Dr Christos Christou's letter from Ukraine

7 October 2022

Dear Colleagues, Dear Friends,

I’ve spent the past two weeks visiting Ukraine, meeting MSF staff and patients, and seeing our programmes on the ground. My primary goal was to take time to be able to listen to the views of those working there, and send a message of support from our movement. It was great to be able to meet with our staff, and to gain a better insight into the challenges they are facing. I also wanted to reaffirm our commitment to providing medical humanitarian assistance to all those affected by this conflict, regardless of constantly moving frontlines, or where people have sought refuge. In order to achieve this, we want to be able to move both staff and supplies from both Ukraine as well as the Russian Federation to the affected areas. The overall situation is chaotic and dynamic, with many rapid changes on the ground. However, as a movement we can be clear: MSF is committed to supporting people in need, whatever side of the frontline they happen to be.  I also wanted to have initial conversations around a Host Country Agreement that will help us to achieve this. It will allow us to operate using a different legal status and operational facilities, that will be greatly beneficial to the further development of our medical activities and support there.

Our work in Ukraine goes back to 1999. Initially, our focus was on offering treatment for HIV/AIDS, TB, and Hepatitis C. Then, between 2014 and 2019 we operated mobile clinics, serving those affected population of Donbass and Crimea. Subsequently, projects we run in the country have been scaled up, and we are providing a range of support to the wounded and sick in those areas most affected by the current fighting. In the East, we are working with the Ministry of Health and the Railways, in order to provide medical evacuation from frontline areas. We are also working closely with local volunteer networks, to try and send medical assistance into districts beyond the frontlines, and doing everything we can to support the ability of those networks to offer medical care to displaced people. By partnering with local groups, our work reaches far beyond what we could achieve alone. Our staff are also treating patients – particularly those with chronic diseases and primary care needs – and we have mobile teams who are providing mental health consultations. In addition to this we have, in recent weeks, commenced a long-term rehabilitation programme for the wounded.

I crossed from Poland and arrived into Lviv - a kind of operational hub for our staff and supplies – where I met with our teams. They spoke of their pride and motivation in working for MSF, but some also wanted to share other feelings. Those who had been working with MSF before February talked about the bitterness they felt in the early stages of the conflict. “The very first days we felt abandoned, not informed and not included in any of the tough decisions made by our coordination teams. As if there was no analysis, no preparedness and no plan to show that MSF values and supports those of us who left and those who stayed in the affected areas. It was disappointing to see how people get lost in rules and policies, neglecting common sense in a stressful moment like that. But after a few days, MSF got back in business, and they did an amazing scale up.” In addition to voicing these feelings from the start of the conflict, we discussed the obstacles on the horizon, including the increased needs of the internally displaced during the winter months, and the great challenge posed by affected populations living in areas beyond our reach.

The next morning, I met with our teams coming together in Ivano-Frankivsk, who outlined the way that MSF is supporting hospitals, reception centres, and providing vital mental health services. As they spoke, their passion and energy were clear. “What does it take to create an MSF entity in Ukraine?” they asked me. I explained that there was no magic recipe and encouraged them to join in with our associative life, interact with their society, and keep doing what they were doing!

Then I took our medical train to Dnipro. It’s an impressive thing – a former charcoal train with several wagons, now transformed into inpatient wards, a fully-equipped ICU, and even additional carriages with oxygen generators. There is space for other patients as well as carers to stay, and wagons with batteries and generators to ensure a reliable supply of power. As we headed to Prokovsk, I had the chance to speak with our colleagues. One of them was Albina, an associate professor in medicine school. She had been busy helping her foreign students evacuate at the start of the conflict. Once they had been able to leave, she then concluded that she too must go. As she reached the border ready to cross over, an MSF poster calling for people to join caught her eye – and that’s exactly what she did, later finding herself part of the team on the hospital train! Staff and patients shared hard stories. Some had lost everything but still felt they could not leave their homelands and travel west. Many of the children wore expressions of, “why is all this happening and why to me?” But there was also one who disembarked the train and said, “that was the best trip of my life!”.

