Effects of conflict on public health in the wake of the Kosovo war

Survivors of the war in the Northern Kosovo: violence exposure, risk factors and public health effects of an ethnic conflict
Authors: Shr-Jie Wang, Mimoza Salihu, Feride Rushiti, Labinot Bala and Jens Modvig
Journal: Conflict and Health, 2010, 4:11
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A majority of the Serb population in Kosovo fled during the war to the north of Kosovo or to Serbia. Although the war ended a decade ago, all ethnic groups continue to be exposed to ethnically-generated violence in the north and eastern part of Kosovo and Serbian enclaves. Thus, violence escalated in Mitrovicë district in February 2008 following the declaration of independence by the Albanian majority in Kosovo.

The aim of the study was to assess the long-lasting effects of ethnic conflict on health and well-being with a focus on injury and persistent pain at family and community level. In late 2008 a total of 1,115 households representing 6,845 individuals were interviewed in the Mitrovicë district. Since the war, the district and the town have been divided. The bridges linking the two sides of the town are strictly guarded and regulated o prevent clashes between Albanians and Serbs.

Findings
The survey concludes that Mitrovicë district currently seems to be characterised by a low level of violence, but the effects of ethnic conflict on health and well-being have not gone. During the two weeks before the survey, 20% of individuals had suffered physical or mental pain. The level of lifetime exposure to violence, the proportion of family members reporting pain and lifetime violence-related injury, and family's financial burden were found to be inter-correlated.

Over 90% of families had been exposed to at least two categories of violence and human rights violations, and 493 individuals reported torture experiences. Forced evacuation and displacement were frequently mentioned. Overall, 80% of households experienced gunshots or shelling or fighting in their neighbourhood and 10% of households reported that at least one of household members was missing or became disabled due to the Kosovo war. There were 493 persons (6.8%) who had been tortured within their lifespan (based on the strict UN torture convention definition), while more than 30% of households were affected as the members had been subjected to wider extent of abusive treatments, including torture or other cruel, inhuman or degrading treatments or punishments. Only 3% of the population reported lifetime experience of violence-related injury, which implies that half of the torture incidents involved could be psychological rather than physical torture.

Pain complaints related to low income families
The survey documents that the proportion of family members with pain complaints was related to a decline in the household income. Families exposed to at least four categories of violence and human rights violations were unlikely to be rich, earning less than 200 € per month during the survey period. These families were also more likely to bear a financial or social burden due to the presence of an injured person.

Both financial and emotional burdens
Figures for torture strictly based on the UN definition were low in Mitrovicë. But over 30% of households were affected if a wider variety of abusive treatments were taken into account as well. Family members can become "secondary victims" because they witnessed what happens to their loved ones. Emotional disturbance can be contagious among family members. And injury and disablement do not disappear with the end of a war. Taking care of an injured or a disabled person at home affects the whole family. Thus, the figures for non-specific pain might be explained by the result of somatic and psychological expressions of emotional distress. In a general population, pain complaints increase with age and reach a plateau between the ages of about 45-75 years or mostly of 55-85 years. In the present study pain complains increased with age from 35 years on.

Pain complaints lower in politically involved families
In general political involvement is a risk factor for organised crime, political violence and human rights violations. In this study, it is notable that in the politically involved families, the proportion of family members with pain complaints was lower. It has been shown in other settings that patterns of social or political participation of a victim of politically-motivated violence can affect the rehabilitation process. Dimensions of empowerment such as self-determination, social inclusion and participation, as well as ability to influence or control one's life and environment have implications for the general health and well-being of a population affected by ethnic or political conflicts. Ethnic, political, and spiritual perspectives may affect symptoms, coping patterns and healing process as well. Of course, there is also the  possibility that families involved with the ruling political party may have better access to financial resources or humanitarian aid.

Limitations and wider scope
The sample which turned out to be confined to one ethnic group in one district limits the generalizability of the findings. Also the results of a district-level study, carried out 10 years after the war, cannot be directly compared with those based on national surveys carried out during the war or some years ago. Therefore the results by no means can be seen as representative for the overall situation in Kosovo.

The survey was conducted in collaboration with Kosova Rehabilitation Centre for Torture Victims (KRCT). The KRCT has been providing treatment since 1999 to traumatised population and training for the doctors in the municipal family health centres across Kosovo in identifying and treating trauma victims.

KRCT plans to improve its facility-based service and extend its community intervention in the violence-prone area of Mitrovicë district. The population-based study consisted of two components: a household survey and a detailed assessment at mobile clinics were offered the identified victims. Thus, the study served as a baseline as well as need assessment.

Written by Heidi K. Tokle