the situation of women and children in the former Yugoslavia
REPORT
Doc. 6903
22 September 1993
Rapporteurs: Mrs ROBERT, Switzerland, Liberal Democratic and Reformers Group and Mr DANIEL, France, European Democratic Group
Summary
In the conflict in the former Yugoslavia, the elementary rules and principles of the laws of war and the protective provisions of humanitarian law have been systematically flouted and violated. The action of humanitarian organisations is, for the moment, the only possible response. It is the urgent duty of European governments to support them, particularly financially.
I. Draft resolution [link to adopted text]
1. The Assembly refers in particular to Order No. 486 (1993) on the protection of human rights and the Joint Declaration of its Social, Health and Family Affairs Committee and UNICEF (United Nations Children's Fund), adopted in Geneva on 24 June 1993.
2. The conflict in the former Yugoslavia is marked by ethnic cleansing and barbarous violence against civilians, in particular women and children. The elementary rules and principles of the laws of war and the protective provisions of humanitarian law have been systematically flouted and violated.
3. The international community has been powerless to provide an appropriate response, although the United Nations decision to set up an international court expresses its unwavering determination not to leave unpunished the war crimes and crimes against humanity committed during the conflict.
4. Humanitarian action has shown its limitations; however, in spite of the difficulties, an attempt has been made to offset the international community's shortcomings. Just tribute should be paid to the remarkable work performed by the various humanitarian organisations such as the UNHCR (United Nations High Commissioner for Refugees), UNICEF, ICRC (International Committee of the Red Cross) and the NGOs (non-governmental organisations), and also to their staff, those women and men who devote themselves to helping others, often at the risk of their own lives.
5. The current lack of subsidies means that this action may well have to be discontinued, despite the increase in and diversification of the demand for humanitarian relief. Steps must be taken to continue to ensure the survival of civilian populations and also to treat the trauma caused by war, to reconstruct the vital infrastructure which has been destroyed and to give the population, especially the children, prospects of a future comprising something other than violence, hatred and revenge.
6. In the last ten years 90% of victims of armed conflict have been civilians; over one and a half million children have been killed; four million suffer from disabilities resulting from war, and a reported five million live in refugee camps. Moreover, in the conflict of the former Yugoslavia it is once again the women and children who are the main losers in the war. They have suffered and witnessed barbaric acts and are liable to pass on a hatred which has devastated them. The rights of the child, the protection of which is one of the most recent achievements of the international community, have been trodden underfoot.
7. The Assembly therefore urges the governments of the member and non-member states grouped together in the Council of Europe:
i. to take the requisite action on the declarations made at the New York World Summit for Children in 1990 by subscribing to the principle of "First Call for Children", according to which meeting the essential needs of children must be a top political priority when resources are allocated and must be taken fully into account when policies are devised, and to undertake, as appropriate, to ratify and apply the provisions of the United Nations Convention on the Rights of the Child;
ii. to express their support for this principle at the Summit of Heads of State and Government (to be held on 8 and 9 October in Vienna) and to focus the discussions of the next Conference of European Ministers responsible for Family Affairs (Paris, 13-15 October 1993) on this central issue;
iii. to undertake to protect children from the scourge of war and to condemn the barbaric practice in recent conflicts of using women and children as targets and human shields, as well as the widespread use of antipersonnel mines, particularly those resembling toys, of which the main victims are children;
iv. if the conflict in the former Yugoslavia continues, to consult with specialised organisations and NGOs with a view to adopting the immediate measures needed to ensure that the children and women of Bosnia-Herzegovina are given the food, water, heating, medical care and treatment and psycho-social help which are vital for their survival, that is to say, to ensure in all cases freedom of access for humanitarian relief and to secure observance for "havens of peace and safety" for the children;
v. to accompany the measures imposing embargoes and other sanctions on the warring parties with the humanitarian arrangements needed to protect the lives and health of the most vulnerable group of civilians, especially children;
vi. to introduce, at a European level, a co-ordinating structure to provide information on immediately available medical facilities (for example, the number of beds reserved for emergency treatment for children in each country) and to develop mutual assistance between hospitals in order to promote the rebuilding of hospitals, donations in kind and personnel support in the former Yugoslavia;
vii. to ensure that rape victims, both women and children, receive the necessary medical care, psychological support and legal aid, not least in host countries;
viii. to provide the appropriate emergency medical, psychological and educational aid for children who have witnessed or suffered cruelty, inhuman or degrading acts or the loss of their loved ones;
ix. in the facilities for accommodating displaced persons, and refugee camps in particular, to help the women to feel useful by providing them with opportunities to engage in occupations and receive education and vocational training and allowing them to retain their active role, notably in performing their everyday family duties and housework;
x. to supply the children of the former Yugoslavia affected by the conflict with a minimum of education and the educational and play material (books, toys, etc.) which is vital for children's development;
xi. to develop, particularly for children, programmes of education in peace, tolerance and democracy;
xii. to assist in the initial and further vocational training of local personnel, especially those responsible for children, and to give them the moral support and psychological help needed for overcoming the burnout syndrome.
8. The Assembly launches an urgent appeal to the governments of the states grouped together in the Council of Europe and to the European Community to contribute financially to humanitarian relief, to relax the conditions placed on the grant of subsidies to the various humanitarian organisations at work in the former Yugoslavia and to increase the size of the subsidies, so that needs can be effectively met.
9. It invites the governments of Council of Europe member states to make optimum use of the instrument constituted by the Council of Europe's Social Development Fund by means of a Special Aid Account, so that immediate practical steps can be taken to meet the manifold needs emerging from the conflict in the former Yugoslavia.
10. The Assembly also invites governments not to overlook the risk that similar conflicts might break out in or around Europe, to continue discussion on humanitarian action in cases of armed conflict, to devise a concerted European strategy, and to take timely steps to develop and reinforce, in every country, all the peace forces in society.
11. The Assembly invites the international community to review and adapt the humanitarian law governing the protection, in cases of armed conflict, of civilians, notably women and children, in keeping with human rights and the rights of the child.
