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The Workshop

The city of Trieste sits in the extreme northeast corner of Italy, near the border of Slovenia, one of the five republics of the former Yugoslavia. A port city on the Gulf of Venice at the head of the Adriatic Sea, Trieste was part of the Austrian Empire from the fourteenth century until the end of World War I. The city was then claimed by Italy, but after World War II it was divided and, like Berlin, was administered jointly by the Allies. In 1954, after a plebiscite, its territory was divided between Yugoslavia and Italy, the latter assuming sovereignty over the city proper.

This history of a division that was overcome seemed a fitting backdrop to the workshop described here, which took place in Trieste from March 27 to 30, 1994. Thirty-four doctors who could speak for child health gathered at a hotel perched on a steep hill above the edge of the sea in response to a war not far away that was moving into what everyone hoped was its penultimate phase.

The workshop was convened by the National Research Council and the Institute of Medicine of the United States. The eight Americans and three Europeans who formed the organizing committee served as mediators, facilitators, and data gatherers for the meeting. They included leaders in academic pediatrics, officers of national and international pediatric associations, and veterans of humanitarian efforts.

The regional participants were chosen as doctors who could make a difference for children, including 19 doctors from the five countries that constituted the former Yugoslavia (five doctors from Bosnia-Herzegovina, two from Croatia, two from Macedonia, three from Slovenia, five from Serbia—including one from Kosovo and one from Novi Sad—and two from Knin and Banja Luka in Serbian-held areas of Croatia and Bosnia-Herzegovina, respectively.



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The Impact of War on Child Health in the Countries of the Former Yugoslavia The Workshop The city of Trieste sits in the extreme northeast corner of Italy, near the border of Slovenia, one of the five republics of the former Yugoslavia. A port city on the Gulf of Venice at the head of the Adriatic Sea, Trieste was part of the Austrian Empire from the fourteenth century until the end of World War I. The city was then claimed by Italy, but after World War II it was divided and, like Berlin, was administered jointly by the Allies. In 1954, after a plebiscite, its territory was divided between Yugoslavia and Italy, the latter assuming sovereignty over the city proper. This history of a division that was overcome seemed a fitting backdrop to the workshop described here, which took place in Trieste from March 27 to 30, 1994. Thirty-four doctors who could speak for child health gathered at a hotel perched on a steep hill above the edge of the sea in response to a war not far away that was moving into what everyone hoped was its penultimate phase. The workshop was convened by the National Research Council and the Institute of Medicine of the United States. The eight Americans and three Europeans who formed the organizing committee served as mediators, facilitators, and data gatherers for the meeting. They included leaders in academic pediatrics, officers of national and international pediatric associations, and veterans of humanitarian efforts. The regional participants were chosen as doctors who could make a difference for children, including 19 doctors from the five countries that constituted the former Yugoslavia (five doctors from Bosnia-Herzegovina, two from Croatia, two from Macedonia, three from Slovenia, five from Serbia—including one from Kosovo and one from Novi Sad—and two from Knin and Banja Luka in Serbian-held areas of Croatia and Bosnia-Herzegovina, respectively.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia The participants included doctors from trauma units and emergency wards who themselves had been targeted in the war; child psychiatrists who had witnessed sieges in which children have been made suicidal, some deliberately exposing themselves to sniper fire; the caretakers of refugees; doctors from maternity hospitals where infants routinely die from a lack of basic medicines, supplies, and equipment; doctors from frontline situations they had not left until they attended the workshop more than 1 or 2 years; and academicians and health leaders of their own countries and officials of pediatric societies and children 's hospitals. The organizing committee had formulated three central questions for the workshop: What is the state of child health in war-torn former Yugoslavia today? What can be done to improve it? And how might this knowledge be used to benefit other children in the world? The discussions began with a series of presentations entitled “Children in My Vicinity.” Each participant had been asked to prepare in advance a short statement describing particular conditions and problems of the children in his or her own region. These statements provided powerful and moving glimpses of child health problems as seen by the doctors who were responsible for the care of the children. In this report the key elements of these presentations, subsequent presentations, and discussions are summarized to provide an insight into the health conditions of children today in the countries of the former Yugoslavia. The ideas and statistics in the report reflect the material included in the presentations and discussions of the participants during the workshop. Specific references are provided for published materials. EPIDEMIOLOGY: GETTING THE FACTS ON CHILD HEALTH IN DIFFICULT CIRCUMSTANCES Accurate and standard management of data is necessary to understand health needs and to facilitate planning for the future in times of peace and war alike. Despite attention by the media and humanitarian organizations, little documented information has yet been available concerning the actual status of child health in the countries of the former Yugoslavia. It is clear that such data can be difficult to come by in wartime situations and that this difficulty is enhanced by rapidly changing circumstances. A number of challenges must be faced in addressing these issues, including the conditions under which the data are collected, the evaluation of the data, and the uses of the data. Furthermore, even when available, the data may be difficult to communicate and incorporate into decision-making processes. For these reasons, the workshop began with discussions of the challenges presented in obtaining health data in situations of war and difficult circumstances and on the needs for and the appropriate uses of such data. Indeed,

