Assessment of immigrant detention centers and detainees health status in Libya

Migrants are extremely vulnerable to various risks including the lack of physical and mental health care. The weakness of the health system in Libya is further undermined by the fragile, insecure, limited access, threats to health care workers and the increased social and economic challenges. This study studied the general environment of Detention Centers (DCs) of migrants in Libya and their health. Information were collected by during visits to DCs using to assess the structure, organization, fi nancing, processes occurring in the center upon arrival of detainees, accommodation, water, sanitation and hygiene, food and nutrition, health-care services, and health status of detainees including their general health, chronic conditions, acute challenges as infections including TB, STD/HIV, hepatitis and malaria, and violence. Mental health was assessed using standard tools. Special questions were constructed for pregnant females and under fi ve children. Sixteen DCs were visited. Thirteen of them had children in their premises, while ten detained women. Of the 427 interviewed, more than half were younger than 25 years of age. Overall environment and amenities were inadequate or poor. In more than half of DCs, deliveries did occur inside the DC itself. According to DCs managers, most common causes of death were TB, malnutrition and depression. The prevalence of acute and chronic illnesses including mental conditions were determined. Specifi c actions are proposed to each in particularly establishing/reviving a dedicated health center to meet the individual and public health needs of migrants. Research Article Assessment of immigrant detention centers and detainees health status in Libya Adel El Taguri1,2* and Aisha Nasef3,4 1National Center for Accreditation of Health Establishments, Libya 2Community Department, University of Tripoli, Libya 3Authority of Natural science Research and Technology, Libya 4Scientifi c Council of Laboratory Medicine, Medical Specialty council, Libya Received: 12 April, 2021 Accepted: 04 May, 2021 Published: 05 May, 2021 *Corresponding author: Adel El Taguri, National Center for Accreditation of Health Establishments, Libya, Tel: + 218910419561; E-mail:


Introduction
The world is currently facing what seems to be the largest ever wave of Displaced-Immigrant-Refugee "DIR" population in history. The Eastern Mediterranean Region (EMR) is carrying the largest burden as more than half of these are in this region. Libya has always been an attractive departure point for economic migrants from Africa and the Middle East.
With the longest coast on the Mediterranean in its northern border and the long and diffi cult to protect other borders, Libya became a major cross-road to Southern Europe not only for human traffi c and irregular immigration. At the end of the previous decade, it was estimated that there were more than one and half million immigrants in Libya. The environment for humanitarian actors in countries of the the whole region is fragile, insecure with limited access; threats to health care workers; and increased social and economic challenges. Libya is a particular case in the region as most of these migrants are of mixed origin populations that are coming from even remote areas and for many variable reasons.
As DIR are extremely vulnerable to human rights abuses, particularly the lack of/or denial of physical and mental health care, protection services should be made available and strengthened to vulnerable migrants with particular emphasis on victims of traffi cking (VoTs); Unaccompanied Migrant Children (UMC); migrants with serious medical conditions (including HIV/AIDS); and other categories of those at-risk.
Despite the current situation consisting of insecurity, a lack of rule of law and the loss of fi nancial stability, Libya is still an important transit and destination country for migrants. In certain instances, migrants remain stranded in Libya and are Citation: Taguri  caught by the authorities, or they become easy targets for the smuggling networks which promise safe travel to desperate people willing to embark on a dangerous trip by sea to Europe.
Since 2014 transiting migrants, primarily from East and West Africa have continued to exploit Libyan political instability and weak border controls and use the country as a primary departure point to migrate across the central Mediterranean to Europe [1]. The total population of migrants in Libya had been about 700,000 -1 million people, mainly coming from Egypt, Niger, Sudan, Nigeria, Bangladesh, Syria, and Mali. The constant tragedies in the Mediterranean, coupled with the deteriorating situation of the local population, make it necessary to address the instability in Libya through various interventions. The Department for Combating Illegal Migration (DCIM), affi liated to the Interior Ministry, managed the formal migrant detention centers. Of note, there are non-formal migrant detention centers ran by smugglers and traffi ckers.
Libya's health sector capacity has been burdened and under-resourced. The repeated emergencies have not allowed a proper recovery of public sector services. A Service Availability and Readiness Assessment survey, conducted by the WHO and the ministry of health, showed that health system has practically collapsed [2]. Although Libya's health system is largely a public-health oriented health system, it is weak in essence, with debilitated Primary Health-Care (PHC) network, and neglected health services. There were only few previous activities for assessment of migration and of Detention Centers (DCs) conditions that were performed [3]. These assessments concluded that more services should be tailored to these vulnerable Migrants.
In this study, a survey was designed to assess objectively the general environment in and surrounding the DCs in Libya and the corresponding health situation of the detained immigrants.

