Reviews PERSONAL VIEWS

Transformation of minds and souls

BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7510.242 (Published 21 July 2005) Cite this as: BMJ 2005;331:242
  1. Vladimir J Simunovic, professor of neurosurgery (vsimunov{at}public.srce.hr)
  1. School of Medicine, Mostar University, Mostar, Bosnia-Herzegovina

    At a time of much transformation of health systems worldwide, I offer this story of transformation of health professionals' minds and souls in the former Yugoslavia. In socialist Yugoslavia the standards and skills of doctors conformed to worldwide standards, although few had an international reputation. The main health indicators in Yugoslavia were in line with most European countries, and in some clinical fields our results even exceeded those of major centres worldwide. Most doctors were paid enough by the government to live comfortably, and only minor, insignificant corruption existed in the hospitals. In short, medical doctors had secure jobs, were respected in their communities, and had a relatively privileged lifestyle.

    When the 1992-5 war started many health professionals fled the country. In Bosnia-Herzegovina the number of people employed in the health sector fell from about 19 000 in 1991 to about 12 000 in 1996. It was not easy to become a wartime doctor overnight. My medical education focused on teaching me the skills to be a lifelong learner, clinician, educator, researcher, and manager. In just a few days I found myself having to perform in completely new roles: as hero, negotiator, expert in logistics, and guardian of principles.


    Embedded Image

    When the war started doctors were without reliable power, water, heating, drugs, and food

    Credit: SIMON TOWNSLEY/REX

    With war the rules of civil society were destroyed. Doctors were no longer automatically considered people of authority; instead authority and power were held by anyone with a gun. Under shelling and sniper fire we rapidly became aware of our own mortality. We also faced danger inside the hospital building: of enraged, drunk, or drugged fighters wandering out of control through the hospital (even into operating theatres). Frightened, we had two choices: to retreat to the shelters or to take on the role of hero, pretending that we, in contrast to all around us, were fearless. When the gunmen shouted at us, promising hell, we did not keep quiet—gaining respect was the only way to ensure a “normal” working situation.

    Some doctors became politicians, war lords, and even war criminals

    To illustrate: just before the war began I was called to the hospital shortly before midnight to attend two patients with bullets in their heads. When I arrived I found both of them comatose and a third man, with arm and leg injuries, surrounded like dying royalty by eight armed henchmen, who clearly had little trust in doctors and demanded to supervise the treatment. In the following weeks I would learn to distinguish these men, but that night I was still blessed by ignorance. The wounded man would soon become “the Wolf”—a national legend and a general of the “special forces.” I pretended to be enraged and asked the henchmen to leave the hospital. They pointed their guns at me and said that I would be the one to leave not only the hospital but “this world.” Standing up to them, I replied, “OK, then you perform the surgery.” Their leader gave a single wink, and I led the men out, like a group of misbehaving schoolboys, to the awe of the staff and hospital security guards. I went to the operating theatre, did what I could, and at around 4 am decided to make a last round. The staff room for the hospital's security guards was filled with 20 armed men, smoking and whispering. “What are all those people doing here? Get them out!” I ordered. “We can't control them,” the guards replied. “There are another hundred surrounding the hospital. They will listen only to you.” Like it or not, I had been assigned the role of hero.

    Sometimes the role of hero didn't work, and we had to cast ourselves as negotiators in a game where argument was usually pointless. If I needed oil for a generator so an urgent operation could be done, and the war lord needed the same oil to drive his stolen car, my argument was unlikely to prevail. However, if the leader of a paramilitary unit decided to take away a wounded patient for torture and execution, our long, hard negotiations were, I am proud to say, almost always successful. But we, the negotiators, were left with a burden—I still have nightmares, even today, 10 years after the war.

    Normally the smooth functioning of a hospital relies on dozens of people and services working in the background. When the war started our infrastructure broke down and we found ourselves without reliable power, water, heating, drugs and other supplies, food, and means of transportation, though still responsible for hundreds of wounded soldiers and civilians, whom we were unable to evacuate. It took no more then a few days for us to understand that unless we took on the role of logistics experts we would have to close the shop. How we managed this role is a long and sometimes funny story but is beyond the scope of this piece.

    Finally, as doctors we cherish the ancient values of our profession, as condensed in the Hippocratic Oath. Sadly, some of our doctors became politicians, war lords, and even war criminals. Others, however, were prepared to sacrifice their wellbeing and even their lives to protect their integrity and professional standards. In every single moment of every day we had, in the role of guardian, to ponder carefully each word and act, being permanently in the spotlight and a role model for all our team members.

    It is hard to believe how, since the war, self interest has grown among the “heroes in white,” as the media used to call us. Most doctors have accepted the philosophy of minimal service for maximum gain. A large number of private doctors' practices (some legal but most illegal) have been opened, charging fees irrespective of the wealth, or lack of it, of their patient populations. Even professional solidarity has died, their colleagues becoming just other “customers.” And this is yet another story to be told—much dirtier than the wartime one.

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