Background

HEALTH CARE IN KOSOVO (Published as "Health Care in Kosovo - Public Health Disaster and Renewal" Midwifery Today, Spring 2000 No. 53 and requested after my work there in August, 1999)

Imagine you live in the province of Kosovo. Imagine are a nurse, or mmia (midwife), or professor at the University of Pristina, or a grade school teacher, or the lady who registers new drivers at the licensing bureau downtown. Imagine you are working for the Serbian government, as you have all your adult life. You get up and get your kids ready for school, your husband is out the door, you drive across town to begin your shift, and there are Serbian policemen at the door of the hospital (or school, or municipal building, or courthouse, or any other public place) demanding you present your ID card. "What's going on?" you ask. The young man looks at your ID card, determines you are an ethnic Albanian Kosovar citizen of the Federal Republic of Yugoslavia, not an ethnic Serbian citizen, and keeps your identification card. Then he tells you that by order of a decree from the president of the Republic, Mr. Milosovic, and the congress in Belgrade, you and every other Yugoslavian of Albanian ethnic descent who works in any capacity for the federal, state or local government, is out of a job, as of this morning. The year is 1989. You've been hearing rumors of this since all those problems started between Croatia and the Serbians, then Bosnia and the Serbians. Now all this carrying on, so far away from your little province, is happening to you. The Federal Republic of Yugoslavia is breaking apart. Since President Tito died, it's been pretty much a chaotic situation with Slovenia, Macedonia then Bosnia declaring independence. Here is an excerpt from the book "Kosovo A Short History" by Noel Malcolm (Harper Perennial publishers, 1999): "In legal terms (according to the Badinter Commission, a committee of experts advising the European Union at that time), what happened when those states became independent was not secession, not the breaking away of a few branches from a continuing trunk; rather, it was the dissolution of the entire Yugoslav Federation into its constituent units. The post-1992 self-styled Yugoslavia, often wrongly described as "rump Yugoslavia", is not the

continuation of the old Yugoslavia but a new state, formed by the coming together of two ex- Yugoslavia units, Serbia and Montenegro. And Kosovo is the province between these two states. The central government in Belgrade had decided by decree in 1989 to fire all ethnic Albanians who are employed in any public institution to prevent seditious activities, and in a socialist country, the government is the major employer. 90% of the population in the Kosovo province is ethnic Albanian. They and their families have lived in this area for a millennium. It would be like saying 90% of the people from Minnesota are ethnic Swedes. To the citizens of this province, it didn't really make sense. They were all Yugoslavians. But not anymore. Milosovic and his party had begun a purposeful and planned campaign of ethnic cleansing for a "Greater Serbian State". Rumors and propaganda were everywhere. The year of 1989 was a stunning one for the people of Kosovo. When I arrived in August of 1999, ten years of unbelievable hell had been going on for the majority of ethnic Albanian Kosovars, as well as for their just as surprised Serbian neighbors. This is a place of amazing abundance from the land. It is very mountainous, with three major agricultural valleys cutting through the province like an upside-down "Y". Farmers have filled the markets and tables of neighboring Serbia, Romania, Albania and Macedonia for centuries with their grain, dairy, and produce. The valleys all join together at the north to enter into the great Morava river basin valley and thus geographic access to the Danube river basin. The people from this province also are known for their generosity, their hearty, loud humor and their good wines. When I talked to the doctors and nurses I had met in Pristina at the Institute for Public Health, they said that at first they couldn't believe this was happening to them back in 1989. Most of the people who are presently working for CARE in Kosovo (where I was hired to review training needs for health care personnel) had worked previously in the refugee camps in Albania and Macedonia, making room for the thousands of neighbors leaving Kosovo. They couldn't believe what was happening, either. "Hundreds of people were getting off crowded buses, just like the big tour buses you see anywhere in Europe. The women had their kids neatly dressed for
2

