Waging peace: A medical military mission to Bosnia- Herzegovina

ABOUT THE AUTHORS Dr. Stanley L. Minken, Col (right in photo), is Professor and Chief of the Division of Academic Surgery at the Uniform Services University of Health Sciences (USUHS) in Bethesda, Maryland. He was accompanied on the mission by Dr. Richard Colgan, LTC (second from right), Associate Professor and Director of Undergraduate Education in the Department of Family and Community Medicine, and Dr. Robert A. Barish (second from left), Vice Dean for Clinical Affairs and Professor of Emergency Medicine, both of whom teach at the University of Maryland School of Medicine in Baltimore; Dr. James Doyle, LTC (left), of the Primary Care Clinic at the VA Maryland Health Care System in Baltimore; and Dr. P. Randy Brown, Col, Commander of the 175th Medical Group of the Maryland Air National Guard, who led this mission. Dr. David R. Welling, Col USAF MC (Ret), Associate Professor of Surgery and Anatomy at USUHS in Bethesda, contributed the weight of his decades of experience with humanitarian military medical missions to this paper.

More than 17 years following a brutal 3-year civil war in Bosnia-Herzegovina, many citizens remain without even rudimentary health care. In 2006, the US government, the Maryland Air National Guard, and the Maryland Defense Force dispatched a team of medical professionals and military personnel to the region with two goals in mind: supply much-needed medical care and engender goodwill among the Bosnian people toward the United States. The authors describe their experiences in Bosnia and offer their insights on how to plan a successful humanitarian mission.

At a Pentagon news conference in September 2005, Marine Corps Major General Timothy Ghormley described military humanitarian missions as "waging peace." The National Military Strategic Plan for the war on terrorism describes humanitarian assistance as a key component in countering ideological support for terrorism. To this end, the US military initiates humanitarian projects in more than 100 countries each year.

In 2006, the 175th Wing of the Maryland Air National Guard, the 10MEDRGT of the Maryland Defense Force, and personnel from the Uniformed Services University of the Health Sciences and the Maryland Army National Guard undertook a medical humanitarian mission to Bosnia. This mission took 2 years to coordinate, and several parties were involved, including the Air National Guard; the US Air Forces in Europe (USAFE); the US Department of State; the US ambassador to Bosnia-Herzegovina; Bosnian government officials; and the Maryland Defense Force, a state militia under the command of Maryland's governor.

A 3-year civil war had wreaked incalculable devastation in the Balkans [see sidebar below], especially in Bosnia, between 1992 and 1995. Since the war's conclusion, the international community has focused on how to address the many needs of the Bosnian people. One of the Bosnians' most ongoing and pressing needs has been medical care. Bosnia suffers from a widespread lack of basic health services and a shortage of trained medical personnel. Various aid programs, both local and international, work hard to alleviate these medical hardships, but the combination of inadequate infrastructure and a beleaguered public transportation system has hindered their ability to provide Bosnians with adequate medical care. This is particularly true for those who live in rural communities.

We had humanitarian and political reasons for offering medical care to some of Bosnia's most deprived citizens. Chief among these were our desire to assure the Bosnian people that the United States remained vitally concerned about their welfare and our commitment to seeing a progressive return to regional stability and peace.

OUR MISSION

Unlike projects that provide engineering aid, such as building a bridge or digging a well, medical humanitarian projects often fail to leave residents with the sense that they have received something of lasting value. Treating medical conditions generally requires a continuum of care that includes follow-up visits or referrals for more advanced therapy. A short-term mission's inability to offer the full gamut of care can foster mistrust or a lack of confidence among the served population and ultimately result in failure of the project's intent, which is to inspire good will in the community for the sponsoring organization.

We recognized the value of providing continued care and explored options for making a series of visits, but it soon became evident that the geographic breadth of the problem and limited local resources would be prohibitive. Indeed, many potential patients were too infirm or lacked the means to transport themselves to centralized facilities for ongoing care. We eventually determined that we would be unable to establish an ongoing treatment program in Bosnia and therefore needed to plan carefully to extract maximum benefit from a short-term mission.

