War Hospital

by Sheri Fink

  At 6:20 in the evening, Ilijaz and Fatima take the bleeding woman to the operating room to deliver her premature baby by Caesarian section. The surgery lasts just over an hour, and the tiny baby they retrieve weighs only three pounds, four ounces, the smallest baby to be born alive since the war began. They wrap her in cotton wool, show her quickly to her mother, and then take her away to warm her by a stove. Ilijaz, exhausted, thinks it would take a miracle to keep her alive. He walks out of the operating room and heads to the doctors’ lounge to collapse, only to be shocked at the sight of a slight Asian man of indeterminate age waiting there to meet him. The man introduces himself by his first name, Dr. Neak, the long-awaited MSF surgeon from France. He wears large, wire-rimmed glasses on his small, animated face, which winces and jerks, brows jumping, as he speaks. Absently, he strokes a long, stringy goatee. Ilijaz, who has only twice before in his life seen an Asian person face to face, thinks of Ho Chi Minh.

  “I’m very tired,” is practically the first thing Ilijaz tells Neak.

  “Yes, I’m here to replace you,” Neak says. “You can take a few days off.”

  But the next day, with nowhere better to go, Ilijaz is right back at the hospital. He finds that the finger he reattached is a healthy pink, not blue, and scratches that patient’s name off the operating list. The premature baby, under the constant care of nurses, who sit with her next to a stove for warmth and feed her through a tiny tube with a syringe, survives and thrives, becoming the hospital mascot.

  A few days after Neak’s arrival, a twenty-nine-year-old woman is brought to the hospital complaining of abdominal pain. The tall, ravenhaired woman gives a poor history, saying only that she’s felt ill for two days. When Ilijaz presses on the left side of her abdomen, she says it hurts. He palpates something hard that Neak thinks might be an abscess.

  “Are you vomiting or having diarrhea?” Ilijaz asks. The woman giggles and answers strangely.

  “I vomited when I was sick.”

  Ilijaz assumes she is slightly retarded—Neak assumes psychotic. In either case, her description of her symptoms is vague and inconsistent, so they admit her to the internal medicine department for observation. The woman maintains her disturbing sense of good cheer, but she complains that her pains are growing stronger. Without the benefit of x-rays or other imaging techniques to aid in diagnosis, Ilijaz and Neak take her to the operating room for a laparotomy—a surgery to open her abdomen to see what is happening inside.

  Her stomach appears unusual, enlarged. When Ilijaz tries to lift it, he finds it adhered to her intestines. Carefully, he palpates its contours and feels some strange protrusions. He asks the anesthetist to pull back the naso-gastric tube to see if that is the cause. Ilijaz feels again. Nothing has changed. The anesthetist pulls the tube out completely, but the bumps remain.

  Ilijaz opens the stomach and finds a steel factory. Nails. Dozens of them. Ilijaz nearly collapses in shock at the sight. Most, forty-two to be exact, are of the small, two-inch variety, but a handful are three times as long. Just when he thinks he’s found all of them, he spots another slipping its way out of the stomach through the muscular sphincter toward the intestines. Ilijaz removes and examines the nails. Their points are dulled, presumably by stomach acid, so Ilijaz guesses they have lain there a long time. It surprises and relieves him to see that the delicate inner lining of the stomach is intact.

  When the woman awakens after the operation she smiles and laughs and asks Ilijaz, “Doctor, when am I going to get some food?” Five days later, when she has recovered enough to eat and walk again, Ilijaz gathers the nails and takes them into her room to ask why she swallowed them. The woman looks at him as if he is the one who’s retarded, then smiles and changes the subject. Ilijaz never does find out. Someone tacks a bagful of the nails to the wall of the operating theater as a souvenir.

  Nobody knows the extent of psychiatric problems in Srebrenica. An MSF medical coordinator suspects that families are hiding mentally ill relatives to avoid stigma and that the psychiatric knowledge of the local doctors is “minimal.” When MSF established an institution in an old store building, the town authorities opposed it, arguing that there were no psychiatric problems in Srebrenica until “the refugees” arrived from the villages.

