War Hospital

by Sheri Fink

  To counter his paralysis, Ejub steers his mind away from the patient and toward the wound. He forces himself to sit down beside the low-standing cot and take up his instruments: a pair of pincer-like forceps in one hand, for gripping skin, and a scalpel in the other. He holds the blade like a pencil and inscribes a semicircle in the skin of the swollen, dusky lower leg. This is his first mistake.

  The patient, knee propped up on a folded blanket, remains still, silent. Ejub stares at the leg as he works, face impassive, deepening the incision, bowing flesh with his scalpel as if playing a violin. The world has constricted to the leg, the leg and the job he has to do, like a piece of wood he needs to whittle into shape.

  He has no assistant to expose tissue according to the display he needs, or to scan for blood vessels and, fingers dancing a delicate ballet with his, tie them off in silence. Instead, he has the help of an older pediatrician who is even less adept at surgery, the recently appointed director of the war hospital, Dr. Avdo Hasanović. The bulbous-nosed doctor seats himself on a stool across from Ejub, takes up the other of Srebrenica’s only two scalpels, and begins to stab at the patient’s calf as the nurse struggles to hold it steady.

  The two doctors work separately, trying to complete the surgery more quickly and thus minimize pain and the dangerous blood loss that could lead to shock and death. The patient has already bled a great deal from his wound, and, with no blood bags and no electricity to run a refrigerator for transfusion products, they cannot give him a transfusion.

  The patient groans—just once. He has barely flinched or bled, and Ejub has overlooked what this means: He is cutting dead tissue. Fragments of the exploding mine have seared the patient’s blood vessels, starving the lower leg of vital blood supply. If the doctors complete the amputation here, gangrene and infection will creep up and ultimately kill the young man.

  Ejub scrutinizes the leg.

  “A little higher,” he pronounces and points to a spot. He looks to the older doctor, who nods his agreement.

  Starting at this point, Ejub slides his knife down, splitting the skin just as the nurse slit open the pant leg. The flesh drops to either side as he cuts.

  After some poking and probing, the other physician picks up the task and begins to slice upward. The nurse can barely keep up with him, untying and retying the rubber catheter being used as a tourniquet, higher and higher, swabbing with disinfectant, injecting with anesthetic, her escaped curl of hair nearly brushing the patient’s bloated skin, her bare fingers flirting with the scalpel.

  Now the skin incision has been extended to its new, higher position. The two doctors resume cutting toward bone. Each stroke of their scalpels takes them deeper, away from numbed skin and tiny capillaries and closer to large nerves and arteries. A loud “Ohhhh!” escapes the patient.

  The doctors intensify their work. Ejub’s scalpel nears the anterior tibial artery. Its caliber measures approximately a quarter of an inch and it contains blood pressurized by every pulse of the heart to roughly 120 mm of mercury or two pounds per square inch. Normally, surgeons defuse the vessel, gently lifting it away from the surrounding tissue and tying it in two places with lengths of absorbable, string-like suture. Only then do they cut it.

  But Ejub, rushing, has little suture or experience. He slices through the artery.

  The doctors fumble to stop the bleeding with the rubber tourniquet, retying it tightly around the patient’s leg, hoping that the external pressure will overwhelm the blood vessel’s internal pressure, giving the blood in the vessel time to clot. To compound the force, Ejub grips the leg tightly between his hands.

  The patient moans.

  The other doctor presses down on the patient’s knee with his left hand to steady it, forceps dangling from his fingers. With his right hand he saws and saws with his scalpel. The edge of the blade slices through a dense network of nerve endings in the membrane around the bone, the periosteum. The patient yells.

  Ejub presses his fingers hard against the skin to close off the broken artery. For now he blocks out his emotions and tries to focus, but the shutter of his mind snaps and his brain can’t help being exposed to the horror. Still, he reaches for the zhaga, a “p”-shaped saw designed for cutting metal, not bone. The man with the camera stops recording the operation. Soon the worst part is over and somehow the young patient survives. The operation is done, and all Ejub wants is a cigarette.

