Doctors In Conflict

Conflict in Bosnia 1992-3

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7225.1639 (Published 18 December 1999) Cite this as: BMJ 1999;319:1639
  1. Donald Acheson Sir, chair
  1. International Centre for Health and Society, University College London, London WC1E 6BT

    After retiring as chief medical officer for England in late 1991, Sir Donald Acheson—who describes himself as “intellectually exhausted” at the time—might have been forgiven for looking forward to a relaxing retirement. Instead the WHO Regional Director for Europe, Jo Asvall, persuaded him to go to former Yugoslavia as his special representative. His mission was to evaluate what public health issues were developing in Bosnia, a country newly wracked by war.

    Sir Donald set up an office in Zagreb, the capital of Croatia, in July 1992. At the time Zagreb was thought to be much safer than Sarajevo in Bosnia. After the invasion of Croatia by Serbia the year before (which had ended with the Vance-Owen Agreement), Bosnia had become the next scene of unrest. When Sir Donald arrived, Sarajevo, with a mixed population of some 350 000 Serbs, Croats, and Muslims living in relative harmony for hundreds of years, had been under siege for three months.

    Although Sir Donald was horrified by much of what he saw in Bosnia, he was not afraid. Coming as he does from Belfast, he understands the concept of ethnic division, where people who look the same as each other break into warring factions.

    9 July 1992—en route from Copenhagen to Geneva

    On my way to Zagreb as Special Representative of the WHO Regional Director for three months. Am currently in a flight from Copenhagen to Geneva for briefing in both places. The other agencies are UNHCR and Unicef and the International Red Cross. My instructions are to meet the other UN officials and all the health ministers of the new states. But of course the big question is what comes next and whether this is window dressing.

    10 July 1992—Zagreb, Croatia

    The key issues (or a few of them) are:

    1. current state of health: (i) in camps; (ii) in UN protected areas; (iii) in besieged cities; (iv) elsewhere.

    2. what will happen next winter, bearing in mind that it is very cold here and many of those currently being looked after by friends or relatives with a government support system are likely to be put out as soon as the system of support has stopped—very soon. But nutrition is good.

    3. Whether or how a “sentinel” system can be set up of health or healthcare provision.

    An epidemiologist from the Centers for Disease Control reminded me that the key problems are likely to be diarrhoea and respiratory illnesses and that excess mortality can be assessed on the basis of (roughly) a norm of 1 per 10 000 per day. Meningitis may also be a problem. I said typhus might [also] and was proved right by a report that it is occurring in Sarajevo [it was not, however, confirmed] …. I met Mme Anne-Marie Demmer, director of the European Bureau of UNHCR. She seemed rather overwhelmed by the Jugoslavian situation, particularly its scale and the problem of getting winterproof accommodation set up in time. She feels that at all costs the “mental consequences of the war” (a further generation of disastrous bitterness and prejudice) should be averted by “rehabilitation.” I wonder how this could be undertaken with any hope of success.


    Embedded Image

    Several hundred thousand refugees were sent to hotels on the Dalmatian coast

    (Credit: LAURENT REBOURS/AP PHOTO)

    12 July 1992—Zagreb, Croatia

    Have just had an interesting conversation with a Croat engineer returning to Zagreb from Paris Slightly older than I but fought with Tito and met Randolph Churchill in 1942. His name is Vinko Arambasin. He says the first thing is to stop the war by the US to destroy the Serbian air force and heavy weapons by pinpoint rockets. Humanitarian aid such as has been sent to Sarajevo is hypocritical so that “people may die with a full stomach.” There are several hundred thousand refugees in the hotels on the Dalmatian coast. He fears widespread massacres in Bosnia.

