Curricular and Extracurricular Activities of Medical Students during War, Zagreb University School of Medicine, 1991–1995

Abstract

War, as a major human disaster, affects many aspects of life, including medical education. This report describes curricular and extracurricular activities of the students at the Zagreb University School of Medicine during the wars in Croatia and neighboring Bosnia and Herzegovina. Although condensed versions of the curricula were prepared in case of a major breakdown in civilian life, the school maintained the continuity and quality of its curriculum throughout the war. Students engaged in extracurricular activities related to medical aspects of war, including organization of resuscitation and first aid courses, collecting medical documentation on war victims, humanitarian help to refugees, and peace-promoting activities. Some students joined mobile surgical teams on the battlefronts. After army service, most of them returned to the school and successfully continued with their studies. The school also accepted guest-students from other new states emerged from former Yugoslavia. The authors found that the students' engagement in extracurricular activities related to medicine was enormously beneficial both to the psychological well-being of the students and to the region's peace-building efforts.

Emergency medicine and disaster medicine have become important parts of medical curricula in many countries.^1,2 However, reports of the effects on medical education of such prolonged human disasters as war are very rare.^3,4 In this essay, we describe the work of the Zagreb University School of Medicine during the four years of war in Croatia and in neighboring Bosnia and Herzegovina, and the war-related extracurricular activities of medical students. The report is based on our own experiences, the experiences of students, and the school's official documents.

BACKGROUND

Croatia (Figure 1) is a central European country with a population of 4.7 million. The war that broke out in Croatia on Easter in 1991 and lasted until August 1995 had a number of consequences for the Croatian population. According to the official records of the Division of Information and Research of the Ministry of Health of the Republic of Croatia, almost 35,000 citizens of Croatia were wounded and 13,000 killed as a direct result of the war. Among these casualties, civilians accounted for almost 8,000 wounded and 2,600 killed, including 780 wounded and 180 killed children. However, these data represent only the firmly ascertained casualties (based on medical and autopsy records) and they may be significant underestimations of the total numbers of casualties. Over 1,000 civilians were the victims of extrajudicial or mass executions. According to the evidence of the Croatian Red Cross's Missing Persons Service, there are presently about 1,700 missing persons, many of whom are being identified by forensic experts after the discovery of 200 mass graves. Between 250,000 and 300,000 people were displaced from their homes. The total direct and indirect costs of war damage and the four years of occupation of nearly 25% of Croatian territory is officially estimated to be at least US $50 billion.^5,6

Figure 1: Geographic map of Croatia.

The war in neighboring Bosnia and Herzegovina broke out in the first half of 1992 and lasted until 1995. Its consequences were even worse than those of the war in Croatia.⁷ Croatia provided shelter for a large number of refugees, so that the number of internally displaced persons in Croatia and refugees from Bosnia and Herzegovina amounted at one point to more than a fourth of the Croatian population.⁶

ZAGREB UNIVERSITY SCHOOL OF MEDICINE IN WAR

Zagreb University School of Medicine is the largest Croatian education center in medicine, with 700 full-time or part-time faculty members and 250 students per class in a six-year curriculum. At the time of the war, the school had two smaller branches in the cities of Split and Osijek, each with 50 students per class and about 100 local faculty members. Throughout the war, the school maintained the continuity and quality of its curriculum. This was accomplished by efficient reorganization of the curriculum, despite the lack of resources and financial support.⁷

At the beginning of the war (May 1991), shortened curricula were prepared, with 30% and 50% reductions in all courses except Introduction to Internal Medicine, surgery, and epidemiology. Specific decisions about course reductions were left to the expertise of individual departments. Fortunately, martial developments in Zagreb did not reach the intensity that would have necessitated major alterations of the curriculum, so that we did not have to implement the shortened curricula during the four years of the war.

The most intense war activities around and in the city of Zagreb happened during the fall and winter of 1991, when there were numerous air raids and artillery attacks. Each of the school's premises had a shelter in its basement and, when an alert occurred during a lecture, students and teachers would go together to the shelter. The lecture was sometimes continued in the shelter, but more often the shelters were crowded by students from different classes. The lecture would continue if the alert finished before the scheduled end of the lecture; otherwise it was lost. The old buildings of the school had solid walls and safe basements, and the whole complex was on a hill without any military targets in the vicinity. The closest hit was the bombing of the Presidential Palace in the center of the city, 2 km from the school.