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The Impact of War on Child Health in the Countries of the Former Yugoslavia the workshop was developed on the premise that the availability of sound data is fundamental to addressing the health problems that result from conflict situations and that such data can also provide an important tool for the basis for reconstruction of society. The first challenge is to select measures that adequately reflect the status of health under wartime conditions. One area to be examined is the trauma of war: killing, pain, injury, and disability. Another is the reappearance of previously controlled diseases such as tuberculosis that occur because of an inability to respond to them. Another is psychological trauma for the generation immediately affected, and perhaps for future generations as well. It is important to decide the impacts that should be measured so that suitable interventions can be prepared and applied. The second challenge involves conflicting demands regarding potential uses of the data. Data are needed to prioritize programs, particularly when few resources are available, and data may be requested to track the outcomes of interventions. Scientific data can also be used or abused for advocacy or for political purposes when individuals or institutions seek to use scientific or medical data to justify specific actions or programs. A third challenge in data collection has to do with the capacity to look beyond indicators and consider possible risk or developmental factors behind any measured occurrence. For example, in registering a case of diarrhea, one can also record whether the child was breastfed, when the child was weaned, the food-handling practices in the child 's home, the child's hand-washing practices, and so forth. This approach to data collection starts an epidemiologic process in the mind of the data collector that will enhance knowledge about the conditions under which the problem occurred, thereby enabling the design of effective interventions. Valid and practical indicators are essential to data measurement as is accurate assessment of basic facts. One example of a practical indicator is the use of imaginative techniques in conducting an epidemiologic study of the ways that children see things, especially children who have been traumatized. Children's pictures, essays, or poems may help to reveal which treatments have an impact in dealing with the experience of trauma. A similar technique is the “photo interview, ” in which children respond to a series of photographs. The skill and time of professionals are needed to interpret such tests, however, and these are not always available. The exact mix of measures differs in different situations, and the selection of measures must always be based on the skills of the measurers. The use of already validated measurement instruments saves the step of validation and provides a background based on more long-term experience. However, such instruments may not, unfortunately, be applicable to some situations. An example of the importance of accurate assessment of basic facts can be shown by considering the documentation of nutritional status. Valid

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The Impact of War on Child Health in the Countries of the Former Yugoslavia interpretation of malnutrition depends on the accurate statement of ages; rounding off of ages to the nearest year can lead to significant errors in judging the nutritional status of infants and young children. Several techniques are available for measuring of health statistics under difficult circumstances. The first technique is to make use of already existing data. In some cases, however, such data may not reflect the current situation and may not be adequate for planning interventions. A second technique concerns what might be called opportunistic monitoring. One or two key questions about problems whose resolution is a high priority are asked at feeding supplementation or immunization programs attended by a large percentage of the population. A third common technique involves the use of surveys and rapid appraisals. It is important that such surveys be done in a way that can make them useful in decision making and other existing efforts and also to facilitate longitudinal follow-up. For example, in selected representative communities in an area, a household survey, an anthropologic survey, and a psychological survey of schoolchildren can be correlated in the same communities. Such surveys do not have to be elegant or complicated; indeed, they should be as simple as possible. More in-depth health surveys can also be developed, once a system of basic ongoing monitoring is in place. It is then possible to select a particular problem and look at every single case within a known area (“all cases everywhere technique ”). The meaningful communication of data is very important. Data are relatively easy to acquire, but they are often difficult to communicate and incorporate into decision-making processes. Data need to be packaged and presented in a form that will allow them to have an impact. To say that infant mortality is 30 or 40 per 1,000 live births has relatively little impact; reformulating this statement to tell how many of 100 infants have actually died tells the story more effectively. It is important to place the concept of risk not only within medical and scientific contexts but also within contexts relevant to the community. One potential pitfall in the presentation of data that may be particularly applicable in conflict situations concerns the political and patriotic wish to present the best possible figures to support one's country. Such inflated reports of data may be helpful politically, but they are certainly not in the best interests of defining the problems that need to be addressed. A final concept of epidemiology and measurement under difficult circumstances is what might be called measurement for peace (Andersson, 1993). This concept has recently emerged from the war in Liberia. In the process of collecting data in Liberia measurement teams of teachers and medical workers involved in the data collection process also addressed some of the health problems affecting children. Teams on various sides of the conflict measured simple things on a community level: the incidence of diarrhea and respiratory infections, the vaccination and nutritional status of children, and so forth. In so

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The Impact of War on Child Health in the Countries of the Former Yugoslavia doing they caused large numbers of people to think about such problems, what lies behind them, and what might be done to remedy them. This process resulted in the people themselves, working through the measurement process, coming up with pertinent requests to various humanitarian aid agencies for intervention. In addition, many people, both the measurers and the measured, had participated in a humanitarian activity that focused attention on children and their problems. People from all sides of the conflict in Liberia, even those who had been guilty of perpetrating traumas against children, became involved in the process, a process that not only provided useful data for guiding the relief efforts of humanitarian aid organizations but also focused attention on children and steps toward positive change. Summary Describing the state of health, defining health needs, and planning for the future depend on the availability of accurate data in times of peace and war alike. Comparison of the state of health of children between regions or countries demands accurate gathering of data and standard management of those data. Discussions of epidemiology and data collection at the workshop focused on the difficulties of gathering data under circumstances such as war and the means by which such difficulties might be surmounted. The issues discussed included the conditions under which data are collected, the standard means of evaluating those data, and the uses of the data. Participants stressed that the availability of sound data is fundamental to addressing the health problems in conflict situations and that accurate and meaningful data can provide an important tool for beginning the reconstruction of society. PRIMARY HEALTH CARE, PREVENTIVE MEDICINE, AND INFANT AND CHILD MORTALITY After World War II, an admirable system of health care was established for mothers and infants throughout the former Yugoslavia. This system provided a model of comprehensive identification, monitoring, and the continuing follow-up of both mothers and children throughout much of the country. This model has now been disrupted in some areas by the war, leading to wide variations in the status of maternal and child health. Discussions of infant and child mortality depend on clear definitions and common frames of reference. A number of questions were addressed by workshop participants in this regard: Is the viability of the fetus determined by gestational age or other factors? How does one define a live birth? Are

