Experience of a Medical Journal in War and Post-War Times

Survive, Help, Learn: Experience of a Medical Journal in War and Post-War Times

Sambunjak, Dario

ABSTRACT

Medical journals and their editors have a unique responsibility in armed conflicts. The experience of the Croatian Medical Journal during and after the 1991-1995 war in Croatia shows how a medical journal can survive, help others and learn in times of war. The first duty of a medical journal in such circumstances is to publish scientific articles on various aspects of war medicine, and to document cases of human rights abuses. In small scientific communities, editors can offer their expertise and assist authors in writing and publishing war-related research and reports. In post-conflict period, medical journals have a responsibility to participate in peace-building and reconciliation efforts. They can do so by publishing good scientific articles regardless of their place or country of origin, re-establishing contacts with colleagues from the opposing sides, striving for the multiethnic or multinational Editorial and Advisory Boards, and engaging in collaborative research and regional initiatives.

Journal of Public Health Policy (2006) 27, 124-135.

doi: 10.1057/palgrave.jphp.3200070

Keywords: medical journals, war in Croatia, conflict resolution, peace promotion, peace through health

INTRODUCTION

In the world of scientific publishing, there is an ongoing and sometimes passionate discussion about how much medical journals should be involved in politics (1-3). However, for some, such debates seem like an irrelevant luxury: medical journals in war-affected areas of the world find themselves in the middle of an armed conflict, bloody violence and full-fledged hatred. Politics in those areas rears its ugliest head, and there is no way to flee from it. Everyone has to face it, even the editors of medical journals. The only question is what a medical journal can do about it?

In a state of general turmoil and social collapse, it is difficult to find a voice that could be objective and politically even-handed. The scientific community in general, and medical journals in particular, have a unique responsibility of providing reliable information and data, as opposed to the prevailing stream of political propaganda, injurious gossips and fabricated half-truths (4). However, the responsibility extends further than this traditional role of reporting and documenting. In the extreme situation of open conflict and war, medical editors cannot confine themselves to the ivory tower of their editorial offices and just continue to “do the job as usual” (5). They have to pull up the sleeves, engage in activities that go beyond their regular scope of work and try to alleviate the suffering in any way possible. And when the war is finally over, it is time to begin with another kind of work, no less difficult, often highly delicate and sensitive: bridging the divide between conflicting sides. A common interest in health issues is a major opportunity to promote peace (6) and medical journals can play a significant role in this effort.

The majority of armed conflicts today take place in developing countries (7). As if they do not have enough problems already (8), the medical journals in these countries are suddenly struck with the calamity of war. To say that the very misfortunes that fall upon them could be the seed of their success is a seemingly outrageous claim. However, the life of Viktor Frankl, a neurologist and psychiatrist who survived the Holocaust, gives a powerful example of success in the face of misfortune. In spite of being deported to a Nazi concentration camp and finding himself in the most horrific situation imaginable, Frankl found enough strength and courage to set himself three goals: to survive, to help others with his medical knowledge and to learn something (9). He achieved all of them, proving that marvelous things can be accomplished even under the most adverse conditions.

Without any pretension to compare the scope of one suffering or achievement with the other, we will use Frankl’s remarkable paradigm to summarize the experience of the Croatian Medical Journal (CMJ) during and after the 1991-1995 war in Croatia (Table 1). The result could be a kind of survival guide for medical journals in areas of conflict, as well as a small treatise on how medical journals can help a society in times of war and post-war reconstruction and reconciliation.

WAR

Armed conflicts in the world differ in their intensity and duration. To paraphrase the famous opening sentence of Tolstoy’s Anna Karenina, times of peace are all alike, every war is tragic in its own way. Medical journals in war-affected areas can find themselves in various kinds of more or less unfavorable circumstances and be faced with variety of problems (10). It is not possible to offer a universal recipe, but some recommendations based on practical experience could prove valuable.

