41(2):124-140,2000

EDITORIAL

Medical Services of Croat People in and during 1992-1995 War: Losses, Adaptation, Organization, and Transformation

Ivan Bagariæ Ministry of Health of the Federation of , ; and of Medicine, Mostar, Bosnia and Herzegovina

During the 1992-1995 war in Bosnia and Herzegovina (BH), Croatian people in BH had 19,600 (2.6%) killed and 135,000 (17.6%) displaced persons, and 222,500 (28.9%) refugees. They lost around two thirds of both physi- cians and other health personnel, and were left with 8.5% of prewar patient beds. Fortunately, the organized de- fence against Serbs was initiated in time and defended the territories where they formed majority. The first defense unit established was the Medical Corps Headquarters (MCH), caring for soldiers and civilians alike. MCH was soon incorporated in the Croatian Defense Council (CDC, armed forces of Croatian people in BH). MCH had two chains of command. The first one went through the district commanders of medical services and their subordinated physicians to paramedics in military units, and the other one directly to the command- ers of 14 war hospitals. After its formation in 1993, the Ministry of Health took the jurisdiction over the civilian medical services and after the Washington Peace Agreement (April 1994) over the war hospitals, too, whereas the medical services within military units remained under control of the Ministry of Defense. Dayton Peace Agreement divided BH into the Federation of BH and Republic Srpska, each with their own army. The Federa- tion of BH Army is composed of the CDC and Bosniac-controlled Army of BH, with overall numerical ratio 1:2.3 for Bosniacs, and organized in accordance with NATO standards. Military medical services are provided by the Logistics Sector of both Ministry of Defense and Military Corps Headquarters (Joint Command).

Key words: armed forces personnel; Bosnia and Herzegovina; ; hospitals, military; military medicine; military personnel; military science; military veterinary service; soldiers; war

Contrary to the expectations (1,2), in the unique political and martial setting, its adaptation 1992-1995 war in Bosnia and Herzegovina (BH), the to wartime circumstances, and final integration into Croats managed to organize and defend themselves the BH Federation system. The establishment of the against powerful Yugoslav Federal Army (YFA). Their CDC Medical Services and the way they were orga- defense forces were formed under the name of the nized illustrate the quality, adaptability, and loyalty Croatian Defense Council (CDC). In the beginning, of the civilian medical services, from which all the the Medical Services were established in parallel wartime medical services were formed. with the CDC. Later they were incorporated in the CDC, but retained a great degree of independence. Organization of Military Medical Services After the war both were incorporated into the BH Army as an undivided peacetime military organiza- In many countries, military and civilian med- tion. ical services are separated. For example, USA has The aim of this article is to analyze the organi- a large system of health facilities (more than 300) zation of Medical Services within the CDC, espe- for war veterans (3-5), that operates under the De- cially with respect to its specificities imposed by partment of Veterans Affairs and answers mainly veterans’ service-related needs. The health care for the military is provided by the three separate Dr Ivan Bagariæ is the assistant to the Minister of Health of the Federation of Bosnia and Herzegovina (BH), in charge of health care medical service corps each within the corre- organization. As a physician and a member of the BH Parliament, he sponding military service – the Army, the Air organized medical service for the Croat population in BH, and became Force, and the Navy, with the medical service the first Head of the Medical Corps Headquarters of the Croatian De- fense Council in BH (1992-1996). During the war he achieved the corps of the Navy caring for the Marine Corps. The rank of Major General. military provides the continuum of medical care

124 www.vms.hr/cmj Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140 from the primary level health care units to the ter- civilian health care system (19). Similar, but in a tiary level health care hospitals. These facilities number of aspects also different, process took place support the military whether peacetime or war- in BH (29-35). time (6). Within systems (states, armies) where military In some other countries, military and civilian health care is separated from the civilian one, the health care services are integrated, and the number former follows hierarchical organization: from the of countries seriously considering such a type of first echelon where medical care is provided by a health care system organization is increasing (7,8). medical orderly in a platoon, to the echelon levels Israel is an example of the country with well- where the wounded are given subspecialized organized health service in which the civilian and health care (36,37). Basically, we accepted this military health services are integrated (9,10). The Is- scheme, but united civilian and military medical raeli medical professionals are prepared through ad- services (30-33). Echelon system was replaced by ditional education to work in war conditions (11). (an imposed!) positioning the war hospitals in the Former Yugoslavia followed the model of the war zones, often very close to the front line. Soviet Union (12,13) and had a large military health care (14). The Republic of Croatia, which suffered Setting great material damage in the 1991-1995 war (15-17), including the intentional destruction of the health Bosnia and Herzegovina care facilities (18-21), started developing its military Before the war, BH was one of the six repub- medical services with the beginning of the war lics of the former socialist Yugoslavia. It had a con- (18,19). First, the mobile surgical teams were orga- siderable degree of autonomy, which included the nized (22) and the civilian health care facilities ur- right to separation, and the population of 4.3 mil- gently adapted to the war circumstances (23-26). lion people (38). The BH population consisted of Then, the establishment of war hospitals followed three nations: (recognized as a nation in (27) and, in the end, Croatia had a well-organized former Yugoslavia; took the name Bosniacs after and efficient health care system (28). Today, Cro- the war) (43.4%), Serbs (31.2%), and Croats atian military medical services are integrated in the (17.4%), all three officially equal and constitutive

2 2 2 1 1 BIHAÆ BIHAÆ BANJA LUKA BRÈKO 3 3

TUZLA EPÆE 4 4 DRVAR 6 VAREŠ B.GRAHOVO 6 N. B.GRAHOVO 10 10 GLAMOÈ GLAMOÈ KUPRES SARAJEVO SARAJEVO 9 LIVNO 9 5 PROZOR 5 TOMISLAVGRAD 7 8 POSUŠJE POSUSJE 7 8 MOSTAR GRUDE MOSTAR Š. BRIJEG Š. BRIJEG ÈITLUK LJUBUŠKI ÈITLUK LJUBUŠKI STOLAC ÈAPLJINA ÈAPLJINA NEUM

125 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140

Table 1. The chronology of the most important events related to the Croat population in Bosnia and Herzegovina (BH) during the 1992-1995 war (adapted from ref. 41)

Date Event Comment

November 18, 1990 Multi-party elections Bosniac (Muslim), Serb, and Croat national parties formed the government according to the votes won at the elections. September 19, 1991 Yugoslav Army forces attacked the village As a part of the aggression against Republic of of Ravno Croatia (the offensive against ). November 17,1991 Announcement of the decision to establish Facing the threat of Serbian aggression against the the Croatian Community of Herzeg-Bosnia Republic of Croatia and BH, representatives of Croat nation in BH, elected on November 18, 1990, founded Croatian Community of Herzeg-Bosnia as a “political, cultural, economical, and geographical entity within the sovereign and democratic BH”. January, 25,1992 The Parliament of BH brought decision on Bosniacs and Croats won two-thirds and were able the referendum for sovereign and inde- to proclaim a sovereign and independent BH (in pendent BH respect to the former Yugoslavia). Serb representatives then left the Parliament and Serbs started the war. April 18, 1992 The decision to establish the Croatian De- Founded by Croatian Community of Herzeg-Bosnia, fense Council as “the supreme body of defense of Croats in BH and the highest executive and governing body of the Croatian Community of Herzeg-Bosnia”. October, 27,1992 Vance-Owen Plan on the draft of the con- An attempt to achieve peace by cantonization of BH. stitution and map of cantonization of BH Signed by Croats only. May 8/9, 1992 Fights between Croatian Defense Council The clashes started as soon as January 1992, due to and BH Army disagreements about the application of Vance-Owen plan and the arrival of thousands of displaced Bosniacs to the area liberated by CDC. June 23, 1993 Owen-Stoltenberg Plan and map on the Another attempt to achieve peace by cantonization organization of BH of BH. Immediately signed by Croats, rejected by Serbs, and reluctantly accepted by Bosniacs. August 28, 1993 Proclamation of the Croatian Republic of Formed with all governing attributes, as the Herzeg-Bosnia response to already proclaimed Republic Srpska and “Bosniac Assembly” in Sarajevo at which BH Muslims changed their name into “Bosniacs” (BH Croats felt that this reflected an intention to organize BH as a centralized state with Bosniac dominance). March 1, 1994 The Washington Peace Agreement on the It marked the lasting armistice between Bosniacs peaceful solution of the crisis in BH and Croats and laid grounds for foundation of (Bosniac-Croat) Federation of BH. November 21, 1995 The Dayton Peace Agreement Representatives of Bosniacs, Serbs, and Croats, with the assistance of international community, ended the war, and agreed on the organization of BH as a state consisting of two entities: Federation of BH (Bosniacs and Croats) and Republic Srpska (Serbs). The Federation was further divided into 10 cantons. May, 1997 All-Croatian Assembly in Neum Within the Dayton Peace Agreement, Croats were proclaimed Croatian Community of obliged to dissolve the Croatian Republic of Herzeg-Bosnia as a cultural association of Herzeg-Bosnia, but wanted to retain some form of Croats in BH cultural and economical unity.

