A Hospital on the Edge of Civilisation
Iain Overton reports on a medical centre in eastern Ukraine which was caught in an unexpected war – a war which transformed everything.
Abandoned hospitals are, like former asylums and empty prisons, places that unnerve. Leprous walls, where wallpaper peels off like a diseased skin. Dark corridors that lead to locked doors, silent as a morgue. Empty chairs waiting for patients who will never come. The stuff of nightmares.
In Avdiivka hospital’s abandoned wing though, this nightmare is born from a living one. In the Spring of 2014, this hospital was caught in a whirlwind of violence. What first began as dispute over a trade agreement, transmuted into what became the bloodiest conflict Europe had seen since the former Yugoslavia was engulfed in war in the early 1990s. Russian troops, and those they supported, launched a major assault across this region, after annexing the Crimea. The eye of that bloody storm was to become the eastern Ukrainian city of Donetsk. Avdiivka lies 20km from that city centre, and just 6km from the regional airport.
Separatists in Donetsk and nearby Luhansk declared independence after unrecognised referendums and, as fighting intensified, the numbers of civilians harmed began to rise significantly. Avdiivka hospital found itself over-run with casualties – more than 500 civilians wounded, many by shrapnel from explosive weapons. At least 54 more locals were killed.
The hospital was to see the war unfold terrible chapter by terrible chapter. Water and electricity were cut off. Eight missile strikes hit the medical centre; two doctors were killed and one nurse badly wounded. Patients died on operating tables with the sound of mortar-fire creeping inwards. Mothers gave birth in crowded corridors. Medical supplies ran dangerously short, and all but the most urgent of medical procedures were abandoned.
Throughout those dark months, the staff worked tirelessly. Three-day shifts became commonplace, doctors taking brief naps where they could, sleeping upright wrapped in borrowed blankets. It was still April, the cruellest month, and the winter winds had not lessened. With no heating, the staff would crowd around coal and wood burners, urging their frozen fingers back to life so that they could operate on the incoming wounded.
The war changed everything.
Today, swathes of the hospital lie unused. Meanwhile, the lands that surround the hospital are filled with late summer wheat that undulates in an eastern wind; beneath those golden waves, landmines lie. The doctors call them the “forbidden fields”, and the legacy that explosive violence has visited on this medical centre seeps into everything.
This war has done as much as diseases can ever do. It has contaminated all that it touched, including the people and places that survived.
Dr Vitaliy Danylovych Sytnik has a nervous tic. He rolls his wedding ring in his fingers when he speaks, but his voice resonates with the authority that comes with his position: the deputy director of the hospital. A specialist in systemic diseases, he oversees the care for in– and outpatients for a region that now covers 34,000 citizens in the local city, and some 15,000 in the regions surrounding.
He has spent the past 25 years working in this hospital – half his life – and the staff are, to him, like family. He was here when the news on their television screens turned, terribly, into reality, and the first patients began pouring into the emergency clinics. They bore injuries that a civilian centre rarely saw. Bullet wounds in the arms of children. Shrapnel embedded in the heads of pensioners. Flesh ripped apart by a storm of steel. For every death, 10 more were wounded.
Without urgent medical intervention, he estimates that at least 50% would have died. And the same percentage needed blood transfusions too – a sudden descent into conflict surgery for him and his team.
“We did what we had to do,” he says, his glasses perched upon his forehead, under his cropped, greying hair. “We were covered in blood, but we went into autopilot.” The conditions worsened and soon they were doing surgery by candlelight, shadows cast against the operating theatre’s walls.
“While the hospital had enough medicines in reserve, what we lacked most was manpower. Before the war, we had 80 doctors, now we have just 40. We had 450 workers in total – now just 190.”
This drop in his workforce came alongside a sharp increase in patients demanding care. In addition, the establishment of an artificial border between Avdiivka and Donetsk, where the main regional hospital stood, meant they had to take on an added burden. At the same time, damage to the hospital meant that they were forced to shut down crucial departments. In turn, the infectious diseases, paediatric and neo-natal clinics closed.
“We just lost specialists,” Dr Sytnik says. “First a cardiologist, then an endocrinologist, then more.” Now, they have to refer patients to clinics 40 or 50km away. Even their ambulance crews struggle to find staff. There is also a crucial shortage of family doctors and the few specialist clinics they can operate are over-run.
For those with life-long disabilities caused by explosive weapons, this lack of specialist care can be devastating. The hospital has no rehabilitation centre and even lacks an operating lift. Incredibly, its x-ray department is up four flights of stairs. Patients have to be carried up the broken steps cradled in blankets carried by relatives. One doctor later complained of having hurt his back carrying an injured patient up those flights.
