Bosnian Divide Extends to Cancer Care

My assignment in Bosnia this past month was two-fold: examine the surprisingly high levels of breast cancer in the country and cover the significant national elections underway. I soon discovered that the two stories would intertwine — that the deep problems within Bosnia’s health care system are made worse by political divisions in this post-conflict country, now cobbled together into a fragile and ethnically based peace.

After the civil war ended in 1995, the country was carved into two autonomous entities: the Federation of Bosnia and Herzegovina, populated primarily by Bosniak Muslims and Catholic Croats, and the Republika Srpska, which was created for the nation’s ethnically Serb population. In most areas, the border between the two entities is completely unmarked (though some nationalist politicians are now calling for clear demarcation). The best way to know when you have crossed from one region to the other is from the shop signs and billboards that use Cyrillic letters in Serb-populated parts of the country.

Bosnia now has three presidents, one representing each ethnicity. Each entity has its own Parliament. The Federation is further divided into 10 cantons, each locally run. In this recent election, there were more than 8,000 candidates on the ballot. No wonder this has been called the most over-governed country in the world!

And so, there is no national health ministry; the Republika Srpska has its own, as does The Federation. This surprised me — something as innocuous as the public’s health is still subject to divisive politics.

Breast cancer care also varies between the two entities. The Republika Srpska, which is currently more stable financially (due in part to investment money flowing from friendly Russia and Serbia and a series of privatizations), has had an entity-wide mammogram screening program in place for several years. The Federation, struggling to stay solvent under the burden of pensions paid to its war veterans, has tried to get its own mammogram screening process up and running, but a pilot program started last year has been temporarily shut down. Breast cancer advocates hope it might start again soon. The Republika Srpksa also provided the breast cancer drug Herceptin to its population sooner than the Federation did.

In the Federation, health care is decentralized even further: each of its 10 cantons has its own health ministry, with each overseeing standards of care and provision of equipment and technology. If a woman in say, Tuzla Canton (in the northern part of the Federation) needs to be treated at the comparatively well-stocked and well-staffed radiology department at the Kosevo Hospital in the country’s capital, Sarajevo, she must first be given Cantonal-level health ministry approval.

The country of Bosnia hasn’t undergone a census since 1991, before the ethnic civil war broke out. It’s too politically loaded: the numbers would make official the now-clearly entrenched ethnic divisions left behind by the horrors of war. So if the country doesn’t even know how many citizens it has, you can bet there is very little nuanced demographic information available to doctors (and reporters) on topics like income level, family size and lifestyle behaviors — all of which impact health outcomes.

Sadly, the results of Bosnia’s election on Oct. 3 will likely change little of the political divisions in the country. But there is a bright side: the efforts being made by non-governmental organizations to serve the people in lieu of their own government’s ability to adequately do so. In the process they are bringing women of various ethnicities together around an apolitical topic like breast cancer — and slowly healing some divisions in the country through collaboration on common goals.

Kira Kay’s report on breast cancer care in Bosnia airs Tuesday night on the PBS NewsHour.