The major war-related problem of the school was the functioning of its two small branches in the cities of Osijek and Split, each some 400 km from Zagreb. Teachers from Zagreb regularly traveled to teach in Osijek and Split, but the war made it very difficult to maintain the normal functioning of the two branches. During 1991, Osijek suffered heavy bombardment, fights, and losses, whereas Split, a city on the Adriatic coast, was cut off from the main-land and left without electricity for long periods of time. The problems of these two medical schools and how they were solved are described elsewhere.⁷

With the onset of war, a number of students wanted to change the places where they were living and studying: some Serbs from Croatia wanted to move to Serbia, Croats from Serbia wanted to come to Croatia, and a number of Croats and Bosnian Muslims (Bosniaks) from Bosnia and Herzegovina wanted to come to Croatia. Their wishes were in all cases met with understanding and prompt assistance, regardless of their nationalities and the directions of the changes. In principle, transfer students got credit for all courses completed and/or passed in the domicile school. In case of discordance between the curricula, students were admitted but had to take missing courses and pass them by a reasonably determined deadline. Since the war lasted for several years, these deadlines were set quite liberally.

Although the conflict between Bosnian Muslims and Croats in Bosnia and Herzegovina lasted almost a year (1992–1993),⁸ the Zagreb School of Medicine accepted and accommodated numerous Bosnian Muslim students from Bosnia and Herzegovina. In addition to the regularly admitted students, 202 students from Bosnia and Herzegovina were accepted as guest students: 76 (38%) Croats, 105 (52%) Bosnian Muslims, and 21 (10%) of other nationalities. Guest students did not have regular student status at the Zagreb University but were allowed to take courses and examinations during their time here.

Students' Extracurricular Volunteer Activities

Below, we describe six major extracurricular activities to which students volunteered their time during the war: data collection, education of the lay public, publishing, hospital work, work with children, and peace-promoting activities.

Systematic collection of data

In order to gather information about casualties of war and human rights abuses, the Ministry of Health asked the Zagreb University School of Medicine at the beginning of the war in 1991 to establish a communication and medical documentation network based on land-line computer communication and a medical documentation network integrated with the system for wireless digital communication.⁹ The crucial step was the establishment of the Division for Medical Information and Research (DMIR). Later, the Medical Center for Human Rights was established at the school as a nongovernmental organization.

Most the DMIR's work relied on student volunteers.¹⁰ The students were first trained to use the computer system and then worked in 12-hour shifts. Frequent air raids and general alerts were disturbing, and it was not easy for all to become familiar with the computer communication system, databank software, and standard forms for compiling and recording the data. However, the importance of the work was stimulating enough that there were no dropouts.

The communication system at the DMIR was used to collect medical data from regional medical centers in the areas directly under attack and in besieged cities, and also to give instructions for preventive medical measures.⁹ The following categories of data were collected: (1) civilian casualties (including medical personnel); (2) arbitrary killings; (3) extrajudicial and summary executions and civilian massacres; (4) prisoners of war; (5) victims of torture; and (6) missing and displaced persons and refugees. The system functioned well, despite occasional breakdowns and emergencies.⁹ The data from local medical centers arrived continually, even during the heaviest fighting: the last report from Vukovar was received on the morning of the occupation of the city's hospital and the fall of the town.¹¹ Reports and medical documentation were regularly sent to the International Red Cross, Helsinki Watch, Amnesty International, and other international organizations, as well as to the United Nations (the UN).