Survive

To survive a crisis situation like war, medical journals should try to turn the adversity into advantage for themselves (10). This can be accomplished by changing a journal’s focus. The conflict should be seen as a medical problem, with all its aspects worth investigating and reporting. Conceptually, it could provide a “niche” for small and less known journals, giving them the opportunity to find and publish highly original scientific data that would otherwise be lost. The CMJ, whose establishment coincided with the beginning of the war in Croatia, recognized that the war-related topics might be interesting to international scientific community, and published a war supplement even before the first regular issue. In subsequent years, the CMJ published many more articles and research papers on various aspects of war medicine (11,12), public health (13-15), epidemiology of deaths, injuries and destructions of property (16,17) and organization of health care during the war (18,19) (Table 2). Some of the articles published in the early issues of the journal had a strong political connotation (20,21), and drew criticisms which were nevertheless also published on the pages of the CMJ (22).

To obtain valid data on war-related issues, editors have to do some “field work” and actively search for possible sources of information (5). This implies assisting the authors in any possible way, and that is the point where the struggle to survive intertwines with an effort to help others.

Of course, survival is not just a matter of conceptual reorientation. The practical day-to-day functioning of a medical journal can be jeopardized by an environment of insecurity and financial constraints related to the conflict situation (23). As a first step, medical journals should strive to formalize their legal status, defining main participants in the making of the journal, as well as their responsibilities and benefits (24). One option would be to work under the auspices of government organizations like universities and scientific institutes. Another step is to establish liaisons with sponsoring organizations, domestic and foreign. War-affected countries often have significant diaspora communities, which could be called upon for help.

The CMJ had very good experiences with the World Association of Croatian Physicians, whose members provided valuable support not only financially and logistically, but also by contributing high-quality scientific articles (10). Some forms of assistance can be asked (and obtained) from bigger and more recognized journals as well as from international editors’ associations (25).

However, no amount of outside help can replace hard and devoted work on the part of the editorial staff. Great enthusiasm and diligent labor are necessary for the survival of a medical journal even in peace time (25), how much more in perilous times of war and conflict.

Help

To help people in suffering is a primary duty of every medical professional. The editors of medical journals are usually physicians by profession, and when confronted with great human suffering brought about by armed conflict, they might feel obliged to offer a helping hand. Sometimes they can do so in an immediate way, for example by providing psychosocial support to the refugees (26). They can also use their international contacts to organize humanitarian actions (17). More close to their field of work as medical editors, they can utilize their scholarship and language skills in helping to write or translate publications vital for performing medical care in circumstances of war (2.8). Some medical journals work in the academic setting, their editors being medical school teachers. In such instances, students can be engaged in a very broad spectrum of peace-promoting and humanitarian projects (2.9).

The above-mentioned activities are undoubtedly valuable and praiseworthy, but they all can be carried out by the people other than medical journal editors. However, there is a particular area in which the editors have almost exclusive competence, and out of which arises a moral obligation to help. That particular expertise is in writing and publishing scientific articles, a skill painfully lacking in many medical professionals and researchers, especially in developing countries (30). In challenging times of violent conflict, it is the duty of editors to help their colleagues working in the field to write and publish scientific reports on various medical aspects of war. Without encouragement and active help, physicians, overburdened with their everyday work, would probably not even think about scientific research and publishing, and much precious data would be lost. Help provided by the editors can at times imply writing or rewriting parts of manuscripts without taking any credit for themselves. And when occasion requires, the editors should even go to the most unsafe areas to offer their assistance (5). Extraordinary circumstances demand extraordinary actions, and medical journal editors should not hesitate to carry their share of the burden.

Learn

To learn something from a terrible and tragic experience is perhaps the most difficult goal to achieve. Medical journals have a special responsibility in preventing the dust of oblivion to cover the true facts and figures (31). Based on rigorous scientific method and peer review process, the reports published in medical journals ought to be credible sources of information for anyone who wants to learn about what really happened in the war.