Population and data collection
Information was collected by different qualitative and quantitative means. It include structured visits to DCs all over Libya using standard questionnaires and discussion with detainees. The focus of the current survey is the status of immigrants in DCs. The list includes all DCIM affi liated and not affi liated DCs to construct a better picture of the situation and challenges facing Immigrants in Libya.
It should be noted that these would only represent a fraction of the total number of immigrants in the country as thousands of immigrants are employed and are contributing actively in Libyan society. The assessment done involved all stakeholders and included accommodation, water, sanitation and hygiene, food and nutrition, health-care services, and health status of detainees.

Assessment tools
The survey involved two questionnaires. First questionnaire was designed to gather data about DCs. The second questionnaire was designed to collect data from detainees.

Detention centers tool
First questionnaire contains general data about visited centers including structure, organization, fi nancing, processes occurring in the center upon arrival of detainees and how is health taken care of in addition to shelter and hygiene (Appendix 1).

Detainees tool
Second questionnaire contains questions addressed to detainees in order to assess their general health, chronic conditions, acute diseases in particular infections and violence that they might have been exposed to. Other data obtained regarding general health and some of the most important infections as tuberculosis, STD/HIV, hepatitis and malaria. mental health using standard mental health tools. Special appendices were constructed for pregnant females and under fi ve children and added to this tool.

Detention centers
Sixteen DCs were visited. Fifteen of these DCs are recognized as affi liated to the designed authority by the Libyan government (DCIM), and one non-affi liated and permitted visiting and surveying of detainees. Ten (62.50%) DCs fi nd that the budget was not enough the last year. Thirteen DCs (81.25%) have children in their premises. Three (18.75%) of these contain more than 50 children. Ten (62.50%) of these centers also detain women. One center contains 520 women.
Among DCs, only three centers were considered part of National program for Immunization, two centers for TB and only one center for HIV. In 12 of these DCs, the health Unit works only during offi cial working hours (Till 14hr). Water supply was considered adequate in 13 DCs (81.3%). Five (31.25%) of DCs have visible fi ssures in the walls and/or ceilings. Humidity (molds) was visible to naked eye in one of DCs. There is evidence of dense presence of insect and/or rodents in seven (46.7%) DCs. In only two DCs, bed linen and covertures were appropriate. They were regularly cleaned and replaced in seven (43.8%) DCs. Enough beds were reported in fi ve (less than 1/3) of the visited DCs.
Detainees are allowed in open air in all DCs. In six (43.8%) DCs, they are allowed just one hour or less. The remaining DCs allow detainees to stay in open air for more than two hours per day. Detainees in almost 2/3 of DCs work during their detention. In most of the cases this happens inside the DCs.
In only fi ve DCs, food presented was of enough quantity. One third of DCs receive food donations, but this occurs less than twice per month. Premises where food is prepared was not considered suitable in more than 3/4 of DCs. Forty three percent of food handlers are not trained. Soap was not available in 42.9% of food distribution halls. In two DCs, hygiene in food halls was poor or very poor.
Only in three DCs, the medical unit supervises hygiene in DC premises. In quarter of DCs, there are no regular visits by Citation: Taguri  It is necessary to have a pre-requested permission to seek medical advice in seven (43.8%) of DCs. Two-Thirds fi nd that this permission to seek medical advice was fast and more than 90% found it easy enough to obtain the permission.
There was an isolation room in 71.4% of DCs. According to staff, 84.6% consider that they need more drugs. In only nine DCs, newcomers are subjected to medical assessment at entry. In more than half of DCs, deliveries did occur inside the DC itself. More than 3/4 of DCs have reported cases of scabies and/or pediculosis. In two DCs, detainees were reported to have scorpion/snake bites. More than 2/5 detainees reported exposure to some form of violence, half of them outside the DC before his arrival. In only two DCs there were health promotion activities which were devoted to mental health. One hundred fi fty (35.10%) detainees reported that they were exposed to some form of physical violence from the start of the journey till arrival to DC. The majority of these incidents of abuse (125) had been exposed to violence during the journey either outside Libya (30 detainees, 7.0%) or inside Libya (90 detainees, 21.1%) or in both (fi ve detainees, 3.6%). The remaining 25 detainees had been exposed to violence during arrest or inside current or previous DC. The type of physical violence they were exposed to is shown in (Figure 3).
One-third (52 detainees) had depression according to PHQ2 screening tool while half had anxiety (Table 1) and only 7% had Post traumatic Stress Disorders (PTSD). More than half of detainees were not satisfi ed with the medical services delivered to them.
There were 32 pregnant women. About half of them (46.9%) did not have antenatal visits. The non-presence of complications and the non-availability of the service were the most common reasons (almost 1/3 for each of them).
Fifty one children under fi ve years of age were approached. Almost 1/3 had diarrhea and 2/5 had cough and respiratory diffi culty in the two weeks preceding the survey. Symptoms of stress among children as diffi culty sleeping (41.2%) and frequent and easily crying (29.4%) were also frequent.  the migrants are particularly exposed to, the vulnerability of migrants to many of the illness they are exposed to before, during and after migration would require a particular set of skills. The presumed center would implement the executive functions handled to them by the currently established division at the Ministry of Health and implemented by many fragmented service providers. It could also function as a house of experience for these morbidity and mortality pattern in the country and in the whole region. .

