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The civilian situation

Treating civilians at the military hospital

Destroyed apartment complex, Sarajevo

By 2000, the guidelines had been relaxed. All patients were to be first assessed at the civilian clinic, but could be referred to our hospital if management -- emergency or elective -- was beyond their resources. Any minor emergency cases were to be sent back to the clinic, though what constituted "minor" was left to the discretion of the SFOR doctor.

In practice, even our more relaxed guidelines proved difficult to enforce. Patients would arrive at our gate with an illegible referral note (usually written in Latin), or with no note at all. Our young, non-medical sentries saw only a patient in distress, and would understandably want to help. By the time the diagnosis had been established, it was difficult to turn away patients who had been inappropriately referred. We saw 10-15 civilian emergency presentations a week, mainly after hours. Many did not fall within our strict criteria, but few were turned away.

In addition to this emergency service, civilians formed the bulk of the work of our specialty clinics. We accommodated up to three new referrals each day, plus patients returning for follow-up. We performed elective surgery, but could accept no more than three civilian patients at one time, and accepted no elective case where the postoperative hospitalisation was expected to exceed four days.

During the first six months of 2000, 66 of the 137 operations performed in our theatre were on civilians; 37 (56%) of these were elective cases (mainly hernia repairs, cholecystectomies, and minor plastic surgery). The extent of the elective services we provided was officially left to the judgement of the individual clinicians. Should we have used our "spare" capacity in this way? Should we have actively encouraged even greater use?

Potential benefits of a foreign military medical presence

Local doctors can receive training and military surgeons can perform operations which have been beyond the capacity of local surgeons -- This applies more in less developed countries. As medical services in Yugoslavia had been relatively advanced, there was little need for this type of work. The problem was more lack of resources than lack of expertise.

The opportunity to offer a program of shared continuing medical education -- The availability of medical journals and funds to attend conferences have been very limited in Bosnia since the war. We were thus surprised to find that this initiative was greeted with little enthusiasm. The reasons for this were unclear, but may have included local resentment at being perceived as requiring "education" by SFOR, or simply inappropriate subject material or difficulties in communication. There was also, at times, substantial tension in meetings of doctors from each of the three ethnic groups.

Equal treatment for all patients -- The civilian clinic in Sipovo was ostensibly open to patients of all ethnic backgrounds. However, many Muslims preferred to seek treatment in the Muslim-Croat Federation rather than in Serbian Sipovo, if this was within their means. Also, we were told that a complex system of social security meant the local clinic received less money for treating Muslims, who were funded by the Federation rather than the Republika Srpska. The Western medical ethic of treating all patients equally, even in a military context, is often not applied by local doctors in countries where peacekeepers are deployed. This bias can persist long after the conflict has ceased. A foreign medical presence has an obvious benefit to groups not adequately served by local doctors, and may encourage displaced people to return to the community.

In fact, there was little to suggest any ethnic bias in the doctors in our region. Deliberate ethnically motivated malpractice after a conflict can be difficult for peacekeepers to detect. The presence of a military hospital may allow identification and even prevention of such malpractice.

During our prolonged deployment, we destroyed our drugs and consumables when they were out of date, even though the civilian clinic could have made excellent use of them. The ethics of supplying expired medical supplies in such situations have been discussed in recent literature.^3,4 There have been accusations that Western doctors are merely shifting the cost of destroying (often inappropriate) expired drugs to the recipient. Conversely, it is argued that drugs can be put to good use if properly selected. We felt we could not donate substandard supplies.

Potential benefits to the military hospital in aiding the civilian population

Opportunity to exercise skills and derive a sense of achievement -- Less cynically, military personnel usually genuinely want to help. Providing humanitarian assistance allows them to put skills into practice and fosters a justifiable sense of achievement.

Fostering goodwill and support among the local population -- There is also a benefit to the peacekeeping mission as a whole. The population is more likely to be supportive if they can see the peacekeepers as an indispensable force for good. This was the Australian experience at the Medical Support Force in Rwanda in 1994,⁵ in a situation where security was much more obviously threatened than during our time in Bosnia.

Potential disadvantages of a foreign military medical presence

There is a conflict between the clinical imperative to treat the presenting patient, and the public health imperative to think of the welfare of the society. The rejection by aid agencies of the offer by 300 ophthalmologists to travel to developing countries to undertake cataract surgery is a well documented example⁷ which parallels many of the issues we faced. This decision was based largely on the notion that international assistance should build countries' capacities to deal with their own problems, with the knowledge that aid money will eventually be diverted to more visible needy causes. It was accepted that this long term view would come at the expense of many individuals who would remain blind.

In addition to this central issue, there were a number of less obvious reasons why we did not encourage more direct humanitarian work. Bosnian society has not only undergone the trauma of war, but a dramatic change from a communist to a democratic system. A major theme of our programs was to encourage ordinary people to pressure their own government for improvement -- a foreign concept only 10 years ago. To provide free First World hospital treatment would have worked against this objective -- why should local people work for improved locally provided healthcare if they are given excellent foreign health facilities with minimal effort?