Among the first considerations in a case of violent conflict is to systematically collect accurate data about casualties and human right abuses (32.). During the war in Croatia, the CMJ published two war supplements with reports on civilian deaths and massacres, child casualties, displaced persons, prisoners of war, and destruction of medical institutions (5). Special attention was given to the description of public health service (13,14) and organization of medical care in war (18). Health practitioners and peace workers were able to develop new theoretical concepts out of the field experience they gathered during the bloody Balkan conflicts (33-37). By publishing these reports and analyses, the CMJ contributed to the development of a new academic discipline – Peace through Health (38).

The ordeal of war is a test of character and endurance for every human being, including medical journal editors. It is a chance to go the extra mile, to stretch oneself beyond the assumed limits and, perhaps paradoxically, to grow personally and professionally. As for the editors of the CMJ, the pressure of war impelled them to devise and develop an author-friendly policy (39), to embrace the Peace through Health concept (6,38) and to show the world that they had something unique to offer. They were laying a foundation upon which to build the international reputation and impact of their journal.

POST-WAR

Peace achieved by military or political means is not enough. It has to be followed up by efforts on all levels of society to bring about longer lasting stability and reconciliation. In that sense, the medical community can play an important role (Table 3). During the war in Croatia, medical students were among the first who met with colleagues from the opposing side, however, delicate and painful it was (29). The CMJ tried to engage in peace-promoting activities from the very beginning of post-war period, though it was not easy. Contacts with Serbia were severed and very difficult to re-establish. The Croatian society itself, having been the victim of brutal aggression (40), was initially suspicious and mistrustful towards any kind of rapprochement. However, the editors of the CMJ were among those who thought it inevitable to rebuild the bridges. They were committed to publishing good scientific articles from all sides of the conflict after an objective and neutral peer review. Still, it was only in 1999 that the first scientific article from Serbia and Montenegro had been published in the CMJ. Scientists from other countries of former Yugoslavia gradually recognized the CMJ as a trustworthy medium for science communication. Since its establishment in 1992, CMJ published 43 articles from Bosnia and Herzegovina, 11 articles from Serbia and Montenegro, 16 articles from Republic of Macedonia and 35 articles from Slovenia.

Inviting prominent colleagues from the opposing side to become members of the journal’s Advisory or Editorial Board can be an appropriate way to re-establish communication between scientific communities. In 2002, a physician from Belgrade became a member of the CMJ’s Advisory Board. Close cooperation was also established with medical professionals from other republics of former Yugoslavia. At present, two colleagues from Bosnia and Herzegovina and one from the Republic of Macedonia are members of the Editorial Board.

Scientific research proved to be an excellent means of getting people from all conflicting sides to work together. The CMJ took part in a research project on medical students’ attitudes and knowledge about science, conducted as a result of collaboration of several countries in the region (41). CMJ’s executive editors participate in the curriculum reform project in five schools of medicine in Bosnia and Herzegovina (42). The International Campaign to Revitalize Academic Medicine was yet another opportunity to involve the authors from various countries of southeastern Europe (43).

During the post-war period, the CMJ continued to be active in the Peace through Health initiative, inviting Dr. Joanna Santa Barbara from McMaster University in Hamilton, Canada, to write a regular column “Medicine and Peace” (44). Through informal collaboration with a representative of the International Physicians for Prevention of Nuclear War, the CMJ organized four-month educational visits to Canada for two colleagues – one from Bosnia and Herzegovina, and the other from Croatia.

Two thematic issues of the CMJ were specifically dedicated to war-related medicine and conflict resolution: “Countertransference Problems in Psychotherapy of War Victims” in 1999 and “Public Health and Peace” in 2002. Today, a decade after the end of war in Croatia, there is still a need for Peace through Health initiatives in this region, and the CMJ strongly supports all such efforts.

The example of the CMJ shows that a medical journal can endure the difficult times of violent conflict, making itself a voice of reason in the sound and fury of war. It can be a helping hand, a bearer of truth, and a bridge builder between the divided – much more than “just a medical journal”.

