"From the air, hunger, fire and war ..." – in recent decades one would only hear this solemn Polish Catholic supplication chant during Lent. However, we have turned a page in history and new chapter has begun, full of challenges, and the enormity of which has yet to fully register in the social consciousness. When in early 2022, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic appeared to be the biggest global problem, a new threat emerged. In only the first seven days after the 24 February Russian invasion of Ukraine, over one million people fled from Ukraine, and of that number, 600,000 arrived in Poland (according to United Nations High Commissioner for Refugees data). This is the fastest mass exodus of people from a European country torn by an armed conflict since World War II. By the 20th day of the invasion, 3 million people had fled from Ukraine, bringing 1.8 million to Poland (United Nations data) [1]. At that time, the European Commission was estimating up to 7 million refugees could cross over, but that there could be more if the scale of hostilities continued or intensified [2].
These staggering numbers translate into concrete human dramas. 17 people, including pregnant women, were injured when a maternity and children's hospital in Mariupol was bombed by the Russians. News media around the world circulated a photo of a young pregnant woman being stretchered out of the rubble by rescuers – the woman and her baby died of injuries – and that photograph has become a shocking symbol of the barbarity of this war (Additional file 1). Ukrainians often do not even have a chance to say goodbye to their dead – during the attack on Azovstal in Mariupol, ceasefires broken by heavy Russian shelling have made it impossible to remove the bodies of the dead. To speak plainly, at the day of Russia’s highly symbolic May 9th celebrations, the ruins of Mariupol have become the backdrop for a celebration of destruction rather than of victory.
In Albert Camus’ allegorical novel The Plague (1947), whose Mise-en-scène is a 19th century epidemic, one character says: ‘It’s impossible it should be the plague, everyone knows it has vanished from the West’ [3]. Echoing the sentiments of this expression in relation to the war in Ukraine, we want to show the extraordinary story of characters who are all too real in the current medical and social conditions.
Connected by an allograft
Two girls, 9-year-old Tetiana from Ukraine and 5-year-old Marcelina from Poland, who suffer from atresia of the biliary tract with polysplenia and visceral inversion. Fate brought them together six years ago at the Children's Memorial Health Institute in Warsaw, where they underwent a liver transplant. Now they have met again since Russia invaded Ukraine.
Tetiana’s family consists of her 24-year-old sister Yiuliia, in the 32nd week of her pregnancy, and her 48-year-old mother, Svietlana. When the war broke out, the girl’s father, Vlad, and Yiuliia’s husband Anatol remained in Ukraine to fight for their homeland. Tetiana’s transplant coordinator in Warsaw was concerned about the possible fate of the girl and her family and she persuaded them to flee to Poland. At the same time, the President of the Polish “For Life” Foundation, working on behalf of post-transplantation children, searched for a new home for them. It was then that families were brought back together by the allograft: Marcelina’s parents, when the war commenced, decided to host Tetiana’s refugee family in their apartment in Gdańsk. Unfortunately, when the family arrived, it was discovered that they suffered from several health problems that had not been well provided for in Ukraine (orthopedic and dental issues in Svietlana; gastritis, dental problems, and impaired vision in Tetiana; and growth retardation of the fetus was also suspected). The Polish woman Paulina, mother of Marcelina, who is equally burdened by the chronic illness of her own child, willingly agreed to host the refugee family because she understood their situation, one that is significantly worse than her own. In this position, Paulina has become a health visitor, social worker, and psychologist trying to secure appropriate care for her Ukrainian guests even while continuing with her everyday life and work commitments (Additional file 2). Paulina (Author [MŚ] had cared for her during her pregnancy) brought the Ukrainian family to me when they arrived in Poland and asked to examine the pregnant Yiuliia. Her fetus was developing normally. A week later, Yiuliia was seen by a public sector doctor, who, without examining her, referred her to a hospital that she did not have to go to.
There is no proper post-transplant care in Ukraine (including comprehensive blood testing, immunosuppression level management, fever management, and dental care). In Poland, in addition to helping with her underlying disease, Tetiana received dental care, a food allergy which was associated with abdominal pain was diagnosed, and she qualified for tonsillectomy. In addition, art therapy classes were organized for her. We decided that this method would be effective in the case of a child with post-war trauma. What's more, therapy through art allowed us to break down some of the language barriers (Additional file 3) (ZB).
After a few days, Yiuliia's husband decided to take his family back to the war-torn country. In this context, it is worth noting that officially, Ukraine has been asking refugees not to return yet, fearing that having fled once they will have to do so again. On the other hand, many refugees are also suffering from, and compelled by their Survivor Syndrome guilt.