Medical students were also involved in collecting medical information after the fall of Vukovar, a Slavonian town that resisted a heavy six-month-long attack and three months of complete siege up to November 18, 1991.^11,12 Students also joined the medical teams that took care of the convoys of refugees and the wounded from Vukovar when they arrived in the free territory of Croatia. The teams provided medical aid, food, and assistance in connecting refugees with their relatives and friends. The students' most important duty was to collect basic information about the refugees so that they could later be informed about their relatives, but they also gathered preliminary information about killed, missing, and captured persons. As refugees reached Zagreb on Friday, 40 students continued collecting data throughout the weekend, interviewing more than 5,000 persons. The refugees took the interview very seriously because it was their only hope to learn about missing family members. The rumors of atrocities and killings were widespread and very real,¹² and people yearned to both give and receive information. They communicated best with physicians and medical students, especially those whom they had seen immediately after crossing the front line. Students also helped with the paperwork in the DMIR, so that the UN received a list of some 2,500 names of missing persons the following Monday. The list was very precise, and most of the individuals were later found and identified in mass graves in Vukovar or its surroundings (according to official data from the Ministry of the Interior).

Education of the lay public

Students also took part in medical training related to disaster and wartime. A team of senior medical students organized first aid and resuscitation courses for university students, citizens, and members of the army and police. Fifty-eight students and young physicians organized 308 courses for 18,282 participants (over 7,000 hours of lessons). The courses included both lectures and practical training. The lectures included disaster preparedness, emergency transport and equipment, and the organization and hierarchical structure of response during the war, as well as information about human rights and the Geneva conventions. In cooperation with the Ministry of Health, three members of the teaching team organized courses throughout the country, mostly in schools and sports centers, often near battlefronts.

Publishing activities

At the beginning of the war, students published a special edition of their journal Medicinar. The special issue contained articles written by the school's experts on war and medicine, as well as articles on the organization of public health care in war situations, war injuries, wound infections, and war surgery. It was a very useful product jointly created by students and their teachers. The main goal of the special issue was educational, because at that time Croatia had virtually no experts on war injuries or the organization of health care in war.¹³

Hospital work

Senior students on clinical rounds volunteered to collect medical data from wounded civilians and soldiers. This work was quite difficult, because patients often could not remember the circumstances in which they had been wounded. Most painful was interviewing heavily wounded men the same age as the students.

Students also helped in the preparation of more than 20,000 first aid kits that were sent out to the battlefront.

Work with children

Many students joined humanitarian organizations providing psychosocial support to refugee children. Students' work included helping children make up missed school lessons and organizing summer and winter holidays, as well as helping the local Red Cross and church charities in collecting food and clothes for the children. Each student worked with 15 children. Students liked this volunteer work, but often said that it was very painful because the children shared with them their fears, sorrow, worries, nightmares, and yearnings for their parents. Most difficult was leaving them at the end of the support program in the camp. This experience taught us that the aid workers should be educated in the fundamentals of psychology, psychotrauma, and rehabilitation and should work with children regularly and on a long-term basis.¹⁴

Peace-promoting activities

Through the International Physicians for the Prevention of the Nuclear War (IPPNW),¹⁵ medical students were among the first who met with colleagues from the newly emerged states of the former Yugoslavia. They met on several occasions: at the Working Together Program in Graz, Austria; during summer breaks; at the Third European IPPNW Students' Congress in Maastricht, The Netherlands, in April 1993; at the Sixth European Students' Congress in Poznan, Poland, in April 1994; at the International Federation of Medical Students' Associations (IFMSA) workshop “Medicine and War,” in Hradec Kralove, the Czech Republic, in August 1996; and at the Appeal for Peace in Goed, Hungary, March 11–13, 1994. Meeting colleagues from ex-Yugoslav republics when the war was still raging at home was very painful. It was difficult to start a dialogue, to face disagreements on such important subjects, and to look for common ground for any kind of conclusion.

Fortunately, the discussion soon became more tolerant, with many common views emerging¹⁰: (1) a dialogue was possible; (2) all participants felt a need to communicate; (3) peaceful and tolerant communication was possible and implementation of the culture of peace was urgently needed; (4) students needed to share their experiences and activities during the war; and (5) there was trust that insisting on peace-building activities would be fruitful.

