Volume 353, Number 9170 19 June 1999

Richard Horton

Lancet 1999; 353: 2139-44

The Lancet, 42 Bedford Square, London WC1B 3SL, UK

As Serbia and Kosovo emerge from yet another European war, their people's health and the region's health care, scientific research, and medical education have been seriously damaged and disrupted. There are lessons to be learned from recent Balkan wars, lessons that might help doctors, international relief organisations, and governments to do better than they have done elsewhere during the long reconstruction period that will follow this recent savage conflict. An analysis of the medical legacies of war may also raise issues for doctors worldwide to consider as part of their role in a larger public-health community. For a week in May, 1999, I travelled to Croatia and the Croat-Muslim Federation of Bosnia-Herzegovina to meet doctors working in peace but next to war. In the first part of this essay, I briefly survey some of the medical consequences of the Croatian and Bosnian conflicts. In the second part, to be published in the June 26 issue, I consider plans for and limitations to restoration, and try to identify possible opportunities for prevention of the adverse health effects of war in a newly enlarged Europe.

Zaklela se zemlja raju da se tajne sve saznaju (The earth swore to heaven that all its secrets would be revealed).

The dispute in the Balkans has had a long and troubled gestation--more than 1000 years--and the 20th century has witnessed its extraordinarily nasty and bloody climax. Violence has halted almost every step the region has made towards democracy. One extreme but important example: Stjepan Radic, the founder of the Croatian People's Peasants Party and a man who fought for Croatian independence, was fatally wounded in Belgrade's parliament on June 20, 1928. Punisa Racic, a Serb nationalist politician, had insisted that Radic be thrown out for his increasingly extravagant insults (Radic had described the ruling Serb radicals as cattle). Racic claimed that Serbia was in great danger from belligerent politicians such as Radic and that he would use "weapons, as need be, to defend the interests of Serbdom".¹ And so he did. He drew a gun and, firing some preliminary rounds among the Belgrade deputies, he shot and killed Radic's nephew, Pavle. A bullet hit Pavle's uncle, by now regarded as the spiritual president of Croatia, and he eventually died from complications on Aug 8. Croatian aspirations for autonomy largely died with him.

Radic was a nationalist, but a pragmatic one. He had no wish to annex Slovenia or Serbia (figure 1) into an enlarged Croatian territory, but he did argue, in 1904, that "we should pursue a policy that will not only lead to a united Croatia and its complete independence, but will also provide for all people a better education and general social progress". It took another 64 years after his death for this objective to be achieved. His political path was blocked by the sort of internecine nationalist disputes that have dominated the region for six centuries. These stories of betrayal still scar the Croatian heart, and they remain symbols of the country's struggle for peace and stability. Radic now appears on the brown worn paper of the 200 kuna banknote. But the memories of these struggles, which have continued to the end of this century, are more than symbolic.

War and health

Tensions among the Croatian people rose in August, 1990, with a minor, almost trivial, clash between Serbs and Croats in the southern city of Knin. Its appalling apotheosis was reached a year later in Vukovar on the northern border of the two countries, a dividing line marked by the gentle twists of the River Danube. Vukovar was besieged and bombed for 3 months, falling to Serb forces on Nov 18, 1991. Almost every house and public building was demolished, including the city's school (figure 2). The hospital was badly damaged (figure 3).

Before the war, Vukovar hospital was a centre for primary and secondary care. 120 doctors had 400 beds to serve a population of more than 80 000. During the bombing, up to 12 000 shells hit the city daily (800 on the hospital complex alone), killing thousands and driving all but 12 000 of Vukovar's people away. While the shelling continued, the hospital admitted 80 patients each day, and staff, a mix of Serbs and Croats, treated the two communities without exception. Damage to the upper floors of the hospital forced doctors to shift care underground into service corridors (figure 4). The intensive-care unit was moved to an anti-nuclear bomb shelter.

