Letter from Sarajevo: On a front lineBMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6986.1052 (Published 22 April 1995) Cite this as: BMJ 1995;310:1052
- Lynne Jones, consultant to Catholic Relief Services and Medecins Sans Frontieresa
Like the patients, doctors in Sarajevo depend largely on humanitarian aid; everyone in the public sector has worked without pay for almost three years. The hospital is on a front line; yet the psychiatric department continues to function, even conducting large scale studies of psychosocial aspects of war in Bosnia-Hercegovina. The type of inpatient morbidity and treatment patterns have changed. A plethora of psychosocial rehabilitation programmes has emerged, including counselling, drop in centres, and attending to special needs of elderly people, schoolchildren, and women. The most prominent psychological symptoms were exhaustion at the prospect of a third winter of war and bewilderment at the Western stereotype of Bosnians as Muslim fundamentalists.
When Christiana Amanpour of CNN came to visit the Bjelave kindergarten, perched on a hill above the Kosevo Hospital in Sarajevo, she asked if there were any children. “No, not any more,” Dr Amira Teftedarija replied. “Raped women?” “No.” “Well, traumatised soldiers perhaps?” “No, this is the home of seventy chronic schizophrenics.” “No story there then,” said the star journalist, retreating with her cameras; which is a pity, because although the members of this tiny multiethnic community lack underwear, socks, shoes, bedlinen, and fruit and vegetables, they certainly have a story.
When the war began in Bosnia-Hercegovina in April 1992, the patients were part of a population of 350 at the Jagomir hospital, 2 km from the former Olympic stadium. Bosnian Serb forces, with the assistance of the Yugoslav Federal Army, rapidly occupied two thirds of the country, including this part, and, according to Dr Teftedarija, all non-Serb doctors were forced to leave in May 1992. The patients were evicted the following month. Ninety of them found their own way across front lines and into the city, where they were housed in the kindergarten. For the first two winters there was neither heating nor beds. Amazingly, in spite of the absence of a shelter and the patients' indifference to the shelling, none have been killed, although lice and gastroenteritis were problems. For the past year the patients have crowded on cots into two downstairs classrooms. They have basic neuroleptic drugs but lack the materials for any other kind of rehabilitation activity, the only stimulation coming from a daily group and television in the evening. “Normally they would be with us only if they were acutely ill, but in these conditions their families cannot cope so of course they are becoming more institutionalised.”
Dr Teftedarija is a refugee herself, displaced from her home, which she can still see across the river. She sent her teenage daughter to Germany in the first year of the war; now she depends, like her patients, on humanitarian aid, plus the daily bread and milk that the hospital provides for its staff and the two additional meals provided for those on duty. Like all her colleagues in the public sector she has worked without pay for almost three years.
Twenty two of the 30 psychiatrists who previously worked at the Kosevo hospital remain. “If someone asked ‘how do you live?’ I would say that I honestly don't know,” Professor Ismet Ceric of the department of social psychiatry told me. “But you quickly learn how many of the trappings of modern life are unnecessary.” He showed me round the clinic, pleasant modern seminar rooms and offices juxtaposed oddly with bullet shattered windows and ubiquitous plastic glass replacement supplied by the UN. The deliberate targeting of the hospital is clear from the shell holes on every building. Fourteen grenades have hit the mental health clinic alone. “We are on a front line here,” one of the junior doctors told me. This was brought home to me more forcibly when another psychiatrist and a nurse were kidnapped on their way to Gorazde to work in the hospital there. Travelling in a UN protection force vehicle driven by British soldiers, with permission from the Bosnian Serb authorities, was not sufficient protection. They were released in a prisoner exchange after two weeks.
Yet in spite of these conditions the psychiatric department continues to function, maintaining a service for over 300 inpatients and approximately 150 outpatients a day. In addition it has set up a large scale, long term study of the psychosocial aspects of war in Bosnia-Hercegovina. Some of the preliminary results were presented by Professor Slobodan Logac, head of the university department, at a one day seminar in November. He focused on the changing pattern of inpatient morbidity in Sarajevo. Some of the findings were expected, such as the overall fall in the number of admissions and the suicide rate in the first year of the war, as well as a change in the pattern of morbidity. The numbers suffering from schizophrenic psychoses stayed the same and the numbers from affective and non-psychotic disorders fell. During the past year, however, particularly since the February 1994 ceasefire, the numbers of admissions have increased again for all conditions, but particularly for reactive psychoses and stress related disorders. The incidence of alcohol and drug related disorders continues to fall, but this is seen as largely due to the lack of available alcohol.
What was particularly surprising was that, whereas before the war 70% of admissions were women, currently 70% were men (and 94% of those with stress related disorders were men), aged predominantly between 25 and 44. Given the deliberate and continued targeting of civilians in this war, it is hard to explain the difference as being due to the greater risks attendant on fighting on the front line. Several women remarked on how much easier it would be if they had some sense of being able to hit back instead of feeling like sitting ducks in a shooting range. Professor Ceric suggested that if “you are dealing with the children, preparing food from nothing, fetching water, heating without gas or electricity, you have no time for nerves.”
Professor Logac pointed out that shifting population patterns also affect the picture. He sees the fall in affective psychoses at the outset of the war as due to the fact that “these people are sensors to forthcoming events. They recognised what might happen and removed themselves in time.” Meanwhile the number of cases of stress related disorders, particularly posttraumatic stress disorder, continues to rise, most significantly among young people. “Elderly people, with one war behind them, are protected by life experience,” Professor Logac suggests.