school, their purses matched their shoes, and everyone was neat and clean and stunned. I've never seen anything like it," said Liz Simes, a nurse from New Zealand who has worked in various refugee camps in Africa and Asia. Chris Woodgate, an Australian nurse with CARE hired to hammer out a health care package for returning refugees in Kosovo, had been in Pristina for a month before I arrived, and taught me the most about public health I have ever learned in one afternoon. "Imagine," she began, "for ten years there has been a parallel health and educational system in place here. Since they fired all the health care personnel, and replaced them with Serbians, people were obviously afraid of going to hospitals or clinics. They also lost their insurance coverage because they were unemployed, so health care costs were determined in a open market, for people without income." What happened was that schoolteachers began taking students from grade school to university students - into their homes for classes. Doctors and nurses moved the furniture around in the basement of a home, or perhaps their garage, and made a makeshift ambulatory clinic. After a couple of years, some volunteers and donors began opening private homes and calling them Mother Teresa Homes, equipping them with basic health provisions such as immunizations for children, or prenatal care for pregnant women. All of this resulted in a variety of self-designed, self-implemented, and self-evaluated training programs in health that were neither accredited, validated nor officially recognized by any governing body. Since 1989, the Albanian Kosovar health professionals have had little or no practice areas in hospitals or clinics and no access to conferences or continuing education. So, although some doctors could find practical training abroad in other European countries, most medical and nursing personnel practice in their own houses or the Mother Teresa private health centers (where there are no x-ray, lab, surgical suites or other practical interventions available.)
3

Then the Serbian government passed a law in 1990 saying that any birth outside the hospital was illegal and wouldn't be registered, unless the mother came in with her newborn and two other immediate family members to say there was an emergency and she couldn't help giving birth at home. Many women, of course, refused to go into the city with their newborn and participate in this farce. Any death had to be validated by a Serbian doctor, or else that wouldn't be registered either. For 10 years then, there has effectively been no official registration of births, deaths, or any other public health information such as registration of people with tuberculosis, syphilis, HIV, measles, or anything else. Current Health Situation (1999) - I met with two wonderful public health doctors, Dr. Drita Salihu and Dr. Merita Koinaj, both Kosvars of Albanian descent, who stayed in the Institute for Public Health despite threats (they were sheltered by their colleagues) during those 10 years. They visited towns and "Health Homes" (as the private health facilities were called) and did their best to register public information in their tattered old paper notebook. These two valiant women have kept the public health system of the province together by sheer willpower and a dedication to public health (see photo). They told me overwhelming stories of personal horror they or a family member had suffered at the hands of a few young men with guns during the 10 years. This Institute for Public Health is attempting to re-group with their medical and nursing personnel in order to put together a uniform reporting system for public health information as well as educational validation systems for professionals.
4

The following summarizes the health situation in Kosovo as of August 30, 1999 (statistics are from WHO, UNFPA, UNMIK, CARE Kosovo field reports, Information Bulletin from "Action Against Hunger" and personal communication with doctors at the Institute of Public Health). 70% of the population is under 30 years of age, 1.5% over 75 years old. Population growth rate 1.7%, infant mortality 23.5/1000 both highest rates for Europe. There are no statistics for maternal mortality or morbidity since 1990. Most common childhood illnesses are respiratory and diarrheas. Adult morbidity and mortality mostly from heart and lung disease, diabetes, stroke and cancer (pre1990 data. Post 1990 most probably war related injuries major cause of death). Pregnancy morbidity primarily consists of hypertensive conditions (pre-eclampsia), diabetes and hemorrhage, with infections primarily in the post-natal period. Tuberculosis incidence high at 60-70/100,000. Injuries due to landmines at 10 per 100,000 during June. Very high incidence of unattended home births during the war, with the last documented information from 1989, which states that 23% of Albanian Kosovar women deliver without a skilled attendant. There are no emergency transport services for obstetric emergencies in rural areas. Comprehensive family planning services are not consistently available in Kosovo due to lack of access to appropriate drugs or devices. STI's, including gonorrhea and chlamydial cervicitis/urethritis, are endemic and likely to remain at moderate levels. Sexual violence has been documented and reported including recommendations from UNFPA consultants concerning the need for personnel training in this area of health care. Labor and delivery services are available at all hospitals and in about seven maternity centers within the Health Houses and in an unknown number of Ambulantas 25% of infants do not start breast-feeding until after 24 hours or more after birth, and 35% of mothers stop breast-feeding before 6 months

The United Nations Mission in Kosovo (UNMIK) is the governing body for public policy, while things get sorted out. There is no connection with the Ministry of Health of Yugoslavia in Belgrade, so the World Health Organization is the acting Minister of Health, until the returnees
5