When the Serb army took over the hospital, the Croatian staff, including the hospital's director, Dr Vesna Bosanac, were forced to leave for Zagreb. They were not able to return until November, 1997, and many now live in hastily reconstructed hostels or hotels. One paediatrician, who later visited Serbia and asked why the hospital was bombed, was told, "Because you held wounded Croatian soldiers there".

One night during the occupation, a Serb soldier toured the hospital with a surgeon, also Serbian. According to at least two witnesses, the surgeon indicated to the army commander which wounded patients were Croat soldiers. About 260 people were identified. The next day these wounded men were taken away, driven at night to the small town of Ovcara nearby, and shot and buried in a rye field. One man escaped, and he was subsequently able to identify a mass grave that contained 200 bodies. That place is now a simple and fittingly bleak memorial on the desolate landscape of eastern Slavonia (figure 5).

Only in recent years has the full story of medicine during the Croatian war been revealed in personal testimonies and published academic papers. The entire health system became geared to the needs of the conflict. For example, mobile surgical teams were created to support special forces of the Croatian police during battle. These units aimed to train surgeons in generalist skills to save lives and salvage limbs directly on the front line.² The broad range of injuries inflicted during these campaigns has been documented,³ and the experience of hospitals has also been carefully audited. At the Osijek University Hospital, from May, 1991, to November, 1992, more than 4500 war victims were admitted and had surgery.⁴ A third were civilians. Their mean age was 33 years. Postoperative mortality was 3%. 780 corpses were taken directly to the pathology department. A similar pattern was found at the Slavonski Brod General Hospital, which admitted more than 7000 wounded between September, 1991, and December, 1992.⁵

Digital wireless communication systems--a personal computer, a digital signal repeater, and a radio station--between medical centres were vital for exchanging "information on casualties, forcibly displaced, detained or missing persons, gross breaches of Geneva conventions and war crimes committed by enemy soldiers, on-site epidemiological and toxicological reports, and the changing needs for medical supplies and drugs in endangered and besieged cities and villages".⁶ 110 000 confidential files were transmitted in this way.

Although the war in Bosnia-Herzegovina started in 1992 and was over by 1995, the structural damage to its major cities is still apparent today (figures 6 and 7). In Sarajevo, the nearby Mount Trebevic provided a site for Serb forces to target government buildings, civilian homes, and public institutions (eg, university and newspaper offices). A huge programme of reconstruction is now visibly underway, partly assisted by grants from the European Union. But damage remains severe. Mostar was the site of an especially violent conflict, first between Serbs and an alliance of Muslims and Croats and then, for a further 2 years, between Muslims and Croats. The newer of Mostar's two hospitals, exposed at the pinnacle of one of its hills, was hit by shells six times and, as in Vukovar, patients had to be moved underground. Despite the intensity of the fighting between different ethnic groups, all wounded combatants were admitted to the hospital.

Two main influences determined patterns of illness during the conflict.⁷ First, the physical trauma of war itself. In Bosnia, for instance, more than 150 000 people were killed and 20 000 were permanently physically disabled, including 5000 who had amputations. Few data have been published on these and other casualties. However, forensic reports on 874 bodies taken to Split University Hospital⁸ indicated that more than 70% died as a result of severe battlefield injuries, most from the effects of shell fragments and gunshot wounds. Civilian numbers of deaths were not small, and women, children, and older people were all deliberate targets of sniper fire (in the Split review, the youngest victim was a 5-year-old boy).

The second main factor influencing health care during the war was risk of communicable disease. In Bosnia, rates of tuberculosis increased by half, and outbreaks of hepatitis A were reported.⁷ In view of these dangers, particular attention was given to public-health efforts to preserve essential sanitation services. In one setting--Lika-Senj county in the centre of Croatia⁹--doctors scoured territory that had been won back from Serb occupation to ensure that water supplies were clean, food depots fresh, animal carcasses safely disposed of, and public buildings (hospitals, schools, shops) free of infestation. Mines, which had been laid around the main water pump in the area, had to be cleared before a secure water supply could be assured.

