<http://www.iht.com/> International Herald Tribune
Could Milosevic's death have been averted?
By Elisabeth Rosenthal International Herald Tribune
SUNDAY, JUNE 4, 2006
<http://www.iht.com/cgi-bin/search.cgi?query=&sort=swishrank> As Slobodan Milosevic's family and the United Nations war crimes tribunal in The Hague spar over whether his death in prison on March 11 was avoidable, a slew of medical information released in the past week has provided new details about the former Yugoslav leader's demise, his medical ailments and his stormy relationship with his court-appointed doctors.
The Milosevic family contends that his medical treatment in detention was inadequate. The court, in an internal review released last week, concluded that its doctors had delivered "proper care," and that Milosevic was an uncooperative patient.
But the new medical facts suggest that there were a number of times when either Milosevic or the court could have done things differently, possibly altering the course of his illness.
Much of the court's inquiry that was released last week documents a turbulent, distrustful relationship between Milosevic and the detention center's officials, which almost certainly affected his care.
He sometimes refused to take pills, or took doses dictated by doctors consulted by telephone. Visitors sometimes brought unapproved medicines and alcohol into his cell.
The inquiry accuses him of secretly taking Rifampicin, a tuberculosis drug that would have blunted the effect of his blood pressure drug and made it hard to control. The drug was found in a screening blood test in January. Milosevic denied taking Rifampicin and said that someone was trying to kill him.
On the last day of Milosevic's life, prison guards who unlocked his cell decided not to examine him when he failed to move or respond to their greeting. Ironically, given his medical problems, they decided he needed rest.
An hour later, when he still had not moved, they noticed his gray color. Milosevic's autopsy, conducted by a Dutch coroner, estimated the time of death at between 7 a.m. and 9 a.m. Could he have been alive, or revivable during the guard's first visit?
The court and Milosevic spent the months before his death wrangling over where he should get a cardiac work-up, which never happened. Milosevic refused hospitalization for important cardiac testing on at least one and possibly more occasions.
"If he had been in a monitored setting on March 11, he certainly wouldn't have died," said Patrick Barriott, a French doctor and longtime friend of Milosevic.
Twice in the past six months, Milosevic petitioned the court to be sent for urgent treatment in Moscow - he refused to be treated in a NATO country. The last petition was on March 2.
Noting that the tests could be performed in the Netherlands, the court rejected the first petition. An appeal was pending when he died.
In its internal review, the International War Crimes Tribunal said: "In these circumstances it cannot be concluded that there was a failure to provide proper care."
Still, the report acknowledged that some of the detention center's systems for monitoring Milosevic's health were inadequate and that some prominent doctors believed that additional tests and procedures should have been performed - measures that could have been lifesaving.
René Tavernier, a cardiologist from Belgium who reviewed the case at the behest of the court, concluded: "There is no test that if carried out would have helped detect or prevent the cause of death."
But on April 5, a Russian cardiac surgeon, Leo Bockeria, wrote to the court that Milosevic "could have been treated easily at any place of the world" with a minimally invasive procedure in which a tube is used to open an artery.
In either case, it is clear from the documents that Milosevic was a sometimes difficult patient who defied doctors orders.
Zdravko Mijailovic, who treated Milosevic at the Military Hospital in Belgrade in 2001, said that important studies had never been completed, because of the patient's "lack of motivation."
>From studies conducted around that time, Milosevic was known to have serious high blood pressure and a thickened heart wall - the result of years of hypertension. He was on a slew of medicines.
All doctors agree that Milosevic was at high risk for stroke, heart attack or fatal heart rhythm. What is less certain is whether his death on March 11, at that particular moment, was inevitable. But little is known about the progression of Milosevic's heart disease during his time in the detention center.
In 2002, Milosevic refused the recommendation of a Dutch cardiologist that he be hospitalized for a cardiac work-up. In 2004, a Russian doctor who he had called to examine him made a similar recommendation, although Milosevic and his lawyer never disclosed that to the court.
In November, a French cardiologist hired by Milosevic, Florence Leclercq, again recommended immediate heart testing, particularly a scan called scintigraphy. She was surprised, she said, that it had not already been performed.
Shortly thereafter, Milosevic requested temporary release for a work-up in Moscow. That plea was rejected and there was no effort made to schedule it elsewhere, in part because the court- appointed cardiologist believed that new testing was not urgent.
"Mr. Milosevic wanted full medical treatment in Russia because they started to control his health from the start," said Milosevic's lawyer, Zdenko Tomanovic, noting that he had frequently consulted Russian doctors by phone. "He did not want medical treatment in a country that was a member of NATO. The charges against him stem from the NATO conflict."
Doctors disagree about whether those tests would have changed anything.
An independent autopsy by the Dutch government showed that one of Milosevic's main coronary arteries was 50 percent narrowed - not generally enough to cause a heart attack in itself. At the same time, he had a severely thickened heart, with an unusual structure called myocardial bridge, where a coronary artery plunges into the heart's muscle rather than lying on its surface.
The significance and proper treatment of such bridges is controversial, according to the medical literature, since many produce no symptoms or problems. But some, especially in combination with other heart disease, can precipitate chest pain, abnormal rhythms and heart attacks.
Such bridges are sometimes treated by placing a stent in the narrowed artery to hold it open. Since Milosevic did not undergo a full cardiac work-up for years before his death, it is impossible to have a good sense of whether he would have been a candidate for the procedure.
Marlise Simons of The New York Times contributed reporting for this article.
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