  As the weeks pass, the hospital atmosphere improves under Neak’s care. He maintains the supply of Turkish coffee and biscuits in the break room, nabbing the treats from MSF stock when necessary. He returns from weekends off in Belgrade, luggage laden with gifts of jeans, English instruction books, nylon stockings, and shoes for those who, unlike Ilijaz, are not shy to ask him for the things they want. His most popular gift is weekly cigarette paper for the operating room staff, allowing them to smoke their locally grown tobacco leaves without scavenging for paper from, among other things, the Guardian newspapers he brings back with him from Belgrade or the wrappers from the hospital’s sterile tongue depressors (when someone first discovered how suitable the paper was, the staff rampaged through the hospital, opening every single one). Whenever the convoys are blocked and there is little to eat at the hospital, Ilijaz notices Neak slip away at lunchtime to return minutes later with food for the medical staff from the MSF reserves. Neak never smokes a cigarette without sharing it. He finds ways to sneak Ilijaz into the U.N. soldiers’ canteen to buy cigarettes and beer.

  All this Neak does in silence, rarely speaking a word. He seems to enjoy just being in their presence, sitting quietly in the break room as the young doctors and nurses laugh and tease one another like brothers and sisters, choosing a daily “victim” as the butt of jokes.

  Once he walked into the green room while they were watching, for the umpteenth time, one of their Vietnam War movies.

  “Shit,” he said, and walked back out.

  Ilijaz has heard that Neak was born in Vietnam. He wonders what the doctor went through there and whether it explains why he seems to understand the Srebrenicans so well.

  * * *

  THE NEXT MONTHS ARE QUIET, and Neak and Ilijaz focus mainly on the so-called cold surgeries of peacetime—appendectomies, hernia repairs, gall bladder removals, and ulcer operations. Neak even has a chance to try acupuncture on some patients, and the hospital staff starts calling him “the needle guy.” But people in Srebrenica fear that the Serbs, though not attacking overtly, are plotting their undoing in other, more insidious ways. The Bosnian government leaks a copy of “Bio-131-S”— allegedly a secret Yugoslav military strategy for harming Srebrenica’s population through its food supply, which comes, for the most part, on aid trucks from Belgrade.

  The plot revolves around salt. Before the advent of iodized salt, Srebrenica used to be the only region in Bosnia with endemic goiter—thyroid disease caused by lack of dietary iodine. Srebrenicans were nicknamed “goiters,” and the famous seventeenth-century travel writer Evlije Celebije noted that city residents were disfigured by goiter and plagued by diseases caused by having drunk water from the “cursed” creek that ran through town. According to the leaked document, Yugoslav military researchers tested the creek and the water supply around Srebrenica before the war and confirmed its dearth of iodine.

  “Thus,” the report says, “the deprivation of salt from the diet will lead to a number of malfunctions in the so-called endocrine organs and, in the psychological area, will lead persons to experience confusion, instability, and aggressiveness; an inclination toward anarchy and panic; and a susceptibility to psychological manipulation.”

  The locals believe that the Serbs are preventing the U.N. refugee agency from bringing iodized salt into Srebrenica, something the agency denies. Humanitarians suspect foul play within Srebrenica and report that enterprising businessmen are making extremely risky journeys through the mountains to Tuzla or Žepa, or raiding Serb farmhouses across the front lines, to bring back salt to sell on the black market. Their fellow Bosnians, famous oversalters who love sodium chloride almost as much as they love nicotine, plunk down the price in Deutschemarks—thirty to forty per ki
logram in August 1993; sixty in December; and a whopping eighty by January 1994, roughly what it cost before aid convoys began supplying Srebrenica.

  The fears might not be entirely unsubstantiated, though. In his two years of practice before the war, Ilijaz never saw a case of goiter, but in 1994, he begins to diagnose it in some patients. He also diagnoses thyroid cancer and what he thinks are a disproportionately high number of stomach, uterine, and liver cancers, particularly in the young. Although scientists believe cancer takes years to develop, Ilijaz, Fatima, and others of the local doctors wonder whether the Serbs might be contaminating or irradiating their food supply.

