Semir Beslija’s tenacious efforts have built the Sarajevo Oncology Institute from zero’ at the end of the war, to the regional centre of excellence and trusted trials centre it is today.
The taxi driver who is weaving through the Sarajevo rush-hour traffic speaks good English. He wants to know why an Englishman like me wants to go to the Clinical Centre of Sarajevo University – the city’s main hospital on a hill on the edges of the city. I tell him I’m going to interview Semir Beslija, head of the medical oncology department. He’s an important man, I tell him.
“Yes, I know,” he says. “You’re not going to take him away to London are you?”
It’s a familiar story to my taxi driver. The high flyers, many newly qualified doctors, all look outside Bosnia Herzegovina to higher salaries in Austria, Italy or beyond. He too wants to escape Sarajevo, a city not just struggling with the legacy of a horrible war, but now in the grip of economic recession. He likes the look of Barcelona: “It’s too dark here,” he says.
But there’s no danger that Semir Beslija will leave. The Institute of Oncology at the Clinical Centre is, along with his family, what gives his life meaning. He worked at the Clinical Centre as a junior doctor throughout the siege of Sarajevo between 1992 and 1995, providing care without electricity, heat and running water, as shells burst around the damaged building. And during that time, he pledged to himself that he would help rebuild the institute and bring to it a state-of-the-art clinical oncology department.
Now, 20 years later, he has. Watching Beslija march confidently down the cool corridors of the well-equipped centre, greeted by everyone he meets, shaking hands, offering advice, he has the aura of a proud business owner. Before the war the Clinical Centre could treat just a few hundred cancer patients a year with radiotherapy and surgery alone. Today it has a comprehensive cancer centre – the only one in Bosnia Herzegovina – with a multidisciplinary approach to cancer diagnosis and care, a new breast unit, and a proud record of undergraduate and postgraduate teaching.
When Beslija started the medical oncology department in 1998, he was the only doctor, with two beds. Now he has 11 doctors and 62 beds, housed in brand new buildings opened two years ago. He shows me the outpatients department, bedecked in brilliant tangerine and blue, capable of accommodating around 100 chemotherapy patients a day; an MRI scanning suite, with three brand new machines; upstairs, a newly opened unit for participants in phase I clinical trials – the first in the region.
This is not just another regional success story. Semir Beslija, now 47, has put Sarajevo on the international cancer map. Three months ago, he tells me, a delegation of leading doctors from Gothenburg in Sweden visited the Sarajevo Clinical Centre to see if there was any assistance they could offer. The director of the Centre sent them to spend the afternoon in Beslija’s clinical oncology department. Later, the Swedish professor reported back to the director and joked: “There must be some sort of misunderstanding. We aren’t able to help that young man in charge of clinical oncology: we need help from him.”
“I am very proud,” he tells me. “We are not witnesses in the revolution in oncology. We are the actors here in Sarajevo.”
Perhaps most importantly, Sarajevo is a valued participant in international trials. “In the Department of Medical Oncology, we are currently running 16 global randomised controlled trials. In HER2-driven breast cancer, we have six molecules under investigation in my institution – probably one of the few centres in Europe to be doing this. You know what it means to have it in Sarajevo? You wouldn’t believe. Because we started from zero.”
The cancer success story in Sarajevo is all the more remarkable because of its grim background. Beslija, like most inhabitants, wants Sarajevo to be characterised by the present, not the past. The war has become like a millstone round the city’s neck, defining it and dragging it back. But he also acknowledges that it is etched into the consciousness of every citizen.
The war has become like a millstone round the city’s neck, defining it and dragging it back
Even to the casual tourist, it is omnipresent in the bullet holes that pockmark the city brickwork, and the gleaming graveyards that astound you in parks, on street corners, and down the hillsides. Over the three and a half year siege of Sarajevo, the city was cut off from the world, with no power, food or water. Around 12,000 residents were killed in the fighting and bombardment.
“Only those who were here can understand what happened in the war,” he says. “I could talk to you about the war for a year, but I am not sure you would come one micron closer to understanding it.”
