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Findings

The roles of physicians as the conscience of the health community, with specific responsibilities to patients and their families, are not yet well understood or defined. Such roles need to be clearly delineated in times of stress and under conditions such as war, when there may be a blurring or confusion of roles, for in these times the ethical responsibilities of physicians become even more important. The formulation of ethical principles can serve as an important guide for professional activities and behavior regarding refugees, prisoners of war, and all other vulnerable populations. Many workshop participants observed that they had received little or no instruction about ethical issues and limited experience with implementing these principles in clinical settings and in practical situations, which are important to social learning through modeling.

Certain general principles emerged in the workshop discussions, such as the need to keep children with their parents whenever possible, the need to protect children within their home communities whenever possible, and the importance of maintaining basic health, educational, and social service systems for children under conditions of great adversity.

The participants examined how these principles might be implemented during the course of dislocations and upheavals, how professional roles can be exercised to minimize the trauma, and how the lives of families and children can be reintegrated within a context in which their growth and development can proceed in a wholesome fashion. The participants also observed the importance of developing social strategies to foster the interaction of knowledge and policy in serving the needs of children.

The strengths and limitations of professional organizations as advocates for children were discussed, including groups such as WHO, UNICEF, the Union of National European Pediatric Societies and Associations, the International



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The Impact of War on Child Health in the Countries of the Former Yugoslavia Findings The roles of physicians as the conscience of the health community, with specific responsibilities to patients and their families, are not yet well understood or defined. Such roles need to be clearly delineated in times of stress and under conditions such as war, when there may be a blurring or confusion of roles, for in these times the ethical responsibilities of physicians become even more important. The formulation of ethical principles can serve as an important guide for professional activities and behavior regarding refugees, prisoners of war, and all other vulnerable populations. Many workshop participants observed that they had received little or no instruction about ethical issues and limited experience with implementing these principles in clinical settings and in practical situations, which are important to social learning through modeling. Certain general principles emerged in the workshop discussions, such as the need to keep children with their parents whenever possible, the need to protect children within their home communities whenever possible, and the importance of maintaining basic health, educational, and social service systems for children under conditions of great adversity. The participants examined how these principles might be implemented during the course of dislocations and upheavals, how professional roles can be exercised to minimize the trauma, and how the lives of families and children can be reintegrated within a context in which their growth and development can proceed in a wholesome fashion. The participants also observed the importance of developing social strategies to foster the interaction of knowledge and policy in serving the needs of children. The strengths and limitations of professional organizations as advocates for children were discussed, including groups such as WHO, UNICEF, the Union of National European Pediatric Societies and Associations, the International

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Pediatric Association, and the American Academy of Pediatrics. The participants explored the importance of improving communications among themselves and the organizations they represented to reduce the professional isolation experienced by many colleagues under conditions of war and dislocation. In particular, the group proposed that the participants reconvene in the future to continue the process of communication and to sustain the relationships and exchanges that occurred during the course of the workshop. The Convention of the Rights of the Child was recognized as a necessary, but not a sufficient, condition for achieving respect for the rights of children. Individual physicians, children's hospitals, clinics, and other institutions can play important roles as supporters and advocates of the provisions of the Convention and can raise the level of consciousness of colleagues and others in different countries about the relevant provisions of the Convention to child health and well-being. In addition to these general findings, the following conclusions were developed in the workshop discussions. General The wars in the former Yugoslavia have exacted terrible tolls on children and families in all parts of the former Yugoslavia. Children and families have suffered as refugees, as displaced people within their own national borders, or as civilians remaining at home in or outside of war zones. The wars have affected children's physical health, mental health, day-to-day life, and hopes for the future. The wars have also extracted a heavy toll on the health care system through the loss of facilities and infrastructure, the loss of supplies and equipment, and the loss of physicians and nurses; and the economic hardships of war have resulted in fewer resources for health care. Professional concerns about child health, child protection, and medical ethics can transcend political differences. Despite political divisions, pediatricians can cooperate in the interests of child health. For example, spare parts from Serbia were offered for non-functioning incubators in Zenica in Bosnia-Herzegovina, and children from Knin were invited to the Children's Hospital in Zagreb, Croatia. Pediatricians and members of the medical and health professions have an important role to play in using their knowledge and influence to protect children and should use existing international documents such as the Convention on the Rights of the Child and professional documents such as codes of professional ethics. Widespread violations of medical neutrality that are in direct violation of the Geneva Accords have occurred frequently in these wars. Such violations

