On 24 February 2022, we awoke at night to the rumble of distant explosions, the sound of fighter jets dropping missiles on Kyiv, and the astonishing news that Russia was invading Ukraine.  

None of us knew what to expect. I had arrived four days previously to try to establish a network of contacts who could help us work if there was a major escalation in conflict. Médecins Sans Frontières (MSF) first worked in the country in 1999 and had been responding to the fighting in eastern Ukraine since 2014, but in truth, we were poorly prepared.  

 For many aid organisations, and indeed a lot of Ukrainians, the denial that had preceded the invasion made way to disbelief and, for ordinary civilians, a sense of impending doom mixed with anger. Numerous NGOs left the country entirely, exacerbating the subsequent need for a massive scale-up in the humanitarian response. 

In those first days, between 10 and 15 million people fled their homes. Remarkably, however, we did not witness any panic or looting. No flights were leaving, as all airports, both civilian and military, had been hit by Russian missiles at the outset.  

This was not the first time I had worked with MSF in a conflict zone, nor the first time I had witnessed the start of a major war. However, inter-state invasions are rare (for example, the US invasions of Afghanistan in 2001 and of Iraq in 2003) and the intensive phase, although bloody, is usually short-lived. The situation in Ukraine has not turned out that way at all. 

We moved from Kyiv to Lviv and started redefining and rebuilding our medical assistance from there. Few international staff felt safe enough to stay so we launched our activities mostly with our Ukrainian colleagues, who stepped up to the challenge even though they were all now displaced, and having to find a roof for their families in safer parts of the country.  

The next question was: what would be the most effective course of action in such a fast-moving war? Where could a medical humanitarian NGO make the biggest difference? 

 It quickly became clear that civilians would not be spared. Families leaving Kyiv were killed on the roads leading east and south, as tanks opened fire on sight without warning. We therefore set up programmes to help hospitals deal with mass-casualty influxes and war trauma, a highly specialised field distinct from ‘ordinary’ trauma such as road traffic accidents.  

We also made emergency orders to resupply hospitals so they could cope with the increased trauma workload – a standard approach to war in a middle-income country with a solid specialist healthcare infrastructure. The idea was to help an existing system cope with an extraordinary workload.

However, Ukraine had been at war, albeit a more geographically restricted one, since 2014. It was better prepared than most healthcare systems would be. Yes, some local doctors and nurses left with their families, but the majority stayed.  

By mid-March, we decided to try something new, as some noticeable gaps in healthcare were appearing. One thing was clear: the railways were still working, and remained a key form of transport. Many people, including those with wounds and other vulnerabilities, were travelling by train, usually westwards, away from the heavily shelled eastern and central regions. But the regions and their hospitals were not used to these long-range transfers.  

Late one evening, in a meeting with the focal points from the Ukrainian national railway company, Ukrzaliznytsia, in Lviv, I proposed using modified ‘medicalised’ trains to evacuate patients to the west. They jumped on the idea and recalled that something similar had been done during the Second World War.  

They set about stripping wagons in the railway depot, as we sent medical equipment and technicians to prepare them for intensive care, complete with oxygen concentrators and autonomous electric power. We had no idea if the project would work beyond maybe a few rotations at best. By the end of the year, some 2,500 patients had been safely moved across the country over 80 rotations, often at night, with trips usually lasting 24 hours or more. 

The war also took a toll on ambulance services, as crews were injured or killed and their vehicles destroyed (notably in Luhansk and Donetsk), while the number of war-wounded patients continued to increase. As a result, emergency ambulance transport became a core component of our medical response in the most war-affected regions of eastern Ukraine, with 50 to 100 referrals a week. Typically, we transferred war-wounded patients from depleted Ministry of Health hospitals near the frontline to the relative safety of Dnipro, where they could receive the care they needed.  

In addition, we ran mobile clinics to assist people who had been cut off from healthcare under Russian occupation in Kherson, Kharkiv, Chernihiv, Kyiv and Mykolaiv. As villages and towns were recaptured by Ukrainian forces, we discovered that most of the elderly people who had decided to stay behind or been unable to flee in time had had no access to care or to the vital drugs prescribed to them before the war to manage their chronic conditions.  

In Kherson alone, our mobile clinic services covered over 160 villages and towns, offering both medical and mental health support. Often people had survived, but their villages and health centres had been destroyed by bombs or airstrikes, or even looted by departing Russian soldiers.

The extent of the destruction must be seen to be properly understood. It stretches along a 1,000-kilometre frontline and is dozens of kilometres deep on both sides. Not a single village is undamaged. It will potentially take decades to rebuild the country. Families who evacuated have told me they may never return, while those who stayed are still living in shelled-out buildings with little medical assistance beyond short flash visits.  

It is important to state that the bulk of assistance here and throughout the country is provided by national authorities, backed by dynamic civil society activists who self-organised from day one. They go where no international organisation dares to, sometimes at great personal cost.

Meanwhile, in spite of prolonged negotiations, Moscow has not granted MSF permission to work on the other side of the frontline, in regions of Ukraine currently under Russian control. This is regrettable, as the situations we have discovered in areas previously under Russian control, lead us to believe that humanitarian access there is a priority. Ukrainians with whom we have been in touch in Mariupol, Zaporizhzhia and Kherson confirm the high level of needs and request assistance.

We can only hope this will change, as the war shows no sign of ending and people continue to suffer the constant stress and danger of daily drone and missile strikes.