Though Beslija would like the story to begin after the war, in truth it began in 1991 when he decided that he wanted to become the first ever medical oncologist in Bosnia. Born and bred in Sarajevo, his father an agricultural engineer, he had decided at the age of seven that he would be a doctor – “I always knew”. Having graduated in medicine at its medical school in 1988, Beslija specialised in internal medicine at the Clinical Centre of Sarajevo University. He initially wanted to head into gynaecology – inspired by his uncle who followed the same profession. But jobs were hard to find, so he began to investigate opportunities in the oncology department.
Everyone thought he was mad: one of the most promising young doctors in the country looking for a job in the clinic with the lowest profile in the Sarajevo Clinical Centre? The cancer clinics had just five doctors, and their most sophisticated piece of equipment was a cobalt radiotherapy machine. Most Sarajevo cancer patients travelled to Belgrade (in modern Serbia), Zagreb (in modern Croatia) and Ljubljana (in modern Slovenia). But Beslija was enthused by the exciting new specialty of medical oncology, and wanted to change things.
Then the war started. Beslija joined the Bosnian army as a medical officer. As bullets and bombs rained down on Sarajevo, he started to live a strange divided life. By day, he was trying to get his education in internal medicine and do his best for patients with cancer. By night he was out in the field, tending to wounded and dying soldiers.
“It was not an easy job,” he says, avoiding the details. “It was unbelievably hard turning from people who were actually dying there and then, to people with cancer. Because it was two totally different kinds of approaches. It was very hard to think about oncology during the war. We didn’t have drugs, we didn’t have electricity for radiotherapy, so perhaps the greatest part of our activity for cancer patients was…” He is lost for the word. “…Empathy.”
“But working in the Clinical Centre was important to us, because it was some sort of connection with the previous life. It kept alive the hope that some day oncology will once more become important.”
“Every day I was dreaming that eventually I would go abroad, finish my education and start the medical oncology department here. The war was hugely motivating. Those four years are probably the period of my life I am most proud of.”
I ask him why. He replies simply: “Because I stayed.”
The fact is that within months of the siege starting, half of the Clinical Centre staff left Sarajevo – fleeing with their families while they could. A skeleton staff, including Beslija and Hiba Basic, then head of the hospital’s Department of Radiation Oncology, did what little they could for the cancer patients, and deep bonds developed between them all. Basic (see Cancer World Nov–Dec 2010) died late last year, and Beslija admits to missing her terribly.
Beslija met his wife Narcisa in the dermatology department of the Clinical Centre during the siege. She was another young doctor, later to become a psychiatrist, and Beslija remembers how astounded he was by her long black hair: “because we had no water, I couldn’t believe how she kept it looking so beautiful.” They married on a glorious April day in 1995: “It was a beautiful war wedding, with the grenades coming down. We were worried about the safety of our guests, but everything was fine.”
“After the experiences my wife and I had during the war, everything else in life becomes one million times easier. If you can find the best solution for you and your family in war, after that the sky’s the limit. And because of that, war is an important part of all people here. War changes everything because you just have one priority, to stay alive, and you learn that everything else is… nothing.”
On his office wall, there are pictures of Beslija shortly after the war ended. He is a thin, gaunt young man with a beard, unrecognisable from the buoyant and muscular doctor squeezed into a white coat who sits at the desk in front of me.
After the war ended in 1995, the couple moved to Slovenia so that, with the help of an ESMO scholarship, he could continue his training at the Institute of Oncology in Ljubljana (his wife gave up a well-paid job with an American non-governmental organisation so that he could do so). In the course of his placement there, he also became a visiting doctor in Milan, at the European Institute of Oncology, and spent three months at the MD Anderson Cancer Center in Houston, Texas, as a guest scholar.
He returned to the Clinical Centre of Sarajevo University in 1998 and took the position of medical oncologist. Then he set about the task of creating a working department, organising the unit for out-patient chemotherapy, forging links with other institutions internationally, finding investment for new equipment, and creating a modern teaching space for students and residents.