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The Impact of War on Child Health in the Countries of the Former Yugoslavia include bombardment of hospitals and other health care facilities and direct attacks by bombardment or sniper fire on patients (including children), doctors, health care workers, and ambulances. Such violations were described in both Bosnia-Herzegovina and Croatia. These wars have constituted a tragic laboratory for the study of the effects of war on children, families, civilians, and the health care system. Lessons from the events in the former Yugoslavia can be applied to similar situations elsewhere. There is an enormous opportunity for meaningful research and follow-up in designing and evaluating programs that address the health problems caused by these wars, but such efforts need to be integrated into services designed to benefit the subject populations. Participants from all of the countries of the former Yugoslavia expressed strong feelings of academic isolation and a wish for renewed and increased professional linkages with colleagues and organizations in the world community. Assistance in obtaining books, journals, and other current information; assistance with attending appropriate international meetings; and the possibility of educational exchanges on various levels were all mentioned. Several of the countries represented including Croatia, Macedonia, and Slovenia, have pediatric societies that belong to or that have applied for membership in the International Pediatric Association and the Union of National European Pediatric Societies and Associations. Participants from Bosnia-Herzegovina and Serbia also expressed an intent to organize pediatric societies. The participation of these societies in the international and the Union of National European Pediatric Societies and Associations and represents an important opportunity for building linkages to the world community of pediatricians that can benefit children in these regions. Health care systems for children in the countries of the former Yugoslavia have many needs and require assistance. Consultation with the recipients of such aid regarding their needs, particularly the identification of needs as defined by current situations, will help to strengthen the capacities of the health care systems within the countries themselves. This approach is preferred to evacuating of large numbers of children and adults to be cared for elsewhere. Adolescents have special needs, especially in the realm of mental health. The age standard of many international organizations often inhibits the development of services for the adolescent population. Most resources of and planning performed by the health care community have been focused on survival. When the wars end there will be enormous problems in reconstructing the health care system and in rehabilitating, both physically and mentally, the child and adult victims of war.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Epidemiology Documenting the facts on child health in difficult circumstances requires the selection of valid and practical indicators that reflect the status of health, consideration of the potential uses and abuses of data, and development of a capacity to measure health status under difficult circumstances. Existing techniques include the use of already existing data, opportunistic monitoring, and rapid surveys and appraisals. Community-based surveys can lead the way to in-depth health surveys. The collection of data can provide both the basis for planning as well as an opportunity for community involvement in formulating resources for child health. Reliable data on child health since the onset of the wars are lacking in most areas of the former Yugoslavia. Standardized measures and data collections would be very useful to facilitate the analysis and comparison of regional data. The identification of appropriate measurement instruments for data collection also needs attention. For example, malnutrition has not been a common problem in this part of the world, and available measures and techniques of measurement are not available. There may also be no available instruments to measure effectively the mental health impact of the prolonged trauma on children in these wars. Existing measures are often derived from the examination of the impacts of single catastrophic events. Primary Health Care Breakdowns in primary health care systems, preventive medicine, and maternal and child health care services in the countries of the former Yugoslavia require attention. Although regional differences exist, well-structured programs for the care of mothers and children have been widely disrupted. Health care systems in all of the countries of the former Yugoslavia have been affected, especially in Bosnia-Herzegovina. Widespread destruction of health care facilities has occurred in Bosnia-Herzegovina and Croatia. Many doctors and nurses have left the war zones, and as a result few professionals and facilities are available to care for the increased numbers of sick and injured children and other civilians. Reconstruction of health care facilities will be a major problem when these wars end. Although immunization programs have been compromised in some areas, there have been no major epidemics of diseases preventable by immunization. However, this area remains a serious concern if programs continue to deteriorate. The widespread breakdown of sanitation and hygiene in the war zones and also in areas outside the war zones, including the loss of safe water supplies

