“Don’t go down there,” warned Andrei, a Ukrainian police paramedic, as he stubbed out his cigarette and scratched his beard. He and his boss, another paramedic named Andrei, then got back in their car and drove off to work. (The two men did not give their last names to protect their anonymity.)
“There” was four miles down the road: Pokrovsk, a Ukrainian mining city that is currently one of Russia’s major war objectives. The two Andreis are police paramedics in Donetsk Oblast, which has been violently contested since 2014. Driving an unarmored civilian car with a life-size rubber severed hand jammed in the dashboard as a macabre gag, the two men brave Russian shellfire, rockets, and attack drones daily in order to treat and evacuate wounded civilians and soldiers from Pokrovsk and the rest of Donetsk. Like virtually all Ukrainian medical personnel, the two Andreis are volunteers.
“Don’t go down there,” warned Andrei, a Ukrainian police paramedic, as he stubbed out his cigarette and scratched his beard. He and his boss, another paramedic named Andrei, then got back in their car and drove off to work. (The two men did not give their last names to protect their anonymity.)
“There” was four miles down the road: Pokrovsk, a Ukrainian mining city that is currently one of Russia’s major war objectives. The two Andreis are police paramedics in Donetsk Oblast, which has been violently contested since 2014. Driving an unarmored civilian car with a life-size rubber severed hand jammed in the dashboard as a macabre gag, the two men brave Russian shellfire, rockets, and attack drones daily in order to treat and evacuate wounded civilians and soldiers from Pokrovsk and the rest of Donetsk. Like virtually all Ukrainian medical personnel, the two Andreis are volunteers.
Ukraine’s front-line combat medics do valiant work as the first echelon of casualty care. But nearly three years into the full-scale war, there are still too few of them. Ukrainian medics usually have just four weeks of training—a quarter of what U.S. Army medics get. This limits them to providing the bare basics: administering medication, fluid resuscitation, and stabilizing traumatic injuries. And the Ukrainian Armed Forces currently have less than 50 percent of their required combat medics, according to the staffing reports of dozens of senior medical officers provided to us during a research trip to Ukraine in September.
The limits of Ukraine’s medical mobilization are even more acute at the next level of military clinicians: the doctors, nurses, and other medical professionals who determine life or death for the seriously wounded soldiers brought to them by front-line paramedics like the two Andreis. They provide what NATO militaries call Role 3 and Role 2 care: field hospitals and forward surgical support, respectively.
Like many things in the Ukrainian military, the situation varies widely from unit to unit. In Donetsk, one brigade’s chief medical officer told us how extremely lucky he was to have a full complement of 30 doctors and nurses. But an adjacent brigade, he said, had to make do with just three clinicians and not a single surgeon or anesthetist. Several senior medical officers told us that around 1,000 additional doctors are needed to cover the demands of front-line units alone.
A major problem is the Ukrainian authorities’ refusal to systematically mobilize medical personnel. An old regulation from the days of the Soviet Union requires all Ukrainian clinicians to be registered for a military emergency. But Ukraine is not currently enforcing this law; doctors and other medical personnel are only mobilized if they are caught up in the broader, corruption-riddled draft to which all men over 25 are now subject. As a result, clinicians are not being systematically mobilized or utilized to help near the front. Most of those serving are volunteers, including a small corps of foreign medical volunteers numbering several hundred at most. But Ukraine’s reliance on domestic and foreign volunteers is unsustainable.
One reason the government has been hesitant to mobilize is that Ukraine’s civilian health care system is already grappling with a critical shortage of doctors, driven by low salaries and decades of brain drain as medical professionals sought better opportunities abroad. Although Ukraine is a renowned training hub for foreign medical students, the domestic retention of its doctors remains a struggle. One brigade surgeon told us that when medical school graduates were sent to him through the mobilization system, they were invariably doctors in name only: They had the degree but no practical experience, having switched to more promising professions after graduation.
