The Role of the Health Care System in Protecting the Future of the Nation During the War: The Case of Bosnia and Herzegovina
(Volume 1, Number 2, Summer 2000.)
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
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.
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.
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.
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