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An elected Libyan government should restore order to the health system

BMJ 2011; 343 doi: (Published 05 October 2011) Cite this as: BMJ 2011;343:d6385
  1. Issam M Hajjaji, consultant physician, Tripoli, Libya

“There are tanks on the streets. Get up! Get up!” cried my mother on 1 September 1969. So started Lieutenant Muammar Gaddafi’s coup d’etat. I was 10 years old and attending an English school in Tripoli. Within two years the ruling military council closed foreign language schools, and I was rushed to a boarding school in Kent because the school year was starting two weeks later. Libya, then with a population of three million, became wealthy in the 1970s as the price of oil shot up. Modern hospitals were built, foreign staff were employed, and the first medical were schools opened in Benghazi and then Tripoli. Doctors were sent abroad for postgraduate training.

Matters began to take a different path in the 1980s. Public executions, imprisonment, and forced military conscription became widespread. Though healthcare was free, there was a noticeable decline in standards. The “revolutionary committees”—groups of zealots who were often violent—were present in hospitals, clinics, and universities.

I went to medical school at Trinity College, Dublin and then returned to the UK to do senior house officer and registrar rotations, attaining membership of the Royal College of Physicians in 1989. When I returned to Libya in 1990 my first impression was that it had undergone a civil war. The health sector was in disarray. Those with the means went to Tunisia or Egypt for medical care—or to Europe if they could afford it. Directors of hospitals were appointed for their loyalty rather than for their ability. Gaddafi travelled with a surgeon, a physician, and an anaesthetist. I was put on this rota in 1995. The first time I met him, he asked about my education and then asked, “Why did you come back?” I was asking myself the same question.

Those around him feared him. Gaddafi did, however, show respect for doctors. I repeatedly asked to be excused this duty, and two years later my request was granted. I taught Gaddafi’s son, Moatassem, and adopted daughter, Hanna, in the medical school. Moatassem was later appointed head of national security and played a key part in the atrocities of the subsequent revolution. I kept the final examination papers for his class’s bachelor of medicine degree at home and took them to the exam hall with a friend in the police, fearing theft by his cronies.

The Arab spring fever caught on in Libya on 17 February this year. Demonstrations started in Benghazi and quickly spread to Tripoli and other cities. We all thought the regime would fall within days. However, Gaddafi had a mercenary army in Tripoli. They quickly quelled demonstrations there and in Zawiya (the third largest city) by firing directly at crowds. People taken to hospitals or private clinics were arrested if their injuries were firearms related. Relatives started to treat injured people at home. I set up a secret clinic at home for first aid, shock, and suturing. Casualties would be sent by members of my extended family, using simple code words on the telephone. The towns of Zintan, in the Nafusa mountains, and Misurata were under siege. I managed, through gun runners, to smuggle insulin, intravenous fluids, and antibiotics to Nafusa but not to Misurata. This smuggling was widespread, I later learnt.

Libyans abroad, both doctors and business people, organised large relief groups. These groups treated Libyans who fled to Tunisia. Libyan doctors in other countries came to clinics in Tunisia to treat injured and sick people. Libyan doctors even left families in the United States, Canada, and the UK to help the rebels. Some were caught and paraded on state television. The International Red Cross, Médecins Sans Frontières, Qatar, and the United Arab Emirates also set up camps on the Tunisian side of the border.

My cousins in law, a family originally from Misurata, played a big part in the covert medical relief in Libya. They founded two charities in the UK to buy medicines, including controlled drugs. They sent these to Benghazi and other eastern towns through the porous Egyptian border, then smuggled drugs inside car tyres to the Nafusa mountain towns through Tunisia. Misurata was besieged for months and fired on haphazardly by Gaddafi’s forces using long range artillery rockets. The main teaching hospital was destroyed, and a private clinic had to be used for injured people. Once its seaport was secured, drugs and medical equipment were brought in on fishing trawlers from Benghazi. Many severely injured people were shipped out to Benghazi and Qatar.

Rebels assumed control of Tripoli and most other western towns on 20 August. Gaddafi’s forces left mass graves and bodies in the main trauma hospital. One of these patients was found to be alive but had dared not move while Gaddafi’s forces were around. The death toll for the conflict so far is estimated to be at least 30 000 for a country of 5.5 million. The extent of injuries and psychological trauma is as yet unknown.

The healthcare sector is still in disarray: drugs and medical equipment are available, but distribution is disorganised. I am optimistic that once an elected government assumes power—and elections are promised in eight months—reorganisation of health services will be a priority.


Cite this as: BMJ 2011;343:d6385


  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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