonal diseases and noncommunicable diseases. One injured child was received last month. No antenatal care or surgical care is available. About 70 staff work in the centre (in 4 shifts) and one visiting general practitioner (coming from Gherian), only in the morning. The centre provides consultations, vaccination and referral (two ambulances), usually to Gherian (the rural hospital in Mezda is non‐functional). It has a laboratory, dental unit and a small pharmacy. Attendance was reported to increase last month by 25%–50%. Ongoing medicine shortages were reported.

• There are plans for a interagency assessment to Bin Jawad during the first week of October, WHO will join this assessment, pending authorization from the UN Department of Safety and Security.

Rehabilitation

• ICRC is deploying a physiotherapist from Geneva in October to work at the orthopaedic centre in Tripoli.

• In Benghazi the rehabilitation programme is continuing and has received 60 new patients and has had 130 consultations in the past week.

• IMC is engaged in a rehabilitation assessment and also involved with the amputee centre and physiotherapy department in Misrata and Tripoli.

• The rehabilitation sub‐group, led by IMC, received new equipment for the refurbishment of the new physiotherapy centre at Benghazi Medical Centre that will hopefully welcome patients starting from next month.

Mental health and psychosocial support

• Mental health and psychosocial support is considered the most urgent unmet need after physical injuries in the Libyan crisis. There are two psychiatric hospitals in Libya (Benghazi and Tripoli), with very few psychiatrists. They are unable to cope with the rising number of patients, which has also increased because of the conflict. In addition, mental health needs are dealt with on a psychiatric basis only. There has been a shortage of psychotropic medicines throughout the crisis.

• IMC has undertaken mental health and psychosocial support and gender‐based violence needs assessments in Tripoli. The assessments indicated that there are significant staff shortages in this field. Training is planned to address increased mental health and psychosocial support needs. IMC has already trained more than 250 people in Benghazi in psychosocial first aid. Also, in Benghazi the Humanitarian Coordinator has established a mental health subgroup, which is meeting regularly.

• The Ministry of Health is reinvigorating an initiative to upgrade mental health and psychosocial support in the country and is coordinating a working group for this with the participation of MSF (Belgium, France and Switzerland) and IMC and WHO. The group meets every Monday in Alrazi hospital in Tripoli.

• WHO will be recruiting a mental health expert to support the Ministry of Health and partners working from Tripoli.

Training

• Training activities have been carried out throughout Libya to strengthen the capacity of national health staff and medical students who are filling in gaps in hospitals. Mental health and psychosocial support training is ongoing as well as training on gender‐based violence and reproductive health.

• IMC have trained 200 frontline medics on first aid in Tripoli.

• WHO conducted a 6‐day training course on logistic support system aimed at training key hospital staff on the logistics system and to further implement it in all hospitals in Benghazi. The participants also entered the medicines and medical supplies needs in the system in an attempt to estimate the medicine 5 requirements for Benghazi in the absence of the previous years’ consumption data. The system aims to track supply and medicine levels and provide supply chain management.

Coordination

• Health partners have provided input to address the residual humanitarian needs covering the period October–December. This plan aims at addressing critical residual humanitarian needs. The Health and Nutrition Cluster is asking for a total of US$ 14.7 million to respond to the needs during the period. The majority of this fund is allocated to procure the most urgent medical supplies on behalf of the Ministry of Health.

• The post‐conflict need assessment process that will shortly start will provide a comprehensive base for planning beyond the 90‐day plan.

• Health and Nutrition Cluster meetings are taking place on a weekly basis in Tripoli and Benghazi chaired by the Ministry of Health and co‐chaired by WHO. Coordination is going on in Zarzis on an ad hoc basis.

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WHO takes this opportunity to remind donors of the need to ensure that any in‐kind contributions comply with its medicine donation guidelines (available at WHO's web site: http://www.who.int/selection_medicines/emergencies/guidelines_medicine_donations/en/index.html).

It is very important that medicines sent to conflict‐affected areas respond to the identified needs and medicines close to their expiry date should be avoided.

Donations should be coordinated with the Medical Supply Organization.

An updated list with Ministry of Health prioritized needs is posted on the Ministry of Health’s web site: www.ministryofhealthlibya.org.

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