Kosovo: army medical supply services in an operational area
Following a recent visit to the Balkans with the British army, Harriet Adcock reports on the army medical supply services provided in Kosovo
The British army currently has over 3,000 personnel serving with the NATO sponsored international security force in Kosovo (KFOR). The region is divided into six military areas, each with a multinational brigade (MNB). Each brigade works to assist the United Nations Mission in Kosovo (UNMIK), the region's interim government, to provide a secure environment and to promote peace and stability in the region.
The UK medical squadron, based in Privstina, Kosovo's main city, provides medical support to the British forces stationed in Kosovo. The army medical services (AMS) have had pharmacy technicians deployed in the Balkans since 1995. A pharmacist was first deployed in 1996.
Field ambulances at a joint British and Swedish military camp outside the Serbian village of Slivovo, near Privstina, Kosovo
84 Medical supply squadron
At the time of my visit, in July this year, Captain Jo Fleming was the pharmacist deployed in Kosovo, on detachment with 84 medical supply squadron (84 MSS). She joined the army in March, 1999, at a time when Kosovo was frequently in the news. Twelve months later, Captain Fleming was sent on her first operational tour, to take responsibility for army medical supply in Kosovo and Bosnia.
The primary role of the pharmacy team, based at the British army base at Horseshoe Lines in Privstina, is to provide logistic support in the form of medical resupply to all British and some foreign units and to provide advice on pharmacy and prescribing issues when required.
Each unit has its own medical store with medical store personnel, usually combat medical technicians (CMT), who distribute the medical supplies within their own units. The CMTs liaise with 84 MSS, usually presenting demands daily for resupply of stock.
Replacement medicines and non-stock medicines are supplied from the UK by the Medicines Supply Agency (MSA) and distributed by 84 MSS. Normally, orders are faxed through to the MSA once weekly. Urgent orders go through as they are received.
Once a week the main supply is received, usually arriving by air from the UK. Supplies sent by land are problematic as containers tend to get delayed at borders. All medical supplies, including drugs, dressings, and medical and dental equipment, are handled through 84 MSS so the weekly order is large. The last supply to have been received by the team during my visit included 2.8 tonnes of medical material. Once the supply is received each item has to be unpacked, checked and catalogued against its NATO store number.
If the system works then things run smoothly, but as with any operational area problems can occur and the system must adapt. At the time of my visit the unit was without a working fax machine so routine orders had to be sent by post. For supplies that were needed urgently it was sometimes possible to go to other military medical units stationed in Kosovo. Local purchasing, however, was not feasible in Privstina due to the collapse of infrastructure in Kosovo. If anything, the army was occasionally called upon to supply the local population when their normal supply routes were disrupted.
One of the main problems that the Royal Army Medical Corps (RAMC) pharmacy team faces in Privstina is the extremes of temperature. Recently, temperatures at the base had reached over 50C so keeping medicines cool was a very real issue. Three refrigerated units, two kept at less than 20C and one at less than 8C, stand outside the warehouse that houses 84 MSS. On the day of my visit the units were being powered by a temporary generator. The permanent generator was being repaired following damage that had occurred during the heat wave.
Combat medical technicians checking the ward's drug trolley
Pharmacy technicians, Staff Sergeant Julian Shevelan (left) and Corporal Gareth Davies, outside one of the refrigerated containers used to store medical supplies
Pharmacy staff at Privstina hospital sorting through drug donations
Systems were in place for dealing with out-of-date and short-dated stock. As orders are received, all batch numbers and expiry dates are entered on to the computer's pharmacy stock control system, Microscript. Each month the database highlights "doubtful stock" which cannot then be distributed unless the system is over-ridden. "Doubtful stock" is isolated and stored separately, remaining in a controlled environment in case of need while the stock is still in date.
Commenting on the recent reports of expired drugs being used by the military, Captain Fleming said that all the medical supplies that had been deployed with 84 MSS last summer had been in date and had had decent shelf lives. Stock that was due to go out of date would have been earmarked. It was possible that the drugs in question had been short dated and as with many things in an operational area the military personnel might have had to make do.