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The Impact of War on Child Health in the Countries of the Former Yugoslavia stillbirths counted in infant mortality statistics? Are the deaths of all infants or only those admitted to a hospital recorded? Infant and child mortality is inseparable from prenatal and perinatal care and conditions. Maternal age, maternal nutrition, maternal stress, substance abuse (tobacco and alcohol), literacy, and the educational levels of pregnant women are all factors in infant outcome, as are the level of care that the mother receives during pregnancy and perinatally and postnatally. Two European participants offered pertinent data in this regard. In the former West Germany infant mortality rates were rather high until 7 or 8 years ago, despite the relative affluence of the population. Implementation of two programs successfully lowered infant mortality in the former West Germany to levels comparable to those countries with low infant mortality rates. The first program involved regionalization of neonatal care, meaning that infants at risk were treated in large centers with intensive care units for infants. The second program involved implementation of a surveillance system for perinatal care, including risk assessment and a transport system for babies from the obstetric hospital to the pediatric hospital. Likewise, in Trieste, infant mortality rates were formerly 25 to 26 per 1,000 births; these rates fell to 13 per 1,000 births within 1 year of the institution of similar measures of perinatal care. A Regional Review During the workshop, reports of decreasing birth rates and rising infant mortality rates were reported from various regions, although in many cases hard data were lacking. These reports are highlighted below. Bosnia-Herzegovina Zenica. The previously well organized system of prenatal and postnatal care for mothers and children has been disrupted by the war. In Zenica there used to be three neonatologists, one intensive care physician, and one neurologist, in addition to pediatricians. Now only one neonatologist remains. Only 3 of 21 incubators are functional; there are often 3 babies in each incubator. Equipment is compromised by electrical failure and the lack of spare parts and maintenance. Perinatal mortality rates have doubled (given as from 14 to 16 per 1,000 before 1992, to 36 per 1,000 in 1993), as have rates of stillbirths (from 8 to 15 percent). Increased numbers of congenital malformations are suspected, with no clear pattern of types, and rates of premature births (birth weight of less than 2,500 grams) are also thought to be increasing. The occurrence of eclampsia in mothers has tripled over prewar levels, as have mental health problems during pregnancy.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Explanations for these trends include the lack of prenatal care, poor maternal nutrition, and increased stress. In Zenica there have also been major problems with refugee women who have been raped. Mostar. The Gynecological and Maternity Hospital, Medical Center Mostar, is the regional hospital for Mostar and neighboring municipalities and served 500,000 people before the war. Before the war there were 4,000 deliveries annually. Two-thirds of the pediatricians have left Mostar, and none of the pediatricians now present is trained in neonatal medicine; half of the nurses have also left. The obstetric hospital has been on the front lines of the war; its bed capacity has been reduced from 100 to 20 functional beds, the rest being destroyed or converted into makeshift clinics. Facilities for prenatal surveillance have been lost, and laboratories are lacking in facilities for diagnosis and monitoring. It is also dangerous to go to the hospital: 3 pregnant women have been hit by shrapnel in the abdomen. Transport of high-risk patients is difficult because of communication disruption. Before the war high-risk mothers went to Zagreb, Croatia, but this is now difficult. An important observation is that many pregnant women in the Mostar area gain excessive weight on a diet rich in starch, mainly eating foods available from humanitarian aid organizations. Increases in preeclampsia and abruptio placenta have been associated with this excessive weight. This paradoxical condition has been referred to as the spaghetti syndrome. The number of premature births has increased from 7.6 percent before the war to 9.7 percent currently, as has the rate of intrauterine growth retardation (from 6.4 to 11.6 percent). Anemia has been a common observation in pregnant women, affecting 84 percent of those with excessive weight gain and 46 percent of those with normal weight gain. The rate of breastfeeding has been declining. Sarajevo. Data from Kosevo Hospital in Sarajevo also indicate a rise in infant mortality, from 16 per 1,000 prewar to 27 per 1,000 in 1993. The rate of stillbirths has risen from 7.5 to 12.3 per 1,000 over the same period, and there has also been an increase in the rate of premature births, from 6 to 12 percent. Fertility rates have fallen from 13.8 per 1,000 prewar to 2.2 per 1,000 in 1993, and abortion rates have risen from 29 percent of pregnancies prewar to 64 percent in 1993. Serious congenital malformations have risen from 3.7 to 7.3 per 1,000 (United Nations Children's Fund, 1993). Primary Health Care. Bosnia-Herzegovina has experienced widespread problems with maintaining primary health care. Vaccination programs have been interrupted because of war and at times because of vaccine shortages. No epidemic of communicable diseases preventable by vaccinations has been reported, but there is concern that this may happen in the future. Immunization with the BCG vaccine against mycobacteria has been a problem in some parts of the country, and there is great concern about a resurgence of tuberculosis. Routine well-child visits and child health surveillance are now lacking. A few

