Mental health under war conditions during the 1991-1995 war in the former Yugoslavia SBren Buus Jensen a
Identifying needs and resources It has been said that the first victim of war is the truth. The health variation of this saying has the practical consequence that medical data are turned into military secrets (death tolls, the number of wounded, etc.). Combined with the fact that the normal, peacetime, health information systems break down, humanitarian assistance programmes are forced to plan on the basis of a very uncertain war epidemiology. One must rely on direct field observations, if access is not hindered by heavy warfare, compiling and analysing scarce data from the past and present, fitting them into a pragmatic mosaic, and making qualified estimates and calculations from existing professional knowledge. The mental health field is no exception. The nature of mental health problems does not especially facilitate this work either.
suffer a "collective trauma". They will probably experience a significant reduction in their quality of life due to mental health problems related to unmet therapeutic needs. The consequences are expected to be a significant threat to the public mental health of these countries. We can expect changes such as: increased frequency of alcohol and drug abuse (e.g., self-medication); increased suicide and homicide rates; increased frequency of criminal and structural violence, and of traumainduced psychotic manifestations; and, in general, transitional problems turning into chronic mental illness.
War traumas: concepts and understanding Psychological war trauma concerns injury or damage to different aspects of intrapsychic and psychosocial functioning. The trauma (e.g., "wound") is caused by the experience of traumatic events. The degree of traumatization varies with the balance between the strength of the stress factors, and individual protective factors and is reflected in the symptomatic traumatic reactions (often categorized as traumatic stress disorders) and the complications thereof (1). Stressor factors (stressors) in the most critical traumatic events contain elements of threat, injury, exposure to death, destruction and human suffering (2). Target object may be a person, a family, a group or even the whole society. Examples of vulnerable groups under war conditions are children and adolescents, the elderly, the refugees and internally displaced people (Fig. 1), and the families of the "disappeared" and killed. In the post-war phase, the home-coming soldiers, who have to change back from warriors to their old roles as fathers, spouses, sons, brothers and lovers, present a new challenge. This group may be traumatized by having witnessed or committed war atrocities. Traumatic reactions are symptoms of traumatic stress and may lead to serious mental health complications as mentioned above. The experience of a traumatic event may cause post-traumatic stress disorder (PTSD) in some, while others may not develop the symptoms. The symptomatology of traumatic stress disorders, however, is quite similar on the individual level regardless of the kind of traumatic event. The most common features are: 213
More than 1 million people are in need of help, but who will help them? An estimate by the WHO mental health unit based in Zagreb calculated the number of people in need of assistance from the perspective of war as a "peacetime disaster". b The estimate indicated that the core group in severe need of help maybe about 1 million people (or 5% of the original population in the former Yugoslavia). It was also estimated that about 5 000 full time professionals, experienced in trauma work, would be needed to cover the emergency needs, while the actual number of skilled professionals in the field amounts to about 200. The consequent imbalance between the needs and the helping capacity bring us to the first conclusions: (i) There is an imbalance between the frequency of mental health problems (e.g., war-traumatized people) and the helping capacity of the local professionals; (ii) It is not possible to solve even the emergency problems through traditional treatment procedures of therapeutic interventions. Self-empowerment and capacity-building in the population and among professionals on all levels are essential elements. (iii) In the war-affected countries a high percentage of the population might for several years WHO Senior Adviser on Mental Health, Mental Health Unit, WHO, Sarajevo, Bosnia and Herzegovina. b WHO,Annualreport 1990, WHOMissionintheFormerYugoslavia, Zagreb, WHO, 1995.
a
Wid hffh statist. Quart., 49 (1996)
Fig. 1 Refugees and displaced patients among 1 801 patients in 9 psychiatric institutions in Bosnia and Herzegovina (BIH), Croatia and the Former Yugoslav Republic of Macedonia (FYROM), 18 October 1994 Refugies et personnes deplacees parmi 1 801 malades de 9 institutions psychiatriques en Bosnie-Herzegovine, en Croatie et dans I'ex-Republique yougoslave de Macedoine, 18 octobre 1994 Non-residents by country - Non-residents par pays
Fig. 2 Frequency of post-traumatic stress disorder (PTSD) and depression amonQ 1 801 psychiatric in-patients in the 18 October 1994 survey, Bosnia and Herzegovina (BIH), Croatia and the Former Yugoslav Republic of Macedonia (FYROM) Frequence de I'etat de stress post-traumatique et de la depression parmi les 1 801 malades psychiatriques hospitalises de I'enquete du 18 octobre 1994, en BosnieHerzegovine, en Croatie et dans I'ex-Republique yougoslave de Macedoine Depression + PTSD by country - Depression et etat de stress post-traumatique par pays 18~------------------------------.
