Human costs of healthcare resilience during the war in Ukraine: Lessons from addiction and HIV treatment

Contrary to apocalyptic expectations, in Ukraine up to 90% of staff in addiction and HIV care facilities (unless physically destroyed) have remained in post since the start of the Russian invasion in February 2022. Ukraine provides insights into the sources of this resilience as well as its limits and costs. In February 2022, Ukraine was a low/middle-income country of 42 million people, of whom 260 000 were living with HIV (PLWH) and over 347 000 injected drugs (PWID) [1]. Through prior efforts, 83% of PLWH were on antiretroviral therapy (ART), and 5% of PWID received opioid substitution treatment (OST) [2, 3]. When the Russian invasion began, experts predicted rapid collapse of HIV and addiction treatment [4, 5], but instead, clinicians have been stalwart in providing continued patient care. Despite nearly a quarter of the population fleeing Ukraine since 2022 [6], in addiction and HIV care facilities remaining physically intact ~80% to 90% of clinicians remain in post [7]. For example, in Kramatorsk (20 km from the front), with one addiction treatment facility destroyed, the remaining four continue daily care, serving 290 in-patients (reduced from 450 beds pre-war) and 141 OST patients. Of 25 HIV care sites of the Donetsk region (where active combat is ongoing), 14 sites are currently still working full-time. After the doctor of the Avdiivka city site (7 km from the front) was wounded, the nurse was evacuated from Avdiivka, but she continues to provide treatment remotely for all 205 patients registered at the site, including organizing the delivery of OST and ART to 40 HIV PWID patients who remain in Avdiivka. With escalating safety risks and intermittent interruption to electricity, internet and other necessities, how have HIV and addiction care facilities endured? First, per testimonies from Ukrainian healthcare workers who participated in the Global Mental Health Humanitarian Coalition panel in May 2022 [8], clinicians value their jobs, challenging as they may be, especially as stable employment is scarce during humanitarian crisis. As an addiction doctor from Chernihiv stated, ‘a medical worker is a profession of the soul, the kindness of the heart and 100% dedication, thus most people stay working. Furthermore, times are hard, and people hold on to any job’. Her counterpart from Kherson echoed by saying ‘healthcare workers have a special way of thinking. There was a time in the 1990s when doctors had no money for food, but patients were assisted. Healthcare workers will treat patients even in the face of a threat to own life’. Since 2015, Ukraine has implemented healthcare reform, including operational restructuring and cost reduction, leading to painful staff cuts by 10% to 20% across addiction and HIV clinics [9, 10]. Coronavirus disease 2019 (Covid-19) pandemic gave temporary respite, with the Ukrainian Ministry of Health slowing the cuts and introducing Covid-19 bonus payments for frontline staff providing critical care (including HIV and addiction treatment) [11, 12]. Relatively small in absolute terms ($200/month maximum), this bonus could exceed 200% of frontline clinicians' modest salary [13]. Bonuses dwindled in 2021, but restarted intermittently during the war through the advocacy of clinical directors and political goodwill of local authorities, providing financial and also moral buoy to clinicians. Despite initial frontline staff shortages in March–April 2022, when some personnel evacuated and others could not access the workplace because of transportation disruptions, many clinicians returned to Ukraine and resumed work throughout the summer [14]. When Ukraine reclaimed territories near Kherson and Zaparizhzhia in October 2022, most internally displaced clinicians returned to their posts. For example, in Kherson, all staff of a local AIDS clinic consisting of a doctor, two nurses and a laboratory technician fled the city during the active combat, but everyone returned when the facility was re-opened on 9 November 2022. Continuing work in their field (as opposed to the uncertainty experienced by Ukrainian refugees abroad) was a key motivator. Second, a supportive working environment, with clinic directors genuinely recognizing clinicians' contributions, is another powerful motivator for coping with adversity. During Covid-19, frontline healthcare staff in many countries felt disenchanted that the public and administrative applause to ‘Our Heroes’ lacked political and financial follow-through [15]. In contrast, during the war, medical directors of Ukrainian addiction and HIV clinics developed bespoke ways to acknowledge their staff's contributions. For example, when clinicians Kyiv lived on clinic premises without going home for 3 days or longer to provide round-the-clock services, medical directors stayed with their staff, equally shouldering every burden. In Kherson, an HIV clinic director who left Ukraine when the city was occupied continued working by Zoom without salary, supporting her staff and patients until the clinic reopened. This authentic ‘being there together’, complemented by patients' overwhelming gratitude, fostered reciprocal empathy among colleagues, lowering the risk of burnout. However, although buoyant, Ukrainian clinicians and facilities are not immortal. Over time, destruction grows, and territory where life is possible shrinks. Literature defines a resilient healthcare system as able to ‘adapt to challenges and changes at different system levels, to maintain high-quality care’ [16]. Learnings from Ukraine suggest this may obscure when medics become expendable, and put the onus on individuals and facilities to absorb all shocks. Inadvertently, it downplays the government's responsibility to mitigate the crisis and protect and support essential