Ophthalmology in Postwar Bosnia

After the Bosnian War (1992–1995) in Bosnia and Herzegovina (BiH), a former republic of Yugoslavia, medical care became more difficult for residents to access because centers of excellence were located in various newly independent nations. Apart from medevac activities during and after the war, the Swedish government supported the Medical Teams Project to help provide medical services in several specialities to the areas where travel had become difficult and dangerous after the war. The goal was twofold: (1) to collaborate with local specialists and staff (Figure 1) and (2) to contribute to and facilitate the rebuilding of health care infrastructure, especially in BiH.

OUR FIRST TRIP

I travelled to Sarajevo and Banja Luka as part of an ophthalmologic team in April 1997. The team had three members: a vitreoretinal surgeon, an ophthalmic nurse/operation assistant, and me, whose focus is cataract surgery and pediatric ophthalmology (Figure 2). The International Organization for Migration provided interpreters, transportation, accommodation, and contacts with local authorities.

Our initial goal was to explore the postwar situation and, by making a long-term commitment, to establish relationships with local staff and ministries that would allow us to determine how we could help improve ophthalmic care in BiH. Activities were planned with the two entities within the State of Bosnia and Herzogovina—the Federation of Bosnia and Herzogovina and Republika Srpska.

Our team performed many examinations—mostly addressing general ophthalmologic problems—at clinical centers in Goražde and Lukavica. We also installed some donated basic equipment for use by local colleagues and visited university hospitals in Sarajevo and Banja Luka.

At each location, we connected with experienced colleagues who explained that, although modern equipment was available, it was not always functional. For example, at one location we were shown a room containing several donated laser units, none of which worked. We therefore decided to include medical engineers on future missions and increase collaboration with the university hospitals because we thought that specialists and residents there could benefit from continued contact.

A LONG-TERM COMMITMENT

We returned to Bosnia twice almost every year until 2008. I took part in 17 missions.

Supply issues. Cataract surgery was often performed without IOL implantation in BiH unless the patient purchased an IOL from an agency in another country. These individuals obtained biometry readings from the clinic and used them to purchase a correctly powered IOL. OVDs were also often bought by the patient and brought to the hospital for use during surgery.

We brought donated IOLs and OVDs for use during cataract surgery at the university hospitals of Sarajevo and Banja Luka. Some equipment for vitreoretinal surgery was available, and it was supplemented by donations within the Medical Teams Project. Single-use materials were resterilized and reused many times. Wear and tear sometimes made surgery with these materials more difficult. We learned, however, that the creative use of resources can save difficult situations—a lesson our local colleagues had learned years earlier. Patients who underwent cataract surgery within the Medical Teams Project were not required to pay out of pocket for IOLs and OVDs (Figure 3).

Building trust and transferring skills. We encountered skepticism during our first meetings with local staff. Several Bosnian ophthalmic surgeons had been in contact with and received training from clinics in Germany and Italy among other countries during and after the war. At first encounter, some experienced ophthalmologists questioned our ability to provide useful knowledge. In time, however, we earned their respect and formed deep collegial friendships.

Within the Medical Teams Project, we examined and treated hundreds of patients with our local colleagues. The transfer of skills and knowledge flowed in both directions. We learned from our hosts valuable tips about what can be done with available resources and equipment if we are willing to work outside our comfort zone. I became more confident about performing clinical examinations and evaluations when sophisticated imaging technology and other modern tools are not available. Key factors in the project’s success were making a long-term commitment, having an open mind, and being willing to break from normal routine to achieve the goals of the program.

CONCLUSION

Soon after writing this article, news of Russian military forces invading Ukraine spread worldwide. My experience in Bosnia occurred after open conflict was over, but the images of destroyed buildings, hospitals, and schools in cities across Ukraine seen in the media trigger strong memories from my first Medical Team missions. There is, and will continue to be, great need for compassion and action to help Ukraine during the war and even more after it has ended.