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The Impact of War on Child Health in the Countries of the Former Yugoslavia

A Report of a Workshop March 27–30, 1994 Trieste, Italy

INSTITUTE OF MEDICINE

In Collaboration with the Office of International Affairs

NATIONAL RESEARCH COUNCIL

NATIONAL ACADEMY PRESS
Washington, D.C.
1995



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The Impact of War on Child Health in the Countries of the Former Yugoslavia The Impact of War on Child Health in the Countries of the Former Yugoslavia A Report of a Workshop March 27–30, 1994 Trieste, Italy INSTITUTE OF MEDICINE In Collaboration with the Office of International Affairs NATIONAL RESEARCH COUNCIL NATIONAL ACADEMY PRESS Washington, D.C. 1995

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The Impact of War on Child Health in the Countries of the Former Yugoslavia NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W Washington, DC20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce Alberts is president of the National Academy of Sciences. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce Alberts and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council. Support for this project was provided by the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the Soros Humanitarian Foundation, and Ross Products Division of Abbott Laboratories, but the support of these organizations does not imply that they take responsibility for any statements or views expressed in this report. Additional copies of this report are available in limited quantities from: Institute of Medicine 2101 Constitution Avenue, N.W. Washington, DC 20418 Printed in the United States of America Copyright 1995 by the National Academy of Sciences. All rights reserved. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staalichemusseen in Berlin.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia COMMITTEE ON THE IMPACT OF WAR ON CHILD HEALTH IN THE COUNTRIES OF THE FORMER YUGOSLAVIA JANE G. SCHALLER, M.D.,* Chairman, David and Leona KarpProfessor and Chairman of Pediatrics, Tufts University School of Medicine NEIL ANDERSSON, M.D., Senior Research Advisor, United Nations Children's Fund (UNICEF) MARY ELLEN AVERY,M.D.,*,** Professor of Pediatrics, Harvard University School of Medicine ROBERT J. HAGGERTY,M.D.,* Professor of Pediatrics Emeritus, University of Rochester ALEX HALLER,M.D., Professor of Pediatric Surgery, Pediatrics, and Emergency Medicine, The Johns Hopkins Hospital SAMUEL L. KATZ,M.D.,* Wilburt C. Davison Professor of Pediatrics, Duke University Medical Center ELENA O. NIGHTINGALE, M.D., Ph.D.,* Special Advisor to the President, Carnegie Corporation of New York WILLIAM PARRY-JONES, M.D., Professor of Child and Adolescent Psychiatry, The Royal Hospital for Sick Children, Glasgow, Scotland JULIUS RICHMOND, M.D., * Professor of Health Policy Emeritus, Department of Social Medicine, Harvard University School of Medicine EBERHARD SCHMIDT, M.D., Professor of Pediatrics, Universitats-Kinderclinik B, Dusseldorf, Germany JAMES B. WYNGAARDEN, M.D., *,** Foreign Secretary, National Academy of Sciences/Institute of Medicine STAFF Joseph Cassells, Interim Executive Officer, Institute of Medicine Rosemary Chalk, Senior Program Officer, Board on Children and Families, National Research Council and the Institute of Medicine Stephen Deets, Program Specialist, Office for Central Europe and Eurasia Office of International Affairs, National Research Council Terri Barba, Project Assistant, Institute of Medicine James Carroll, Rapporteur Julia Chill, Rapporteur * Member, Institute of Medicine ** Member, National Academy of Sciences

