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The
Role of the Health Care System in
Protecting the Future of the Nation During the War:
The Case of Bosnia and Herzegovina
Marko
Radoš, Miloš
Judaš, and Ivan
Bagarić*
Center
for Crisis Management, School of Medicine, Zagreb, Republic
of Croatia
* Ministry of Health of the Federation of Bosnia and Herzegovina,
Sarajevo, Bosnia and Herzegovina
ABSTRACT
The aggression of
the Serbian-dominated Yugoslav Army in 1992 caused the
dissolution of the health care system of Bosnia and Herzegovina,
which was unable to sustain itself without external assistance.
In 1992 and early 1993, this assistance was provided almost
exclusively by the Republic of Croatia, whereas the involvement
of the international community began to materialize only
from late 1993 onwards. Through the heroic efforts of
local communities, Croatia and the international community
secured the most basic level of health care for segments
of the population in parts of Bosnia and Herzegovina not
occupied by Serbian forces. However, the preservation
and improvement of that health care system since the end
of the war has been almost completely dependent on the
support of the international community. A country cannot
secure its own future if it is not able to establish and
maintain a basic social system, such as the health care
system. Therefore, the international community's efforts
to preserve the independent state of Bosnia and Herzegovina
might fail unless a serious reevaluation of current approaches
does not occur.
Introduction
As
one of six constituent republics of former Yugoslavia,
Bosnia and Herzegovina (B&H) has been relatively undeveloped,
ethnically mixed, and burdened with all the major economical,
ethnical and religious problems which characterized the
former Yugoslavia. The ruling force in the former Yugoslavia
was the Communist Party, which tightly controlled all
segments of social and economic life down to the level
of the local community. This was not a promising starting
point for the successful development and democratization
of the individual republics when the former Yugoslavia
disintegrated. In addition to this, the population of
B&H was poorly educated as a whole, and suffered from
complex ethnic and religious tensions. Even the minimal
chance for a normal and peaceful transformation of B&H
was destroyed by attempts of the nationalist Serbian Communist
Party to create a "Greater Serbia" with the
assistance of the Serbian-dominated Yugoslav Peoples'
Army (JNA). Moreover, in the decade preceding the outbreak
of the war, the Serbian ethnic entity had a disproportionately
large and influential role in the institutions of B&H
(9).
The
health care system of B&H was a part of the larger,
unified health care system of the former Yugoslavia. Therefore,
the central administrative bodies and the most complex
and specialized (tertiary) health care services were situated
largely, if not exclusively, in Belgrade (the capital
of Serbia and former Yugoslavia) (20).
Since the civilian and military components of the health
care system were separate in the former Yugoslavia, the
situation was even worse with respect to military medical
service: the central administration, as well as most important
infrastructure (e.g., Military Medical Academy) of that
service, was in Belgrade (3).
There were several military hospitals in major cities
of other Yugoslav republics (Ljubljana, Zagreb, Sarajevo,
and Skoplje), but these hospitals were unable to independently
organize and perform wartime medical services.
The
Health Care System During the War
After
its complete retreat from Slovenia and Croatia during
1990/91, and partial retreat from Sarajevo in the spring
of 1992, the JNA confiscated most of the medical equipment
and material. Since the majority of employees (medical
doctors, medical technicians, and nurses) in military
hospitals were active officers of the JNA, they retreated
together with the army. The consequences were devastating:
the medical institutions were left without equipment,
supplies and professional staff (6).
The
situation in B&H was aggravated even further because,
at the beginning of the 1990s, the civilian health care
system of B&H suffered from a serious lack of sophisticated
medical equipment; the supplies of drugs and other medical
materials were almost exhausted; and there were very few
highly educated medical professionals. However, the above
described only the situation in larger B&H cities
(e.g., Sarajevo, Tuzla, Zenica, Mostar, Foča, Bihać).
In other smaller cities and large rural parts of B&H,
conditions were disastrous (1,
17).