20-.-----------------------------, 18 '" Cl 16 '" 14 c
~ 10
'" 13 o
16
12
'" 1S c: 8:
e
8 6
4 2
o BIH [] Croatia FYROM 2
Displaced persons - Personnes deplacees Refugees - Retugies
o BIH Croatia FYROM
II
o •
PTSO - Etat de stresst post-traumatique Depression - Depression
Source: Based on data from the WHO Mental Health Unit, Zagreb (The 18 October Survey). - D'apres des donnees fournies par I'unite OMS de Sante mentale, Zagreb (Enquete du 18 octobre).
(i) intrusive phenomena related to the trau-
matic event (nightmares, flashbacks and intrusive thoughts - most often accompanied by anxiety); (ii) various forms of avoidance, detachment, memory loss and psychic numbing; and (iii) provocation of the symptoms when exposed to trauma-like or trauma-symbolic situations. Under war conditions, traumatic events involve frequent, repetitive impact of stress factors which are experienced by the victims in a context of threat, and of systematic and deliberate violation of fundamental human rights. The symptomatology of war trauma, therefore is more complex than the symptomatology seen in "single event traumas" in peacetime.
Source: Based on data from the WHO Mental Health Unit, Zagreb (The 18 October Survey). - D'apres des donnees fournies par I'unite OMS de Sante mentale, Zagreb (Enquete du 18 octobre).
of nearly 200 psychosocial projects which were in progress in Bosnia and Herzegovina and Croatia. This overview has created a comprehensive understanding of such interventions in future conflicts. In a recent evaluation study of the outcome (4), the efficacy of the psychosocial projects was strongly su bstan tiated.
The WHO Regional Model on Mental Health In 1994, the newly created WHO mental health unit, located in Sarajevo, developed the WHO Regional Model on Mental Health based on field observations and an intensive dialogue with local mental health professionals (5). On 10 October 1994, World Mental Health Day, the first regional model was inaugurated in Sarajevo. Since then, 6 additional regional models have been implemented in Bosnia and Herzegovina (Mostar, Tuzla, Bihac, Zenica/Travnik), Croatia (Split) and Montenegro (Kotor). A further 4 or 5 models are planned, to be implemented during the post-war phase, in 1996.
Psychosocial and mental health interventions under war conditions The massive media interest in reports of mass rape in 1992 provoked the international community to respond. Funds were made available for the support of rape victims. Due to the problems of identifying a sufficient number of raped women, most of the projects, in practice, turned into broad-spectrum psychosocial assistance to women and children. This is the first war where large scale psychosocial/mental health interventions took place as part of an emergency programme. In January 1995, Agger et al. (3) reported and analysed the content 214
What is the WHO Regional Madelon Mental Health? The WHO Regional Model on Mental Health is a coordinated set of mental health activities for a defined geographic area with a population of Rapp. trimest. statist. sanit. mond., 49 (1996)
300000 - 400000 inhabitants, including 4 essential elements.
WHO-chaired regular coordination meetings on psychosocial/mental health Participants are representatives from the inter-governmental organizations, the non-governmental organizations (NGOs) and national health organizations working in the psychosocial/mental health field within the region.
mary health care professionals. All courses have elements oftheoretical and practical training, case supervision and self care (i.e., "taking care of the caretakers"). As of June 1996 more than 200 psychologists/psychiatrists had participated in the one-year postgraduate PTT-programmes.
