Saving lives, preserving Ukrainian health care to combat Putin’s ‘kill twice’ effect

Among the Russian Army’s many atrocities in its invasion of Ukraine, one stands out because of its ability to produce a continuum of pain and death: the targeting of Ukraine’s health care system, its medical professionals, and the patients under their care.

The damage by artillery and missile fire of Ukraine’s civilian health care system sets a benchmark for the violation of the rules of war and, if shown to be intentional, meets the definition of crimes against humanity.

The magnitude of destruction and the long-term implications to the suffering and death of Ukrainians is not fully appreciated. Prior to Russia’s invasion, Ukraine’s medical and public health systems were among the best in Eastern Europe. Decades of investment, rigorous medical training in-country and abroad, and advanced medical technologies allowed Ukraine to provide quality medical care to 44 million citizens. Medical services were delivered through a network of public and private hospitals, clinics, and community health programs, all staffed by clinicians trained at accredited medical and nursing schools.

Like other modern medical care systems, Ukraine’s had some baseline vulnerabilities. It was dependent upon fragile supply chains for foreign pharmaceuticals and on solitary centers of excellence for rapidly changing disciplines such as oncology and transplantation medicine. These centralized civilian systems proved especially defenseless in the face of Moscow’s missiles. The World Health Organization, in its most recent report, documented more than 109 attacks on healthcare facilities, 56 attacks on ambulances bearing red crosses, and the killing of more than 90 health care workers and patients. If found to be deliberate, these would be in gross violation of The Geneva Conventions.

In disaster medicine, the phenomena of increased deaths that follows the wreckage of health care services and loss of medical professionals is known colloquially as the “Killing Twice Effect.” In natural disasters, such as the 2010 earthquake in Haiti or the 2014-15 Ebola outbreak in West Africa, the deaths continued for years due to the destruction of local hospitals and loss of health care workers. In Ukraine, the disaster is not an earthquake or an epidemic, but rather, Russia’s Vladimir Putin. His senseless war in Ukraine is a textbook example of the Killing Twice Effect, resulting in an expansion of illness and death long after the last missile hits its target.

Our international team of Ukrainian and American physicians, disaster medicine and chemical weapons experts, and academic medicine leaders have been working with Ukraine’s government, both within Kiev and across Europe and the U.S. Our team has offered a prescription to help protect what remains of Ukraine’s health care ecosystem and prevent its annihilation. Our solutions are not notional; they draw on painful lessons learned during past disasters, from an understanding of the Killing Twice Effect — and, most importantly, they leverage the resiliency and strength of Ukrainian clinicians and citizens.

This emergency guide to protect and preserve Ukraine’s health care has three critical components:

Protect and resupply Ukraine’s remaining hospitals. Our immediate priority is to protect Ukraine’s surviving hospitals in occupied and unoccupied territories. This includes preserving Ukrainian physicians, nurses and technicians, critical medical assets for wartime injuries such as blood banks and surgical services, and difficult-to-replace assets including imaging equipment and ultrasound. We prioritize people and the hospital community over the buildings themselves, which we cannot shield from Russian artillery.

In order to survive, Ukraine’s hospitals are becoming distributed, not centralized, and virtual, not physical. Much of this transition from peacetime effectiveness to wartime strategy is well underway. Examples of this include the March 9 attacks on Maternity Hospital No. 3 in Mariupol; the nurses had already relocated labor, delivery, and an improvised high-risk newborn nursery to the hospital basement, saving many lives during the bombardment. Similarly, the surgical team in Mariupol Hospital No. 4 relocated to the pre-op room because the windows of the operating room had been blown out as a result of bombing. Furthermore, in the National Cancer Institute in Kiev, patients received chemotherapy on hospital floors below ground during the first weeks of the war. These highlight a few of the ingenious tactics applied to reduce the impact of Russian bombs on civilian healthcare delivery.

Our team continues to expand our expertise and seeks additional assistance to keep Ukraine’s medical services operative during the expanding conflict. We also call upon physician counterparts practicing at prestigious Russian institutions to honor our shared, Hippocratic oath and join Russian protests demanding an end to strikes on Ukraine’s medical facilities. In the meantime, resupplying Ukrainian hospitals from countries including the U.S., Canada, Europe, and Israel must be ongoing. Ukraine has transformed itself to fight this war, and we aim to support its hospitals and healthcare workers in doing the same.

