Chapter 10: Physicians, Leaders by Default

ANATOMY OF DECEIT, by Jerry Blaskovich, M.D.

Chapter 10: Physicians, Leaders by Default.

In most countries, an overwhelming majority of legislators and politicians come from the legal profession; former Yugoslavia was no exception. Because Communist Party membership was usually compulsory for politicians in Yugoslavia, the anti-Communist sentiment that pervaded newly independent Croatia resulted in the ouster of a great number of the old guard. Although unprepared for the nuances of politics and governance, physicians filled the political vacuum by replacing the ousted lawyers in the new government. The appearance of physicians in government isn't unusual, but the large percentages that filled Croatia's government offices is unique.

As a group, physicians were viewed with suspicion by the Communist system. Aside from having work habits considered abnormal for a socialistic society, their traits of ethics and humanism weren't part of the Communist lexicon. Physicians were still able to flourish because the practice of medicine was less dependent on politics than professions such as economics, law, or journalism. Without political interference, physicians were able to preserve their own free thoughts and individuality.

When it came time to replace the old regime, the Croatian public readily accepted their physicians as leaders. The public perceived them as intellectuals who possessed the qualities of credibility, dedication, and integrity. Most importantly, many physicians weren't tainted with past Communist Party affiliation. These virtues far surpassed their main liabilities: naiveté and ignorance about the machinations of power and the importance of public relations.

The innocents had been healing the physical needs of society and were now nurturing the new democracy while rapidly adjusting to their new roles. Ministries in the new Croatia, particularly the Foreign Office, resembled medical conventions. The number of physicians holding local political positions was equally impressive. Croatian physicians, perhaps to a greater extent than other professionals, were driven by altruism and a strong sense of patriotism, and put off satisfying careers to help manage the new democracy. Given their professional experiences, the physicians-turned-leaders approached the new nation as they would have an infant with an unpromising prenatal history whose congenital abnormalities were amenable to corrective surgery and rehabilitation.

None of the physicians suggested that they planned to remain in government. The majority of the physicians planned to return to practicing medicine when a cadre of qualified leaders had matured to the point where they could effectively run the government. Most of the physicians participating at the federal level were professors at the medical school. All were specialists in their respective fields of medicine.

For example, the position of Deputy Head of the Office of the President of Croatia was filled admirably by Branimir Jaksic. Prior to the conflict he had been a professor at the medical school and the coordinator of the International Multicentric Research Project on the Clinical Therapy of Chronic Lymphocytic Leukemia and the European Organization for the Research and Therapy of Cancer.

Ambassador for Human Rights and Deputy Prime Minister Ivica Kostovic had been the dean of Zagreb's medical school and a professor of neuro-anatomy. He had received postdoctoral training at John Hopkins University and had researched neuro-anatomy and neuropathology at Harvard, Yale, and several prestigious institutions in Europe.

Kostovic, who is also the leading investigator of Serbian atrocities, has become the victim of a bitter irony. His daughter was almost killed during a Serbian missile attack on Zagreb in May, 1995, while walking to the children's hospital, which the Serbs had targeted. Cluster bomb projectiles penetrated her chest and abdominal cavities, severely damaging vital organs. Although she survived a number of major surgeries, 18 pieces of shrapnel remain in the tissues and muscles of her back.

Zdenko Skrabalo, who played a key role in the formation of the new Croatian state, was a professor at Zagreb's Medical School and head of the Diabetes and Endocrinology Institute before being named Deputy Foreign Affairs Minister. He briefly served as Minister of Foreign Affairs. He's presently representative to UNESCO and Ambassador to Switzerland. Skrabalo was one of the few Croatian officials to recognize the importance of the media. Addressing the World Congress of Croatian Physicians in 1995, he said, "Croatia has overcome a number of major obstacles since declaring independence. But it has not been able to overcome the most important one--getting the message to the media."

Andrija Hebrang led the exodus of physicians into government. Stumbling to get its sea legs, the newly christened Croatia has been characterized by an extremely high turnover rate in the ministries. Minister of Health Hebrang, probably the most respected and charismatic individual in the government is one of those rare exceptions who have remained in office since the day Croatia was formed.

Unlike its counterpart in the United States, the health ministry in Croatia isn't merely a symbolic office.

Aside from being responsible for the entire country's health needs, it cares for the social welfare of the citizenry.

