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Abstract
Introduction The Libyan Civil War (LCW) is an ongoing internal armed conflict that started as a peaceful protest in February 2011, resulting in a power vacuum after the regime collapsed and an uncontrolled spread of arms, which caused a significant increase in violence and trauma. Our review aims to investigate the war-related epidemiology and mortality in patients who have been injured during this conflict.
Methods A systematic review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Web of Science and Cochrane Library databases were searched for studies published between February 2011 and May 2024. Studies were included if they involved patients with trauma during the LCW and outcomes of interest were type and anatomical distribution of injuries and mortality. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation.
Results Thirteen studies met the eligibility criteria, with a total sample size of 4665 patients. There were seven studies (n=4378 patients) that reported mortality rate, with 438 (10%) who died. 13 out of the 14 studies documented the mechanism of injury of their participants with a total number of 4543 injuries, most commonly from firearm-related trauma (60.3%). 12 studies recorded the anatomical distribution of their sample of 4123 anatomical sites, with extremities being the most affected part, accounting for 54.5% of injuries.
Conclusion The LCW has caused a high burden of morbidity and mortality among the Libyan population. This review provides an insight into the adverse health consequences of this active war and highlights the difficulties in collecting reliable information on the wounded during conflicts.
PROSPERO registration number
CRD42024527289.
- TRAUMA MANAGEMENT
- WOUND MANAGEMENT
- Military Personnel
- EPIDEMIOLOGY
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
WHAT IS ALREADY KNOWN ON THIS TOPIC
There is scattered published research of war-related epidemiology and mortality of the Libyan Civil War (LCW), but there is no systematic review to evaluate it.
WHAT THIS STUDY ADDS
This study provides research evidence for healthcare professionals and policymakers within Libya about common traumatic injuries to be able to plan and allocate resources.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This review advocates for an urgent need for a trauma registry within Libya to monitor the impact of the ongoing LCW on the affected individuals.
Introduction
The Libyan Civil War (LCW) is an ongoing internal armed conflict that started as a peaceful protest in early 2011 as citizens sought to end decades of authoritarian rule and establish a democratically elected government.1 2 What started as non-violent demonstrations escalated into an 8-month armed struggle, resulting in the fall of the ruling regime later that year.2 3 The failure to establish a new ruling government after the fall of the previous regime created a power vacuum with an uncontrolled spread of arms, which resulted in a significant increase in violence and trauma as subsequent Libyan governments were unable to assert authority.2 4
This long-standing on–off conflict between armed groups coupled with the failure of Libya’s political administrations to form a united government has resulted in a devastating humanitarian crisis with a high burden of death, physical disabilities, population displacement and destruction of healthcare facilities.2 5 6 The ongoing nature of this conflict has depleted the country’s resources and prevented the recovery of the healthcare infrastructure6 and as such international organisations have advocated for an urgent need to resolve this crisis and end the suffering of ordinary citizens.4 7 The United Nations (UN) have attempted to introduce enforcement measures for arms embargo to reduce the war-related mortality and civilian injuries.4 7
This prolonged urban conflict with its cumulative traumatic events was also linked to considerable psychological damage to the affected Libyan population.1 An increase in common mental health disorders like depression, anxiety and post-traumatic stress disorder was documented, but there was not enough epidemiological data, especially from war-affected areas of Libya to make definitive conclusions.1 Therefore, our study tackled the lack of epidemiological data regarding the psychological impact of this conflict, by focusing on conflict hotspots with a high prevalence of war-related injuries, as these casualties are likely to benefit from psychological support.
This conflict has also resulted in an increase in the prevalence and severity of traumatic injuries, which have become one of the leading causes of morbidity and mortality.8 Consequently, it is critical for policymakers and healthcare professionals in war-torn countries like Libya to have accurate and reliable data about the extent of traumatic injuries in their affected populations.9 The current systematic review aimed to analyse the injury epidemiology and outcomes in this conflict in order to provide guidance in allocating available resources depending on the need of affected communities.
