November 3, 2024
The Economist
Cut deep into the innards of the southern front, Ukraine’s first underground hospital feels like something out of a James Bond movie. State-of-the-art gadgetry begins with admissions. Wounded soldiers arrive directly from the battlefield: in cars, ambulances, quad bikes, or whatever else can carry them. They are assessed and colour-coded into modules by urgency: “red zone” cases for immediate operations, “yellow zone” for other treatment. Alongside an operating theatre, enclosed in steel barrels several metres below ground level, is an intensive care unit. There is a ventilator, and even a laboratory for blood tests. The centre is set up for sophisticated operations: bone repair, soft tissue reconstruction, and even arterial bypass surgery.
In military jargon, this is a “role 2” facility, the second of four treatment tiers from front-line triage to tertiary hospital care. Doctors move people on if they can. Those stable enough are whisked off to “role 3” facilities, approximately 30km away. The rest are treated and stabilised here, a little over 10km from the contact line. The hospital’s immaculately joined wooden beams—chosen over concrete to soften shrapnel in the event of a Russian strike—project a deceptive warmth, like being in a Scandinavian sauna. The drones and glide-bombs that terrorise the skies outside make clear that this is not a place to relax. Ukraine’s medics are here, underground, not by choice. Like the soldiers they treat, they are among the hunted.
Evhen, the underground hospital’s chief medical officer, grunts at any suggestion that Russia might follow the Geneva conventions, which forbid targeting medical units. “They don’t even know what it means,” he says. To the Russian military, doctors are “force multipliers”—they patch up soldiers and send them back to fight, take a long time to train and are hard to replace. Ukraine now tells its medics to remove any markings that might set them apart. “If you put a red cross on a car, you’ll be fired on within 15 minutes.” The goal is still to get wounded soldiers from the front line to a role 2 treatment unit within an hour, but drones drag out the process, often for hours. The delays often mean life or death; limb or no limb. Leave a tourniquet on for more than a few hours, and tissue damage is irreversible.
Ukraine believes survival on the battlefield is the key to regaining the edge in a war that has become largely attritional. The underground hospitals are a key part of the puzzle, says Roman Kuziv, the 35-year-old doctor who helped design them. A technocratic planner with experience of working as a surgeon in Europe, Dr Kuziv has quickly risen through the Ukrainian ranks: from local hospital chief to medical commander of the entire eastern and southern front. He lets data guide him to new standards and protocols. War pulses through the monitors in front of him. He claims the medical data give him “80% of the picture” about what is happening on the battlefront. Where units are well organised and where they are not. Where morale is good and where it is not. He makes a call to commanders whenever he spots a problem.
Swiping through images on his smartphone—a surreal blend of family photos and flesh wounds—Dr Kuziv reveals the brutal injuries and hard choices his teams face daily. He pulls up a photo of a man with a gaping hole in his upper body, alongside a kidney sliced in two, and a 30cm slab of missile metal that had been lodged deep in his midriff. “Did the man make it?” Remarkably, yes, he did. Another soldier, this time with a deep gash across his back, part of his spine missing, internal organs spilling out. That soldier survived initial surgery in the underground hospital, but died two days later. A third clip shows a soldier in his 30s, convulsing violently as he tries to drink a cup of water. What was up here? “Hydrophobia,” the commander says. “An extreme aversion to water.” In short, the soldier had rabies, caused by a single bite from a cat, and it was too late to save him. The army saw a handful of such cases before culling wild animals in the area.
Almost three years of war have brought Ukraine’s army doctors a mountain of unexpected challenges. Drones have largely rewritten the rulebook on battlefield wounds. The numbers are rocketing, and the attacks are more persistent, more targeted. The “golden hour”—NATO doctrine for evacuating a soldier to proper care within 60 minutes—has become something closer to fiction. Chemical weapons have returned to the field, too, with the re-appearance of agents like chloropicrin, a poison gas first seen in the trenches of the first world war. The gas, used to flush out Ukrainians from their trenches and foxholes, attacks the soft tissues of the respiratory system. At higher doses, it kills.
The demands have seen Ukrainian military medicine develop in quick time. Today’s setup is unrecognisable from seven years ago, when Dr Kuziv first began working with the army. The commander regularly tracks Russian social media to gauge how well he is doing. He’s usually happy with the comparison with Russian front-line medicine. “It’s the second world war over there.” But the demands and need to stay ahead are relentless. The ministry of defence has just approved another 20 of his “role 2” underground hospitals, which are being co-financed by an industrial sponsor. The commander is also working on an overhaul of “role 1” facilities, front-line triage units. According to his futuristic vision, these will be accessible underground by a system of mechanical elevators.
There have been mistakes, thousands who could have been saved. But Russia’s war without limits would test the resources of any military medical service, Dr Kuziv insists. “All-out war gives you one or two months to study and adapt.” NATO countries should be thinking about how they would cope, he says. “Honestly, they are not prepared. They wouldn’t know what’s hit them.”