  The doctor peels off his gloves, pulls off his gown, and doffs his blue cap. He walks out of the operating room and down the dark hallway, pushes open a wooden door, enters a vestibule, and exits the hospital through its back door. He walks down its steep driveway and turns left onto the main street.

  Hills lurch up around him, casting evening shadows on the road. He strides uphill, past old homes that once had terra-cotta tile roofs. Shrapnel marks splatter some façades; others are destroyed, skins burned off, just skeleton masonry remaining. Brick chimneys trace jagged silhouettes against the sky. The roofless hulks are like open dollhouses. He knows the people who lived in these houses, can recite them by name as he walks up the street—Begić, Delić, Fazlić…

  A child of the mountainous villages just south of Srebrenica, Ejub has never liked living in a valley. Even when he first arrived in Srebrenica to work as a doctor six years ago, six years before the war, he felt trapped.

  Now men sow the hills with mines instead of corn, wheat, oat, and tobacco seeds. They drop explosive-filled shells into mortars and let them fly. Every missile that comes whizzing out of these hills, bursting into hot metal fragments, reminds him of his vulnerability. His body, too, can be pierced like Swiss cheese. And who would take care of his wounds?

  Ejub, a nominal Muslim, had liked his Serb neighbors, and they had liked him. He has his own way of rationalizing why people who like each other have begun to fight. War is like a marriage squabble. Sometimes you get into an argument with your wife, and you realize, somewhere along the way, that you might have been wrong, but then it is too late to go back and admit it. You keep on fighting. In war, there are times you wish there weren’t a quarrel and that you could go back to the beginning, but you can’t because blood has been spilled and, almost by natural law, it goes on and on and you have to defend yourself. That is how he makes sense of it, if any sense can be made of it at all.

  He reaches his orange brick apartment building and enters the door on the west side. He goes to sleep in his marriage bed. Like every night for three months since the fighting started, no matter where he sleeps or for how long, he dreams about the wife and son he sent away for safety.

  He awakens gripped with the fear of death and the certainty that he will be killed before seeing them again. Perhaps sleep is where the operating room images develop, where gruesome photos from the surgeries he’s done stack up. He lies in bed and prays for a replacement to come.

  * * *

  FOR DIFFERENT REASONS, the commanders of the ad hoc troops defending the territory around Srebrenica also want a qualified surgeon to take over the makeshift operating theater. Medicine is a war weapon. The presence of six doctors on six islands of land around Srebrenica has correlated with their successful defense.

  Now that the islands have been connected, five of the six doctors have come together in a central place, forming the Srebrenica war hospital and temporarily boosting morale among soldiers and civilians. Amputations take place in the hospital room rather than on the kitchen tables or living room floors of village houses where they did the first three months of war.

  For a while, just knowing that a doctor stands behind them has kept up the defenders’ morale. But in many ways, medical care is still in the Middle Ages. A head, chest, or stomach wound means near-certain death. As more soldiers realize this and lose the will to fight, their commanders believe, there is more of a chance that Serb forces will succeed in expelling the Muslims from their land, “ethnic cleansing.”

  The nearest big city controlled by Bosnian government forces—Tuzla—lies only fi
fty miles away but a world apart, inaccessible beyond miles of enemy territory and minefields. With no working telephones, making a link with that outside world means finding the man who used to run the amateur radio club and outfitting one of his ham radios with a car battery.

  When the amateur radio operator makes a connection, he speaks slowly and clearly:

  “In Srebrenica, we are running out of medical supplies.”

  “We are in desperate need of a surgeon here.”

  “People are dying of injuries that could be treated.”

  The people who hear these words pass them on to Bosnian radio, where the message is broadcast into the homes of Bosnia’s biggest cities, where it sticks in the memory of a self-styled war surgeon named Dr. Nedret Mujkanović.

