War Hospital

by Sheri Fink

  The United States also had surveillance drones and observation satellites focused on eastern Bosnia, as the release of several before and after satellite photographs of mass graves reveals. Soon after the massacre, a diverse coalition of activist groups, prominent citizens, and congressional representatives applied for the release of other surveillance photographs and reports under the U.S. Freedom of Information Act, with the aim of ascertaining whether the United States had information about the massacres during the several-day period they were being committed.

  The Department of Defense, CIA, and State Department, citing concerns about national security and the divulgement of sources and intelligence-gathering techniques, refused to provide the specific information sought. The group filed a lawsuit for release of the information, “Students Against Genocide et al. vs. State Department,” but was denied in District Court and on appeal. The question of how much the United States knew and when remains unanswered. Many of the groups that initiated the lawsuit, including the named plaintiff, the group I led as a medical student, are now defunct. It remains for others to renew the campaign for release of this information, as well as the results of an investigation, rumored to have been conducted by the United States, of the use of chemical weapons in the attack on Srebrenica. On January 31, 2003, Doctors Without Borders called upon the United States and Great Britain to heed the U.N.’s request and conduct public investigations into the fall of Srebrenica.

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  FINALLY, WHAT TO MAKE OF THE ROLE of the individual humanitarians and doctors in this story? Without in any way minimizing the major issue, genocide, and the blame belonging to those who committed the massacre, I would like to examine a few other moral questions related to aid and medical assistance.

  Many MSF staff members involved with Srebrenica believe that international political leaders used them and their work as a cover for states’ unwillingness to intervene decisively to end the war. Some feel that they themselves bear part of the responsibility for the deaths that occurred as an unintended consequence of their work. The question is, what can humanitarians possibly do to prevent being used this way in the future?

  One idea is that aid workers should refuse to participate in missions that lend populations a false sense of security. In August 2000, MSF pulled its medical teams out of parts of Kosovo. The statement announcing the pull-out reads as if it could have been written about Srebrenica seven years earlier:

  “MSF questions the appropriateness of humanitarian medical and psychological assistance when, in the presence of internationally mandated protection forces, the fundamental rights of people are being denied.”

  Not surprisingly, Dr. Eric Dachy helped draft the statement.

  But would Srebrenicans have been better off had MSF launched a major publicity campaign to get them out of the jail-like enclave before it fell, and in so doing risked losing MSF’s permission from Serb authorities to work there? Eric Dachy thinks so now. While some staff members rang alarm bells within MSF about the situation in Srebrenica in 1994 and 1995, overall MSF was lulled over months and years of routine into accepting Srebrenica as a normal work place. Eric regrets having dismissed the U.N. refugee agency’s idea of evacuating Srebrenica in 1993. At the time, it was an odious idea to assist the Serb military in “ethnic cleansing,” but it would have been the lesser of two evils (although it must be pointed out that it is very far from sure that Serb forces would have permitted Srebrenica’s menfolk to be evacuated even in 1993). In retrospect, Eric compares Srebrenica to a dying patient who MSF, along with General Morillon and others, put on artificial life support.

  “I think we made a strategic mistake,” says Eric. “If people wanted to leave they should have been given a chance to leave.”

  On another topic, many of the doctors involved in these events found they could not remain neutral in the face of atrocities. The revered principle of medical neutrality, a construct drawing on international humanitarian and human rights law, in combination with medical ethics, begs wider examination. Whenever doctors shot guns or engaged in military planning, they effectively forfeited their special protected status under international law. (Doctors are allowed to carry guns in wartime, but only for their personal protection—medical neutrality simply requires they treat any patient who needs their care, without regard to factors besides medical need, and that they don’t participate in the fighting.) Certain humanitarian groups, traditionally bound by the related principle of humanitarian neutrality (which includes the demand that they not ally themselves with one or another side in a conflict), seemingly renounced their neutrality when they called publicly for military action against forces violating international humanitarian and human rights law. A notable example was MSF President Rony Brauman’s call for military intervention in Bosnia in 1992.

