Background to the Libyan Conflict

Libya’s long-ruling leader, Muammar al-Qaddafi, ruled the country from 1969 to 2011. Qaddafi outlined his political ideology in The Green Book and he exercised unrestricted control over the country. This led to vase human rights violations both inside the country as well as outside as the leader funded non-state actors and groups around the world.

Inspired by the popular protests in neighboring countries of Egypt and Tunisia, demonstrations erupted in Benghazi and spread to other cities against the authoritarian government. The government of Libya quickly responded with violence in an effort to suppress the popular uprising. Anti-Gaddafi rebel groups and Libyan security forces engaged in armed conflict to gain control of the country. Rebel groups captured Gaddafi and killed him on 20 October 2011. Despite the promise to hold elections within eight months by the National Transitional Council (NTC), clashes continued to repute between numerous rebel forces. By 2014, Libya slipped into an ongoing fractious civil war as local militias in the country begin asserting independent control in different areas.

Disrupted Access to Healthcare

The ongoing conflict in Libya has created great instability and left the health sector in ruins. In 2011, shortly after the first demonstrations in Tripoli, government forces began militarizing hospitals, including removing any patients deemed suspicious. The militarization of hospitals forced Libyan doctors to build a connection of clandestine clinics around the country. In order to supply their makeshift clinics, doctors were forced to steal medical supplies from militarized hospitals.  After the government’s six-month crackdown and the period of unrest that followed, the General National Congress (GNC) was founded as the legislative authority of Libya. The country witnessed a period of relative normality from 2012 to 2014, and the Tripoli Central Hospital became accessible again. Libya had struggled to rebuild state institutions following 2011, but the GNC was able to play an active role in the restoration of some facets of the medical system for a short period.

In September 2014, the internationally recognized House of Representatives (HoR) launched an attack on Islamic militant groups in Benghazi, and called for the dissolution of the GNC. Islamists led the GNC and the party had become affiliated with many Islamic armed groups.  As the GNC refused to disband, another government came together in Tobruk, leading to a second civil war in 2014. Those involved in the civil war included the Tobruk and Tripoli governments as well as 1,700 other armed groups. The fighting and armament of warring factions grew rapidly as fighting erupted mostly in the densely populated cities of Tripoli and Benghazi.  Warring parties looted and destroyed drug stores, and medical supplies ran dangerously low. To add to this political fragmentation, the Islamic State in Iraq and Syria (ISIS) joined the battle in 2015 with an estimated two to three thousand fighters in Libya.

According to a World Health Organization (WHO) report published in 2014, major aid programs and UN agencies stopped operating in Libya. Medical organizations such as the International Committee of the Red Cross (ICRC), and Médecins sans Frontières (MSF) ended operations in Libya following security concerns. The absence of these organizations, coupled with the unavailability of a fully functioning government on either side of the conflict, left the Libyan medical sector in an unsuitable state.

Hospitals in Benghazi and Tripoli that were already overcrowded with patients were now running short on supplies. The already unstable and weak medical facilities were now performing at a much lower level. Some hospitals, such as the main trauma hospital in Benghazi known as Al-Jalah hospital, closed their doors in addition to the closure of many other medical facilities located in conflict zones. In 2014, one Libyan medical staff member reported, “a non-exploded rocket, which fell in the hospital grounds but did not explode, has been cordoned off by tape but not removed since it fell two weeks ago.” As for the staff, many of the foreign medical workers operating in Libya fled the country due to poor working conditions and lack of security.

In June 2015, MSF began operating in Libya by providing support and supplies to a few medical facilities. While MSF decreased some of the strain on the Libyan medical sector, many medical facilities remained closed. Still a large portion of the Libyan population did not have access to suitable medical services as many areas remained out of reach.

This situation persisted up until 2016. In 2016, nearly two million Libyans were not receiving adequate medical services. The humanitarian situation in the country continued to deteriorate with the stalling of the process to establish a unity government. A WHO representative in Libya stated that the WHO could no longer wait for a political solution in order to respond, and action was needed as soon as possible. The representative stressed the need for both financial resources and efforts from the international humanitarian community to save the lives of the most vulnerable segments of Libyan society. Libyan Minister of Health, Dr. Reida Oakley, added that due to the successive and rapid nature of the unfortunate events affecting Libyan medical facilities, there was no room left for the proper recovery of the health system.