Beaten S ck beaten
Fire arm Electric shock More than one Figure 3: The type of physical violence the detainees were exposed to during the journey until arrival to current DC.  Table 2: Main issues and proposed measures related to migration and impact of health on individuals and public in Libya (Detention Centers).

Main Issues Proposed Measures
Budget not enough for running DCs and meet requirements Ensuring and allocating adequate resources from different local and international sources Many DCs detain children and women Special consideration to the presence of women and children and vulnerable groups in DCs.
Visible fi ssures in the walls and/or ceilings, humidity (molds) Constructing, maintaining, or allocating suitable buildings to be used for detention if needed or if considered as a must.
Evidence of dense presence of insect and/or rodents. Training on/outsourcing service to institutions or agencies for insuring insect/rodent free premises.
Inadequate water supply in some DCs Measures for insuring adequate water supply to all DCs. Might include relocation of detainees.
Health unit works only during offi cial working hours Insuring 24hrs coverage of basic medical/health services in each facility or through networking. Networking is mandatory for services not to be delivered by the health unit.
Many DCs were not considered part of National programs for Immunization, TB, or HIV.
Considering migrants (intra/Extra mural) in planning and delivering services within national vertical programs as tuberculosis, HIV/STDs, immunizations and others.
Non regular cleaning and replacement of bed linen Insuring appropriate amenities (regular cleaning and replacement), introducing appropriate hostel/room services.
Inadequate number of beds Allocating of resources fi nancial and goods.
Inadequate quantities of food. Limited external Aid that is almost non-existent.
Allocation of resources, provision of adequate food supply, insuring regular consistent well-supervised donations.
Non-suitable food promises, poor hygiene, limited availability of soaps.
Constructing, maintain food halls within DCs, implementing standards of food delivery in collective settings, provision of sanitary goods as soaps and towels.
Non-trained food handlers. HACCP training/certifi cation of food distributors and handlers according to norms Medical Units not supervising hygiene in food premises. hygiene in food halls was poor or very poor Standardization of health/medical package delivered in DCs to include food safety, food hygiene and food handling.
Referral of sick detainees to privet clinics and public hospitals.
Standardization and proactive organization of referral system process including the trigger, fl ow, documentation and payment if necessary.
The necessity of having a pre-requested permission to seek medical advice. Some DCs fi nd that the permission to seek medical advice albeit easy, but for some might not be as fast.
Standardization and proactive organization of referral system process including the trigger, fl ow, documentation and payment.
> 90% do not keep fi les for patients, but ½ keep registers for them. ≈ 2/3 of DCs, the access to these documents are not limited to physicians.
Proper registration and record keeping that contain data that would be useful for planning and management and also for proper follow-up of patients including data needed for the future and upon departure while keeping the data secured.
Informed consent is not universally requested before performing blood investigation.
Raising collective, community and personnel awareness including legislative, religious, professionalism and good manners, ethics and human rights.
Not all DCs have isolation rooms.
Restructuring and fi nancing of medical units.
Shortages of drug supplies as perceived by DC managers. Provision of enough but supervised drug supply (drug management system) Not all newcomers are subjected to medical assessment at entry.
Standardization of procedures and process in management of detainees from detention till departure including all dimension of health (physical, mental and social wellbeing) and to include promotive, preventive, curative, rehabilitative and palliative healthcare services. Special focus on fragile groups as pregnant women, children, elderly and adolescents.
Limited health promotion activities which were devoted to mental health.
Standardization of management of detainees including all dimension of health (physical, mental and social wellbeing) and to include promotive, preventive, curative, rehabilitative and palliative healthcare services. Special focus on fragile groups as pregnant women, children, elderly and adolescents.
>3/4 of DCs have reported cases of scabies and/or pediculosis. Proper sanitation and hygiene of premises and individuals.
Reported cases of scorpion/snake bites. Location of centers to be in safe places, protective measures including those against dangerous insects/ animals.
>2/5 were subjected to some form of violence, ½ of them outside the DC before their arrival.
Raising collective, community and personnel awareness including legislative, religious, professionalism and good manners, ethics and human rights.
Most common causes of death among detainees according to DCs managers are Tuberculosis, Malnutrition, and Depression.
Special emphasis in medical services on infectious diseases, mental health and proper nutrition and provision of adequate food supply. These should include early detection and active surveillance and management. > ½ had no job before arrival or did not specify it, The job range of detainees varied widely: Farmers, Construction workers, Nurses, Engineers, English teachers, Clothes designers, Carpenters.
Regularization of status of migrants who could participate in development of local economy.
In the 6 months preceding the survey, 2/5 of detainees had acute diarrhea, 7% had food poisoning, 1/3 skin diseases as scabies and/or pediculosis, 14.7% had respiratory infections , 3% reported snake/scorpion bites Improving service delivery to detainees including general hygiene, proper nutrition and provision of safe food. Emphasis to be put on promotive, preventive and early detection measures,