Over 15 years, his most important priority has always been to surround himself with the right people. In creating a new service from scratch, choosing the right personnel has been far more important than equipment, drugs or advanced technology, he says.
“This is a lesson from the war,” says Beslija, whose work as Associate Professor at Sarajevo Medical School has helped him find the right people. “My main rule has always been that I choose doctors personally: I count on their behaviour, their humanism and the qualities they bring from home. When you have young people like this, it is very easy to make them into excellent medical oncologists.” Interestingly, most of the doctors he appoints are themselves children of doctors.
All of Beslija’s medical oncologists are from Sarajevo, and all have stayed with him since their appointment – a rather different picture from the gloomy one painted by the taxi driver. What keeps them working in their home country despite higher pay elsewhere, he says, are the excellent working relations and honesty in the department. Plus the fact that all doctors have excellent opportunities for exchange and continuing education in oncology centres in Europe and the United States – the result of Beslija’s networking efforts. “In medicine, you always have to give people some sort of challenge, to fulfil their expectations,” he says.
But despite Beslija’s emphasis on the importance of his staff, you can’t get away from the fact that his department is founded on his persistence, intelligence and force of personality. At first sight he looks serious, intimidating even, but he has a power to engage with his passion and his honesty about his achievements. His words persistently reveal glimpses of a conviction about the underlying value of soul, empathy and humanity – perhaps most of all about the value of human life.
This has stood him in good stead in his national and international engagements to try and gain funding and make Bosnia part of the international cancer community. In 2010 he covered 300,000 miles as he attended meetings around the world. He has to be a good politician, he acknowledges, as well as a good manager and a good doctor.
Over the past ten years, Beslija and his counterpart in the radiation oncology department, Nermina Obralic, have built the reputation of cancer services at the Clinical Centre, and as a result have attracted funding from local and national government, the World Bank and European funding agencies. This has allowed investment in new buildings, beds and equipment. Around 90% of the buildings and infrastructure of the Institute of Oncology is less than five years old.
They have linked with organisations such as the European School of Oncology, which supported the education of many doctors and nurses at the centre, and helped it set up international conferences in Sarajevo such as the international Interconference Breast Cancer Meeting, held every two years. Beslija joined societies such as ASCO and ESMO (he is currently national representative for Bosnia Herzegovina).
Perhaps most importantly, Beslija managed to overcome negative perceptions about the abilities and facilities of oncologists in the region so that they could become involved in international trials. This meant that the department had new sources of income; that patients had access to new treatments which otherwise would be too expensive; and that doctors were less liable to burn out because they were not faced with the frustration of not having the right treatments available.
This only became possible because, 15 years ago, Christoph Zielinski, director of the Division of Oncology at the University of Vienna, Austria, took at leap of faith. Beslija made a point of meeting him at a cancer conference in Europe, to tell him about his vision for Sarajevo. Zielinski asked him to be involved in a trial of a medicine for metastatic breast cancer. It involved 90 women and Beslija conducted it by himself, every day after his clinic finished at 4pm. He was working a 20-hour day for one and a half years.
“The trial was later published in the Journal of Clinical Oncology. Can you imagine my pride, six years after the end of the war, the name of my institution in the best oncology journal? It was amazing. Now people knew about Sarajevo because of oncology, not because of the war, or the First World War, or the Winter Olympics. I will be grateful to Professor Zielinski all my life. After that, everything became easier, because the door was open.”
Can you imagine my pride, six years after the end of the war, the name of my institution in the best oncology journal?
The centre has now become a regional centre of excellence for clinical oncology trials and is in a position to refuse around 35% of trial offers. Two of the young doctors in Beslija’s team already have 10 years’ experience as principal investigators. Today, around a fifth of patients are involved in trials – most of them in Beslija’s main interest areas of breast and gastrointestinal cancers. “That is unbelievable, because I still believe strongly that the best possible way to treat a patient is participation in a good randomised controlled trial.”
“To be part of the global story like this is 100 times harder for Sarajevo than Munich, or Milan. You have to be 100 times better to meet expectations from sponsors. We have been.”