II. Draft order [link to adopted text]
1. The conflict in the former Yugoslavia dramatically illustrates the fate of children in time of war. It poses the more general question of the implementation and protection of the rights of children and of policies for children in Europe. In some countries, particularly those in transition to democracy, their situation is developing in an unsatisfactory and sometimes a tragic way.
2. The Assembly instructs its Social, Health and Family Affairs Committee to inquire further into matters connected with policies for children's survival, development and protection; to develop, in co-operation with UNICEF, a European strategy for children; and to that end authorises the committee to hold periodical meetings with UNICEF at its office in Geneva.
3. The Assembly further instructs its Social, Health and Family Affairs Committee to study and make practical proposals for establishing at European level an appropriate structure to co-ordinate supply of and demand for immediately available medical care for civilians - and in particular children - in the case of armed conflict, notably in the former Yugoslavia.
III. Explanatory memorandum
by Mrs ROBERT and Mr DANIEL
1. Under Order No. 486 (1993) on the protection of human rights, the Assembly, inter alia, instructed its Social, Health and Family Affairs Committee to consider a number of problems emerging from the current conflict in the former Yugoslavia.
2. In its efforts to comply with the order, the committee decided to accept the invitation from the office of the United Nations Children's Fund to visit Geneva. On 24 June it held an exchange of views with Dr Samir Basta, Director of the office, and with Mr Tom McDermott, special representative in the republics of the former Yugoslavia, and heard a number of its staff — men and women who had worked directly on the ground.
Discussions centred on the situation of women and children in the republics of the former Yugoslavia and other war-stricken areas, and on the scope for co-operation between the Council of Europe and UNICEF, notably the introduction of a European policy on children. A joint declaration (see hereafter) was unanimously adopted, and forms the core of the text of the resolution as proposed.
3. A hearing was held in Strasbourg on 28 June on human rights in the former Yugoslavia, at the initiative of the Committee on Legal Affairs and Human Rights. The hearing was attended by a number of organisations and NGOs working on the ground, including the High Commissioner for Refugees, the International Helsinki Federation for Human Rights, Médecins sans Frontières and UNICEF, which recounted their experiences and described their action in situ. As an example, an account of some of the achievements of these organisations is appended to this report.
Tribute must be paid to these organisations' humanitarian action. We would thank these men and women for having performed difficult and dangerous work for the welfare and protection of others, often at the risk of their own lives, and we congratulate them on their professionalism and their admirable personal commitment.
5. We would extend very special thanks to UNICEF for its help in preparing this report. The allotted time was insufficient to deal with all the problems involved. We decided initially to focus our attention on the tragic fate of children in this war-torn part of Europe, which is, so to speak, enlightening in that it prompts us to question not only the merits of the current protection afforded to civilian populations in time of war, particularly children, but also the situation as regards awareness, recognition and implementation of the rights of the child across the world.
Certain other aspects of the terms of reference allocated to the committee, including the abandonment and adoption of new-born babies, would necessitate additional information and studies, or indeed in situ investigations, and must be dealt with in subsequent reports.
6. It is said that about 35 000 children die every day throughout the world in "silent emergency" situations, especially in the developing countries, as a result of extreme poverty, malnutrition and disease. Women and children are increasingly frequently the targets of the horrors of war. Apparently, over 90% of the victims of current armed conflicts worldwide are civilians. Over one and a half million children have been killed in the last ten years; four million children are handicapped as a result of war; five million children live in refugee camps and twelve million have lost their homes.
7. Everyone knows, but it must be repeated, that the parties to the conflict do not respect the rules recognised as being part of the laws of war. In the face of these barbaric and systematic violations of humanitarian law, perusal of the 1949 Geneva Convention relative to the Protection of Civilian Persons in Time of War and the 1977 Additional Protocols leaves one with an overwhelming feeling of unreality: virtually all the protective provisions have been violated.
8. Among the elementary humanitarian principles which are being flouted and violated on purpose is the one to the effect that children should be involved neither passively nor actively in warfare. As early as 1924 the League of Nations approved a declaration on the rights of the child which stipulated that the child must be the first to receive relief in situations of distress and stated that men and women of all nations recognised that mankind must give children the best it could offer.
During the conflict in the former Yugoslavia more than seventeen of the forty-one articles in the first part of the Convention on the Rights of the Child adopted by the General Assembly of the United Nations in 1989 have been violated. Articles 38 and 39 lays down the principle of the protection of children in situations of war.
9. For exhaustive and detailed accounts, we would refer the reader to the various published reports, including that by Mr T. Mazowiecki, United Nations Special Rapporteur. However, it would not be redundant here to point out and to condemn that children have been the victims of summary executions, have been systematically targeted, killed and wounded, often to serve as bait so that adults coming to help them can be shot down. The projectiles used are specifically designed to cause irreversible injuries.
10. The parties to the war have targeted social institutions, including hospitals and schools, for purposes of warfare and destruction. A prime objective of international co-operation must be to reconstruct these and restore them to an operational state. In recent armed conflicts women and children have increasingly been used as human shields, and there is also increasing use of antipersonnel mines which look like and are the same colour as toys, and children are of course the prime victims.
This has been the case in the former Yugoslavia. It was said that about 60 000 antipersonnel mines per week were being spread around the territory. Children are particularly hard hit by the deprivation of, or difficulties in securing, food and water and the lack of heating, not to mention the difficulties in receiving proper medical treatment and care. Children in Sarajevo have long been subsisting mainly on bread, rice and pasta.
11. Violence, terror and collective madness are the children's everyday environment. Not only have they suffered barbaric acts, they have also witnessed them. In the republics of the former Yugoslavia approximately one million children are suffering from psychological trauma and 150 000 children and their parents have been directly exposed to terror for long periods. The symptoms of post-trauma stress have been observed: guilt about having survived; depression and anxiety, inability to imagine any future; irritability; miscellaneous psychosomatic disorders and symptoms; and time does not alleviate the after-effects: the individual keeps the psychological scars for years, hence the need to set up psychological support services without delay.
12. In connection with refugees on protracted stays in camps, UNICEF experience in other conflicts, such as that in Cambodia, has shown that children there stay on the sidelines of real life and, having lived in a state of complete dependency for too long, suffer from "total institution syndrome", with, ultimately, the possible risks of begging, stealing, prostitution, etc.