(Fig. 1). Minorities and “” accounted for its independence early in 1992. This proclamation 7.9% of the population. elicited the aggression of Bosnian Serb paramilitary The war in BH started in April 1992, following forces and YFA, which tried to gain control over the the 1991 war, which YFA started against former Yu- BH by arms. In 1992, BH Croatian people and Mus- goslav Republics of Slovenia and Croatia. In both lims (Bosniacs) lost much of their territories and these conflicts, YFA in Slovenia, and YFA and Serb manpower, but managed to hold out. Having paramilitary forces in Croatia, were defeated. They learned from the war experience of the Republic of withdrew to BH (wherefrom they continued to at- Croatia during 1991, Croatian people in BH was tack Croatia), while Slovenia and Croatia became better prepared for the armed conflict and actually recognized as independent states. BH proclaimed led the defense. Thus, throughout the 1992, the de-

126 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140

Table 2. General data (No., %) on human suffering in Bosnia and Herzegovina during the 1992-1995 war Nations No. (%)a Killed and missingb Displacedb Refugeesb Total affectedb Bosniacs 1.898,963 (43.4) 138,800 (7.2) 602,000 (31.1) 640,000 (33.0) 1.380,800 (72.7) Serbs 1.365,093 (31.2) 89,300 (6.5) 350,000 (25.4) 330,000 (23.5) 769,300 (56.4) Croats 759,906 (17.4) 19,600 (2.6) 135,000 (17.6) 222,500 (28.9) 377,100 (49.6) Other 353,071 (8.0) 10,300 (2.9) 83,000 (23.1) 57,500 (16.0) 150,800 (42.7) Total 4.377,033 (100.0) 248,000 (5.8) 1.170,000 (26.7) 1.250,000 (28.6) 2.678,000 (61.2) aBefore the war (1991). bAccording to ref. 44. Percentages in brackets are with respect to the size of the entity. fense was predominantly organized and led by the Key Events CDC, while Bosniacs were either included in the Key events related to 1992-1995 war in BH are CDC forces or were fighting organized as Territorial listed in Table 1 (41). The official date of the com- Defense Forces. Rather complicated geographic dis- mencement of the war in BH is still a matter of contro- tribution and different interests of the three nations versy. In reality, the Serbian aggression against in BH gradually weakened the alliance between BH non-Serb nations in BH started on September 19, Croats and Bosniacs (Table 1). They fought together 1991, with the occupation and destruction of the against Bosnian Serb paramilitary forces and YFA Croat-populated Ravno village in southeast BH (32). until early 1993, but then, forced by Serbs to one However, since this attack was connected with the third of the BH territory, they began fighting against Serbian offensive against the Dubrovnik area in the each other. These fights lasted until early 1994. As Republic of Croatia (42), it is considered that the war this conflict begun, the CDC and Territorial Defense in BH really started early in 1992, when BH Serbs, Forces separated. The war in BH ended in 1995, backed by YFA, attacked other two nations after the with Dayton (USA) Peace Agreement. Two entities January referendum on BH independence (see Table were created, the Serb-controlled Republic Srpska 1). Croats and Bosniacs voted in favor of independ- (49% of the territory) and the Federation of BH (51% ence and Serbs voted against it. The BH Parliament of the territory) controlled by both Bosniac and Cro- brought the Declaration of Independence that was fol- atian people. The Federation was divided into 10 lowed by referendum. Since they lost in the Parlia- cantons, 5 with Bosniac and 3 with Croat people ment, Serb representatives left and Serb paramilitary majority, and 2 mixed. forces, backed by YFA, attacked Croatian people and During the war, except losing the major part of Bosniacs. The aggression spread over the country and , Croats successfully defended other areas the war continued for 4 years until the Dayton Peace in BH where they formed majority, whereas Agreement signed in USA on November 21, 1995 Bosniacs lost the entire eastern half of BH. During (41,43). The armed conflict between Bosniac forces the armed conflict between Croats and Bosniacs, and Croats (CDC) started as sporadic small group Croats lost some parts of the territory in central clashes, early in 1993. The clashes became more and Bosnia, where they ended up in enclaves encircled more frequent and grew to a large-scale conflict in by either Serb or Bosniac forces for a long period May 1993, which lasted until March 1, 1994, when (Fig. 1) (40). the Washington Peace Agreement was signed (41). It

Table 3. Self-management units of health carea in Bosnia and Herzegovina before the war (1991) and their fate in war No. of health professionalsb No. of patient bedsc Jurisdiction Location Per 1,000 after ward Total Physicians Total population Banja Luka 3,935 849 2,696 4.5 Serbs Bihaæ 1,429 286899 3.4 Bosniacs Bosanski Brod 117 27 — — Serbs 2,338 513 2,783 7.0 Serbs 192 49 13 0.3 Bosniacs Livno 43686338 4.1 Croats Mostar 2,313 472 1,352 4.2 Croats 1,307 302 616 2.4 Serbs Sarajevo 9,030 2,298 5,672 6.7 Bosniacs 468 103 242 4.2 Serbs Tuzla 5,524 1,305 3,349 3.4 Bosniacs 3,058 737 1,952 3.7 Bosniacs Total 30,147 7,027 19,912 4.5 aIn the communist Yugoslavia, health system was “self-managed”; the institutions were organized in units which did not correspond to ei- ther municipalities, districts, or institutions. b According to ref. 45. The data are as of 31 December 1991, except for Mostar and Livno (1990). cAccording to ref. 46. The data are for 1989. dAs a result of the war, but the division has persisted after the Dayton Peace Agreement in 1995.

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Table 4. Territorial distribution of hospitals and other health care institutions in parts of Bosnia and Herzegovina with Croat majority before the war, number of inhabitants for which they cared until the war, and hospitals to which they referred the patients Largest health No. of health Population under carec Town Referring hospital institutiona care workersb Total Croats Jajce MC 367 45,007 15,811 Jajce Bosanski Brod HCa 117 34,138 13,993 Doboj HC 29656,48921,951 Doboj OdMak HC 78 30,05616,338Doboj Orašje HC 7628,36721,308 Doboj Doboj Regional HC 1,255 102,549 13,264 Doboj Konjic HC 193 43,878 11,513 Mostar Tomislavgrad HC 87 30,009 25,976Livno Livno MC 274 40,600 29,324 Livno Èapljina HC 103 27,882 14,969 Mostar Èitluk HC 49 15,083 14,823 Mostar Grude HC 87 16,358 16,210 Mostar Jablanica HC 54 12,691 2,291 Mostar Široki Brijeg HC 68 27,160 26,884 Mostar Ljubuški HC 73 28,340 26,127 Mostar Mostar Regional MC 1,528 126,628 43,037 Mostar Neum HC 20 4,325 3,792 Mostar Posušje HC 70 17,134 16,963 Mostar Prozor (Rama) HC 56 19,760 12,259 Mostar Stolac HC 104 18,681 6,188 Mostar HC 170 16,296 6,623 Sarajevo Kiseljak HC 99 24,164 12,550 Sarajevo Kreševo HC 24 6,731 4,714 Sarajevo Vareš HC 111 22,203 9,016Sarajevo Sarajevo University MC 4,200 527,049 34,873 Sarajevo Bosanski Šamac HC 134 32,960 14,731 Brèko Brèko MC 513 87,627 22,252 Brèko Tuzla University MC 2,148 131,618 20,398 Tuzla Bugojno HC 163 46,889 16,031 Travnik Busovaèa HC 41 18,878 9,093 Travnik HC 160 55,950 16,556 Zenica Kupres HC 28 9,618 3,813 Travnik HC 100 30,713 12,162 Travnik Travnik MC 600 70,747 26,118 Travnik Vitez HC 71 27,859 12,675 Travnik Uskoplje (G. Vakuf) HC 59 57,164 10,706 Travnik Zenica Regional MC 1,490 145,517 22,510 Zenica Mepèe HC 59 22,966 9,100 Zenica Banja Luka University MC 2,318 195,692 29,026 Banja Luka aHealth Center (HC) – health care institution with outpatient specialist services. Medical Center (MC) – health care institution with specialist patient beds. bTotal number of the health workers in the town, dentists not included. According to refs. 45 and 47. Data are for 1991. cAccording to ref. 38. Data are for 1991. must be emphasized that BH survived due to the re- the grounds of these estimates only, the trend and sistance and survival of the Croatian people in the en- extent of the catastrophe are obvious. claves scattered through Central BH and Posavina (Fig. 1), which functioned as a connective tissue keep- ing the country from being taken apart. Health Care System War-Related Damages in Bosnia and Herzegovina

