Personal views: Disappearing hospital
Authors: Mary E Black
Journal: BMJ (2002)

The hospital is disappearing day by day. I sit by my bullet holed kitchen cabinet and watch it through my large picture window—a liability during the 1992-5 siege, but a real estate asset now. Then, mortars poured down on this old hospital from the hills around Sarajevo. It burnt down and, when the last sniper withdrew, Sarajevans salvaged the plumbing, tiles, and the best of the bricks. Now, during the week, staff from the rebuilt nearby state hospital park their cars. During the weekends, families forage in the rubble and squeeze out little vegetable plots, teenagers play basketball and romance, my children roller blade, and I sit on the safest piece of wall discussing life with my husband.

Hospitals are like coral reefs. On a lifeless shell arises a teeming and complex ecosystem of people, lives, and events. This seems real, solid, and everlasting. My life as a young doctor in Dublin was so caught up in Trinity College teaching hospitals that it was unimaginable to think of them ending or closing. Sacrilege to imagine that history—that memory holding of people's lives, deaths and dreams—could be swept away in the name of efficiency. Yet close they did—Sir Patrick Dun's, the Adelaide, the Meath, Mercers . . .

As I get older and directly involved in planning health services, I can provide sensible and rational arguments about why it might be best to close a hospital or move it elsewhere. But at another level it hurts and offends me. In the midst of a planning exercise to close an old small hospital in London during the 1980s I was pained to see a little bunch of placards outside the House of Commons protesting against the closure of the hospital in Liverpool where I had been born. Somewhere another planning committee had made the rational, logical decision for this closure. My emotions won and I joined the picket line for a while. 

At least the passing of hospitals in peacetime can be discussed, planned, and managed. In war the passing of hospitals is disgusting. During the war in Croatia, and Bosnia and Herzegovina, hospitals were directly targeted to force their catchment populations to move. Patients and staff in Vukovar's main hospital were massacred when the city fell, a guided mortar hit and killed eight patients having lunch in Bihac hospital, and a surgeon was decapitated by a mortar at the entrance to the operating room in Sarajevo's Kosevo hospital. I have vivid pictures of walking through knee high piles of half burned handwritten medical notes, and standing in a trashed operating room adorned with obscene graffiti and beer bottles, its walls smeared with shit. Professional lives had been spent in these hospitals and now all traces of them were scattered in rubbish, rubble, and graves.

Enthusiastic donors have rebuilt many hospitals in Bosnia and Herzegovina, usually in exactly the same out of date and irrelevant original design. The health staff and donors could neither envisage a new structure nor let go of the old one lost so painfully. Sometimes hospitals have been rebuilt bigger and better, and are now half empty. Sometimes they are in the wrong place or have been replicated on either side of an ethnic divide, and now public funds can barely sustain them. All have been recolonised with new lives and events. A sort of Chicago Hope soap opera of the Balkans runs on here.

So I sit at my kitchen window as the seasons change. Snow comes and goes, as do health ministers, health planners, and a dwindling bunch of donors set on rebuilding the buildings. Our disappearing hospital is not on the rebuild list and we colonise its ruins and await its fate. It is part of the post- war city organism, a wound that has fed on sorrow in a strangely creative way, and which celebrates the vitality of Sarajevo and the Sarajevans that live round it. The trees get taller, birds nest, cars park, the national team and local teenagers play basketball, older people gather to compare vegetables from the makeshift allotments, the best bricks are now part of local house repairs.

Our disappearing hospital is a dynamic living monument. I already miss it in the way that I miss my own life and the lives of my husband and children that will, in turn, disappear. During the last days of summer, the bulldozers moved in to level it. The planning committee spared the basketball hoop but flattened the vegetables.

What next?