13. If the children's stay in the many refugee camps in the former Yugoslavia is perpetuated, we are liable to see the emergence of the same phenomena, and we must help the host countries, which will be, or are already, faced with the great financial responsibility of providing not only essential medical treatment and food and accommodation for these persons, but also schooling and vocational training for the children, and of ensuring their future integration into working life and society.
14. The collective rapes of women and children, which have been used as a weapon of ethnic and cultural destruction, have elicited the unanimous indignation of the international community. The Assembly must endorse the judgment given by the Committee of Ministers of the Council of Europe, which last February declared that rape "is a violation of human rights and ... the use of rape as an instrument of warfare and within the context of a strategy of ethnic cleansing is a war crime and should be considered as a crime against humanity".
15. This indignation and outrage at such crimes and the ethnic cleansing issue were to some extent addressed by the decision taken in February 1993 by the United Nations Security Council to set up an international court — whose membership is currently being decided — to consider the violations of international humanitarian law in the former Yugoslavia.
Will this be enough? Should we not be backing ideas such as the preparation of a protocol to the United Nations Convention on the Elimination of All Forms of Discrimination against Women which would deal with violence against the latter, or else considering reviewing military codes of conduct, as advocated by the European Parliament's Committee on Women's Rights, in order to have done with the idea that rape might be an acceptable consequence of war?
16. Like many wars, the one in the former Yugoslavia is marked by the handing down of hatred from generation to generation. Dr Samir Basta quoted the example of young boys from the Middle East who, whatever their religion, are taught by their mothers from their earliest infancy to speak in a war-like, aggressive manner and hate the enemy, and are indoctrinated to become warriors or martyrs. War is culture-based. If children are brought up in a spirit of tolerance, dialogue and peace, hatred may be held at bay and the instinct for peace may at last be allowed to germinate.
17. The invaluable work done by organisations such as the HCR, ICRC, UNICEF and the humanitarian NGOs has constantly been hampered, if not rendered impossible. Humanitarian action is the expression of a form of solidarity which sometimes comes too late. It is highly reliant on voluntary funding, which is invariably insufficient to deal with the actual needs encountered. The UNICEF budget, for instance, comes solely from voluntary contributions made by governments and the public via sales of greetings cards and other products; despite repeated requests by the organisation, only 22% of the funds currently needed for children in the former Yugoslavia were available.
18. At the aforementioned hearing of 28 June, the HCR pointed out that the European contributions had not come through that year; in August it told the press that it had only $162,8 million at its disposal, whereas it would need $420 million to cover needs up to the end of the year; similarly, Médecins Sans Frontières reported a drop in subsidies from the European Community and blamed the drastic conditions to be fulfilled to qualify for them; one more winter would increase the tragic consequences for the most vulnerable group of populations on the ground.
19. The economic difficulties facing neighbouring countries which take in refugees has decreased the sympathy felt for the latter, as well as the available supply of accommodation and assistance. The embargo imposed on Serbia and Montenegro has had terrible consequences for the health and nutrition of the most vulnerable groups of civilians, and a number of humanitarian concessions must be made to avoid the consequences which are not the purpose of the embargo.
20. In this conflict, on-the-ground protection has usually been necessary to enable the soldiers to get supplies and medicines through to those whose survival depends on them. Where operations aimed at evacuating civilians, women and children have been possible, they have been carried out under dangerous conditions and have been criticised for resembling "Wild West exploits" — or because the whole underlying principle was felt to be wrong.
21. Again, some controversial attempts to evacuate the injured have prompted disputes about the number of persons involved and the criterion for the choice of evacuees. For example, during "Operation Irma" in August 1993 the sudden frantic competition between governments to offer treatment seemed to have more to do with a political and media operation than with humanitarian relief. Moreover, the press has passed on allegations about bureaucracy and the excessive length of time taken to reach and implement decisions. Even the humanitarian organisations mention the lack of policy guidelines and confusion.
22. This leads us to the question of what practical arrangements are needed to achieve optimum effectiveness in, and co-ordination of, humanitarian action. It is a fact that the European public are in very broad agreement that such action is needed, and cannot understand the hesitations and hitches, which they consider are the fault of the politicians.
23. The conflict in the former Yugoslavia clearly shows that the issue of humanitarian action in time of war must be treated separately from disaster relief, and that it requires further study. Even if such action must ultimately remain the responsibility of the competent international organisations and NGOs, this conflict demonstrates that European governments must be involved and that a concerted strategy for humanitarian action is sadly lacking.
24. In the short term, consultation and co-ordination are the only way to flesh out the international provisions on the protection of civilians and make them something more than mere wishful thinking. In the longer term, we should be reviewing these provisions in the light of the new worldwide context and in liaison with the concept of human rights and the rights of the child, and not waiting until such time, perhaps in the none-too-distant future, as the same kind of barbaric acts are perpetrated in similar conflicts, in or around Europe, before discussing how to bring the provisions into line with reality.
25. The Convention on the Rights of the Child (ratified by twenty-six member states of the Council of Europe) is the result of a broad consensus and the meeting point for the upholders of civil and political rights and the supporters of economic and social rights, who have traditionally remained separate. For the international community, to enforce the rights of the child is also to provide better safeguards for human rights.
26. In accordance with the undertakings made in 1990 at the World Summit for Children in New York, it is necessary to ratify and implement this convention, subscribing to the principle of, "First Call for Children", according to which meeting the essential needs of children must be a top political priority when resources are allocated and must be taken fully into account when policies are devised.
The first Summit of Heads of State and Government of the Member States of the Council of Europe to be held on 8 and 9 October 1993 in Vienna should express their support for the above-mentioned principle. And this concern should not be absent from the debate of the next European Conference of Ministers responsible for Family Affairs (Paris, 13-15 October) which will be dealing with: "Family policy — children's rights, parental responsibilities".