The mix of populations within Bosnia and Herzegovina and the conflict between them produced a severe refugee crisis. By 1994 about 300 000 Bosnians had left for Croatia. The network of health care available to them was fragile. Although Croatia has been able to supply basic services, more specialist care could not be given, except in emergencies. For Bosnian patients with cardiovascular disease who travelled to Zagreb, the supply of pacemakers and valve replacements has been severely rationed,¹⁰ with serious consequences. In one group of refugees, for example, the overall prevalence of heart disease was twice that of the local Croat population. Rates of hypertension, ischaemic heart disease, and cerebrovascular disease were also substantially higher among refugees. The burden of chronic illness in these displaced populations may be high and perhaps overlooked while the immediate concerns of more acute conditions take precedence.¹¹

The experience of war can lead to important improvements in trauma care. Descriptions of these advances range from detailed case reports¹² to substantial case series.¹³ Although it is difficult to conduct rigorously controlled studies in a war zone, short-term and long-term follow-up investigations provide useful clinical data. Zvonimir Lovric and colleagues, for example, assessed the results of reconstructions of major limb arteries after war injuries. Debate has continued about the use of autologous vein grafts or allografts in vessel-injury management. Although end-to-end anastomosis is the preferred technique of repair, grafts are usually necessary because of the extensive vessel damage associated with battlefield injuries. Some surgeons believe that synthetic grafts are inferior to vein grafts. In their early results, Lovric and colleagues¹⁴ reported successful placement of both vein grafts and synthetic prostheses in highly contaminated wounds. Longer-term follow-up¹⁵ showed that the 40-month cumulative limb salvage rate for vein grafts and synthetic grafts was 92% versus 87%, a difference that was not significant. The investigators concluded that, "we consider our data a good step forward in changing the opinions of synthetic prosthesis use".¹⁵ Such opportunities to advance learning are one of the perverse advantages of war. They are few.

Psychological sequelae

The drive from Zagreb to Split takes 5 hours, weaving through broadly cut valleys to Karlovac, skimming the border of the Croat-Muslim Federation of Bosnia-Herzegovina, through Knin, and finally circling around mountain roads into the 1700-year-old former Roman port. The track is marked by clusters of abandoned houses, many burnt out, which have been left by Croats and Serbs alike--families driven from their homes during army occupation (figure 8). 4·5 million people live in Croatia; 600 000 of them were "displaced" as refugees and about the same number eventually entered the country as refugees from Bosnia.

On May 4, one of Zagreb's largest hospitals opened a National Centre for Psychotrauma. Hundreds of thousands of Croatians are living with some form of post-traumatic stress disorder (PTSD). It is difficult to find someone who has not been so affected. A common mistake is to think of PTSD as a homogeneous condition. Croatian psychiatrists have discovered that the symptoms of PTSD among tortured prisoners of war--guilt, psychic numbing, headache, and lethargy--differ strikingly from those among soldiers with combat-related illness (mainly panic attacks and aggressive behaviours).¹⁶ Definitions of PTSD have mostly come from studies in men. But much of the burden of PTSD in Croatia has fallen on women and children. Here, again, the clinical picture is different--fewer symptoms of arousal and more evidence of avoidance and silence.

Treatment from first presentation usually involves a multidisciplinary team of doctors, psychologists, and special educators, together with a brief stay in a day-hospital and a mix of group, work, and relaxation therapies. I watched therapeutic work with ten women who had been variously raped, bereaved, or displaced. The team of psychiatrists at the Zagreb clinic--Dragica Kozaric-Kovacic, Dubravka Kocijan-Hercigonja, and Vera Folnegovic-Smalc--believe that it will take two to three generations before the psychological effects of the war pass.

