Ukrainian Army training near Lviv. (Photo: Mihir Melwani)
LVIV, Ukraine—Anton needs morphine. The combat medic, whose squad is on the front line of the war in the Donbas, has 80 soldiers and only 20 doses of the opioid commonly used to manage battlefield injuries during evacuation. “It’s not enough,” he says, over a shaky phone line. “We must have more than we need.” More than six months after Russia invaded, a lightning offensive by the Ukrainian military has recaptured more than 1,000 square miles of territory in the northeastern Kharkiv region, including the city of Izium and strategic rail hub of Kupiansk. Despite that success, the war has descended into a battle of artillery in the Donbas region and across the south, with Ukraine now reliant on deliveries of howitzers, missile launchers and other weaponry from Western allies.
But as the battles get bloodier, the front line is also seeing shortages of essential battlefield medications and supplies. Combat medics are seeing limited oversight from the ministry of defense, leaving volunteers to fill the role of tactical medicine suppliers. In a desperate move, these volunteers are smuggling unlicensed foreign drugs to the front line so medics can properly care for their soldiers. Authorities are turning a blind eye to this smuggling operation—and the front line is making do with whatever they’re sent.Even the 20 doses Anton has are not all from official government sources. “Part of what I have is official, part is unofficial. Nobody is checking how much I have and how much I use.” He’s desperate, and he’ll take whatever drugs come to him. “He came today and said, ‘I have morphine’,” Mykyta, a soldier in Anton’s squad, told VICE News. “I don’t ask him where he got it.”On one occasion, Anton found himself with 10 extra vials of morphine, through unfortunate circumstances: A battalion in the same area came under attack, and many soldiers suffered bullet wounds to their arms and legs. The entire squad was evacuated, and their medic gave Anton his supply of morphine. “If somebody has damage, please use it well,” he told Anton. Mykyta and Anton are at the frontline of the fight against Russia in the Donetsk region, and the situation there is desperate. In his training, Anton learned to administer Ukrainian medications, which the army and territorial defense are expected to supply to medics. But he and his troops now rely on foreign medication, including Tramadol from Poland and morphine sulphate capsules from France. Both medications are opioid painkillers used to suppress pain sustained by traumatic injuries in combat. He’s not familiar with these foreign brands of morphine, but he makes do with what he has: For each new type of painkiller that comes in, he searches Google to find out how to administer correct dosages.
You can find this kind of resourcefulness all across Ukraine, as civilians volunteer what skills they have to support the country’s resistance. Officially, Johanna, a volunteer with a medical background, runs the logistical operation behind a large humanitarian aid warehouse on the outskirts of Lviv. Unofficially—and only when necessary—she facilitates smuggling operations to bring essential controlled pharmaceuticals to the frontline. Johanna’s name has been changed at her request, to protect the security of the ongoing medical supply operation.
Johanna, 40, was a dentist in her past life, and like Anton, she’s making do with what she has. Treating injuries from artillery and mortar strikes requires external bone fixations, which are used to keep fractures in the arms and legs stable, especially during evacuation, when sharp bone fragments can knick arteries and lead to critical bleeding. The devices can cost up to 100 euros each when imported from Germany; Johanna has hired Ukrainian metalworkers to produce them for the war effort for as little as 28 euros a piece. Her operation focuses on the official side of things. Foreign aid imports arrive at her warehouse by the ton, ready for distribution. She receives calls from the country’s east, and sends out what’s required. Often they’re what she calls “Grandma boxes”: crates of aspirin, Panadol, and other necessary supplies she’s assembled for elderly villagers stuck in Russian-occupied and war-torn territories. They’re sent by the van-load to towns under siege, while “hospital boxes”—with IV needles, among other supplies—are sent to short-stocked civil medical facilities in Dnipro and Donetsk, where they’re used to treat critically injured soldiers who’ve been medevaced there.
Then there are Johanna’s “special boxes,” reserved only for her boys in combat. She leans in and whispers, “We have a little bit of a different box for our warriors on the front line. They have some special orders.”“They’re not eating good there. They can’t eat,” she says, explaining why those boxes contain hemorrhoid cream. But the boxes can also contain fentanyl patches, vials of adrenaline, or doses of morphine. While the majority of Johanna’s operations are licensed and perfectly legal, desperate times call for desperate measures, and she doesn’t have enough time or resources to engage in the proper licensing and legal pathways to get scheduled medicines to the front line. Her “special boxes” contain these highly controlled pharmaceuticals that are necessary to save the lives of those who’ve been injured by bullets or blasts; the opioids can be used to manage the pain in the critically wounded, and adrenaline used to restart the heart. Johanna’s supply comes into the country as humanitarian aid by the container-load, a hodgepodge of random pharmaceuticals, some controlled and some over-the-counter. She never knows exactly what’s inside, so it’s a pharmaceutical gamble. Once, she received a full palette of unlicensed Tramadol and Panadeine. Smuggling and transportation of either of these narcotics is punishable by up to 8 years, or as much as 12 for larger quantities. But authorities are looking away, for the sake of their warriors on the battlefront. Everyone seems to be on the same page.