Help millions one person at a time
One of the key elements of support in a war situation is the provision of medical assistance. There ongoing shipments of medical supplies, ambulances and specialist equipment being sent from Poland to Ukraine. This humanitarian assistance helps non-government organizations (NGOs), foreign foundations (e.g., in oncology, St. Jude's), the medical council, scientific societies, and hospitals.
The most vulnerable, namely pregnant women and children under 5, as well as the chronically ill (e.g., diabetics), are provided for first. The evacuation of vulnerable and seriously ill patients is complicated due to a variety of issues, including their clinical condition, the need to comply with regulations governing children crossing a border, difficulties for fathers related to the prohibition of men leaving Ukraine, and the ban on Ukrainian truck drivers from crossing the border into Poland.
During the first three weeks of the 2022 war, approximately 1,800 Ukrainians were admitted to Polish hospitals, and half of these were children, including patients requiring dialysis and cancer therapy. Bank Pekao analysts estimated that the cost of hosting 2 million refugees from Ukraine may require government expenditure of PLN 24 billion (EUR 5.04 billion) during 2022 and 2023.
Medical assistance has also been available online. Two doctors from Białystok set up a group called “Medics for Ukraine”, which connects practitioners from various medical professions [4]. The purpose of this initiative was to facilitate the linking those people who need medical help with those who are willing and able to provide it. So far, over 16,000 medics have registered. Medical services have also been provided within Poland at border crossing points, along the ‘green corridors’ used by refugees on the Ukrainian side of the border, and doctors are offering free in-clinic consultations for refugees.
Notwithstanding the dramatic humanitarian needs arising from the war, the coronavirus disease 2019 (COVID-19) pandemic has not gone away and cannot be forgotten. Since the end of February, Poland’s south-eastern border has seen a massive influx of people from a country where the COVID-19 vaccination rate (34.5%) has been one of the lowest in Europe.
Fragile affections and a shared fate
No country can withstand the impact of such a rapid and massive migration without stress. Of first importance, is the need to work towards creating a system that could be resistant to all kinds of crises, that is operationally flexible, that can adapt to changing needs, and that is realistically financed and well managed. After all, we need to care for all those who have escaped the war, into Poland, and who are likely to remain in our country for some time. Both individual and groups of medical practitioners, as well as NGOs, must be able to meet the refugees’ health care needs in a more organised way than we did with Paulina and her family. Part of this is to develop a nationwide register of refugees who receive assistance, to know what kinds of skills and resources they need.
Secondly, there is no doubt that the arrival of Ukrainian doctors in Poland may be extremely valuable in boosting the provision of medical care, especially given the language needs of Ukrainian patients, who mostly speak Ukrainian and/or Russian. However, how these doctors are integrated into the Polish system need to consider that the training of doctors in Ukraine is fundamentally different than in Poland in many respects, including that specialization lasts one or two years (not four to six), and relatively few know the Polish language.
The third matter, and this is no less important than other needs during wartime, is that we must take care of ourselves and of our own society, because only then will we be able to help our guests from Ukraine. This sentiment can be seen in the article “Historical perspectives on xenotransplantation” by Schlich and Lutters in which the authors discuss how the history of medicine, and its socio-political contexts, touch human lives [5]. When we consider that the procedure of xenotransplantation has encountered a series of social obstacles that the authors call a form of “cultural rejection”, we can see there are likely to be parallels in the present social domain, between host and refugee. We are convinced that long-term assistance to refugees in Poland must begin with the Poles themselves. We cannot allow prejudices, a badly organized health care system, or an unfair distribution of financial resources to ruin the very community that we want to share and co-develop with our Ukrainian guests.
In Poland, there is a very long tradition of rapid “mass movements”, but that history is also full of the failure of such movements, many of them uprisings, not only because of external forces. Given this history, and the present context, medical practitioners must not forget about themselves. Long periods of providing voluntary help are exhausting both physically and mentally. The enormity of suffering and the prospect of failing to help everyone who needs help can lead to a feeling of hopelessness and burnout. That is why it is important to foster solidarity within the medical community, and tenderness, expressed as concern for others and the consciousness of a shared fate. As the Polish Nobel laureate (2018) Olga Tokarczuk says: “Tenderness is the most modest form of love. […] Tenderness is spontaneous and disinterested; it goes far beyond empathetic fellow feeling. Instead, it is the conscious, though perhaps slightly melancholy, common sharing of fate” [6].
Postscript
The refugee family that we helped have returned to Ukraine. Our feelings about their decision match those expressed by Paulina in this message:
I have mixed feelings. On the one hand, I understand it, because Mrs. Svietlana said that she had to plant vegetables so that they could eat all year round. On the other hand, I think it's a stupid decision. After all, Yuliia could stay at least until the birth to be sure that the baby was healthy. I would not have gone back, if only because of the health care needed for Marcelinka.
But the most important thing on our minds is that this decision did not have to be made by no one of us and we must accept it. This is their life and choice after all.