Jeffrey Levett, a professor at the National School of Public Health, Athens, was in Kosovo in November and December 2006 to visit the regional center of the European Center for Peace and Development in Prizren. In this report for Kathimerini English Edition, Levett talks about the collapse of the health system amid continuing chaos and a lack of a democratic context, in a country where patients themselves must buy the materials necessary for a surgical operation and where «violence, held in check by the presence of international forces is never far from the surface.» The contemporary pattern of disease in the Balkans is a complex blend of a repetitious past, rising chronic disease, the consequences of socioeconomic upheaval resulting from the disintegration of the Soviet Union and so-called «transition.» Both within the Balkan countries and in comparison with Europe, there is a growing health divide, aggravated by state weakness and an inability or unwillingness to create and enforce rules within a democratic context. Additionally, there are problematic issues relating to the movement of populations [refugees, displaced persons], to groups with conflict-related mental disturbances and disability as well as the collapse of social security systems against a backdrop of human insecurity [fear of want and fear of conflict]. The road to equity through development with tolerance and reconciliation is a long one, since the sources of dissension are still very much present. In the absence of any common vision and shared regional goals, neither the prerequisite of reconciliation nor following reintegration can be achieved. Currently, political and nationalistic pressures for cultural dissension exist both from within and without. An unsettling polarity still grips the Balkans and nowhere are conditions worse than in Kosovo, where in its remoter parts and across the border in Shkodra [northern Albania], the blood feud lives on despite efforts over the centuries to terminate it. Everything remains blood-linked, protected, or not, by the hand of fate. Today most young people are far removed from such traditions. In some parts of the Balkans, ordinary people and scholars are reconnecting across political boundaries. Progress is on the rise, in Croatia, Montenegro and to a lesser extent in Serbia. Southern Serbia, however, is a sad place, with roads like patchwork quilts, dingy structures as well as whitewashed churches and ochre-painted buildings. The roads are replete with carts, small tractors and old vehicles, while off to the side of the road the loam of the soil is richly dark. I am not sure whether it was imagination but I felt a just noticeable difference in tension as I entered Kosovo to conduct a brief survey of the health of its peoples. Mist and fog most probably added a melancholy-provoking note. Kosovo is considered the most backward part of Europe, until recently impenetrable, mysterious and little known. Consequently, even today, data are either missing or considered problematic. This is certainly true in the health sector. In this report, I present here a few personal observations, brief background material and the informed opinion of people on the ground provided insights into the malfunctioning of the health system. Local experts It happened within the context of an examination of the continuing needs for additional training in public health and health systems management. I spoke with experienced individuals with training in Scotland [nursing/ Caledonian University Glasgow], in the USA [public health/Harvard], or working within UN structures [law and order, civil administration], with local personnel [Institute of Public Health, Municipal Health Services], as well as cardiologists, neurosurgeons, psychiatrists, public administrators, lawyers, sociologists, water irrigation experts, educators and businesspeople. One health service director who is studying management through a European Reconstruction Agency-sponsored program provided additional information. Over a pleasant dinner in hospitable Kosovo, I chatted with the ministers of health and their advisers in a frank and open fashion. In general they provided insights into the significant challenges faced by the health sector. Without data one can be skeptical of opinion but the descriptions given were intelligent, convergent overall and came from the heart. Sometimes a little window dressing crept in, which came more from pride in the effort being made to improve general health. All this happened against a troubled background mood of the pending withdrawal of international protection, potential secession from Serbia as well as the expressed hope for Kosovo’s greater engagement with the European Union. Contrasts Kosovo is doing its best to act European. The euro is standard currency, which, when introduced, provoked an increase in the cost of living, doubling it, according to some. Glass-fronted pizza parlors, glittering motels and hotels and expansive petrol stations dot the landscape close to inadequate roads and in towns built after the conflict and which mimic the West. Many things strike one in Kosovo, such as the cabbages piled high on carts pulled by horse and tractor or by rickety truck. There are fields of refuse and garbage adding to the considerable problem of sanitation as well as junkyards of discarded cars and machinery littering the terrain. Just outside Camp Casablanca, a large tank came rolling down the road with its goggled and heavily armed tank commander perched high above the turret. I saw my first black bird sitting on a refuse pile pecking away at trash far from the Field of Blackbirds and its traditional food of the grapevine. In parts, telegraph poles push up from the road and there is a persistent rush hour, even in small towns and on country roads. Kosovo is rich in youth [which makes up more than 60 percent of the population] and in coal, which is a source of environmental pollution highly detrimental to health. According to some, the technological filtering of harmful toxic effluents is dysfunctional or does not exist. Kosovo’s mineral wealth has made it a special land to conquer, the last time being during the Second World War. One happy moment was seeing the young people out and about enjoying