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A 'Crisis of the Spirit' in Kosovo

Yale Medicine Magazine, 1999 - Summer


Nail polish for a young girl. A scrap of paper with a child’s weight and height written on it. An origami bird that flapped its wings. A stage production of Cinderella for an audience of 400.

In the accounts that follow, six Yale medical students, a physician associate and an emergency room physician evoke these images as they recount what they saw, heard, did and felt in the four weeks they spent at the Senekos refugee camp in Macedonia in April and May. Their stories tell of the seemingly little things that offered comfort to emotionally fragile people, as well as the projects they undertook to improve life in the camp.

The group traveled to Macedonia in late April to work with ethnic Albanians forced from their homes in neighboring Kosovo. The trip was organized by the Dean’s office under the auspices of Doctors of the World, an international relief organization. Chosen by lottery from more than 100 volunteers, the students arrived expecting to be put to work at any number of tasks, from digging latrines to handing out blankets to changing bandages. “We went with the understanding that we were not going to practice medicine,” said Aaron Covey. “We went with the understanding that we would do anything that would be needed to help.”

With most of the refugees’ material and medical needs in the hands of others, the students devised a unique role for themselves at Senekos, which grew from an initial population of 800 to more than 6,000 in the month they were there. “As a medical student,” said Margaret Bourdeaux, “you’re not constrained by your professional role. You have the luxury and the privilege and the time to sit and talk with people and not have a goal, not need something from them. I think that was extremely special, yet it is difficult to convey to people how important that is.”

From the very beginning, the group plunged into personal contacts with the people they had come to help. A key was the presence in the group of Emine Alijaj, R.N., P.A.-C. ’96, an ethnic Albanian who left Kosovo with her family when she was four years old and who now works as a physician associate in the Emergency Department at Yale-New Haven Hospital. At a camp called Stenkovac, an hour’s drive from Senekos, she was reunited with the cousins she had last seen on a railroad platform 27 years earlier. “I was absolutely hysterical, crying and crying,” Alijaj said of the reunion. Two days later, her relatives left for a refugee camp in France. The students’ visit with the family, early in their stay, influenced their view of their role in the camps. “Just being part of their lives,” said Sharon Chekijian, “is often enough.”

The students came to know the inhabitants of Senekos through a tent-to-tent survey of medical needs and a similar assessment of the nutritional status of children in the camp. These visits not only helped them establish a rapport with the refugees, but brought patients to the camp clinics for treatment. “We identified a lot of health problems and health needs that would never have shown up in the clinic had we not been there to refer people and encourage them to go there,” Bourdeaux said. “A lot of it was like being a small-town doctor. You knew where everyone lived, so you could go make house calls.”

While Alijaj and Pamela Perry, M.D., had duties in the camp clinic, the students saw to other needs and concerns. Some camp inhabitants had tasks and chores to occupy their days; children under 15 attended school in a nearby town and mothers washed clothes, cooked and cleaned their tents. But men and older children often had nothing to do except think about what they had lost and wonder what lay ahead. The medical students organized soccer and volleyball leagues for 15- to 18-year-olds. “There was a sense of camaraderie within these teams,” Covey said. “People enjoyed being a part of it and it was important for this age group.”

Seth Goldbarg organized a theater production, with children in the camp acting out the story of Cinderella. “I thought it would be a really good idea to begin community-building activities to involve a spectrum of people,” he said. The play had a therapeutic benefit that reached beyond those actively involved in the production, said Chekijian, who added: “If you make the kids happy, it makes the community a whole lot better.”

Moments of happiness, however, often gave way to memories of war. When Covey gave children crayons and paper, they drew pictures that “showed a lot of burning houses, tanks in villages, sometimes dead bodies,” he said. The war just across the border in Kosovo became real not only through the children’s drawings, but through the stories the medical students heard often in the camp. When a young man recounted how Serbian paramilitaries took his family from their home, ordered them to lie down, then shot his father and two brothers, Goldbarg said, “I just thought of my parents and sister lying in the front yard in the grass.”

The faces of new arrivals in the camp, who disembarked from buses in a state of exhaustion, dehydration and confusion, also reflected those horrors. “There was an older woman, about 75 years old, and she got off the bus and just stood there and looked around,” said Bourdeaux. “I walked up and offered her a glass of water and she waved it away. I offered her a Kleenex and she grabbed it and burst into tears and she grabbed me and just stood there crying and holding on for dear life.