Inside Johanna’s warehouse, metric tons of carrots and potatoes occupy one hall, while stacks of children’s toys and clothes fill another. She led us to one of the largest rooms in the structure, where floor-to-ceiling shelves are filled with boxes of needles, tourniquets, trauma packs, and pharmaceuticals. But the secret pièce de résistance of her warehouse lies in a small corner at the back of the medicine room. Inside an unassuming office closet sit the unlicensed opium, Tramadol, and oxycodone, which Johanna sends out as fast as she can. These special little boxes are transported only by trusted private drivers, and are hand-delivered straight to the front line.“It’s really important that these [dangerous] drugs don’t go to every soldier but just the medics,” she says. The personal first aid kits all soldiers carry, known as IFAKs, generally don’t contain any pharmaceuticals, and Joanna makes sure her special boxes don’t end up in the wrong hands.“I contact the medics personally to ensure they understand what they’re asking for. [Was] he just a massage therapist, or a doctor [before the war]? I ask him, do you need some special painkillers? Some of them say no, but for others, it’s critical.” In the first two weeks of war, some combat doctors at field hospitals in areas under siege ran out of propofol and operated on patients using vodka to numb the pain.Out of desperation, the army has been recruiting some combat medics with little medical background, so Johanna includes anti-overdose medication with every package of opioids she sends. “[W]e can’t be sure that all doctors on the front line are great doctors. That’s why when we send some morphine, we also send naloxone.”
And while her official meds will go through official channels, with trucks and delivery vans shipping them to distribution points closer to the front line, Johanna only trusts her shipments of unlicensed medicine to locals who are familiar with the front-line area. If she needs a delivery to a front-line position in Donetsk, she’ll recruit a “normal guy driving his normal car”—somebody who calls the combat area home, and won’t have any problem getting through checkpoints. He’ll drive from Donetsk to the Lviv warehouse, where Johanna will personally hand him the box. He’ll then drive back to Donetsk and personally hand it to the front-line medic who requested it. There’s no middlemen and no documentation. It’s a process based on trust.“If I don’t hear from the medic that the box was delivered, I’ll never give [the driver] anything again. And I’ll tell other volunteers never to work with him,” Johanna explains sternly.
Johanna is frustrated that the army has both neglected medical supplies and holds what supplies it has to a standard she says soldiers can’t afford in a time of crisis. If the front line needs more medication, some hospitals refuse to send their stocks of marginally expired pills to support them. Even “expired” bandages cannot be used, though the soldiers on the front line don’t care about the date on the package. “When I speak with people on the front line, they tell me they need everything. I say, ‘I have pills with expiry date of last month,’ they say, OK, please send it,’” Johanna said.
“For the army, the priority is weaponry. Not drugs.”
Andrii is a combat medic leading a company of soldiers in the trenches of southern Ukraine. He’s different from many combat medics: In another life, he was a medical doctor with a Ph.D. in clinical immunology. When the Russians invaded, he arranged the evacuation of his family to Western Europe and went straight to a recruitment center. “I brought few personal belongings here. They are my toothbrush, my phone, and one Metallica T-shirt,” says Andrii, as he blasts a Kasabian record in the trenches. Andrii instructs all of his medics against using painkillers for soldiers with heavy bleeding in the red zone, where troops are under risk of direct attack (tranexamic acid, which reduces blood loss, is one of the few drugs Andrii uses in the red zone). But pharmaceuticals are also needed to treat all kinds of war injuries and illnesses: respiratory infections from cold nights on watch, digestive infections stemming from unsanitary trench conditions, spinal injuries from sprinting with 45 kg of combat gear on your body. Antibiotics, antiseptics, and painkillers are some of the most used drugs.Andrii has no shortages of supplies in his trench, but that’s because “100 percent of supplies I use in my combat medical practice is from volunteers,” he says. He refuses receipt of medical supplies from the ministry of defense, because of the bureaucratic roadblocks associated with official military processes. Andrii has not worked with Johanna, but he has his own network of trusted volunteers to supply all his equipment. “My task is not to make good account reports. My task is to increase the number of people [who can survive if given medical aid]. I know that it is much easier to contact volunteer organisations, send them a list of what I need, and receive directly. You do not encounter stupid walls like you do in the system. [Volunteers are] just more utilitarian.”
Johanna believes the only way the current army medical system can change in the long term is with oversight, and a helping hand from Western allies.“If you’re a child, and you’re growing all the time, how do you know that a knife can cut your fingers? You try it, and then you know. Your teachers and parents tell you. We need somebody who can show us and provide control. I think Ukraine is like a child.”In the long term, she says, the country needs to learn from its more experienced allies. “In the short term, we just need money.”