Libyan refugees in Tunisia- May 2011

May 10th 2011 Since the start of the Libyan people uprising thousands of Libyan families crossed the Libyan-Tunisian border for safety and to flee the indiscriminate bombardment. There is no definite figure as to the number of Libyans who have crossed the border, with the latest surge in refugees on May 1st and 2nd when thousands crossed from Zentan and Rujban. As of 4th of May this year it is thought that 33,000 Libyan refugees crossed to Tunisia. Again with definite statistics, but the refugees are mostly children, women and elderly. Several medical teams visited Southern Tunisia over the last few weeks aiming to assess the refugee situation on the ground and establish new and support established primary health care service points to serve Libyan refugees in southern Tunisia. Between April 23rd and May 8th several teams of Libyan doctors met in Tunisia travelling from Canada, Ireland, the UK, and Saudi Arabia. What follows is authors assessment of the situation as they saw it, within the time constraints they were faced with and the fast moving nature of the refugee situation.

Camp Dhaiba: This camp was set up by the United Arab Emirates Red Crescent (UAERC) with some help from the Tunisian Red Crescent (TRC) and Tunisian army (TA). It currently provides shelter to 850 to 1500 refugees mostly from Nalut, and it is by far the best run of the camps. Tents provided are of high quality, well-built and supported to stand sand storms, and well lit as well. Toilets and showers are also of good quality; all have running water and can be flushed. Cleaning is done almost daily. The quality and quantity of food provided to camp residents is very good. Food is cooked in a central kitchen by professional chef. Fresh fruit is provided with each meal and bottled drinking water is provided. There is a TV tent, that tends always to be tuned to Aljazeera or Free Libya satellite stations. There is no common room for the ladies, and children in the camp do not have a dedicated play or even shaded area. As yet no provisions for schooling are provided. The UAERC dedicated two good sized tents for medical care; one as a waiting area and one for use as a clinic. Equipment was mostly provided by UAERC, and some were bought by Libyan doctors. Two TA doctors are running the clinic, with help from two nurses. Medicines
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are provided free of charge at a nearby small local hospital. Free basic investigations including x- rays are available as well at the same hospital. The camp clinic will also provide vaccination to the Libyan children. An agreement between Libyan doctors and TRC and UAERC is that we will cover any shortage in equipment or medicines needed in this clinic. The clinic is up and running, two sessions a day, 0900-1200 and 1500-1800 hrs. One to two Libyan family physicians/ internists would be called to cover this clinic which is currently covered by two TA doctors. Patients who need specialist care will be transferred to the nearest hospital or clinic in neighbouring main Tunisian towns and cities and the bill will be sent to our representative on the ground. For over two weeks now and given on going events, it seems that this camp is going to be relocated to Tatween shortly because of safety reasons.

Camp Ramada: This is the largest and the worst accommodation ever across the border. It was sat up by the UNHCR with Al-ta’awen Society, a local Tunisian charity, as a subcontractor. It shelters between 1,300 to 1,700 refugees mainly from Nalut and Zintan. The standards in this camp are very low and every effort should be made to improve conditions in the camp. The UNHCR tents are of very poor quality, made of nylon like material, without electricity and with no running water in the toilets and showers have no proper closing doors to provide privacy. Most of the tents collapse on their occupants during sand storms, some even blown away completely. The central kitchen provides basic meals, with no fresh fruits and the generally the quality is much lower than in Dhaiba. Bottled drinking water is provided daily. The camp relies heavily on donations from people and other charities as well. A common TV tent is tuned to Aljazeera or Free Libya satellite stations. There is no common room for the ladies and no play or even shaded area for the children. No schooling. Due to recent surge in refugee numbers crossing the border the camp is being expanded to accommodate more refugees. Although there are some rumours that this camp might also be relocated to Tatween, ongoing expansion work continues in this site with more tents being built every day. We were told that the plan was to increase its capacity to accommodate up to 15,000 refugees; a figure that seems to be unrealistic. One of the important features of this camp is, its strategic location which is far enough from the border that ensures safety, yet, not too far

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for the refugees who are mostly women and children to be easily visited by their male relatives attending to their national duties inside Libya. We were part of an initiative led by the TRC and Physicians across Continents PAC (a Saudi charity organization) and Libyan Canadian family physicians, that managed to set up two clinics in Ramada. The first one is in the camp itself, initially in tents and later in port cabins donated by the Free Libya Society (Libyans in the USA). These were furnished and equipped to good standards last week with the help from PAC. The clinic is up and running and doctors are seeing reasonable number of patients. Medicines are provided for free inside the camp and basic investigations will be done in the local hospital free of charge as well. Due to the large numbers of Libyan refugees living outside the camp, PAC set up clinics in the local hospital in Ramada. Conditions in the hospital are very basic due to chronic under investment. The service will essentially be a primary care outlet, with access to basic lab and x-ray investigations. The demand on the service in the first few days was substantial and the clinics ended up seeing both Libyan refugee patients and Tunisian patients travelling from far a field. Last week, it was agreed with the local hospital management that a Libyan doctor would be available daily in the clinic to see any patients that come to the clinic. As stated before, they will have free access to the pharmacy, vaccines, basic lab and radiology. There is a small observation area which works as an ER where medical emergencies can be assessed and managed. ECG, nebulizers, oxygen etc, are made available. It was agreed that Libyan doctors and doctors sponsored by PAC (obstetrics and gynaecology) will staff and run those two clinics in Ramada. On average 1-2 family physicians (one internist) will cover the camp, with one family physician or internist to staff the clinic in the local hospital. There was a great demand for both the obstetrics and gynaecology, and paediatrics clinics in Ramada, and the service has to be maintained.

