Kosovo Diary

An American physician in a land of refugees.

By Pamela Grim and Steve LehmanAug 1, 1999 5:00 AM


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On June 9, eleven weeks after NATO began raining bombs on Yugoslavia, Slobodan Milosevic agreed to withdraw Serb forces from Kosovo. By then, more than 850,000 Kosovars had fled the region. A few refugees managed to immigrate to other countries; the vast majority are housed with host families or in refugee camps in Macedonia, Albania, and Montenegro. 

The refugees’ future is still uncertain, and the obstacles to their safe return are many. Kosovars going home face land mines, booby traps, and poisoned wells. Many have no homes to return to. More than 50 percent of the homes in Kosovo are reportedly destroyed. Food is scarce. The Kosovars are likely to remain in refugee camps months after nato finalizes a peacekeeping agreement. Says Laura Guimond of Mercy Corps International, “The camps aren’t going away anytime soon.”

The problems surrounding Kosovo are by no means unique. Around the world, the estimated number of refugees and people displaced within their home countries has risen from 10 million in 1980 to 50 million today. Many refugees never return home. They stay in refugee camps, often for years.

Pamela Grim, an American emergency physician, volunteered her services at a Macedonian refugee camp during the thick of the war. This is her journal.

{5/6/99} Managers of Senokos Camp, a refugee shelter in northern Macedonia, have been notified that 4,000 to 5,000 Kosovars are to arrive. Doctors of the World, the organization that provides medical care in the camp, has called for physician volunteers, so I find myself in their headquarters in New York City, signing an insurance policy for, among other things, kidnapping, ransom, and extortion.

{5/8/99} I arrive at the headquarters of Doctors of the World emergency relief project in Skopje, the capital of Macedonia. The dominant architecture is pseudo-Soviet, cement Gothic. Senokos Camp is about an hour’s drive away, near the Macedonian-Kosovar border.

I am introduced around the office. Doctors of the World had been in Pristina, Kosovo, for six years, long before the town was in the nightly news. The staff had been evacuated two days before the bombing began in March. In the kitchen I meet the cook, an elderly Kosovar who has been here a month. As she serves me potatoes and Turkish coffee, she tries to explain something. But she speaks no English. She seats herself abruptly, takes off her glasses, glares around the room, and starts to cry.

My welcome to the war.

Later that evening, we head off to Senokos Camp. It is just dusk when we arrive. The guard waves us through the chicken- and barbed-wire fence that surrounds row upon row of tents. The medical clinic is a small complex of three tents joined by an awning.

The refugees have not yet arrived; the borders are closed. They are still waiting on the Kosovo—that is, the Serb—side of the border. We are not needed tonight. Even so, there are problems. I am taken to examine a girl of 10 or 11. Her right hand is bandaged, and a metal splint braces her index finger.

I am told she was bitten by a horse two weeks ago, just before the Serbs cleared Pristina. The family fled; the bite went unattended. While they waited a week at the Macedonian border, the girl’s wound festered and eventually turned gangrenous. Finally, the family came to this camp, where an orthopedic surgeon, also a Kosovar refugee, saw the wound and dressed it. As I unwrap the dressing, the orthopedic surgeon silently materializes beside me. “It was an open fracture,” he tells me in gruff English. “Very bad, very bad.”

We unveil the wound. The index finger is broken; it cants off at an odd angle. Two large wounds on either side of the finger had obviously extended to the bone. Each laceration involved half the finger, at least, but if they were once infected, they are now quite clean. The red angry flesh I see is actually good, healing tissue.In the United States, a surgeon would have put the bone back into place and secured it with a metal pin. In the transit camp, however, the best the orthopedist can do is splint the wound and dress it.

“Fantastic,” I say looking up, “this wound looks great.” The orthopedic surgeon smiles. I’m not sure how he did it, but he saved this child’s hand.