  The radio operator’s plea also makes its way into the ears of local translators who work for the United Nations in the Bosnian capital, who tell their international bosses about the situation, who pass the information to other aid workers, who pass the word to a particularly strongwilled Belgian doctor named Eric Dachy, who works for an aid group called Doctors Without Borders.

  2

  ERIC

  FOR DR. ERIC DACHY, Srebrenica sounds like salvation. By the summer of 1992, the thirty-year-old Belgian generalist has arrived upon some of the most brutal scenes of the wars of Yugoslavia’s dissolution, but always after the fact, when nothing is left to do but offer succor to the survivors. The fact that an island of non-Serbs is holding out in eastern Bosnia means there is still a place to intervene before the worst occurs.

  Over his past eight months as regional director of Doctors Without Borders, Eric has come to be considered, by dull U.N. functionaries and the few unenthusiastic aid workers in Belgrade, Serbia, the capital of what remains of Yugoslavia, as “our best example of local color.” With his keen mind, unorthodox appearance, and steady-burning pilot flame of outrage at injustice, Eric has made his mark. When he strides into coordination meetings chronically late in his black leather jacket, uncut brown hair stuffed back in a ponytail, looking as if he’s been up all night, the others can almost hear a Harley-Davidson roaring behind him. But his teen rebel appearance belies a mature sensibility.

  Eric doesn’t need the meetings, the others agree. The meetings need him. He seems to grasp what it is taking others, even those older and more experienced at this work, much longer to figure out. For one thing, they aren’t in the tropics. The malaria pills the aid workers dump here are a useless source of medical waste. This population, older and with more chronic diseases than most recent refugee populations, needs its blood pressure pills, diabetes medications, and dialysis fluids. If the agencies are serious about restoring dignity to these refugees, they need to start providing soap, toothpaste, shampoo, and other items for personal hygiene, regardless of the fact that aid workers in poorer countries have to fight for enough syringes to immunize children.

  But even this doesn’t seem to be enough anymore in light of the horrors Eric has witnessed. Increasingly, he challenges his colleagues with the idea that the real issue isn’t how to provide humanitarian aid, but how to stop the war. The nightmares he has seen these past months have made him question everything—the value of life, the principles that can be defended here, and the impact of his presence as a humanitarian aid worker. He searches for a corner of this war where what he can provide will be truly needed.

  Sometimes he wonders how the hell he landed in this violent place and why the hell he stays here. Religion, which motivates so many others who go out in the world to “help,” has nothing to do with it. In fact, Eric’s upper-middle-class parents in Brussels, Belgium, raised him as an atheist in the predominantly Roman Catholic country. On the one hand, atheism has led him to take a rational approach to the world rather than a moralistic one. On the other hand, Eric’s father, a lawyer whom he loved and revered, instilled in him a hunger for justice.

  Eric isn’t a stranger to conflict. Angry voices echoed through his childhood home. Growing up in the tumultuous 1960s with two older siblings acting out their adolescent rebellions, well-behaved and highachieving Eric didn’t draw too much attention from his parents. Family quarrels helped Eric hone his skills in argumentation and critical thinking and heightened his desire for justice, but he hated the fights and hated the splintering relationships between people he loved. Fed up, he left home at age seventeen to attend college and live with a girlfriend. He harbored dreams of putting everyone back together again, giving each of them what they deserved to make them happy, stop blaming one other, and be friends again. A half year later, on Eric’s eighteenth birthday, his father died suddenly. Eric’s plan to mend the family went into hibernation.

  Eric struggled through medical school and then opened a general practice in his suburban Brussels apartment, but found his work less than stimulating. He dawdled through the post-graduate training needed for full physician certification, dabbled in learning psychoanalysis, and filled out his nights and his gut at Brussels bars.

  What captivated him in the late 1980s was news of the changing international order. When the Berlin Wall fell, symbolizing an end to the conflict between east and west, he expected world peace to break out. Instead came the 1991 Gulf War. He wasn’t a pacifist, but he opposed it, believing that Iraqi leader Saddam Hussein’s foray into Kuwait could be stopped by other means.