Camp Bengerdan: This camp houses only non-Libyans and mainly single refugees who have not been able to go back to their original countries. There are reports of some Libyan families in the camp as well, and we did not have the chance to verify this.

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A new camp is being built in Tatween by Qatari government, hopefully to house around 1000 refugees and the National Transitional Council has secured a plot of land to establish a new camp in Jerjees shortly.

Other Accomodations: More refugees, however, have been housed in accommodation provided for free by Tunisian families and few rented houses for themselves. These people are mainly scattered within Tatween, Ramada and a number of small villages around to these two towns. The housing capacity seems to have reached its limit in Ramada and Tatween and refugees are being accommodated further north, as far as Kairawan and beyond. Many Tunisian families all over Tunisia are still offering to house refugee families. There may be reluctance on the part of refugee families to move far from the Libyan Tunisian border and out of the refugee camp for various reasons; proximity to family members on the battle front, proximity to homes and live stock, or simply fear of the unknown and pride. Their needs, which include food, nappies, water, feminine towels, and clothing if available, are being provided by charities on weekly basis. The charities keep records of families they house locally and assume responsibility for their needs. Almost all charities currently working in Tatween are newly formed; have very little prior experience, if any in relief work, and rely on donations in their work. Several Libyan and Tunisian charities are already working to house and provide essential food and other items to between 1,200 to 1,300 families as of Wednsday 4th of May 2011. Prior to our arrival, there was no proper medical set up for these people. By now there two separate clinics up and running in Tatween: The first clinic is the Women and Children clinic; was established with the help of the local representative of the reproductive medicine society in Tunis, will provide gynecology, obstetric and paediatric services. A group of Libyan doctors from the UK managed to furniture and equip it to good standard including gynaecology table and new USS machine. The gynaecologist will be a local female doctor and the paediatric clinic will be run by Libyan doctors from the UK. There will be one experienced midwife and a nurse. Medicines will be provided for free and investigations will be done at the local hospital free of charge. The running cost of this clinic will be provided by the doctors in the UK. This clinic will also provide vaccination to children as well.
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Through this clinic any rape victims, if any, will be identified and appropriate steps will be taken. A psychologist is available to provide support both to children and women in the clinic. The second clinic is a primary health care centre which was set up with the help of the TRC. This will be run by Libyan doctors, a nurse was provided by TRC and drugs will be available free of charge. Investigations including radiology will be done at the local hospital at no cost to the patients. We are in the process of negotiating a contract with a local private lab to do the specialist work, which is not available at the local hospital and a monthly bill will be sent to us.

Challenges facing Libyan refugees in Tunisia: 1- Health care for injured people: For the most part the injured are transferred and being cared for in private hospitals in cities beyond Tatween. Funding of their care is being provided by various parties with no single party over looking the process or picking up the bill. It is all run on a case by case basis, and funding is being arranged by individual donors and variety of Libyan charities and from the National Transitional Council (NTC). There are a small number of injured people from the other party and being cared for in Tatween hospital and basic needs covered. This week 30 newly injured patients arrived from Zintan front to Tatween, the details of their injuries and the plans for their further care are not available at this time. The quality of care might not be up to the tertiary standards that some patient need and we feel that a formal evaluation process for the service provided should be done by qualified Libyan doctors from surgical specialties. Many of these patients would benefit immensely by transferring them to advanced centers in Europe. We are aware of an initiative led by a Libyan businessman aiming at transferring 15 injured patients to Austria but nothing has been done yet. Furthermore, injured Libyans and their watchers need psychological and other types of support. Many of these patients that we visit were asking for Qur’an books and have questions related to performing salat and other religious obligations.

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2-Transportation: Many Libyan refugees crossed the border with their cars. For obvious reasons they are having to travel widely between camps, cities and the border. Some may not be able to pay for petrol and others have no cars or their cars are in very bad shape

2- Reuniting and communication with families: Already families are widely dispersed in camps, and Tunisian towns and cities with no central register of the refugees. Although families tend to travel together, a need may arise for service to reunite families. These families also face difficulty in terms of access to communication services that secures contact with their relatives in Libya and Tunisia.