{5/9/99} Several of the doctors working in the camp are Kosovars who fled when the war began. The doctor in charge of the camp health facilities, Visar Nushi, fled Pristina a few days after the bombing started. He was separated from his fiancée and does not know if she is alive or dead. He does not know if his parents are alive or dead. His sister—with his two nephews—has also disappeared. Still, Visar puts in 14-hour days, organizing the camp, hiring and scheduling the doctors, arranging the supplies, fighting with local health authorities. He works from 8 a.m. to 10 or 11 at night. He has done this for six weeks without a day off.

The most common disease of camp life is boredom. The other chief pathogens are depression, anxiety, and fear. Senokos Camp is a small shelter, one of the smallest. It is equipped for 10,500 people. Some 2,500 have arrived; we await the rest. Everyone has shelter, food, potable water, and privies nearby. After that, they have nothing but one another. For entertainment the men of the camp gather in the one small clearing among the tents; it is close to the makeshift gate, the only official entry through the wire fence that girdles the camp. They stand there, sometimes sharing cigarettes—the only available vice—while they watch the comings and goings of the various aid officials and the Macedonian police. Along the edge of the clearing are the old men wearing felt skullcaps, their faces wizened and sun-darkened. A month ago their lives were whole. Now they have nothing, no cafés, no coffee, no beer, no dominoes. No news of the village, of their families and friends.

The married women tend to remain in the tents, out of public sight, as is traditional in Islamic societies. The girls, though, parade back and forth, hair nicely combed, heads held high, jeans tight, T-shirts short enough to reveal their young bellies. They walk with their girlfriends or lead their small brothers and sisters by the hand or sometimes even walk with their boyfriends. They are the scandalous next generation.

The problems in Senokos—the crowding, the boredom, the anxiety—are severe but manageable. At Stenkovec II, just down the road, there are sometimes as many as 30,000 exiles. One of the aid workers I meet shakes her head wearily as she talks of the conditions there. At Stenkovec II, the expanding population has assumed a critical mass, a level of chaos that breeds rioting.

We are starting to experience similar problems. Today a doctor treats a refugee with two teeth knocked out by another refugee. There was no disagreement; they didn’t even know each other. The assailant had just walked up to this man and kicked him twice in the face.

As I fuss with paperwork, Drew Fuller, an American internist, sees the first patient of the day. A 32-year-old woman has been brought in by her husband. She is accompanied by their 4-year-old son. The mother sits on the stretcher, looks around cautiously, and then stares up at Drew. She says something in Albanian.

“She has a headache,” the translator explains.

Drew gives her a minute to continue, but the woman says nothing.

“How long has she had it?”

The woman just stares off into the distance. Then she covers her face with her hands. Her shoulders start to shake; she is weeping noiselessly.

“What’s the matter?” Drew says. The translator prods the woman verbally. She says something from behind her hands.

The translator frowns. “She says she just found out her mother and her father were massacred in Kosovo. They are dead.”

The woman weeps. Beside her, her son stares up into the woman’s face, confused. He is too young to understand what grief really is. His hand reaches up to his mother, and he starts sobbing in sympathy.

That is one kind of case. Alan Fisher, one of the doctors working here, tells of another. A 17-year-old kid who had stepped on a land mine in Kosovo had been treated by an orthopedic surgeon in the chief referral hospital in Pristina. In fact, the surgeon had fled with him across the border and was now seated next to him on the canvas cot. “This is a medical emergency,” the orthopedic surgeon told Alan. “He must go to Germany for surgery immediately to save the foot.”There is a medevac system for Kosovo refugees. Patients who are seriously injured or chronically ill can be evacuated to Europe or the United States for medical care. It is hard to arrange but still possible.

“It’s the only way,” the orthopedist told Alan.

When Alan unwrapped the injury to take a look, he saw that the foot had been blown open. But the wound had been well tended and was now healing beautifully.

“You must transfer this boy,” the orthopedist pleaded. “He will lose his foot.”

Alan shook his head. “But this foot is healing very well. You’ve done a terrific job. It looks great.”