establish their own systems. This includes infrastructure (Serbians destroyed toilets in most public facilities, sewer and water treatment systems and took all garbage collection trucks back to Belgrade when they left.), educational validation, and re-organization of facilities, meanwhile concerning themselves with immediate emergency health care needs such as mine detection and clearance, vector control (there were mountains of garbage around the city), potable water, sewage and detection/treatment of communicable diseases such as syphilis and STD's. Health Service Delivery - Nurses do not deliver any direct services. They are trained to serve the doctor. They don't even take vital signs. I found out why, when I went to visit the "Medical High School" in the capital, Pristina. Shqipe Pacolli, a young 16 year old who became a new friend of mine, explained to me that she was going to attend the Medical High School because she wanted to be a doctor. She then explained to me that going to this high school had been an option only for Serbian kids before 1989 (she has never been to a public school). If she qualified, she would enter at 9th grade and begin a course of study that included "hard" sciences, psychology and social sciences. Upon graduation from the twelfth grade, depending on the curriculum one decided upon during the 9th grade, one would graduate as a nurse, midwife, lab tech, physical therapist, radiology tech, respiratory tech, or pharmacy tech. If you "made the grade", you could go on to the University to study medicine for 5 years and become a general practitioner. With 3 more years, you could study to become a physician with a specialty, such as obstetrics. I went to visit the Medical High School on the other side of town near the monolithic public hospital. The high school is three stories tall, "L" shaped, cement, and totally destroyed. I passed a huge mountain of white, porcelain toilets on the way in. Students and adults were inside scrubbing the walls of graffiti, painting, trying to put the sinks and toilets back in, and taking out the bits of broken glass from every single window that had been broken by the departing Serbians. I met with the director of the school, Dr. Aisha Bolen Castriti, a well-dressed middle- aged woman with three teenagers of her own. She talked to me about the curriculum, how it had
6

always been a matter of approval by the Ministry of Education, and how she felt it had never really met the needs of the health problems of Kosovo, especially under the current circumstances. She was very proud that she was finally able to open the school again (she had been the previous director until the 1989 mass firing) and was anxious about opening on time for the new school year. The saddest thing I have ever seen was the room full of their "training equipment". There were several old, iron beds with straw mattresses and no sheets, an old wooden mannequin with one arm (for learning how to deal with a patient, I suppose), a part of a small doll's torso for learning about infant care, and two torn posters on human anatomy. That's it. No videos. No overhead projectors. No charts or laminated posters. Not even a skeleton! Dr. Castriti wasn't too concerned about training materials just yet. Her priority was on getting the physical building in shape for the coming winter. Over 400 windows had to be replaced! As far as maternal and infant health care, I will tell you of a visit we made to the big referral hospital in the beautiful eastern town of Prizren. The hospital is huge, a cement-gray building built in the 1950's. The nurses wear green cotton dresses with a white scarf tied over their hair. The doctors all wear white lab coats over green smocks. We squeezed through dozens of people waiting by the door to hear news of their relatives (no visitors!) and went to the third floor maternity ward (have you noticed that almost everywhere the maternity ward is on the third floor?). We walked past the "delivery room", with the door wide open. Three women were in this large, open room with no curtains or other separation between them, all with their exposed perineums facing the door. One was about to give birth, her legs up in stirrups, shaved perineum, IV drip, a crowd of people around her (no relatives) and someone with a mask on cutting an episiotomy. The nurse giving us the tour proudly pointed out this delivery room. Everything stopped and all the women, including the poor soul trying to give birth, looked up at us strangers standing in the doorway. I smiled an apology, and closed the door. Someone opened it up again after we had left.
7

"Where is the labor unit?" I asked. It is an open ward with 25 beds. No privacy. "We average 400 births a month", she said proudly. "How many midwives?" I asked her. There are only three now, the Serbians all left and the ones who were here before haven't come back yet. There are 9 doctors, 3 of them OB/GYN (the rest general practitioners). There is one anesthesiologist. There are about 30 nurses who rotate shifts. The doctors are the only ones allowed to deliver the babies. The midwives mostly work in post-partum unit, she replied. That means 9 doctors for 24 hour shifts attending around 400 births in one month. We met with Dr. Jlldze Gonani, Chief of OB/GYN who was very happy to be back in the post she had been discharged from in 1989. She proudly told us how she intended to promote "natural childbirth" and had the 6 general practitioners in training to do just that. "Our Cesarean rate is only 7%, she announced with pride. I didn't ask if that was because they had had no training in the practice of surgical operations in 10 years, or if they had no anesthesiologist on staff. We just congratulated her enthusiastically. Then we visited the Neonatology unit, where all the babies were "in with their mothers". The Neonatologist in charge explained that she was trying to make this a "Baby Friendly" Hospital according to UNICEF guidelines, and that meant that the babies stayed with the mothers "at least a few hours a day". She then proudly showed me the "milk room", where they mixed the formula and sterilized the bottles. I gently asked her about breastfeeding protocol. "Oh, yes, well if the mother wants to, but we find that most of our mothers prefer the bottle, it's so much easier." Family planning is now called "Family Health" because of the insinuations of restricting the size of the family. After a war, most people will want to hurry up and re-populate what they feel has been a mass elimination of their people. The most popular method of family planning seems to continue to be abortions, as that is legal and free. In an interview I did with 4 ethnic Albanian Kosovar women who were all pregnant, every one of them knew of someone personally who became pregnant "with an IUD in place". They had also heard rumors of mass sterilization by Serbian doctors of Albanian women who had given birth in hospitals during the previous 10-year period, and as far as they were concerned, the contraceptive pill causes cancer of the uterus.
8

