Intended for healthcare professionals

Feature Medicine and War

Trying to heal the scars left by the war in Bosnia

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3004 (Published 10 July 2018) Cite this as: BMJ 2018;362:k3004

Opinion

Medicine, trauma, and sexual violence—healing the wounds of war

  1. Richard Vize, freelance journalist, London, UK
  1. richard.vize{at}publicpolicymedia.com

More than two decades after the Bosnian war, memories of the conflict and caring for the living—and the dead—still define many lives in the Balkan state, reports Richard Vize from Srebrenica and Tuzla

Ilijaz Pilav was a doctor in the mining town of Srebrenica, close to the Serbian border, when Serb forces encircled the largely Muslim population in 1992. Like many Bosnian towns it is surrounded by hills, an easy target for artillery and mortars.

The 1992-95 war followed the breakup of the former Yugoslavia. After the republic of Bosnia and Herzegovina voted for independence Serb forces mobilised to secure continuous territory across a swathe of the country, forcing out inhabitants through its policy of ethnic cleansing.

Most doctors in Srebrenica fled. That left five—including Pilav and one trapped there while visiting after graduating medical school—for a population swelled to 40 000 by refugees.

“The city was under siege from the beginning—no electricity, no medicines, no sanitation materials, and for a couple of months no food. We five doctors with humble experience of medicine had to solve every problem,” Pilav says.

Until the Serbs advanced on Srebrenica three years later and massacred Muslim men and boys, in what the International Criminal Tribunal in The Hague described as genocide, “there were bombardments every night,” says Pilav, who as a Muslim was at risk himself. “From the beginning the number wounded was huge.”

During the siege, Pilav and his colleagues operated in an improvised theatre. For more than a year they had no anaesthetics: “Simple operations like treating wounds to complicated operations like amputations or even opening the stomach cavity. All that without anaesthetics.”

Lacking antibiotics or the proper dressings, they had to improvise surgical techniques: “We were forced to challenge protocols which said that a war wound must never be closed,” says Pilav.1

“We didn’t have the time or capacity to wait for these wounds to heal naturally. We made the decision to close them. After some time we realised we were achieving results.”

In 1993 Srebrenica was declared a safe haven by the United Nations. Some medical supplies started getting through, and a surgical team from the international medical aid agency Médecins Sans Frontières arrived.

He tries to focus on happier stories. In 1994 he delivered a premature girl by caesarean section weighing just 1.5 kg. She spent six months in the hospital. There was no incubator and the mother could not breastfeed. Eighteen months ago, the girl gave birth to her own daughter.

“That gives you the energy and hope to continue, but there were so few of the nice things compared with the evil. My father died in my own hands.”

On 11 July 1995 Serb forces attacked Dutch UN peacekeepers, and Pilav took his chances with several thousand other men, escaping through the forest to try to get to the city of Tuzla, 100 km north west of Srebrenica and which never succumbed to Serbian advances. After six days of avoiding minefields, ambushes, and bombardment he made it to safety.

Pilav, now head of thoracic surgery at Sarajevo University Clinical Centre, performed some 4000 operations during the siege in Srebrenica. His eyes betray the enduring distress of his experiences. Even 23 years later he cannot go inside that hospital: “It was so extreme; 17 of my male relatives were killed.”

How to identify thousands of dead

As Srebrenica fell, Serb forces massacred 8372 Muslim men and boys. In the subsequent years remains have been uncovered in almost 100 mass graves. In 1996 the International Commission on Missing Persons was established to find the remains of around 40 000 people who died in the Yugoslav wars.

Dragana Vučetić is the senior forensic anthropologist at the Podrinje Identification Project at Tuzla. For the past 13 years she has been part of the team excavating and assembling remains and trying to determine cause of death and identify.

Talking in the autopsy room, Vučetić looks at the bones laid out on the table, complete except for a hand. She estimates his age at 19 years.

After the killings, the Serbs moved bodies to try to obliterate evidence, the international court heard: “When they removed the bodies they destroyed the integrity of those individuals,” Vučetić says. “That’s why in 10% of the cases we find complete bodies and in the rest we find body parts. One individual we found in four mass graves in 15 different locations. So it is confusion.”

By 2002 only about 50 people had been identified. But DNA profiling has transformed the ability to reassemble skeletons—known as reassociation—and to identify them by matching remains with living relatives. “In an ideal situation we can complete identification in three months if we have a complete body—if it only takes one DNA sample and that DNA sample is successful. That is not often the situation. Often we need more months, sometimes years,” Vučetić says.

Around 6700 victims have been identified, most of whom are buried in the cemetery at Potocari, on the outskirts of Srebrenica, where the UN troops were based. The marble gravestones stand in condemnation of their failure. Burials take place annually on 11 July, the day the genocide began. Around 60 are expected this year.

The identification team exhume remains for which they have found additional bones. Everything is minutely documented and photographed. They can manage around 15 exhumations a day. So far there have been 550.

The identification project has around 400 active cases. They have yet to find remains for 800 people.

Vučetić tries to maintain a professional distance from her work: “But of course everything is emotional and stressful. It is not a job for everybody.”

Helping victims of sexual violence

While the male genocide at Srebrenica is the world’s most vivid memory of the Bosnian war, tens of thousands of women are living with the physical and mental pain.

As well as enduring the loss of homes and communities and the murder of fathers, husbands, sons, and brothers, more than 20 000 women were subjected to sexual violence, according to Amnesty International. Some were imprisoned in “rape camps” as Serb forces used rape as a weapon of war. For the first time The Hague declared systematic rape and sexual enslavement in war as crimes against humanity.

Medica Zenica, based in a therapy centre in the central Bosnian town from which it takes its name, provides mental and physical care to thousands of women, and more recently some men, who have experienced sexual violence. Although those who come to it are largely Muslim, the centre supports survivors from all communities.

Its director, Sabiha Husić, also Muslim, says that working with families is core to their approach, “so they understand trauma and can give support and help.”

Eighty five per cent of the service’s clients had post-traumatic stress disorder, 58% had family problems, and 42% had illnesses associated with the violence. Some reported difficulty conceiving.

Medica Zenica has trained more than 200 doctors, nurses, and midwives to treat people who have experienced sexual violence: “It is important that survivors feel safety and security in health institutions. We also need to know how to show empathy. People did not know how to react when a woman started crying.” Husić says.

She stresses that clinicians need to look after their own mental wellbeing if they are to be sensitive to others: “Often when working with victims we forget about our own mental health. Doctors especially think, ‘I always need to show that I am strong and powerful and that I know everything and I cannot show any emotion.’ But that is not possible.”

After a quarter of a century, Husić detects a growing willingness among women to speak out, saying, “I don’t want to die with this secret. I want to speak about my experiences so new generations learn. I am ready to talk about my life story.”

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References

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