The medical teams

Our mission lasted 30 days (all of July 2006) and consisted of two teams. Each team operated 14 daylong clinics over a 2-week period. The teams were headquartered at an American military base outside of Tuzla, and members rode in a convoy of vans to the clinic sites each day. Combined, the teams comprised 7 physicians from the United States, including a surgeon, internist, family physician, emergency physician, and an infectious disease specialist; 4 dentists; 4 dental technicians; 2 optometrists; 2 optometry technicians; 2 physician assistants; 6 technical assistants, which included pharmacy, clerical, and laboratory staff; 8 nurses; 16 nursing assistants; 3 supply staff; and 34 armed security and command structure personnel. Three Bosnian military physicians of differing ethnic origins were attached to the unit. This proved beneficial to all parties, with former enemies forging positive relationships with one another and the US medical team offering practical medical education in the field. The presence of the Bosnian physicians also helped instill trust among the Bosnian patients served by our mission and eased some of the many difficulties that often arise from language barriers.

The clinics

We wanted to ensure that our services were available to every faction of the population, including Muslims, Orthodox Christians, Croatians, Serbians, and Romas. To this end, each location was carefully selected. The makeshift clinics operated out of small schools or community buildings, but occasionally we had to improvise and set up in a field or forest clearing. We had initial concerns about the possibility of anti-American demonstrations, and every proposed site was assessed for risk. Clinic sites were also evaluated for possible external threats, structural problems, and environmental hazards. Another challenge we faced was circumventing the approximately 3 million landmines located within a 150,000-square-mile area of Bosnia.

The Bosnian government supplied local translators, and each clinic had a central registration area manned by at least one Bosnian interpreter and an American staff member. Patients were triaged at central registration and directed to the appropriate medical service area. Separate areas were established for optometry and dentistry. One area was designated as the "pharmacy," and this was stocked with a large supply of common medications. Another was the "laboratory," where we performed routine blood and chemistry tests. We located the pharmacy and laboratory as centrally as possible, knowing that they would experience the heaviest traffic. Limited space required us to group physician sites together, but the "surgical area"?consisting of a folding standard table?was placed at a distance from the central area of the clinic for hygienic reasons. Pressed for room, we created improvised waiting areas that were adjacent to each work station.

Each patient was registered, and his or her medical complaints were documented carefully. Certain personnel were designated as runners, and they accompanied patients as they were referred from site to site and tracked each patient's progress. Every patient was assigned an interpreter to translate inquiries and responses concerning medical history and relay findings. The interpreter also explained care rendered, possible expectations, and follow-up instructions. For those patients whose medical problems required additional or sustained treatment, interpreters relayed our recommendation that they pursue such care, although we knew most would be unable to do so.

Multiple medications were distributed freely at each clinic. These primary consisted of diuretics and antihypertensives, pulmonary decongestants, antibiotics, and topical skin medications. All patients were offered vitamins, skin creams, and over-the-counter medications for simple conditions. Patients were also furnished with handouts describing their medical conditions and how to care for themselves more effectively.

"Many patients came to us with infected toenails or necrotic toes."

Our patients

The majority of clinic visitors received treatment for typical primary care problems. These conditions were often more severe than commonly seen in American patients due to Bosnia's overall lack of available heath care and inadequate ongoing treatment. Several patients suffered from untreated advanced hypertension, diabetes and its attendant complications, respiratory ailments, and skin disorders. We were surprised at the numerous cases of untreated coronary artery disease we identified among the rather small patient population. While the vast majority of Bosnian patients lacked routine access to medical care, some had been receiving regular treatment from members of a nongovernmental support organization (NGO) whose staff made infrequent visits to the areas we served. A handful of patients lived within reasonable proximity to a larger city and were receiving appropriate, routine care from a local clinic.

Most of our patients were elderly and, as one might expect, many screened positive for multiple chronic problems, such as hypertension, heart rhythm disturbances, diabetes, and generalized arteriosclerosis. We started these patients on medical treatment, explained the severity of their conditions to them, and advised them to seek ongoing care.

Just as we had anticipated, children arrived at the clinics in large numbers, reinforcing the importance of being prepared to handle a multitude of pediatric problems.

Fortunately for the children, their problems were rarely serious and consisted primarily of common childhood afflictions, including ear infections and skin conditions. We did, however, encounter some patients with chronic childhood problems that were beyond the scope of our program. Most of these involved orthopedic conditions, such as scoliosis and bone deformities.

The future looks bleak for the thousands of Bosnian women widowed during the war; most are illiterate or suffer from psychological disorders related to stress.