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The Impact of War on Child Health in the Countries of the Former Yugoslavia nutritional surveys have not documented the occurrence of malnutrition or increased levels of anemia among children (World Health Organization, 1993), but sample sizes have been small and measurement techniques may not be exact. All participants from Bosnia-Herzegovina mentioned the problem of hungry children and reported widespread disruptions of basic sanitation, water supplies, and electricity. The general lack of supplies for proper hygiene such as soap, detergents, and disinfectants were thought to contribute to increased rates of diarrhea, hepatitis, scabies, and lice observed in Sarajevo, Zenica, and Tuzla. Both displaced and local children have suffered from the lack of primary health care and preventive medicine. Displaced children are eligible to receive food from the United Nations High Commission for Refugees (UNHCR), at times ensuring that their nutritional needs are met more than those of nondisplaced children living in war zones. Banja Luka. In Banja Luka, a Serbian-controlled city of Bosnia-Herzegovina, there have been many problems with maternal and infant care. Difficulties with transport have resulted in fewer prenatal visits, and functional equipment is often lacking (only one ultrasonograph is working). The number of births has been dropping (from 5,300 in 1988 to 3,341 in 1992), and fetal and infant mortality is thought to be rising. The rate of premature births was 9.8 percent in 1993. There are major problems in caring for premature infants; 50 percent of infants weighing less than 2,500 grams die, and no baby weighing less than 1 kilogram has survived recently. Causes of neonatal death include sepsis, respiratory disease, hypoxia, and intracranial hemorrhage. Problems with Rh factor incompatibility disease in newborns have risen because of the lack of the immunoglobulin used to prevent sensitization of mothers: parents must supply their own if they can. Phototherapy units and transfusion kits are in short supply. Deliveries of infants in the home are increasing, with the ensuing problems of hypothermia and neurologic damage to the newborns. A particularly severe problem has been the lack of oxygen and functional respiratory equipment; 12 newborns were reported to have died in hospital in 1992 and three in 1993 for the want of oxygen or incubators. As in Zenica, there are sometimes three premature infants per incubator. Hospitals experience sanitation problems because of the lack of basic hygienic materials for washing and sterilization of equipment, and infestations of insects and rats have been noted. Croatia Also greatly affected by the war, the republic of Croatia has maintained good levels of primary health care and maternal and child care despite the war. Although child health services remained in place during and after the war, increased risk factors for pregnant women were noted, including stress, poor diet,

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The Impact of War on Child Health in the Countries of the Former Yugoslavia harder working conditions, generally unfavorable conditions for childbirth, and inadequate care of mothers and newborns after delivery. These factors may result in increased rates of premature births and morbidity and mortality in infants and children, and the resulting defects and disabilities may lead to long-lasting effects that will remain after the war. The health and education infrastructure has been severely damaged, with 15 hospitals or medical centers destroyed and 14 others damaged, and 128 preschool centers, 335 primary schools, and 65 secondary schools damaged or destroyed. Eight homes for children and five children 's rehabilitation centers have been destroyed or damaged. About 30 percent of the health care facilities have been destroyed by war, particularly in the regions of eastern Slavonia, and great burdens have resulted from the economic effects of war and the destruction of facilities. Indications of decreased levels of prenatal care and increased rates of premature births and perinatal mortality are also being reported from Knin, representing a Serbian-held area of Croatia. Common factors include stressful living conditions for pregnant women, the lack of adequate prenatal care, and an inadequate capacity to care for newborns in the hospital because of shortages of medical supplies, oxygen, and disinfectants. Vaccine shortages have been reported, as well as shortages of powdered milk formulas for children in the first year of life. Adequate refrigeration of milk during the summer months is impossible because of frequent power shortages. Rickets has appeared in children, as has iron deficiency. Macedonia Although Macedonia has not been directly affected by war, its health services have been disrupted by a blockade of routes to neighboring Greece. In 1966 Macedonia had a high infant mortality rate (105 per 1,000) but child health services and preventive pediatrics efforts beginning in 1965 successfully reduced infant mortality rates to 28 per 1,000 in 1991. Infant mortality rates are thought to have increased to 32 per 1,000 in 1992 because of advanced maternal age and poor education, as well as perinatal causes, congenital anomalies, and gastrointestinal and respiratory infections. Immunization rates declined in 1992 and 1993 because of the lack of vaccines, secondary to the blockade; vaccine supplies are now dependent on air transport and humanitarian aid sources. Serbia Increases in infant mortality rates have been reported in Serbia (from 21.6 per 1,000 in 1991 to 22.3 per 1,000 in 1992) and in Montenegro (from 11.2 per

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The Impact of War on Child Health in the Countries of the Former Yugoslavia 1,000 in 1991 to 13.2 per 1,000 in 1992). The Kosovo region has always had a higher infant mortality rate than the rest of Serbia (34.4 per 1,000 in 1992). Some cases of neonatal tetanus and poliomyelitis are also being reported. The health care system has been significantly affected by the economic impact of the war and the economic sanctions, with the resulting loss of general resources, medical supplies, medical equipment, and spare parts. In Novi Sad, increases in premature births and birth defects are being reported, as are the complications of anemia, diabetes, and high blood pressure in mothers. A formerly good system of prenatal care, with five to six prenatal visits per mother and the wide use of ultrasound and monitoring devices, has deteriorated. Slovenia Primary health care, preventive medicine, and maternal and infant health are exemplary in this relatively small country, which has been at peace since 1991. All mothers receive prenatal care, all infants are born in a hospital, and all infants and mothers receive routine postnatal follow-up care. The infant mortality rate in Slovenia (8.3 per 1,000 in 1991) is one of the lowest in the world, and immunization rates exceed 90 percent. Summary A formerly good system of primary health care, preventive medicine, and maternal and child health has been disrupted by war in a number of republics, including Bosnia-Herzegovina, Serbia, and to a lesser extent, Croatia and Macedonia. Adverse changes include decreased levels of prenatal care, decreased capacity for monitoring pregnancies, disrupted transport systems for high-risk pregnancies, increasing rates of premature births, decreased capacity to care for premature infants, increasing rates of infant mortality, decreasing immunization rates, widespread incapacity for basic hygiene and sanitation measures, and suggestions of an increase in congenital malformations. The available data are not standardized, however, and are sometimes confusing. The workshop participants generally agreed that the development of standard measurements and the collection of standard data concerning maternal and infant health in all of these countries would be useful for future planning. Prior to its divisions, Yugoslavia had a centralized, state-run health care system that provided widespread access to health care and maternal and child health services. A number of countries, including Serbia, Macedonia, and Slovenia, are now considering measures to privatize the health care systems. This

