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Steadfast in Sarajevo
Half the staff at the Clinical Centre left and 50 were killed during the siege of Sarajevo. But Hiba Basic stuck to her post and took over the oncology department.
» Simon Crompton
Perched on a hill on the north east side of Sarajevo, is the city’s century-old hospital, now part of the Clinical Centre, University of Sarajevo. It looks on quick inspection like many other European hospitals – a mix of dirty old and gleaming modern. Then you notice the bullet holes in the buildings around the main entrance. Here and there are strange splashes of missing brick and plaster, made by shell explosions. This is a hospital with a dark story of suffering, resilience and professional commitment, and at its heart is radiotherapist Hiba Basic.
During the Bosnian war between 1992 and 1995, the city was subjected to the longest siege in modern history, bombarded for three and a half years by shells and sniper bullets from forces on the hills that surround every side of the city. Around 10,000 civilians were killed. Power, water, heating, medical and food supplies were all cut off.
Yet the Clinical Centre kept going throughout. And somehow, as those injured and dying in the hostilities poured in and pulled on the hospital’s dwindling resources, Hiba Basic and other staff in its oncology and radiology unit still managed to provide care and life-saving treatment for people affected by cancer.
Within months of the siege starting, half of the Clinical Centre staff left – fleeing with their families while they could. Basic, a consultant radiotherapist who became head of the hospital’s Department of Radiation Oncology during the war, doesn’t blame them. Living conditions became worse and escape more difficult with every week that passed. But she decided to stay and try and keep cancer services going – even though lack of electricity made radiotherapy almost impossible, and cancer drugs were in short supply.
“Just because people were dying on a daily basis from bullets and blast injuries, that didn’t mean that people with cancer didn’t deserve their chance of life too,” says Hiba, now 64, who helped rebuild the Clinical Centre’s cancer services from the ruins of the war, so that it could again serve as the country’s primary oncology and radiotherapy centre.
Civilians were under fire in all parts of the city during the siege – some were killed while queuing for bread and fresh water. Even to today’s tourist, the reminder is constantly there in the dozens of new graveyards scattered around the housing areas of the city: when siege conditions make travel virtually impossible, people are buried near where they fall.
“I would queue all night for water for me and my family,” says Basic, “and then in the morning I had to go and buy food under shelling and gunfire – we had to run to escape the snipers. I lived about an hour away from the hospital by foot – there was no petrol for cars. So every day on my way into work and back home, I was in danger.”
On the hospital wall is a list of the 50 members of staff killed during the siege. One, a surgeon, was the husband of one of Basic’s radiotherapy colleagues. He was killed by a shell as he entered an operating theatre. Looking after cancer patients became a matter of improvisation and rudimentary care.
Having wanted to be a doctor since age eight, and having studied medicine at the University of Sarajevo, Basic started her specialism in radiology and clinical oncology at the hospital in 1976, and over the years since then saw it develop its services into an Institute of Radiology and Oncology. By 1992 there were facilities for telecobalt therapy, X-ray therapy and brachytherapy, and plans to develop oncology services further, with two separate institutes for radiotherapy and medical oncology. Work began on a new hospital building to accommodate the institutes, including a new underground radiotherapy department. The war put an end to all that.
IMPROVISE AND ADAPT
What power the hospital had during the siege was rationed for basic heat, cooking, washing and urgent surgery. So the only radiotherapy machine that could be used was the telecobalt machine, run from a small generator donated by the International Atomic Energy Agency. Basic had earlier pioneered new techniques of using brachytherapy in breast cancer, but this had to end, along with treatment planning and staging using CT scans. Chemotherapy was limited because of the short supply of cancer drugs.
Yet demand for cancer care was high because there was nothing else in Bosnia. As word spread that the hospital was still providing cancer services, the United Nations Refugee Agency flew in sick cancer patients from the other besieged enclaves of Goražde and Srebrenica. With patients unable to return home, because it was simply too dangerous, most became long-term.