workers. Resilience during the crisis can trap clinicians in compulsory altruism [17], working over and above the call of duty to save vulnerable patients, until the point where the staff eventually collapse. Furthermore, as with vulnerable patients who cannot leave dangerous places because of limited resources and eldercare responsibilities, the same is true for clinicians. As the humanitarian crisis continues, there is a real danger that resilience is assumed to be ever-extendable and able to absorb growing workloads under shrinking resources, and regarded as a default for HIV and addiction treatment facilities. Yet, there is still time to help as meaningful work performs a therapeutic function for medics, with Ukrainian clinical leaders keeping their organisations alive despite adversity. Insights from the research evidence and learnings from Ukrainian HIV and addiction clinicians' coping in recent years suggest three recommendations. First recommendation: extending the timeline of the ongoing healthcare reform in Ukraine, as previously agreed before the Russian invasion. The last phase of reform aims to reconfigure many addiction and HIV clinics from January 2024, subsuming some staff into special departments in larger hospitals and passing other functions to primary care facilities. Extending the timeline would allow clinicians to meet increased patient care demands during the humanitarian crisis, lessen immediate job security concerns and incorporate learnings from crisis adaptations to ensure the reform's long-term success. Second recommendation: establishment by the Ukrainian Ministry of Health of a re-employment pathway for clinicians of destroyed clinics, including nationwide co-ordination of available posts, and allowing HIV and addiction care facilities to open additional positions and hire new staff. This could alleviate staff burnout and permit clinicians from war-destroyed facilities to follow their transferred patients, with the latter benefitting from continuity of care from medics with whom they already have rapport and trust. One option could be increasing the number of mobile care teams, following the model used by the Public Health Alliance, whose care vans visit de-occupied rural areas to deliver hepatitis C treatment [18]. With support from the Ministry of Health, re-deployed clinicians could provide addiction, HIV and other infectious diseases treatment to people living in communities where clinics have been destroyed, helping to curb the epidemics. Third recommendation: support by the Ukrainian Ministry of Health for regular professional development activities for clinicians across all facilities. From a humanitarian perspective, each facility risks becoming an island and training activities can increase social support and alleviate burnout risks, while giving clinicians opportunities to learn from each other's empirically tested coping strategies. International partners' donation of laptops, power-banks and light-generating devices to clinics across Ukraine has facilitated online access. Additional paid leave and/or travel funding to clinicians from regions with active hostilities would support in-person participation while also giving respite. The achievement of Ukrainian addiction and HIV care clinicians to maintain capacity during a crisis should inspire medics and planners elsewhere. Just as previous wars led to advances in anesthesiology and surgery with clinicians learning from a massive evidence base [19], so too lessons from Ukraine have the potential to reduce the human costs to healthcare resilience. Julia Rozanova: Conceptualization (lead); funding acquisition (lead); investigation (equal); methodology (equal); project administration (equal); writing—original draft (lead); writing—review and editing (equal). Irina Zaviryukha: Conceptualization (equal); data curation (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); validation (equal); writing—original draft (equal); writing—review and editing (equal). Alexandra A. Deac: Conceptualization (equal); data curation (equal); investigation (equal); methodology (equal); project administration (equal); resources (supporting); software (lead); writing—original draft (equal); writing—review and editing (equal). Oleksandr Zeziulin: Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (supporting); supervision (equal); validation (equal); writing—review and editing (equal). Tetiana Kiriazova: Conceptualization (supporting); data curation (supporting); funding acquisition (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Valerie Earnshaw: Conceptualization (supporting); funding acquisition (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Katherine M. Rich: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); validation (equal); writing—review and editing (equal). Sheela V. Shenoi: Conceptualization (supporting); funding acquisition (equal); investigation (equal); methodology (equal); supervision (equal); writing—review and editing (equal). Harry Skipper: Conceptualization (supporting); resources (supporting); validation (equal); writing—review and editing (equal). Volodymyr Yariy: Conceptualization (equal); investigation (equal); resources (equal); validation (equal); writing—review and editing (equal). Sir John Strang: Conceptualization (lead); investigation (equal); methodology (equal); writing—review and editing (equal). We thank HIV and addiction treatment providers from Kherson, Zaporizhzhia, Odesa, Donetsk, Zhytomyr, Dnipro and Kyiv regions, with whom we have worked on clinical studies for many years, for sharing with us their testimonies of experiences being a clinician in Ukraine during the war. We have written this article on their behalf. This article is dedicated to medics quietly doing their job amidst the roaring crises. None.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.