We arrived in Dnipro with the dawn. Another MSF team was waiting to drive us to Zaporizhzhia, an industrial city with a large nuclear plant, in an area recently taken by the Russian army. Here I met with the leader of the local district, who offered me an insight into the challenges of trying to keep occupied areas supplied with basic items. He had been forced to flee his area, and now worked to bring supplies across checkpoints and into the hands of those who need them. This was also the work of a small NGO I spoke to, as I tried to understand how MSF could better support in areas where we could not be physically present. We call these “cross-line” activities, and they come with many limitations, perhaps most significant of which is that we cannot by ourselves assess or meet the needs of  patients. Inevitably, we cannot always be sure of where supplies end up, or if they are denied to those who may be seen as standing with “the other side”. But in a situation where there are few options, cross-line activities have their place, and they offer a better choice than doing nothing. Such activities are not new of course, and many of our staff have fresh memories of trying similar approaches in Syria.

The following day we drove via convoy to the Kharkiv region, to Kostiantynivka, a city in the north east and close to the front line. At points on the journey, it was hard to imagine how close the conflict was, as we looked out over beautiful, seemingly endless fields of sunflowers. Then the smoke and fires came into sight, shelling on the horizon, and finally the battlefields. Arriving at the hospital, I met with our emergency doctor and surgical team. They work hand-in-hand with Ukrainian colleagues from the Ministry of Health, without any military presence, and provide emergency and surgical care to the population. Once again, the recent experiences of patients were shocking. One man, on a ward and fitted with a chest tube, had been transferred following a bombardment that had killed five people, including his wife. Down the corridor, the man’s father was also a patient, still in a state of shock. 

Later on I had a chance to meet with our surgeon, Martial, who had just finished an exploratory laparotomy on yet another wounded civilian. He is in his seventies, and joined MSF back in the 1980s. He was one of the founders of the Belgian section, and has worked with the organisation in several conflicts across the globe. “The surgeons in Ukraine are skilful and highly trained… so, you need to wait until they ask for our help, and this is what is now happening here. We cannot suddenly change their habits, but we can slowly share with them our knowledge by just giving them a hand every time they ask for it” he said to me. It was a real insight being able to speak with someone who despite all of their valuable experiences remained so humble and committed – one from the “old generation” of MSFers still working on the very front.

From there we headed back to Dnipro, where the nights are broken with sirens and the need to move into the bunker. The Ukrainian counter-offensive had begun, and the sirens were warning us of the air-strikes that the Russians were launching in response.

With the unpredictable nature of the situation at the forefront of my mind, I wanted to meet with the authorities. I wanted to listen and understand how we could do more, and how we might be able to come up with ways to help those people who remained out of reach. Before these meetings, I visited our rehabilitation and physiotherapy activities in a hospital in Kyiv. I met with our teams and some of the patients. I visited the new department - fully equipped with new instruments by MSF. It was here that I met Hassan, a physiotherapist from Jordan, with deep experience from other wars in Afghanistan and the Middle East. “People here are not used to seeing foreigners from countries like mine. We have much to share, but it’s so tough to shift mindsets and apply new techniques. We need to do it by having them in the driving seat” he explained, sounding a bit sceptical but optimistic at the same time.

While listening to him though, I was struck by just how powerful the notion of sans frontierism can be. You just have to look at our staff there: 150 people from countries including Canada, Colombia, Argentina, Japan, Jordan, Brazil, Turkey, EU states, Ghana, Burkina Faso, and Iran. Together they work alongside more than 500 Ukrainians, all of them committed to assisting fellow human beings.  

Across all of my meetings and media interactions in Ukraine, the same questions kept on appearing.  What more can we do? What is going on with those civilians, for whom we have zero visibility? How can we reach them? Does the world understand that we, as a medical humanitarian organisation, must keep trying to negotiate access with all sides?