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The Impact of War on Child Health in the Countries of the Former Yugoslavia This page in the original is blank.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Preface The wars that began in 1991 in the countries of the former Yugoslavia have horrified the world. Yugoslavia, a once reasonably affluent country with Western medicine and good standards of child health, was being destroyed in some of the most brutal ways imaginable, and children were suffering greatly. And yet it seemed that no one was capable of intervening. The idea of the workshop described here began in April 1993, during a visit of scientists to Croatia and Slovenia under the auspices of the U.S. National Academy of Sciences (National Research Council, 1993). On that occasion I spent a pleasant day on the Adriatic Sea with several marine scientists from Slovenia, Croatia, and the United States. These scientists were old friends and colleagues who had not met since the war began, but on that sunny day they seemed perfectly happy and able to discuss oceanography and science together. The thought arose that professional concerns should be strong enough to transcend politics and the horrors of war. If marine scientists could meet in this way, why couldn't pediatricians meet to discuss child health and devise plans to remedy the terrible situation for children in many parts of the former Yugoslavia? Furthermore, why couldn't pediatricians reestablish their professional ties and invoke existing codes of professional ethics and international instruments such as the Convention on the Rights of the Child to protect children? The project, which came to be known as the Workshop on Child Health, was convened by the Institute of Medicine in collaboration with the Office of International Affairs of the National Research Council, with additional support from the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the Soros Humanitarian Foundation, and Ross Products Division of Abbott Laboratories. The members of the organizing committee included senior

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The Impact of War on Child Health in the Countries of the Former Yugoslavia representatives of the U.S. academic pediatric community, the American Academy of Pediatrics, the International Pediatric Association, and the Union of National European Pediatric Societies and Associations. Invited participants from the countries of the former Yugoslavia included leaders in child health from their respective countries as well as physicians who knew and could speak about conditions of child health. These participants were chosen as individuals who might have the power to effect change in their own areas. Trieste was chosen as the site for the workshop because it is a neutral territory to which all participants could travel and because it was relatively close to the countries of the former Yugoslavia. Nonetheless, the journeys involved were often long and circuitous because of disruption of travel routes by the war. For example, participants from Bosnia-Herzegovina waited for military flights to take them from Sarajevo to Ancona, Italy, and then embarked on a 17-hour train trip with numerous changes to reach Trieste. Many participants had not left their countries since the war began 2 or 3 years before, and some had had few days off since that time. Some, particularly our colleagues from Bosnia-Herzegovina, were noticeably thin and gaunt because of the circumstances under which they had been working and living. We all arrived, alone or in small groups, on Saturday or Sunday, March 26 or 27, 1994, at a small hotel perched on a hilltop outside Trieste overlooking the Adriatic Sea. None of us of the organizing committee was entirely sure that the invited participants would actually arrive, or that if they did that the workshop could be maintained or that we could really stay together and talk for 4 days. The first official gathering was a reception and a dinner on Sunday, March 27. As the sun was sinking beyond the low mountains over the Adriatic Sea, we all sat down together, somewhat tensely, around a single large banquet table. Midway through the dinner, we began with welcoming remarks from the U.S. National Academy of Sciences and institute of Medicine (James Wyngaarden), the International Pediatric Association (Robert Haggerty), the Union of National European Pediatric Societies and Associations (Eberhardt Schmidt), and the American Academy of Pediatrics (Birt Harvey). Then I gave the following welcoming statement on behalf of the organizing committee: My Friends and Colleagues in Child Health: We of the organizing committee are very happy to greet you here tonight at this Workshop on Child Health. We are both honored and delighted that each and every one of you has been able to come, and we bid everyone a warm welcome! Why are we here? We of the organizing committee are pediatricians and professionals devoted to children's health. We care deeply about child health, we care deeply about our profession and its standards, and we care deeply about you, our professional colleagues. We feel that children everywhere are the proper concern of pediatricians everywhere and that we must all pull together as professionals to help each other and the children whom we serve.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia We hope that this workshop will result in better health for the children of your countries and that, through sharing what we learn here, will result in better health for other children of the world as well. And we also hope that this workshop will result in professional friendships and bonds which will make us all feel part of the world community of pediatricians and children's doctors. In beginning this workshop, we feel that we must acknowledge the horrors and the hostilities and the bitterness of the wars that have beset your countries in recent years. In the cause of child health and of our common professions, we beg you to view this workshop as a moment in time to put these feelings aside and to work together for children and their health. We are all doctors here, and we all share common professional bonds. In this present reality of the horror of war, someone in this world must find the strength and the wisdom to transcend the horror, to rise above the bitterness, and to allow inherent human decency to shine through and guide us all to a better future. Let that someone be each of us here, and let this workshop reflect the mood of the future and not of the past. In the common spirit of our professions, let us talk here about all of our children and about what we can do to help them find better health and better futures. And so may we toast: The health of all of our children. Our common professions and the ideals for which they stand. All of us here tonight and all of us everywhere who work for children. And finally, A better world for all of us and for all of our children. Following these toasts, we asked each person present to rise and introduce himself or herself. The ice was already breaking, but it really melted when the head trauma surgeon from Sarajevo stood up —a man who had had only 3 days off in the last 2 years and who had been working under terribly difficult circumstances. He introduced his 15-year-old son, a refugee in Italy whom he had not seen for 2 years until that day. Barriers dissolved, and people began to tell of their own children and grandchildren, and their own lives. Onetime colleagues greeted each other across the table, and although people hinted at the suffering they had seen and experienced, they also affirmed their hopes for the future. Many of their comments were indeed heartwarming, and nearly all were collegial: “It is good to see old friends again.” “We have not seen you for a long time.” “We must all remember that what has happened to some of us could happen to any of us.” The spirit of the workshop was established that night. The next morning we gathered around a single conference table and began 3 days of sessions that were truly extraordinary in the attentiveness, the hard work, and the generally good