Methods
Study design
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO (Ref: CRD42024527289).10 The full literature search was achieved using Medline (via Ovid), Embase (via Ovid), Web of Science (Core Collection) and Cochrane Library on 31 May 2024 with relevant medical subject headings (MeSH) search terms such as (Libya OR Libyan) AND (War OR Conflict) AND (Injury or Trauma).
Search strategy
Studies were eligible for inclusion if they included data regarding traumatic injuries in patients in Libya after February 2011 (the start of the LCW). Language, age or location restrictions were not applied as long as they reported on patients affected by exposure to this conflict. We included all types of research studies apart from case studies with fewer than six patients. Studies without a clear timeline of data collection were excluded if there was no response from the corresponding author and the relevant data remained unavailable via any other means.
Study selection
Two reviewers (MA and VDP) independently screened all titles and abstracts and performed full-text evaluation, against pre-determined inclusion/exclusion criteria (online supplemental table 1). If different studies were published from the same patient sample, the study with the most relevant data was selected for inclusion. The screening process was conducted using the Covidence systematic review software (Covidence.org, Melbourne, Australia) and any discrepancies were resolved by discussion.
Supplemental material
Study quality assessment
We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance to assess the certainty of evidence of relevant outcomes and classify studies into (Very low, Low, Moderate or High), as described previously.11 The GRADE assessment was conducted by (MA), which was then reviewed by (VDP) and any disagreements were resolved by discussion.
Data extraction and analysis
Data extraction included characteristics of included studies (eg, study type, duration, trauma location and quality assessment), patients’ demographics and clinical information (eg, sample size, gender, mean age, type of attendees, mechanism of injury, injury anatomical location and mortality). Missing outcome data were handled by directly contacting the corresponding author and if there was no response by 31 August 2024, the study was excluded. Mechanism of injury was categorised into firearms related which encompassed all firearms, stray bullets or blast-related trauma which included explosion, missile, bomb, improvised explosive devices and rocket propellant. Other mechanisms of injuries were blunt instrument, burn, stabbing and unspecified battlefield traumatic injuries.
Outcomes of interest
The outcomes of interest were injury type, anatomical region of injury and mortality.
Data synthesis
All extracted data from included studies were summarised in a narrative form. There was no planned meta-analysis because there was no intervention or control required in included studies. Data are reported verbatim from included studies where applicable, and when summarised, number and percentage were used for categorical data.
Results
Study selection
Our search yielded 170 studies of which 48 were duplicates (figure 1). After title and abstract screening, 89 studies met the eligibility criteria, and 13 studies remained after full-text screening. Two studies used the same population sample,12 13 so only the study with the most comprehensive data about traumatic injuries was included.12 Two other studies contained incomplete data or unclear timelines for data collection, and after sending emails to corresponding authors, raw data was sent by one author,14 but the other was excluded since the author did not respond in time.15 Population-based studies were excluded from the analysis because they were ‘whole-population’ studies that clearly overlapped with patients in the remainder of studies.5 6
PRISMA flow diagram of a systematic review of trauma casualty epidemiology during LCW. LCW, Libyan Civil War; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Study characteristics
Seven studies were descriptive, four were cohort studies, one was a retrospective cross-sectional study and one was a prospective descriptive case series (table 1). Four studies collected data from 2011 only12 14 16 17 and another five studies that started data collection in 2011.18–22 Six studies were based in Benghazi city (east of Libya) and its surrounding areas,12 16 18–21 three were based in the western coast of Libya and involved casualties from the capital city, Tripoli, and the city of Misurata,14 17 23 and four22 24–26 were from unspecified locations. Six studies involved participants who were injured and treated at the same location within Libya,12 16 17 19–21 while seven studies involved foreign healthcare professionals stationed on the ground during the start of this conflict or abroad.14 18 22–26 Two out of these seven studies14 18 were conducted by staff from the Jordanian military field hospital in Benghazi city and the International Medical Corps field hospital in Misurata city. The remaining five studies22 24–26 involved the treatment of Libyan casualties in healthcare facilities outside Libya (eg, four in Turkey and one in Germany).