Addendum
Joint statement of the Social, Health and Family Affairs
Committee of the Parliamentary Assembly of the Council of
Europe and the United Nations Children's Fund
Geneva, 24 June 1993
The Social, Health and Family Affairs Committee of the Parliamentary Assembly of the Council of Europe conducted a hearing with the office of the United Nations Children's Fund (UNICEF) in Geneva, on 24 June 1993, in order to review the situation of women and children, in particular in the republics of the former Yugoslavia and other zones of conflict and need.
The Social, Health and Family Affairs Committee of the Parliamentary Assembly of the Council of Europe and UNICEF:
— underline, in view of the fact that, according to UNICEF, 35 000 children die every day in a "silent emergency" and that two-thirds of these deaths could be avoided through preventive measures, the need to combat "social bureaucracy" in order to accelerate the most urgent interventions in social assistance and support to children;
— request member states of the Council of Europe to increase their financial aid and support to countries most in need, to the most vulnerable groups, in particular women and children, who need protection, and to countries in transition to market economies: Albania, Bulgaria, the republics of the former Yugoslavia, Romania, as well as Estonia, Latvia, Lithuania, and other newly independent states;
— urge the international community to protect children from the scourge of war and, in particular, to condemn the barbaric practice in recent armed conflicts of using women and children as targets and human shields, as well as the widespread use of anti-personnel mines, especially those which look like toys of which children are the most frequent victims;
— request all states to accompany measures to enforce embargoes or sanctions with the necessary exemptions of a humanitarian order that will allow protection of the lives and health of civilian populations, especially children;
— call on all those states which have not yet done so to ratify the Convention on the Rights of the Child as a matter of urgency, as well as to sign the World Declaration and Plan of Action on the Survival, Protection and Development of Children, which was agreed to at the World Summit for Children in 1990, and to prepare national plans of action to address children's needs as a priority;
— call on all governmental, parliamentary and non-governmental officials to adhere to the principle of "First Call for Children".
Reporting committee: Social, Health and Family Affairs Committee
Budgetary implications for the Assembly: None
Reference to committee: Order No. 486 (1993)
Draft resolution and draft order: Unanimously adopted by the committee on 17 September 1993
Members of the committee: Mr Pini (Chairman), Mrs Håvik (Vice-Chairman), Mr Rathbone (Vice-Chairman) (Alternate: Baroness Hooper), Mrs Albrink, MM. Banks, Benvenuti, Bloetzer, Bowden (Alternate: Mr Cox), Curto, Diaz de Mera, Mrs Fleetwood, MM. Foschi, Geoffroy, Gerontopoulos, Gouteyron, Mrs Guourova, Mr Gusenbauer, Mrs Haarstad, Mrs Halonen, MM. Hörcsik, Jacquat (Alternate: Mr Daniel), Jurgens, Karaka_, Laanoja, Liberatori, Libicki, Marques, Menzel, Meyer zu Bentrup, Mrs Moynihan-Cronin (Alternate: Mr Gregory), MM. Mozetic, Ottenbourgh, Miss Özver, MM. Palacios, Pécriaux (Alternate: Mr Monfils), Pottakis, Psaila Savona, Mrs Ragnarsdottir, MM. Regenwetter, Reimann, Schwimmer (Alternate: Mr Strimitzer), Siemienowicz, Mrs Soutendijk-van Appeldoorn, MM. Ternak, Wielowieyski (Alternate: Mr Malachowski).
NB: The names of the members present at the meeting are printed in italics.
Secretaries of the committee: Mr Hartland and Ms Meunier
APPENDIX
to the
REPORT
on the situation of women and children
in the former Yugoslavia
(Rapporteurs: Mrs ROBERT,
Switzerland, Liberal, Democratic and Reformers Group
and Mr DANIEL,
France, European Democratic Group)
Appendix I: UNICEF's programme for traumatised children in the former Yugoslavia
Appendix II: MSF (Médecins sans frontières) activities in Bosnia-Herzegovina
UNICEF's programme for traumatised children in the former Yugoslavia
Why?
Three basic facts are guiding UNICEF's programme for traumatised children in the former Yugoslavia.
1. Due to the nature of the war, that is the widespread use of violence and direct targeting of civilian population including children, a large proportion of the children have been directly exposed to war-related trauma.
2. Professionals as well as volunteers often need extra support and new skills to meet the increased needs brought on by war — and they need personal support to cope with the enormous workload they are facing.
3. Substantial new knowledge has been gained during the past years within trauma and crisis psychology, and such knowledge needs to be more widely known among professionals.
How?
In co-operation with the concerned authorities, suitable professional institutions have been identified and involved in the development of national programmes addressing the problems of traumatised children.
Psychologists, teachers, primary health care workers and others are trained through seminars in how to understand, detect and deal with childhood traumas caused by war. International experts are involved in training of national experts as a means of transfer of such skills.
People trained in seminars are addressing teachers, parents and others in ways of helping traumatised children to express, understand and cope with their traumas.
Professionals are offering therapeutic support to children at special risk, either individually, in groups or in the families. Children at risk are identified through screening.
Through detailed monitoring and evaluation of programme activities UNICEF is supporting authorities in developing a new body of knowledge — how to help children and families in large scale during a crisis situation. For proper assessment of the children's situation, data are collected on a routine basis.
What has been done?
During the first half of 1992, UNICEF supported several projects in Croatia, such as training of volunteers and the production of videos on how to help traumatised children.
During the second half of 1992, a more systematic approach for reaching traumatised children in schools was developed and implemented. By March 1993, forty-five schools were directly involved in this project. From each school a psychologist and a teacher attended national training seminars. These professionals afterwards trained teachers and others in their schools, and offered therapeutic support to children and parents. During the first five months of the project period, forty professionals from twenty schools (those attending the first seminar) reached more than 2 500 teachers, 4 600 parents and 400 other professionals directly. More than 1 100 children were identified and offered therapeutic help.
A smaller-scale project started in Sarajevo in October 1992. During the last winter, three seminars were arranged, and two "war-schools" were supported. Systematic expansion of the programme in Sarajevo was not possible due to the security situation and practical hindrances.
What is being done?
Bosnia-Herzegovina
The war in Bosnia-Herzegovina not only destroyed infrastructure and people, but it also disrupted the social fabric of peace time society. Children are often the worst victim of this situation, which is aggravated by absence of normal childhood activities such as schooling and the opportunity to interact with friends. The preoccupation of parents with war and it's consequences further contribute to their psychological problem.
