Supporting Health Care Workers During the Armed Conflict in Ukraine

Abstract

“Look for the helpers…”1Rogers F. Head B Prokell J. Mister Rogers Talks with Parents. Berkley Books, 1983Google Scholar – Fred Rogers Conflict is an unfortunate but recurring theme in human history. Although the rationale and setting for violence varies, the latest conflict in Ukraine has provided a tapestry of events that remind us of the dire consequences of 21st century warfare. The purpose of this commentary is to describe the health care challenges created by the modern battlefield and international disaster response and to provide brief reflections on opportunities and challenges for clinicians who provide medical assistance, based on the authors’ personal experiences. War has been described as a humanitarian crisis in disguise, disrupting the fabric of society and promoting violence, terrorism, and social injustice.2Jain N. Prasad S. Bordeniuc A. et al.European countries step-up humanitarian and medical assistance to Ukraine as the conflict continues.J Prim Care Community Health. 2022; 1321501319221095358Crossref Scopus (1) Google Scholar The nonlinear and expansive nature of the modern battlefield typically creates an early surge of both military and civilian casualties. Military weapons increase the risk of lethal hemorrhage from high velocity penetrating injuries; burns and multiorgan trauma from the thermal and blast effects of explosive munitions are common.3Kazmirchuk A. Yarmoliuk Y. Lurin I. et al.Ukraine’s experience with management of combat casualties using NATO’s four-tier “changing as needed” healthcare system.World J Surg. 2022; 46: 2858-2862Crossref Scopus (7) Google Scholar As of November 21, 2022, the United Nations (UN) Office of the Commissioner for Human Rights reported 16,784 confirmed civilian casualties in Ukraine, including 6,595 deaths.4United Nations Office of the Commissioner for Human RightsUkraine: Civilian Casualty Update. UNOCHR.https://www.ohchr.org/en/news/2022/11/ukraine-civilian-casualty-update-21-november-2022Date accessed: November 29, 2022Google Scholar The Ukrainian health system, already challenged by chronic tensions with Russia and strain from the COVID-19 pandemic, has experienced further damage as hostilities have progressed.5Romaniuk P. Semigina T. Ukrainian health care system and its chances for successful transition from Soviet legacies.Global Health. 2018; 14: 116Crossref PubMed Scopus (31) Google Scholar Although international humanitarian law stipulates that the medical neutrality of health care systems must be protected in time of war, the World Health Organization has documented 544 attacks on health care facilities in 15 Ukrainian oblasts as of November 15, 2022.6World Health OrganizationWar in Ukraine: Situation Report from WHO Ukraine Country Office. World Health Organization.https://apps.who.int/iris/rest/bitstreams/1479290/retrieveDate accessed: November 29, 2022Google Scholar Military actions have created barriers to causality evacuation, humanitarian aid delivery, damaged infrastructure, and disrupted essential services that include energy, water, communications, food, and sanitation. Currently, almost every hospital in Ukraine is treating military and civilian wounded; even major referral centers are using generators and internal radio communication and stockpiling clean water. Unofficial Ukrainian reports suggest approximately one-half of the health care workers who staff these facilities have either fled or joined the military response as a combatant or medic. Continuing conflict rapidly creates widespread population displacement. These refugees include disproportionate numbers of women, children, and older adults who are at risk for both acute and worsening chronic illness in temporary, often overcrowded, living conditions. These vulnerable groups also often experience abuse, human rights infringement, and discrimination in the increasingly lawless environment that surrounds them; behavioral and posttraumatic stress disorders are common. In the first few weeks of the Ukrainian conflict, a daily estimated 100,000 refugees crossed the border to Poland alone, overwhelming local resources. According to the UN High Commissioner for Refugees, an estimated 6.9 million people have been displaced inside Ukraine and more than 7.2 million people have registered as refugees in Europe alone.7United Nations HighCommissioner for Refugees. Ukraine Emergency.https://www.unhcr.org/ukraine-emergency.htmlDate accessed: November 29, 2022Google Scholar “How can I help?” is a question many altruistic health care teams have asked as the events in Ukraine have unfolded. The answer is unfortunately not straightforward. Health care teams in combat zones face many unique challenges and must be prepared to care for large numbers of patients who are experiencing both trauma and medical illness (including COVID-19) in austere settings with variable levels of skill, equipment, and supplies. They must also cope