Hebrang's talents haven't been limited to his work in the ministry. Even before Croatia declared independence, he was an insider intimately involved in the political aspects of running the government. To better understand why many Croats, such as Hebrang, welcomed the overthrow of communism, I should mention his family history. The history, an example of how the Communists treated enemies of the state, isn't unique.

His father, Andrija Sr., was one of the founders of the Communist Party in Croatia. While serving as Party Secretary, he'd helped organize the most effective fighting unit of the Partisans during World War II.

Despite his power, status, and idealized commitment to communism, he was executed by order of Tito; his sin had been Croatian nationalism. Thereafter the Hebrangs were treated as second class citizens. To punish them further, the authorities imprisoned Andrija Jr.'s mother for many years and forbid her from seeing her son.

Since the family name was considered anathema by the regime, the children were forced to assume pseudonyms. School stipends were closed to them. Family members were harassed frequently and followed sporadically, and when they were suspected of having contact with personages of influence, these measures intensified.

Despite the inordinate amount of pressure placed upon the family, they prospered intellectually. Against all odds, Andrija was accepted into the medical school. He eventually specialized in the field of radiology and became a professor of medicine.

In the months before the Serbian-led Belgrade government attacked Croatia, Hebrang's life was in jeopardy. Although Yugoslavia was less rigid and dogmatic than other Soviet Bloc countries like East Germany, its secret police (UDBA or SUP) were 100% Stalinist and probably the most effective and sophisticated in the Eastern bloc. But by the late 1980s, many in the secret police ranks had either lost faith, were jaded, or didn't care any longer. Had SUP preserved its original zeal, it would've crushed any opposition.

A few committed Stalinists in SUP still relished the special cases assigned to them. As the Hebrang name was an abomination to the Communist Party, surveillance of them was stepped up. SUP sensed that Hebrang was up to something. But despite vigorous surveillance, Hebrang and his medical colleagues, Mate Granic, Ivica Kostovic, and Zdenko Skrabalo, the Big Four, were able to set up an ironclad cell and become the nucleus of the physicians' movement. Anticipating the imminent breakup of Yugoslavia, the Big Four's first priority was to draw up contingency plans to maintain the health needs of Croatia's population. Their calculation of 10,000 dead and 20,000 wounded Croats was remarkably close to the mark.

The Big Four's next step was to select trustworthy individuals to form new cells to implement their plans. This task was formidable because some of their friends and colleagues were members of SUP. At the time, SUP had approximately 22,000 members and countless informers in Croatia.

One of the first acts of the new government was to revamp the secret police into a more open intelligence gathering agency. SUP, the greatest nemesis of the Croatian people, had been a law unto itself. The power it wielded and the fear it evoked had kept the old regime in place. The new order was forced to make compromises with SUP to prevent bloodshed. For other valid political reasons, the new government had to keep some of the ruthless old guard in place. A few were even given positions in the highest levels of the government.

The ex-SUP members, regardless of how well they performed, were viewed with suspicion by their new colleagues. Ironically, former suspects, such as Hebrang, found themselves working alongside their former oppressors. But the new government appointed individuals from outside the system to fill the most sensitive positions. For example, Goran Dodig, a psychiatrist, was appointed the top official of Military Counter-Intelligence and Assistant Minister of Defense.

In former Yugoslavia, by design, only 17 of 500 military surgeons were Croatian. Weapons of modern warfare, with their awesome projectiles, inflict wounds that are difficult to repair for even the most sophisticated surgeon. Treatment requires a special expertise other physicians lack. So Hebrang immediately assembled a team of the few experts available in Croatia to write a practical handbook for treating war trauma.

Miraculously, the book was delivered in 24 hours. Soon after its circulation morbidity rates fell dramatically.

Immediately preceding the conflict, the Serb-led JNA confiscated most of the supplies and equipment from the military hospitals in Croatia. In contrast to other countries, military hospitals in Croatia weren't limited to military personnel; civilians were admitted as well. Because Croatia lacked even the most fundamental supplies, such as dressings and gauze, the country was ill-equipped to treat the enormous number of casualties, let alone patients with mundane diseases.

Zagreb, the capital of Croatia, gave no hint that the front lines were only 30 miles away. But its hospital wards, filled with civilians without limbs, with gaping visceral wounds, and blinded from shrapnel, painted a different picture--a picture of a medical infrastructure that had been stretched to the breaking point.