In this situation two priorities are singled out: 1. support to normal childhood activities (in close collaboration with UNICEF's Education Programme); and 2. support to therapeutic work with traumatised children.
In Sarajevo programme activities have been intensified during the spring. Information seminars for teachers and psychologists are now held at regular intervals. material for therapeutic work with children are provided (in addition to educational materials provided to schools). UNICEF estimates 1 500 professionals will be reached, who in turn will cover 10 000 children. As soon as the security situation allows, activities will be expanded significantly.
In the Tuzla area programme activities are being implemented through a network of professionals working with children, with local health centres and social welfare centres as key co-operating institutions. The same is being planned for Banja Luka area.
In other areas of Bosnia-Herzegovina, programme activities are being planned in co-operation with local authorities. In addition, UNICEF is distributing different materials like drawing material and specific toys for therapeutic work with children.
Croatia
The school project in Croatia is expanding. By the end of this year 130 schools with 130 000 pupils will be involved in the programme. Among these it is estimated 10 000 children will be offered therapeutic help.
A parallel programme will be implemented in special schools or refugee centres. One component of this programme is aiming at work in small groups of children with emphasis on creative games. UNICEF is supporting a specific prevention and intervention project benefiting 1 600 children in refugee centres directly.
A programme for pre-school children will be implemented in kindergartens for displaced children and in refugee centres. One hundred pre-school teachers and psychologists will be trained, they will organise specific activities for 3 000 children.
The programme will also expand to cover health facilities. In a training programme for primary health care workers 500 paediatricians and other health professionals will be trained in how to detect and help traumatised children.
In addition to the approach through the education and health system, parallel projects are reaching local groups. UNICEF is providing education and supervision for 200 para-professionals from NGOs working with refugees in camps and host families. UNICEF is co-sponsor of a psycho-social project for 500 families in Croatia's largest refugee centre. UNICEF is also supporting 100 small groups of refugee children among which volunteers are addressing their traumatic war experiences through specific creative games.
Serbia and Montenegro
Implementation of two national programmes started in March 1993. A programme for pre-school institutions and schools will train 100 school psychologists and 300 teachers in methods for therapeutic work with children. These professionals will offer help to 12 000 children, as well as provide information to parents and teachers.
The second national programme aims at reaching primary health care workers. One hundred paediatricians will be trained, these will reach 32 000 children throughout 1993.
In addition, UNICEF is supporting some smaller-scale projects in areas having a high number of refugee population.
Slovenia
All refugee children in Slovenia are attending special refugee schools. Professionals, parents and children in these schools are offered counselling through a UNICEF-supported project; it will reach 2 000 adults and 1 000 children in 1993. An additional UNICEF project aims at training of social workers in the refugee centres.
The former Yugoslav Republic of Macedonia
A national programme for training of psychologists and social workers will be implemented in all twelve municipalities of Macedonia, reaching children in schools, refugee centres and host families. National experts will train thirty-six local experts, who will reach approximately 2 000 refugee children and 3 000 parents and teachers.
The future
The programme will expand into new geographical areas as soon as possible. Monitoring and evaluation of ongoing activities will be a continuous process, and further development of programme activities an important task.
Parents will be addressed, not only through education on how they can support children's development, but also in how they as parents can cope with their own personal stress and trauma reactions. An important aspect in this regard is the parent's acceptance and integration of the new social, political and economical context within which they have to live and raise their children. Special support to tortured and severely traumatised parents will be important.
A major task in the coming years will be help to the helpers, that is systematic support to professionals as well as volunteers who are taking part in the demanding work of providing therapeutic support to children. The helpers are not only under stress because of the demanding work of offering therapeutic help to traumatised children and parents. The helpers themselves also are suffering from the direct results of the war.
Children's conceptualisation and understanding of the world, including moral development, development of empathy and of tolerance and democratic values, is severely jeopardised in times of war. For this reason, a specific programme for development of tolerance, empathy and co-operation abilities in children should form the base for restructuring their confidence in the world and the future. In the long run this programme hopefully can represent a serious attempt at describing, understanding and resolving the underlying conflicts that resulted in a war in Europe at a time Europe was hoping wars should forever be history.
UNICEF in Sarajevo
The United Nations Children's Fund (UNICEF) established a presence in the former Yugoslavia in November 1991. Today, it has offices in Sarajevo, Zagreb, Belgrade, Split, Podgorica and Skopje. Recognising the acute suffering of children and mothers in this war, UNICEF has deployed more than eighty local and international staff members. The staff are specialists in logistics, health, psychology, education and water and sanitation. In addition, consultants are helping UNICEF with security, adoptions, urban water supply, peace education, and the evacuation of the sick and wounded children from Sarajevo.
UNICEF has eleven staff members in Sarajevo who work with other United Nations agencies and local and international humanitarian organisations to carry out the following vital projects in the city.
Water: UNICEF's contribution to the city's survival has been crucial in this area. Sarajevo's water system relies on pumps to move the water from wells into the mains and to the higher elevations of the city. Many of the pumps have been damaged and the electricity to power them has been sporadic. In addition, many of the city's pipes have ruptured, cutting the water flow, or increasing the risk of contamination from sewage. As a result, some parts of the city have not received running water since the war began in April 1992. Others areas have had water cut off for a month at a time. When the water is cut, residents must walk several kilometres through dangerously exposed streets to reach the few still-functioning wells. People have been killed collecting water. At the same time, residents have had to resort to drinking contaminated water, resulting in thousands of cases of enterocolitis and hepatitis. There is concern that in summer there may be an epidemic of water-borne diseases. UNICEF staff and consultants are working under life-threatening conditions, along with other experts and local water engineers from all sides, to rebuild Sarajevo's water distribution system. UNICEF has begun repairs on several pumps that feed water to essential locations. This should soon provide fresh water to some 50 000 residents. UNICEF has also provided the city with a generator, which is now feeding some water into undamaged city pipes. In addition, UNICEF is supplying new pipes, tools and equipment to repair the numerous major leaks in the city system. Finally, in anticipation of the threat of epidemics, UNICEF, in co-operation with the World Health Organisation, is distributing water purity testing kits, chlorine to treat the city mains and individual tablets to treat water collected from outside areas.