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The Impact of War on Child Health in the Countries of the Former Yugoslavia has raised concerns about the ultimate effects of such changes on the access of mothers and children to primary and preventive health care and of children to curative health care. Control of the health care system for children is another area of concern. In some countries, such as Slovenia, primary care physicians or family physicians, rather than the pediatricians who have traditionally managed child health services, would direct child health. In some countries, such as Serbia, some aspects of child health such as primary health care and prevention would be transferred to family physicians, and pediatricians would be retained for other duties. Many participants expressed concerns about these changing systems, their economic and social effects on accessibility to medications and services, and the treatment of those who cannot afford to pay for medical care. In addition to these changes in the health care system, tremendous burdens are being imposed on countries such as Bosnia-Herzegovina and Croatia, whose health care and educational facilities have been destroyed and which have lost health care personnel, supplies, and equipment. TRAUMA Even without wars, trauma and injury are major causes of childhood mortality and morbidity and are major reasons for hospitalization and the utilization of health care resources by children in the United States and throughout the world (Institute of Medicine, 1993). Through collaborative efforts, pediatricians and surgeons have sought to improve the means of preventing childhood injuries as well as treating them. Many leading causes of childhood injuries such as falls, motor vehicle accidents, and house fires can be controlled or prevented. Rapid and efficient transport is often missing not only in places of armed conflict but also in many parts of the United States, both urban and rural. Because children's physiologic reserves are less than those of adults, children demand more rapid transport and initial resuscitation. The treatment of multiple trauma and multiple systems injury requires basic principles of care that are well known: achieving an airway, respiration, and circulation. Many emergency physicians are not aware of the special problems of children, such as the anatomical differences of infants that affect the skills required to achieve an open airway. Breathing and ventilation are different in infants and young children; for example, their chest walls are so mobile that a small pneumothorax may cause significant changes, in both circulation and ventilation. The earliest sign of inadequate circulation in the adult is usually a drop in blood pressure, but the earliest sign in a child is an increase in pulse; children's blood pressures do not drop until they have lost 35 to 40 percent of their blood volume. These kinds

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The Impact of War on Child Health in the Countries of the Former Yugoslavia 2 consecutive days of training per month and periodic visits from Institute staff to the centers where pediatricians had been trained. Pediatricians and psychologists from areas with the highest densities of refugees were chosen. In evaluating the effectiveness of such programs, pediatricians were asked to register the psychological symptoms among children who had come to them for somatic illnesses, and a prevalence of the mental disorders detected in children consulting pediatricians was thus established. This approach found that 9 percent of local children, and 30 percent of refugee children, were affected by mental disorders according to the scales used. These findings are very close to the prevalence of disorders detected by mental health professionals, and they suggest that there was no significant difference in the assessments between trained pediatricians and mental health professionals. Furthermore, pediatricians are able to give basic interventions such as family counseling along with the other kinds of treatment needed by children and their families. An increase in violent and aggressive behavior has been noticed in the local populations of children and adolescents in Serbia. It is of concern that adolescents are somewhat of a lost group in the eyes of humanitarian organizations; for example, UNICEF programs provide services for those aged 14 years and younger. Other problematic issues include drug abuse, early engagement in sexual activities, and antisocial behavior. A program of youth clubs established through the Institute was developed in Belgrade and is expanding to other areas. Experience with programs for violent youth in the United States and other parts of the world could provide helpful inputs. A group of 102 refugee children and youth between the ages of 8 and 18 years were studied in Novi Sad. Nearly all were found to have problems, including sadness, anxiety, and easy distraction, differing significantly from the numbers of a control group of local children with such problems. Psychosomatic symptoms were noticed in children 16 years and older, but not in younger children. These refugee children did not identify themselves as people who were taking part in the war, and 84 percent of them assigned a negative meaning to the word refugee. War to them represented stress, family divisions, death of parents or family members, destroyed homes, departure from normal living, and adjusting to a new lifestyle. The Serbian participants in the workshop emphasized the need for scientific information in psychiatry, recommunication with the world medical community, and respite care for the helpers, not only for those working in Belgrade but also for those working in other parts of the country.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Slovenia In Slovenia mental health problems similar to those described in the other former Yugoslav republics have been noticed. Although Slovenia was involved in direct warfare only for a brief period of time in 1991, a rise in violent and antisocial behavior in young people and adolescents and increasing problems with drug use have been documented. These problems seem similar to those described by individuals from the other countries. Slovenia received considerable numbers of refugees, as many as 80,000 to 100,000, mostly from Bosnia-Herzegovina. At present an estimated 30,000 refugees live in Slovenia, with 21,000 of them living with families and 9,000 living in refugee centers. As in other areas, most of the refugee children have suffered mental health consequences. Intervention programs in Slovenia have involved local professionals who have access to children, most notably schoolteachers. Discussants at the workshop noted that psychiatrists have traditionally waited for children to come to them, but that in situations like this, psychiatrists need to enhance the training of those professionals who encounter most children on a regular basis. The involvement of institutions with routine access to children, such as schools and kindergartens, is often important to the success of intervention programs. Innovative efforts have been developed to train teachers in techniques of recognizing and helping disturbed children, and school-based programs appear to be more effective than family-centered interventions. The Slovenian mental health system for children has been severely challenged by the thousands of refugee children who require assistance. Few refugee children went to the clinics for consultation. Mobile teams from mental health clinics visited refugee camps, with a team consisting of psychologists, psychiatrists, and special teachers. As a first step in offering effective assistance, they acknowledged the stressful circumstances in which the refugee families were living. Many teachers in the schools are refugees themselves and they have received special training, psychological help, and consistent support at follow-up visits. Programs of interest in Slovenia included Volunteers Helping Refugee Children, Kindergartens for Refugee Children, and Professional and Vocational Orientation for Eighth-Grade Children. Teenage children in particular are suffering and lack a clear sense of their future careers or vocations. The Slovenians have established mobile mental health teams, visiting centers, and therapeutic interventions for children with more severe problems and are also concerned about the general need for mental health support for caregivers. The matter of simple human kindness in dealing with childhood trauma was emphasized. On a human level, children can learn firsthand that the world is not an entirely bad and unsafe place and that there are caring individuals who wish to do good for rather than evil to children. Such human input may be more practical and important than what is considered traditional psychiatry.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Summary Mental health professionals in the countries of the former Yugoslavia have been quite innovative in their approach to a massive problem. New scientific information is being generated about the impact of traumatic stress on children and young people, and new ways of coping with large-scale disasters and prolonged emotional trauma are being instituted. These efforts may prove to be important in a much wider sphere than the countries of the former Yugoslavia. The evidence at hand suggests that the kind and extent of psychological disturbance depends on a range of factors, including personal vulnerability, family support and stability, and social setting. Psychological effects seem related to the type, the degree, and the duration of exposure to traumatic events, as well as to the number of stressors. Such effects may appear among refugees, the homeless, and those exposed directly to war, as well as individuals, including children, living in traumatized families, under poor economic conditions, and indeed, in a traumatized society where normal childhood development and a normal adolescence have been interrupted by recent events. The implications of these widespread problems for education and health care services are enormous throughout the countries of the former Yugoslavia. Mental health professionals in all of these countries, who had well-developed frameworks for providing mental health services prior to the war, must now address the disruption of care and the destruction of facilities in many areas, as well as shortages of resources. Despite these circumstances, mental health and psychiatric services have been maintained in many regions, and programs have been developed even under the present conditions of war and economic difficulties. Various centers have developed innovative screening and intervention programs that use not only psychiatrists but also other professionals with wide access to children, including teachers, psychologists, and pediatricians. There is concern, however, that the challenge presented by mental health problems in these regions may be greater in the future. In this regard it is important to realize that both already established psychosocial programs and community resources will require long-term support from local governments and from the international community. An additional concern in the mental health field is recognition of the need for supporting the caregivers themselves. Professionals and volunteers alike have been working under grave difficulties with major case loads, and these conditions can traumatize these individuals. It was clear from the information presented at the workshop that any program set up by mental health professionals must also take into consideration the help needed for the caregivers themselves. There is a great opportunity for learning from the experiences of these countries, but research in this field needs to be integrated with intervention services as well as with assisting those affected by the war. With the large