Hebrang, as Minister of Health, was confronted with an enormous number of problems that demanded immediate solutions. An escalating war, a shortage of weapons with which to defend themselves, an economy and infrastructure in shambles, no cadre of experienced personnel, and nationwide psychological stress caused by a system in transition from dictatorship to democracy, made Hebrang's job all the more difficult.

From the onset of active fighting, the Serbs targeted medical complexes. So basements, bunkers, and warrens created from destroyed buildings became new medical centers, forcing patients and medical personnel underground. The destruction of ten major hospitals in a country the size of Maryland proved devastating.

Osijek's General Hospital, the largest hospital closest to the battle line, was blasted by rockets and heavy artillery, but continued to function inside the remaining 20% of its structure. All medical and surgical care was conducted in a maze of tunnels beneath the hospital.

Meanwhile the director of Osijek's Hospital, radiologist Kresimir Glavina, after having served valorously during the trying days of Osijek's bombardment, was elected to serve as a representative in Croatia's Parliament. Another war hero, Juraj Njavro, who was chief surgeon during the siege of Vukovar, became Minister of Health. After the fall of Vukovar, the Serbs imprisoned Njavro. His experiences and exploits were duly recorded in his book, Glava Dolje: Ruke Na Ledja ("Head Down: Hands on the Back in Front").

The Serbian ethnic cleansing program in Croatia resulted in hundreds of thousands of displaced persons and severely strained Croatia's remaining medical facilities. But the enormous influx of refugees from Bosnia-Herzegovina, many suffering from major trauma, further overtaxed the already fragile health care system.

The Health Ministry was responsible for operating the refugee camps. By December, 1992, 663,493 refugees and displaced persons from Bosnia-Herzegovina had found safety in Croatia. Despite adverse conditions, Croatian medical personnel were able to keep the rates of refugee mortality and infection morbidity at almost the same level as the general population. Fortunately there were few epidemics. The statistics reflect good hygienic conditions, nourishment, and selfless medical management. But caring for the refugees placed an enormous strain on the teetering Croatian economy. Croatian citizens bore 70% of the cost of operating the camps; the international community donated the rest.

Slobodan Lang serves as Administrator for the Red Cross and special advisor to the chief of the Croatian Office for Displaced Persons and Refugees. A human rights activist since his student days, Lang is also vice-president of the Croatian Helsinki Watch Committee. Lang is no mere armchair human rights dilettante. At great peril to his life, Lang has run many Serbian blockades to deliver humanitarian aid in Croatia and Bosnia-Herzegovina. He's also an assistant professor at the medical school.

Many physicians in Croatia have become critical of Hebrang. But much of the criticism is self-serving, arising soon after Hebrang abolished the "envelope system." Croatian patients, like patients in many communist countries, bypassed the bureaucratic boondoggle by offering tokens of appreciation to medical personnel.

Originally the tokens were commodities, like hams or chickens. As the country became more prosperous, money became the token of choice.

After communism imposed its will in Yugoslavia, the practice became more common. By the mid-1980s the corruption was rampant. The process of seeing specialists after being referred or admitted to hospitals for elective procedures was snail-paced. Producing an envelope had the same magical effect as the words "Open sesame."

Although illegal, the envelope system became the accepted norm. The system's tacit approval was the way the Yugoslav government controlled the medical profession. If a physician was perceived by commissars as deviating from the ideological party line, the government would invoke the law against him. Instead of receiving a political trial, which would come under the scrutiny of international human rights groups, the physician would be tried in civil court. Before the breakup of Yugoslavia, Human Rights groups had cited Yugoslavia as having one of the worst records of abuses.

Because the envelope system provided physicians with a large share of their incomes, Hebrang's ban seemed draconian. Yet even his most vocal detractors admit the envelope system had corrupted and compromised the ethics of the profession.

Economics proved to be the main problem for the Health Ministry. Unbelievable as it may seem, the medical system in Croatia had been operating without a budget for years, with absolutely no form of accountability. "Cost containment" was an expression unknown in the Croatian medical vocabulary. To make the system function effectively, revolutionary changes were necessary. The expectations of the medical personnel and patients had to be altered.

The delivery of health care in Croatia was a true miracle. Although the Health Ministry had 70% less money in its budget during the war than it had in 1990, Croatia's morbidity and mortality rates remained almost constant through 1994. The statistics were much better than those from all other formerly communist countries.

