A ruse or poisoning?
Medical mystery swirls around Milosevic
By Elisabeth Rosenthal and Marlise Simons International Herald Tribune
THURSDAY, MARCH 16, 2006
Was Slobodan Milosevic a normal 64-year-old with manageable medical problems - from high blood pressure to hearing loss - that he manipulated and exaggerated in an attempt to gain his freedom? Or was Milosevic, as his supporters claim, perilously ill, in need of urgent medical evacuation from his detention center, mistreated by prison doctors and perhaps poisoned as well?
For months before his death last weekend, Milosevic and the United Nations war crimes tribunal in The Hague had been sparring over the state of his health. His passing prematurely ended a war crimes trial that had dragged on over four years, but only deepened the medical mystery that was evolving as he lived.
Preliminary autopsy results found that Milosevic had died of a heart attack, although doctors who examined him just months ago did not feel he had significant heart disease. Likewise, blood work before he died detected the presence of a medicine he had not been prescribed, one that would have put him at grave risk by reducing the effectiveness of his blood pressure pills.
Court officials and some scientists have been quick to insinuate that Milosevic was secretly ingesting the extra medicine to exacerbate his medical problems so that he could be transferred to a clinic in Moscow, where his family now lives.
But some confidants, including doctors who spoke to Milosevic in his last weeks of life, said he was alarmed by his poor health and feared prison doctors, as well as Dutch specialist consultants. were providing inadequate treatment.
In any event, several doctors who recently examined Milosevic concluded that the tribunal, in its skepticism about his litany of ailments, at times failed adequately to investigate them.
"His medical condition was not good, so we asked for additional tests to evaluate his cardiac situation," said Dr. Florence Leclercq, a prominent French cardiologist who examined Milosevic for about three hours last November.
"But these investigations were never performed and now that's a problem."
Dr. Patrick Barriot, another French physician who visited Milosevic frequently - last in December - said the former Serbian leader was suffering from increasingly severe high blood pressure in the six months before his death, with symptoms including headaches, visual changes and a constant thrumming noise in his ears.
The pressure routinely read 180/110, the physician said, well above safe limits.
"Each time I saw him, he was clearly deteriorating, more and more tired," said Barriot, who came to know Milosevic when stationed in the former Yugoslavia, and who testified as a defense witness.
Although long-term high blood pressure strains the heart and increases the risk of heart attack, Milosevic did not have any classic symptoms of heart disease, such as chest pain, Leclercq said.
When she heard the autopsy verdict of heart attack, she was surprised.
Attempts to make sense of Milosevic's death are hampered by the fact that reams of medical exams, a list of the medicines he was taking and details of the autopsy are regarded as confidential by the court.
Doctors permitted to see him, or medical records, said they had to sign promises not to divulge details. A toxicology report is expected later this week.
What is clear is that recently Miloevic's blood pressure, a problem since the start of his trial, had became increasingly difficult to control, and prison doctors long suspected him of not taking his medicine, said Donald Uges, one of two Dutch toxicologists consulted on the case.
After several weeks of sleuthing, the toxicologists recently determined instead that he had ingested the antibiotic rifampicin, which would blunt the effect of his blood pressure medicine. Uges, as well as tribunal officials speaking on the condition of anonymity, suggested that the antibiotic was taken intentionally, smuggled in by visitors.
But Barriot dismissed the charge, saying that Milosevic had called him several times recently, "very anxious about his blood pressure" and whether detention-center guards were giving him the right medicine - a worry he brought up in court as well.
"He had no confidence in the drugs or the treatments that were given him in jail," Barriot said.
Leclercq said that when she examined Milosevic last Nov. 4 with two other physicians, "his cardiac situation was extremely difficult to evaluate."
Prison officials assured her that some cardiac tests, like an ultrasound, had been done and were "normal" but could not show her the actual test results, leaving her to conclude that more was needed, she said from her clinic at the Hôpital Arnaud de Villeneuve, in Montpellier, France.
"What was shocking was that in four years lots of tests and exams on his heart had never been done," said Dr. Vukasin Andric, a Serbian physician who also examined that day, noting that Milosevic had had thorough evaluations of organs.