  The cancer patients need treatment outside of Srebrenica, but by the spring of 1994, U.N.-organized medical evacuations have been stalled for nearly eight months. The Red Cross, whose physician oversaw the large helicopter evacuation a year ago, now refuses to participate, in large part on principle. Red Cross officials are unwilling to compromise their “humanitarian neutrality” by working with the armed forces of the United Nations.

  Doctors Without Borders officially ceases participation, too, also on a matter of principle: MSF opposes the Serb demand that patients flown out of Srebrenica be exchanged for Serbs living in Bosnian governmentcontrolled areas. Still, during his six months in the enclave, Neak sends list after list of patients to a U.N. evacuation commission in Sarajevo. He never receives so much as a response, and he wonders whether they are even seeking approval from the Serbs for evacuations. Meanwhile, the patients waste away, trapped in Srebrenica.

  Spring 1994 comes, and so, too, the second anniversary of the war. The weather warms and the military situation remains quiet, so the medical staff relaxes, accepting invitations from former patients and their families living in various parts of the enclave. Ilijaz uses these visits with the “common people” to escape from the reality of his everyday life. He brings a walkie-talkie with him and usually doesn’t permit himself to drink, in case of a hospital emergency. Still, he relishes the chance to spend time with his team outside of the hospital.

  After a particular MSF nurse with long black hair, clear white skin, and a natural sort of beauty begins working in Srebrenica, Naser Orić, the Srebrenica commander, starts showing up at parties thrown by Doctors Without Borders. He takes the MSF team on horseback to the countryside for picnics, riding the enclave’s single white horse. Rumor has it that the two are having an affair, which seems to violate MSF’s principle of independence from the military, not to mention the commander’s marriage. On the other hand, this nurse works so hard and is so sympathetic and respectful to the local staff—even going so far as to dress for a party in traditional Bosnian Muslim dimije trousers—that she endears herself to almost every local staff member at the hospital. Then she helps solve one of Srebrenica’s biggest problems.

  In Bosnia, having a baby out of wedlock is considered trouble. There is a special word for it, belaj. But as of the spring of 1994, none of the humanitarian agencies have brought a single means of birth control into the enclave. Women are so desperate to avoid having unwanted children that several infant killings are rumored to have taken place. The police once brought a woman and her newborn to the hospital after catching her trying to drown it in the river. The baby died a few days later.

  In the early months of the war, Dr. Avdo Hasanović, the bulbous-nosed pediatrician who serves as hospital director, watched a woman die of infection after someone tried to terminate her pregnancy with a piece of metal. Avdo had never before performed an abortion and had no books to guide him, but, with some theoretical knowledge, a gynecological table, and a set of instruments he found in the hospital, he began offering the procedure. He “trained” several of the other doctors to do it, too. A few girls in the enclave had been charged with prostitution, rumored to be “seeing” the Canadian soldiers the previous year, and doctors performed three or four abortions for them, free.

  It wasn’t long after beginning to perform abortions that Avdo, in his incompetence, ruptured a woman’s uterus and nearly caused her to hemorrhage to death. Ilijaz helped save her in the operating room, and then he took Avdo aside.

  “This has finished happening,” he told him. “Don’t risk it again. Maybe I won’t be able to fix something more complicated the next time. You’re not competent.”

  “No problem,” Avdo said. “I’ll stop.”

  Since then, Ilijaz has found himself rushing to save the lives of several more women whose abortions Avdo has botched. Avdo’s practice has grown to roughly two abortions a day. The women bring him offerings of cigarettes, coffee, and plum brandy. He calls their “grateful” gestures “good will.” Everyone else—from MSF to the local medical staff—calls it payment. They start referring to him as “Dr. Abortus.”

  In June 1994, the MSF nurse manages to bring 15,000 condoms into the enclave. She wants to distribute them widely and offer them at a popular reopened discotheque, but in Bosnia, condoms are considered odd. They’re things to giggle about, items to wear with prostitutes rather than to use for birth control. Town leaders insist they must be prescribed at the clinic.