From our teams, there were also similar questions. Are we happy that we are doing enough? Are we meeting humanitarian needs? Are we reaching enough patients? What should we be expecting in the coming months? Do we need all five Operational Centres to be present in the longer term? Other questions addressed the issues facing our “cross line” activities, whether they were doing enough, and whether it was realistic to try and run them from the Russian side. Familiar questions also arose, such as what neutrality means in a context like Ukraine.

Before leaving Ukraine, I spent the morning visiting the train station again. Our train had just arrived from another long trip from the East, carrying the wounded, those with medical problems, and other so-called social cases. Tankred, the medical coordinator, explained that there were elderly people from care homes, who had to be evacuated, “but had nowhere to go. They are invisible, outside the social net. What we are doing here, is trying to meet a true humanitarian need.”

The people were disembarked before being moved by ambulance to the places we had located. And then the train rolled on. Next stop Vinnytsia. And then Lviv...

As a movement we’re constantly being confronted by dilemmas that are not new, but which are none the less important to tackle. As I said in my letter at the start of this conflict, all situations are unique but also the same. We see similar patterns of human suffering, civilian casualties, and the longer-term consequences for all. I was struck with what Vitalyi, our advocacy advisor, said to me. He had perfectly organised and coordinated my visit, and accompanied me in all meetings. As we travelled back to Lviv, he told me that, “every male in this country, between the ages of 18 and 60, is not allowed to leave the country and may be conscripted. I may be next. I have never been trained in fighting, and I will be lucky if I stay alive for more than an hour in the battlefield.” In recent days, hundreds of young Russians now also find themselves in a similar situation.

Uncertainty dominates the situation. But in our approach at least, we can be clear: we stand in solidarity with our people in Ukraine, our people in Russia, and all those who may be targeted or discriminated against for working with us. We stand by those who are forced to take impossible decisions to care for themselves and their families. We stand in solidarity with all those affected by this conflict, just as we always try to stand by our people, our patients, and their communities in all places where we provide medical and humanitarian care. This much, at least, we can be clear on. 

As I left Ukraine the border was quiet. A few people were waiting to move out, and empty tents left behind by NGOs stood as a reminder of the massive exodus a few months before. This same spot has now been replaced by a line of tens of kilometres, with trucks from both sides, trying to keep on with their trade…

This war has already brought many geopolitical shifts – the kind that might otherwise take years or even decades to come about. And it’s not going to be over anytime soon. But it is not the only tough situation facing the world at the moment; we must keep that at the forefront of our minds. Afghanistan’s health services are collapsing; Pakistan is challenged by extreme weather conditions; populations in Ethiopia are still without access to any basic health services or any essential medicine; Somalia, and the Horn of Africa, are facing extreme food insecurity and crises of malnutrition. People are still stranded in the “mega camps” of Cox’s Bazaar and Dadaab; drowning in the Meditteranean Sea, living in inhumane conditions in the Greek islands, or held  in detention centres in Libya. In Haiti, the complex social, economic, humanitarian, and political situation is combining with an escalation in violence to bring utter chaos, preventing our teams from accessing those in need and forcing many people to flee. 

This is the world we are living in.

These are the situations in which we work, and about which we must consider how our energy and resources can be used to greatest impact, in every sense. We will continue to mobilise MSF resources - from right across the world - and send them to those who need them most. To those who are neglected; to those who others cannot help; to those in greatest need. Thanks to generous support from millions of individuals, the huge effort by all our colleagues who enable and implement our work, and all those who trust their lives to us, we will keep challenging ourselves on how to do it better. We will keep holding ourselves accountable for our choices, and we will keep looking at how we can engage more with those in need.

Just as Samedi said to me when I met him in Chad: “Fasten your seatbelts: there is a lot of work to do!”

Dr Christos Christou

International President

Médecins Sans Frontières ׀ International Office

CP 1016 ׀  Route de Ferney 140 ׀  1202 Geneva 1 ׀  Switzerland