In
April 1992, the JNA began a "creeping" occupation
of B&H. The first skirmishes in Sarajevo and the more
extensive JNA operations against the joint Croatian and
Bosniac-Muslim defense forces in the area of Kupres in
central B&H, and in Brčko and Bijeljina in north-east
B&H, led to the complete breakdown of the civilian
health care system in B&H. Therefore, both the civilian
population and the ill-equipped Croatian-Bosniac military
forces were deprived of organized and effective health
care (2).
On
the other hand, western Herzegovina - the part of B&H
territory situated along the border of southern Croatia
and populated predominantly by Croats - had a slight but
significant advantage: the health care system of Croatia
was prepared to assist that part of the B&H population
in every possible manner. During April and May of 1992,
newly formed defense forces of the Croat-Bosniac coalition
in western Herzegovina and Central Bosnia were equipped
with their first military medical units due to extensive
logistical support from Croatia (15).
These medical units cared not only for wounded soldiers,
but also for diseased civilians and large numbers of displaced
persons and refugees who were either settled in that part
of B&H, or were in transition to neighbouring Croatia.
Furthermore, the Croatian hospital in Split, Dalmatia,
served from the onset of the aggression as the tertiary
health care center for both civilians and soldiers from
B&H (6).
In
the subsequent months and years, this would prove crucial
for the health care, and thus survival, of the major part
of the Bosniac B&H population as well. In neighbouring
parts of B&H populated predominantly by Bosniac-Muslims,
e.g. in the areas of Konjic, Jablanica and Central Bosnia,
this benefit was immediately realized. The same applies
to the Posavina region, situated in the northern part
of B&H along the river Sava River, bordering with
Croatia. For that region in the north, the Croatian hospital
in Slavonski Brod played a role equivalent to that of
the Split hospital in the south (18).
On
the other hand, those parts of B&H which were populated
predominantly by Bosniac-Muslims, but which were completely
surrounded by Serbian and JNA forces, were deprived of
such assistance. The health care system in those regions
had not only disintegrated but was also exposed to continual
attacks by Serbian JNA and paramilitary forces. And with
the exception of a few isolated enclaves (Goražde and
Srebrenica), the Bosniac-Muslim population of those regions
was ethnically cleansed, i.e. expelled from its settlements
and/or detained in concentration camps.
During
June and July of 1992, Croatian forces (HVO = Croatian
Defense Council) assisted by Bosniac-Muslim forces (TO
= Territorial Defence of B&H) attempted to establish
a basic health care system in the remaining parts of Central
Bosnia and in the region north of Sarajevo. The major
problem was that, as a consequence of Serbian aggression
and the dissolution of the civilian health care system
of B&H, a number of medical workers from the cities
of Jajce, Travnik, Zenica, Žepče, Fojnica and Sarajevo
had already abandoned their medical institutions and had
attempted to escape from B&H to a safe country. But
the efforts of these forces eventually led to the establishment
of at least the military medical component in that part
of B&H (19,16).
During
this entire period, which was characterized by brutal
Serbian and JNA aggression and the tremendous suffering
of the civilian population, Croats and Bosniac-Muslims
were left completely to their own devices. Assistance
from the international community was conspiciously lacking,
although UN forces and allied international humanitarian
institutions (e.g., UNHCR, ICRC) were already present
in neighboring parts of Croatia and actively engaged in
monitoring the situation in B&H.
Further
additions and improvements to the health care system continued
during the second half of 1992 and during 1993, although
that period was already characterized by the first conflicts
between Croatian HVO forces and Bosniac-Muslim TO forces
(13,12).
However, these military conflicts did not prevent cooperation
in the area of health care, which was a necessity for
the survival of both parties and depended on support from
the civilian and military health care system of the Republic
of Croatia (14).
This activity was coordinated by the Croatian Medical
Headquarters in Zagreb, and continued operating successfully
until the end of the war in 1995. In spite of the Croatian-Bosniac
military conflicts, both parties continued to cooperate
in the evacuation of displaced persons and refugees, and
the Croatian health care system continued to provide medical
care and treatment for ill Bosniac-Muslim civilians as
well as for wounded Bosniac-Muslim soldiers (for details,
see the paper by Kostović & Henigsberg in this issue).