Students in the Army

Some students voluntarily joined the Croatian Army during the war, serving mostly as members of medical teams or in war hospitals. Many of them worked under difficult conditions on battle-fronts.¹⁶

A total of 196 medical students from the Zagreb University Medical School joined the army during the war, as judged from the student benefits they received. Benefits for students with active army status included transferring of examinations to the next academic year, justified repetition of the current year, temporary cessation of studies, waiving of tuition, and extra time to finish taking all required examinations. The largest number of students (39 women and 30 men) received such benefits in the 1992–93 academic year. This is understandable considering that the war in Croatia had been most intense in the previous year (1991–1992). Most of the students regularly advanced to the next academic year, or advanced with one or two unpassed examinations from the previous year.

Three medical students were killed in war, one on a battlefield during artillery attack, one as a civilian in an accident, and one in Bosnia and Herzegovina under unknown circumstances. Five students were slightly wounded at battle-fronts.

Students from Bosnia and Herzegovina

During the first half of 1992, when the war spread to Bosnia and Herzegovina, some of our students who were citizens of Bosnia and Herzegovina voluntarily returned to their homes and joined the Croatian Defense Council, which was set up to organize civil and military services that could no longer be provided by the government in the besieged city of Sarajevo. Most of them served as paramedics in hospitals or as part of mobile surgical teams.¹⁶ They were also eligible for the same academic benefits as colleagues in the Croatian army. Students also participated in organizing and actively joining humanitarian convoys to their homelands.⁸ Those activities required special courage and endurance, but to many of our colleagues from Bosnia and Herzegovina, this meant food, medicine, and psychological support for their families and fellow citizens.

DISCUSSION

Different places may take different approaches to war or disaster situations, and the activities of the medical profession in a country at war may vary from place to place.¹⁷ At the onset of war in Croatia, the faculty of the Zagreb University School of Medicine could not draw from the existing literature in drafting a wartime-preparedness plan. Instead, we followed general models from the Second World War,⁴ and we aimed at protecting medical students, carrying out our professional duties, and assuring the quality of medical education. We also incorporated the system of dealing with war developed for the civilian medical system (similar to the centrally planned civilian medical system in Sweden), which serves as both a disaster medicine system and a military medical system in the event of war.¹ The Croatian health system did not have any experience in war or disaster medicine because that aspect of medicine was taught only at the Military Academy of the former Yugoslav Federal Army, in Belgrade, Serbia. At the beginning of the war, Croatian physicians had to learn about war surgery, posttraumatic stress disorder, and many other health problems related to war.¹³ The faculty of the Zagreb Medical School, especially those in clinical departments, were actively involved in planning, organizing, and carrying out comprehensive health care for different population groups with very different health needs. Teaching activities did not cease and the curriculum was carried out in full (with minor modifications according to the current war situation).

At the beginning of the war, medical students found themselves in a difficult situation: they were torn between the patriotic duty to defend their homeland and take care of their families and the need to continue their studies and help as medical professionals. Our experience during the five years of the wars in Croatia and neighboring Bosnia and Herzegovina showed that the best option for the medical students was to continue their studies and engage very actively in a number of activities where their education and medical experience were important (see List 1). Medical students made a very important contribution to the effective and comprehensive assessment and management of health care in a situation of prolonged humanitarian disaster. These activities were directed towards life (first aid courses), justice (collection of medical data on the suffering of civilians), and solidarity (accepting guest students from endangered areas). The work of medical students was especially important in view of the shortage of medical professionals at a time of greatly increased demand for medical interventions and of the reorganization of the health care to function as both a civilian and a military system. Psychologically, intensive engagement in extracurricular activities related to their profession was of enormous benefit to the students. That feeling of satisfaction with their contribution to their homeland and people was important for their studies. Most of the students regularly attended classes and passed required examinations, in spite of tiring and long hours of working in hospitals and refugee camps, teaching courses in emergency medicine, and engaging in other activities.

List 1. Possible Activities of Medical Students during War or Other Disasters, Based on the Experiences of Faculty and Students of the Zagreb University School of Medicine, Zagreb, Croatia, 1991–1995

To our knowledge, there were no incidents or frictions among students of different nationalities throughout the war and its various phases.⁷ Actually, the school's faculty and students became an important factor in maintaining the psychological and social health of the public, including amelioration of political disagreements.^6,7,10,16 They became a symbol of safety, consolation, and help in many complicated and tragic situations.