“We had to adapt,” says Basic. “For example, in gynaecological cancers, brachytherapy is usually an unavoidable part of treatment, often in combination with external radiotherapy. But we had to replace it with external radiotherapy, because any treatment is better than no treatment. We explained all this to the patients, and they were happy just to be receiving treatment.”
Chemotherapy agents came through to the hospital in small amounts from time to time, and treatment was adapted according to supply. “We naturally moved towards palliative care, because most of the patients were not in the early stages of cancer. They often became better after treatment, but they had to live here for months, and some of them died here. We buried them in the hospital cemetery.” After the war, many families took the bodies of their loved ones back to be buried in their homeland.
No ethnic tensions existed in the hospital, says Basic. Serbs, Croats, and Bosnian Muslims all received the same treatment, and treated one another with respect.
“I’m a Muslim, but I tried to help everyone the same, to prolong their life, if I could, to the end of the war so that they could see their families and children who had left the city. It was right that we did this, and I know that there were Bosniaks [Bosnian Muslims] who were also treated just the same as everyone else in hospitals in Belgrade [capital of Serbia].”
THE PRICE OF ISOLATION
Basic is clearly proud about continuing to teach students and train young doctors wishing to specialise in oncology throughout the war, so that foundations for the future of Bosnian cancer medicine were already being laid. But she was always aware that those years of isolation from the outside world, with entry and exit from Sarajevo impossible, would bring long-term consequences for health services.
“Besides the sheer fight for survival, the worst thing was the lack of information,” she says. “While the rest of the outside world was making huge progress, introducing computers, talking a new language of Windows and so on, we lived in the dark.”
“Besides the sheer fight for survival, the worst thing was the lack of information”
“While the outside world was making huge progress, we lived in the dark”
So if what Basic and her colleagues did to maintain services during the war is remarkable, so has been the rebuilding of oncology services in Sarajevo. The siege left the hospital damaged. The new building to house cancer services was unfinished. The telecobalt machine was ageing, the brachytherapy machine was damaged. And most of all, there was an enormous knowledge gap between Bosnia and other European countries.
Support came from many international organisations. The International Atomic Energy Agency provided new dosimetry equipment, a new cobalt-60 machine, repaired the brachytherapy equipment and provided experts to train local staff in working the new machines and treatment planning systems. It supported intensive training of the team of 11 radiation oncologists, three medical physicists and 10 radiographers at the department – and it is still involved in continuing education at the Institute of Oncology (as it is now known).
ESO, meanwhile, supported the education of many doctors and nurses from the unit, setting up a series of international workshops on breast cancer, starting in 2001. These later developed into the international Interconference Breast Cancer Meeting, which is held in Sarajevo every two years, and involves ECCO, Europa Donna and other organisations alongside the Clinical Centre, the Association of Oncologists of Bosnia and Herzegovina and ESO. Its aim is to bring the very latest in breast cancer research, treatment and care to the Balkan area and central and eastern Europe.
A CENTRE OF EXCELLENCE
From having been able to treat just a few hundred people a year during the war, the Institute of Oncology is now a national centre of excellence, treating around 4800 people a year, half as outpatients. It is a well-equipped, airy centre, proud of its role in teaching undergraduate and postgraduate students, and its multidisciplinary approach to cancer diagnosis and care, involving 12 teams of professionals in the main cancer groups. Now there are plans to establish Bosnia’s first breast unit in the institute. “We have some very positive support, especially from the association of women treated for breast cancer in Bosnia,” says Basic.
It is now a well-equipped, airy centre, proud of its role in teaching students, and its multidisciplinary approach
The return from isolation to the international world has been of personal as well as professional significance for Hiba Basic. After university, she trained in radiotherapy in Amsterdam, Utrecht, Heidelberg and Hamburg University hospitals. She has relatives in Sweden, Croatia and Germany, and her outlook has always been international. So for her, being locked away from the rest of the world was one of the worst aspects of the siege.
“At one stage, I wanted to get out, to go down the tunnel that had been dug to the airport. But I wasn’t allowed to because it was only for food, soldiers and special needs. But it’s strange that the moment the siege ended, I didn’t want to get out any more, because I felt free. The worst thing is to be restricted in movement. Even if we had lived those three years free of danger, with the best food, the best conditions, it would still have been like living in prison.”