(Please refer to box) A series of reproductive health assessments had been conducted previously by CARE, with men, women and adolescent groups of refugees while in the camps, which demonstrated that there was a lack of knowledge for appropriate pre- and post-natal care, child spacing methods, nutritional care during pregnancy, care of infants and children, teenage sexuality issue and very little knowledge of STD's or HIV/AIDS. There is much to be done. The many people I met with and got to know impressed me with their optimism and energy for working towards a healthy future for themselves. They all want to make a better life for their children, as all people want in all countries, of any ethnic descent. Interview with Four Pregnant Ethnic Albanian Kosovar Women 26 August 1999, Pristina, Kosovo Our conversation took place in the afternoon, in the outdoor patio at the CARE office in Pristina, on a beautiful, warm fall day. The four women range in age from 25 to 28 years old. All are married and in apparently stable relationships. 3 of the four are pregnant with their first baby, one has had a previous abortion, and the fourth is pregnant with her second baby. Only the woman with her second pregnancy planned it, while the other three did not. All mentioned that they wanted to be pregnant, although each of their individual doctors had asked, on their first prenatal visit here in Kosovo, if they wanted to keep the baby, regardless of the month of gestation. All four women are of Albanian ethnic descent living in Pristina, Kosovo. They range in gestation from 4 months (2 of them) to 7 months (1) and nine months (1). Active warfare in the area can be considered to have occurred from the end of March of 1999 to the end of June 1999. In the year 1989 Kosovar citizens of Albanian descent were purposefully and systematically dismissed from all governmental jobs, including health and education positions. This means they lost their right to state health care insurance and benefits, including prenatal care, in public hospitals and clinics.
9

The Kosovars of Albanian descent then created a parallel health and education system, in private homes or private clinics. Any discussion with people now living in Kosovar must revolve around the social political context of separation, warfare, massacres, sexual violence, exodus, refugee camps, and recently, since July of 1999, returning to their homes and villages, with hospitals and schools having been largely destroyed by the retreating Serbian ethnic Kosovars. The first question elicited much information parallel to the answer sought, because of the circumstances of the war and displacement: "How did you feel when you first discovered you were pregnant with this baby?" "Very happy, both my husband and me." (Refugee in France). "We went to the clinic (in France) for our physical examination and that's when I found out I was pregnant. The nurse was very nice to me, and my husband was also very happy." "I felt very confused and disoriented at first". (Refugee camp in Macedonia after being at the border for three days). "My husband was very happy, but we were also very worried." (Of the four women, she is the only one who tends to manifest more physical complaints and discomfort about her pregnancy). "I felt good. It felt interesting and strange, but good. My husband said he was happy if I was happy." (Became pregnant in Pristina, before the war had started, and did not leave as a refugee). "I was very happy, this was a planned pregnancy because my little boy is 3 years old and we wanted another baby now." (She and husband and child were living in Macedonia at the time and not in a refugee camp). "My husband is also very happy." All four women mentioned that they had had sexual relationships before getting married, and none were married because they became pregnant. All four said that having sex before marriage is "quite common", but that being pregnant outside of marriage as "very taboo." "If a girl gets pregnant she must get married. It is a socially shameful thing." None had used family planning methods.
10

There are no sex education courses in schools, even before the separation and closing of educational systems to Albanian Kosovars, except for a one-day class in their high school biology course (topics were menstruation, masturbation, HIV/AIDS, STI's and "how babies are made.") One learned from her mother about "the time of the month when you could get pregnant." Concerning Family Planning (FP) issues, a free style and lively conversation took place, with laughter about mistakes made and sharing of information. Some interesting insights may be gleaned from the following quotations: "We were using condoms when we were first married, but I didn't like them because they felt funny. We tried the withdrawal method." (All laughed out loud at that comment). "Everyone tries withdrawal, but I don't think the men can do it, it's very difficult." (All agreed that most teenagers probably only know about the withdrawal method, and most girls learned from their friends or sisters when they were teenagers too). "Most people say that family planning methods will cause cancer." (I asked which specific methods). "They say the pill causes breast cancer." (All had heard this rumor). "I remember my sisters talking about the pill causing sterility. They said the Serbs were giving family planning methods to cause sterility in us Albanians, so nobody wanted to use any methods." (All agreed to that theory and had their own personal anecdotes around the theme of "forced sterility", including tubal ligation, by Serb doctors toward ethnic Albanians). "You cannot get an IUD put in if you have never been pregnant. I don't like the IUD because I don't like to have to have a vaginal exam every month." (Each woman in the group, and three other non-pregnant women in the office, all knew of someone personally that had become pregnant while the IUD was "in place") When asked who makes the decision to use methods or not, all said the couple makes it together. (An interview of 6 men of reproductive age were also asked this question and agreed that the couple makes the decision). When I asked if it was that way in the country too, they said "probably so because there is more education now." Before it was only the husband who decided how many children to have and how often, "like with my parents or people their age," said one of women, and they all agreed.
11