Losses Resources In 1991, at the time of dissipation of the former Losses during the 4-year war were huge on Yugoslavia (wars in Slovenia and Croatia had al- each side (Table 2). Since the exact data are not yet ready started), the health care services in BH were available due to the destruction of services, proto- still organized in a socialist manner specific for for- cols, and archives, Table 2 offers rough estimates mer Yugoslavia, i.e., there were self-management provided by Bosniacs, which have been the only units of health care and insurance. These units were estimates given so far (44). Nevertheless, even on financially independent, constituting thus centers

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Table 5. Regional distribution of physicians specialists in Bosnia and Herzegovina before the wara No. of physicians specialists Location Pathology, Neurology, Surgery Anesthe- Transfu- Gyneco- Other forensic psychiatry, Public Total siology siology logy surgical medicine physiatry health Banja Luka 66 17 6 66 38 2 72 19 286 Bihaæ 17 4 1 12 62 10 5 57 Doboj 23 4 5 19 21 1 31 12 118 Foèa 7 2 1 12 6– 7 5 40 Mostar 40 14 5 38 25 2 39 18 181 Sarajevo 148 51 9 100 127 12 188 88 723 Tuzla 70 18 7 74 50 1 4688 354 Zenica 49 10 5 41 28 1 3618 188 Total 420 120 39 362 301 21 429 253 1,945 aOnly specialties important for war-related medicine are presented. According to ref. 45. of power that determined the organization and way Table 5. During the war, almost all of these areas of financing of the area they covered (Table 3). came under heavy military attacks and/or siege. There were 4.5 patient beds per 1,000 inhabitants This caused migrations of the people and a corre- on average, but their distribution was relatively un- sponding the migration of health personnel (Table even (from 0.3 in Konjic to 7.0 in Doboj), with re- 6). Approximately two thirds of physicians and mote rural areas faring the worst (45). The distribu- other health professionals left their domicile insti- tion of physicians was just as uneven (Table 3). tutions during the war (Table 6). The consequence During 1992, Croatian people in BH and of this was that, for example, Croat population Bosniacs used the same health facilities, but with could receive medical specialist services only in the development of Croat-Bosniac conflict (early Mostar and, to a smaller extent, in Livno. Mostar 1993) only a small fraction of human and material was left with less than a half of its prewar person- resources remained under Croat control – a gen- nel, e.g., only one out of 14 pre-war anesthesiolo- eral hospital in Livno and less than a half of Mostar gists stayed in the hospital (Table 6). Some areas health care staff, which made about 8.5% of the to- listed in Table 6were lost in the war to either Serbs tal patient beds in BH (Table 3). Such a situation (Bosanski Brod, Jajce, Derventa, and Brèko) or continued after the war, with lasting political divi- Bosniacs (Jablanica, Bugojno, Kakanj, Zenica, and sion of the country and separate canton jurisdic- Konjic). In the case of Bosanski Šamac area, its big- tion. ger part was lost to Serb forces, but in a small zone that was successfully defended, “Domaljevac” Table 4 shows basic data on health care re- Health Center was established. The same was done sources in the areas with considerable proportion after losing Brèko – “Brèko Ravne” Health Center of Croatian people in the local population. When was formed in the defended part of the Brèko area. needed, people living in these areas were referred It should be emphasized that, in the beginning of to the nearest medical center. With the war devel- the war, Croat and Bosniac forces, as the CDC opments, only those with access to Mostar and forces, jointly defended the areas with Croat and Livno hospitals had the opportunity to receive sec- Bosniac majority. This explains why it was the CDC ondary medical care. that organized war hospitals in the locations listed Since the very beginning of the war (April in Table 5 at that phase of the war. During the 1992), Sarajevo, the capital of BH and the seat of 1993-1994 conflict with Bosniacs, Fojnica and central administration, had been cut off from the Vareš came under Bosniac control. After losing rest of the country, and the periphery was left with- Vareš, the CDC instituted a health center in the vil- out any material and financial supplies or guidance. lage of Daštansko, and did the same after losing Moreover, the martial developments brought a Fojnica, moving its medical services to a nearby vil- number of areas and groups of people (e.g., Croatian lage. When Travnik was lost to Bosniac forces, part people in , see Fig. 1) under military of its medical services moved to Nova Bila. Another siege, isolating them and preventing any help and example is the town of Kupres with its surround- assistance from their allies. For example, Mostar ings, which was lost to Serb forces early in 1992, stayed under Serb siege for six months in 1992 and, and regained in 1995. All these war events influ- until it was liberated by Croat and Bosniac forces enced the number of physicians who remained in united under CDC, its medical services were acces- those areas after the war, especially as the control sible to its inhabitants only. Also, at that time of the over the territories imposed in the war still persists. war, the assistance from international humanitarian Health personnel were also injured or killed at organizations was relatively small. their workplace (Table 7). Physicians There were three sources of assistance to Croat The prewar distribution of specialists in the medical personnel in BH (Table 8): volunteers from surgical fields of medicine, extremely important in the Republic of Croatia, volunteers from other coun- war situation, in different BH regions is shown in tries, and personnel of Croat nationality displaced