Health: The major health concern for the summer is the effect of disrupted sewage systems and unclean water supplies on a hunger-weakened population. Widespread infestations with lice and scabies are likely, and concern has been raised over the possibility of epidemics spread by water, insects or rodents. UNICEF is pre-positioning drugs to fight water-borne diseases, including typhoid. The immunisation status of children in Sarajevo is generally good. UNICEF provides vaccines, cold chain equipment (kerosene refrigerators, cold boxes and vaccine carriers where electricity has been cut), and injection supplies to local health authorities, as well as paediatric drugs and basic equipment to dispensaries, health centres and paediatric hospitals. It distributes gynaecological and midwifery equipment. Finally, UNICEF has helped evacuate over ninety sick or wounded children to other countries for treatment.
Nutrition: The most vulnerable of Sarajevo's citizens are undernourished. UNICEF has begun distributing supplementary food and vitamins to the city's pregnant and lactating women to help them maintain the nutrition levels necessary to have healthy babies, or to allow them to breastfeed. The programme also covers infants up to one year of age whose mothers are unable to breastfeed, children up to five years of age whose mothers are either pregnant or lactating, and all children up to fourteen years in the most exposed areas. The supplementary food is distributed by UNICEF staff to nine health centres in the city. UNICEF has approved a plan to expand the programme to children up to seven years of age throughout the city.
Education: Formal pre-school and primary school education has been totally disrupted in Sarajevo. School buildings serving the city's estimated 59 000 pre-school and primary school students have either been damaged or turned into refugee centres or shelters, and there is a severe shortage of basic school supplies. Nonetheless, throughout the winter, many children have shown a fierce determination to continue with some kind of education, attending makeshift classes set up in the darkened and cold stairwells and basements of apartment buildings. UNICEF is providing notebooks, pencils, chalk and teaching aids for this temporary programme, and proposes to fund and assist the training of teachers to carry out a programme of peace education that promotes cultural and ethnic understanding and tolerance.
Psychosocial support: Almost all children in Sarajevo are suffering from war trauma. A UNICEF survey shows that many have nightmares and display symptoms ranging from apathy to aggression. UNICEF has initiated a support programme that consists mainly of technical advice for the screening of traumatised children and financial assistance for training seminars for child psychologists, teachers, and health and social workers on psychological support to war-traumatised children. UNICEF is exploring ways to reach children through mobile theatres and special radio and television programming.
MEDECINS SANS FRONTIERES
SUMMARY
MSF ACTIVITIES
BOSNIA-HERZEGOVINA
June 1993
Introduction
In reaction to the problems related to the break-up of the former Yugoslavia, and becoming acute during the summer months of 1991, MSF has sent medical teams to Croatia, Serbia and Bosnia-Herzegovina. These different teams have since constantly identified the health needs in the three republics.
MSF has started a medical distribution programme in the three aforementioned republics in close co-operation with federal, national and local authorities, and other international organisations/NGOs present in the former Yugoslavia.
From the beginning, MSF has participated in the discussion about disaster preparedness with the Ministers of Health of the federal government and of the republics, as well as with the different relief organisations, all represented in the different emergency committees.
Originally started in Croatia, the MSF programme was extended to Bosnia-Herzegovina as of September 1991. By that time the medical infrastructure in this republic rapidly collapsed, and MSF therefore has been operational in Bosnia-Herzegovina since.
Outbreak of the war in Bosnia-Herzegovina
At the end of 1991, MSF has opened, and to date still has, a medical-logistical base in Sarajevo. From this central distribution point, Bosnia-Herzegovina was supplied with medicines, medical material and medical equipment. Close contact was maintained and information exchanged with the local authorities (Institute for Public Health, Crisis Committee) and with the EC monitoring mission and UNPROFOR.
At the beginning of 1992, the capital of Bosnia-Herzegovina, Sarajevo, became more and more isolated.
In May, when war broke out on a big scale, Sarajevo became an isolated island in mid-Bosnia. It was completely cut off from the outside world and no more distribution of medicines and medical material could take place from Sarajevo into Bosnia-Herzegovina.
Until the forced but temporary evacuation out of Sarajevo on 5 May, four expatriate MSF staff were working in Bosnia-Herzegovina.
During two months, local MSF staff then continued the MSF distribution in Sarajevo.
Meanwhile, other operational centres were set up. Two in Croatia, one in Serbia and a second one in Bosnia-Herzegovina, respectively Zagreb, Split, Belgrade and Kiseljak, staffed with MSF expatriate staff. From these centres distributions into Bosnia-Herzegovina (Sarajevo excluded) have continued since.
Several distribution channels into Bosnia-Herzegovina are being used: UNHCR, local NGOs, ICRC, UNPROFOR (to Sarajevo), and local trucks by means of the "pick up" system.
On 25 June 1992, MSF expatriate staff re-entered Sarajevo, and except for some short intervals has been present in Sarajevo since.
Actual situation in Bosnia-Herzegovina
The situation in Bosnia-Herzegovina deteriorates by the day. In 1992, one could still speak of war zones and non-war zones. By now, the situation in whole Bosnia-Herzegovina is one of an acute crisis. Even in those regions where war activities are relatively limited, the crisis has paralysed the entire society.
Health Crisis
The level of the different health structures has changed. As a consequence of the war, the primary health care, once well functioning at the level of the "Dom Zdravlja's" (DZ) and "ambulanta's" has collapsed.
First priority at most places now is the treatment of the war injured. Therefore, most DZs have been upgraded. Depending upon the supplies and the size of medical staff, many DZs now function as surgical hospitals. In-patient facilities have been created and operation theatres are established in the cellars of these former health centres (for example, Tesanj, Cazin, Jablanica). The regional and general hospitals (for example, Tuzla, Zenica, Travnik) have become referral centres with all specialisms, except neurosurgery.
By now, health facilities in Bosnia-Herzegovina are totally depending on the relief aid from abroad. Although relief aid has been stepped up, it is often not tailored to the real needs.