Alexandra Milenov, a spokesperson for the tribunal, said Milosevic had been examined repeatedly by prison doctors and independent specialists, including cardiologists, and that medicine had to be taken under supervision, though in court papers doctors complained that they could not properly monitor Milosevic's medicine intake because of his relatively unen- cumbered access to visitors.
Carla Del Ponte, the chief prosecutor, said she knew Milosevic was ill and had a dossier of about 150 medical reports from various doctors concerning his case.
"If there was one person who was not overlooked it was Milosevic," she said.
Since Milosevic arrived in The Hague in 2001, neither side trusted the other's medical opinions, and debates about his health often eclipsed testimony.
Last Nov. 15, when Milosevic repeatedly interrupted trial proceedings with attempts to discuss a medical report, judges cut him short:
Judge Patrick Robinson: I do not wish to have it discussed now. Are you deaf? Call your next witness.
Milosevic: I probably am deaf.
Judge Robinson: Well if you are, we'll see about that. Call the next witness.
Last fall, because of concerns about his declining health - notably the severe phantom noise in his ears - Milosevic requested a consultation by the outside doctors, a review that Barriot helped to arrange. The experts included Leclercq, Dr. Margarita Shumilina, a Russian vascular specialist, and Dr. Vukasin Andric, an ear specialist.
Shumulina and Andric concluded that Milosevic's hearing problems were "symptoms of disordered brain circulation because of hypertension," according to a confidential report, part of which was read to a reporter.
In practical terms, the team suggested a six-week break in the trial to "reduce or at least stabilize" symptoms - an idea met with skepticism on the court, whose own experts had concluded that the hearing problems were not indicative of serious vascular problems, and that rest would have no effect.
After more than four years of proceedings, the judges were also under some pressure to bring the trial to an end.
Judge Iain Bonomy, in a scathing dissent, noted that the whole consultation was highly suspect because of political ties between Andric and Milosevic. Andric, who had practiced in Kosovo, was a defense witness at Milosevic's trial for war crimes, asserting that Muslim children in Kosovo had pretended to have been poisoned by Serbian troops.
On the day last December the court was to adjourn for a Christmas holiday break, Milosevic upped the ante, requesting permission to fly to Moscow for treatment, which was denied.
By January his blood pressure readings became increasingly erratic, with levels as high as 260/180, Andric has said in the Serbian press. Irate at charges that he had not been taking his medicine, Milosevic agreed to an examination in the prison infirmary, remaining under observation for hours after taking his pills.
"The test established that when I take medication under control, the level of that medication in my blood is far below the expected level," he told the court.
Ironically, it was in part that exercise that led prison doctors to suspect foul play, perhaps by Milosevic, Uges said.
Was there some substance that would nullify the blood pressure medicines?
"We realized that the only thing that could do this was rifampicin," he said. A blood sample was found to contain the compound.
Used commonly to treat tuberculosis, rifampicin is known to reduce the effect of other medicines, from oral contraceptives to blood pressure pills, by stimulating liver enzymes that break down a host of drugs.
But how did rifampicin get into his blood: Was Milosevic intentionally taking it? Or was someone with access to the prison trying to poison him, a charge his supporters and family make?
The drug is common in prison pharmacies in Russia and the United States, where tuberculosis is relatively common, but TB is rare in the Netherlands. Milenov could not say if rifampicin was stocked in the detention center.
In any event, some experts said rifampicin itself was unlikely to explain Milosevic's death, since he did not die of a stroke, a far more common problem with high blood pressure.
Also, its effects on blood pressure "could have simply been counteracted by increasing the dose of President Milosevic's medicine," as is commonly required in patients on rifampicin, said Joris Delanghe, a physician and toxicologist at the University of Ghent.
Skeptics point out that rifampicin is a difficult substance for anyone to use surreptitiously, since its effects are variable and it turns the urine red. And this 64-year-old with a history of smoking and high blood pressure may well have had undetected heart disease, doctors said.
"Refractory hypertension exists and some patients are hard to treat," Delanghe said. He added that for Milosevic, the mental stress of being imprisoned must have been "a major cardiovascular risk factor in itself."