“It’s strange that, the moment the siege ended, I didn’t want to get out any more, because I felt free”
Nevertheless, when in 1998 she was awarded a European ‘Art for Care’ prize for her outstanding work, and invited to Milan to receive it, it was an opportunity she couldn’t refuse. She spent two days in Italy, talking to colleagues, visiting ESO, attending lectures.
“It was so exciting for me, because I was in Milan, in the normal developed world, where I thought I belonged. I was alone, and the war was finished. And yet, when I flew back, I saw below me the airport still damaged and improvised, and I could see all the houses around the airport, and none of them had a roof. They had all been destroyed. And though I was so excited, I couldn’t stop myself from crying.”
Since then, Basic has thrown herself into work on behalf of her profession, nationally and internationally. A member of the European radiation oncology group ESTRO and the clinical cancer research group EORTC, she has also held the top posts of both the Association of Radiologists of Bosnia and Herzegovina, and president of the Association of Oncologists of Bosnia and Herzegovina. And she has been heavily involved in running and chairing the biennial Interconference Breast Cancer Meeting.
A NETWORK OF CENTRES
She is encouraged by the developments in treatment that have occurred in Bosnia and Herzegovina in recent years. Until this spring, the Institute was the only cancer centre in the country offering radiotherapy, but units have now opened in Tuzla and Banja Luka. Well-organised chemotherapy services are now being offered in Tuzla, Banja Luka and Mostar too, says Basic. And although expensive targeted therapies are not easily available across Bosnia Herzegovina, hormone treatment is state funded for all who need it.
Yet her international awareness and appetite for clinical knowledge also makes Basic painfully aware of the ways in which her country still lags behind. Surgeons in other centres in the country are unwilling to collaborate or take a multidisciplinary approach. There is a shortage of doctors well-trained in cancer diagnostics. And a lack of trained pathologists and cytologists means that cancer diagnosis and staging are still too often based merely on tumour size and site, not on molecular biology.
In breast cancer, which is Basic’s special interest, diagnosis and treatment decisions in some hospitals are still dictated by mammogram alone.
With retirement approaching, Basic finds it bittersweet to look back on what has been lost, what has been achieved, and what it still to be done in her country. She is a small bundle of energy, but acknowledges that the stresses of the past two decades have sometimes been too much for her.
“I could never have imagined living through something like this. We all lost relatives and friends,” she says. “But it becomes normal. You manage.”
Thankfully her immediate family was left unscathed – at least by bullets. Her son, a member of the Bosnian forces defending Sarajevo survived, “not wounded, not mad”. A mechanical engineer, he now works at the airport, and is married and has two children. Her mother and brother died on the same day in 1995 – her mother in old age, her brother of a heart attack. “He wasn’t killed in the war fortunately. It’s easier to accept.” Sadly, her husband died this September after a long-term illness. She now hopes to spend more time, in her retirement, with her grandchildren, and tending to the garden in a small holiday home owned by her family on the Bosnian coast.
Was there anything good, I ask, anything at all, that came out of the Bosnian war? She thinks hard, gives a brief and resigned laugh, thinks some more, and then shakes her head. “It is very difficult,” she concludes.
The key to the future of her country, she believes, is becoming fully engaged in the European Union. Just as becoming engaged in the international community has allowed for the rebuilding of cancer services, so international political and economic engagement will finally dissipate the long-term effects of wartime isolation. But for now, she can at least consider her retirement knowing that, for hundreds of people with cancer, things would have been considerably worse if she hadn’t stayed at her post and tried to make things better.
COMMENTS (1)
| Jean-Claude Horiot (Hiba Basic) says: | 10 December 2010 12:10:33 |
| Thank you so much Hiba for giving us such an admirable example of courage and dedication under the most terrible conditions. Thank you too for your your humility in narrating this nightmare and for your ability to forgive to those who fled. Jean-Claude Horiot | |
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