Adapt Ukraine’s medical systems for war. Under normal circumstances, Ukraine’s health care system is modern, technically advanced but also centralized and highly interdependent. The customary medical and surgical system is high maintenance, requires particularly skilled professionals, and lacks resiliency for wartime. These systems require adaptation to meet the needs of civilians who find themselves in the crosshairs of war.

Ukrainian physicians, nurses, and prehospital providers are being rapidly retrained to care for those suffering combat injuries. Russia’s most recent threats require, too, that capacity to treat victims of chemical, nuclear, and radiologic attacks be immediately expanded. The U.S. Congress should mobilize the nation’s chemical, biological and radiation-nuclear diagnostic and treatment capabilities found in the Strategic National Stockpile, as these systems are purely defensive and unlikely to escalate tensions further. 

Needed resources include personal protective equipment for medical professionals during decontamination of patients, small battery-operated battlefield ventilators that can be run by lower-trained medical personnel, and the FDA-approved atropine autoinjector for the treatment of chemical attacks using Russian nerve agents.

These measures should be coupled with Just-In-Time training as practiced by U.S. Disaster Medical Assistance Teams before field deployment. Training and equipping of medical personnel can be staged at secure locations along Ukraine’s western border.

Continuous reconstruction of Ukraine’s health care. One key principle of disaster medicine is to ensure that urgent medical priorities are met without undermining future medical capabilities. For example, while Ukraine desperately needs trauma surgeons, emergency medicine, and infectious disease doctors and nurses right now, the elderly, pregnant women, sick children, and those with chronic illnesses continue to need quality care as well. The goal here is to help Ukraine balance treatment for combat and chem-rad-nuke injuries while still allowing for the efficient return to peacetime medicine. Therefore, the uninterrupted education of Ukraine’s medical and nursing students in areas free from bombardment should be arranged. Proposed solutions include temporarily relocating Ukrainian nursing and medical students to schools in Europe and North America, reducing interruptions to the preparation of Ukraine’s future medical workforce.

Russia’s invasion has flouted all modern warfare conventions; the rules of war have been violated, and the targeted destruction of life-saving infrastructure has exponentially increased the number of lives not only lost now but also in the months and years ahead.

These actions can be minimized with international protests, further sanctions, provision of humanitarian and medical relief and by the collective experience of international experts in disaster and conflict medicine.

Ukraine is not on a one-way trip to wartime footing. We must adapt, preserve and engineer the health care system now in order to prepare for a future peace.

Michael V. Callahan, M.D., DTM&H, MSPH., is an infectious disease and outbreak physician who served as medical director for the U.S chemical and biological weapons demilitarization program in Russia between 2001 and 2006 and is director for Clinical Translation, Vaccine and Immunotherapy Center at Massachusetts General Hospital.  

Mark C. Poznansky, M.D., PhD., FIDSA., is director of the Vaccine and Immunotherapy Center, Massachusetts General Hospital, and professor of medicine at Harvard Medical School. 

Serguei Melnitchouk, MD, MPH., is a cardiac surgeon at Massachusetts General Hospital and co-director of the Heart Valve Program and an assistant professor of surgery at Harvard Medical School. Dr. Melnitchouk is the founder of the Global Medical Knowledge Alliance.

The following professionals also contributed to this op-ed:

Oleksandr Stakhovskyi, MD, PhD, works in the Department of Uro-Oncology at the National Cancer Institute, Kyiv, Ukraine, and is co-founder of the Ukrainian Society of Clinical Oncologists (USCO).

Nelya Melnitchouk MD, MSc, FACS., is a colorectal surgeon at Brigham and Women’s Hospital and an assistant professor of surgery at Harvard Medical School. She is the president and founder of Global Medical Knowledge Alliance.

Jacqueline A. Hart, M.D., is director of the Bassuk Center on Homeless and Vulnerable Children, Families and Youth in Needham, Mass., which works with communities and organizations nationally to promote housing, health and other opportunities for individuals and families. She has more than 20 years experience working in lifestyle, behavioral and integrative medicine, applying those principles to vulnerable populations and marginalized communities.