On top of this, the number of displaced is increasing daily. Daily, people are pushed out of different regions and forced into a small area in central Bosnia. As a result, all places in central Bosnia under Bosnian control are packed with displaced.
Actual MSF programme
Currently, the MSF distribution network supplies a big part of the health structures in Bosnia-Herzegovina.
MSF Holland continues the work in those parts of Bosnia-Herzegovina which are accessible from Croatia. Mobile medical teams are travelling to these areas to assess the medical needs. As a result of MSF's early and continuous presence and resulting expertise, the results of these assessments are highly appreciated by many other organisations.
MSF Belgium implements a programme in Serbia and the eastern part of Bosnia, accessible from Belgrade.
Since May 1992 until to date, MSF Holland delivered over 1 000 tons of drugs and medical material in Bosnia-Herzegovina. Funding for these deliveries has come from:
— Dutch Government;
— European Community;
— USAID;
— Project Hope;
— ODA;
— UNHCR;
— Soros;
— Dutch public.
Next to that, over 100 tons of drugs and medical material was supplied directly to Sarajevo with funds from:
— the Dutch Government;
— Belgian Government, and
— the Austrian Society of Haemodialysis.
The following kinds of material are distributed:
— medicines;
— dressing material;
— disinfectants;
— testing material;
— haemodialysis material;
— instruments;
— textiles;
— diet food;
— non-medical material.
Distribution in Bosnia-Herzegovina encounter many obstacles, and certain places remain inaccessible for humanitarian aid. The inaccessibility of towns and besieged villages for relief convoys, the insecurity of certain areas, together with the lack of co-operation of the different parties to the conflict, not to mention the manipulation of humanitarian aid, has turned relief work into a political and negotiable issue.
During the winter, accessibility of the roads due to bad weather conditions has been another important limiting factor. Although compared to last year, trucking capacity has increased, the dirt tracks and mountainous areas delay the relief convoys. Rain and snowfall, as well as fighting, isolated several communities in Bosnia-Herzegovina completely.
As long as there is no consensus whatsoever among the International Community, and politicians can play their own game in spite of several resolutions of the Security Council, the humanitarian aid will not be able to avoid a disaster in the former Yugoslavia.
Central Bosnia
This area, with a mainly Muslim population, could for a long time be reached by road from Split. In the centre of this region, in the village of Kiseljak, MSF has a warehouse and office. Many representatives of the health institutions from central Bosnia come to the MSF offices in either Split or Kiseljak. When security allowed, an MSF team visited the different locations herself and assessed the situation on the spot.
Recently, however, the process of ethnic cleansing, initially mainly exercised by the Serbs, was extended to regions under Croatian control, among which the Kiseljak region. This has made our activities in this area increasingly difficult and dangerous.
Eastern Bosnia
For over two months now, MSF teams have been able to work in Srebrenica. Since 22 June, MSF has re-established its presence in Gorazde and is presently assessing the medical situation and the situation in the field of water and sanitation.
Bihac
Several MSF assessments in this area were done over the last year. Regularly, supplies have been made available to the different health structures in the area. In this pocket some 350 000 people are trapped. Shortness of food and medicines is evident, but in close co-ordination with ICRC, MSF has continuously tried to fill the gaps.
Bihac region is largely surrounded by Krajina (the Autonomous Serbian Republic in Croatia). The UNPA area is the buffer zone between Bihac and Krajina in the north and west; on the eastern side there is an active front line.
Upon assessment by MSF medical staff, MSF regularly sends medicines to the Bihac area, either with UNHCR convoys or with its own trucks. These convoys travel through the UNPA area.
Banja Luka
This area is totally controlled by Bosnian Serbian troops. There are reports that the medicines brought in are exclusively supplied to the Serbians. Due to insecurity, our teams did not visit the area for some time. Recently the security situation has improved and a new visit was made. Because the region is now completely under Serbian control, fighting stopped. Although tension at the road blocks is still high, a new distribution is planned for the weeks to come.
Krajina
Krajina is the "independent" Serbian Republic in Croatia (capital: Knin). Several assessments showed that compared to the problems in Bosnia-Herzegovina, those in the area covered by Knin health service (Krajina South) are not too bad, as they used to get supplies from Serbia.
Since the sanctions were imposed the situation has deteriorated. MSF will therefore continue to support the Knin area health service by supplying a limited quantity of priority drugs/medical material.
Sarajevo
1. Sarajevo City:
In December 1991, MSF Holland established an office in Sarajevo. MSF's objective is to supply basic drugs and material to keep health care operational to an acceptable level under war circumstances and to investigate more specific requests concerning drugs and medical material. After a period of gathering information and making assessments of medical and non-medical needs, MSF had to develop its own distribution system because the existing governmental structure was not efficient. Since then, medicines and medical materials and equipment have been sent to over seventy destinations in Sarajevo on a regular basis. Medical supplies have been distributed directly to the state and Dobrinja hospitals, thirty-six clinics of the University Clinical Centre Kosevo, the Hrasnica war hospital, the four community-based health centres (Stari Grad, Centar, Novi Grad and Novo Sarajevo) and to the pharmacies of local NGOs. Our distribution network has functioned without interruptions since the beginning of the war.
In recent times MSF Sarajevo has managed to organise a weekly (10 a.m. Wednesday at BH Command Fwd. HQ) inter-agency meeting open to all of the international organisations operating relief programmes in Sarajevo. We have also established a separate medical meeting for all United Nations and NGO medical agencies operating in Sarajevo which meets after the larger general meeting (11.30 a.m.).
One important initiative which has developed out of these meetings is the establishment of a Medical Information Centre (MIC) which has been set up in the MSF satellite office located on the third floor of BH Command's Fwd. HQ. The MIC can provide up-to-date information on most of the medical programmes being carried out and planned for Sarajevo City. It also includes supply/shipment lists, assessment reports and planned activities from all of the participating agencies (MSF, WHO, PSF, MDM, UNICEF, ICRC, UNHCR, etc.) to facilitate greater co-ordination of all medical programmes so as to avoid duplication and improve efficiency.
