Bosnia and Herzegovina

6 World Health • 48th Year, No. 6, November-December 1995 Bosnia and Herzegovina Manuel Carballo & Arif Smajkic The war in former Yugoslavia has produced hundreds of thousands of displaced people. Some will never regain their mental or physical health, and some children will be psychologically scarred for life. Wars have displaced individu-als and families throughout history. The twentieth cen- tury has been no exception. The displacement of populations often helps to save lives, but it is always painful and dangerous. It is often accompanied by aggression directed against specific individuals, families, and entire communities. Forced displacement is a political tool, directed towards debilitating people and disorganizing society. Its health implications are dramatic. Bosnia and Herzegovina's popu- lation numbered some 4.5 million people before the war- an ethnically mixed and culturally heterogeneous population that brought together Islam, Christianity and Judaism. Its capital city, Sarajevo, was home to over 600 000 Moslems, Serbs and Croats. Health care was universal and health indicators such as infant and maternal mortality and immu- nization were equivalent to those in most western European countries. With the onset of war in 1992, the ethnic and cultural heterogeneity of Bosnia and Herzegovina (as indeed of former Yugoslavia as a whole) was dramatically disrupted. Over the next three-and-a-half years, more than 50% of the original population villages and towns. Most fled to other parts of Bosnia and Herzegovina, but over a million sought sanctuary elsewhere in Europe. According to data provided by the National Institute of Public Health in Sarajevo, they are distrib- uted as follows: Germany Serbia and Montenegro Croatia Austria Slovenia Sweden France Switzerland Italy Netherlands Norway Turkey Denmark United Kingdom 350 000 300 000 100 000 73 000 60000 50000 40000 35 000 30000 30000 25 000 25 000 20000 20000 For the displaced who remained in Bosnia and Herzegovina, towns such as Bihac, Mostar, Sarajevo, Tuzla, Travnik and Zenica became sources of relative safety, but truly safe havens rarely materialized. "UN safe zones" were besieged and subjected to repeated attacks. In Sarajevo alone, more than 10 000 civilians were killed and another 61 000 injured. Water supplies and electric- ity were cut off for months at a time. Fuel for heating became impossible to find , and parks and sidewalks were quickly denuded of any trees and shrubs that could be burned. Cold winter weather made the care of the ill and wounded all the more precarious, and freezing tempera- tures were common for weeks on end in hospitals and in the city. Thousands of Bosnian men of so-called military age (from 16 to 60 years) were conscripted. Those who survived returned with serious physical and even more profound psychological injuries. In the mean- time many families were forced to move on, often losing contact with their menfolk. Housing became a critical issue. Where possible, empty houses and apartments were allocated to dis- placed families, and local families were also asked to provide rooms for the homeless. But many schools, hotels, disused factories and ware- houses had to be requisitioned and hurriedly converted into temporary, was forced to move from its homes, A patient being evacuated by aircraft from the Bosnian capital Saraievo. World Health • 48th Year, No. 6, November-December 1995 7 A United Notions humanitarian convoy en route to Saraievo. Refugees from former Yugoslavia reach safety in Switzerland. and often grossly unsatisfactory, shelters for thousands of the dis- placed. As in all wars, many of these temporary shelters quickly become "permanent" and will continue to be needed pending the reconstruction of towns, villages and individual homes that were destroyed as part of the "ethnic cleansing" campaigns that were waged. The besieging of key towns exposed hundreds of thousands of displaced as well as local people to severe and persistent food shortages. Although periodic WHO nutrition monitoring surveys indicated an absence of gross malnutrition, hunger was widespread and most people experienced severe weight loss. Elderly people and pregnant women were particularly vulnerable and in danger, the incidence of low- birth-weight babies tripled, and the number of nutrient deficiency-related congenital abnormalities increased even more. To these health problems were added the effects of overcrowding, poor sanitation and badly ventilated rooms in displaced persons' centres. In Sarajevo, where few buildings had intact windows, the plastic sheeting provided through UNHCR was an important life-saving measure but not always a sufficient source of insulation. Epidemic outbreaks of respiratory diseases were a frequent problem. Water shortages, with even greater shortages of chlorine to purify what water there was, pro- duced widespread gastrointestinal infections and hepatitis outbreaks. Displaced people in collective cen- tres were inevitably more affected than others. The task of providing health care to them was shared be- tween local health services and nongovernmental organizations, but many displaced people, especially those coming from small rural com- munities, were often too traumatized or unused to the health care system to make effective use of it. Many of the elderly and the disabled (including young men with war injuries) became psychosocially and physically isolated. Unable to carry water when it was available from neighbourhood standpipes, unable to carry firewood, and unable to collect food when humanitarian aid supplies got through, they suf- fered more than others. Sexual violence became closely associated with "ethnic cleansing" . Whether used as a means of inciting departure, or as an expression of ethnic aggression and gratuitous violence, sexual abuse became a major health problem and a cause of severe post-traumatic stress. Counselling of sexually abused people (both women and men) had to become an important part of the care of displaced people throughout Bosnia and Herzegovina. Throughout the war health care workers everywhere provided a strong and highly visible source of leadership at every level of society. They became involved in a wide variety of humanitarian relief activi- ties as well as providing health care. From the onset of the war their work was supplemented by that of UN agencies , nongovernmental organi- zations and volunteers from all over the world. Action carried out by agencies such as UNHCR, WHO, UNICEF, WFP, IOM and UNPRO- FOR combined well with that of national staff in a vast arena of emergency work. The war in former Yugoslavia has caused the death, injury or dis- placement of hundreds of thousands of people. Some will never regain their mental or physical health, and many children may be psychologi- cally scarred for life. But important lessons have also been learnt. The most important is that, although humanitarian crises may not always be preventable, the combination of national resilience and commitment - when supported by international humanitarian efforts - can help to avert even greater man-made disas- ters. • Or Monuel Carbo I/o was based in Soroievo os the WHO Health Development Adviser for Bosnio and Herzegovino; he is now Coordinator of the International Centre for Migration and Health, 24 Avenue de Beau· Seiour, I 206 Geneva, Switzerland. Professor Arif Smoikic is Director of the Notional Institute of Public Health and Head of the Department of Community Medicine at the University of Soraievo.