For two decades, I have worked to improve health systems in countries during conflict and natural disasters, or those in recovery from these events. As an emergency medicine physician, I am accustomed to seeing suffering, and I have absolute respect for healthcare workers who are enduring in Ukraine’s harsh, grim environment. The abundance of graphic media coverage fails to capture important pieces of the healthcare workers’ real experience.
In a disrupted society, healthcare workers face a triple threat: they and their families are affected; their work environment is in disarray; and their burden of work increases in tandem with the severity of the crisis, as both the intensity and volume of work soars.
What’s more, although their feelings may not be visible or acknowledged, healthcare workers have the same anxieties about safety and the sense of loss and grief as their patients — and less opportunity for self-care and self-compassion.
Compelled to focus their attention and efforts away from themselves and their families, they face an impossible task: to do more with less.
Disaster medicine specialists talk about the three S’s that describe what’s needed for healthcare delivery: staff, space, and stuff. War affects all three.
Hospitals are shorthanded when clinicians and ancillary staff face the same chance as anyone else of being injured, killed, or needing to prioritize their family’s needs. Clinicians who remain in these circumstances face an unimaginable burden, as they must provide care beyond their usual sphere of practice. Think of the psychiatrist managing a bleeding wound or the dermatologist delivering a baby.
With healthcare facilities out of service, destroyed, or unsafe, those in need of care are funneled into smaller clinical spaces. Healthcare facilities are also seen as safe havens, and shelter seekers with no pressing medical needs can nonetheless strain resources.
The lack of space to work and recover also sows chaos, impeding hygiene, privacy, and therapeutic environments. Crowding and unsanitary conditions tend to drive up disease transmission among refugees, patients, and care providers alike.
I witnessed this in 2009, years after the civil war in Monrovia, Liberia, where large numbers of children were suffering from typhoid — a disease that is spread by lack of hygiene. Due to overcrowding and continued poor security, the disease circulated widely in Liberia. It is an easily treatable infection when caught early, but by the time I was able to provide medical attention, many people were tragically too far along in their disease course for me to help them.
Disrupted health systems mean loss of a healthcare providers’ tools. The media simplistically mentions bandages and oxygen, which belies the complexity of modern medicine: a modern operating room requires thousands of material items, and critically ill patients may require dozens of medications.
There are unacceptable trade-offs inherent in crisis. Outside of Goma in the Democratic Republic of Congo, during a period of active conflict in 2011, I spoke with a hospital administrator who had to choose between paying salaries or paying for gasoline to run the generator that enabled lifesaving surgery. He understood that delaying surgery would mean unnecessary death for some, however, if he continued to underpay his staff they would leave, endangering all the patients.
Ingenuity and substitutions have their limits. Eventually, the ability to provide care without material resources grinds to a halt.
The result of all these factors is that clinical medicine in situations of war and severe social unrest — as we are seeing in Ukraine today — is itself as ravaged as a bombed-out building. From a psychological perspective, healthcare providers bear witness to the worst of the tragedy, up close and personal, and for an extended period. Unable to provide adequate care, providers may be left to watch patients suffer and die unnecessarily. After the 2011 earthquake in Haiti, I worked alongside citizens who had multiple family members die or go missing, including children. Yet they persevered.
The situation in Ukraine is untenable, yet, in the same way, dedicated healthcare workers persevere. They deserve our attention and admiration, here and abroad.
Stephen Morris, MD, MPH, is an assistant professor of emergency medicine and public health at the University of Washington’s Schools of Medicine and Public Health in Seattle, and the physician lead for disaster education and training for UW Medicines’ Departments of Emergency Medicine.