Promoting a community-oriented mental health approach The pre-war mental health system focused on a traditional, institutionalized approach. Due to the destruction of mental health facilities, the unequal distribution of mental health institutions caused by the new borders, and the "brain drain" of local professionals, favoured a shift towards the community-oriented approach. The war context offered an opportunity for change that was pro-actively supported by WHO. These key activities were further supported through distribution of medical supplies (in 1995 WHO distributed 373 mental hospital kits in the region), exchange visits, seminars and special mental health/ human rights activities.
A WHO regional coordination centre The WHO coordination centre's main activity is the assessment of the psycho-social/mental health needs and resources in the region through systematic field observations, updated overviews and monitoring of the situation. Focus is both on the war-traumatized population and the traditional target group of patients with mental illness and learning disabilities (Table 1, Fig. 2).c
Self-empowerment and capacity-building among professionals at all levels Systematic training oflocal professionals was established in different types of courses. Some targeted therapists (post-traumatic therapy, or PIT, courses), other counsellors, school teachers and pri-
Mental health and human rights The substantial increase in mental health problems is basically due to war-related traumatic reactions and the consequences hereof. These are primarily caused by violations of basic human rights. Widespread trauma must be seen as the reaction of normal people to a sick situation. The international community was able to offer protection for projects which addressed special mental health issues related to
C
The data in Tabk 1 and Figs. 1 & 2 are based on a survey of all in-patients carried out in 14 institutions in Bosnia and Herzegovina, Croatia and the Former Yugoslav Republic of Macedonia on 18 October 1994.
Table 1 Distribution of main psychiatric diagnosis among 1 801 psychiatric patients in the 18 October survey Tableau 1 Repartition des principaux diagnostics psychiatriques chez les 1 801 malades psychiatriques dans I'enquete du 18 octobre Bosnia-Herzegovina Bosnie-Herzegovine Croatia - Croatie Former Yugoslav Republic of Macedonia Ex-Republique yougoslave de Macedoine
Schizophrenia - Schizophrenie Depression - Depression Dementia - Demence Other psychotics Autres troubles psychotiques Borderline - Cas limites Psychopathy - Psychopathie Neurosis - Nevrose Suicide attempts - Tentatives de suicide Other non-psychotic disorders Autres troubles non psychotiques Post-traumatic stress disorderEtat de stress post-traumatique Substance abuse - Abus des drogues Mentally retarded - Arrieration mentale
47% 3% 1% 9% 0% 0% 17% 0% 5% 14% 2% 2%
36% 13% 1% 20% 1% 1% 2% 1% 1% 3% 14% 6%
46% 7% 1% 11% 0% 0% 1% 0% 1% 0% 23% 10%
Source: Data from the WHD Mental Health Unit, Zagreb, The 18 October Survey. - Donnees de I'unite de Sante mentale de I'OMS, Zagreb: enquete du 18 octobre 1994.
Wid hlth statist. quart., 49 (1996)
215
human rights violations. Examples are the problems offamilies of the "disappeared" and killed (6), the sexually violated (7) and mixed marriages (8).
Resume Sante mentale en temps de guerre au cours de la guerre en ex-Yougoslavie, 1991-1995 Si cette guerre avait ete une «catastrophe en temps de paix», on estime a plus d'un million Ie nombre de personnes qui auraient besoin d'une assistance pour des problemes de sante mentale. Toutefois, la capacite d'aide estimee ne peut couvrir qu'une petite proportion des besoins. Ce desequilibre risque de menacer gravement, a moyen et a long terme, la sante menta Ie d'une population dechiree par la guerre. Les complications liees a I'etat de stress provoque par les traumatismes de guerre risquent d'accroitre sensiblement I'abus d'alcool et de drogues, la violence domestique et criminelle, Ie suicide, les homicides et les maladies mentales chroniques. Le present article decrit les efforts deployes au niveau international pour inclure les interventions psychosociales et de sante mentale dans Ie cadre du programme d'aide d'urgence. L'accent est plus particulierement mis sur I'elaboration du nouveau modele regional de I'OMS concernant la sante mentale. Ce modele est un ensemble coordonne d'activites de sante mentale prevu pour une zone geographique definie comptant une population de 300 000 a 400 000 habitants. Les elements cles en sont: la coordination, Ie recueil de donnees de base (<<epidemiologie de la guerre»), Ie renforcement des capacites et I'autonomisation des professionnels locaux a tous les niveaux, ainsi qu'une approche des soins de sante mentale et des soins de sante primaires axes sur la communaute.