The stories from children are the most wrenching. A boy, displaced aged 7 years in 1991: he was moved with his family to a camp in Zagreb, while his father, a soldier, went missing in Vukovar. A prisoner of war, the father was eventually exchanged for a Serb and returned to his family--a hero in their eyes. But he was by now alcoholic, withdrawn, and depressed. The war transferred to his family. At 10 years of age, this young boy took an overdose of whichever pills he could find. He survived, only to say that his family was no longer his family, his father a father no more.

As Vesna Bosanac, the reinstalled director of Vukovar hospital, told me, "the hardest thing is to face the loss". Psychotrauma is a massive problem for the former inhabitants of this extinguished city--in Osijek too, where outpatient psychiatric attendance has risen from 15 000 per year before the war to 26 000 per year today (PTSD was 5-6% of this number pre-war; it now accounts for 27% of attendances). Prof N Mandic, who runs the psychiatric service in Osijek, argues that he needs another ten psychiatrists to meet clinical demand (he already has a team of 15 specialists). Unemployment rates as high as 25% and a ruined primary-care system do not help his work.

Research is difficult to do when the service needs are so great. But in Split, Slavica Jeroncic is studying the organisation of medical and psychological care for children and their families. She is trying to find a way to unlock bereavement in settings in which someone remains missing. Her aim is to compare reactions among an experimental group of parents whose sons disappeared in war and remain missing today with a control group consisting of parents who know the fate of their children through post-mortem identification. In another Split-Zagreb collaboration, the emotional responses of displaced individuals have been described and linked with positive or negative clinical outcomes.¹⁷ The most important features for future mental health were found to be self-control, self-disclosure, and altruism. Many war exposures were intense: among 199 children, 85% experienced shooting, 67% shelling, and 24% bombing. And the reactions to these traumatic events were highly age dependent (table). How they combine to produce the different patterns of stress disorder remains unexplored.

Women, children, and the old during war

Analysts of modern war, such as Chris Gray,¹⁸ agree that rape "is hardly a new war strategy but it seems to be increasing". Evidence to support this view was amply available in the Croatian and Bosnian conflicts, during which as many as 25 000 women may have been raped. For example, one report from Zagreb described 18 women (13 Muslim, five Croatian), who were under psychiatric care in 1993 for the consequences of rape.¹⁹ All had PTSD, ten were depressed, four had attempted suicide, and 11 became pregnant. Seven had undergone repeated sexual torture. The practical difficulty for management is to separate the effects of bereavement, violence, and displacement from those of rape.²⁰

In one study of 55 rapes that took place in Bosnia-Herzegovina,²¹ most (32) had occurred while the victims were held in captivity. Others were perpetrated randomly when homes were attacked, broken into, and looted. "Rape camps" have been described in which women were gang-raped by soldiers and subsequently expected to wash clothes and prepare food. Libby Arcel and those who worked for the International Rehabilitation Center for Torture Victims concluded that the main aim of systematic rape is political--namely, to hasten the expulsion of national groups by spreading terror, fear, humiliation, and stigmatisation.

248 children were killed during the Croatian war,²² almost half through injuries caused by explosions. 901 were injured, including 86 who were permanently disabled. Few of these children received immediate or adequate medical assistance. Well over 4000 children in Croatia lost at least one parent, and 54 lost both. By 1974, 72 000 children had become refugees, and 6725 had been evacuated abroad. The psychological morbidity from this trauma in the decades after the war is barely being addressed, although there is, at last, an effort to document the different ways in which children have been harmed.²³

Some of the traumas experienced by children are almost inconceivable. I heard of one child who was 6 years old and living in Vukovar in 1991. Her father had been killed, and she and her mother were in a prisoner-of-war camp along with her older sister, aged 17, and her 1-month-old brother. In this camp, Serb soldiers raped her sister daily, leaving the 6-year-old to watch while holding her brother in her arms. The troops continually threatened her and eventually she was raped too. It took another 5 years for the effects of that incident to surface. At school, she became detached and absent. It took several further months of drawing and playing with psychologists before she was able to tell her full story.