Treatment patterns have also changed. “We are all biological psychiatrists now,” said Professor Ceric. This is not just because of the lack of staff, space, and material resources to provide any other form of treatment but also because the risks of taking drug treatment at home, even the high doses of depot neuroleptics given to prevent relapse, are less than those of attending an outpatient clinic. Notwithstanding these problems, Professor Ceric sees the war as an opportunity to institute reforms in the mental health service that he has had in mind for 20 years; that is, to introduce community based, multidisciplinary care. “Seventy per cent of our mental health problems could be managed at the primary health care level.” But at present there are no community psychiatrists, and general practitioners are not trained in psychological medicine. Ceric hopes to set up 22 multidisciplinary community psychiatric teams, integrated with social services and functioning from local health centres. So far he has established one. But he is optimistic and is making use of the plethora of psychosocial rehabilitation programmes that have emerged in the city in the past two years.
Mental health programmes
Currently at least six international non-governmental organisations, as well as WHO and Unicef, provide mental health programmes of some kind, ranging from postgraduate education and training paraprofessionals to running counselling and drop in centres and attending to special needs, such as those of elderly people and schoolchildren. Professor Ceric sees the counselling centres as providing support and early diagnosis and the training programmes as playing an important part in increasing the level of psychological awareness in the professional community. “One of the biggest gaps,” he says, “is the low level of psychological education for social workers.”
To their credit, the agencies have focused on integrating with and bolstering local services. Though initiated by expatriate staff, the projects are now largely run and staffed by Bosnians, and thanks to Professor Ceric's insistence on coordination there is remarkably little overlap. Thus, for example, while Catholic Relief Services has focused on the education and group supervision and support of social workers, Medecins Sans Frontieres runs a diploma course in counselling at the Institute of Public Health and has set up four counselling centres in local health clinics. Their project leader, Vesna Puratic, agrees with Professor Ceric that Bosnians are not accustomed to taking minor psychological problems to counsellors. “But in this situation it is really needed. There is so much loneliness, fear, and anger. There has to be a place where one can go and talk to someone who is confident and professional without waiting and without stigma. In one centre we currently see about 65 clients a week.”
Marie Stopes International has established an impressive network of drop in centres and self help groups for women, where the primary reason for attendance seems not to be traumatic stress but the enjoyment of meeting regularly in a warm place to discuss topics (generated by the women themselves) such as “Is the husband the boss or not?” and “Do you have to be married to have a baby?” showing that, as in other wars, one of the noticeable psychosocial effects is the sea change in women's thinking about themselves.
The presence of all these programmes is evidence of growing Western preoccupation with mental trauma caused by wars and disasters. This raises the questions posed by Derek Summerfield as to whether any universal model of mental suffering can be usefully applied to very specific cultural and political contexts; of the dangers of treatment programmes increasing individuals' sense of themselves as passive victim rather than as survivor, and the appropriateness of individual psychological treatments for problems that are collective in their impact and whose causes are clearly social and political.1
What was stimulating about working in Sarajevo was that, though welcoming and making good use of the various programmes, the Bosnians were raising these issues themselves. WHO, for example, runs a post-traumatic stress disorder training course” for postgraduates. Though the course is well attended, the usefulness and appropriateness of the concept of posttraumatic stress disorder in a situation that is clearly not “post” traumatic was questioned on all sides. Outside the hospital the question of whether someone had the right constellation of symptoms to fit ICD-10 criteria was of much less relevance than their personal ability to function and the methods used to enhance this. My impression was that work, for example, although it was without pay and exposed one to the risks of walking the streets or taking the tram, provided community, meaning, an opportunity for patriotism, and a consequent protection from stress that staying safely at home could not.
In addition the framework of post-traumatic stress disorder cannot encompass the wide range of people's psychosocial experiences and needs in this situation. How, for example, can one find the time and space and acknowledgement of private grief in the context of massive collective loss? Nor does it help in distinguishing what is appropriate behaviour and what is pathological behaviour. Every day from my office window I watched students crossing the most dangerous street in the town, to reach the philosophy faculty, in full view and easy range of Serbian snipers. Were they exhibiting a courageous determination to continue normal life or unhealthy, life threatening denial?
And the social workers with whom I worked repeatedly reminded me, as I sat in their crowded, shattered, and freezing offices in various parts of the city, that the majority of their psychological problems could be wiped out tomorrow if my own government would use its political and military muscle to lift the seige of the city. Indeed the most prominent psychological symptoms I encountered were exhaustion at the prospect of a third winter of war and bewilderment at the Western stereotype of Bosnians as Muslim fundamentalists. “You have seen the orthodox and catholic churches in this city,” said Dr Semir Beslija, my colleague of Catholic Relief Services. “Tell me where one mosque remains in the territory controlled by Karadzic? What kind of fundamentalism is that?” Throughout the population I encountered growing feelings of frustration, betrayal, and incomprehension at the failure of the West to understand the dangers of appeasing fascist aggression and anger at the denial of the basic right to self defence. “We have to act for ourselves,” Professor Ceric told me, “because the international community does nothing.” He keeps a cartoon above his desk, in which an elegantly dressed young woman addresses a psychiatrist: “I have neither illusions nor delusions, Doc, my problem is that I exist day after day in grim reality.”
During the two months I spent in Sarajevo last autumn, what I had to offer in the field of mental health was welcomed and valued, but the insistence that I understand the political and social context from which the psychological problems arose reminded me yet again of my own responsibilities for prevention as well as cure.