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The Impact of War on Child Health in the Countries of the Former Yugoslavia numbers of affected children, appropriate follow-up programs could help to answer questions about the scale and scope of the impacts of war on children, families, and future generations. CHILD PROTECTION The duty of physicians to render care and protection to patients under all circumstances is expressed in existing instruments including international conventions and professional codes of ethics. Many professional codes include specific reference to the need to protect and care for children, who require greater attention in times of stress and difficult circumstances because of their vulnerability and dependent status. Specific attention to the need to safeguard the human rights of children is included in many international instruments as well, the most pertinent of which is the International Convention on the Rights of the Child (United Nations General Assembly, 1989; Verhellen, 1994; Institute of Medicine, 1994). Although the vast majority of nations have now signed or ratified the International Convention on the Rights of the Child, and although all of the world 's doctors should be governed by codes of professional ethics, effective protection of children in the countries of former Yugoslavia and in many other parts of the world has not occurred. This failure to protect children has an enormous negative impact on child health in the form of direct injuries sustained by children; effects on psychological well-being; the destruction of family, community, and child life; and the disruption of systems of health care and education. Protection of children in difficult circumstances was an important topic at the workshop. Discussions concerned the codes and instruments that might be applicable to the protection of children, the reasons that effective protection of children has not occurred, and possible solutions to this problem. Workshop participants examined the relevance of the Convention, professional codes of ethics, and other related efforts to protect children in difficult circumstances as well as the roles of pediatricians and children's doctors in these situations. Evolution of the Concept of the “Rights of the Child” Until the end of the Middle Ages there seemed to be little social awareness of children as a group. Many children died in early life; their main task was to survive past the age of 6 or 7 years, when they were considered adults. In this system, children were regarded as the father's private property and treated like any other goods. During the Enlightenment of the eighteenth century children were considered differently, as the future makers of an enlightened society. They

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The Impact of War on Child Health in the Countries of the Former Yugoslavia were thus turned into “not-yet” human beings who did not yet exist but who someday would be of great importance to the state. Children were not perceived to have rights in the present but only in the future. The world entered the twentieth century with this image of children. Essentially three main generations of human rights exist at present. The first came about after the American and French Revolutions and evolved into the concept of traditional civil and political rights, such as the right to freedom of assembly, the right to freedom of opinion, and so forth. These first-generational rights provided a defense against sovereign rulers and implied that the state should abstain from interference in the private lives of its citizens. The second generation of human rights, which has come about more recently, deals with economic, social, and cultural rights, such as the right to a minimum income, work, health care, education, and leisure. These second-generational rights imply that the state, in fact, bears some responsibility for the lives of its citizens. Current thinking has now begun to address a third generation of human rights, the so-called solidarity rights, such as the right to peace, the right to a healthy environment, the right to cultural integrity, and so forth. Over the last two decades there have been profound changes in the perceived status of children. Recent human rights movements have viewed children as full-fledged individuals with their own human rights and with competence to exercise them independently, although this latter point is a subject of considerable controversy. The status of the “not-yet” human being has been challenged in a number of ways. This new way of thinking has stimulated considerable controversy concerning the competence of children to exercise their rights independently. The main aim of recent human rights movements has been to consider children as full-fledged individuals with their own human rights and with competence to exercise them independently. The Convention on the Rights of the Child The Convention on the Rights of the Child was adopted by the U.N. General Assembly on November 20, 1989, 30 years after the adoption of the Declaration on the Rights of the Child and 10 years after the International Year of the Child (Verhellen, 1994; Institute of Medicine, 1994; United Nations General Assembly, 1989). This Convention is the legal instrument that has evolved from the moral obligation defined in the 1924 Geneva Declaration and the 1959 Declaration on the Rights of the Child. Within 1 year the required number of United Nations member states had ratified it, and on September 2, 1990, the Convention entered into force. At

