The frontline of a conflict reaches further than where the shells drop. It enters cities, villages, camps and clinics miles away, in the hearts of those who have fled.
The medical-humanitarian organisation, Médecins Sans Frontières/Doctors Without Borders (MSF) arrived in the Donbas region in eastern Ukraine in May 2014 to provide free primary healthcare and psychological support to those living on land divided between the control of the Ukrainian Government and the self-proclaimed Donetsk and Lugansk People’s Republics.
Since arriving in Ukraine in January 2017, I have witnessed two harsh winters, which exacerbate the effect of having limited or no access to medical care on the (mainly) women living in the conflict zone. On my first visit to Granitne, a frontline village, one lady arrived with the insulin she needed to treat her diabetes in a plastic bag with a hot water bottle, to stop it from freezing on her journey to the clinic. The stories I have heard range from the loss of loved ones during shelling, the psychological trauma of living in dark, damp basements haunting villagers in their sleep, and unfortunately, for some, the loss of the will to live.
The conflict has broken up infrastructure, transport lines, and ripped apart the region’s health system, with many healthcare staff leaving to safer areas. However, for fear of losing their homes and possessions, or for lack of opportunity to leave, many people have stayed.
Sixty percent of MSF’s patients, caught up in the conflict and living along the frontline, are elderly and mostly women. They suffer from chronic diseases and need psychological support to manage the trauma they have experienced over the last three years.
For MSF, it is imperative to ensure that those who have left all their belongings, and in some instances homes they occupied since birth, can access medical care while on the move to safety.
This is not only to provide consistency in their access to medication for life-threatening chronic diseases but to keep psychological trauma at bay - a trauma intensified by the loss of support networks built up with neighbours and families that have had to separate.
The waiting room in Hospital One
In Mariupol, eastern Ukraine, MSF runs four mobile clinics for people who have fled home as a result of a four-year conflict between Ukrainian forces and those fighting for the self-proclaimed Donetsk People’s Republic, in the Donbas region.
In Mariupol’s Hospital One, in the east of the city, MSF staff use two small consultation rooms at the end of one of the hospital’s dimly lit corridors to provide free access to a nurse, doctor and psychologist. The waiting room outside, with benches lining the walls, is quietly tense.
As with most of MSF’s mobile clinics in eastern Ukraine, patients desperately await the doctor’s door to open, many burdened with swollen legs and bad memories. But there is a marked difference in this clinic to those in villages close to the frontline, where despite the sound of shelling, despite a military presence, despite unpredictable public transport and closed health centres, those in the villages are still home.
Patients in Hospital One remained guarded, watching on as one woman described to me her fear of an illness affecting the blood vessels in her brain, requiring intravenous treatment, and as another elderly lady, her arm in a cast, broke into muffled tears as she asked for support in receiving her missing pension.
Eventually, as one 58-year-old woman began to share her story, others chipped in, on the premise that although they all strictly wished to remain anonymous, with the hope of one day peacefully returning home, they felt their stories needed to be heard.
Alongside diabetes, she had high blood pressure, cardiovascular problems and what she described as problems with blood vessels – which the MSF clinic for primary healthcare cannot treat.
“I live in a small village. We have a feldsher station (healthcare professional who provides emergency care), no pharmacy, no doctor, just a nurse practising,” she said.
“We are IDPs, we stay in Mariupol because my husband has a job here at one of the steel plants.”
Alongside her husband she arrived in Mariupol in February 2015, during a period of heavy shelling.
“We have no sleep at night, we are all nervous,” she said.
“I can’t sleep until 4am because of my nerves. I also hear the shelling in Mariupol.”
“Just take away the war and bring us peace”.
“We wish for the peace to come, for the calmness to come.”
‘Our village is dying out’
That day’s inhabitants of the waiting room may all come from different villages, have different stories but are united by their experience.
“There is a picture that really depicts the scene,” the woman said, describing an image on a Russian social media site now blocked in Ukraine.
