Julian Sheather: Medicine, trauma, and sexual violence—healing the wounds of war

julian_sheatherThe shadows fall early in the crumpled hills surrounding Sarajevo. It is 25 years since UN intervention finally brought the war here to a close. In May I was invited to Bosnia by the UK based charity Remembering Srebrenica, part of a national health delegation. The charity works to preserve the memory of the Srebrenican genocide: 8373 Muslim men and boys were murdered by Serbian forces after the town fell. Drawing on that bitter memory it also works for community cohesion. The UK is not as fissile as the Balkans, but Brexit has uncovered deep divisions: hate crime has leapt, the government is actively promoting a hostile environment, anti-Islam feeling is rising. Across Europe, old nationalisms are growing restive. In Hungary, Viktor Orban has decreed the end of liberal democracy.

I wanted to understand the role health services play in the aftermath of such a savage, internecine conflict. Our host, the wonderful Resad Trbonja, described it as “the most intimate war.” Before the conflict Muslim Bosniaks lived easily alongside Catholic Croats and Orthodox Serbs. Confessional differences were weak: minarets shared skylines with steeples. Intermarriage was common. In Resad’s words, the people of Sarajevo were more belongers than believers: many of the young in Sarajevo were atheists; Resad was more interested in Converse trainers and rock music. Nor are there any visible ethnic distinctions between people, no visual clues to difference. Time and again people told me they didn’t believe war could come.

But it did come, and rape of Muslim girls and women by Serbian soldiers was systematic. Some were raped repeatedly then murdered: one 11 year old girl was raped then thrown from a six storey building. Women were held as sexual captives in “rape hotels”—many were imprisoned until pregnancies were too advanced for abortion. The Bosnian conflict has the dark accolade of forcing international recognition of rape as a war crime.

Dr Branka Antić-Štauber greets us in an airy meeting room in a house overlooking Tuzla, in Eastern Bosnia, close to the border with Republika Srpska. It is the headquarters of the NGO she directs: Snaga Žene (Strength of a Woman). A GP and infectious disease specialist, Branka set up Snaga Žene in 1999 to support refugees dispersed—effectively ethnically cleansed—by Serbian expansion. In addition to being raped and forced from their homes, many of the women lost male relatives—killed fighting or victims of the genocidal onslaughts in Srebrenica and Žepa. One woman lost 37 close relatives. To sexual violence and displacement was added unimaginable grief.

Branka is dark haired, animated, and softly spoken. As everywhere in Bosnia we are greeted with sweets and thick Turkish coffee. In traditional Muslim societies, rape and sexual violence have long been taboo—cloaked in shame and silence. But unless the traumas of war were addressed, until the women could start to talk about their experiences, they were unlikely to heal.  

There was little international experience for Branka and her colleagues to draw upon, little knowledge of what worked in such a context. Gradually they felt their way—slowly building what they call an “ecological” or holistic approach. For these women who have lost so much they provide interlocking services. Medical and psychological support are essential. PTSD is widespread. Rates of anxiety and depression were, initially at least, stratospheric. There were also physical problems—difficulties conceiving, high rates of some cancers, the physical effects of long term stress. But it was clear the women also needed legal services. Traditionally, men were seen as protectors and providers. With so many of them dead, women needed help securing basic legal rights: to retrieve property stolen during the war, to access pensions and social support, to find education.

I can’t help noticing a tall, empty Perspex stand in the corner of the meeting room, advertising something called Herbasense. It seems out of place: more at home in a wholefood store or upmarket chemist. But it gives the clue to an extraordinary success story. Many of the women supported by Snaga Žene came from the country. Before the war they worked their own land. Outside the cities, every house has its own carefully tended small holding: as we drove through the fertile valleys, women were out everywhere in the fields, weeding and hoeing between the rows of new crops.

The women were desperate to work. Idleness compounded their distress. And so Snaga Žene acquired 15 acres of land for them to cultivate. They started to grow medicinal herbs: echinacea, lavender, arnica, calendula. The work brought extraordinary therapeutic benefits. The numbers of women reporting depression fell from 72 to 28 per cent. Initially, if there was a drawback, it was overproduction: they grew much more than they could use. But then they started to manufacture and market herbal teas—in Bosnia at first, then overseas. The project is starting to support itself, bringing renewed purpose and self-respect to the women.

We head out into spring sunshine. In the tight valleys the shadows are already lengthening. There is birdsong and the clean air smells fresh. It is difficult to square this quiet country with such terrible violence. Our host, Resad, has told us that fault lines remain. Old animosities are near the surface. There is much to be done. The work of Snaga Žene and its sister is as critical as ever.

Julian Sheather is ethics manager, BMA. The views he expresses in his opinion pieces are entirely his own.