Vision disturbances were the most frequent complaint. Fundo-scopic examinations and refractions were the two procedures performed most often, and we distributed over 2,000 pairs of glasses that the Lions Club had generously provided. Dental problems were the second most common concern, and many patients?young and old? had multiple teeth that required extraction. We extracted approximately 800 teeth from 680 mouths. Most dental work was performed as the patients sat upright in straight-backed chairs and personnel held lights up to their mouths. Clinic visitors had universally poor oral hygiene, and we offered everyone toothbrushes and various dental products, along with instructions in their native languages on how to perform daily, prophylactic dental care. Ear problems, such as impacted wax and external otitis, were also prevalent, and patients appeared greatly relieved when the issue could be resolved with simple irrigation or wax extraction.

The surgical condition we encountered most often was infected ingrown toenails, which were often bilateral. The toenails were excised in standard fashion, after which the patient's throbbing pain would rapidly diminish. We repaired a few acute lacerations, drained minor abscesses from various body parts, and remedied small but troublesome afflictions, such as painful plantar warts and wound infections, most of which were easy to treat. We could not address complex surgical problems because of our limited resources and the lack of available follow-up care. While single gangrenous digits could be amputated, we turned away a handful of patients who came to us with multiple necrotic toes. We also turned away patients with severely ischemic limbs or feet and one man with diabetes whose foot was terminally gangrenous.

Other patients we were unable to treat included those with multiple nevi that were highly suggestive of melanoma; women with suspicious breast lumps; and patients with sizeable tumors, including one individual who had a scalp tumor so large that its removal would have necessitated performing a skin graft. Through interpreters, doctors explained the severity of these patients' conditions to them and urged them to seek care at a hospital. The inability to help these patients constituted one of the greatest disappointments of our visit, to patients and providers alike. Many patients lacked the financial resources or a means of transport to one of Bosnia's few adequate medical facilities, all of which were several hours' drive away, and we knew they would never receive care for these potentially mortal conditions.

The Bosnians we treated and even those whom we could not help almost universally expressed their appreciation that America had not forgotten them. While it would have been simpler to send money, it was much more meaningful to them that our government sent human beings.

HUMANITARIAN MISSIONS

Humanitarian missions are designed to alleviate the appalling consequences and suffering that follow wars, natural or technological disasters, and extraordinary occurrences, such as prolonged famine or widespread disease. These situations cause colossal devastation and pain, both physical and psychological, that can take years to alleviate.

The aftermath of a crisis

Aside from the affected population's immediate medical needs, far-reaching health problems may arise, such as emerging diseases or the effects of nutritional deprivation, which are exacerbated by insufficient treatment options. If infrastructure has been destroyed, it hinders the government's ability to implement reconstruction projects and consequently hampers the populace's ability to recover. This can instill fear and insecurity within a community or even in the population of an entire country.

The cumulative effect is a steady population decline and a measurable shift in demographics as those who are able to leave do so, leaving behind individuals who have the poorest health and the fewest resources. Eventually, the region's infrastructure decays completely and institutions vital to the area's support and recovery collapse. These institutions generally encompass medical care, education, and security, and their disintegration leads to a further exodus. This massive destabilization erodes the public's confidence in the government's ability to restore normalcy and, in the worst cases, creates an unstable political situation ripe for chaos or armed conflict, such as civil war or revolution. The desire to avert a negative progression of events following a large-scale disaster is usually the catalyst for a wellspring of humanitarian programs that originate from outside the affected area. Religious groups or NGOs are generally the first to jump in, but governments are becoming increasingly involved in supplying disaster relief, whether it is through funding specific aid agencies or establishing military programs.

The US government and disaster relief

The US government has long recognized the importance of offering assistance to countries in need and has distributed vast quantities of expertise and goods for medical, engineering, construction, security, and nutritional support worldwide. Unfortunately, a number of US governmental and military medical humanitarian programs failed in their effort to leave a lasting positive impact on the served population. This was especially true of programs undertaken during an ongoing conflict, such as the Civil Operations and Rural Development Support Program, which was implemented during the Vietnam War. It was designed to win over the South Vietnamese people and was operated by the US Agency for International Development in conjunction with the Central Intelligence Agency.

Other US military aid projects have achieved remarkable success, particularly those initiated during peacetime with the cooperation of the host government. Examples include the US Southern Command (USSOUTHCOM) Army projects in Honduras and El Salvador. USSOUTHCOM reported that in 2007 it completed more than 100 humanitarian projects spanning 26 nations.

In any given year, national and regional organizations in the US military undertake numerous missions at home and abroad. These missions are designed to reduce the impact of a disaster or conflict on the affected communities, their economies, and the environment.