 All want to have 2 or three babies total, but none of them were quite sure what family planning method would be the best for them. All wanted more information on this subject. The most emotional part of the conversation for them that afternoon had to do with prenatal care and the lack of information, as well as the sharing of experiences by 3 women who had already had babies. (Two other neighborhood women joined the group for this discussion, a 27 year old with one baby and a 26 year old with a three year old and a five year old.) During prenatal care before the war, women only went once or twice "to see if the baby was alright and in the correct position." Even today, the women don't like to have a prenatal visit, because "I don't like having a vaginal exam each time" and all agreed. They all talked about the lack of any information, especially nutritional information. Three of the four women said they got most of their information from baby books, and all said they talked with their own mothers for information about pregnancy, including any questions or doubts they may have concerning vaginal discharge. All said that they received prenatal examinations from the doctor, never the nurses. Before the war they could choose their own doctor for prenatal exams, and he or she would be the same one to attend the birth. They all liked that system very much, and all four of the pregnant woman now expressed concern that they would have to have a different doctor attend the birth than the one who did their prenatal care. None of them liked the "rude treatment" from the nurses or the long waiting times (up to 6 hours). To summarize, the prenatal exams: are only done once or twice because of the long waiting periods and the rude treatment by the nurses, plus the fact that they receive a vaginal exam every time they go. they receive very little, if any, educational information about nutrition, exercise, breathing during labor, how to prevent problems or how to recognize danger signs. The women who had already given birth explained labor as, one of those awful experiences that you just pray will be over as soon as possible.
12

In fact, said one, if they do a cesarean it's better because you don't have to suffer as much." In labor, women are routinely shaved of all pubic hair, given an enema, put up onto a gynecological exam table with feet in the stirrups, have an IV drip with Pitocin inserted, have a vaginal exam every two to three hours by her doctor and one or more medical students, and her vital signs are taken by the doctor not the nurse. Meanwhile, the husband or other support persons are not allowed into the labor room, the laboring woman is not allowed any liquids or food, not allowed to walk unless it is to the bathroom, and she remains there during the entire labor without anesthesia if there is no medication or anesthesiologist. One woman said it was winter and she was shivering so much from the cold because there was no heat in the room, that her teeth were chattering, which attracted the attention of the nurse who told her to quit complaining. For childbirth they are transferred to another large, cold, brightly lighted room, where they are placed onto a different gynecological table, feet up in stirrups, covered with sterile sheets, everyone is masked and gowned, and no husband or support person at her side ("or that would NEVER be allowed!" they all emphasized, but none knew the reason for it). She may or may not have an episiotomy cut, and all three of the pregnant woman who had previously given birth in the hospital said they received the Kristellar procedure (supraficial abdominal forced pushing by another person upon the woman's belly during the expulsion stage). The baby is taken away immediately and is not seen again by the mother for 24 hours. She then delivers the placenta and the doctor "cleans out the uterus cavity with an instrument with a gauze on the end." This was the most painful, they all said. If a cesarean operation occurs, they are taken into the operating room and given general anesthesia or a spinal, depending on the anesthesiologist. They are then taken to post-partum ward, where they are still not allowed to eat or drink for another 24 hours. They all said the nurse does not take vital signs, only the doctor, and if he went home after the delivery, then no one does it. There is no one to help with breastfeeding, unless your mother is allowed in to see you the next day. Most women prefer to bottle feed because the
13

government gave them free supplies, and "no one teaches you how to do it anyway," said one woman. These women were very sober and sad after the amount of information exchanged, and wanted to know how they could access more information. We continued the conversation for some time and they were encouraged to seek out each other for future get-togethers, as well as talk with other pregnant women for more emotional support and information. ___________________________________ Ann Davenport, Pristina, Kosovo, August 1999

14