THE BALKAN'S PUBLIC HEALTH ISSUES: MARGINALIZATION AND NEGLECT

Millions became refugees, hundreds of thousands were killed, tens of thousands women raped; can it be a marginal public health issue? All that happened because of their nationality and religion; can it be a marginal human rights issue? Can we face our responsibility without health and human rights in Balkans becoming a major issue?

One day in June 1993, Serbian bombardment of Gora`de killed 52 patients in a hospital. At the same time, Franciscan Hospital in Nova Bila in Middle Bosnia is filled with patients and completely cut off from medical supply, with a dim chance to be saved. There has been no reaction, in any form - meeting, statement, appeal or other, by WHO or other international health or medical organization. The fate of hospitals, health workers and patients, all the way to complete destruction and killing, has become a marginal question. This marks the entire approach to the tragedy occurring in the first major armed conflict in Europe after the World War II (1). Basic public health questions opened before the world, crying for the answers (2).

These events clearly indicate a desperate need for mass and utmost involvement and coordination of the medical and health community, from local to global. Local health and medical communities largely fulfilled their professional role (3). Internationally, it was not the case. It failed for the following reasons: 1. WHO had neither theoretical nor practical framework of approaching, organizing and presenting health needs in wars and other catastrophes. 2. Justification for this professional lack of responsibility is found in the phrase of political neutrality. WHO can be neutral to politicians but not to patients' rights and population health. 3. Health, medical, humanitarian and human rights issues have been marginalized in importance in relation to political and military questions. 4. While separate individual and institutional international support has been performed globally to a fascinating level, WHO completely failed in coordinating health efforts. 5. Major need for WHO involvement started with hunger strike by Albanian miners in Kosovo in 1989 (1). While there are precise World Medical Association rules for individual hunger strikes, when 1,000 people went on a hunger strike - WHO declined to get involved - for political reasons. During 1990, no attention was paid to mass poisoning of Albanians, closing of health institutions, firing of Albanian health workers and medical school teachers all the way to imprisonment and torture.The WHO remined inactive also in 1991, when the direct conflict begun, from the very beginning based on systematic destruction of medical and health institutions and civil populations. In 1992, when the war reached its full destructiveness in Bosnia, including mass deportation, mass rape and concentration camps and when the number of refugees reached millions (1), WHO intervened for the first time in late summer of that year. Owing to the great work of Sir Donald Acheson, one of the best public health experts of our times, all that an international public health effort can accomplish in war situations was dramatically shown in mere few months. While a handfull of international health and humanitarian workers (Kushner, De Mistura, Grant, Ogata) became involved as early as in autumn of 1991, Director General of the WHO came for the first time to Sarajevo in June 1993, two years after the beginning of war, four years after massive health and human rights abuses begun and five years after the beginning of induction of mass hate campaign (1). 6. Up to June 1993, not a single report on health and medical conditions in the area of the conflict was presented. So far, there was no meeting of hundreds different health organizations active in the area or any stronger effort to organize a more effective health work or to influence political, diplomatic and media factors to mitigate the suffering of the people. While the international meetings of diplomatic, political and military levels occur regularly, there was not a single medical meeting. Such marginalization of suffering of millions of people and efforts by thousands of health workers and organizations from all over the world is not easy to understand.

It appears that the war in the Balkans has caught WHO and other international health and humanitarian organizations completely off guard. They have completely failed, not only in prevention and treatment, but also in shere presention of the level of suffering and efforts of directly involved health workers and institutions. The WHO appears completely unaware of the enormity of further tragedy and health destruction that can still occur in the Balkans through further war destruction, ethnic cleansing and genocide, religious and national hate inducement, refugee care, next Bosnian winter (4) and all forms of blocking medical and health work. Furthermore, the WHO is setting a dangerous precedent for lack of an adequate international health response to the war anywhere on the planet. The international health community should immediately face the entire complex issue of health and medical responsibility in the Balkan War, starting from evaluation of own results, admitting its failures and planning its role for future involvement. The Balkan conflict for international health work must become a milestone of responsibility. Instead of political neutrality we achieved neutrality to patients and populations up to the level of their individual and collective death, torture, disease and killing.

Beside such direct health suffering, major health and human rights issues have not been adequately faced either. Instead of analyzing the methods of inducing hate in populations, the world was left with the concept of "ancient hatred" in the Balkans, justifying the lack of compassion and opposition to aggression and human right abuse. Genocide was not analyzed as a means of a mass destruction of people for their national and religious characteristics. The medical community still appears hesitant to clear its position towards this most dangerous risks to human life and dignity. The international health organizations did not use contemporary Balkan events to move the field of genocide from political misuse to professional analysis, from punishment to prevention. The term genocide is not present in Index Medicus and Meadline. While politicians took great liberty in (mis)using the term, world medical community did not live up to the professional responsibility of identifying its obligations to the world's "never again" addressed to Holocaust. At the opening of the Museum of Holocaust in Washington, E. Wiesel, one of the survivors of the Holocaust, appealed to president Clinton: "Please, do something in Bosnia!" That appeal was as well addressed to the entire medical and health community.

Particularly tragic is the concept of equal guilt (5). It has lead Croatian and Moslem victims to give in and start participating in destruction themselves: after having watched the burning of their homes, slaughter of their parents, raping of their wives and daughters, they saw no sign of the willingness of the international community to stop the terror, and acted in pure despair. Now, the international community immediately became effective in blaming the victims! It easily forgot that in the Warsaw Ghetto Nazis had a Jewish police as an instrument of terror and that finally the doctors on the second floor of the paediatric hospital in the Ghetto, while the Nazis were entering the first floor, went for their own final solution of medicine in despair: they put children in beds, gave them poisons and looked at them all die before the Nazis could take them to death chambers. They gave them death with dignity, while the children were completely healthy and prepared for a full life. Is this what the world is asking for the health workers in Gora`de, Nova Bila, Sarajevo and other to do? Or, do we have to wait for bombs to kill them while in their beds, for soldiers to torture and rape them, or watch them die for hunger and cold or because there is no more medicine or any other help? Is the world medicine capable to answer to its professional responsibility, medical ethics and human rights? If it is not, we should know it, and the WHO should better stop existing so that young people and future generations at least know that their duty to create World Health has not yet been accomplished.

Slobodan Lang, M.D., Ph.D.

Zagreb, Croatia

1. Lang S. The Third Balkan War: Red Cross bleeding. Croatian Medical Journal 1993;34:5-20.

2. Toole JM, Galson S, Brady W. Are war and public health compatible? Lancet 1993;341:1193-6.

3. Lackovic Z, Markeljevic J, Marucic M. Croatian medicinein 1991 war against Croatia: A preliminary report. Croatian Medical Journal 1992;33(War Suppl 2):110-9.

4. Lang S. The Bosnian winter. An open letter to Mr. Al Gore, the vice-president of the United States of America. Croatian Medical Journal 1992;33:236-9.

5. Anonymous. Will there ever be peace in Europe? Nature 1992;358:439.

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