Dr Sytnik points through a dirty window over to the abandoned wing of his hospital. It could once accommodate 220 patient beds, he says. Now it’s down to 150. Some rooms have eight beds in a space designed for four.
Below us, the sound of drilling can be heard. They are renovating an entire floor, he explains, funded by the local Avdeyevskiy Coke Plant, which produces 18% of Ukraine’s coal coke output. The repairs are much needed, judging by the chipped floors and peeling wallpaper of the doctor’s office, but they are expensive – costing as much as seven million Ukrainian hryvnia or some $300,000, a fortune in a place where some junior doctors get paid just $120 a month. The hospital is in dire need of an upgrade, but any repairs are costs that come on top of a budget already stretched thin by the war.
With the poor conditions and overwork, his job seems Sisyphean. “Doctors who have left, ring us up and call us crazy,” he says. “The levels of work, the conditions, the lack of specialists, all falls on our shoulders. One doctor does the job of two here.” He claims tens of thousands of doctors have left Ukraine in the past five years, with as many as 16,000 in 2019 alone. It is hard to confirm this, but it is easy to see how an attractive job in Poland or further afield attracts. His secretary earns just $130 a month and has to ask her mother to help support her and her child.
When asked if he feels supported by the Ukrainian Government, Dr Sytnik goes quiet. He cannot leave a city where six generations of his family once lived, where his pregnant daughter is expecting her first baby, where he has to take out a loan to afford the renovation for the newborn’s room in a shared flat. If you ask him how this war has impacted him personally, he shrugs. “What can you do?” he asks. He knows what a psychiatrist will say: go away, go to the seaside, go camping. But he has no money to do this and, besides, he has to spend his weekends repairing his parents’ house which has been destroyed by the fighting.
And with that, this softly-spoken man, in his canvas shoes and plaid shirt, rises to go. He has a clinic. Heart attacks are on the increase, he says, along with mental health issues, suicide attempts, depression and physical disorders related to poor psychological health. The list goes on. His work is never done.
“We will survive,” he says, and extends his hand. This is what war does: it reduces everything to a simple binary. Survive or die.
The three male doctors gather in their faded common-room. A dusty games console sits to one side. One of them, Alexandrz, is in his late 40s. The other two – Orlov and Arkatov – are in their sixties. The youngest doctor in this hospital is 42; the younger doctors left long ago, before the roots that tie a person to a place grew too deep.
The sound of patients comes from outside. Opposite, is a room garishly covered in flock wallpaper where nine beds are squeezed in. Two patients lie inert, facing the wall, curled up in sickness. But others have their families there, and bread is being shared, slices of meat offered up, cheese laid upon thick black bread. Spirits are raised where they can be.
The three doctors speak above the noise. They talk to each other in the way that soldiers do. One begins a sentence, the other finishes it. The oldest seems frail, even beyond his 68 years.
“We have two psychologists,” he jokes, “three stars and five stars.” He is referring to brands of cognac in the region. The others do not laugh.
The lack of electricity was one of the hardest things about the war, they say. They froze. They had to operate without x-rays. One man with a subclavian arterial rupture died under their knives as they just didn’t have enough blood in the bank for that one. Then there were the children who were brought in with head traumas. That was the hardest of all.
They lacked supplies. Basic pain relief, antibiotics, dressings all ran perilously short and, while they were able to treat everyone, they had to make hard decisions as to how much treatment they could give. They became experts at triage – who needed help and who did not. Without assistance from aid groups – the Red Cross, Medicin Sans Frontiers, the Premier Urgence – they do not know what they would have done, they say. Dozens of medical items around the hospital are labelled as gifts from the Germans, the Czechs, the French and the Swiss.
“What doesn’t kill you makes you stronger,” the anaesthesiologist says, as the older surgeon trembles. “You know the US have ‘Vietnam Syndrome’?” he continues. “And in Chechnya, they have the ‘Chechen Syndrome’? Well, here you have the ‘Donbas Syndrome’,” he says referring to the region of eastern Ukraine and southwestern Russia. You see it, he explains, in the mass of internally displaced people, in the inhibited economy, in the reduced quality of life, in the people whose paths in life have been disrupted so deeply.