“Your first reaction is you don’t want to see this person cry. But that is really the first step in healing for them, just to have permission to be sad and angry and to think about what they’re going to do next. This is not a medical crisis. It’s a crisis of the spirit. Giving people a sense that they exist is the most important thing to do there.” The volunteers’ observations, edited from their journals and letters, follow.


Assistant Professor of Surgery (Emergency Medicine)

April 5
The dean’s office sent an e-mail today, seeking a faculty member to accompany a group of medical students to Macedonia to assist with relief efforts. When I asked myself, “Why drop everything and go to Macedonia for four weeks?” the answer was clear as a bell: If my family were suffering from the atrocities forced upon the ethnic Albanian people of Kosovo, I would expect the world to stop and help.

April 23
The planning for the trip complete, yesterday we were on our way: New York to Brussels, to Vienna, to Thessaloníki, to Macedonia (roughly 24 hours of traveling). Finally, we’re here. Our accommodations are sufficient: a rented, four-bedroom house in the capital city of Skopje. I will be rooming with Anya, a first-year medical student. I haven’t had a roommate since I was 15! Group spirits are at a high. We will commute an hour by car to the camp with volunteer drivers from Doctors of the World.


Physician Associate, Emergency Department
Yale-New Haven Hospital

April 25
Yesterday we made our way to Stenkovac, the largest Albanian refugee camp in Macedonia, to look for my cousins. (I was born in Kosovo in 1968 and lived there until I was four, when my family emigrated to the United States.)

How we were going to get into the camp — and how we were to find my cousins there among 20,000 refugees — was a mystery to us, but somehow we did it. Sharon was able to get the number of the tent where my cousins were staying, and we walked through the camp calling out their last name, “Avdiu.” A woman approached us thinking we were long-lost family coming to rescue her. When she realized that we were looking for someone else by the same name, the expression on her face changed to utter disappointment. I wished I could have been the family member she had hoped for.

And then I found my cousin Bashkim, whom I last saw 27 years ago when he accompanied my family to the train station in Kosovo. We cried and embraced as if the time had not gone by. He told me of his family’s journey from Kosovo four weeks ago. Now they are living in a tent, 15 people in all. They welcomed all of us, and, within a few minutes, everyone in the Yale group felt like an Avdiu, despite not being able to say much that would be understood. When I saw my cousins, my first thought was, “Thank God they are alive.” Then I thought, “God, how could this have happened to all the Kosovar Albanians?”


Class of ’01

April 26
On the road from Skopje we had seen other refugee camps, kilometers of white tents stretched along the base of the lush, green mountains bordering Kosovo. But it was muddy in Stenkovac, where we went in search of Emine’s cousins.

The Macedonian police guarding the camp looked at our American passports and let us in, to our great relief. Emine and I talked our way into the camp’s administrative area, where the lists of refugees and their tent assignments within the camp were kept. The people working in this makeshift office hardly looked up, perhaps from fear that they would have to answer the endless questions fired at them by the crowd of refugees. Everyone here is looking for a lost relative or friend, or seeking asylum in France, Belgium or elsewhere.

We caught the attention of one of the workers, who looked up reluctantly and seemed to notice that we were somehow different from the others. It’s that difference — our sense of self — that allows us to walk out of camp unchallenged at the end of the day and to ask questions when we need answers. It empowers us with confidence. Every single refugee — doctors, lawyers, teachers, farmers and children alike — seems to have been stripped of it.

The relief worker returned minutes later, surprising us with the tent numbers of Emine’s cousins. We headed off as a group, followed by a crowd of people. After Emine was reunited with her cousin Bashkim, other family members appeared and the group of us from Yale were surrounded by 20 Albanian refugees, curious and excited. We had not expected that on our first evening we would find an instant connection to these people we had never met, whose culture and language were so different from ours. As our communication was limited to a mixture of French, Albanian, and English, Aaron taught us all the international language of origami.