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The Impact of War on Child Health in the Countries of the Former Yugoslavia present 171 nations of the world have ratified or signed this Convention; only 19 have not, including the United States. The United Nations Convention on the Rights of the Child reflects wide changes in society. This Convention is made up of an extensive preamble (13 paragraphs) and 54 separate articles. Articles 1 to 41 cover substantive matters, defining the rights of the child and the obligations of state parties ratifying the Convention. Articles 42 to 55 regard procedures for monitoring implementation of the Convention, and Articles 46 to 54 contain formal provisions governing entry into force of the Convention. The Convention is summarized in Appendix C. Workshop participants agreed that although all of the countries of the former Yugoslavia have now ratified this Convention, violations of this document have been frequent in the wars among the countries. Specific provisions of the Convention that are particularly applicable to children caught in the wars of the countries of the former Yugoslavia and wars elsewhere include the articles that address the age definition of children, which is an important consideration in the collection of statistics. The Convention recognizes children as all persons under age 18 (Article 1) or under 15 in the case of military service (Article 38). In collecting trauma statistics, however, the United States applies a standard of 14 years or younger for the age of the child; older children are subject to different kinds of accidents (automobile accidents, alcohol and drug abuse, and so on). Similarly, in Croatia and Bosnia-Herzegovina, adolescent boys are at times serving as soldiers and are also subject to different kinds of trauma. Other articles within the Convention address the state's obligation to protect children from any form of discrimination and to take positive action to promote children's rights, the state 's obligation to provide a child with adequate care when the parents fail to do so or cannot do so, and the state's obligation to use its authority and resources to implement all of the rights contained in the Convention. The Convention states that every child has the inherent right to life, that the state has an obligation to ensure the child's survival and development, and that every child has the right to a name and a nationality and to know and be cared for by his or her parents. The Convention requires the state to protect a child's name, nationality, and family ties; to respect the child's right to freedom of thought, conscience, and religion; and to protect the child from interference with privacy, family, and home. Furthermore, the state shall protect the child from all forms of maltreatment by parents or others, establish appropriate social programs for the prevention of abuse and for the treatment of its victims, and provide special protection for children deprived of family environments. Disabled children have the right to special care, education, and training so that they may enjoy full and decent lives.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia With respect to refugee children, Article 22 states that special protection shall be granted to refugee children or to children seeking refugee status. The Convention states that the child has the right to the highest standard of health and medical care attainable, with special emphasis on the provision of primary and preventive health care and the reduction of infant mortality, and that every child has the right to a standard of living adequate for his or her physical, mental, spiritual, moral, and social development. Additional articles address the child's right to education and schooling; the rights of children of minority communities to enjoy their own culture and practice their own religions and languages; and the child's right to leisure, play, and participation in cultural activities. The Convention states that the state shall protect children from sexual exploitation and abuse; that no child shall be subjected to torture, cruel treatment or punishment, unlawful arrest, or deprivation of liberty; and that the state shall ensure the protection and care of children who are affected by armed conflict as described in relevant international law. In addition, Article 39 states that the state has an obligation to ensure that child victims of armed conflict, torture, neglect, maltreatment, or exploitation receive appropriate care for their recovery and social reintegration. In conclusion, the Convention states that if any standards set in applicable national and international law relevant to the rights of the child are of a higher standard than those set forth in the Convention on the Rights of the Child, then the higher standard shall always apply. Translation of human rights declarations into legally binding treaties requires both monitoring and effective means of enforcement (Verhellen and Spiesschaert, 1994). States that ratify the Convention are obliged to make the rights contained in the Convention widely known to both adults and children. They are also required to submit within 2 years after ratification a country report on the status of children's rights, and follow-up country reports are required every 5 years thereafter. These reports are evaluated and distributed by the Committee on the Rights of the Child, which can also request that special studies be undertaken. All countries of the former Yugoslavia have ratified the Convention, and such country reports will be sought in the near future. Codes of Professional Ethics Throughout history the relief of pain and suffering and the treatment of disease and disability have been viewed as being very important by society. Physicians who perform these crucial functions have been given power and privilege and have received the trust and dependence of their patients. This gives physicians and health care workers very special responsibilities.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia The codes of professional ethics of physicians specifically support the protection of children as human beings. Professional guidelines for physicians' conduct have existed in most societies, although modern medical practice presents new bioethical dilemmas with every technological and scientific advance. The traditions of medical practice have placed greater emphasis on respect for the individual patient 's decisions and integrity, even if the patient is a child. There is no universal agreement about the age at which a child should enter into decisions about treatment or about being used as the subject of research. In the United States, the age of 7 has been selected as an age at which a child can give assent, which means that a child needs to understand treatments or experiments and that the child 's views must be taken into account in making decisions. The oath of Hippocrates, one which physicians all over the world take when they enter medical practice, dates back more than 2,300 years. It states, among other things, “I will keep them [the sick] from harm and injustice.” Hippocrates also addresses both confidentiality and the relationship of physicians to their colleagues. Patient confidentiality is of particular importance in times of war, regardless of the politics of either the patient or the doctor. Centuries after Hippocrates, Maimonides, a physician to the Sultan Saladin in the twelfth century, also had a great influence on medical ethics. In his prayer, Maimonides says, “Preserve the strength of my body and of my soul that they ever be ready to help and support rich and poor, good and bad, and enemy as well as friend.” From this tradition has evolved the obligation of the physician to treat anyone who has a need to be treated without discrimination. Different groups and associations have developed many versions of codes of ethics and professional guidelines. The Declaration of Geneva of the World Medical Association represents a modernized version of the Hippocratic oath (Stover and Nightingale, 1985). An Islamic code of medical ethics dates back to 1981. Medical associations of many countries also have their own codes. In 1980 the American Medical Association produced its code, which is patterned after the Hippocratic oath. The British Medical Association took 100 years between the mid-nineteenth and mid-twentieth centuries to produce a 16-page document that addresses medical ethics; in recent years, the British Medical Association has been active in promoting the professional responsibility of physicians worldwide. Most codes of professional ethics for physicians cover similar points: The professional duty of a physician must be guided by the best interests of the patient without discrimination. The confidentiality of the patient must be protected. Both health and life must be preserved in the best interests of the patient.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia The physician must know the limitations of his or her knowledge and seek consultation when needed. The physician must both teach and continue to learn throughout his or her professional life. The physician must behave honestly and place concern for the needs and well-being of the patient rather than concerns for his or her own person first. The physician must communicate with colleagues. (The workshop described here provides an excellent example in which colleagues from places in very difficult circumstances communicate.) The declaration of the World Medical Association emphasizes that the same regulations and guidelines apply in times of armed conflict as in times of peace. In times of armed conflict, it is completely unethical for a physician to act in any manner not in the patient 's interest, even if the patient is an enemy. The 1975 Declaration of Tokyo, also from the World Medical Association, deals with a difficult subject—the participation of physicians in torture—and prohibits any physician from participating in this activity. Yet a publication of the British Medical Association, Medicine Betrayed (British Medical Association, 1993), documents the breach of this principle in a number of countries all over the world. The Roles of Professional Organizations The international community of physicians and their associations can be important influences in supporting physician colleagues and their families whenever physicians are being pressured to participate in unethical behavior such as torture, breach of confidentiality, falsification of death certificates, falsification of health data, or other abuses for political purposes (Stover and Nightingale, 1985). Publicity regarding such abuses can help generate support from areas outside the country. Outside pressure can make a difference, although the risk remains for those physicians who withstand the pressure but remain in their country. Violations of professional ethics can be policed by the medical profession when necessary. Global consensus on the ethical behavior of physicians is particularly critical when speaking of physicians who care for children, because children are vulnerable and cannot defend themselves. Physicians can serve as advocates not only for their own patients (children in their own vicinities) but also for children everywhere. This includes protection of the human rights of children and fulfilling their obligations as physicians to deliver care to those in their