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The Impact of War on Child Health in the Countries of the Former Yugoslavia and a general lack of soap, detergent, and disinfectants, has resulted in increases in diarrheal disease, lice, and scabies in many areas. Proposals for the privatization of the health care systems in several countries have generated concerns about the further disruption of maternal and child health care services and the role of pediatricians in a new system of medical services. The result could be a loss of universal health coverage, and the availability of treatment and medications could be based only on the ability to pay. Available statistics indicate increasing infant mortality rates, increasing rates of premature births, and the increasing occurrence of birth defects. Birth rates are decreasing, and abortion rates are increasing. These changes have been most notable in Bosnia-Herzegovina, but were noted in all countries except Slovenia. Maternal nutrition has been poor in many areas. In Mostar, Bosnia-Herzegovina, excessive weight gain by pregnant mothers, who eat the starchy foods available as relief aid, has been associated with an increase in complications during pregnancy, such as eclampsia. No good figures are available concerning malnutrition in children, but many participants repeatedly mentioned the problem of hungry children. Adequate measurements of the nutritional states of children may be a problem. Widespread shortages of supplies and equipment have resulted in a number of preventable deaths. The items in short supply include respirators for infants and oxygen; drugs such as insulin, anticonvulsants, and antibiotics; as well as vaccines. These shortages may result from the lack of supplies or the inadequate distribution of the available supplies. Participants from Serbia reported that economic sanctions were a major cause of the declining state of health in their country. The economic strains of war also contribute to the diversion of resources from the health care system. The economic sanctions contain provisions for humanitarian aid, but these provisions are not thought to have been adequate or effective in allowing access to medical supplies and the basic commodities necessary for health and health care. Trauma War-related trauma has become a major cause of childhood mortality and morbidity, particularly in Bosnia-Herzegovina but also in Croatia. The majority of war-related deaths and injuries have resulted from direct shellings, bombardment, and sniper fire on civilians. Some snipers have targeted children. Unexploded land mines, small arms, and other types of weapons pose a major health hazard to children, and a number of incidents of death and injury