Elisabeth Rosenthal reported for the International Herald Tribune, and Marlise Simons for The New York Times.
Was Slobodan Milosevic a normal 64-year-old with manageable medical problems - from high blood pressure to hearing loss - that he manipulated and exaggerated in an attempt to gain his freedom? Or was Milosevic, as his supporters claim, perilously ill, in need of urgent medical evacuation from his detention center, mistreated by prison doctors and perhaps poisoned as well?
For months before his death last weekend, Milosevic and the United Nations war crimes tribunal in The Hague had been sparring over the state of his health. His passing prematurely ended a war crimes trial that had dragged on over four years, but only deepened the medical mystery that was evolving as he lived.
Preliminary autopsy results found that Milosevic had died of a heart attack, although doctors who examined him just months ago did not feel he had significant heart disease. Likewise, blood work before he died detected the presence of a medicine he had not been prescribed, one that would have put him at grave risk by reducing the effectiveness of his blood pressure pills.
Court officials and some scientists have been quick to insinuate that Milosevic was secretly ingesting the extra medicine to exacerbate his medical problems so that he could be transferred to a clinic in Moscow, where his family now lives.
But some confidants, including doctors who spoke to Milosevic in his last weeks of life, said he was alarmed by his poor health and feared prison doctors, as well as Dutch specialist consultants. were providing inadequate treatment.
In any event, several doctors who recently examined Milosevic concluded that the tribunal, in its skepticism about his litany of ailments, at times failed adequately to investigate them.
"His medical condition was not good, so we asked for additional tests to evaluate his cardiac situation," said Dr. Florence Leclercq, a prominent French cardiologist who examined Milosevic for about three hours last November.
"But these investigations were never performed and now that's a problem."
Dr. Patrick Barriot, another French physician who visited Milosevic frequently - last in December - said the former Serbian leader was suffering from increasingly severe high blood pressure in the six months before his death, with symptoms including headaches, visual changes and a constant thrumming noise in his ears.
The pressure routinely read 180/110, the physician said, well above safe limits.
"Each time I saw him, he was clearly deteriorating, more and more tired," said Barriot, who came to know Milosevic when stationed in the former Yugoslavia, and who testified as a defense witness.
Although long-term high blood pressure strains the heart and increases the risk of heart attack, Milosevic did not have any classic symptoms of heart disease, such as chest pain, Leclercq said.
When she heard the autopsy verdict of heart attack, she was surprised.
Attempts to make sense of Milosevic's death are hampered by the fact that reams of medical exams, a list of the medicines he was taking and details of the autopsy are regarded as confidential by the court.
Doctors permitted to see him, or medical records, said they had to sign promises not to divulge details. A toxicology report is expected later this week.
What is clear is that recently Miloevic's blood pressure, a problem since the start of his trial, had became increasingly difficult to control, and prison doctors long suspected him of not taking his medicine, said Donald Uges, one of two Dutch toxicologists consulted on the case.
After several weeks of sleuthing, the toxicologists recently determined instead that he had ingested the antibiotic rifampicin, which would blunt the effect of his blood pressure medicine. Uges, as well as tribunal officials speaking on the condition of anonymity, suggested that the antibiotic was taken intentionally, smuggled in by visitors.
But Barriot dismissed the charge, saying that Milosevic had called him several times recently, "very anxious about his blood pressure" and whether detention-center guards were giving him the right medicine - a worry he brought up in court as well.
"He had no confidence in the drugs or the treatments that were given him in jail," Barriot said.
Leclercq said that when she examined Milosevic last Nov. 4 with two other physicians, "his cardiac situation was extremely difficult to evaluate."
Prison officials assured her that some cardiac tests, like an ultrasound, had been done and were "normal" but could not show her the actual test results, leaving her to conclude that more was needed, she said from her clinic at the Hôpital Arnaud de Villeneuve, in Montpellier, France.
"What was shocking was that in four years lots of tests and exams on his heart had never been done," said Dr. Vukasin Andric, a Serbian physician who also examined that day, noting that Milosevic had had thorough evaluations of organs.