Characteristics of included studies and GRADE evaluation of its certainty
Quality assessment
All included studies were scored low at the initial GRADE assessment (table 1), but two studies12 22 were upgraded to ‘moderate’ due to large effects or lack of plausible confounding factors. Five studies16 20 24–26 remained at an overall GRADE score of ‘low’ due to common themes of poor study design or lack of bias control measures. The remaining six studies14 17–19 21 23 were downgraded to ‘very low’ due to serious concerns such as inconsistency and imprecision. For example, one study contained a small sample size (n=23) with no randomisation or bias control,18 while another showed bias prior to treatment since selection for their treatment abroad was done by the Libyan War Casualties’ Committee, who were affiliated with a certain political group and only sent patients from a specific militia.23
Patient characteristics
There were 4665 patients across all included studies (range 21–1761), summarised in table 2 (for full table, see online supplemental table 2). One study provided gender distribution of their fatalities (table 2) and reported that out of 98 documented deaths, male: female mortality was 18.6:1 with a mean age of 26.12 Three studies12 18 24 described their fatalities’ anatomical sites of injuries, with head and chest trauma associated with the highest proportion of deaths (29.8% and 24%, respectively). However, 21.2% of casualties did not have documentation of their anatomical sites of injury, while the remaining casualties had severe injuries to their abdomen, extremities and spine, accounting for 12.5%, 7.7% and 4.8%, mortality, respectively. Firearms were the only documented cause of death in four studies,12 18 19 24 with a total number of 120 fatalities due to gunshot wounds.
Summary table of patient characteristics in included studies during the LCW from February 2011 to May 2024
Characteristics of injured patients
There were 3787 injured patients in the included studies with 12 studies that reported gender (3699 male, 98 female) (table 2). Of these studies, 11 reported ages,12 16 17 19–26 with a calculated overall mean age of 29, while two studies12 18 included data on 29 children (<18 years). The type of participants was either separated into civilians,18 25 combatants,17 23 mixed12 14 21 22 or unspecified.16 19 20 24 26
Mortality rate
Seven studies reported the number of deaths per its collected sample, which reached a combined total of 438 from a total population of 4,37812 14 17–19 22 24 (table 2). This gave an overall calculated mortality rate of 100 in 1000 (range from 6.9 to 258.3 between studies). Six studies did not document the number of deaths or only stated ‘low mortality’ without specific figures, so it was not possible to use their samples in the calculation of the overall mortality rate.16 20 21 23 25 26
Anatomical distribution of injuries
Some studies specified the injured body part in their populations,12 16–26 with five focusing on one specific body region16 19–21 24 (table 3). The total number of injuries to specific anatomical sites was 4123, with the most affected body part being the extremities, accounting for 54.5% of the total affected anatomical regions. The second most injured body parts were the abdomen and pelvis, with 686 injuries (16.6%). Two studies also reported 50 injuries specifically on male external genitalia,20 26 but there were no details about 502 injuries, which were documented as ‘other’.
Anatomical site of injury of patients who were exposed to the LCW
Mechanism of injury
Thirteen studies reported the mechanism of injury, with a total documented mechanism of injury of 4543 (table 4).12 14 16–26 Firearm-related injuries accounted for 2741 patients, representing 60.3% of the total mechanism of injury. Blast-related trauma affected around 15.6% of casualties, whereas only 6.8% of injuries were due to blunt instrument, burn or stabbings. There were also 151 unspecified forms of battlefield injuries and 344 injuries were unrelated to military combat.
Mechanism of injury of patients who were exposed to the LCW
Discussion
To our knowledge, this is the first systematic review to investigate the unique epidemiology of traumatic injuries developed during this conflict over its ongoing 13-year period. The main finding from this study was a 10% mortality rate among injured patients. Many injured patients were male, the most common mechanism of injury was gunshot wounds, and extremities were the most injured anatomical region. These findings may help to set the context for the understanding of trauma care during the situation within Libya.