    Sir Donald's resources consisted of a tiny office containing a packing case table and two chairs, and the “enthusiastic and cheerful support” of a personal assistant and interpreter called Sanja Viscovic and a driver, Branco Pelko. Being Croatian, neither of them could cross the border into Bosnia. Sir Donald quickly ascertained that he would need to establish a number of other offices in various cities if he were going to really get a handle on the level of public health problems that were fast arising. His first foray into Bosnia was into Sarajevo itself, by Italian cargo plane.

    18 July 1992—Zagreb, Croatia

    I have had a call from Tony Land of UNHCR asking me to go to Sarajevo to try to sort out the drug and equipment distribution problems there. Of course I agreed, subject to careful preparations being made so that there is a maximum chance of a positive outcome. Apparently the equipment etc does not get to the wards.

    22 July 1992—en route from Zagreb, Croatia, to Sarajevo, Bosnia

    Sitting in Hercules flown by the Italian air force bound for Sarajevo. The flight takes 1 hour and 15 minutes and is by Split. The seat is one of two rigged sideways against the shell of the aircraft facing inwards. The fuselage contains pallets of humanitarian stores plus one oxygen concentrator for personal delivery by me to Kosovo Hospital. I had intended to take three but in the light of yesterday's events [Sir Donald had met two doctors from Tesanj, a remote Bosnian town, and discovered that operations were being performed without anaesthetics] am retaining two. I have just been presented with a pair of earplugs. Two of the crew are reclined on top of the pallets, having scrambled past me. [A week later, this same plane and all its crew was shot down. This, among all the horrors he experienced, seemed to bring the war in Bosnia to a personal depth for Acheson.]

    One of the first journeys taken by Sir Donald out of Sarajevo was to join a convoy to Gorazde. Gorazde is an enclave of Muslims that had been isolated by Serbian forces, and the inhabitants were in danger of being starved out. The convoy—under the protection of armoured vehicles supplied by the United Nations Protection Force (UNPROFOR)—was making an attempt to bring urgently needed food and medical supplies into the enclave. The road to Gorazde was heavily mined, and several vehicles were blown off the road.

    23 July 1992—on the first convoy to Gorazde, Bosnia

    As we passed out of Sarajevo, I rode in a Nissan patrol jeep with Fabricio Hochschild (the senior UNHCR person) and his translator. Throughout there was some uncomfortably close sniper fire, at whom directed I know not. Fabricio and his interpreter did not budge so neither did I. Such is the force of example. By roundabout ways through road blocks and parleys we slowly wound our way across Bosnia. But 15 km from Gorazde, after a drive of about eight hours, disaster struck. The armoured personnel carrier (APC) immediately ahead of us and leading the convoy ran over a mine with a huge explosion and flash of light. We were perhaps 15 metres behind but our windscreen was not shattered. The place was a classic position for an ambush: a narrow dirt road in a forest on a steep upward incline with hairpin bends. Our convoy consisted of an APC at the front and the rear; two 20 ton trucks driven by Swedish volunteers, our Nissan jeep, and Serbian escorting police armoured cars in the lead and at the rear. Immediately after the explosion all hell broke loose with very close firing of high velocity rifles and at least one heavier machine gun. All of us not in armoured vehicles dived for the ditch. It is not clear how much of the firing was from the Serbian police armoured car, but those who know better than I identified Kalashnikovs and a heavy machine gun firing from about 100 metres on both sides of the road; fortunately they must have had a poor view because no one was hurt. Also, although the APC lost the rear right wheel completely and was turned about 45 degrees on its side, the only injury to the people inside was a slight graze and bump on the head to one person (our Serbian translator) who had not got her helmet on.

    This first convoy did not succeed in reaching Gorazde, nor did the second. The third attempt, however, was successful. Nevertheless, the publicity that was achieved by the earlier convoys helped fund raising enormously. A German television company that was present was responsible for alerting the rest of the world to what was happening to the convoy, and when it became apparent that they had taken on a hands-on approach rather than being deskbound, the WHO team helped bring in $50 million for medical equipment and general sanitary supplies.