REFERENCES

1. Delamothe T. How political should a general medical journal be? BMJ. 2002;325:1431-2.

2. Daniels A. The politics of medicine. QJM. 2003;96:695-7.

3. Barr D, Fenton L, Edwards D. Politics and health. QJM. 2004;97:61-2.

4. Horton, Richard, 2005. Violence as a health issue (interview). Bridges. December 2004-January 2005.

5. Marusic A, Marusic M. What can medical journal editors do in war? Lancet. 2002;360(Suppl):s59-60.

6. MacQueen G, Santa-Barbara J. Peace building through health initiatives. BMJ. 2000;321:293-6.

7. Harbom L, Wallensteen P. Armed conflict and its international dimensions, 1946-2004. J Peace Res. 2005;542:623-35.

8. Marusic A, Marusic M. Small scientific journals from small countries: breaking from a vicious circle of inadequacy. Croat Med J. 1999; 40:508-14.

9. Frankl EV. Man’s Search for Meaning. New York: Washington Square Press; 1985.

10. Marusic A, Misak A, Kljakovic-Gaspic M, Marusic M. Educatione ad excelentiam – ten years of the Croatian medical journal. Croat Med J. 2002;543:1-7.

11. Korzinek K, Pavlovic K, Greguric I, Korzinek M. CMC (Croatian Medical Corps) external fixator intended for war surgery. Croat Med J. 1992;33:71-6.

12. Definis Gojanovic M, Andelinovic S, Ivanovic J. Forensic data on 874 victims of war autopsied in Split, 1992-1994. Croat Med J. 1992; 33:97-100.

13. Baklaic Z, Ljubicic M, Benic N, Ropac D, Svjetlicic M. Public health service in Croatia during the homeland war 1991/92. Croat Med J. 1993;34:197-202.

14. Lang S, Javornik N, Baklaic K, Swenlund S, Ghidi V, Luetic V, et al. “Save Lives” operation in liberated parts of Croatia in 1995: Emergency public health action to assist abandoned elderly population. Croat Med J. 1997;38:265-70.

15. Herceg M, Melamed BG, Pregrad J. Effects of war on refugee and non-refugee children from Croatia and Bosnia and Herzegovina. Croat Med J. 1996;37:111-4.

16. Judas M, Chudy D, Priscan A, Radonic N, Papic J, Marusic A, et al. Chronology of civilian suffering in the war against Croatia. Croat Med J. 1992;33:15-23.

17. Hirsl-Hecej V, Fattorini I. Children casualties in the war against Croatia. Croat Med J. 1992;33:26-33.

18. Bagaric I. Medical services of Croat people in Bosnia and Herzegovina during 1992-1995 war: losses, adaptation, organization, and transformation. Croat Med J. 2000;41:124-40.

19. Mijatovic D, Henigsberg M, Judas M, Kostovic I. Use of digital wireless communications system for rapid and efficient communication between Croatian medical centers in war. Croat Med J. 1996;37:71-4.

20. Marusic M. Editorial – war supplement 1. Croat Med J. 1992; 33(Suppl. 1):1-2.

21. Klain E. Yugoslavia as a group. Croat Med J. 1992;33(Suppl 1):3-13.

22. Sulovic V, Grbic R, Dukanovic V, Kalicanin P, Bjelogrlic M, Vidojkovic S. The Belgrade letter. Croat Med J. 1992;33:152-5.

23. Al-Ward NJ. Medical journals in Iraq. Saudi Med J. 2004; 25(Suppl):S35-6.

24. Marusic M, Bosnjak D, Rulic-Hren S, Marusic A. Legal regulation of the Croatian medical journal: model for small academic journals. Croat Med J. 2003;44:663-73.