Older people were often a forgotten group during this war. Yet they were badly affected and frequently less able to cope with their experiences than their younger counterparts. Older people had the homes they had worked for all their lives destroyed, their families torn apart, and their routines disrupted. These events often took place on a background of undiagnosed or deteriorating chronic disease.²⁴

There were isolated examples in which older people were in especially vulnerable settings. One such instance occurred in four UN Protected Areas within Croatia during 1995.²⁵ These regions were occupied by Serb forces and were later won back by the Croatian army. After re-occupation it was clear that elderly people made up a large proportion of the remaining population. More than 75% of 10 000 people in 524 villages were aged over 60. Their ethnic mix was diverse: Serbs (70%), Croats (27%), and Muslims (1%). Half were living without electricity, a third had no income, and 6% needed emergency care. A team of doctors conducted a "humanitarian census", interviewing every one of the 10 000 abandoned population, and provided immediate medical and social care, irrespective of ethnic status. Slobodan Lang and his colleagues²⁵ agreed that "This operation was based on a premise that the present warfare was targeted against the civilian population, which resulted in a total social collapse requiring a planned and co-ordinated effort to regain control". The elderly continue to be one of the most under-studied groups of war.

Meanings of conflict

On Nov 21, 1995, after signing the Dayton Accord with representatives of Serbia and Croatia, the Muslim leader Alija Izetbegovic said, "And to my people I say, this may not be a just peace, but it is more just than a continuation of war". The desperate search for a way to end war comes inevitably, no matter how bold the initial calls to arms and despite every convincing justification to fight. The attrition of death and fatigue eventually silences even the most ardent of warring voices. When one surveys the legacy of the Croatian and Bosnian wars across their populations, their most vulnerable peoples, and the health-care teams that were deployed to look after them, the patriotic enthusiasm for battle can seem hollow. Croatians would disagree. They won the right to a long-sought-after self-determination. Those living in Bosnia-Herzegovina may take a different view from their Croatian neighbours as the cantonised Federation struggles haphazardly on.

Modern wars, politicians say, are fought on grounds of humanitarian need, liberal philosophy, and progressive politics. Some writers go so far as to claim that the conduct of war also differs today from in the past.¹⁸ There are new, more precise technologies of warfare, the media's role has changed, and the conflicts now arise between different civilisations rather than competing nations.

These layers of interpretation are revealing, but they obscure the truth of war's brutal legacy. The subject of landmines easily erases fashionable and convenient rationalisations. In Croatia, there are at least 2 million live mines yet to be found, preventing the safe return of thousands of refugees. In one study of 57 landmine victims,²⁶ the mean age of those injured was 28 years. The injuries were carefully recorded: foot or lower-leg amputation (19); splenectomy (2); hip fractures (4);internal organ damage (16); abdominal, pelvic, and thoracic damage (33); nerve lesions (9); and head and face wounds (11). The lowlands of eastern Slavonia, where those mines were laid, saw a violent frontline between Serbs and Croats. Here, there was no debate about the meaning of a "just war". The aim was simply to kill, disable, or maim.

Emile Zola's novel, The Debacle, describes the hopeless course of the 1870 Franco-Prussian war and begins with one of its main characters, Maurice, a well-educated intellectual, asking whether "the very condition of nature [is not] a continuous struggle, the survival of the fittest, strength maintained and renewed through action, life rising ever young out of death?". Maurice recalled the "great fever of excitement" in Paris, which launched the war. Even today we still see war as a matter of principled victory or defeat, and we are often encouraged to do so by those who lead us into it. But a view across the health of a country that has recently been through--and claims to have won--a war reveals a different, more entangled story.

My thanks to Matko and Ana Marusic for encouraging my visit to Croatia and Bosnia-Herzegovina and for giving me unlimited assistance to learn about Croatian and Bosnian medicine and science.

References

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