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The Impact of War on Child Health in the Countries of the Former Yugoslavia humor with which the workshop proceeded. There were few formal presentations, but there was much discussion guided by members of the organizing committee who served as chairs of topical sessions. Throughout the workshop there were many moving and meaningful descriptions of what happens to children in wartime. Unfortunately, the participants from former Yugoslavia have had many firsthand experiences in the past 3 years. Their presentations made all of these problems come alive in a vivid way. The organizing committee expressed a deep debt to the participants who have been almost literally in the trenches and who were willing to share their experiences with us. Many indicated that we have been facing a crisis of values in our societies in terms of how to resolve conflict, and that when conflict breaks out we do not consider enough what this does to the lives and futures of children. Our hope is that this report will bring due consideration to what war has done to the health of children in this part of the world and that this knowledge will focus attention on protection of the health of children in difficult circumstances around the world. Jane Green Schaller, M.D. Chairman

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Acknowledgments The logistics of the workshop were difficult, to say the least. The United Nations Children's Fund offices in the countries of the former Yugoslavia were of great assistance in helping with communications, appropriate documents, and travel. We are particularly grateful to Thomas McDermott, the special representative from UNICEF to the former Yugoslavia, and Michel Duprat, the UNICEF physician in the former Yugoslavia, who regularly visits all of the regions. We also thank Sergio Nordio and Mario Andolina for assistance with arrangements in Trieste. The project staff, Joseph Cassells, Rosemary Chalk, Stephen Deets, James Carroll, and Julia Chill, provided valuable support with the administrative, rapporteur, and production tasks associated with the management of the workshop and the development of the final report.

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The Impact of War on Child Health in the Countries of the Former Yugoslavia Participants at the Workshop on Child Health, March 29, 1994, Trieste, Italy. Seated (left to right): Kulenovic and son (Sarajevo), Chill (Washington, D.C.), Avery (Boston), Ivanoska (Skopje), Schaller (Boston), Kos (Ljubljana), Vucak (Zenica), Nightingale (Washington, D.C.), Ispanovic (Belgrade), Begolli (Pristina), and Deets (Washington, D.C.). Standing (left to right): Harvey (Palo Alto), Carroll (Boston), Nordio (Trieste), Krzisnik (Ljubljana), Strbac (Knin), Sofianov (Skopje), Cassells (Washington, D.C.), Schmidt (Dusseldorf), Lolic (Banja Luka), Soce (Mostar), Haggerty (Rochester), Jamakosmanovic (Tuzla), Duprat (UNICEF), interpreter, Andersson (Botswana), interpreter, Haller (Baltimore), Katz (Durham), Krstic (Novi Sad), Ceric (Sarajevo), Parry-Jones (Glasgow), Wyngaarden (Washington, D.C.), Andolina (Trieste), Richmond (Boston), and Radonjic (Belgrade). Not pictured: Banicevic (Belgrade), Fattorini (Zagreb), Grguric (Zagreb), Kuhar (Ljubljana), and Verhellen (Ghent).