Defining the mission

Every mission's paramount concerns must be meeting the needs of those being assisted and satisfying the mission's goals, which should be defined early on in the planning process and disseminated to all personnel. How to accomplish these objectives simultaneously should be studied thoroughly to ensure that adequate resources and personnel are secured. It is easy to underestimate the quantity of supplies and manpower necessary to treat medical problems that are not considered severe but are, nonetheless, debilitating and troublesome.

A humanitarian medical mission generally falls under one of three categories: multiple clinic sites for single visits, which offer little or no follow-up care; semi-permanent or permanent general health programs with centralized headquarters, which dispatch mobile field units to offer a range of services and some continuity of care; and focused projects of limited duration, which are usually located centrally and aim to satisfy one objective, such as instituting a program to eradicate a specific disease or address a specific surgical need (ie, cleft palate repair or cataract removal).

If it will not be possible for the program to provide sustained care, as was the case with our mission, the team should be equipped with a configuration of personnel and materials capable of addressing the populace's most basic medical needs. Dental and ophthalmologic problems are common in underserved populations, and treating these should be a priority. Planners should consider arranging for provisions of eyeglasses and oral hygiene products. Other medical concerns the team will likely encounter in high volume include foot ailments, skin lesions, and ear and nasal problems. The team must include individuals skilled in treating these types of conditions.

The mission should investigate whether there are any health problems endemic to the area or in the prospective patient population. Make sure appropriate medications and vaccines will be available, particularly for the vast number of children likely to show up at the clinics. If the underserved population consists primarily of elderly patients, expect to encounter a host of chronic diseases. While acute problems may be addressed at the clinics, the mission's lack of continuity may limit the overall care it can?or should?supply.

It is vitally important to realize that although team members are providing a valuable service, they are still guests in the host country. All participants must remain cognizant and respectful of the customs and culture of the native population. Any local collaborators should be credited for their role in coordinating care. Most importantly, the wellbeing of the community receiving assistance should show notable signs of improvement once the program has concluded.

MISSION ACCOMPLISHED

Although we treated many patients whose problems were readily addressed, a vast number received diagnoses for chronic conditions, including advanced hypertension, diabetes, and arteriosclerosis. We provided appropriate diagnostic testing and initiated medical care of these ailments, but these patients required ongoing care that we could not offer. This does not negate the value of alerting them to their health problems and beginning their treatment, but it highlights why the efforts of limited clinics like ours to sustain the populace's goodwill over the long-term can be frustrated.

We did witness several instances in which our mission provided care that was of immediate and sustainable value. Extracting severely diseased teeth, unblocking clogged ears, and draining abscesses offered the patients remarkable relief with no follow-up required. Patients who had long endured such unpleasant medical conditions were extremely grateful and appreciative for their treatment, as were those who benefitted from our optometry services. Individuals who were fitted with glasses?often for the first time in their lives?were overjoyed to find their vision instantly restored. For several patients, the experience proved life-changing.

While we would have liked to do more, and would still like to do more, we believe that our mission's primary goals, which were to improve the lives of those we treated and serve as US medical ambassadors to Bosnia, were satisfied.

Acknowledgement

The editors would like to express their appreciation to Dr. Richard Colgan for providing several of the images used in this article.

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the United States Government.

Civil war in the Balkans

In the early 1990s, war raged throughout the Balkans, and various regions of the Serbian-governed country of Yugoslavia broke off and declared independence. In February 1992, the Muslim-dominated government of the multi-ethnic Republic of Bosnia-Herzegovina declared its independence, as well. Ethnic Bosnian Serbs viewed an independent Bosnian state as a threat to their cultural security and rebelled, not only against the Muslim government but also against the Catholic Croatian population. To further complicate matters, various armed conflicts arose between the Muslims and the Croats.

Allied with neighboring Serbia, the Bosnian Serbs possessed overwhelmingly superior strength. The Serbian president, Slobodan Milosevic, supplied arms and fighters to aid Bosnia's Serbs in attacking major population centers and villages throughout the country. Serbian fighters waged a campaign of "ethnic cleansing" and massacred entire villages of Muslims and Croats. Thousands of Muslim and Croatian women were systematically raped. The Serbs destroyed homes and infrastructure. Millions of Muslim and Croatian families who had lived peaceably among their Serbian neighbors were driven from their homes to produce purely Serbian enclaves.