Bashkim handed me a business card from the time that he spent away from his family in Switzerland. “I worked for 12 years to make a home and now nothing is left,” he said. “It is all gone.” As we learned later, most refugees don’t even have pictures of the lives that they left behind. But Emine’s teenage cousins had rescued two little albums, which they meticulously narrated as they turned the pages showing classmates, family members and vacations to the Adriatic. We are thankful to Emine for sharing her family with us. The experience was invaluable in influencing our view of our role here. We don’t need to be medical students, doctors, volunteers, relief workers or foreigners. Just being part of their lives at this point is often enough.


April 26
Our first day in Senekos refugee camp. Initial impression: a sea of white tents and somber faces. We had driven by the camp the day before but were asked not to enter without ID cards, so we didn’t go in. I have met so many beautiful people! The children are incredible. A lot of the doctors seem to have a certain bedside etiquette that surpasses any I have witnessed at home. It is refreshing to see people who take care of others merely because they want to and not because of the prestige attached to it. I met a neurosurgeon working in the Senekos clinic who could have left for America weeks ago but chose to stay and help his people. He’s working as an internist!


Class of ’01

April 26
Yes, mind-body therapies are effective in treating illnesses related to stress. But I could not have imagined their application in a situation such as Kosovo. Given what the refugees entering Senekos had been through, I doubted they would have felt like sitting quietly and meditating on the inspiration and expiration of their breath. Wouldn’t it have been presumptuous of us to ask them to take their minds to a more peaceful place, just days after they had watched their homes burned down and family members assaulted by Serb paramilitary troops?

To my utter surprise, then, I found myself participating in a stress-reduction workshop on my first day in the camp. James Gordon, M.D., a Georgetown University psychiatrist and an expert on mind-body therapy, led the session. His audience was a small group of refugees from Kosovo in their teens and early 20s. When I arrived, Dr. Gordon was describing the fight-or-flight response to acute stress.

“What happens to your body if you realize that a tiger is chasing after you?” he asked. “My heart races,” replied a teenage boy. “My eyes open wide and I start breathing fast,” said another. Dr. Gordon explained the physiology of stress in terms that seemed to reassure his young audience. The message was that this tension and continued alertness to danger were normal, despite the discomfort associated with them. Further, they might be able to influence these sensations by a conscious effort.

Dr. Gordon led his group in an exercise of guided imagery to demonstrate how the body responds physiologically to a particular mental picture. “Close your eyes and imagine a lemon in front of you,” he said. “Now, slice it with a sharp knife and then place it into your mouth. Bite down on its juicy texture. What do you feel?”

Some were refreshed by the image. Most felt their salivary glands activated by the sourness of the lemon that hovered in their mind’s eye. “You see, our bodies respond to mental images. This can be an effective way to calm your body during stressful times,” Dr. Gordon said. “Not by imagining lemons, necessarily. But taking one’s mind to a more peaceful place can be relaxing physiologically.”

Never has a lemon seemed so instrumental to me.


April 27
Bashkim and the rest of the Avdiu family have left Stenkovac for another temporary home in Lyon, France. He was reunited with his parents, brothers and sisters who are in France and Switzerland. They are all well.


Class of ’01

April 29
Every child in the camp between the ages of 6 and 14 is waiting at the gated entrance of our refugee camp. Today is the first day that these children will attend school while in Senekos, and I am the unofficial photographer!

The town that surrounds our camp is largely ethnic Albanian, and local officials have agreed to let the refugeesuse the schoolhouses for four hours each weekday. For many of the 300 or so children, it is their first day of school ever. Under recent law, most Kosovar Albanians were not permitted to attend school in their homeland.

I followed the children as they sang their way to school. I tried to sing along to make the children laugh. It worked. They were excited and eagerly waved as I took pictures. Some held up the two-finger symbol for “Free Kosovo” for my camera. They were accompanied by older residents of the camp who had been teachers or teachers-to-be back in Kosovo. I went to a couple of classrooms and, unintentionally, disrupted them. The children tried to get me to take their photograph instead of paying attention to their teachers.

I peeked in another door to see if I would be disturbing another class in progress. I wasn’t. I did not even see an adult in the room. I thought I could get some good pictures here. When I opened the door, these 6- to 7-year-old children started cheering. They had recognized me as the American who made balloon animals, sang and played ball with them.