2. Outside of Sarajevo:
MSF Sarajevo's medical relief programme also includes providing medical assistance to communities outside of Sarajevo City. This work has been carried out within both Serbian and Bosnian communities. Medical and logistical assessments have been done by MSF expatriate staff and medicine and medical materials have been delivered with the assistance of the UNHCR, the ICRC and the French Battalion transport facilities.
MSF prepares and sends shipments to a number of destinations outside of Sarajevo City, including hospitals and health centres on Serbian-held territory. In the past, MSF Sarajevo has either delivered or prepared medical and logistical assessments of Serbian and Bosnian communities.
3. Expanded programmes:
At the moment MSF Sarajevo has two principle concerns with regard to its humanitarian medical relief programmes:
— to maintain and expand existing MSF medical programmes in Sarajevo city where resources permit; and
— to expand further MSF medical programmes outside of Sarajevo City to all parties involved in, and suffering from, the conflict.
At the present time, MSF medical programmes in Sarajevo City are very well established and require only maintenance and supervision. We also keep a watch for any new problems which may occur (water, sanitation and hygiene problems this summer). The situation outside of Sarajevo is a different matter and it is in this direction that MSF Sarajevo plans to focus much of its future activity.
4. Bosnian-Serbian territory:
In particular, MSF Sarajevo will be responsible for leading the initiative to establish an MSF presence in Bosnian-Serbian controlled territory in co-operation with MSF Kiseljak and MSF Belgium which operates out of Belgrade, Serbia.
MSF Sarajevo has recently contacted the Bosnian-Serbian Liaison Office in Sarajevo (PTT Building) to initiate a number of new programmes:
a. to propose discussions with the appropriate Bosnian-Serbian authorities regarding MSF establishing an office in Pale and other important Bosnian-Serbian locations;
b. to receive a current Bosnian-Serbian list of communities (hospitals, DZs and ambulatories) and displaced or refugee populations which require medical assessments and medical supplies;
c. to identify potential emergency humanitarian medical situations before a vulnerable population suffers acute disaster.
Both Bosnian and Serbian communities require medical assistance to varying degrees depending upon their individual circumstances. MSF is willing to provide emergency humanitarian medical assistance only after completing a medical and logistical assessment to determine those needs. This initial assessment is followed up by regular medical and logistical assessments to identify changing needs and circumstances over time. A precise record of these assessments is maintained by MSF to provide a reasonable basis upon which to determine priority medical and humanitarian needs given the limited resources available. MSF also co-operates with other organisations to share information on assessment visits and medical deliveries to locations.
As part of this important work, MSF Sarajevo hopes to expand its co-operative working relations with other NGOs, governmental organisations, UNPROFOR and in particular the United Nations Military Observers (UNMOs) who themselves have a mandate to provide humanitarian assistance.
Tuzla region
Tuzla region has become a place of refuge for thousands of displaced people from eastern Bosnia.
The last weeks have been a period of insidious but marked deterioration in the general situation in Tuzla. There has been no mass influx of refugees or sustained shelling to the town, and so world attention has been focused elsewhere. During this time there has also been essentially no traffic in "commercial" vehicles with cargo coming into town. The region, which is heavily dependent on outside supplies and food, is truly cut off from the outside world.
Médecins sans frontieres-Holland has been active in the Tuzla region of Bosnia, helping support the local medical institutions since autumn 1991. Our first convoy of medicines, after the total outbreak of war in Bosnia, reached Tuzla on 17 May 1992. Since that time we have expanded our operations considerably, and now distribute medicine and medical supplies to twenty-two hospitals and health centres of the Tuzla region. We operated out of our Kiseljak office until 5 April 1993 when we established a full-time presence in Tuzla. At this time the staff in Tuzla consists of one to two expatriate and two assistants.
The scope of our work remains primarily the distribution of medicine and medical supplies. At this time we make monthly assessment visits to nine war hospitals and eight health centres in the region, and the clinics and pharmacies of Tuzla town. The assessment is then followed up by a delivery, or in special security cases the two visits are merged. Our objective is to provide the essential medicines and supplies to enable the local health authorities to care for patients with both war injuries and chronic diseases. We are confident that at this point this objective is being met. We find that pharmacies at most hospitals are generally well supplied. The challenge at this point is to maintain a consistent pattern of assessments and fill in holes as they arise.
In addition to distribution of supplies, MSF has stimulated local production of three essential medical items. We have provided raw materials to a local factory which is now producing intravenous fluid in Tuzla. Since 10 April 1993 this factory has produced 13 000 bottles of intravenous fluid, saving significant transportation space and cost, since previously this material arrived by convoy from outside of Bosnia. At this time we are also supplying raw materials for the production of dialysis fluid which again will negate the need to import this bulky and expensive medical product. Production of dialysis fluid has begun in early June. The third item now produced locally is external fixators, needed for the repair of complicated bone fractures. To date, 180 fixators have been produced in Tuzla at approximately one-tenth the cost of purchasing them outside the country. They have been distributed to the war hospitals by MSF and the Medical Logistic Centre.
In addition to continuing the programmes discussed above, MSF is currently working hard to meet the special needs of war injured patients who have peripheral nerve injuries. Because this is a severe but reversible problem, we are hoping to provide equipment and expatriate expertise to help cope with the overwhelming number of patients suffering from this injury.
We attempt to remain flexible and responsive to the changing and varied medical need. Over the next several months we hope to be providing new items, from cancer chemotherapy to belly button ties for newborn infants. We believe strongly that supporting the local health institutions in caring for the sick and injured is a profoundly more sensible approach than the costly and socially disruptive practise of medical evacuations.
It must be stressed that the food supply is the most critical issue in the Tuzla region. The common theme among these three very serious problems (collapsing infrastructure and health care being the other two) is the blockade of traffic through central Bosnia. While a long-term solution clearly requires changes in behaviour of the military and "political" leaders, for the short and intermediate term supplies must reach the Zenica Tuzla region. Anything less than a determined solution of this supply problem is a quiet complicity with a form of ethnic cleansing to which western society has pledged "never again". Ignoring this problem will not solve it; it must be seriously addressed. It must be seriously addressed now.