3- Cash: Many Libyans who crossed the border did so in an emergent situation without securing enough cash and this puts them into a very difficult situation.

4- Women and children special needs: iChildren:

A- Vaccination: Maintaining vaccination schedule. B- Schooling: For the most part the current school year is all but finished and children have missed over half of the school year work. Accommodating children in Tunisian schools is unrealistic and a separate set-up is required in terms of facilities, staff, curriculum and organization. Centertainment: Due to the sudden, continuously unfolding and escalating nature of the Libyan refugee crisis, little was provided towards the psychological wellbeing of children. A starting point will be
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Wellbeing: psychological,

setting up community centre type and activity facilities for refugee children both within and outside refugee camps to provide entertainment and get kids engaged in suitable activities. Psychological support can follow on from such a set-up which will include management of post traumatic stress.

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Women:

A- Privacy: Unfortunately the camp set-up does not cater for providing any privacy for traumatised victims and less densely populated camps with dedicated women’s common rooms will be a start. B- Pregnancy: The clinic in Ramada camp and the women and children clinic in Tatween picked up large number of pregnant women and adequate antenatal care, and beyond will need to be maintained (patient held notes will help). C- Rape victims care and support: No accurate information is available but there are leads that need to be followed urgently, albeit sensitively particularly in Tatween. Drawing from other similar international experiences may become necessary. 5- Advanced medical care: There is no system in place that ensures predictable and consistent access for Libyan refugees who need advanced medical care which is beyond the scope of the primary care services mentioned above. A number of example we have encountered including patients who need advanced surgical procedures, chemotherapy, eye glasses etc. 6- Refugee register:

Can help to facilitate provision of supplies and healthcare and in reuniting families. Already tens of thousands of refugees are dispersed in Tunisia and reaching and registering all will have logistic implications and it may well be better overlooked by the NTC.

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Comments on Libyan refugees’ relief in Tunisia: • • • • • • • A local logistics medical teams coordinator is already on the ground, contact details on demand A great need is there for FEMALE obstetrics and gynaecology doctors. The family physician / internist rota is covered through to 30th May. A 12 day round is suggested for teams with 10 days work and 2 days travelling. A day of overlap and hand over between teams is highly suggested. Dr Khaldonn Alnaemi will coordinate the family physician/ internist rota (khaldonn@yahoo.com). Dr Tarek Alezzabi in Britain is over looking the paediatrics rota and has already covered several weeks ahead. Requests for medical relief rounds need to be addressed to Khaldonn, and Tarek, as above. • • • • • Differentiate between delivering direct medical care and other refugee relief work. Medics can still contribute to the non-medical relief effort. Primary care type practice (camp medicine) is required. Sub-specialists won’t be able to practice in Southern Tunisia. Obstetrics and gynaecology, general paediatrics, and generalists are needed. The Tunisian Red Crescent will allow Libyan doctors to see patients under their banner under a temporary licence, provided they bring with them the original document proving current registration/ licence in their country of practice, so take yours with you. • • • It is a very contingent situation that can change fast and the situation in Tunisia itself is precarious. Further agreements, based on Tatween model need to be secured in other towns and cities. A team leader among each group should deal with staff deployment in various sites and maintain an over all view and scan the horizon for other opportunities of cooperation. • Coordinate the flow of Libyan medical professionals to southern Tunisia (6-8 are needed at any one time, for now).

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One day of over lap between teams will allow continuity and “smoother” transition of service. Basing medical teams in Jerzees will mean that over 2-3 hours are spent travelling every morning. Accommodation in Tatween is of a lower quality but will mean less travelling time and will essentially do OK.

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The best mobile phone coverage is that of Tunis telecom, Tunisiana and Orange coverage in southern Tunisia is patchy. Consider long term contract with one of the agency for a car with a driver. One can always rent a car and drive but hire cars are in great demand in southern Tunisia these days.

Establishing links with well reputed private health facilities in cities like Safx, Bengerdan to refer patients requiring secondary care and beyond will be useful. Funding of such service will have to be secured and a differentiation between basic healthcare and specialized healthcare that goes beyond the scope of relief work will have to be kept in mind and better decided on individual basis.

The situation is very dynamics and conditions surrounding relief need and provision is changing on daily basis which necessitate flexibility, continuous vigilance and fast decision making process.

There is plenty to do for every body, but differentiating healthcare and other relief and welfare work remains important. It is probably difficult to bring all refugee healthcare provision under one banner, however communication and a complementary approach to service provision is key (small groups can contribute by complementing existing effort by filling any gaps and covering any shortcomings). We do apologise for any, unintended omissions in the above.

Tarek Kashur King Fahd medical city, Riyadh, KSA Khaldonn Alnaemi Toronto, Canada

Salamah Abosaad Hull and East Yorkshire NHS Trust, Hull, UK Khalid B. Akkari King Fahd Specialist Hospital, Dammam, KSA
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