In Ukraine’s most remote eastern and southern communities, daily life in a year of full-blown war is difficult to recount. Natalya Tunik, a doctor in the small southern town of Novotroitske, in the Kherson region, says that normality “turned to ashes” even before the Russian army took control of her town in June. Despite the continuous drone of planes and shells flying overhead, Tunik explains how hard it was to comprehend Russia‘s invasion, even though there have been on-and-off hostilities since 2014. “When the invasion begins, you feel like you’re dreaming and just hope that you’ll [wake up],” she tells me via the messaging app Signal. “But then you realise that you won’t and that things will never be the way they were.”
Tunik describes what her town is like under Russian control. “Imagine going back to a pre-digital era. Limited electricity, internet and mobile connection. Payment in cash, with big interest rates for cash withdrawals. No law and order. No state reimbursement programmes for the pharmacy and other services. Queues, lots of queues,” she says. “It caused a state of helplessness.”
That helplessness has been especially acute for doctors such as Tunik, because they’re unable to help many patients; following the invasion, deliveries of basic medicines such as insulin and narcotic painkillers to Novotroitske have been interrupted. “As a doctor in a small town, you know people and feel their pain and fear. It was unbearable. You see the development of a disease but can’t provide thyroxine, salbutamol, psychotropic drugs, insulin. How was I supposed to anaesthetise a palliative patient? Everyone suffered, even just from lack of vaccines. Anyone with chronic health problems deteriorated, particularly coronary artery disease and diabetes.”
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The situation in Novotroitske is grim but not unique. Doctors and NGOs across rural eastern and southern Ukraine have reported that a physical and mental health disaster is growing among children, the elderly and disabled people in areas under – and even those liberated from – Russian occupation.
When possible, Tunik has used her time to organise and attract humanitarian aid for the community, especially medicines, which they inconsistently received through the Ukrainian government, or even the black market.
During the months of occupation of the region, until last September, humanitarian aid and healthcare from the Russians was “chaotic”, says Tunik. “The Russians helped the villages that they liked, not us and others. But this selection process was sporadic and unclear. Our town mayor was kidnapped by the Russian military [and] our pharmacy refused Russian suppliers [as part of a boycott]. Russian doctors from Russia’s Adygea region arrived in several communities close to us, travelling in a mobile clinic, but their support [was haphazard].”
The humanitarian organisation Médecins Sans Frontières (MSF), which works in Ukraine’s remotest communities along the former front line, has also heard reports that Russian-supplied medication has been doled out sporadically. Will Edmond, MSF’s project co-ordinator for the Kharkiv region in the north-east, told me: “We hear some reports of the Russians donating medications in the communities under their control, but not nearly enough to cover the huge healthcare support gap in rural areas.”
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The inconsistency of medical support from Russia is corroborated by the experience of another Ukrainian doctor, who asked to remain anonymous because of safety concerns, in rural Kharkiv Oblast. Unlike Novotroitske, her town – which was under Russian occupation until September – did receive support. “The Russian invaders supplied us with medicines, including insulin. So we didn’t feel any major shortages in our department,” says the doctor, who we’ll call Olga. “[Maybe this is because] the top level management at our clinic agreed to co-operate with the invaders. When the Russians withdrew in September, many of [those in management] fled to Russia because they feared that the Ukrainian military would come punish them and make them hara-kiri [kill themselves]. Many people in my community were brainwashed by Russian TV.”
Despite the reliable supply of medicine, Olga explains that since the invasion mental health in her community has deteriorated enormously. Tunik echoes this point, emphasising that PTSD and depression are common.
MSF is also witnessing a mental and physical health crisis among the villages and towns that have been taken back by Ukrainian counteroffensives. “Generally, access to healthcare outside of urban areas has been very slim since the start of the war,” says Edmond. “Remember, many of these locations have seen awful fighting, loss of life and very difficult times. They’re desperately in need of services, not least since they’re very heavily populated by children, the elderly and the immobile or disabled – and far more women than men. The middle-aged generation is missing. It’s very striking.”
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Even before the war, rural parts of Ukraine had fairly low youth populations. Russia’s invasion only depleted that demographic further, since thousands of men over the age of 18 joined the fighting, while families that could afford to move westwards fled. As such, the communities that were left behind in rural locations had large numbers of the “most vulnerable”, says Edmond. It is these groups that have borne the brunt of the front-line conflict.
MSF has been sending out a series of mobile healthcare clinics to some of the most remote parts of eastern Ukraine, most of which were under Russian military control for months. Just getting to these towns and villages is a big challenge for aid workers, since so many roads and bridges have been destroyed by the war, while the routes that remain somewhat intact are littered with mines and unexploded ordinance. Winter is only making such journeys even more difficult, while the risk of shelling and crossfire remains very real for teams like MSF that operate near the front line.
For residents too, Ukraine’s cold winter weather is a challenge; countless rural homes have been partially or completely damaged. As such, MSF is particularly worried about the elderly population. “Among that demographic we’re seeing so much untreated chronic disease, like hypertension, diabetes and lots of other non-communicable diseases,” says Edmond.
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Evacuations to urban centres from these remote locations are ongoing, but not everyone can make the journey. Moreover, even in regional capitals such as Kharkiv, services for immobile, disabled or geriatric people have been sidelined by the war, according to MSF.
Russia’s invasion of Ukraine has only exacerbated pre-existing healthcare issues in rural Ukraine. “Even before the war, it was very difficult to reach remote villages and towns with appropriate health care services,” says Pavlo Kovtonyuk, co-founder of the Ukrainian Healthcare Centre. “Ukraine’s peculiarity is that it is a very large country, bigger than Germany, but with a very low population density and limited transport infrastructure.”
Kovtonyuk says that there are many areas of the country that do not need international support, since Ukrainian humanitarian services can cope by themselves. But when it comes to healthcare in remote communities, international assistance like that of MSF is “extremely in need”. As the war grinds into its second year, the need is only growing.
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