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Table 6. Number of physicians and other medical personnel Table 7. Casualties among the personnel of the Croatian in areas with Croat majority, before and after the war in Defense Council Military Medical Service during the Bosnia and Hercegovinaa 1992-1995 war in Bosnia and Herzegovinaa No. of personnel No. of casualties Health professionalsb Location Before war After war Wounded Killed Total Physicians Other Physicians Other Physicians (300-360) 13 3 16 Jajce 79 288 4 15 Nurses and technicians 97 16123 (1,000-1,200) Bosanski Brod 27 90 – –b b Ambulance drivers 85 19 104 Derventa 74 222 – – (280-300) OdMak 24 54 3 85 Tomislavgrad 17 70 16154 aData on casualties of soldiers educated to serve as paramedics are Livno 46151 not known because they were registered among soldier casualties. 56218 b Èapljina Numbers in brackets are estimates because a formal census of 25 7615 46 the health professionals was not done, and their number varied Èitluk 9408 42 during the war. Grude 19 68 11 61 Jablanica 14 40 – –c Ljubuški 1657 16 51 Mostar 312 1,216 243 685 Table 8. Assistance to medical personnel in the Croatian Neum 416614 Defense Council Military Medical Service during the Posušje 14 567 56 1992-1995 war in Bosnia and Herzegovina (BH)a Prozor 11 45 7 23 Origin of the personnel Physicians Nurses and Stolac 19 85 8 24 technicians Široki Brijeg 17 51 15 58 Volunteers from the 25 67 Fojnica 37 133 1 11d Republic of Croatia Kiseljak 27 72 25 83 Volunteers from other 623 Kreševo 618 4 25 foreign countries Vareš 2685 4 13 d Personnel from other parts 45 77 Brèko (”Ravne”) 141 372 10 40 of BH b Bosanski Šamac 39 95 1 5 a (Domaljevac) Only the personnel working permanently for the Corps; temporary volunteers (some of them coming and leaving several times) were Orašje 21 5629 73 not included. Bugojno 44 119 – –c Busovaèa 11 30 7 34 Kakanj 44 116 – –c Kupres 7212 7 1,000 physicians from Croatia came to assist their Novi Travnik 25 75 12 37 colleagues in BH for a shorter or longer period. They Travnik 137 463 18 74e mostly came as organized medical teams. Vitez 18 53 10 41 Loss of manpower in health care was not a Mepèe 14 45 8 68 characteristic of the areas with the Croat majority Zenica 358 1,132 – –c only. Major demographic changes within health Uskoplje 18 41 10 30 personnel occurred in all parts of BH (Table 9). Konjic 49 135 – –c Usora –– 3 15 Hospitals Total 1,759 5,773 549 2,021 Before the war, the BH medical institutions pro- viding secondary and tertiary medical care were aThe data are for the municipalities of the former Croatian Republic of Herzeg-Bosnia in Bosnia and Herzegovina, with Croat majority. The university hospitals, regional medical centers, and prewar data are according to ref. 45, as of 31 December 1991, except for local medical centers (Table 10). Primary care was Mostar and Livno (1990). The postwar data are according to ref. 48. provided by health centers in each municipality. Physicians include all physicians in the area. “Other” include dentists, pharmacists, and auxiliary medical personnel. The difference between medical centers and health bLost to Serbian control. In the case of Bosanski Šamac, the centers was that the former had specialists and pa- Health Center “Domaljevac” was established in the small area tient beds, whereas health centers offered outpa- that remained under our control (7,000 inhabitants). tient services only. The institutions listed in Table cLost to Bosniac control either by military force (e.g., Bugojno) or political division (e.g., Zenica). 10, which represent most of the country’s capaci- dCDC hospital was lost to Bosniac forces, and we were left with ties, had a total of 15,159 beds and 2,435 physicians. only one medical office located in a small village that remained As the only health institutions that remained under under the CDC control. eAfter Travnik was lost to Bosniac forces, the hospital in Nova Croat control, in Livno and Mostar, were in the Bila was reactivated. south of the country (Table 10), the Croats that ended up encircled in enclaves in central northern BH (Fig. 1) when the Croat-Bosniac armed conflict from other parts of BH to Croat-controlled territo- started in 1993, were left without secondary and ter- ries. The numbers given in Table 8 apply to person- tiary levels of health care. nel who were within the CDC Medical Corps from Damage or destruction of the medical institu- the start of the war until the Washington Peace tions caused further losses to the health care sys- Agreement (April 1994). Since then, within the pro- tem. In the areas with Croat majority, only 4 out of gram of humanitarian assistance, approximately 35 institutions did not suffer any damage (Table

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Table 9. Number of physicians in 10 cantons of Bosnia Table 10. University and regional health care institutions in and Herzegovina before (1991) and after the war (1995)a Bosnia and Herzegovina before the war, and their fate in the a No. of health care personnel war No. of Jurisdiction Pharma- Techni- Location No. of beds Year Physiciansb Dentists Total b cists cians physicians after war University Medical Centerc Canton 1: Unsko-Sanski Sarajevo 913 4,256Bosniacs 1991 377 (162) 86 33 1,248 1,744 Tuzla 317 1,519 Bosniacs 1995 168 (80) 23 14 797 1,002 Banja Luka 249 1,586Serbs Diff. -209 (-82) -63 -19 -451 -742 Regional Medical Centerd Canton 2: Posavski Bihaæ 93 825 Bosniacs 1991 35 (9) 11 4 104 154 Doboj 131 998 Serbs 1995 21 (10) 5 5 43 74 Mostar 145 914 Croats Diff. -14 (1) -6 1 -61 -80 Foèa 44 412 Serbs Canton 3: Tuzla- Zenica 158 1,047 Bosniacs 1991 799 (394) 115 90 2,304 3,308 Local Medical Centere 1995 688 (330) 60 50 2,083 2,881 Bosanska 22 245 Serbs Diff. -111 (-64) -55 -40 -221 -427 Gradiška Canton 4: Zenica-Doboj Jajce 22 170 Serbs Prijedor 60 452 Serbs 1991 632 (310) 130 73 1,703 2,538 Drvar 13 200 Serbs 1995 317 (192) 66 49 1,642 2,074 Derventa 19 408 Serbs Diff. -315 (-118) -64 -24 -61 -64 Livno 33 338 Croats Canton 5: GoraMde Trebinje 30 217 Serbs 1991 47 (24) 13 7 126193 32 296Serbs 1995 22 (3) 3 0 66 91 Brèko 54 488 Serbs Diff. -25 (-21) -10 -7 -60 -102 37 273 Serbs Canton 6: Central Bosnia Travnik 63 515 Bosniacs Total 2,435 15,159 1991 418 (212) 65 49 1,224 1,756 1995 224 (119) 33 16959 1,232 aData according to ref. 45, as of 30 December 1991, except for Diff. -194 (-93) -32 -33 -265 -524 Mostar and Livno (1990). Physicians and beds from primary health care (HC, special hospitals, rehabilitation centers) are not counted Canton 7: -Herzegovina in. 1991 443 (278) 100 78 1,477 2,098 bAs a result of the war, but the division has persisted after the 1995 Dayton Peace Agreement in 1995. 300 (159) 53 13 980 1,346 cLarge institutions with medical school teaching facilities and per- Diff. -143 (-119) -47 -65 -497 -752 sonnel. Canton 8: West Herzegovina dInstitutions with special hospital beds. eInstitutions with outpatient specialist services. 1991 66 (18) 33 1 198 298 1995 49 (24) 19 3 203 274 Diff. -17 (4) -14 2 5 -24 the beginning of the war; during the war, these ar- Canton 9: Sarajevo eas were lost and medical services were then orga- 1991 1,799 (1,299) 342 170 4,408 6,719 nized in the neighboring locations which were 1995 955 (639) 175 103 2,146 3,379 still under Croat control. After the war, these insti- Diff. -844 (-660) -167 -67 -2,262 -3,340 tutions became either health centers (Nova Bila, : Herzeg-Bosnia Daštansko, Ravne Brèko) or general hospitals (Ora- 1991 137 (54) 39 22 434 632 šje, which replaced the CDC Tolisa war hospital). 1995 65 (35) 12 2 236 315 The case of Usora is especially interesting: before Diff. -72 (-19) -27 -20 -198 -317 the war, this location did not have its own medical Total: Federation of Bosnia and Herzegovina service. During the war, it became the only 1991 4,753 (2,760) 934 527 13,226 19,440 Croat-controlled part of Tešanj and Tesliæ area, 1995 2,809 (1,591) 449 255 9,155 12,668 where the medical service was organized for the Diff. -1,944 (-1,169) -485 -272 -4,071 -6,772 needs of the local population under siege. These aPrewar data are from ref. 45, and post-war data from refs. 47 and institutions continued to work after the war. 48. The war caused considerable number of people bTotal number of physicians; number in brackets shows the number of specialists. to migrate (Table 11). The number of Croats de- creased 35.3% – from 784,176in 1991 (before the war) to 507,007 in 1996. However, this did not ease the burden the health care system had to carry be- 11). The extent of destruction varied, but 5 institu- cause the needs increased: large numbers of injured tions were destroyed to the ground. As described and psychically traumatized soldiers and civilians earlier, some of the institutions (Travnik, Mepèe, demanded organization of medical services in areas Orašje, Brèko, and Usora) were what remained of without adequate health care institutions (Table 12). the institutions organized and held by the CDC at These needs were met by the war hospitals – institu-