    24 September 1992—Zagreb, Croatia

    This evening I met a Jewish doctor and his wife who had escaped from Sarajevo, who gave a first hand account of the seige of Sarajevo up to six weeks ago. These people are going to die in tens of thousands…. My talk with the Jewish doctor and his wife leaves no doubt that there is a serious gap in the humanitarian supplies in respect of sanitary articles—soap, toilet paper, household disinfectants, washing powder, insecticides, tampons. The difficulty is that some of the articles are bulky.

    Although the initial aim of the WHO was simply to provide policy advice, Sir Donald quickly established that there was a severe shortage of medical supplies in Sarajevo.

    1 October 1992—Banja Luka, Bosnia

    When we called at the hospital in Banja Luka we met the chief pharmacist, who to begin with was extremely hostile, particularly in relation to UNHCR. Apart from 25 tonnes of surgical medicines and equipment the hospital has had no assistance. No other NGOs are operating in this area. They have 1600 acute beds in the city and treat a large number of wounded of all degrees of severity every day. A total of 7000 seriously wounded cases have been treated since the beginning of the war. They need anaesthetics, gauze, intravenous solutions of all kinds, drugs for cancer and psychiatric illness, and haemodialysis fluid. There are 400 patients on dialysis in Banja Luka, says Dr Radjoka Malbasic …. Merhamet [a Muslim non-governmental organisation] was represented by two doctors who to my surprise brought a Serb doctor with them. Their concern in relation to discrimination in the health field was threefold: (1) refugees and displaced people from the minority groups are never able to “register” and therefore become eligible for health care; (2) likewise if they become unemployed, which most of them are, due to discriminatory practices, they do not receive social security benefit; (3) in the hospitals, although they will be treated if they are acutely ill, they are in serious danger from Serb patients Muslim mothers are frightened to go to the hospitals as a senior official at the hospital has said he does not want Moslem babies there.

    By liaising with the Overseas Development Agency in London, Sir Donald secured enough medicines for a population of three million for one month. They arrived by plane all in separate boxes. With no available local pharmacists to sort them out, it was left to the WHO office to decide how they should be effectively distributed. Adopting the International Red Cross convention of creating “emergency kits,” and after discussion with health workers in the field, Sir Donald's team came up with the idea of dividing the medicines into a number of specialist kits. About 20 different types of kit were created. These included kits of emergency drugs for a population of 10 000 for one month, kits for mental hospitals (supporting 30 beds for three months), kits of surgical supplies to support 100 operations, anaesthetic drugs for 100 major operations, and kits containing toiletries for camp refugees (supplies for 100 families for one month).

    23 January 1993—Split, Croatia

    It turned out that as compared with Slavonski Brod or Bihac, for example, the Sibenik Hospital [on the Croatian coast] had been relatively little affected by the war—it had treated some 320 wounded and received about 100 dead. The immediate problem was that they had completely run out of anaesthetics and had stopped operating. Fortunately we had been warned and had an anaesthetic kit to give them. The pharmacy was well stocked and most of the diagnostic machines worked. Once again, as elsewhere, the problem is secondary distribution. The [Sibenik] hospital pharmacy supplied the “donation pharmacy” [a distibution system where medicines were handed out to the needy on a charitable basis] (no charge) for the district, including some 26 000 refugees and displaced people. But did the material get there?


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    The main meal for refugees was often a pathetically thin soup and some bread

    (Credit: MIKI AJDER/AP PHOTO)