The Croatian statistics seem more impressive when taking into account the fact that none of those other countries was at war, or taking care of refugees and displaced persons. The credit belongs to the cost containment programs instituted by the Health Ministry and the cooperation of most of Croatia's physicians.

Several other individuals from the health field participated in Croatia's government. Josip Juras and Ivan Majdak are veterinarians. Juras became Minister of Labor, Social Welfare and Family; previously he was chairman of the Executive Council of the city of Sibenik. Majdak, besides being a veterinarian, is also a medical doctor. He became Minister without Portfolio as Advisor for Economic and Regional Development Questions for the President's Office.

Ivica Kracun, head of the Laboratory of Neurochemistry, Chemistry and Biochemistry, at the Zagreb School of Medicine, also serves as Deputy Minister of Science. Drago Stambuk, an internist, unable to tolerate the system in Yugoslavia, chose exile in England over ten years ago. He became renowned in the clinical aspects of HIV positive patients. By avocation a writer and poet, he is well regarded in literary circles in London. Long before the onset of hostilities in former Yugoslavia he took up the gauntlet to combat the misinformation that was so prevalent in the British media regarding Croatian affairs. His commentaries had a strong influence on Margaret Thatcher. Once Croatia was independent he abandoned his brilliant medical career to serve Croatia's diplomatic needs. After a stint in London, he was appointed ambassador to India.

Croats at large should also be proud of another achievement. At a time when Serbs controlled over 25% of Croatian territory, the Croats were taking care of refugees whose numbers equaled over 25% of the indigenous population. The Croats accomplished this feat with an economic output that was less than 50% of pre-war production.

By relating these stories about physicians now in government, I don't mean to detract from the exemplary work of the physicians who continued to practice their art under unimaginably adverse conditions. I simply mean to illustrate how individuals from that most honored of professions unhesitatingly changed roles to assist Croatia during its birth as an independent nation.

Although a few physicians serving in the government have proved to be inept administrators, all have been sincere in their patriotism. A surgeon with golden hands, Franjo Golem, put his medical career on hold when he was named the first Foreign Minister of Croatia. But his forte wasn't diplomacy, and so he was removed from his post. To honor his loyalty to the cause, Franjo Tudjman ignored objections from the cabinet and appointed Golem the first Plenipotentiary of the Republic of Croatia to the United States. Golem's performance in Washington D.C. was viewed by many as less than satisfactory.

Mate Granic, an internist, professor at the medical school, and deputy director of the Vuk Vrhovac Institute who had done post-graduate studies for several years at prestigious institutions including Harvard, exceeded all expectations when he blossomed into a world caliber diplomat as Minister of Foreign Affairs and Vice Prime Minister of Croatia.

Bosnian Foreign Minister Irfan Ljubijankic was also a physician. Ljubijankic was elected to parliament in 1990, and the Bosnian government hierarchy soon realized that his inherent political talents surpassed his formidable medical skills. So Ljubijankic was appointed President of the Bihac district. In April, 1992, Bihac became a major target for Serbian bombardment. While the Serbian attacks intensified, and Bihac's civilian

population suffered huge numbers of casualties, Ljubijankic divided his energies between the healing art of surgery at Bihac's hospital and service in the political realm. He reluctantly agreed to serve as Bosnia's Foreign Minister, in October, 1993. Unfortunately, he didn't live to see the seeds of his peace negotiations bear fruit because he was killed when his helicopter was shot down by Serbian artillery in May, 1995.

By a remarkable coincidence, individuals from the medical professions seem to be the main actors in the tragedy being played out in other parts of former Yugoslavia. Although contrary to naturalization laws, the United States government allowed a naturalized American citizen, Milan Panich, to serve as Prime Minister of Yugoslavia. Panich is the owner and founder of ICN Pharmaceuticals, one of America's largest drug firms.

Milan Babic, the Serbian rebel leader in Croatia, is a dentist. The Bosnian-Serb leader, Radovan Karadzic, is a psychiatrist who did post-graduate training in the United States. Another psychiatrist, academician, and professor, Jovan Raskovic, was president of the Serbian Democratic Party. British peace negotiator Lord David Owen is also a physician. Given their performances in the conflict, it seems to me that Doctors Owen and Karadzic either kept their fingers crossed or were absent when they were supposed to take the Hippocratic Oath.