I took some photos, but still no one arrived to teach the children. “Hello,” I said. I said it a few more times, cupped my ears and stretched my neck until they said hello back. Then “Goodbye!” I left the classroom. I went back in again. … “Hello!” I did this a few more times and soon found myself teaching English. A man who I recognized from the camp poked his head in and nodded for me to keep teaching. At least that’s what I think he said. It’s what I wanted to hear!

I taught the things that I had myself learned in Albanian this past week. “How are you?” Si je? “Good morning.” Mir minges. It was difficult to know whether the children actually learned any English, and, after two and a half hours I was feeling mentally drained. Relief came in the form of crayons and paper, brought by the organizer of the program. The children drew whatever they liked. After this, the class was dismissed back to the camp. I accompanied them with the pictures in hand, again singing songs.

I had lost myself in the fun of teaching and I felt energized the rest of the day, knowing how much the children enjoyed it. Yet that night, my perspective changed a bit while looking through the drawings that they made.

Most children draw what is on their minds. In this case, almost all drew their homes and villages. Some of these images included burning houses, tanks and warplanes, even dead bodies. The pictures reminded me that I wasn’t teaching kids at home, nor was I just having fun. These 6- and 7-year-olds are living through an indescribably awful time. While balloons, singing, and drawing will never erase the horror these children have witnessed, I hope that what we are doing at the camp has helped start their healing.


April 30
The camp has grown over the last four days from 800 inhabitants to 2,300. It is run by Mercy Corps International and is the smallest of all nine camps. It is rumored to be the cleanest and the most hospitable, too. The clinic or “Ambulanta” is a structure composed of two large tents joined by a canvas waiting room.

The clinic is staffed by three ethnic Albanian doctors, who are themselves refugees from Kosovo, and two American physicians. There are four Kosovar nurses on staff, as well as several interpreters. Currently there are few acute problems. Most medical problems are chronic in nature; diabetes, hypertension, heart disease and pulmonary problems predominate. Medications are adequate, but the supply is limited. New influxes of refugees introduce occasional acute considerations of dehydration, diarrhea, upper-respiratory infections, and minor trauma.

Two evenings ago, Emine, Seth and Aaron remained at the camp overnight to assist with the arrival of a new group of refugees who came by bus after spending days at the border camp at Blace. They arrived exhausted, dehydrated and disoriented. A triage area was set up and the sickest were given seats, taken to the clinic and evaluated for treatment.


Class of ’02

May 3
I brought five jars of nail polish to the camp yesterday to paint little girls’ fingernails. They loved it. It might seem like a trivial thing to do when we have issues of overcrowding and shortages of clothes, diapers, and sanitary pads. A few days earlier I was talking with a 14-year-old girl named Havishe, who had told me that her hands were once beau-tiful in Kosovo, but have become ugly from her travels to Macedonia and living in the camp. I then noticed that many of the little girls (between 3 and 10 years old) had just scant remains of blue and green nail polish. I thought they might enjoy it.

I found Havishe and asked if she would like her nails painted. She was delighted. We sat down beside a tent and I asked her to choose a color from the bottles that I had brought. I was soon mobbed by 20 other people — small children and their parents, as well as an elderly woman and man. They had come to watch. When I was finished, I asked if anyone else wanted her nails painted. The response was overwhelming. I painted over 50 people’s nails over the next few hours.

The strangest response was from the fathers. They kept saying, “Bravo! Bravo!” My reading of these events is that here in the midst of a refugee camp — where they have been degraded by being forced to leave their homes and flee for their safety, where there is no hot water and the few clothes they have are dusty and dirty — this was something normal and civilized, something completely frivolous, something that fulfilled more than a basic human need such as food, shelter or clothing.

I asked the elderly woman who had been watching whe-ther she would like her nails painted. The man with her shook his head discouragingly. She shook her head, too, and lowered her gaze. From what I could gather in my small Albanian vocabulary, the man didn’t think she should have her nails painted because she was finished, too old; it wasn’t important for her to feel pretty. The woman, I think, felt ashamed by this and thus agreed with the man. I insisted that I paint her nails. The smile on her face was priceless. In that one gesture, I conveyed that she was worth it.