During a brief visit to the main hospital in Kosovo, I was able to talk to the head pharmacist there, Mr Elviv Azizi. Mr Azizi, an ethnic Albanian, had been responsible for the hospital pharmacy for the past three and a half months.
The pharmacy relied heavily on non-governmental organisations (NGOs) for its supply of pharmaceuticals. Up until recently, the hospital had been managed and funded by the UK Department for International Development (DFID). DFID had in turn funded Pharmaciens Sans Frontieres (PSF) - an NGO - to supply drugs to the hospital pharmacy. Mr Azizi told me that since April this year nobody had been officially supplying his department and that donations were starting to diminish.
One of Mr Azizi's main roles as head pharmacist is to liaise with NGOs and to arrange for appropriate drugs to be donated. However, inappropriate drug donations sometimes arrive at the hospital and the pharmacy floor was covered in boxes of poorly packed and leaking medicines. The disposal of these unwanted drug donations creates a lot of work for the pharmacy staff. The more established NGOs, such as PSF and Project HOPE, supply a list from which Mr Azizi is able to select the drugs required. This ensures that drugs are not wasted and that pharmaceuticals are targeted appropriately. Occasionally, the RAMC and other KFOR medical units supply the hospital with a particular drug that is needed in an emergency. At the time of my visit the hospital did not have a supply of fentanyl, so all operations had been put on hold until some was donated. During my discussions with Mr Azizi, Major Richard Gale, the commanding officer of the UK medical squadron in Kosovo, offered to arrange for an interim supply.
Security for Serbians
In Kosovo there is currently no emergency ambulance service for civilians, so patients requiring medical treatment have had to rely on transporting themselves between primary health care centres called "ambulantas" and hospitals.
Since the conflict ended and Kosovar Albanians started to return to their villages, many Serbs have become increasingly isolated and feel threatened when they travel through Albanian areas. This has created enormous problems for Serbs seeking medical treatment.
To address this problem, "Operation Trojan" was initiated by UNMIK and KFOR to create a "Serb confidence zone" around what is known as the "Serb Crescent" (an area of Kosovo encompassing the Serbian dominated municipalities of Lipjan, Obilic and Kosovo Polje). By supplying food, improving roads and providing security and medical support to the Serbian communities within the crescent it is hoped that this feeling of Serbian isolation will disappear.
Talking to our Kosovar Albanian interpreter, I began to understand some of the human suffering in the province. We picked him up early in the morning ready for our visit to Privstina hospital.
He told me that before the conflict he had owned a bookshop in a town in the south-east of Kosovo. The bookshop had been destroyed so to support himself and his family he had come to Privstina to find work. Having taught himself English from the books in his store he was able to work as an interpreter for the military. As the only working member of his family, he supported 10 people on a sporadic wage.
As we entered a pathology laboratory at the hospital, a pungent smell hit us. Our interpreter could not bear it and waited for us outside. The technicians in the laboratory had been performing an autopsy on a body dug from one of the many mass graves that are dotted around Kosovo. Later, I learnt that for our interpreter the smell had brought back many sad memories.
At the height of the conflict he and his family had been driven from their town by a lack of food and by the threat of Serbian aggression. Many of the town's 6000 Kosovar Albanian inhabitants had walked for over 30 hours to reach the relative safety of Macedonia. In Macedonia they had found food and shelter with relatives or at refugee camps. Our interpreter's uncle had refused to leave the town and had stayed to care for the old and infirm who could not manage the long walk over the border. When they eventually returned, the town was deserted and they were confronted with a mass grave of more than 70 bodies. One of the bodies, identified only by its clothes, was his uncle.
The conflict in Kosovo is still very real. Freshly laid mines are discovered daily and injuries inevitably result. Earlier this month three Kosovo gypsies were killed and another injured by a mortar bomb planted on their property in Malialas, 18 miles from Privstina.
Harriet Adcock is on the staff of The Journal
Citation: The Pharmaceutical Journal