themselves in great numbers in the old town of Prizren. There is a need for measures to support youth job creation. Fertility is still high and demography has played a significant role in shaping the shifts in the mix and the current makeup of the population as well as the politics. One further optimistic note was a mosque and church standing in the same yard. Kosovo has a population of 2 million. It is crowded (too many people with not much land) and has an old fleet of as many cars adding to the pollution. It is dirty and dingy but at times bright. Kosovo is not in limbo but embedded in troubled times of social turmoil with poor health status and rundown services. There is no report on transition. Population health status is not accurately known but still has to be the worst in Europe. Violence, held in check by the presence of international forces, is never far from the surface. Also the presence of a more predominant hope for better days illusively bouncing back and forth is also never far from thought. The health system is in virtual collapse, with totally inadequate financing [less than 50 euros per capita], which means that a patient’s family must subsidize even a simple surgical operation. All necessary materials for surgery are bought by the client on the free market and provided to the doctor on behalf of the patient. Most Kosovars do not have the means for such extravagance. There are sufficient numbers of doctors but they require access to continuous medical and management training. Health sector reform is of the essence. Strong opinions were voiced for the development of clinical facilities and training activities in management, health economics and public health. The main clinical center of Kosovo [QKU] has recently been on strike, demanding better wages and clinical facilities. Access to services in general is limited and patient treatment poor. While chronic diseases are extremely serious, facilities for cardiac surgery and cancer treatment are non-existent and at the moment there is no state mechanism for sufferers to obtain service elsewhere. I came across an interesting monthly publication about family medicine [Mjekesia Familjare], saw plans for the new regional hospital, in Prizren, which was recently opened and I was told of the development of a strategy for avian influenza. In villages close to towns, we almost ran down free-range hens. The basic elements of a normal life are missing [sanitation, water]. Infant mortality is the highest in Europe but slowing down. Elderly people lack everything. One doctor blamed much on Milosevic and UN sanctions and what ensued was an interesting discussion on the political determinants of health. The numbers of the sick as well as the number of diseases are both increasing. Acute diarrhea is a latent problem, hepatitis is serious, TB is on the rise and new diseases are creeping in, such as tularemia and brucellosis. Some positive outcomes include moderate gains in the reduction of the crude mortality rate, a drop in peri-natal and maternal mortality and life expectancy is edging upward. Vaccine-preventable diseases are under control. There are no polio cases and measles is now absent for the seventh year running. The minister of health shared some of his ideas with me and he was very proud of his Harvard-trained public health expert. However, in the aftermath of conflict, the prevailing anarchy has led to many corruptive practices, such as the spurious provision of credentials to healthcare professionals based on favoritism, as well as drug abuse in young people. One of the main challenges is to shift the system from a medical-or-disease oriented model toward a prevention-based public health model. Doctors and the free market will surely resist this. Quick and effective approaches to change on limited budgets are needed. Creeping disaster One health professional prophesied a creeping disaster that will result in increased mortality in the middle-aged population in the next several decades, a result of smoking, poor nutrition, obesity and changing lifestyles. Pressed for Kosovo’s first three health problems, a policy specialist rated mother and childcare, healthcare financing and the necessity of sending some patients abroad for treatment. Epilepsy, which leads to retardation as a result of high body temperature, is significant. High temperatures often go unchecked and lead to convulsions and epilepsy. In villages without access to a simple thermometer, «hand on head» [made by gesture] is the measure of body temperature. Old remedies such as brandy or vinegar rubbed on the infant’s body are used to treat fever. Measures are necessary to improve the farming and marketing of agricultural products as well as for support in the case of natural disasters affecting agriculture or disease affecting livestock. Animal vaccines must be available and free of charge to farmers. Veterinary public health is in need of strengthening. Most knowledgeable people state that cancer is on the rise but when the subject was raised of increased levels of radiation from depleted uranium, which were reported after the conflict, it is reluctantly talked about in the north and meets with a curtain of silence in the south, where usually the subject moves to the great number of mines left by the Serbian army, which has also left about 300 persons dead. Monitoring of birth defects should be undertaken as a priority. Since the 1999 war, the United Nations has administered Kosovo, which formally remains part of the territory of Serbia. In 2000, half of the overall budget was financed by external sources in a general framework of humanitarian assistance [EU, World Bank, UN agencies and several countries]. Help was given to the newly established Ministry of Health to identify and implement a sustainable financing model for the healthcare system. The World Health Organization continues to play a leading role in organizing activities in the health sector after the conflict. Blood transfusion services received substantial funding for modernization and funding is provided for financial and technical assistance for the support of healthcare reform. Over and over again health professionals stressed the need for financing of management and further management training.