131 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140

Table 11. Health care institutions within the political territorial areas of Bosnia and Herzegovina under Croat jurisdiction; situation after the war (1996) Area (m2) and Population 1996b No. of Population Location Categorya percent (%) of (% difference physiciansc 1991d destructionb to 1991) Grude HC 2,010 (38) 11 16,358 19,635 (+20.3) Ljubuški HC 1,950 (24) 16 28,340 32,636 (+15.6) Posušje HC 1,000 (0) 7 17,134 19,183 (+11.9) Široki Brijeg HC 1,860 (0) 15 27,180 3,100 (+14.8) Èapljina HC 3,250 (14) 15 72,882 28,000 (-61.5) Èitluk HC 2,100 (0) 8 15,083 20,239 (+34.1) Mostar HC+UH 3,302 (99) 243 126,626 49,914 (-60.5) Neum HC 1,008 (69) 6 4,325 6,882 (+59.1) Rama HC 1,400 (71) 7 19,760 12,350 (-37.5) Stolac HC 2,000 (65) 8 18,681 10,000 (-46.4) Kreševo HC 432 (27) 4 6,731 6,426 (-4.5) Fojnica HC 250 (64) 1 16,298 2,500 (-84) Kiseljake HC 860 (19) 25 24,164 20,396 (-15.5) Busovaèa HC 550 (34) 7 18,897 11,081 (-41.3) Vitez HC 1,450 (32) 10 27,859 17,155 (-38.4) Novi Travnik HC 1,650 (26) 12 30,713 10,000 (-67.4) Travnike HC Nova Bilaf 700 (59) 18 6,000 Uskoplje HC 350 (100) 10 25,181 7,645 (-69.6) Jajce HC 1,900 (30) 4 45,007 12,810 (-71.5) Vareš HC Daštansko 250 (100) 4 22,203 2,500 (-88.7) Mepèee HC 1,100 (60) 8 22,066 20,000 (-9.3) B. Grahovo HC 1,850 (12) 1 8,311 500 (-93) Glamoè HC 2,400 (98) 1 12,593 3,000 (-76.1) Drvar HC 2,500 (29) – 17,1263,000 (-82.4) Kupres HC 1,450 (72) 2 9,618 3,813 (-60.3) Livno HC+GH 1,900 (13) 46 40,600 34,000 (-16.2) Tomislavgrad HC 2,300 (0) 1630,009 32,284 (+7.5) OdMak HC 2,500 (80) 3 30,056 4,000 (-86.6) Orašjee GH 1,660 (95) 29 28,376 24,082 (-15.1) Ravne Brèko HC 950 (37) 7 22,000 17,236(-21.6) Usoraf HC 600 (40) 3 – 11,400 Total 51,020 547 784,176507,007 (-35.3) aHC – Health Center (outpatient facilities only), GH – General Hospital, UH – University Hospital. bAccording to the official estimates of the Intercounty Institute for Public Health, Mostar 1997. cAccording to refs. 47 and 48. dAccording to ref. 38. eLocations of war hospitals, that were transformed into civilian institutions after the war. fDid not exist before the war, but were created during the war due to isolation of the area. tions established by the Medical Corps Headquar- those that went on in the CDC military part: from a ters of the CDC, which received the wounded from simple organization of the people by themselves, the most active battlefields. Various buildings of dif- followed by amateur forms of organization, and fi- ferent sizes and prewar functions were transformed nally to a relatively well organized army. into the war hospitals 14 in total (Table 13). They provided secondary and tertiary health care for the The Beginning military as well as for the civilian population (see Croat population in BH was the first to face the below). In the beginning of the war, and before the Serbian aggression in 1992. The data in Tables 2-11 conflict with Bosniacs, all these hospitals were orga- illustrate the (rather sudden) loss of resources, nized by the CDC and served local inhabitants and which was worsened by a lack of any experience or soldiers regardless of their nationality. During the education in war medicine. When the war broke conflict with Bosniacs, Jablanica, Bugojno, Fojnica, out, a group of physicians, who were all members of and Kostajnica (near Konjic) came completely un- the BH Parliament, too, started a systematic plan- der the Bosniac control, except for the Fojnica war ning of the concept of medical care for the oncom- hospital, which was transferred to Kiseljak. ing catastrophe. They used the war experience of the Croatian health care and were helped by the Organization of the Croatian Defense physicians from Croatia, mostly those who were of Council Medical Services BH origin. I was one of the physicians from the BH Parliament who initiated the establishment of the The development, adaptations, and transforma- Military Medical Headquarters, by the end of March tions of the CDC Medical Services corresponded to 1992, just before the open Serbian aggression. Ser-

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bian occupation and destruction of the Croat-popu- Table 12. Medical institutions and other buildings in areas lated Ravno village in the southeast of BH occurred with Croatian majority, transformed into war hospitals at the as early as September 1991, and it was obvious that beginning of the war in Bosnia and Herzegovina the aggression would spread over the whole country Previous function of the Beginning of Location in no time. building work We toured the areas populated by Croats, listed Tomislavgrad health centera 1992 all the health centers, and prompted their adapta- Livno medical centerb 1992 tion to the situations of emergency in which there Sturba anti-atom bomb 1992 would be a large number of the wounded. Strategic shelter Mostar new hospital under 1992 points for the war surgery units – future war hospi- construction and surgery tals – were determined. Health care institutions wardc were connected by a computer network and packet Grude tobacco repository 1992 radio connection (49), which soon proved ex- Neum “Sunce” Hotel 1992 tremely important since many of the war hospitals Jablanica health centerd 1992 became isolated and this technology was the only Rama floppy disc factory 1992 means of communication for a long time. War expe- Gornji Vakuf Franciscan rectory 1993 rience of the Republic of Croatia (where the war Jajce hospital 1992 started in May 1991) was kept in mind: the concept Bugojno “Kalin” Hoteld 1992 Kiseljak health center 1993 of Medical Corps Headquarters was adopted (19), but Fojnica rehabilitation centerd 1992 mobile surgical teams (22) were not organized in BH Nova Bila church 1992 because we had neither surgical clinics nor suffi- Busovaèa health center 1993 cient number of surgery specialists. Thus, we opted Mepèe primary school 1992 to use primary health care institutions with what- Bosanska Bijela primary school 1993 ever personnel they had. The Croatian model of Orašje Tolisa Franciscan rectory 1992 computer network, which helped Croats immensely Kostajnica private housed 1993 during the evacuation of the hospital in aHealth care institution with outpatient specialist services. November 1991 (49), was used in its entirety. Later bHealth care institution with specialist patient beds. it proved crucial for commanding and coordinating cNew hospital was under construction; “old” hospital was partly de- medical activities. Since there were no military for- stroyed at the beginning of war, and only the surgery ward was used. dEstablished by the CDC Medical Corps Headquarters, but lost in mations, we asked the heads of health institutions to subsequent war operations. be in charge of preparing municipal medical ser- vices for a war situation. This reflected the future structure and organization of the MCH, i.e., Munici- pal Medical Service Headquarters were established Table 13. War hospitals of the Croatian Defense Council on in each municipality where it was possible. Most territories with Croat majority in Bosnia and Herzegovina, with numbers of workersa, hospital bedsb, and inhabitantsc health institutions had already started building up for which they cared the reserves of drugs and medical material for future Location No. of No. of other No. of Population needs related to emergency situations. physici- health care beds under care These preparations were done in time. We rec- ans workers ognized the danger for Croat population to be left Tomislavgrad 10 5640 30,000 without any larger medical institution and with in- Livno 12 64 60 40,000 sufficient medical personnel in case of war. Our Rama 14 35 40 20,000 strong belief that the war was imminent stemmed Grude 7 30 15 30,000 from the political developments in the BH Parlia- Mostar 32 120 200 80,000 ment, and the knowledge about the tragic experi- Tolisa 11 30 35 30,000 Mepèe 8 18 40 25,000 ence of our colleagues from the Republic of Croatia Fojnica 9 35 60 35,000 in 1991 war (27,50-52) was precious to us. We Kiseljak 25 67 56 25,000 learned a lot from contacts with the health person- Bos. Bijela 5 18 30 20,000 nel who worked in the neighboring parts of Croatia Nova Bila 10 54 50 50,000 and with whom we had always cooperated since Bugojno 15 42 30 46,000 large areas of northern and southern BH relied on Jajce 10 32 40 45,000 the secondary and tertiary health care services in Uskoplje 10 30 10 27,000 Croatia in former Yugoslavia. aThe numbers include only personnel working in war hospitals, The overall result of our activities was the es- which were either the only health care institution in the region or a part of the existing civilian health institution. Other health per- tablishment of the Medical Corps Headquarters sonnel worked in Health Centers, civilian parts of local health in- (MCH) of the BH Croat population on March 12, stitutions, or battlefield in medical units. 1992, which makes it the oldest defense unit in the bThe number of beds in war hospitals; those were emergency beds, from which the wounded either returned to the unit or were sent to entire BH. Not much later, the Croatian Defense another health institution for final treatment. Council (CDC) was formed as a civilian and military cThe population changed greatly according to the war situation – organization in charge of defense of the Croat- many left the area and refugees settled in. The numbers in the table populated areas from Serbian aggression (53). are estimates of an average population during the war.

