HMD RESPONSE PROGRAMMES IN BOSNIA - HERZEGOVINA - TRAVNIK

Until the signing of the Dayton, HMD Response came to be the sole NGO with an operational presence in Travnik; a centrally located Bosnian city. Travnik has been inundated by refugees from different parts of Bosnia Herzegovina and its already limited resources are further stretched by a continuing influx. The medical conditions in Travnik have attracted government attention and it was at the request of the Minister of Health that HMD Response extended its attention to Travnik; it being important to the area as the capital of the canton and the tertiary medical centre for the region.

Evident was the plight of refugees and their new host communities by the forcible ethnic cleansing of the Srebrenica enclave by Serbian and Bosnian Serb military forces in May and June of 1995. Many thousands of people, mainly women, children and the old, were put on the road and pushed towards the west and the south, and into central Bosnia towns such as Tuzla, Zenica and Travnik. These bore the main weight of this most recent migration; adding in number to that of previous refugees now accumulating in and around these urban centres. Most of the displaced left at short notice under cover of a lull in the fighting and under coercion from the invading force. Very few belongings were carried and the general state of the refugees was one of destitution. Most NGOs working in the general region made attempts to direct resources to the new humanitarian disaster as the victims were dispersed.

Travnik was a point long sought by the migrating displaced coming from the northern part of Bosnia and the eastern enclaves. Travnik and its surrounding area has a total population of approximately 200,000, of which perhaps 40 percent are displaced from other regions. These refugees are partly absorbed into the resident population: approximately 5,000 are lodged in community buildings and some 10,000 in a refugee camp. The latter are mainly Serbs who have their movements restricted. Successive waves of displaced have sought shelter in this town and its surrounds which has been for four years of war tightly hemmed in by Serb and Croat forces alike. We were requested that we centre our activities on the town’s two main hospitals.

HMD Response Programmes In Travnik

1 - STATE HOSPITAL, TRAVIK
Pre-war the capacity of the hospital was 500 beds on five floors which dropped during the war period to 400 beds on two floors; the hospital serves a regional population for approximately 200,000 people. The Hospital figures as the third most important medical centre after Sarajevo and Zenica; with excellent staff who maintained a level of medical hygiene and practice that was considered high given the adverse circumstances. The hazardous situation advised that operating theatres and intensive care wards were relocated in the basement (for reasons of security) which in terms of equipment and environment so not compare well with the modern theatres situated on the higher floors

The hospital has made admirable efforts to establish a regime appropriate to the disaster. However, it has had to deal with the privations caused by a combination of isolation and large numbers of poly-trauma injuries. Extended military action by the Bosnian Serb Army created an environment that was inaccessible to NGOs. Fears for the town’s security caused the inhabitants to be reluctant to admit those NGOs which might have assisted. Until the signing of Dayton there were no NGOs other than HMD Response with a permanent presence in Travnik. This despite the fact that the Minister of Health regards Travnik as a pressing case.

Programme :

• Provided HMD Response pattern accident and emergency resuscitation kits to be carried in the improvised ambulances. A total of 20 kits have been supplied;
• Supply of equipment to orthopaedic department: drills, splints, implants, and screws, external fixtures;
• Drugs and medical supplies: general;
• Personnel
  (Supported by Irish Aid, APSO and VOCAL)

Provision of a Laundry:

During disaster situations, where medical needs are the issue, the need to support a laundry is not always the most obvious need.

In peacetime, the laundry is calculated as one pound per patient per day: to include bedding, staff clothing and surgery requirements. In the summer months the manual washing of laundry and its drying is inconvenient but possible although to an amount not near to the quantity stated above. Travnik has an alpine climate which means a long winter of snow and mists. If laundry cannot be cleaned and dried in these months then it accumulates. It then becomes a health hazard and finally has to be incinerated to prevent the spread of infections. In many hospitals in the larger regions this has happened repeatedly, the problem being only temporarily solved by appeals to the public for donations of linen. Travnik had been subjected to a downward spiral of maintainable infrastructure equipment and the laundry had finally reached the end of its usefulness and its possibility for repair. This resulted in a grave and negative impact on the hygiene of the hospital.

