The Impact of War on Child Health in the Countries of the Former Yugoslavia (1995) / Chapter Skim
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THE WORKSHOP
THE WORKSHOP
Pages 3-38
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From page 3... ...
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.
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From page 4... ...
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.
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From page 5... ...
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.
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From page 6... ...
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.
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From page 7... ...
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.
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From page 8... ...
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.
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From page 9... ...
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.
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From page 10... ...
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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From page 11... ...
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.
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From page 12... ...
The infant mortality rate in Slovenia (8.3 per 1,000 in 1991 j 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.
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From page 13... ...
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.
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From page 14... ...
The almost equal numbers of killed and wounded overall reflect both the severity of the injuries and the lack of access to care for trauma in many areas; the ratios of killed to wounded in Sarajevo are 1 to 6 for adults and 1 to 9 for children. At Kosevo Hospital in Sarajevo, the largest trauma service in BosniaHerzegovina, 70 to 80 percent of the wounded have been civilians.
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From page 15... ...
. The problems of caring for large numbers of trauma patients have been compounded by the fact that Kosevo Hospital has been heavily bombarded.
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From page 16... ...
At the time of the workshop, the staff on the trauma service consisted of nine general surgeons, two pediatric and three thoracic surgeons, six residents, and about 75 nurses. Supply and Personnel Shortages Since May 1992 the Kosevo Hospital has operated most of the time without communications, a regular water supply, or electricity.
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From page 17... ...
Numbers and Ages of Victims A registry of child victims of the war in Croatia was established in the Institute for Maternal and Child Health in Zagreb in the summer of 1991. This registry has been updated continuously.
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From page 18... ...
Children Killed Children Wounded Age (years) NumberPercentNumberPercent 0-6451912716 7-1039171421 8 1 1-14552322428 15-17763228035 Unknown219293 Total236100802100 SOURCE: Institute for Mother and Child Health, Zagreb, Croatia, March 25, 1994.
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From page 19... ...
The wide distribution of unexploded mines and other ammunition is a major child health hazard in Croatia, and one which will remain for years to come. Unexploded mines, bombs, grenades, and mortars cover the land, particularly in eastern Slavonia.
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From page 20... ...
Appropriate management of childhood trauma demands both pediatricians and surgeons knowledgeable in the principles of pediatric medicine and trauma and trauma services that are geared to the care of children. In general, childhood trauma has been a neglected field throughout the world.
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From page 21... ...
Given the breakdown of safe water supplies and sanitation in war zones, this has been a major problem in many areas of Bosnia-Herzegovina, particularly among populations of displaced people. Gastroenteritis has been a frequent health problem for years in both Macedonia and Kosovo.
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From page 22... ...
These discussions made it quite clear that children wounded or killed by the war were not the only casualties in these conflicts. An increased frequency of nosocomial infections was reported in many hospitals in Serbia by physicians and other health professionals.
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From page 23... ...
There is concern about sexually transmitted diseases, notably AIDS. For children with chronic conditions such as asthma, diabetes, malignancies, seizure disorders, congenital heart disease, birth defects, and chronic disabilities, care has been difficult and inadequate in many areas.
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From page 24... ...
Many acute and chronic illnesses could be prevented by relatively simple measures such as basic hygiene and sanitation; the use of dietary supplements such as iodine, vitamin D, and iron; and the appropriate distribution of needed medications. More challenging problems include the management of complex chronic conditions such as malignancies and heart disease, the delivery of specialized care under difficult circumstances, and the transport of children to centers with the capacity to provide appropriate care.
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From page 25... ...
Brief group psychotherapy has been the only treatment available to traumatized children, most of whom continue to live in stressful environments. In one 6-month program, mental health professionals visited children in their homes because of the dangerous conditions children encountered when they went to the clinics.
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From page 26... ...
A commission to coordinate assistance for child victims of war has been established in Croatia and includes representatives from child health professions in Croatia and also representatives of UNICEF, WHO, and various nongovernmental organizations. This commission has dealt with issues such as nutrition, primary health care, vaccination, and drug therapy and has also helped in the development of programs providing psychosocial assistance.
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From page 27... ...
Mental health services for refugee children have involved primary health care services; school psychologists, and the Red Cross, and other humanitarian organizations have also been involved. The Institute of Mental Health in Belgrade has established training seminars for school psychologists, teachers, and primary health care workers and has prepared a curriculum booklet.
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From page 28... ...
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.
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From page 29... ...
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.
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From page 30... ...
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.
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From page 31... ...
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.
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From page 32... ...
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.
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From page 33... ...
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.
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From page 34... ...
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.
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From page 35... ...
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.
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From page 36... ...
(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.
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From page 37... ...
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.
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From page 38... ...
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.
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