In this respect, the hospitals in Split, Slavonski Brod,
Osijek, Županja and Zagreb carried the major burden. Although
complete and exact data is not yet available, preliminary
data show that at least 10,000 wounded soldiers and civilians
from Bosanska Posavina alone were treated in Croatian
hospitals in Slavonski Brod, Osijek, Županja and Zagreb.
This represented an additional burden to the Croatian
health care system, which was already devastated by Serbian
aggression during the 1991-1992 war in Croatia (4).
Although the United States and European countries delivered
drugs and other medical supplies during this period, the
amounts were minimal and were directed predominantly to
besieged Sarajevo.
The
role of the International Community
The
major international humanitarian institutions such as
UNHCR, ICRC, Medecines sans frontieres and others were
engaged in crisis management in B&H only from the
beginning of 1993. By that time, Serbian and JNA forces
had already taken control of over 70% of total B&H
territory, and one million Bosniac-Muslims and Croats
had been driven into the remaining quarter of B&H
territory. The major burden for the care of this huge
and desperate population, which consisted mainly of displaced
persons and refugees, fell again to the Republic of Croatia
(for details, see K&H article in this issue).
In
the spring of 1993, the international community attempted
to establish several primary health care centers in larger
and relatively safe cities, such as Zenica and Tuzla,
with the aim of reinvigorating the former health system
with medical supplies and a small number of medical professionals
(11). They
were not successful in Zenica and Tuzla, as they benefited
almost exclusively the Bosniac-Muslim population, since,
at that time, the humanitarian efforts of the international
community were focused on Bosniac-Muslims, considering
them the weakest party in the war. On the other hand,
the result of the growing conflicts between Croatian and
Bosniac-Muslim forces was that the only remaining hospital
in the western part of Mostar was admitting only wounded
Croatian soldiers (although civilian patients were admitted
regardless of ethnicity).
Additionally,
the remaining medical professionals continued to abandon
B&H. By the end of 1995, only a third remained in
B&H. Unfortunately, representatives of the international
community did nothing to prevent that process, and, in
fact, actively assisted medical doctors and nurses to
escape, even from parts of B&H which were relatively
safe, i.e. not exposed to direct military activities (14).
During
the first half of 1994, the situation in B&H was as
follows: large numbers of Bosniac-Muslims were completely
surrounded by the Serbian-dominated Yugoslav Army and
paramilitary forces in several enclaves in western B&H
(Bihać area) and eastern B&H (Srebrenica and Goražde),
while approximately 200,000 Croats were completely surrounded
by Bosniac-Muslim forces in Central Bosnia. All these
enclaves were completely cut off from the health care
systems of western Herzegovina and the Republic of Croatia.
Therefore, international community representatives and
institutions were the only remaining source of possible
aid to the populations of those besieged enclaves, especially
since the ICRC and health care-oriented NGOs had relatively
safe access to these areas. However, the international
effort was focused on Sarajevo, and efforts to improve
the situation in other besieged enclaves were of a political
nature, leading ultimately to negotiations which resulted
in the Washington Agreement in March, 1994.
Although
the representatives of some humanitarian organizations
and medical volunteers managed to enter some of the besieged
areas under the auspices of UN forces, their activities
were badly-coordinated, inefficient and occasionally even
biased by ruling policies of their parent countries (13).
Nonetheless,
during the second half of 1994 and the first half of 1995,
a number of international humanitarian organizations attempted
to establish some sort of health care system in the remaining
part of B&H which was controlled by the Croatian HVO
or Bosniac-Muslim TO forces. These efforts consisted mainly
in attempts to establish small-scale models of modern,
"western-style" health care organizations (7).
However, these attempts were usually ill-prepared and
based on standards of procedure which were appropriate
to affluent western societies, but inefficient in the
contemporary B&H situation, and thus led to false
and unrealistic expectations. Some of these international
efforts could be characterized as expensive but useless
field experiments conducted by foreign experts and/or
institutions.
The
representatives of local communities played only minor
roles in the planning and execution of these international
humanitarian efforts (8).
However, this was partly due to the chaotic military and
political situation arising from clashes among different,
local interest groups. Additionally, the situation was
abused by certain paramilitary or criminal groups which
attempted to seize control over the delivery and distribution
of goods. Even members and/or small units of international
humanitarian organizations and UN forces were accused
of taking part in such ignoble activities, and, on some
occasions, were found guilty (5).