Medical care is often hailed as a Ukrainian advantage over Russia. Despite the personnel shortage and often inadequate training, Ukraine experiments and innovates to save as many lives as possible. It has hardened hospitals (which Russian forces deliberately target) and became the first country to conduct combat medevacs with drones. Although each side’s total casualty numbers are well-guarded secrets, by all estimates Ukraine is losing people at a far lower rate than Russia, not least due to Moscow’s preference for deploying its infantry in atavistic meat grinder attacks.
If Ukraine’s medevac capacities have manpower shortages, the situation on the Russian side is incomparably worse. On Russian Telegram channels and elsewhere, reports abound of wounded soldiers just being left to die on the battlefield. The numbers speak for themselves: Ukraine records an estimated five wounded soldiers to every one soldier who dies. On the Russian side, that ratio was estimated to be as low as 2-1, indicating an enormous number of preventable deaths from battlefield wounds. Western armies have not experienced a similar proportion of wounded to killed in more than a century.
On the Russian side, front-line medical capacity ranks low on the list of priorities; to the Kremlin, life is cheap. Russia’s forlorn brigades are manned mostly by men considered expendable in Russian society: ethnic minorities from the country’s periphery, prisoners, the rural poor. They are not conscripted but lured into service by enormous bonuses or, in the case of prisoners, promises of freedom. In the Russian system, medical care for these men is an afterthought at best.
Ukraine’s medics and military clinicians are better than Russia’s, but the need for them is also far greater. Total Ukrainian casualties are approaching perhaps half a million killed or wounded, with an estimated 40 percent of wounded Ukrainian soldiers suffering permanent injuries. Soldiers are a precious resource, especially given Ukraine’s smaller population, the absence of total mobilization, and the greater value the country places on citizens’ lives. With the average age on the front line between 43 and 45, soldiers physically fit enough for the rigors of combat are in even shorter supply. Prompt and skilled medical care can be the difference between a soldier being severely disabled for life and one able to return to combat.
The speed and quality of front-line medical care is critical not just to saving lives, but also to morale. Competent care is a motivational boon, stiffening the resolve of soldiers by giving them the confidence that they are in good hands and will recover if they are wounded. The absence of good medical care, easily publicized in the age of social media, has the opposite effect, demoralizing soldiers and providing the enemy with an enormous psychological weapon.
There are no technological or logistical silver bullets at hand. Medical supplies to front-line units are now better and more consistent than in the past, despite the struggles of Ukraine’s military medical bureaucracy. Farther from the front, well-equipped and fortified hospitals save many lives. But during the critical first hour of trauma casualty care, the most important factor is having enough skilled medical personnel on hand where they are needed.
Ukraine’s foreign supporters have helped on the margins. Though a small corps of foreign medical volunteers have done brave and valuable work, they now number in the hundreds at most. Ukraine’s reliance on volunteers, both native and foreign, is unsustainable.
There are ways that Ukraine’s Western partners can help, even though NATO countries will resist the idea of deploying their military medics and surgeons to Ukrainian battlefields. European military or civilian clinicians could relieve some of the pressure on Ukrainian civilian hospitals away from the front, freeing up Ukrainian medical staff to be mobilized. This would also be a good way for European NATO members, their military stocks largely exhausted, to show the incoming Trump administration in Washington that they are serious about supporting Ukraine.
But Ukraine’s Western partners cannot solve the fundamental problem of Ukraine’s refusal to mobilize.
Ukraine’s missing medical mobilization parallels the much larger failure of its military mobilization. Although Kyiv has steadily increased the scope of its conscription efforts, it has stopped far short of a general mobilization and still refuses to draft men under 25. As Kyiv stares down the barrel of a second Trump administration that seems likely to push for negotiations on Russia’s terms, Ukraine faces hard choices. Raising sufficient troops may be the decisive factor in the war’s fourth year.
The tremendous bravery and sacrifices of Ukrainian soldiers and civilians, many of them volunteers, have camouflaged the failures of mobilization and enabled Ukrainian President Volodymyr Zelensky to delay an unpopular but necessary ramping up of conscription and compulsion. If Ukraine wants to survive, let alone win, it needs far more soldiers and the doctors, nurses, and medics to keep them in the fight.
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