Alexandra Milenov, a spokesperson for the tribunal, said Milosevic had been examined repeatedly by prison doctors and independent specialists, including cardiologists, and that medicine had to be taken under supervision, though in court papers doctors complained that they could not properly monitor Milosevic's medicine intake because of his relatively unen- cumbered access to visitors.
Carla Del Ponte, the chief prosecutor, said she knew Milosevic was ill and had a dossier of about 150 medical reports from various doctors concerning his case.
"If there was one person who was not overlooked it was Milosevic," she said.
Since Milosevic arrived in The Hague in 2001, neither side trusted the other's medical opinions, and debates about his health often eclipsed testimony.
Last Nov. 15, when Milosevic repeatedly interrupted trial proceedings with attempts to discuss a medical report, judges cut him short:
Judge Patrick Robinson: I do not wish to have it discussed now. Are you deaf? Call your next witness.
Milosevic: I probably am deaf.
Judge Robinson: Well if you are, we'll see about that. Call the next witness.
Last fall, because of concerns about his declining health - notably the severe phantom noise in his ears - Milosevic requested a consultation by the outside doctors, a review that Barriot helped to arrange. The experts included Leclercq, Dr. Margarita Shumilina, a Russian vascular specialist, and Dr. Vukasin Andric, an ear specialist.
Shumulina and Andric concluded that Milosevic's hearing problems were "symptoms of disordered brain circulation because of hypertension," according to a confidential report, part of which was read to a reporter.
In practical terms, the team suggested a six-week break in the trial to "reduce or at least stabilize" symptoms - an idea met with skepticism on the court, whose own experts had concluded that the hearing problems were not indicative of serious vascular problems, and that rest would have no effect.
After more than four years of proceedings, the judges were also under some pressure to bring the trial to an end.
Judge Iain Bonomy, in a scathing dissent, noted that the whole consultation was highly suspect because of political ties between Andric and Milosevic. Andric, who had practiced in Kosovo, was a defense witness at Milosevic's trial for war crimes, asserting that Muslim children in Kosovo had pretended to have been poisoned by Serbian troops.
On the day last December the court was to adjourn for a Christmas holiday break, Milosevic upped the ante, requesting permission to fly to Moscow for treatment, which was denied.
By January his blood pressure readings became increasingly erratic, with levels as high as 260/180, Andric has said in the Serbian press. Irate at charges that he had not been taking his medicine, Milosevic agreed to an examination in the prison infirmary, remaining under observation for hours after taking his pills.
"The test established that when I take medication under control, the level of that medication in my blood is far below the expected level," he told the court.
Ironically, it was in part that exercise that led prison doctors to suspect foul play, perhaps by Milosevic, Uges said.
Was there some substance that would nullify the blood pressure medicines?
"We realized that the only thing that could do this was rifampicin," he said. A blood sample was found to contain the compound.
Used commonly to treat tuberculosis, rifampicin is known to reduce the effect of other medicines, from oral contraceptives to blood pressure pills, by stimulating liver enzymes that break down a host of drugs.
But how did rifampicin get into his blood: Was Milosevic intentionally taking it? Or was someone with access to the prison trying to poison him, a charge his supporters and family make?
The drug is common in prison pharmacies in Russia and the United States, where tuberculosis is relatively common, but TB is rare in the Netherlands. Milenov could not say if rifampicin was stocked in the detention center.
In any event, some experts said rifampicin itself was unlikely to explain Milosevic's death, since he did not die of a stroke, a far more common problem with high blood pressure.
Also, its effects on blood pressure "could have simply been counteracted by increasing the dose of President Milosevic's medicine," as is commonly required in patients on rifampicin, said Joris Delanghe, a physician and toxicologist at the University of Ghent.
Skeptics point out that rifampicin is a difficult substance for anyone to use surreptitiously, since its effects are variable and it turns the urine red. And this 64-year-old with a history of smoking and high blood pressure may well have had undetected heart disease, doctors said.
"Refractory hypertension exists and some patients are hard to treat," Delanghe said. He added that for Milosevic, the mental stress of being imprisoned must have been "a major cardiovascular risk factor in itself."
Elisabeth Rosenthal reported for the International Herald Tribune, and Marlise Simons for The New York Times.