“There is an image of a house and there is an IDP carrying his luggage and you can see the shadow that he is casting over the house. On the shadow his hands are in that house and not letting it go. The heart of the person really stays in that house.”
Of her own home, she tries, with her husband, to check on it once a week.
“We do not sleep there, we go to the place and come back the same day because I feel really nervous staying there,” she said.
Next to join our conversation was a man who gave the name Nikolai and clutched a small plastic bag bulging with medication.
And so it continued that, as one patient told their story, another offered support through their shared experience, each reminiscing over their peaceful villages before conflict broke out.
“Our village (Myrne, which translates as ‘peace’) is dying out. We have no public transport. We have a distance of seven kilometres to the closest bus stop. We hire a car,” he said. “The roads are in a really bad condition.”
The same man said the bus from his village to Volnovakha district – the nearest small city - cost 100 UAH one way (3.21 EUR) but the nearest hospital which would treat them was in Mariupol – a further 60 km.
“People stay in our village. They can’t afford to buy such expensive medication,” he said.
Of the health situation he said there were ‘huge problems’ and receiving a monthly pension of 1,500 UAH (48.99 EUR) he pays around 150 UAH (4.90 EUR) for a single x-ray.
“I am an IDP here, I was forced to move because of the shelling,” he said, dispirited.
“I used to be an operator of an excavator in an open pit mine for granite.” Now he is unable to find employment.
“Nobody pays any attention to me, just MSF doctors, I can’t really afford to pay for private doctors,” he said.
Others continue to move around in search of safety and comfort, disrupting their medication. 61-year-old Katerina said when the conflict began, there was heavy shelling and she decided to flee.
“First I went to my son, he lives in the north of Russia but then I returned to Ukraine and moved to Mariupol because of the shelling,” she said.
“It didn’t hit my property but there was shelling next to it which hit some of our neighbour’s property.
“You can’t see people in the streets, people are afraid to go outside.
“If they stop killing then we will of course return to the village.”
As a displaced person she became a patient with MSF in 2015, taking medication for high sugar levels which are now improving.
“[In the village] we used to have an in-patient clinic but then it was closed down. Now there is just an out-patients clinic, where people can come and go,” she said.
“Doctors don’t work there on a permanent basis, they used to come one day a month, now they are planning to come twice. The medication is very expensive for us.”
‘We are on the edge’
Sat close to the door, a younger couple waited for their appointment and the man caught my eye. They were from Donetsk.
“I just took my family, we went to a car, took some basic necessities and came to Mariupol,” he said. This was July 22, 2014 “when all the terrible things started in Donetsk”.
“It was three of us, my mother was with us but she died here in Mariupol,” the 59-year-old said, with the tanned skin of a Donbas miner.
“Everything is okay. We rent an apartment here and we have been living in that for all that time.”
The pair receive financial support from the regional social services to cover the cost of rent.
Having worked as both a miner and electric mechanical engineer, he experiences pain in his legs and hypertension.
“People called me to come back to continue to work there but I didn’t want to,” he said.
“I’m [in the clinic] for the first time. We managed to keep on top of the problems on our own but now the prices have really increased. Not only for pills, for food, for everything and it’s getting difficult for us.”
He explained how he spends his days cycling around the town, paying bills, buying food and trying to keep busy. This resilience to keep going, to stay active and ‘normalise’ his situation is a coping-mechanism I have heard from others and one MSF’s psychologists, alongside talking to people close to you about your feelings, recommend to stay healthy in such an uncertain setting.
“We try our best to fix our problems,” he said. “We have no contact with other IDPs. We are here all on our own and we manage to cope with our problems on our own.”
His wife looked less convinced and I asked if the pair have sought any psychological support from the clinic. “No but we are on the edge, the whole family are,” she said while he nodded.
Reluctance to seek psychological support makes the work of psychologists, who report symptoms of acute stress among many patients, a struggle. But it doesn’t hamper their efforts. In this instance, upon hearing of this woman’s unease at sharing her feelings, our MSF psychologist took the opportunity to invite her in to a consultation room, ‘just to see’ how she felt, and in she went.