“Please,” the orthopedist went on. “Otherwise he will need an amputation.” Then he bowed his head and leaned forward. “This boy,” he whispered, “is kla, Kosovo Liberation Army. If they find him here, they will kill him. You must get him out.”

Alan looked down at the foot, shaking his head. “You’ve worked a miracle here,” he told the orthopedist sadly. “I just can’t.”

The orthopedist, Alan adds, was himself very lucky to make it out. According to the refugees and the people that I talked to in the camp, the first thing that the Serbs did was kill all the doctors.

{5/14/99} Doctors, nurses, and other medical technicians make up half of the organizations like Doctors of the World. The other half is “Logistics.” No doctor can work without nurses, translators, or the tools of modern medicine: iv fluids and catheters, sterilized equipment, antibiotics, bandages, needles, and syringes. You may have all the skills in the world but, without supplies, you can’t do anything.

Carl Fraser is a big, infinitely weary Canadian who regards every request with a basset-hound look of despair. Still, he works miracles. He is the logistician in Macedonia for Doctors of the World. Need more cars? More drivers? More iv catheters, special id cards, dispensation from the local police, tents, food, translators, bail money? You name it, it is Carl’s job to supply it. He is the major reason doctors get to practice modern medicine on the edge of a war zone.

Tonight, at the general staff meeting, Carl describes the campaign to distribute tightly sealed buckets filled with local foods. Each bucket contains enough food and bottled water for one person for three days. These are to be handed out to the refugees in the transit camps at the border. About 900 have been prepared, and recent donations have provided funding for 20,000 more. There is talk of making up boxes with enough food to feed a family of five for a week. These are for the refugees when they go home.

After this, there is silence. No one really talks much about what will be needed when the war ends.

{5/15/99} Although every humanitarian disaster is unique in its own way, several features are common to what relief workers call complex emergencies. Any combination of war, civil unrest, or natural disaster can produce the devastation and death that has wracked regions like northern Iraq, the Balkans, and Rwanda in recent years. Refugee populations that result from these emergencies can vary from a few hundred displaced over the course of months to the 1.2 million refugees thought to have crossed the border from Rwanda into Zaire between July 14 and July 17, 1994. Death haunts refugees no matter how large or small the population or where they seek asylum.

One measure frequently used to assess a refugee crisis is the Crude Death Rate (abbreviated cdr in the public health literature). Relief workers first get a look at a population’s cdr, based on deaths per thousand people per month, before the crisis emerges. That figure is then used as a baseline to gauge how much mortality has increased among the displaced population. During recent crises in Ethiopia, Kenya, and Nepal, the estimated cdr has risen 5 to 12 times the baseline rate. During the crisis in Rwanda, the cdr was among the highest ever recorded, 40 to 60 times the expected death rate. Nearly one in ten died during the first month of their flight from their homeland.

Children under 5 years of age and particularly those under 1 are at highest risk. Women also tend to be at higher risk than men. The most obvious killers are starvation and dehydration. Next come infectious diseases. Cholera, shigella, and E. coli are frequent causes of severe diarrheal illnesses in refugee camps. Measles and malaria can kill too.

Over the past 20 years, the international response to complex emergencies has improved. The task of coordinating international emergency relief efforts has been assumed by the United Nations High Commissioner for Refugees. They provide direct services and coordinate the action of other relief groups. Nongovernmental organizations, called ngos by aid workers, also contribute substantial amounts of relief service. These are typically nonprofit organizations that provide shelter, civil engineering expertise, and medical care to populations at high risk. These groups often work cooperatively. For example, my ngo, Doctors of the World, provides medical services for a camp built and maintained by Mercy Corps. Other refugee camps are managed by other international agencies.

Providing food, water, and shelter in a clean environment is the simplest way to prevent devastating disease and death among refugees. Just a few low-tech public health weapons help a lot: water chlorination, vaccinations, and basic health education.