How should the aid provided in an international mental health emergency end? Since this is the first war where large scale psychosocial/mental health assistance was introduced as part of an international emergency response, we may conclude by asking the question, "How should such an intervention end?" The essential problem is that the mental health consequences of war trauma are expected to continue for many years after the war. There is a need for continued and sustainable activities to prevent a health disaster rooted in the complications of war trauma. The European University Centre for Mental Health and Human Rights (EUC-MHR) (9) is proposed as a new structure to document the past ("What did really happen during the war?") and to monitor the future mental health consequences with the aim of developing comprehensive preventive strategies. Besides documentation, EUC-MHR can continue undergraduate and postgraduate training and can explore the transferability of the lessons learned from the 1991-1995 war in the former Yugoslavia as a form of disaster-preparedness for future conflicts.
Summary If this war were a "peace time disaster" it is estimated that more than one million people would be in need of assistance due to mental health issues. The estimated helping capacity, however, can cover only a small proportion of the need. This imbalance may create a severe threat to the mental health of the war-torn population in a medium- and long-term perspective. Complications related to war-trauma-induced stress disorders may give rise to significant increases in alcohol and drug abuse, domestic and criminal violence, suicides, homicides and chronic mental illness. This article outlines the international efforts to include psychosocial and mental health interventions as part of the emergency assistance programme. Special emphasis is directed at the development of the new WHO Regional Model on Mental Health. The model is a coordinated set of mental health activities for a defined geographical area with a population of 300 000 400 000 inhabitants. The key elements are: coordination, collection of background data ("war-time epidemiology"), capacity building and self-empowerment of local professionals at all levels, as well as a communityoriented approach to mental health care and primary health care. A new structure to achieve sustainability and continuity of preventive mental health interventions, the European University Centre for Mental Health and Human Rights, is proposed for the medium- and long-term perspective of assistance. 216
a assurer la durabilite et la continuite des interventions
II est propose de creer une nouvelle structure destinee
preventives de sante mentale, Ie Centre universitaire europeen pour la sante mentale et les droits de I'homme, dans la perspective d'une assistance a moyen et a long terme.
References - References 1. Jensen, S.B. Identification of intelVention and assessment strategies to improve mental health status under war conditions. The case example of former Yugoslavia. Health monitor, 11: 1-4, 1994. 2. WIlson, J.P. &: lindy, J. (Eds.) Countertransference in the treatment ofPTSD. New York, Guilford Press, 1994. 3. Agger, I., etal. Under war conditions: What defines a psychosocial project? In Agger, I., et aI. Theory and practice ofpsychosocial projects under war conditions in Croatia and BosniaHerzegovina. Zagreb, ECHOjECTF, 1995. 4. Agger, I. &: Mimica, J. ... To lose my dearest one. ECHO Psychosocial assistance to victims of war in Bosnia-Herzegovina and Croatia. An evaluation. Brussels, ECHOjECTF, 1996 (in press) . 5. Jensen, S.B. &: Wilson, J.P. The WHO Regional Model on Mental Health. A new approach to emergency assistance developed during the war in the countries of former Yugoslavia. Journal of stress medicine, January 1997.
Rapp. trimest. statist. sanit. mond., 49 (1996)
6. Agger, I. Be Jensen, S.B. Trauma and healing under state terrorism. London, Zed Books, 1996. 7. Jensen, S.B. Be Loncar, M. Sexually violated men. A pilot study from Croatia and Bosnia-Herzegovina. InJensen, S.B. Mental health interoentions under war conditions. Copenhagen, WHO, (in press).
8. Agger, I. (Ed.) Mixed marriages. Mamage and ethnicity in a context ofethnic cleansing. Brussels, ECHO/ECTF, (in press). 9. Jensen, S.B.Mental health and human rights: The European University Center for Mental Health and Human Rights. In Jensen, S.B. Mental health interoentions under war conditions, Copenhagen: WHO, (in press).
Wid hlth statist. quart., 49 (1996)
217