  I would argue that there is nothing inherently unethical about doctors engaging in or calling for military activity against forces committing atrocities. In fact, quite the opposite. This is not about taking sides in a territorial conflict—it is about taking the side of the almost universally recognized humanitarian and human rights principles. Neutrality in the face of genocide amounts to complicity.

  There are times when the higher moral duty to oppose attacks on civilians should outrank the doctor’s loyalty to medical principles or the aid worker’s loyalty to humanitarian principles. Of course, because doctors have no particular expertise in military matters, diplomacy, or conflict resolution, there is a limit to how far to go with this. But military intervention or advocating military intervention must remain an option for those who would act to prevent crimes against humanity. This remains a highly controversial topic in medical circles.

  On a related note, even strict adherence to the concept of humanitarian neutrality should not prevent international aid workers from assisting wounded combatants who are, by definition, hors de combat. So many aid groups, MSF included (as described in this book), shy from such activity, demanding that soldiers be kept out of the hospitals where the aid groups operate and focusing their efforts instead on the civilian victims of war. I have witnessed this on the ground in all of the war-torn regions I have visited—aid workers don’t want to touch soldiers. However, refusing to treat soldiers who have no other medical options is a breach of a fundamental medical tenet: Physicians must provide emergency care unless assured that others are willing and able to give such care (incidentally, by the same principle, Dutch military doctors were wrong to deny emergency care to Srebrenica civilians in July 1995, based on their military order to keep an “iron ration” for themselves; and any medical workers who went on strike, left, or otherwise refused to treat patients from Srebrenica could rightly do so only to the extent that there was someone else available to treat patients or—I would argue—in cases where their own safety would have been put at grave risk for doing so). It should not be forgotten that the Red Cross itself, the bastion of humanitarian neutrality, had its genesis with the wounded soldiers on the battlefields of Solferino.

  On the other side, what is it worth to maintain one’s neutrality these days? Taking the example of Srebrenica, combatants, particularly Bosnian Serb forces (who fired on Srebrenica Hospital and the grounds of the 1993 medical evacuation, detained and killed patients and medical workers, and repeatedly denied access to humanitarian assistance) but also Srebrenica’s soldiers (who killed a Serb nurse in the war’s early days) and the Bosnian government (which included military supplies on helicopters bound for Srebrenica that were marked with a red cross—thus abrogating their neutral status and making them legitimate military targets) failed from the very beginning of the war to respect the neutrality and protected status of medical workers and medical objects.

  This begs another question: How can doctors and humanitarians who are observing medical neutrality and humanitarian impartiality assure their own protection? From the first MSF workers to be injured in Vukovar, experiences in the former Yugoslavia throughout the 1990s have left many aid work
ers questioning how to go about assuring their own safety when respect for the Geneva Conventions can no longer be counted upon for their protection. Many humanitarians were and are unwilling to accept armed protection from militaries: Independence from military authorities is a fundamental concept of humanitarian work, and one over which MSF in Srebrenica was even willing to go on strike.

  In the case of Bosnia, however, humanitarians, including Eric Dachy, wouldn’t have been able to function in places like Srebrenica without at times accepting military escorts. It was simply the only way for him to get access to the people who needed him and to perform his humanitarian work. The humanitarian-military cooperation and military involvement in humanitarian assistance that Eric and other aid workers first witnessed in northern Iraq in 1991 has only expanded since Bosnia; there are many examples, including Kosovo in 1999 and, in the post-9/11 world, Afghanistan. In the latter, it was feared that a blurring of the distinction between military and humanitarian actors was leading to the targeting of neutral aid workers. In the spring of 2003, the controversy reached its highest pitch in Iraq. Aid groups split over whether and how much to cooperate with coalition (U.S., Great Britain, Australia) military to gain access to populations in a highly insecure environment; whether to “boycott” a major funding source—the U.S. government—if the U.S. Department of Defense, rather than the U.S. State Department, maintained control of relief efforts; and whether to work at all in post-war Iraq, given the capability and legal responsibility of the “occupying powers” to assure adequate health service delivery.