HMD Response has organised the supply of full laundry facilities which were considered a priority.

This included the following:

• Supply of hospital specification washing machines and dryers;
• Outfitting the space for installation and ventilation;
• Installation of equipment;
• Translation of instruction manuals for staff;
• Instruction on usage and maintenance of equipment to hospital staff

This should reduce infections in the hospital; an important consideration given that much of the work dealt with by the hospital includes trauma cases. HMD Response is grateful to IFOR (British Battalion at Vitez) for installation. Olga Heckova, our Field Officer was responsible for this project. (Supported by USAID and DART)

Ultrasound Clinic:

Using its programme in Sarajevo as a model, HMD Response has set up an Ultrasound Screening Programme to facilitate early detection of congenital orthopaedic disorders in children. John Beavis, Medical Board Member, is implementing similar training programmes for local medical personnel, as already established in Sarajevo. The provision of the Ultrasound Scanner was the first new piece of equipment supplied to the hospital since the start of the war.

Note: John Beavis is presently organising an advanced course in Trauma Management for Bosnian Surgeons visiting the UK. (Supported by VOCAL)

Provision of Personnel

Technical : One of the greatest challenges facing the hospital staff is the breakdown of equipment. HMD Response has, since September 1995, placed hospital engineers and medical technicians within the hospital to repair, maintain and commission medical equipment and hospital machinery.

Medical : Since January 1996 three HMD Response nurses have worked on wards and taught within Travnik’s two main hospitals. They have been involved with accident and emergency, paediatrics, maternity and theatre. Training was extended to the local ‘war nurses’ who have practical skills though often no formal training.

Christine Higgins, Senior Theatre Nurse, has contributed to the following:

• organised relocation of operating theatres from its temporary basement location to its original site on the 5th floor;
• established a Training Programme for the Hospital Staff;
• established protocols for hygiene and theatre organisation.

HMD Response hopes to continue in its attempt to rehabilitate the hospital to its pre-war condition. It is at present trying to improve the services provided to patients by upgrading: electricity supply, medical gasses and gas supply, paediatric facilities, maternity facilities, operating theatres, boiler room.

2. DOM ZDRAVLJA HOSPITAL ‘COMMUNITY HEALTH CENTRE’

This hospital serves the more general health needs of Travnik; that is, it provides community based medicine rather than the specialist focus of the State Hospital. The hospital has six ‘ambulanta’ clinics. These provide a range of services to the outlying districts. Some of the main problems facing the hospital at present are the complete absence of child medical records and a lack of an adequate motor ambulance services.

Action by HMD Response :

• Supplying deliveries of general medical drugs and equipment;
• HMD Response engineer is co-operating with the centre’s technician on a repair and maintenance programme of existing equipment;
• Accident and emergency resuscitation kits (HMD Response pattern) installed in all the centres’ improvised ambulances.

HMD Response provided a medical team to be based at the hospital, initially for a period of three months. However, some of the medical personnel elected to stay longer despite having borne great personal hardship while working during the winter session. The medical team consisted of two General Practitioners (Michael Gent with an interest in Gynaecology and Paraic Curran with an interest in Paediatrics) and three nurses (Christine Higgins, Senior Theatre Nurse, Louise McKenna and Paula McCloskey, General Nursing).

The Doctors provided much needed support as there has been a high incidence of injury amongst the local medical staff; they extended care and training in their chosen specialities. Further, they provided an assessment of the needs of the hospital and prioritised these for use by the Hospital Administration and for other NGOs. Further, they lent their services to CARE Austria which runs a mobile gynaecological clinic for use by all the ethnic communities. CARE wished to expand this service to Travnik and elsewhere and has asked HMD Response to provide an appraisal of its project and so develop future services.

The Nurses provided medical services and training for their local counterparts in general nursing care.

Support :

Programmes in Travnik have also been supported by USAID, Irish Aid, APSO, and VOCAL.