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The Impact of War on Child Health in the Countries of the Former Yugoslavia community who may be in great need. Physicians are often in a position to be the first to document and see abuses against children. The ethical conduct of physicians is vital to the protection of the human rights of their patients. Yet, medical education often neglects instruction in medical ethics and the role of medical professionals in the protection of human rights. How can physicians help to protect the rights of children within the guidelines of ethical behavior for their professions? One method is to document and publish abuses, including the physical and psychological impacts of war on children. Credible documentation is extremely important, especially the use of accurate data and case histories. Documented cases and reliable data need to be distinguished from impressions and rumors, particularly since health data may be used for political purposes. Medical associations have a responsibility to ensure the accuracy and validity of health data in their own countries so that they cannot be distorted for political purposes. An example of how the presentation of data can be a violation of human rights occurred in Chile during the height of the Pinochet regime, in which the government Ministry of Health published a set of figures about child health. The Chilean Medical Association collected its own data and published a set of figures that was quite different. Chilean children were suffering much more than the government would admit, yet the government data often determined the level of aid that the children of Chile received. Medical associations can do a great deal to protect physicians who are trying to behave ethically under difficult circumstances by documenting abuses. Outside medical groups can often publicize abuses more safely than an individual or group of physicians who reside within the country where the violations occur. Medical associations also have a responsibility to address violations of medical ethics by their own members, such as participation in torture, rape, falsification of records, and breaches of confidentiality. The formation of linkages, or networks, of health professionals can be an important strategy in addressing human rights concerns. Meetings such as the one described here, where physicians from different areas exchange views and information, are extremely valuable opportunities to reflect on the challenges and resources that affect professional ethics in difficult situations. Such linkages can be extended to medical associations, both national and international. Forums for discussions of these issues provide an opportunity for physicians and students to examine exemplary practices for decision making and behavior. In considering the health needs of children in regions characterized by war and violence, the conduct of research requires respect for the rights of the subjects of research. The guidelines recently published by the Council for International Organizations of Medical Sciences are widely accepted and can be

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The Impact of War on Child Health in the Countries of the Former Yugoslavia helpful in this regard. Physicians themselves also have a responsibility to communicate their needs to improve the status of their own patients. Summary The participants observed that violations of the rights of children in the war in the countries of the former Yugoslavia and in other wars affected their health and were thus the proper concern of pediatricians. The participants explored ways to act effectively as a conscience for children in the world today, building on the foundation established by the Convention on the Rights of the Child. All of the countries of the former Yugoslavia are responsible for the rights of the children within their own national boundaries. However, attention to the rights of children should transcend national boundaries and should apply to the children of other states as well. For example, the U.S. participants commented that as advocates for children, health professionals in the United States should seek ways to implement the Convention both within the United States and elsewhere. This matter of collective responsibility for the health and rights of all children was emphasized repeatedly. Hope was also expressed that the lessons learned about the protection of children in the countries of the former Yugoslavia could be applied to children in other war zones. The Convention represents an important vision of the future as well as an innovative legal instrument in implementing the achievement of children's rights. Pediatricians can serve as the consciences for adults regarding children and children's rights and, by making violations visible to the international community, can achieve the realization of better efforts on behalf of children and their families.