Health Care Under Siege: Voices From the War in Ukraine

THURSDAY, March 10, 2022 (HealthDay News) -- As the war in Ukraine enters its third week, the scale of the devastation is placing the health of all Ukrainians — and the country's health care system itself — in peril.

"It's mind-boggling," said James Elder, a spokesperson for UNICEF, who arrived in the western city of Lviv just two days after the Russian invasion began.

Since then, "a million children who are refugees have had to flee the country — in 13 days. Imagine the stress and the trauma. The world has not seen anything like this since World War II," he noted.

"But it's also really important to remember those who are at risk trapped in-country, as much as we see this huge outflux of people," Elder added. "People who can't move. People in hospitals who are on drips. Babies in incubators. People who are trapped in bunkers. I visited a hospital here in Lviv just yesterday that took in 60 children, some injured in Kyiv, others just unwell after hiding out for days in a cold basement."

Compounding the problem is the direct threat to hospitals themselves.

Doctors Without Borders noted that intentional wartime attacks on medical personnel, hospitals and health care facilities are a direct violation of the Geneva convention.

On Tuesday, the Ukrainian Health Minister Viktor Liashko announced that since Russia launched its invasion, 61 hospitals throughout the country have essentially been "put out of action," intentionally or not. According to the Ukrainian Defense Minister Oleksii Reznikov, 34 of them were destroyed by Russian bombardments.

That number grew on Wednesday, when a Russian airstrike hit a maternity hospital in the besieged city of Mariupol. Three people were killed in the blast, including a child, while 17 were injured.

These attacks put Ukrainian public health officials — such as Shorena Basilaia in the capital city of Kyiv and Linnikov Svyatoslav in the southern port city of Odessa — on the front lines of the struggle.

Hospitals under fire

Though Lviv has so far been something of an oasis from the sort of heavy bombardment that has engulfed cities in the eastern and southern parts of the country, the capital city of Kyiv (population 3 million) and its surroundings haven't been so lucky.

Deputy director of Kyiv's City Hospital for Adults No. 27, Basilaia tries to strike a can-do tone, despite the obvious risks that come with ensuring continued access to health care in the heart of a war zone.

The 270-bed hospital she helms — which has largely been attending to COVID-19 patients of late — "has not been hit [by missiles] so far, and I hope it remains like this," Basilaia said, adding that medical supplies are still on hand.

"We do have medicines, no shortage so far," she said, though she points out that medical facilities in other parts of the country are in far more dire straits. For now, her staff remains "functional and ready for all kinds of scenarios," she said.

Even so, the situation is "very stressful and difficult right now," Basilaia acknowledged.

"War has a negative effect on everything, including the health system," she noted. For example, safety concerns have made it impossible for some of her staff to even make the journey into work. And those who do get to work find themselves on constant alert, ready to scramble at the sound of an air raid siren — not to mention the start of actual shelling — as they race patients into the protection of a bunker below.

"It's insane," agreed Svyatoslav. He directs the department of health promotion at Odessa's Regional Center for Public Health (RCPH), a local equivalent of the U.S. Centers for Disease Control and Prevention.

"I am not a warrior," he stressed. "I've never held a gun. But I feel like I'm in a movie. Actually, 'The War of the Worlds,' with Tom Cruise. Because, if you remember, in that movie the first alien attack was in Ukraine."

But Slava, as he's known, is not a Hollywood film star. A native son of Odessa, he's a surgeon by training. Pre-war —and pre-pandemic — his main role at the RCPH was to promote and teach public health interventions aimed at lowering the risk for both infectious diseases, such as HIV and viral hepatitis, and non-communicable illnesses such as heart and vascular disease, strokes and cancer.

Still coping with COVID

"But with the onset of the coronavirus pandemic I started fighting a new threat," he explained, quickly shifting his attention towards prepping materials on infection prevention, facilitating vaccinations and debunking pandemic misinformation.

According to the World Health Organization, the nation of roughly 44 million has registered 5 million confirmed COVID-19 cases and about 112,000 deaths, a population-wide death rate comparable to that of Italy.