  The MSF nurse’s randomized survey of more than 1,000 families shows that well over half of the population wants another means of contraception besides abortion. But while they seem to want the condoms, the Srebrenicans don’t always use them or their packaging as prescribed. Long, thin balloons begin popping up all over town in the hands of children. Patients walking out of the doctor’s office, where paper is in short supply, look down to find their prescriptions written on condom instruction sheets. And MSF staff members still complain of being awoken every Sunday morning by the howls of girls undergoing abortions without anesthesia in a clinic room near their bedrooms. It takes MSF bringing in birth control pills to begin to solve the problem. The demand for the pills is so overwhelming at Fatima’s twice-weekly gynecology clinic that she must delegate the job of dispensing them to nurses.

  * * *

  JULY 6, 1994, IS A SUNNY SUMMER MORNING in Srebrenica. Beneath babyblue skies and green hills, the scent of linden blossoms wafts through the valley as it did two years previously when Srebrenica’s war hospital first opened. Conditions have changed dramatically since that time, when amputations were done with a crude saw and no anesthesia. Now, the eighty-five-bed hospital has departments for emergency, surgery, anesthesia, general medicine, pediatrics, and obstetrics and gynecology. There is a sometimes-functional x-ray machine, a laboratory staff capable of performing urinalysis, hematocrit, blood cell counts and blood typing, and a transfusion service. The hospital’s outpatient clinics average 300 consultations per day, and twelve nurse-staffed dispensaries provide basic services throughout the safe area.

  The operating room has acquired the same sterile, generic look as any operating room in late-twentieth-century U.S. or Europe. There are neat shelves of surgical supplies, a small oxygen concentrating machine, and a wooden box filled with glass ampoules of anesthetics, painkillers, and other operating room drugs in small, neatly labeled bins. The room has a real, adjustable operating table, operating lights, a generator, and the antiseptic smell of a normal medical facility. Medical workers dressed in bright, clean scrubs glide back and forth, laying instruments in place and chatting with one another while preparing for an operation.

  Two local male nurses, trained by MSF anesthesiologists for over a year, now function independently as anesthetists. This morning’s patient lies calmly on the operating table while one of the two anesthetists holds open a shiny metal drum. A male instrument nurse, wearing sterile gloves, selects a hemostat and a shiny silver bowl from among the ample stock of equipment, laying them on a cart atop a sterile, creased green cloth.

  All at once the double doors of the operating room swing open and Dr. Ilijaz Pilav breezes in from the scrub sink, his hands held out in front of his body, dripping wet.

  “Come in, chief!” the men in the room greet him in Bosnian.

  Ilijaz takes a sterile towel from the instrument nurse,
dries his hands, and then waits with mock impatience to be helped into a pair of sterile gloves.

  “I have to put my gloves on, but he’s not serving me well,” Ilijaz teases. His playful eyes are framed from above by his unorthodox surgical cap, a green cloth creation someone made for him in the style of a baseball hat. Ilijaz wears it with its bill pointed backwards. A fringe of dark hair peeks out from the sides of his cap and his sideburns merge into a beard that grows well behind his white paper mask. With his head and most of his face covered, his most notable features are his small, intense eyes and the tuft of hair growing across the bridge of his nose.

  The low cut of Ilijaz’s v-necked scrub shirt reveals the bony prominences of his collarbone and upper ribs. He has not regained many of the forty-five pounds he lost during the worst days of war. His scarecrow appearance is evidence that stress, hard work, and an inadequate diet have continued to wear on him throughout his year in the “safe area.” There are days he can’t stand up due to his back problems, which ibuprofen and even acupuncture with Dr. Neak haven’t touched.

  “Are you afraid?” someone asks the patient.

  “He’s quaking like Armenia.”

  “Who, the professor?” Ilijaz teases the twenty-two-year-old anesthetist who has earned this moniker for being more thorough than his MSF instructors.