These
humanitarian crises were ultimately resolved in the following
way: in July, 1995, the Serbian-dominated JNA and paramilitary
forces occupied the enclaves of Srebrenica and Goražde;
Bosniac-Muslims of that area were victims of mass murders
and ethnic rape, and survivors were detained in concentration
camps or expelled. There was an imminent threat that the
Bihać area would soon suffer the same destiny. This outcome
was prevented by the large-scale military operation "Storm",
conducted by the Croatian Army, the primary aim of which
was the final liberation of parts of Croatia still occupied
by Serbian paramilitary forces. However, one of the most
important goals of that operation was the prevention of
a humanitarian disaster in the Bihać area (21).
The extension of that operation onto the territory of
western B&H, which led to the liberation of significant
parts of the formerly occupied B&H territory, had
the full support of the Croatian military and civilian
medical institutions and units. As a consequence, the
population of Croats and Bosniac-Muslims in Bihać and
Central Bosnia regained access to already-existing health
care services in other parts of B&H territory controlled
by Croatian or Bosniac-Muslim forces.
Conclusions
After
the outbreak of war and aggression of the Serbian-dominated
Yugoslav Army against Bosnia and Herzegovina in 1992,
the social and economic structure of that multiethnic
community began rapidly disintegrating. Because it was
one of the most vulnerable social systems, the health
care system of B&H was especially endangered. The
Serbian forces occupied almost three quarters of the B&H
territory and thus drove the Croatian and Bosniac-Muslim
populations into the remaining one fourth of the country.
The health care system of the country was unable to sustain
itself without the assistance of the neighbouring Republic
of Croatia and the international community. Since the
burden of that aid in 1992 and 1993 was carried exclusively
by Croatia, the international community became involved
only at the end of 1993. However, joint Croatian and Bosniac-Muslim
forces were able to provide medical care and treatment
only upon the territory under their control, and international
efforts were focused on besieged Sarajevo. As a result,
during 1994 and the spring of 1995, large and isolated
enclaves in western, central and eastern B&H were
forced to fight for survival without any organized health
care system. After the fall of Srebrenica and the large-scale
military operations in the summer of 1995, the balance
of military power in B&H was radically changed in
favor of Croatian and Bosniac-Muslim forces, which enabled
the successful termination of the war under the Dayton
Agreement.
After
the arrival of thousands of NATO troops (from January
1996 onwards), the NATO Medical Service began to establish
health care centers for the support of their own troops.
A number of these centers were established during 1996
and 1997, e.g. in Sarajevo, Tuzla, Zenica, as well as
at the Zagreb airport "Pleso". However, the
civilian population of B&H did not (and still does
not) enjoy benefits from these centers, since the NATO
Medical troops were not directly engaged in providing
health care to the local population, although they tried
to help indirectly, through assistance to various NGOs
and education of local medical workers. The technological
and organizational gap between NATO Medical troops and
local medical workers has been so wide that attempts to
bridge that gap have had only symbolic value. The number
of properly trained and fully qualified medical doctors
and nurses in B&H is still insufficient, and the existing
health care system is still entirely dependent on external
assistance and guidance. In spite of huge investments
to improve this system, the international community still
faces a long and uphill battle. The crucial question is:
how long will the international community support the
lack of progress on the part of the B&H government
in implementing modern standards of health care?
Can
an analysis of the health care system in a war-torn country
provide useful and important lessons on operational methods
of international peace-keeping forces during humanitarian
crises caused by local military conflicts? On the basis
of the evidence presented, the answer is affirmative.
Obviously,
there are countries which, when exposed to brutal and
unexpected aggression, are unable to organize even basic
systems crucial for the survival of the nation (such as
the health care system) without outside assistance. In
the event that the international community undertakes
aid to such countries, it must be clear that routine approaches
and procedures are doomed to failure. New approaches are
needed, developed and designed for the local population
and environment. International efforts must rely on the
customs and resources of the local population, and officials
must acknowledge the fact that, without cooperation from
neighbouring countries, the best intentions and plans
cannot succeed.
References
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