133 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140

Growth of the Croatian Defense Council Croatian Defense Council The establishment of the CDC was immedi- ately followed by the organization of military units. These units were organized on a territorial Medical Headquarters Military Headquarters principle – soldier volunteers were assigned to units defending their homes. The MCH joined the CDC and with the CDC Headquarters became the Department Department Department Department of of Preventive of War of Operative key leading factor in the defense of the BH Croat Medicine, Hospitals Informatics Medical Veterinary Service and all other populations in the areas it covered. District Military Medicine, and (“echelons”) Supplies Headquarters It should be emphasized that neither the CDC Headquarters nor MCH had emerged as a continu- Figure 2. Hierarchical structure of the Military Medical ation of an organization of the former YFA and had Corps of the Croatian Defense Council (CDC) in the Cro- not taken over their doctrine either. The number of atian Community of Herzeg-Bosnia (CC H-B) from the be- officers of the Croat nationality in the prewar YFA ginning of the war in Bosnia and Herzegovina until Octo- was insignificant and there was nobody of such ber 1992. profile to contact or learn from. Besides, with the 1991 wars in Slovenia and Croatia, the YFA be- came completely Serb-controlled. Since the MCH CDC Military Headquarters CDC Medical Headquarters and CDC Headquarters were organized independ- ently from each other, the MCH did not become a Military District Medical District Commander of formal part of the CDC Military Headquarters; the Commander Commander War Hospital two bodies cooperated closely, but, within the CDC, they were on the same hierarchical level

Brigade Head Physician (Fig. 2), which is probably a unique case in mili- tary medicine. The MCH had 4 departments (Fig. 2): 1) Pre- Battalion physicians ventive medical care, veterinary services and med- ical supplies; 2) War hospitals; 3) Echelon medical services; and 4) Informatics. This scheme was es- Medical technicians tablished before the actual organization of the mil- itary units and formal establishment of CDC (April Paramedics in the 1992) and Military Headquarters (May 1992). Ech- company, platoon, squad elon Medical Services took care of the wounded until they would reach a hospital with tertiary Figure 3. Commanding line in the Military Medical Corps medical care. Municipal military commands in- of the Croatian Defense Council (CDC) in the Croatian cluded municipal heads of medical services as as- Community of Herzeg-Bosnia (CC H-B) from the begin- sistants to the military commanders in the District ning of the war in Bosnia and Herzegovina until October Military Headquarters. In the field, the Armed 1992. Forces Headquarters had the military commanders of the municipalities under command, and these military commanders had the heads of the head- Department of Defense quarters of the municipal military medical ser- vices as assistants (Fig. 3). Military medical ser-

Health Care Sector vices encompassed physicians in military units (brigades and battalions), medical technicians, Department for Operative and finally paramedics in companies, platoons, Medical Service Control and Inspection (“Echelons” Service Medical Logistics and squads. The chain of command of the medical Medical Service) services went from the MCH, to the municipal Operative Infectious disease, heads of medical services, to brigade physicians, zone Medical War Hospital Epidemiology Unit and Toxicology to battalion physicians, to medical technicians, and to paramedics. Another vertical chain of com- Brigade Informatics and mand went directly from MCH to the commanders Medical Unit Investigation of war hospitals (Fig. 3). War Psychology Battalion Figure 4 depicts changes in the structure of Medical Medical Supplies Team MCH. As of October 14, 1992, the MCH became Dental Medicine integrated into the CDC Department of Defense Missing Soldiers and became its Health Care Sector. To increase War command efficacy, the commands of field medical Surgery/Logistics units and war hospitals were integrated at the Administration level of the Department of Operative Medical Ser- vice of the Health Care Sector. This Service was Figure 4. Structure of the Croatian Defense Council mili- similar to an echelon medical care system, with tary medical service from October 1992 until August 1993. the difference that it did not have a proper eche-

134 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140

Ministry of Health Ministry of Defense

Assistant to the Minister of Defense CDC Military Headquarters

Health Care Sector District Military Commander

Medical Assistant Department of Department Department of to District Preventive of Specialist Education and Commander Medicine Medicine Documentation

Medical Assistant to BrigadeCommander Epidemiology Dental Data Analysis Medicine

Communication Supplies War Hospitals Medical Assistant to and Archiving Battalion Commander

Veterinary War Psychology Medicine and Psychiatry

Physical Health Assessment Figure 5. Structure of the Croatian Defense Council military medical service from August 1993 until the end of the war in Bosnia and Herzegovina. lon organization. Commander of the Operative situations. Basically, all medical institutions and Medical Service was a surgeon, who received personnel in the given area in the war zones, in- commands from the Health Care Sector Head- cluding the war hospitals and medical personnel quarters, and was directly superior to the com- serving in military units, were obliged to assist manders of operative medical units. Commanders both military and civilian populations and were in of the brigade medical corps were responsible for charge of the entire medical care of the area. With the physicians in battalions, and the downward this reform, civilian medical institutions in the ar- chain of command remained as before. Although eas unaffected by war came under the jurisdiction the commander of the Operative Medical Service of the newly formed Ministry of Health. At that was technically a superior officer to the com- time, MCH had 3 departments: 1) Department of manders of the War hospitals, these hospitals had Preventive Medical Care and Supplies, with the a special position, which will be described later. Epidemiological Division, Division for Veterinary Due to the growth of the system, a Control and Medicine, and Division for Medical Supplies; 2) Inspection Service was formed and headed by a Department of Specialist Medicine, with Divisions specialist in occupational medicine. for War Hospitals (War Surgery), Psychology and Operative Medical Sector Service and Control Psychiatry, Dentistry, and Physical Health Assess- and Inspection Service were the operative part of ment; 3) Department of Education and Medical the Health Care Sector, whereas Medical Logistics Documentation, with Divisions for Education and Service provided logistics to their work, as well as Analysis, and for Communications, Acquisition health care other than direct treatment of the and Archiving of Information. wounded in the field, such as epidemiological ser- After the CDC forces liberated Mostar from the vice, dental medicine, psychology, and psychiatry Serbian occupation in August 1992, most of the (Fig. 4). Health Care Sector moved to this city. Only a small Formation of the Ministries part of it remained in Tomislavgrad, the town at the crossroads of communication routes defined On the basis of war experiences in 1992, the by military developments (see Fig. 1). This loca- CDC and Health Care Sector underwent another tion rendered optimal communications with the major reform in August 1993 (Fig. 5). With the for- field units and institutions and served the units mation of the Ministry of Health, standard civilian and war hospitals in the central and northwest BH. medical services and their organization in the ar- eas that were not affected by war became the re- The Head of the Health Care Sector was first sponsibility of the Ministry of Health. MCH was stationed at the Ministry of Defense, located in assigned the jurisdiction over the military medical Mostar, but soon moved to the premises of the services only. Civilian and military medicine had Health Care Sector at the Mostar War Hospital never been completely separated but their organi- (from March 1993 until the Vienna Peace Agree- zation and functioning were adapted to the local ment in March 1994).