with the human factors of war, which include family separation, exhaustion and burnout, and their own personal risk of injury and illness. In April 2022, an international group of collaborators partnered with Ukrainian military and civilian anesthesiologists from the Central Military Hospital and the Ukraine Society for Anesthesia and Critical Care to offer clinicians across the country rapid trauma critical care training with the use of an adapted version of the Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN).8Vukoja M. Dong Y. Adhikari N.K.J. et al.Checklist for early recognition and treatment of acute illness and injury: an exploratory multicenter international quality-improvement study in the ICUs with variable resources.Crit Care Med. 2021; 49: e598-e612Crossref Scopus (7) Google Scholar This collaborative has delivered monthly, bilingual virtual webinars on best trauma critical care practices on a private YouTube channel, a web page with clinical practice guidelines and translated key points, and a private Viber group for general questions that as of December 7, 2022, has 946 members. This is just one of many initiatives to deliver trusted information rapidly, training, and supplies to Ukrainian providers to improve care delivery and reduce burnout in their strained health care environment. International disaster response is a complex, collaborative patchwork informed by the Geneva Convention of 1949 and International Disaster Response Laws, Rules, and Principles. The initial response lies with local, regional, and national government agencies, followed by appeals for military and civilian assistance from other sovereign states. Ukraine and its surrounding countries shouldered most of this early response while the European Union implemented their Joint Standard Operating Procedures for Coordination of Disaster Response. A wide variety of intergovernmental and nongovernmental organizations have played important coordinating roles, including the World Health Organization, the UN Office of the Commissioner for Humanitarian Assistance, the Red Cross, and Doctors without Borders to name only a few. Volunteers and private companies from around the world have also raced to provide financial contributions, spare equipment and supplies, continuous internet access provided by SpaceX Starlink-enabled communication, coordination, and rapid knowledge exchange through tele-education and telemedicine programs. Unfortunately, media reports and our own personal observations suggest that these response mechanisms struggled to deliver coordinated, timely support to refugees in the early phases of the conflict. It is important for volunteers without an established nongovernmental organization relationship to research the mission, medical personnel needs, location, equipment, and time commitment required by organizations engaged in this work and to expect change in response to constantly evolving conditions. Previous authors have highlighted the need for better volunteer preparation to deliver basic trauma and medical care in these challenging settings and the importance of understanding the local landscape, culture, transportation systems, health care system governance, and their role within it.9Asgary R. Lawrence K. Characteristics, determinants, and perspectives of experienced medical humanitarians: a qualitative approach.BMJ Open. 2014; 4e006460Crossref Scopus (10) Google Scholar Volunteers must be prepared to be flexible and to anticipate both language barriers and emotional challenges through this important but difficult work. Thankfully, the prevalence of war injuries among refugees who crossed the border was rather small, but the need for common primary care interventions was substantial. Dehydration, respiratory infection, exacerbations of chronic cardiac and respiratory conditions, diarrhea, and mental trauma were not only common but also were readily treatable without extensive resource requirements. Social media and local websites proved to be invaluable tools to ensure timely volunteer support and delivery of needed medical services to refugees who were arriving in Poland and other international settings. As health care workers, we have an obligation to use our skills to alleviate human suffering and tragedy and to help each other in times of need. Disasters are occurring with increasing frequency, and our shared experience during the COVID-19 pandemic has provided us with a new appreciation of the importance of the global medical community. The ongoing conflict in Ukraine is a health care crisis in urgent need of many helpers to address both a broad range of medical needs and to pave the path to long term recovery. Together, we can make a difference. None declared. Other contributions: We acknowledge the Society for Critical Care Medicine, whose members provided a portion of the administrative support for the Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) for Ukraine program briefly described in this commentary.