A list of the things that have been lost begins. Access to transport, access to study, access to entertainment, the theatre, cinema. They have seen a rise in alcoholism. A rise in drunk drivers. Traffic accidents have spiked in a population for whom death’s presence became all too familiar. Data, too, has been a victim of the conflict. During the fighting, the internet was down, computers not working. Much evidence recording the harm of the conflict was lost in the chaos.
What they do know is that, today, they have seen a spike in tuberculosis – caused by the fact that many were forced to shelter in damp cellars for months at a time, herded together under the threat of shellfire. The exodus of the young to Kiev and abroad has also brought a shortage of young medical personnel. Underpinning everything is the shadow of the war, leaving them perplexed and filled with sorrow.
“How is it,” the anaesthesiologist says, “that here, in the middle of Europe, in the 21st Century, you have such a war? Such things you cannot understand.” And he looks down at the pockmarked floor, where a broken tile reveals a square of crumbling concrete, and no one answers. “We are living in a strange reality,” he continues. “A lost time. A lost dimension. We live on the edge of civilisation.”
The hospital bears scars, just like its patients. Outside, a group of medics huddle, dragging at contraband cigarettes. Dying from lung cancer is the last of their concerns. They stand next to a man slumped to one side. On his bandaged hand can be traced a line of blood, from a finger lost in an industrial accident.
Beside him is a man from UNFPA, the United Nations sexual and reproductive health agency. Yes, there has been a rise in HIV rates here, says the official, pulling at a cigarette. Where there are more men than women, he says, referring to the massive influx of soldiers, you’ll get that. It is not just the HIV virus that is spreading. A shortage of medicines to combat the spread of sexually transmitted diseases; a lack of funding for condom disbursement; a rise in risky behaviour amongst young people – all of these have led to a spike in sexual diseases such as Chlamydia, Gonorrhoea and Hepatitis C.
What starts as explosive violence has transmuted into other healthcare impacts, transforming into deep, private tragedies. Ill-health stalks bomb craters.
“Some tests you have to pay for personally too,” the man says, and because of this, all too often a disease goes undiagnosed. It then spreads through a community unchecked, transmitted by people for whom intimacy might offer the kindest relief from the trauma of war.
The radiologist, Marina, dreams of army tanks. “They are not nightmares,” she says, but it is hard to see how a line of attacking soldiers can be anything but.
She sits alone in a building abandoned by everyone. The only operating part of the hospital in this building is the one she oversees – the x-ray department. There, she records every visit from every patient in neat blue lines in her neat blue folder. Three days ago, there were 53 x-rays taken. Yesterday, 37. Today, 50.
She will input them into the computer later. When the war took away the electricity, she says, it seemed that a written record was the best thing to have. In the meantime, she sits alone, four floors up, waiting for her patients to come. When you ask her what she would like most, she replies: “Another Marina. To keep me company.”
Dr Tatiana Teplyakova points to a hole in the desk. “Shrapnel,” she says. She points to a hole above the door, and another above a lintel, and says the same.
A burst of shellfire pierced her laboratory, shattering glass and plaster. Luckily, it was deep into a night shift and no one was hurt, but these are pockmarks that haven’t been fixed. Perhaps they are there as a reminder.
That attack led to her having to shut down one of her testing laboratories: the bacterial infectious disease unit. The vials of disease that she, as head of Avdiivka’s testing laboratory, once stored there could easily have been weaponised. Besides, if a shell had wiped out that centre… Today she makes do with what she has. She urgently needs modern testing devices, but the budgets have already been depleted, and the war has delayed countless upgrades.
“Stagnated,” she pronounces – a statement that shows her love of getting to the heart of the matter. It’s a skill she developed during the conflict. She used to have 30 people working for her in the testing facilities, now they have just six, and they have to cater for the military wounded, too. Hers is a burden that is unrelenting.
During the height of the conflict, when the power was cut, they really struggled. Even when the generator was in use, they only had time to recharge their cell phones and do some urgent testing. Complex tests became a rarity and, instead, their focus was on emergency analysis – white blood cell counts became the mainstay. All they had left was glucose tests and urine analysis.
Even running water they could do without. They took it from the pond, filtered it, boiled it, filtered it again and then used that to wash their implements. But without electricity, testing devices, communications, email, data – all was impossible. She wonders what western Europe would do if they ever had such a descent into the pre-modern.
Complex tests have to be sent 70km away. Once, she could send samples to the laboratories of Donetsk. No longer. This means she can no longer test for drug-resistant MRSA. Luckily, basic sputum tests mean that tuberculosis can be identified. But the rest? She shrugs. “We do what we can,” she repeats.
And here, in this hospital on the edge of civilisation, it seems that is all they can do.