Attacks on Medical Facilities and Staff

In 2015, the Islamic State (ISIS) attacked Ibn Sina Hospital in Sirte and kidnapped 20 foreign health professionals working at the hospital. ISIL later released the health workers, ordering them to remain in the town. With the rise of ISIS in Libya, the US has begun bombing campaigns in the country. According to Human Rights Watch, on 7 February 2016, unidentified aircraft targeted the Al-Wahda hospital in the city of Derna, eastern Libya. On 26 June 2016, the WHO condemned two attacks on health facilities in Benghazi on 21 June and 22 June respectively. The attack on the 21st of June occurred on the Ear, Nose and Throat and Urological Centre, which had the capacity to welcome 300 inpatients. At the time of the attack, the Centre held more than 460 people. Due to the widespread damage caused by the strike, the operating theaters of the Centre no longer functioned, and patients had to be relocated to other health facilities.  On 22 June, a car exploded causing extensive damage to the administration building of the Benghazi Medical Centre. This Centre had previously been targeted multiple times and sustained extensive damage. The Center has 1100 beds and serves a population of half a million in Benghazi. It is also the only facility offering tertiary health care services in the city.

Before 2011, foreign nurses in Libya were the “backbone” of the country’s medical staff. Since 2011, 80 percent of these nurses have been evacuated. Due to fighting, health personnel have fled the country. Attacks on healthcare workers continue as WHO states five health workers have been killed and more than 20 health facilities damaged in 2015 and early 2016. Due to the instability and violence, aid agencies and UN agencies have reduced staffing levels in the country, and have moved international staff to Tunisia. Additionally, hospitals, laboratories, blood banks, and other health facilities are unable to function as they face shortages of medicines and health supplies. Many of the warehouses in the country have been destroyed. Nearly 60 percent of public hospitals in conflict areas of Libya have shut down or are inaccessible. A total of US$50 million in 2016 would be needed by the WHO and other health partners to meet the critical health needs of nearly two million people. The long years of violence have not allowed for the proper recovery of the health system. Violence and instability are widespread as nearly half, or three million, of the population is affected.

International Law Violations

In March 2011, the ICRC stated that a non-international armed conflict (NIAC) existed in Libya. The country ratified the Geneva Conventions of 1949, and is party to their Additional Protocol II. The parties to the conflict are therefore bound by the international humanitarian law (IHL) obligations. Article 3 common to all four Geneva Conventions provides that civilians, members of the armed forces who are no longer participating in the hostilities, and those placed hors de combat by sickness, wounds, detentions, or any other cause be treated humanely. Further, Common Article 3(2) states that “the wounded and sick should be collected and cared for”. Attacks on medical facilities violate these provisions because civilians and others, taking no active part in the hostilities, are denied access to basic health care.

Moreover, Additional Protocol II (APII) prohibits any attacks on civilians, and medical personnel and infrastructure. The random attacks on hospitals and medical facilities in Libya violate Articles 11 of APII, which provides that “Medical units and transports shall be respected and protected at all times and shall not be the object of attack”. As a result of these attacks, medics in the country have come under serious attack, and sometimes suffer deaths and injuries; the medical team is therefore not being afforded the protection guaranteed under Article 9 of APII, which states that “Medical personnel shall be respected and protected and shall be granted all available help for the performance of their duties”. Further, the warring parties that looted and destroyed drug stores are thereby breaching Article 14 of APII, which calls for the protection of objects indispensable to the survival of the civilian population.

Medical Impartiality Violations

The attacks on medical facilities, the militarization of hospitals, and the destruction of drug stores violate the principle of noninterference of medical impartiality. The principle of noninterference prohibits the attacks on medical services, the obstruction of a patient’s access to medical services, and the obstruction of medical personnel’s access to patients. It also states that every person has the right to the highest attainable standard of living, including medical care. The warring parties are therefore violating the principle of medical impartiality, which states that no person or group shall interfere with the delivery of, or access to medical services in times of conflict and civil unrest.

Conclusion

In Libya, the civilian population and the medical team are being threatened on a daily basis. The multiple violations detailed in this paper breach the principle of medical impartiality and IHL, thus constituting war crimes. The warring parties in Libya should respect international law and refrain from attacking civilian objects, including medical infrastructure. Libya needs sustainable peace, security, and stability in order to recreate a stable and adequate medical system.