  In theory, traditional humanitarianism requires independence from governments and militaries (impartiality—providing aid based on need alone—is the fundamental precept of humanitarians, and adherence to the principles of independence and neutrality help to ensure it); in reality, most NGOs require government funding (inevitably meted out according to political priorities) to function and military intervention or protection to reach certain target populations. The humanitarian community, with its “classicist” versus its “political humanitarians,” still struggles with these contradictions. A search for other options is under way, from private funding of NGOs and the U.N.’s Central Emergency Trust Fund to the European Rapid Reaction Force and the creation of a capable U.N. intervention force. For now, the coexistence of orthodoxy and pragmatic reform related to humanitarian independence, neutrality, and speaking out about human rights violations allows some humanitarian organizations to operate more effectively in some situations, and others in other situations. The fact that the international order and the nature of conflicts have continued to change in the years since Srebrenica fell, with no let up in human suffering, shows that humanitarians must remain flexible and open to constant reexamination of their work in order to remain effective.

  Finally, the shining example of a doctor who observed medical neutrality in this book was Boro Lazić, who repeatedly demonstrated his willingness to treat all who requested his assistance, regardless of their ethnicity, and never took part in the fighting. How ironic that he ended up serving the forces that committed the greatest act of genocide on European soil in fifty years.

  There is a burgeoning idea among medical leaders and ethicists, such as the renowned Arthur Caplan of the University of Pennsylvania, that “medical neutrality is not enough.” It is a doctor’s special duty, as someone dedicated to healing and the preservation of health, to protest atrocities. By this principle, it would have been incumbent upon all of the doctors in this story to speak out and try to stop human rights violations being conducted by the military forces with whom they had contact. Of course, this would not have been an easy task. In the case of the Bosnian doctors—both Serb and Muslim—it could have put them in significant danger. So, too, with the Doctors Without Borders internationals, who had to balance condemning those authorities who violated human rights (like Radovan Karadžić) and working with them to gain access to people in need.

  That tension—between carrying out their duties as doctors and humanitarians and ensuring their own safety and survival—was one that every health professional in this book was forced to face. Each of them, as a result of their individual personalities and belief systems, made different decisions about how to react to the war zone, when to practice medicine, when to refuse to do so, when to speak out about moral issues, when to keep silent, when to participate in military actions, when to enter dangerous areas, and when to leave their patients behind. A great deal can be learned from the dignity and humanity every one of them showed in the outrageous situations in which they found themselves.

  It is my great, albeit unrealistic, hope that no doctors or nurses will ever again have to face such decisions.

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  YOU MAY BE INTERESTED in knowing the fates of the main characters and their reflections on the events described in this book.

  —Dr. Boro Lazić opened his own psychiatry clinic in Belgrade, Serbia, the Special Hospital for Addiction Medicine, in March 2003. After returning home from the offensives on Srebrenica and Žepa, he tuned into Bosnian television and saw a hospital bedside interview with Sadik Ahmetović, learning that the medical technician he helped save was indeed alive. (Sadik later went on to become vice president of the Srebrenica municipal assembly in the Serb Republic, elected because thousands of displaced Srebrenicans voted for government representatives in absentia.) War followed Boro and Boro followed war. After the peace settlement in Bosnia, his sense of adventure and desire to earn money led him to enlist as a mercenary with Mobutu Sese Seko’s troops in Zaire. Seko’s regime was overthrown and Zaire became Congo. Boro returned to Bosnia, gave up on the idea of training in surgery, and moved to Belgrade, Serbia, to do a residency in psychiatry. There, he found himself caught in yet another war, NATO’s 1999 bombing of Serbia over Kosovo. He is hopeful that his war days are over.