Sarajevo’s breakthrough is now being reflected elsewhere in the region. Beslija is on the scientific board of the Central European Cooperative Oncology Group, formed in 1999 to bring together centres of clinical oncology from central and southeastern Europe so that they can design and conduct clinical trials to the highest standards. Professor Zielinski is President.
“I think these regional collaborative groups are showing the Western world that there’s great activity and great potential in the region,” says Beslija. “Through publishing articles, through announcements at European conferences, at ASCO and so on.”
Beslija points to the increasing international profile of oncologists such as Tanja Èufer (from Slovenia – see also Cancer World May–June 2007), Eduard Vrdoljak (Croatia) and Alexandru Eniu (Romania) as indications that the cancer community in Eastern Europe is becoming less marginalised. “If you have excellent people, who are part of important oncological associations, and who are breaking borders, things that look impossible can be done. We are witnessing that strongly in this region, and I have to say that I have a lot of patients who were on treatment in Paris and Munich, and come back here, and the treatment is just as good.”
But the picture is not all rosy. Ask Beslija about the biggest challenge that he and his Eastern European colleagues in oncology face, and the answer is still prejudice. “The first association that many oncologists in the Western world have about Sarajevo is the war – the bad,” he says.
He tells me that his grandfather was a priest in the Bosnian part of the Austro-Hungarian Empire army (Bosnia Herzegovina was occupied and then annexed by the Austro-Hungarian Empire between 1878 and 1918). He could travel without restriction to Vienna without any problems, as could every Sarajevo inhabitant 100 years ago. Yet after the war in the 1990s, the European Union imposed visa restrictions on Bosnian travellers, which clearly angers Beslija, who feels that he and professional colleagues are stigmatised by having to stand in queues at airports for hours when lecturing in other countries.
“I remember that when we held our Breast Cancer Conference here in 2005, we had oncologists from Western Europe who didn’t want to come. They didn’t feel safe. And still sometimes, when you say you come from Sarajevo, they look sorry for you.”
“But it also gives me a little push, and makes me all the more determined to show how good the people here are. It is becoming better. You cannot find something of any significance in oncology now without names from this part of Europe, which was not the case ten years ago. Hopefully, at the end of the day, quality will be recognised.”
“It gives me a little push, and makes me all the more determined to show how good the people here are”
Beslija insists his main motivation is not proving a point about his country: it is giving the best possible oncology care to his people. “They deserve it,” he says. With five chemotherapy and radiotherapy centres elsewhere in the country, and a clinical oncology department now established in Banja Luka, the ripples of quality are spreading nationally.
Still working 16 hours a day, Beslija insists he enjoys every minute of life. Somewhere he finds the time to cook at home, to enjoy wine, to ski – most importantly of all, to spend time with his family. He clearly dotes on his daughter Majda – born when he was in Ljubljana nearly 17 years ago – who has a passion for horses, he says, which exceeds his own for oncology. She wants to go into equine medicine.
But he is contemplating a change. This year he has been officially appointed director of the Institute of Oncology and, with a remit for radiotherapy, surgery and pathology as well as clinical oncology, he plans to spend the next two years improving coordination between the centre’s 43 clinics and engaging national and international support so that the centre can develop even further.
“I will have to be even more of a politician now,” he says.
But when he is 50, he adds, he will slow down, and commit himself wholly to clinical investigation. No one has infinite supplies of energy. As Beslija finishes his guided tour of the Institute, he gives an indication of the emotional as well as the physical investment he has made as we pause at an upstairs window with a panoramic view of Sarajevo. It looks glorious in the Spring sunshine, nestled beneath the wooded mountains from which it was once bombarded.
“I am so proud,” he says, reflecting on the thriving facilities we have just seen. “It is like building your own home, brick by brick.” Then he points out a tower block below, still scarred by a massive star-shaped hole from a shell which hit it two decades ago. “You see that?” he says. “These are reminders.” Then he taps his head. “But they are always in here too.”