The United Nations (UN), the United States, and a host of other governments tried unsuccessfully to resolve the volatile situation. The Serbian army refused to allow delivery of humanitarian aid to displaced persons and defied attempts by the North Atlantic Treaty Organization (NATO) and the UN to intervene militarily. By mid-1994, the Muslims and Croats had tired of the war's demoralizing effects and agreed to a multinational peace plan for the country. The Serbs refused to recognize the plan and, despite NATO air strikes on Serbian strongholds and an embargo on general supplies, continued their devastating attacks. These included mass executions in small villages and major cities, particularly Sarajevo and Srebrenica. More than 7,800 Muslim men and boys were executed in the Srebrenica region, and mass graves continue to turn up.

Muslims and Croats formed an alliance, and by late 1995, they had regained control of slightly more than half of Bosnia. This convinced the Serbians to join in tripartite peace talks and sign the Dayton Peace Accords in December 1995, marking an official end to the war. The peace accords essentially partitioned Bosnia along ethnic lines, and these areas are still being patrolled by EUFOR, an international peacekeeping force from the European Union.

This brutal conflict produced 1.8 to 3.0 million displaced persons, and many have yet to return to Bosnia. The Serbian attempt to "cleanse" Bosnia of Muslims had a significant and lasting effect on much of Bosnia's rural populace. It has been projected that between 100,000 and 250,000 Bosnians died during the war, most of whom were Muslim. This has stalled redevelopment. In many areas basic services remain non-existent, including medical, educational, and civil facilities vital to maintaining quality of life. If peace is to be sustained, the international community must help Bosnians rebuild.

Q&A with Drs. Brown and Colgan

Dr. Brown commanded the 2006 military medical mission to Bosnian-Herzegovina, and this was Dr. Colgan's first time serving on an international humanitarian project.

Is it important for the military to organize these missions?

Very. We have a logistical ability that exceeds anyone else's. Also, these missions address the non-kinetic aspects of warfare. (Brown)

How do you prepare personnel for the mission?

I place huge emphasis on education and training, providing them with information on the area and its conditions, local cultures, endemic diseases, and disease prevention, such as vaccines. Education and training are mission-critical. (Brown)

Were the patients receptive?

They were all extremely grateful and appreciative, and you could tell they were excited that "the United States" was demonstrating that it cared. I don't think that, having met us, the people whom we treated will ever again view us according to negative stereotypes. (Colgan)

What were common medical conditions?

Common primary care issues included diabetes, hypertension, skin lesions, upper respiratory complaints, and coronary artery disease. (Colgan)

What was most difficult about the mission?

Convincing myself it was beneficial despite treating a low number of patients. Significant amounts of energy, time, and money were spent on far fewer patients than I had expected. Our real mission, however, was to serve as medical ambassadors for our country and show Bosnians that we cared. (Colgan)

What was most enjoyable?

The camaraderie among like-minded medical humanitarians and the adventure of serving with the military; working with the MDDF was my first military experience. (Colgan)

The reward for having done a job well, giving my troops a fantastic training experience, and knowing that, at least for a moment, we helped someone in need. (Brown)

Did anything surprise you?

I was surprised that while many Bosnians received world-class health care from their local doctors, others received none at all, such as the Romas, because they were not part of the "right" ethnicity. (Colgan)

Are limited clinics like this worthwhile?

That's a tough one to answer. They are for those who receive care, but [these programs] are extremely costly on a "per-head" basis. (Colgan)

The greatest impact is not from the medical care but from the lasting impression that we came because we cared. But we need to go back! And soon. (Brown)

What are the Bosnians' greatest needs?

Access to primary care. (Colgan)

To relearn to live together and to forgive and to have their infrastructure and economy rebuilt. There are also many widows in Bosnia, from middle-aged to elderly, with no "safety net" programs for them; their future is bleak as it stands now. (Brown)

What experience affected you the most?

A teenage girl saw me for a forgettable medical problem, but what I could not forget was that she walked 3 hours to school and 3 hours back each day. She and her family were humble, gracious, and dignified. (Colgan)

I have at least one every mission; usually it concerns a tough or tragic case, where we cannot help the patient or I have to make a Sophie's Choice. I commit to memory at least one experience to counterbalance those cases, and kids provide the most joyful memories. (Brown)

How can doctors help from a distance?

Doctors can raise supplies or funds for other missions. Consider participating in an exchange program where a surgeon from Bosnian [or any underdeveloped area] comes to the United States to learn alongside you. (Colgan)

Any plans to return?

Yes, I pushed for a civil engineering mission that will take place in the summer of 2008, and I am trying to arrange a medical mission to follow as soon as possible. (Brown)