  Boro has visited Dr. Nedret Mujkanović several times in Tuzla, where they attended medical school together. The doctors of Srebrenica Hospital maintain the highest regard for Boro and what he did for them.

  Boro looks back on his war years as a “painful, dirty, torturous” experience, and he considers himself one of the many “ordinary, little people” who suffered in a war led by politicians and soldiers. However, he remains proud of having helped others and carries with him one enduring lesson: “Good should be done regardless of the difficulty of the times and regardless of the level of power or importance that one possesses.”

  —Dr. Nedret Mujkanović won the Golden Lily, the highest medal of the Bosnian army, for his year of volunteer service in Srebrenica. After his whirlwind trip to Croatia and France with Bianca Jagger, he returned to Bosnia and completed training in plastic surgery, finding himself much more capable of handling difficult moments in the operating theater than his colleague trainees who hadn’t worked in Srebrenica. In July 1995, he stood at the edge of the battlefield and watched as the surviving Srebrenicans broke through the front line and entered free territory near Tuzla. In 1999, he returned for the first time to the abandoned hospital in the Serb-held town of Srebrenica with the author, posing as her driver. The Serb doctors leading a tour of the empty hospital must have thought it strange that this “driver” asked to take a copy of a medical book, Sudski Medicine, that he found lying on a chair on the second floor. It had been his book in Srebrenica.

  For several years, Nedret served as minister of health of the Tuzla Canton, and in 2003 he became director of the Tuzla Clinical Center. He often intervened to assist friends from Srebrenica. They speak of him fondly as their champion.

  —Dr. Ejub Alić works as an internist in a town called Srebrenik outside of the city of Tuzla. Every afternoon he returns home to the top floor of a split-level house (built after the war with monetary assistance from the guilt-stricken Dutch government) and to his bright son, Denis, and his beloved wife, Mubina. They sat, arm in arm, throughout the hours-long interviews for this book. In the fall of 2001, Ejub returned to Srebrenica as a physician, voluntee
ring once a week to staff a clinic where both Serbs and the small but growing number of returning Muslims seek care.

  —Dr. Eric Dachy learned of Srebrenica’s fall one morning in July 1995, when reading the French newspaper Liberation.

  “It really slashed me,” he recalls. “I thought: Shit, Ilijaz and the others, they might be dead. Suddenly I realized all we did during these two years not only was canceled, but maybe made it worse! And that the evil forces that were working there had not been stopped at all. Never. They simply went to the end of what they intended to do. And no one ever changed, no one ever helped anybody. And then of course my philosophy became questions, and I realized that to help did not work. Not in such circumstances. There is no justice without power and humanitarian compassion is not power.” He sat and thought a long time of Ilijaz and the others and wondered if they would survive.

  Srebrenica’s fall cast Eric’s entire personal philosophy into doubt. As part of his subsequent soul-searching, he began writing a memoir of his time in the former Yugoslavia, and he concluded an early draft with this reflection:

  Injustice, which I loath so strongly, which I fight against, is in fact a part of reality. My rebellion was vain because, in a way, I wanted to eradicate the evil. I must tell this story, but not cast blame or foment fear. I no longer want to strike others with the weight of the world’s suffering. As for the violence and evil that I brushed up against, I no longer want to oppose such things with anger, but rather with intelligence.

  …My destiny has returned to its own place, at home, with a broader vision of my past…. In this rediscovered peace, liberated from any mad idealism as well as of any bitter resignation, I view the world differently. A game of good and evil. Everyone chooses a side. With more or less determination. The future is open and belongs to us.

  Less idealistic, perhaps, but still passionate, Eric overcame his disillusionment and returned to aid work. He went on to serve as a research director for MSF’s headquarters in Brussels, Belgium, and in 2003 he returned to clinical medicine, entering a residency program in psychiatry. Several years ago, he fell in love with the smart, beautiful banker who handled his finances. The couple now has a son. Eric has a motorbike now, too, and when he takes it out for a ride he throws on his black leather jacket from Belgrade, sturdy as ever.