Creation of a vacuum of resources and skills -- One principal SFOR objective is to ensure there is no "vacuum" left when NATO departs. The Bosnian government is unlikely to have the resources to provide a surgical hospital in Sipovo, so, short of seeing no civilians, we can not achieve this objective. Further, the Bosnian government may not allocate appropriate healthcare resources to the region while our hospital is present. We may also be creating a vacuum in skills when we leave, as there has been an understandable tendency for local doctors to refer patients with more complex problems to our hospital. Over time this must reduce the expertise of local healthcare personnel in managing these cases.

Questions of standard of care -- The ophthalmologists referred to earlier felt bound to offer the highest standard of treatment, while many of the aid agencies favoured cheaper alternatives which could be more universally applied. The implication that an inferior procedure was "good enough" for the target population invited criticism. However, in our case, running a large primary care and tertiary referral system to Western standards could have created long term problems, as "best practice" drugs may not be available after we leave. Should we have used different standards of care for Bosnian civilians and military patients?

The practice of rotating military part-time consultant doctors for short periods may be necessary, but can result in less than optimal care, as doctors are often not around to see delayed complications. Indeed, many humanitarian organisations avoid the use of volunteer doctors on brief tours in the belief that this can foster poor medical practice. Fortunately, we did not see military doctors delivering a different standard of practice to that at home -- perhaps we are becoming more skilled at working in such a setting.

Adverse effects on the status of local doctors -- Patients regarded our hospital as superior to any of their civilian facilities, even in specialty areas where this was plainly not the case. As highly educated members of their community, many local doctors hold positions of significant power, both formally and informally. There is the risk that if their medical services are superseded by our First World facilities, their influence in the community could diminish, destabilising the somewhat fragile order which has been re-established since the end of the war. In more tangible terms, the incomes of local practitioners may be eroded if our presence renders their services redundant. Antagonising community leaders in this way is not sound strategy for a foreign peacekeeping force. This is why, in all but emergency cases, we only saw patients if they had a referral note from their local doctor.

Potential for abuse of the system by local doctors -- There is a risk such a referral system may be abused. It would be easy to simply scribble an unintelligible note and charge the patient the full fee while taking only a brief history and no responsibility. Local doctors could also abuse this role by charging an exorbitant fee for giving access to the elective surgical resources of the military hospital. Fortunately, we had no evidence that this was occurring in Sipovo.

Unrealistic expectations -- The presence of a foreign military hospital may raise the expectations of a poor community to an impossibly high level. Disappointment may result for many reasons -- lack of resources, lack of appropriately trained doctors, or simply an impossible clinical problem. Local populations often do not appreciate that a military hospital is equipped only for conditions likely to affect young, fit soldiers, and that many chronic health problems of civilians will be outside the expertise of military staff. When combined with a lack of knowledge of local medical practices and resources, and the difficulty of follow-up for civilians living far from the hospital, the standard of care delivered may be inferior to that available locally.

Impossibly high expectations can also have medicolegal consequences. Refugees treated for war wounds immediately after a conflict are unlikely to want to sue the treating doctor. However, five years after the conflict, a civilian who perceives he is the victim of a doctor's poor judgement may rightly contemplate seeking compensation. Should a patient be eligible for the same award of financial damages as a patient treated in the surgeon's home country? Or is the expected standard of care different?

Inadvertent attraction of skilled locals into unskilled employment -- This was a definite negative effect of our presence in Sipovo. We employed tradesmen and cleaners from the local population. Our cleaners were paid around 600 deutschmarks (A$500) per month. Some would criticise this as exploitation of cheap labour, but a doctor in the local clinic earned only 500 deutschmarks, and a teacher much less. Inevitably, we removed many educated Bosnians from jobs essential to their society's reconstruction.

Obstacles in aiding the civilian population

Persistent antagonism between patients from different sides of the former conflict -- Fortunately, this was not a problem in our hospital, as we were in a predominantly Serbian area and much of the animosity caused by the war had diminished. One could imagine former combatants accommodated in adjacent beds might add to the list of problems usually encountered by ward staff.

Limits to the number of civilians able to be treated -- It is tempting to forget the real reason for the spare capacity in a hospital such as ours -- to be able to cope with a sudden large influx of military casualties. It is most important not to fill a ward with elective civilian surgical patients who can not be discharged rapidly if necessary.

Conclusions

Acknowledgements

References

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3. Berckmans P, Dawans V, Schmets G, et al. Inappropriate drug-donation practices in Bosnia and Herzegovina, 1992 to 1996. N Engl J Med 1997; 337: 1842-1845.
4. Hoehn JB. Inappropriate drug-donation practices in Bosnia and Herzegovina [letter]. N Engl J Med 1998; 338:1472-1473; discussion 1473-1474.
5. Ramsey W, Bridgford LR, Lusby RJ, Pearn JH. The Australian medical support force in Rwanda. Med J Aust 1995; 163: 646-651.
6. Bower H. Divided health is a minefield for Bosnia-Herzegovina [news]. Lancet 1997; 350: 1011.
7. Gray BH. World blindness and the medical profession: conflicting medical cultures and the ethical dilemmas of helping. Milbank Q 1992; 70: 535-556.
8. Plan of action for humanitarian health assistance and public health action in response to the crisis in Timor. Geneva: World Health Organisation, 2000.

Authors' details

Reprints: Dr M C Reade, Clinical Research Fellow, Nuffield Department of Anaesthetics, University of Oxford, Radcliffe Infirmary, OX2 6HE, England.
michael.readeATbrasenose.oxford.ac.uk

©MJA 2000
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