25. Marusic M, Marusic A. Good editorial practice: editors as educators. Croat Med J. 2001;42:113-20.

26. Arcel LT, Folnegovic-Smalc V, Kozaric-Kovacic D, Marusic A. Psycho-Social Help to War Victims: Women Refugees and their families from Bosnia and Herzegovina and Croatia. Copenhagen: IRCT; 1995.

27. Marusic A, Marusic M, Lang S. White road for Nova Bila and Silver Bosnia: a chronology of the humanitarian convoy. Croat Med J. 1994; 35:3-7.

28. Bowen TE, Bellamy RF (editors). Emergency War Surgery NATO Handbook, United States Department of Defense. Washington DC: United States Government Printing Office; 1988.

29. Gluncic V, Pulanic D, Prka M, Marusic A, Marusic M. Curricular and extracurricular activities of medical students during war, Zagreb University School of Medicine, 1991-1995. Acad Med. 2001; 76:82-7.

30. Marusic M, Markulin H, Lukic IK, Marusic A. Academic advancement of authors receiving tutoring from a medical journal. Teach Learn Med. 2006;18:126-9.

31. Sambunjak D, Kovacic L. Guard against the oblivion: a role of public health in war. Eur J Public Health. 2006 (in press).

32. Geiger HJ, Cook-Deegan RM. The role of physicians in conflicts and humanitarian crises. Case studies from the field missions of physicians for human rights, 1988 to 1993. JAMA. 1993;270:616-20.

33. Lang S, Marusic A. Peace hospitals – technology of hospital protection in a conflict. Croat Med J. 1994;35:53-4.

34. Lang S. Challenge of goodness: twelve humanitarian proposals based on experience of 1991-1995 wars in Croatia and Bosnia and Herzegovina. Croat Med J. 1998;39:72-6.

35. Lang S. Challenge of goodness II: new humanitarian technology, developed in Croatia and Bosnia and Herzegovina in 1991-1995, and applied and evaluated in Kosovo 1999. Croat Med J. 1999540:438-45.

36. Lang S, Kovacic L, Sogoric S, Brborovic O. Challenge of goodness III: public health facing war. Croat Med J. 2002;43:156-65.

37. Terselic V. Building peace from scratch: some theoretical and technological aspects. Croat Med J. 1999;40:446-9.

38. Arya N. Healing our planet: physicians and global security. Croat Med J. 2003;44:139-47.

39. Marusic M, Misak A, Kljakovic-Gaspic M, Fister K, Hren D, Marusic A. Producing a scientific journal in a small scientific community: an author-helpful policy. Int Microbiol. 2004;57:143-7.

40. Kostovic I, Judas M, Henigsberg N. Medical documentation of human rights violations and war crimes on the territory of Croatia during the 1991/1993 war. Croat Med J. 1993;34:285-93.

41. Burazeri G, Civljak M, Ilakovac V, Jankovic S, Majica-Kovacevic T, Nedera O, et al. Survey of attitudes and knowledge about science in medical students in southeast Europe. BMJ. 2005;331:195-6.

42. Simunovic VJ, Sonntag HG, Marz R, Horsch A. Reform of medical education in Bosnia-Herzegovina: luxury or necessity? Croat Med J. 2004;45:31-7.

43. Marusic A (editor). Revitalization of Academic Medicine. Zagreb: Medicinska Naklada; 2005.

44. Santa Barbara J. Medicine as a bridge to peace. Croat Med J. 2004; 45:109-10.

DARIO SAMBUNJAK* and ANA IVANIS

* Address for Correspondence: Zagreb University School of Medicine, Croatian Medical Journal, Salata 3, Zagreb 10000, Croatia. E-mail: dsambunj@mef.hr

DARIO SAMBUNJAK is at the Croatian Medical Journal, Zagreb University School of Medicine, Salata 3, Zagreb 10000, Croatia, dsambunj@mef.hr

ANA IVANIS is at the Croatian Medical Journal, Zagreb University School of Medicine, Salata 3, Zagreb 10000, Croatia, aivanis@mef.hr

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