In medical school when we are learning the physical exam, we are taught about the power of touch. Touch can calm you. It lets you know that someone notices your pain. When I talk to the refugees, I try to touch them. Sometimes I am afraid to touch them, especially when we first arrived, but I know they need to be touched. My need to help them overwhelms my fear of being too personal with someone I met just five minutes ago. It is one of the most powerful experiences to hear someone’s story of devastation and when they are weeping to reach out and gently squeeze their arm, or hold their hand, or put your arm around their shoulders. You cannot help but weep yourself. You do not need an interpreter for that. When they see you crying, the storyteller knows that you understand the pain that they have been through. When you listen to their story, you take some of the pain away.


Class of ’01

May 5
As medical students, we tend to fixate on the care that we can give to treat an illness, to cure an infection, to ease the pain of a disease. Here in Senekos we see battered souls in need of healing. We meet children starved for attention and parents struggling to do all they can for their families. Fifteen-year-olds have become the heads of households. Old men weep as their sons tell their stories to us.

We are with a group of refugees who have survived the physical trauma of the flight from Kosovo and the border crossing into Macedonia. They have before them many long, hot days confined to a fenced-in camp with only their few possessions as diversion. Passports and papers confiscated, homes looted and burned, relatives missing, and their country in turmoil, the people of Senekos seem to survive by living in the moment.

Without a sense of identity, how can they begin building community? No one can predict when this crisis will end or what will happen when it does. With this in mind, I have been speaking with my Yale classmates about trying theater here. They agree that it might be a good way to bring people together and get them to use their talents within the confines of Senekos.

May 8
Kadrush is a 28-year-old teacher who is thrilled by the idea of putting on a play. He seemed skeptical at first, but he picked out Cinderella (La Perhitura in Albanian) from among several children’s books and has gathered together three university students who were begging for something constructive to occupy them. They wrote the script, cast eight children in the roles and are about to begin rehearsals in one of the unoccupied vaccination tents above the camp.


Class of ’02

May 10
What happens to a dream deferred? Does it dry up like a raisin in the sun? Or fester like a sore — And then run? Does it stink like rotten meat? Or crust and sugar over — like a syrupy sweet? Maybe it just sags like a heavy load. Or does it explode? —Langston Hughes

Technically, I had spent my day collecting data for a nutritional assessment of the pediatric population of the Senekos Refugee Camp. But that description, while accurate, belied the reality of the task: bending on one’s knees in the muddy gravel and reading off the weights and heights of squirming, indignant children who would not be still for too long. The weighing and measuring of these refugee children had also proved unexpectedly therapeutic for their mothers — women with hardened faces and creases around their mouths, mothers deeply worried about their children. They insisted that I write their children’s measurements down for them on slips of brown, recycled paper. It took some time for me to understand their eagerness for this documentation: These little slips of paper were the only written proof that their children existed. Birth certificates, baby pictures and immunization records had all been burned, stolen or left behind in the course of their forced exodus. And what documentation it was! Slips of paper that recorded the physical space their children occupied in this world — space that had almost been violently denied them. Every centimeter a defiance! Every kilogram hope for future growth.

Hope, in fact, was what I needed now. I was talking with Gazmend, one of our interpreters, in Kapan An, an Albanian-owned bar tucked away in the Turkish section of Skopje, the capital of Macedonia. Gazmend had just returned from a meeting with a Kosovo Liberation Army commander who turned up in Skopje two days ago. Gazi was set on joining the KLA when his work with us was finished. Through persistent, heated discussion, I had been able to cast some doubt in Gazi’s mind about his plan, but I was afraid this meeting would seal his resolve. It turned out quite the opposite — the KLA commander had been very discouraging. “He said that if I joined the KLA I would be dead in two weeks,” Gazmend reported. “Go somewhere and study, learn something that will help rebuild our country,” he had told Gazmend. I was relieved, but not as much as I thought I would be. Gazmend’s face was in his hands as he mulled over the commander’s advice. “But who cares if I die?” he finally exploded. “At least I will have done something!”