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Hierarchically, Health Care Sector was under Military Medical Service command of the Ministry of Defense and the Head of the Military Medical Services served as an Assis- Medical Services in Military Formations tant to the Minister of Defense. He also collaborated In the beginning of 1992, when the defense with the Ministry of Health (Fig. 5). The same was organized on the municipal level, the munici- scheme was applied to all commanding instances: pal military formations relied on local health cen- all medical commanders in military units were as- ters for medical personnel and supplies. When sistants to the military commanders of the respec- needed, local military formations included physi- tive unit. However, war hospitals, regardless of their cians and other medical personnel as ordered by locations, were completely autonomous from the the municipal head of medical services (director of both the military and civilian commanding chain. the health center in most cases). These local for- They also had a high degree of freedom within the mations had from several hundred to 1,500 men; Health Care Sector. For example, the Head of the two medical teams took care of 500 soldiers. Each Health Care Sector appointed their commanders, team consisted of a physician, two medical techni- but their connection with the Sector’s Department cians, and two ambulance drivers. Selected sol- for War Hospitals was primarily a logistical and not diers were trained in first aid and resuscitation, a commanding one. The Chief Surgeon from the and then assigned as paramedics to every platoon. Health Care Sector (previously the Commander of With the formation of the brigades, brigade the Operative Medical Service), who headed the De- medical service commanders were appointed, and partment for War Hospitals, controlled the quality of the function of the municipal head of medical ser- medical work, but in decision-making respect, war vices was abolished. Commanders of the brigade hospitals were quite autonomous. This feature medical service took care of the personnel in bat- stemmed from the way in which they were estab- talions and companies. Each battalion had a physi- lished and high professionalism of their personnel, cian, 2 medical technicians, and 2 ambulance but also from the fact that many of them ended up in drivers. There was a medical technician on each encircled enclaves, having only computer packet ra- company and a paramedic for every 10 soldiers. dios as the means of communication with the Subsequent reorganization of military forma- Health Care Sector. Thus, the Sector’s strategy to- tions included the formation of operative zones, ward war hospitals was freedom in initiative and with their medical service commanders in charge commanding and taking full responsibility for the of medical service of all brigades constituting the work. It should be emphasized that a military com- operative zone. They relied upon all medical insti- mander never entered any war hospital and issued a tutions in the area and the closest war hospital. command. In the military conflict with the Serb forces, there was a regular front-line because the YFA pre- After Washington Peace Agreement ferred classical warfare, with artillery, armored ve- After the Washington Peace Agreement be- hicles, and infantry. The rear was shelled, and air tween Bosniacs and Croats in April 1994, as a con- forces were used in attacks at the beginning of the sequence of cessation of hostilities and a sign of war. This allowed us to position physicians very good will, the Head of the Health Care Sector sug- close to the front-line, where they could help the gested to the Minister of Defense to transfer the ju- wounded much quicker and send them by short risdiction over all war hospitals to the Ministry of evacuation routes to a brigade medical station, Health, except those in Orašje and Bosanska Bijela where basic resuscitation measures were under- (Posavina, north-east BH), where the war with Serbs taken (hemostasis, inspection of airways, place- continued. From that time on, the personnel of the ment of iv. line) (32). These medical stations were Health Care Sector were considerably reduced and positioned from few hundred meters to at most 2 Health Care Sector became one of the administra- km away from the front-line, and all the wounded tion departments of the Ministry of Defense, headed would reach them within an hour after injury. Af- by the Head for Health Administration. ter that, a patient would be transported to a war hospital. All routes of evacuation were relatively Several war hospitals were reactivated in 1995, safe, aside from artillery attacks. In contrast, when BH Army (Bosniac armed forces), CDC, and mostly city fights, often head-to-head, character- Army of the Republic of Croatia jointly undertook ized the conflict with Bosniacs, and echelon prin- several offensives to liberate west BH from Serb oc- ciple was inapplicable. Instead, the wounded cupation. For example, during the battles for the lib- would be taken directly to the nearby war hospital. eration of Kupres and other southwest parts of BH They were very close to most of the places of fight- (west of Livno to Grahovo, see Fig. 1), war hospitals ing , anyway. in Rama, Tomislavgrad, and Livno were reactivated within several hours. Immediately after the libera- War Hospitals tion of Kupres, 4 days after the commencement of All CDC war hospitals were located in build- offensive, Kupres War Hospital was formed by com- ings. Almost all were within the zone of the active bining the personnel and equipment from other 3 fighting, and some were on the very front-line in the war hospitals, to serve the armed forces in their fur- , especially during the armed conflict with ther military advancements. Soon, the same hap- Bosniacs. The closeness of the front-line was the pened in Jajce after it was liberated (see Fig. 1). reason that the CDC, in distinction from many other

136 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140 armies, including that in Croatia, neither needed the Bosniac-controlled Army of BH, whose organi- nor could use mobile surgical teams or field hospi- zation stemmed from the key principles of authen- tals. This was probably the most specific character- ticity and sovereignty of both nations of the Feder- istic of the CDC medical services in BH. ation of BH. Currently, every commanding post In the CDC military medical service, surgeon has a deputy position alternately occupied by had a key position in a war hospital. Due to the Bosniacs and Croats. Overall numerical ratio is closeness of the front-line and location of war hos- 2.3:1 for Bosniacs. The army is organized in accor- pitals, positioning surgeons in the rear was neither dance with NATO standards, which means that its necessary nor advisable, unlike the positioning of organization and training is provided through the battalion surgeons within the framework of the “Equip and Train” program by the Military Profes- NATO doctrine (36). sional Resource Inc. (MPRI, Alexandria, VA, USA), Only the most serious cases, such as head and a forum of US military experts. brain injuries, were transported further after first At the level of the Ministry of Defense, medi- aid and stabilization, most often to Croatia (32). cal service, together with veterinary medicine, is Although generally short in personnel and part of the Logistics Sector (Fig. 6). equipment, the war hospitals were able to offer At the level of Military Corps Headquarters complete medical care, after which the soldiers (Joint Command) military medical and veterinary would return to their units. Most of the wounded services also belong to the Logistics Sector (Fig. 7). received definite treatment in the war hospitals. Patients needing longer recovery and rehabilita- Discussion tion were sent to civilian hospitals in the rear. The MCH was established as a managerial and The 1-5 echelon principle of care for the organizational body with the task to conceptualize wounded, as well as distribution of the equip- the system of health care in war circumstances. ment, was mostly condensed to two or three steps The concept of integrated civilian and military of care (31). medical services was adopted. Health care was War hospitals did not have a strict organiza- based on the resources within the primary health tional structure, but were the result of needs, ca- care (health centers), small local hospital in Livno, pacities, and initiative of their commanders. It and Mostar regional center, whose personnel was should be emphasized that the war hospitals, al- reduced by at least a half. The development of mil- beit located within operational zones, were under itary formations was adequately followed by the command of the Health Care Sector of the Depart- development of medical formations within them. ment of Defense (Fig. 4). Moreover, since all CDC War hospitals were established depending on the physicians were officers, they had a considerable development of military actions, and most of them independence and freedom in making decisions, were positioned close to the battlefront. War hos- which not only resulted in high-quality leadership pitals cared for both soldiers and civilians. Since a but was also indispensable for survival in encir- complete treatment and rehabilitation of the cled enclaves. wounded were provided, these war hospitals

After Dayton Peace Agreement Commander of the Joint Headquarters Dayton Peace Agreement (21 November 1995) Deputy Commander of the Joint divided BH into two entities – Croat-Bosniac Fed- Headquarters eration of BH and the Republic Srpska, with two respective armies. The Federation of BH had the army composed of two components – the CDC and Commander of the Joint Headquarters Deputy Commander Minister of Defense

Assistant and Deputy Logistics Sector Assistant Commander for Logistics

Medical and Veterinary Medical and Veterinary Services Services Figure 7. Structure of the Joint Headquarters of the Figure 6. Proposal of the structure of the Ministry of De- Army of Bosnia and Herzegovina and Croatian Defense fense of the Federation of Bosnia and Herzegovina (after Council (Army of the Federation of Bosnia and Herze- Dayton Peace Agreement in 1995). Lines with arrows indi- govina) after Dayton Peace Agreement in 1995. Lines cate other Sectors or Departments. with arrows indicate other Sectors or Departments.