    27 February 1993—Tesanj, Bosnia

    We arrived at Tesanj at about 2 o'clock, leaving us at the most one and a half hours to give us time to get back before dark. Our first interview was with the head of the local Red Cross, who said the health of the 87 000 people under his charge was good due to timely preparations Nevertheless people were losing weight. I asked him directly whether anyone was going hungry but he evaded the question. In the last month they had received from UNHCR 102 tonnes of flour, 4700 litres of oil, 7 tonnes of beans, 7 tonnes of lentils, and 7 tonnes of (? high protein) biscuits …. Dr Hadzija, the director of surgery, had escaped from Doboj and wanted to remain anonymous as he still had many relatives in that town. I was impressed by the quiet way in which he described how his department in a health centre which had never before the war taken inpatients had treated more than 1000 severe injuries since May and how they had an improvised a further hospital for minor injuries nearby …. In the end it was clear that there is an urgent need for antibiotics, dental supplies of all kinds, mental kits, vitamins (there had been cases of scurvy), insecticides, and rodenticides; also drainage tubes, antiseptics, and external fixators. As far as infectious diseases are concerned they have 120 cases of tuberculosis under treatment and triple therapy is short. Life goes on in this sorely pressed town—three babies are delivered every day.

    One of the WHO's worst fears was the freezing temperatures likely to be found in Sarajevo during the winter. As it turned out the winter of 1992-3 was unusually mild.

    2 January 1993—Sarajevo, Bosnia

    A surgeon at the State Hospital described how he wakes up with his face frozen each morning in spite of covering himself as best he can with all available blankets. There is no coal or fuel oil and no electricity for heating. Another doctor who walks up and down when he is on duty at night in his overcoat to stop himself shivering said as the weeks passed and the shortages of food and fuel became critical they would fight each other like animals if necessary to survive but they would not leave. Without heating, the group practices and clinics will not be able to treat frostbite or hypothermia. No such cases have yet appeared but few people dare to come to this clinic as it is so dangerous (four of his colleagues have been killed and 17 injured while at work here), and he believes many older people will be found dead at home.

    24 February 1993—Sarajevo, Bosnia

    With regard to the state of the people, the local view is that people are still losing weight but in physical terms there is no perceptible difference. With regard to the public utilities, the position is much the same as in January The main meal being served for refugees and displaced people in Novigrad was pathetically thin pasta soup plus a quarter of a loaf of bread each. But I am convinced that anaemia is widespread. I have persuaded Simon Mordell [of the WHO] to attempt a simple survey using finger pricks plus portable battery driven haemoglobinometer and smears.

    Sir Donald left Bosnia in April 1993, having set up a number of systems that remained effective throughout the rest of the war, but suffering by this stage a degree of emotional burnout. He returned to Sarajevo for two weeks in July that year, to relieve his WHO successor, Simon Mordell, who wanted to take some leave.

    7 August 1993—Sarajevo, Bosnia

    The last full day in Sarajevo. We started by visiting the Apoteka on to which my window looks. In spite of all our efforts it is two thirds empty. What are missing are the medicines in the chronic disease kits. Some of the WHO's material for the treatment of diarrhoea was visible. Next I paid a call on the central open air market, which was absolutely packed. Stalls with vegetables and salads at 8 DM a kilo, also many recognisable articles from the French military rations here—one “meal reheatable container” at 6 DM. A homemade wood burning cooking stove 320 DM. Also a throng of young men standing trading in currency and cigarettes. Not surprisingly the stall holder to whom I spoke said that, all things considered, times were good. Good for those who have the money to deal. He was one of the very few people in Sarajevo who were still overweight. [Shortly afterwards, the market was demolished by a direct hit from a mortar shell, with many casualties.]

    In the street we stopped an old man to try to find out what it is like living here in old age. Before he was prepared to say anything about the war he said he was a retired teacher who had tried all his life to teach the children here to live together regardless of race or religion. As far as the war was concerned his pension was now negligible—sufficient only to buy a few apples. He and his wife and daughter (who although 30 had never found a job) had lived so far on his life savings, which were now exhausted, and humanitarian aid. He did not like to think about what would happen next winter. I gave him my card, he lifted his hat and walked off. He was very thin indeed.

    Acknowledgments

    The work described was under the auspices of the WHO's Regional Office for Europe. The support of the many members of staff not mentioned in the paper is also acknowledged.

    Footnotes

    • Competing interests None declared.

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