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The Impact of War on Child Health in the Countries of the Former Yugoslavia have been reported in Croatia and Bosnia-Herzegovina, and in war areas such as Knin and Banja Luka. Such weapons are widely strewn about; children stumble on them and use them as toys when they find them. Indeed, children in most areas of the former Yugoslavia are playing war games. The full extent of this danger is not known; most children in Bosnia-Herzegovina, for example, have not been outside of shelters for any prolonged period of time. The mines and unexploded weapons there will remain a health hazard for children for years to come. Maintaining adequate transport systems for trauma victims has posed an enormous problem. Transport has been disrupted by war and by the long circuitous routes necessitated by political divisions, resulting in increased mortality of wounded patients. Trauma teams have been sent to the front lines in both Croatia and Bosnia-Herzegovina. Trauma is an important cause of mortality and morbidity for children all around the world, and a background of similar trauma also exists in all of the countries of the former Yugoslavia. Those who are responsible for trauma care for children require special training to understand the care needs of children that differ from those of adults. The collaboration of pediatricians and surgeons in the early management of trauma is essential. In the future the rehabilitation of trauma victims will require increased attention. Prevention of trauma is another important consideration, especially with regard to safety programs, including mine and weapon removal efforts, in the countries of the former Yugoslavia. Children directly affected by trauma are not the only victims of these wars. Routine therapy for children affected with common conditions such as cleft lip and palate and congenitally dislocated hips has often been deferred because of the load of trauma patients in selected areas, including Croatia and Bosnia-Herzegovina. Such children, even though they have treatable conditions, may suffer long-lasting ill-effects because of their lack of timely care. Other medical conditions such as childhood cancer, congenital heart disease, and malformations such as esophageal atresia have been impossible to manage in many areas. Evacuation of wounded children is not always the best solution to their care. It is often preferable to strengthen the local care systems available in the home area. If children are evacuated, members of their immediate families need to accompany them. There is a great need for surgical services, particularly in Bosnia-Herzegovina. Surgeons with special technical skills such as microsurgery and plastic surgery and equipment such as external fixation devices are needed. However, it is essential that recipients be consulted about their needs before developing any program of assistance.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Acute and Chronic Illnesses Morbidity and mortality from both acute and chronic illnesses in children have increased as a result of the war. Acute infectious diseases have included gastroenteritis and hepatitis. Several contained epidemics of salmonella have been reported, but no typhus or cholera has been reported. Infestations with scabies and lice have also increased. Concerning chronic infectious diseases, there is concern that the incidence of tuberculosis may increase, at least among adults. BCG vaccine, purified protein derivative, X-ray film, and laboratory facilities for detecting mycobacteria in sputum are lacking, and antituberculous drugs are in short supply. Human immunodeficiency virus infection and AIDS are also of concern, particularly given the history of rape and sexual abuse in these wars. Several cases of HIV infection are already known in Sarajevo. Diabetes mellitus, asthma, seizure disorders, malignancies, congenital heart disease, and birth defects have all posed problems because of either decreased drug availability or a decreased capacity of the health care system to provide care. Factors 8 and 9 are not available for individuals with hemophilia. Rheumatic fever remains present, although it is not clear whether this is an increasing problem. In spite of attendant problems, evacuation of children for care of complex conditions such as congenital heart disease may be necessary when adequate care is not available at home. An increase in nosocomial infections was reported in Serbia. Surprisingly, salmonella was mentioned as one of the offending organisms. Deficiency diseases such as rickets, iodine-deficient goiter, and iron deficiency anemia were noted in several areas. Widespread shortages of drugs including insulin, antibiotics, asthma medications, anticonvulsants, and simple preparations such as aspirin, iron, iodine, and vitamin D have been reported. These shortages may be related to supply or distribution problems. Mental Health Mental health problems pose a massive health concern in all of the countries of the former Yugoslavia and may prove to be the most devastating health problem resulting from the wars. There is great concern that after the wars mental health problems will emerge as an even larger problem than they seem at present. The majority of children living in the countries of the former Yugoslavia seem to be at risk of mental health problems. This includes both those children who are directly affected by war and those who are living under difficult

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The Impact of War on Child Health in the Countries of the Former Yugoslavia circumstances in a traumatized society. Children from many areas now play war games, and exhibit a pervasive sadness. The effects of prolonged exposure to multiple stresses, as opposed to those of a single catastrophic event, appear to be additive, but these effects are poorly understood. Additional research and new measurement instruments are needed to determine the dose and duration of exposure to severe stress and the outcomes of these experiences. All areas of the lives of children living in war zones have suffered terribly, including the disruption of education and the social order. A rise in violent and delinquent behavior, drug usage, and sexual promiscuity has been noticed in adolescents in a number of countries. Prostitution has been reported in girls as young as 11 or 12 years. Suicide has also become a problem in children. The widespread nature of mental health problems has caused mental health professionals in these regions to devise new ways of therapy that entail the training and utilization of community professionals such as teachers. Child Protection All countries of the former Yugoslavia have ratified the Convention on the Rights of the Child, but this Convention is being widely violated. Within the next few years all countries will be required to present a country report to the Commission on the Convention in Geneva, offering an opportunity for the discussion of problems. Codes of professional ethics of physicians and pediatricians have not served effectively to protect children. Adherence to codes of medical ethics and professional standards are extremely important in times of war. Pediatricians bear a collective responsibility for protecting the children in their regions, and indeed throughout the world. Pediatricians have an important role to exercise in educating policymakers and service providers about the special needs of children in these regions. This role requires careful documentation and the reporting of abuses. The dissemination of the Convention in children's hospitals and incorporation of the Convention into the curricula of medical students and residents are important ways of increasing public awareness of its existence and purpose. The teaching of medical and professional ethics is an important component of medical education, particularly when incorporated into clinical settings.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Professional Development The professional isolation of colleagues in these regions requires the identification of ways in which collegial ties can be established both internally and with the world medical community. Professional development in these regions will require access to current scientific and health information and participation in the international academic community. Practical needs for teaching and training in professional areas not adequately represented in the countries of the former Yugoslavia also need attention.

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