137 Bagariæ: Croat Medical Services during War in BH Croat Med J 2000;41:124-140 could be considered the 5th echelon (36), although mous in their medical command. Although they they were too close to the front-line (31). were the assistants to the commanding officers, they Patients who needed further medical care were not subordinated to them. Commander of the were sent to the tertiary level institutions in the MCH was at the same hierarchical level as the com- Republic of Croatia. There were many of them, mander-in-chief of the armed forces. and they were sent to Croatia from both Bosniac After the Dayton Peace Agreement and cessa- and Croat medical institutions in BH (19,23,31, tion of war in BH, integration of war hospitals into 32,34,35,54), regardless of patients’ combat status, the civilian health system allowed the establish- nationality, or religion (55,56). The cost of care for ment of the civilian sector of medical services, BH patients in the Republic of Croatia reached whereas the CDC military services remained in the DM35 million (official data from the Croatian CDC armed units, i.e., in professional brigades and Health Insurance Institute), which is surely one of teaching centers integrated into the BH Federation the greatest humanitarian supports ever given Army. The MCH was dissolved, with only medical from one state to another. documentation remaining. In addition to with primary health care for the Medical service and its professionals in the wounded and the sick, preventive and epidemiolo- BH Federation Army now exist within the both gic measures were also carried out efficiently, be- Ministry of Defence and Joint Army Headquarters. cause there were no epidemic outbreaks despite the My personal opinion is that Medical Service is not sharp decrease in the living standard and a large- given the importance it should have in a military scale refugee crisis. system. “Low” positioning of medical officers Medical supplies, equipment, and sanitary within the officer personnel, as well as the hierar- materials were not manufactured in BH, but their chical position of the medical service itself, is not supply to war and civilian medical institutions adequate. It is true that the current BH Army was adequate. The help came from many humani- model has been made according to the NATO sys- tarian organizations and individuals from all over tem, but neither tradition, health care experience, the world, especially those who had experience or nor traditionally respected status of a physician connection with Meðugorje (a famous pilgrimage were taken into account. Communication with the destination in West Herzegovina). civilian health care system is weak, which is a set- Our doctrine of independent war hospitals, back for any country or situation. Hopefully, the headed by a strong-minded and highly educated existing tendency of reducing armed units in BH commander, grossly alleviated problems of person- will lead to eventual demilitarization of BH, mak- nel shortage. A smart commander could greatly af- ing the discussion on the position of medicine and fect functioning of the hospital by retraining of the physicians in BH armed forces unnecessary. personnel (e.g., dentist into surgeon), or organizing additional training (e.g., of a medical technician to References perform anesthesia). Medical specialists were re- 1 Mandiæ D. i Hercegovina. III. Etnièka povijest cruited partly from displaced physicians from Bosne i Hercegovine. Rome: Croatian History Insti- other parts of BH, and partly (at the beginning) tute; 1967. from the volunteers from abroad, mostly Croatia. 2 Ivanoviæ V, Vlahušiæ A, editors. Ethnic cleansing of Although we were acquainted with military Croats in Bosnia and Herzegovina 1991-1993. Grude: medical doctrine of the former Yugoslav Federal Croatian Community of Herzeg-Bosnia; 1993. Army, NATO, and other countries, we could not 3 Adley R, Evans DHC, Mahoney PF, Riley B, Rodgers use any of their models. We were actually com- CR, Shanks T, et al. The Gulf war: anesthetic experi- pelled to build a unique system of our own. Our ence at 32 Field Hospital Department of Anaesthesia system was a mixture of NATO (36), Israeli (9-11), and Resuscitation. Anaesthesia 1992;47:996-9. and Croatian (19,52) doctrine, but on the whole, it 4 Jennings SA, Cohen DL, Corrow LK, Harper ML, was our own doctrine, specific for the given situa- McCain G, Wiedeman J. Deployment of an air trans- tion (31). Its main feature was independence – of portable hospital in support of allied forces during politics and of the army. Relative independence, operation provide comfort: April 29 to July 17, 1991. Mil Med 1993;158:135-41. high level of education, and experience of the phy- sicians resulted in satisfactory organization of mil- 5 Kizer KW.The health of Persian Gulf veterans. JAMA itary/civilian medical services and made these 1995;273:1817. very physicians, as those in Croatia a year earlier 6Beary JF III, Bisgard JC, Armstrong PC. The civil - (57), leading figures in peace initiatives, ex- ian-military contingency hospital system (CMCHS) – pro and con. N Engl J Med 1982;306:738-40. changes of prisoners of war, and humanitarian ac- tions. Organizing care for the refugees and dis- 7 Wedel KH. Military-civilian collaboration for disas- ter medicine in the Federal Republic of placed persons and the surveillance of prisons (FRG). Prehosp Disast Med (J WAEDM) 1985;1:33-4. were physicians’ merits. 8 Rocha Da Silva FF.Military concepts and emergency Since there were not many highly educated medical services in Portugal. Prehosp Disast Med (J military commanders, the MCH opted for independ- WAEDM) 1985;1:25. ent position in the planning and organizing, as well 9 Adler Y. Military-civilian collaboration for disaster as in operational activities. All head physicians in medicine in Israel. Prehosp Disast Med (J WAEDM) armed units were officers and completely autono- 1985;1:32.

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48 MeðuMupanijski zavod za javno zdravstvo. Pregled Croatia and Bosnia and Herzegovina in 1991-1992. mreMe, kapaciteta i djelatnosti zdravstvene sluMbe u Mil Med 1995;160:588-92. 1996. godini. Mostar: MZJZ; 1997. 55 Gottstein U. International Physicians for the Preven- 49 Mijatoviæ D, Henigsberg N, Judaš M, Kostoviæ I. Use tion of Nuclear War (IPPNW) delegate visit to the hos- of digital wireless communications system for rapid pitals in Split, West Mostar and East Mostar, Novem- and efficient communication between Croatian ber 29-December 6, 1993. Croat Med J 1994;35: 53-8. medical centers in war. Croat Med J 1996;37:71-4. 56Becker S. The Angel of Mostar. London: Hutchinson; 50 Kapulica Z. Croatian Medical Corps first echelon: a 1994. front line doctor. Croat Med J 1992;33 War Suppl 2: 57 Blaskovich J. Anatomy of deceit. An American phy- 172-4. sician’s first-hand encounter with the results of the 51 Petraè D, Georgijeviæ A, Kusiæ Z, Valent I. Organiza- war in Croatia. New York (NY): Dunhill Publishing tion and functioning of the Sisters of Mercy Univer- Co.; 1997. sity Hospital in the war against Croatia. Croat Med J Received: February 22, 2000 1992;33 War Suppl 2:193-6. Accepted: April 18, 2000 52 Janoši K, Lovriæ Z. War surgery in Osijek during Correspondence to: 1991/92 war in Croatia. Croat Med J 1995;36:104-7. Ivan Bagariæ 53 Boban M. Odluka o formiranju Hrvatskog vijeæa Ministry of Health Care of the Federation of obrane. Narodni list HZ Herceg-Bosna 1992;(I):4. Bosnia and Herzegovina 54 Balen I, Prgomet D, Gjaniæ D, Puntariæ D. Work of the Titova 9 General Hospital during the war in 71000 Sarajevo, Bosnia and Herzegovina [email protected]

The 3rd International Conference on Priorities in Health Care

Amsterdam, The Nederlands 23-24 November, 2000

Constrained resources and increasing demands make the setting of priorities in health care a pressing issue. The conference will focus on the daily practice in which choices are made. What is the role of the various parties involved, and which factors exert influence? What can be learned from the way in which the issue of choice is handled at all levels of the health care system? What are the consequences of implementing priorities in health care? The conference will show that, although results from health services research and health technology assessment are needed, translating from theory into practice needs to be done with great care. The conference will offer a stimulating exploration of two main themes: “The role of various actors in priority setting” and “Why choose for investing in health”. The former concentrates on how choices are made in the interactions between the different actors, e.g., policy makers, managers, physicians and other health professionals, patient and consumer organizations, and researchers, and what is needed to achieve change. The second theme is more reflective in its orientation: investments in health care are compared with other social issues like housing and education. All parties involved in or affected by decision-making concerning priorities in health care are invited to submit papers on this issue and to participate in the conference.

For more information, visit the web site: www.healthpriorities.net or contact: • Boerhaave Congress Office, c/o Mr. J.J.L. Muller, PO Box 2084, 2301 CB Leiden, the Netherlands fax: +31 71 527 5262; phone: +31 71 527 5294; [email protected]

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