Here in Macedonia, the number of refugees in camps has risen from a handful in March to 250,000 in June. So far, the weather is good, camp conditions are stable, and most people are in good health.

{5/16/99} Visar and I are sitting in the office when Carl comes in. “Marku just called.”

“Oh?” Visar says.

“He wanted us to know he’s alive.”

 I remembered. Marku was the last unaccounted-for person who worked in the Doctors of the World offices in Pristina before the war.

“Did he say where he was?”

“Albania, Tirana.”

Visar sits there, saying nothing, just smiling. Two days ago, he had learned that his sister was also alive in Albania.

{5/19/99} It’s nine o’clock at night when we get word: A couple of busloads of refugees—the first to cross the border in weeks—will arrive in a half hour. We don’t know where these refugees are from, how long they have been trying to get across the border, or what their physical health is.

When the buses pull up, young men stand crowded in the aisles while old women, hair hidden under scarves, peer out through the windows into the night. Macedonian soldiers are shouting, pointing at the gates and at cars parked in the way of the buses. The medical staff stands ready. Behind us is the gate and beyond that the refugees have lined up on either side of the central clearing, straining for a first glimpse of the arriving passengers. Most are looking for people they know—relatives, friends, neighbors. They strain to see those they knew were trying to get out, others they have had no word about, and even people everyone thought dead. Anyone could get off that bus. The doors open slowly. Faces, harshly lit by the camp light, descend, one after another. Everyone looks startled by the light, the noise, the idea of safety. Children are sobbing; old women weep openly; young men look bewildered, as if they are surprised they are still alive. Some carry bundles off the bus, others carry nothing at all. One man, unbelievably, wheels a baby carriage down the steps.

We learn that the convoy had left Pristina this morning and traveled all day with nothing to eat. They were given water at the border. They all knew that the borders were closed and that thousands had been turned back; they really did not expect to get through. Miraculously, both the Serbs and the Macedonians let this bus by.

No one looks critically ill, although everyone appears shell-shocked. Some older people, hunched and frail, stumble feebly in the direction of the camp, some with families, some alone. I stop an ancient woman who appears to have a broken nose. It happened two days ago, she tells me. She fell running from the Serbian police. I direct her to the hospital tent.

I stop and gaze up at the sky. It is a beautiful night, just moonrise. The sky is clear and the air translucent.

Perfect weather for bombing.

Back toward the gate, I see two men standing, arms around each other, chest to chest, cheek to cheek, staring off, looking at nothing. They could have been brothers or lovers, or just two friends who have found each other and are now rejoicing in the warmth of each other’s breath, the touch of each other’s cheeks, the strength of each other’s arms.

{5/20/99} Today Alan and I have a rare day off, so we decide to drive up to the border, about 25 kilometers from Skopje. We drive north through undulating hills; the dry countryside looks like the foothills of the Sierras in southern California. Miles later, I can see buses but no border gate, just a crowd scattered along the roadway and a couple of Macedonian policemen yelling at them to move back.

An aide from the camp, a sandy-haired Texan in a Mercy Corps baseball cap, stands next to me.

“Well, you can’t see Serbia from here,” he tells me, “but you have a better view than you might think.” He points to a patch of hillside that overlooks the roofs of a small village beyond. Amid the rooftops I can see a small copper dome and the white spire of a minaret.

“The Serbs were there three weeks ago. Emptied the town right out and set fire to everything that would burn.”

{5/27/99} It is nearly a month since I arrived at Senokos. The number of refugees has risen from 2,500 to 7,500. Today we learn that Milosevic has been indicted by the United Nations War Crimes Tribunal for being personally responsible for crimes against humanity, including murder, deportation, and violation of the rules of war. It is late at night when we get the news. I’m tending to an elderly woman who can’t sleep, hasn’t slept for days. She insists that otherwise she is fine—as the tears stream down her face. I prescribe Valium for what seems to be the hundredth time tonight. In the waiting room are three more just like her.

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