Mental Health in Bosnia and Herzegovina: Situational Assessment and Policy Recommendations A thesis submitted to the Graduate School of the University of Cincinnati in partial fulfillment of the requirements for the degree of Master of Public Health in the Department of Environmental Health of the College of Medicine by Mohamed H. Elzarka University of Cincinnati 28th March 2019 Committee: Aimin Chen, MD, Ph.D., Chair Jun Ying, Ph.D. ABSTRACT Background: The war that plagued Bosnia and Herzegovina in the mid-1990s has had far reaching effects on mental health within the nation, and its aftereffects have further exacerbated the challenges to mental wellbeing faced by the country’s citizens. Although the initial post-war support for mental health was robust, resources and investments into mental healthcare infrastructure in the country have diminished, and access to mental healthcare services is significantly lower than the incidence of mental health conditions would necessitate. Objective: Identify and characterize the mental health challenges present in Bosnia and Herzegovina and propose policy recommendations that can address the root causes of these obstacles to strong mental health in the country. Methods: A comprehensive literature review was conducted to perform a situational assessment of the major mental health challenges experienced in Bosnia and Herzegovina today and the current mental healthcare infrastructure that has been set up to deal with them. Results: Findings show that Bosnia’s key mental health challenges are rooted in larger challenges with post-war recovery, effective governance, sustaining a robust economy, educational integration, substance abuse, social inclusion for minority groups, and perceptions of mental health in civil society. These challenges are exacerbated by a healthcare system which has found some success in improving mental healthcare access and quality but which today is also overburdened, understaffed, and in need of serious streamlining. Ultimately, policy recommendations focusing on addressing these key challenges and shoring up infrastructure to better care for Bosnia’s mentally ill will be critical. Conclusions: Important policy recommendations to be considered for facilitating improved mental health in Bosnia must look to address the societal, political, economic, educational, and ii comorbid medical issues in the country. Particular focus should be paid to stigma reduction, health education, educational integration, governmental and economic reform, and coalition building and the consolidation of resources between the public and non-profit sectors. iii iv ACKNOWLEDGEMENTS Mohamed Elzarka was supported by the Fulbright U.S. Student Program – a program of the United States Department of State, Bureau of Educational and Cultural Affairs – with a Study/Research Grant to Bosnia and Herzegovina for the 2017-18 academic year. A very special thank you to the members of my committee for their time and effort, and to Prof. Charles Doarn for his mentorship and support as the Global Health Concentration Director and the guidance that he has given which I hope will stay with me long into my career. v Mental Health in Bosnia and Herzegovina: Situational Assessment and Policy Recommendations TABLE OF CONTENTS ABSTRACT ................................................................................................................................... ii ACKNOWLEDGEMENTS ......................................................................................................... v LIST OF FIGURES AND TABLES .......................................................................................... vii BACKGROUND ........................................................................................................................... 1 POST-TRAUMATIC STRESS AS A PRODUCT OF THE BOSNIAN WAR ....................... 4 Comorbidity of Psychiatric Disorders ........................................................................................ 8 Secondary Traumatic Stress ...................................................................................................... 11 ADDITIONAL KEY MENTAL HEALTH CHALLENGES ................................................. 13 Post-War Economic Struggles and Despondency ..................................................................... 13 Ethno-Religious Identity in the Classroom ............................................................................... 16 Substance Abuse ........................................................................................................................ 20 Acceptance of LGBT Identity .................................................................................................... 22 MENTAL HEALTHCARE INFRASTRUCTURE IN BOSNIA AND HERZEGOVINA .. 25 Post-War Reconstruction of Mental Health Services ................................................................ 25 Current Mental Healthcare Infrastructure ............................................................................... 27 POLICY RECOMMENDATIONS ........................................................................................... 30 Standardization of Mental Healthcare Policy and Integration of Partners .............................. 31 Governmental Reform ............................................................................................................... 33 Educational Interventions ......................................................................................................... 34 SUMMARY ................................................................................................................................. 35 BIBLIOGRAPHY ....................................................................................................................... 37 APPENDIX A: FIGURES AND TABLES ............................................................................... 47 vi LIST OF FIGURES AND TABLES Figure 1: Map of the distribution of ethnic identity in Bosnia and Herzegovina based on data from the 1991 census Figure 2: Map of the separate federal entities of Bosnia and Herzegovina (A) and the distribution of Bosniak, Croat, and Serb ethnic groups in the country based on the 2013 Bosnian census (B,C, and D, respectively) Table 1: CIA World Factbook Data on GDP per capita for the sovereign nations of the Former Yugoslavia vii BACKGROUND Bosnia and Herzegovina (hereinafter referred to as “Bosnia and Herzegovina” or simply “Bosnia”) is a nation in southeastern Europe and a former constituent republic of the Socialist Federal Republic of Yugoslavia. On March 3, 1992, the country declared its independence from Yugoslavia as part of the larger dissolution of the Yugoslavian state over the course of the 1990s which eventually split the South Slavic republic into 7 sovereign nations today (Keil & Stahl, 2014). Yugoslavia (then known as the Kingdom of Serbs, Croats, and Slovenes) was a nation- state constructed after the end of the First World War that integrated the pre-war kingdoms of Serbia and Montenegro with substantial territory from the former Austrian Empire. The majority of the resultant nation’s citizens shared a common South Slavic identity, as well as a common dialectical continuum (Langston & Peti-Stantić, 2014). Despite these shared characteristics, differentiation between people groups in Yugoslavia was common, based primarily upon ethnic and religious identity, as well as linguistic differences (Greenberg, 2001). These dissimilarities informed the creation of constituent republics within a socialist Yugoslavia after the end of the Second World War. To develop an understanding of the history of Bosnia and Herzegovina, three different ethnoreligious identities must be discussed: Bosniak, Croat, and Serb. These ethnic groups are primarily separated from one another on the basis of religion, since in the former Yugoslavia, religion was almost synonymous with ethnicity. Indeed, before the breakup of Yugoslavia, religion was not only a matter of private belief, but also a public identifier (Petrovich, 1967). Previous censes underscore this point, by identifying the ethnic group which would later come to be known as “Bosniak” by the racial identifier of “ethnic Muslim” (Dyker, 1972). The ethnoreligious equivalences are such that Bosniaks are practitioners of Islam, while Croats are 1 Roman Catholic and Serbs are adherents to the Serbian Orthodox Church. The affiliation between these identities of religion and ethnicity was so strong that a religious conversion was often thought to result in a simultaneous change of nationality from the perspective of other Yugoslavs (Petrovich, 1967). This concordance between identities is both an interesting sociological phenomenon, and also a key factor in explaining the dissolution of Yugoslavia based upon ethnic nationalism. Bosnia is, and was at the time of its independence declaration, a nation of diverse ethnic and religious identity (Figure 1). Surrounded on either side by the republics of Croatia and Serbia, Bosnia contained large ethnic Serb and ethnic Croat populations in addition to its population of Bosniaks. As tensions grew in the early 1990s with increased calls for nationalism within Yugoslavia, these ethnic differences boiled over into outright violence. After the Bosnian independence referendum and declaration of 1992, conflict between ethnoreligious groups resulted in a three-year, often tripartite civil war that also saw numerous human rights abuses including ethnic cleansing and