Health of Albanians and Serbians Following the War in Kosovo: Title and subTitle BreakStudying the Survivors of Both Sides of Armed Conflict

Scientific studies focusing on survivors of war began in earnest following World War II, with work largely conducted in relocation countries, such as Scandinavia¹ and Australia,² years after the traumatic events. This pattern of delayed studies conducted in relocation countries persisted following later armed conflicts, such as those in Hungary³ and Southeast Asia,^{4 - 6} except that contemporary sampling methods and data collection instruments were used.

Two articles in this issue of THE JOURNAL represent yet a third generation of studies of the survivors of armed conflict. These studies differ from earlier studies in 2 respects. First, they were conducted either in the midst of or soon following armed conflict (in this case, Kosovo). Second, they were conducted in the country where the conflict occurred, removing the complicating elements of permanent geographic relocation, loss of home and occupation, and cultural change or adaptation. These new approaches provide important information about the acute health consequences of armed conflict, and they separate the stress of involuntary migration (itself a massive stressor) from the stress of armed conflict. Thus informed, those responsible for social and public health recovery following armed conflict can more effectively achieve their purpose.

These studies from Kosovo involve many logistical and methodological challenges. Among them are safety of the study participants and investigators. Additional logistical challenges evident in these 2 studies include matters such as land mine dangers, curfews, and ongoing reprisals. Methodologic issues, such as those related to sampling, confidentiality, and ethics, represent areas that will continue to challenge those conducting research during or immediately after war and armed conflict.

The Kosovo studies found high rates of psychiatric symptoms among the Albanians and Serbs residing in Kosovo after the war. However, each of these studies broaches new topics of special importance. In addition to evaluating the mental health of ethnic Albanians, Lopes Cardozo and coworkers⁷ asked the Albanians about feelings of hatred and revenge toward Serbs. Unfortunately, the authors did not analyze their data to assess the association of these emotions with mental health, social function, or physical health. This topic may have practical significance. In another study of refugees, hostility following relocation was associated with greater financial, marital, and mental-emotional problems, and also predicted chronic hostility.⁸ Thus, hostility, rage, or revenge may pose risks both for the aggressor group (if vengeful acts are promulgated) and for the traumatized group (in terms of adverse psychosocial function).

The study by Salama and colleagues⁹ of the Serbian minority in Kosovo likewise addresses a taboo area: the health implications of armed conflict for the defeated aggressor group. Although German and Japanese people suffered greatly following their defeats in World War II, their psychological morbidity and psychiatric sequelae have not been formally studied in the manner or to the extent that researchers have studied the mental health of the survivors of German and Japanese aggression. Salama and colleagues⁹ have broken this taboo by evaluating nutritional status and mental health among the Serbian minority who remained in Kosovo after the war. The comparison of psychiatric symptoms of the Serbs with those of the Kosovar Albanian majority reveals the extent of the morbidity among both groups.

Both groups of investigators^{7 ,9} avoided problems commonly associated with previous investigations (ie, making psychiatric diagnoses from self-report symptom scales). Norms from stable populations when applied to samples exposed recently to armed conflict produce extremely high rates of psychiatric disorders. Additional studies are needed to assess whether symptom levels are related to disabling or chronic psychiatric disorders in such populations. Until then, it is possible that high symptom levels may be the norm or may reflect temporary adjustment reactions, rather than a reflection of psychiatric disability.¹⁰ In the study of ethnic Albanian Kosovars,⁷ the fact that employment and other demographic factors were not related to psychiatric morbidity (as usually occurs in stable populations) underscores the need for a fresh approach to the assessment of mental health in recently traumatized populations.

These studies also have produced counterintuitive findings. For example, the lower symptom levels among divorced ethnic Albanians vs married Albanians⁷ differs notably from other survey findings in stable populations.^{11 - 12} Perhaps the exigencies of armed conflict were more stressful for those in intact marriages who may have greater responsibilities to spouses and children. Ethnic Albanians who were internally displaced reported greater mental-emotional symptoms than either those who remained at home or fled to other countries. Psychosocial symptoms were as severe in the defeated Serbs as in the traumatized, relocated Albanians, with even higher mean scores for depression and social dysfunction among the Serbs. Clearly, armed conflict and its resultant stresses and insecurities create situations that nullify or distort much of the current knowledge base and beliefs about mental health in stable society.

As in all good studies, these 2 laudable investigations stimulate additional questions of much importance for social planning. Does social "function" (such as having a job) facilitate mental health, or does mental health facilitate function? Does relocation of displaced persons back to their society of origin result in better psychosocial outcomes than relocation to a new society? Do revenge and hatred produce adverse psychosocial consequences for persons on both sides? Of greatest importance, these investigations have demonstrated that rapid assessments based on valid and reliable research methods can be conducted under the difficult circumstances associated with war and armed conflict. Thus, it is now feasible to understand the health consequences of armed conflict proximate to that conflict. These studies also point to the next step—the need to design and implement effective rapid interventions to reduce the acute and chronic psychosocial consequences of armed conflict for all survivors.