I understood Gazmend’s desire to fight. Seven years ago, just after he finished his second year of medical school at age 20, Serb soldiers knocked on his door and informed him that he had been conscripted into their army and that he was to come with them immediately. He grabbed the conscription notice from their hands and ran — and kept running for two years before settling in the western Kosovo town of Pec and opening a dress shop. After Kosovar businesses were deemed illegal by the Serb government in late 1997, Gazmend went to work in Kosovo for the Office of Security and Co-operation in Europe, an organization that documented human rights abuses. Working out of Pristina, he donned a bulletproof vest and drove through combat zones investigating atrocities. Six weeks ago his American boss had entered the office and announced that he and the rest of the expatriate staff had to evacuate due to the escalating violence. He wished all the Kosovars luck finding their way out of the country. Gazmend packed up his mother and father and sent them ahead to Macedonia. He followed weeks later after a brutal journey through burned villages, sniper fire, and the burial of a travel companion who did not survive.

But Gazmend did not want to fight, as I had thought. He wanted to contribute, to do something that mattered. Gazmend would much rather face the Serb military than the cold terror of a wasted life. He was 27. He had no diplomas, no transcripts, no way of leaving Macedonia, no way of working after his job with us was finished. He was a talented leader and resourceful thinker, and he knew it. But what now? As I looked at Gazmend and at the other young refugees who populated the darker corners of the bar, I wished I could give them slips of paper with the measurement of their potential in the world written upon them. How does one treat this kind of stunting, this malnutrition of the soul?

The KLA commander was right: go study, go learn how to write constitutions, create school systems, care for the sick, and heal communities. However, these young refugees cannot create the opportunities to learn these skills out of thin air. Educational opportunities can be provided only by those of us in the international community who care enough to do so. And as I look at Gazmend considering his choice between a future of violence and a future of dreams deferred, I know that we do not have much time.


May 14
The students are really proving what they are made of. Their work is important, useful, and they appear to be deeply moved by the experience. The depth of Emine’s emotion must be incredible. We have found three sets of her relatives, each very loving and caring. The concept of family among ethnic Albanians reminds me so much of my own parents and nine siblings.

I think everyone is now realizing how short four weeks really is. The weather is HOT, and we are expecting more refugees at Senekos any day. I am having a ball with the kids. Moussa is by far my favorite. He is an 11-year-old boy who witnessed a Serbian soldier cutting an Albanian man’s throat. Moussa has had nightmares for three weeks. When he sees me coming, he wants to arm-wrestle or play whatever game I have in mind. He reminds me so much of my nephew Max.


May 18
We bought red and purple sheets of material in Skopje yesterday, and a seamstress in the camp is making costumes. We have a crown for the princess and we found a plastic sword in the old market in Skopje. Today, volunteers built a crude but sturdy stage over a drainage ditch from scrap plywood, the most visible location in the camp. Erfan, my invaluable assistant and friend, even strung up a curtain from one of his family’s blankets. Kadrush and the students helped design the flyers that we put up to advertise the performance. The names of the actors and writers are proudly written on every sheet, which we posted on the community bulletin boards.

May 19
Hundreds of people, mostly children, watched La Perhitura today while the sun set behind the stage over the snowy mountains of the Kosovo border. Every face wore a smile as Cinderella, with a beautiful dress and flowers in her hair, slipped her foot into the glass (or in this case, black plastic) slipper. Ramadan, who played the prince’s young steward and, at age 14, has an incredible command of English, promised that this was only the beginning of dramas in Senekos and that he personally intends to direct one every two weeks.


May 22
Today Vivian and I returned to Stenkovac and found two more of my cousins. They are hoping to come to New York to see my family. Last week, I met another cousin, Mergim, and his wife and children. They are living in an apartment in Skopje. [Mergim returned to Kosovo to find his home destroyed. He planned to return to Macedonia in late June and then make the journey to Kosovo one final time.]


May 23
We are going home. I cannot believe the time has come to leave! Last night was so emotional. I stayed up until 3 a.m. with Moussa’s family, talking, dancing and laughing. My final goodbye at the camp was so emotional! After hugging all of the kids who walked me to the gate, I started crying and we all just stood there weeping for what seemed like ages! Moussa would not let go of my hand. He was so sweet. I hate saying goodbye.

A month after the group’s return, Emine and Margaret returned to Senekos to spend the summer working in the camp. Emine took a three-month leave of absence from her job in the YNHH Emergency Department to work with Doctors of the World. Margaret returned as a Wilbur Downs fellow investigating malnutrition in the refugee population and exposure to diarrhea and upper-respiratory infections.