  One day Eric stood up from his TV set and decided to do something to help the war’s victims. He made an appointment at the Brussels office of Doctors Without Borders and asked to be sent to Baghdad. When they told him they didn’t work there, he deemed them a bunch of fraidy-cat “wankers” and went home. That was it. He’d considered it just one afternoon. But two weeks later, someone from the aid organization called him back. Kurds were fleeing Iraqi air strikes in long columns toward the north. They needed assistance. Could Eric go?

  He went, not knowing much at all about the organization that the French-speaking call by the acronym MSF, for Médecins Sans Frontières. He knew them only by their poster campaigns, which proclaimed, “We didn’t study medicine to cure imaginary patients.” Eric interpreted this to mean that they got things done for people in need and challenged prevailing attitudes. He liked those who “shook the tree” a little bit.

  MSF had been born kicking and screaming its way out of the Red Cross in Biafra, Nigeria, in the late 1960s. As Nigerian forces brutally squelched a secessionist struggle, a group of young French Red Cross doctors arrived to find famine sweeping across the rebel-controlled area. The doctors could do nothing to help. Hands tied by the International Committee of the Red Cross’s strict operating procedures (based on international conventions not yet updated to cover internal armed conflict), the doctors could not deliver crucial food supplies to rebel areas without the consent of the official government. The Nigerians weren’t willing to give it. Even worse, as evidence of genocide against the Biafrans grew, the Red Cross kept silent. This infuriated the French doctors. Thirty years earlier, Red Cross officials had failed to speak out about the mass deportations they documented during the Holocaust. That inaction had led some progressive intellectuals to discredit the very concept of humanitarianism. “The ethics of the Red Cross,” one ranted in a criticism of Camus’s The Plague, “are solely valid in a world where violence against mankind comes only from eruptions, floods, crickets or rats. And not from men.”

  The French doctors in Biafra seemed to agree. They revolted and broke their International Red Cross pledge to “abstain from all communications and comments on its mission.” They accused the Nigerian government of genocide and the Red Cross of failing to provide aid as famine ravaged the region. After leaving the Red Cross, they founded the group that would, in 1971, become MSF.

  MSF took the rigid, law-based approach of the Red Cross and bent it. Staying at work night after night, red-rimmed eyes burning with conviction and the smoke of dozens of cigarettes, its founders crafted a new philosophy of humanitarianism: MSF would go wherever people suffered, regard
less of political or military boundaries, with or without permission. Aid workers would bear public witness to outrages, from human rights violations to the blocking of humanitarian relief.

  Although some came to consider the typical MSF volunteer an adventurer or, in the words of a former MSF worker, a “naïve, Schweitzerlike individual, who seeks to change the world through medical skills and goodwill,” the idea of humanitarian doctors who went where needed, blind to all obstacles, and spoke out about what they saw, took off in the public imagination.

  “The age of the ‘French doctors’ rapidly replaced that of heroes in the mould of Che Guevara—the latter more romantic, undoubtedly, but disqualified by reason of their enthusiasm for gulags,” wrote Rony Brauman, president of MSF-France, in the early 1990s. “The humanitarian volunteer, a new, newsworthy figure, neither statesman nor guerrilla, but half-amateur and half-expert, began to appear at the flashpoints which light up the progress of history… the victim and his rescuer have become one of the totems of our age.”

  By the late 1970s, the world began catching up. The 1977 Second Additional Protocol to the 1949 Geneva Conventions—the modern version of humanitarian law aimed to protect civilians, the injured, and other noncombatants from the effects of war—authorized humanitarian assistance even in internal armed conflicts, situations increasingly common after World War II. Dozens of similar groups, known as nongovernmental organizations or “NGOs,” formed around the world, an alphabet soup that included IMC (International Medical Corps) in the United States and MDM (the French acronym for Doctors of the World) in France. They recruited doctors and other experts to volunteer for varying amounts of time—from a few weeks to a few years—providing medical or technical assistance to those in need. Each had its own philosophies and strengths; MSF specialized in acute conflict and disaster assistance.