Slava noted that he and his colleagues have spent much of the past two years on a countrywide effort "aimed at saving people's lives from the coronavirus" with considerable success: Until now, Ukraine had managed to administer roughly 31.5 million vaccinations.

Then, the unthinkable happened.

"On Feb. 24, at 5 a.m., I was awakened with the most terrible words: 'Get up. The war has begun. They are bombing our cities.'" Slava admits that he and his friends initially reacted to the "surreal" Russian invasion with shock and disbelief. "In the first hours after the start of the war, it became quite difficult to understand what to do next," he said.

"It is impossible to prepare yourself for war," he said. "Your brain doesn't want to believe it."

But Russia's assault on Ukrainian sovereignty dates back to the annexation of Crimea in 2014, so the shock quickly faded.

"After five hours from the beginning of the war, the first groups of volunteers appeared. We begin to collect aid for the first victims, and look for ammunition for volunteers, and form warehouses for humanitarian aid," Slava said.

Top of mind was also the conviction that the work of public health can't just stop when bombs start falling. Nor can ensuring that the chronically ill have continued access to critical treatment. "War is a threat to physical health here and now. Our main task now is to provide uninterrupted medical care to those who need it," Slava said.

"We are talking about patients with diabetes who need daily insulin," he explained. "Or people who live with HIV. It is impossible for them to be left without medicine for a single day. So, now doctors across all Ukraine are doing everything to provide them with medicines."

Medical supplies, training paramount

"It's all about supplies," agreed Elder, one of roughly 130 UNICEF staff working in Ukraine right now. "It's absolutely critical. Over this past weekend alone, we got 60 tons of medical supplies into the country: surgical kits, resuscitation kits and midwife kits, because women are now having babies in bunkers and basements," he noted.

"Of course, getting these supplies to people who are being shelled and attacked — getting food and water and medical attention to whole families, who in some cases have been trapped without water for days on end — is a big issue," Elder said. "What we need — the surest and quickest way out of this — is for the bombing to stop. But if not, then we need humanitarian corridors, to bring in lifesaving assistance and to bring out the vulnerable. It has to happen."

Beyond that, Slava said that the Ukrainian health care system must also now take on the added responsibility for "teaching the civilian population the skills of first aid, survival in critical conditions, maintaining mental health and adapting to stress," in addition to continuing the COVID vaccination program "where it is still possible and safe."

For now, Odessa (which is 300 miles south of Kyiv) has not yet experienced a large-scale attack. But with Russian land forces only 80 miles to the east and Russian naval ships poised just outside the strategic city's territorial waters, Slava suggests that the ever-present sense of threat and dread is itself posing a health risk, undermining the psychological welfare of an entire nation.

"The uncertainty is frightening," he said, adding that he fears this is just the calm before the storm.

"Odessa is my home. It's very beautiful and it's a very important symbol in our country, like L.A. for America. But it's in a very dangerous position now and of course we want to fight," said Slava. "We want to protect the city. We want to help people, provide the care they need. But we also want to run, because we know it will be very dangerous for my friends and me to stay there."

Ukrainians are now caught on an emotional seesaw, teetering between anger and rage and fatigue and fear.

But "there is no despondency, no powerlessness," Slava hastened to add. "There is no time for depression right now. Post-traumatic stress syndrome, depression and other mental problems will come later."

Still, the war has profoundly shifted the ground beneath his feet.

"I no longer feel the days of the week," Slava said. "Or the dates of the months. Now there are only hours. The hours of war: 24, 48, 168…"

And counting.

More information

There's more detailed information on the war's impact on health in Ukraine at UNICEF.

SOURCES: Linnikov Svyatoslav (Slava), MPH, PhD candidate, head, department of health promotion, Odessa Regional Center for Public Health, Odessa, Ukraine; James Elder, UNICEF spokesperson, Lviv, Ukraine; Shorena Basilaia, deputy director, City Hospital for Adults No. 27, Kyiv, Ukraine