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Democratic health care for a democratic Kosovo

2002; Elsevier BV; Volume: 360; Linguagem: Inglês

10.1016/s0140-6736(02)11821-6

1474-547X

A.I. Nussbaum,

Balkans: History, Politics, Society

Andrew Nussbaum worked in Kosovo as a volunteer field representative for the International Balkan Peace team in 2000. Working as an international volunteer in Kosovo was hard, but living there as a citizen was close to impossible. Already a poor province before the war in 1999, the ethnic conflict that followed destroyed the fragile agrarian economy and the country's infrastructure. Food and water were already in short supply, of the poorest quality, and probably also polluted by depleted uranium used by NATO in their munitions. The health-care community can only wait for the long-term effects of such pollution. Electricity was at best erratic, especially in the municipalities outside Prishtina, the capital. The uncertainties of life in Kosovo were exacerbated by the politics of the land. Extremists and criminals within the Albanian community were vying for political power and money; exacting revenge for their own victimisation by the Yugoslav authorities and their supporters in the years before the war; and revisiting old prejudices against other minorities, Ashkala, Roma, Goran, and others in the same fashion. The most popular tools for revenge and power were violence and intimidation, which took lives and controlled the population—minorities and majorities alike—through the fear they inspired. In the broadest terms, this was the state of the province I came to in the summer of 2000 under the vague job title of field representative for a small non-governmental organisation, the International Balkan Peace Team, who had a commitment to non-violence and non-partisanship. I was one of a team of five placed in the field to implement cross-community initiatives between the different and opposing ethnic communities—in this instance, the Albanian majority and the Goran (Slavic Muslim) minority. Three of us worked in Dragash, the southernmost municipality of Kosovo, which is dominated by the Sharri Mountains, and bordered by Albania in the southeast and Macedonia in the southwest. The flagship project was a youth centre, set up in what was once a post office, between the Turkish K-for (Kosovo force) barracks and the police station (CivPol), in Dragash Town. The town also had a school to which students caught buses from the outlying villages, and then home again; a municipal building for the local government and the United Nations Mission in Kosovo (UNMIK); and a hospital from which I got a bird's eye view of health care in Kosovo. Parked outside the hospital was an ambulance from the 1970s. The hospital itself seemed too big for the nurse and doctor who occasionally staffed it. In the time that I was there, I heard of only one incident in which the hospital received a patient; most patients went to Prishtina, where a wider range of treatment was available. In one of the explosions that occurred during our tenure in the town, a friend lost her life. We had been visiting with her in her garden as she prepared food. The electricity was out again so she was going to use the wood-stove in the garden shed. 10 min later, back on the balcony of our own apartment, we saw an explosion that shot debris 200 feet into the air. According to sources at CivPol, her son had hidden explosives in the wood-stove; in the months before this event, the electricity supply had been consistent and the son had hidden the explosives in the wood-stove, thinking that it would not be used. The tragedy of the explosion was in the media for days to follow. Each version of the event pursued its own political agenda—the father was the local leader of LDK, the political party currently in power and led by Ibrahim Rugova. The mother was driven to the hospital in Prishtina over 3 h away. She was already dead from the force of the blast, but having to travel such a distance is the plight of so many who live in isolated places and require emergency care. The young Goran neighbour who responded to the blast and found the body was taken to the local hospital suffering from shock. After receiving an injection to calm him he was sent home. A health-care infrastructure weakened by years of Serbian oppression before the war, destruction by the war, and the poverty of a post-war Kosovo unable to rebuild it, is compounded by a population habituated to the health problems created by mental and physical violent conflict. This habituation has become so extreme that it borders on indifference to the possibility of a better and healthier future. A psychiatrist ran a private clinic treating people with post-traumatic stress syndrome and other mental illnesses. Although he was a Goran, all sides respected him for his services to the region. He was one of the few Gorans who could move freely from village to village despite his ethnicity. Most Gorans could not even travel to the closest major city, Prizren. Eventually, bending to pressure from Albanian extremists and the lack of opportunities for himself and his family, he left to set up a practice elsewhere in Europe—following the tide of skilled Albanians, Gorans, Serbs, and others. In the decade before the war, the Kosovar Albanians created a parallel system in response to the oppression by the Yugoslav authorities that had excluded them from all realms: education, work, and health care. Clinics and schools were set up in private residences and wages were paid by a voluntary tax levied on the population. With the start of war, the parallel system that had been a practical success and a flagship example to civil rights movements worldwide fell apart. Albanians ran the risk of detention and arrest, and the chances of receiving medical attention became increasingly arbitrary. Patients were treated only if they paid or brought their own drugs, and if they could get past the guards outside major hospitals. When the war ended, the problems that had been kept in check by the parallel system became too great. There were too many patients and those who had worked in the parallel system had nowhere to work and nothing to work with. The extent of the health-care system's demise struck me on arrival: in the middle of a food poisoning epidemic. It was the hottest summer the locals could remember, so they claimed. It was hard to sit in cars; people spent most of the day on their balconies. On the street, meat in the butcher shop sweated and on the grills of the numerous and popular kebab shops, the meat sat until someone bought it. This meat came from cows fed on the rubbish that piled up on the sides of the road. Without money for sanitation, no-one cleaned up the rubbish. One volunteer couldn't get rid of the illness until she returned to the USA. I couldn't digest solid food for 5 days. British K-for refused to treat me on the basis that I did not have a life-threatening injury, but treatment did finally come from a clinic reserved for UNMIK employees. One system of treatment was available to foreigners and one to locals, just as the traffic violations of foreigners were overlooked by what was in the beginning a mainly international police force. However, in the months I was there, change became visible. The Dragash Town pharmacy became fully stocked, Prishtina University started functioning again, the piles of rubbish were ever present but lower, and many schools now had computers. The problems are still serious and the solutions themselves bring problems. As soon as hospitals are restocked, they are robbed; as soon as people are trained, they leave the province—driven away by fear and poverty. Every new programme implemented by the UN and others brings cultural clashes. The parallel system was a model for development of a civil society that grew out of a population's need, using its own methods. There is no doubt that outside help is necessary and welcome, but as the years go by the welcome could turn to resentment if people feel they are not in charge of what they fought for—their freedom. Health care is one component of a healthy democracy and a yardstick by which to measure that health. People must take part in the improvement of their health-care system and be left in charge on their own terms, but while Serbs and others are excluded from the health-care system and the rest of society, as Albanians once were, the old conflict remains. The question then arises: when will the democracy in Kosovo come into being if health care, education, employment, and personal freedom are not available to all equally? What is required is that health care is separated from politics and that the country changes from one supported by aid to one with increased self-sufficiency and self-government—from habituation to hope.