The overall mortality rate determined by this review was higher than the observed rates in the Middle East and North African regions, which experienced or are still experiencing an ongoing war. For example, the Syrian Civil War (SCW) had an overall mortality rate (per 1000) reaching 86.3 while the Iraq war with a violence-related mortality reaching up to 10.25 per 100027 28 (table 5). These comparisons can be helpful in providing context about the severity of the LCW and the devastating impact on its population. However, it is important to highlight that these figures may not necessarily be directly generalisable to the true level of violence due to the considerable variations in time and place, and the difficulty of collecting accurate and timely data.
Comparison between Libyan and Syrian Civil Wars
The conflict is like many other conflicts where males represented the majority of injured or killed individuals. For example, males formed around 88.8% of injured individuals in the SCW and 91% of deaths in the 1991–1992 Croatian War.28 Another study looking at 18 countries that were involved in conflicts, also showed that males were over-represented, accounting for 79.3% of injured individuals.29 There are many proposed explanations for this difference, including studies stating that in most North African societies, men played a bigger role in outdoor activities both in peace and war times.12 19 In addition, traumatic injuries in children (defined as <18 years) were under-reported in this conflict with only two studies12 18 providing figures for this age group. This could be due to the lack of clear documentation of patients’ demographics as most studies only provided the mean age of their casualties rather than the exact split of their included age groups.
Firearms were the most common cause of injury (60.3%), aligning with other civil wars where gunshot wounds represented up to 66.3% of injuries.27 The increase in gunshot injuries, especially outside the battlefield was most likely linked to the uncontrolled spread of firearms, as civilians were not allowed to own guns prior to 2011.12 A significant increase in injuries caused by stray bullets was also reported with injuries outside the battlefield attributed to the use of firearms for celebrations such as weddings.18
Extremities were the most commonly affected body part during this conflict accounting for 54.5% of all injuries. A similar pattern was also identified during other conflicts such as the Second Palestinian Intifada with 50% of injuries localised to extremities.28 However, during the SCW, the head was the most commonly affected anatomical region, accounting for 26.6% of all injuries.28 A possible explanation for the high rate of extremity injuries could be that these weapons and their users were not very accurate, resulting in stray bullets. This finding emphasises the importance of tailoring the surgical training of Libyan doctors towards learning about the overall management of injured extremities.
This conflict is a complex urban war with many internal and external variables that are difficult to control. This, coupled with a lack of documentation from many included studies, made it difficult to conduct further statistical analysis such as age-specific mortality rates or subgroup analysis. A possible solution to address this challenge could be introducing a national trauma registry to record all traumatic injuries and deaths during these sporadic conflicts. This suggestion is one of the chief assessment tools that the WHO has been advocating since 2009 and formed part of its trauma care quality improvement manual.30
Limitations
Our systematic review is limited by the relatively low quality of included studies. Most studies did not follow a rigorous methodology in their study design nor did they have mortality as a primary outcome. Other studies excluded fatalities that happened in the first and second days of admission and did not provide figures of how many of these patients were excluded, lowering the number of recorded deaths in this study.16 The locations of the conducted studies affected the calculated mortality rate, as three out of five studies looked at casualties who were treated abroad and did not report mortality data.
Conclusion
This conflict has caused a high burden of morbidity and mortality among the Libyan population, which was reflected by the high overall mortality rate and prevalence of traumatic injuries. This review provides an insight into the adverse health consequences of this conflict and highlights the urgent need for further research on these adverse health consequences over the short and long term. This review also highlights the difficulty in collecting accurate data on the types of traumatic injuries and their effects on mortality, during times of conflict.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
Contributors Study conception and design by reviewer (MA). Material preparation, data collection and analysis were performed by reviewer (MA). Reviewer (VDP) helped with the data collection during screening phase. Reviewers (DN) and (ZA) provided guidance during the writing process and supervised the project. The full draft of the manuscript was written by reviewer (MA) and all authors reviewed, edited and approved the final manuscript. ZA is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.