Dr. Nataliya Pogadayeva, the head of the pediatric endocrinology department at the Ohmatdyt National Specialized Children’s Hospital in Kyiv, relives February 24 as both the day Russia invaded Ukraine, and the start of another war for the life of a child brought that morning by ambulance from Mariupol.
One-year-old Polina from the Ukrainian capital had been visiting with family in Mariupol, the industrial port city that was besieged, destroyed, and occupied by Russian forces after President Vladimir Putin ordered the invasion. The girl suddenly became very ill with the acute onset of Type 1 diabetes. Her tiny body had lost its ability to produce the insulin that cells need to turn glucose into energy. She will spend the rest of her life dependent on insulin injections – regardless of the war’s outcome.
“When the war began, all of the logistics were broken, the pharmacies were closed, many pharmacy staff fled with their children, and we only took emergency cases,” which also included parents with diabetes in desperate need of insulin and children with shrapnel wounds, said Dr. Pogadayeva.
“I arrived in the hospital on Feb. 24 and didn’t leave until April 22,” she told Direct Relief recently when it became clear the war had entered a protracted phase. “During the first month, we practically lived in the bomb shelter,” recalling a missile that fell nearby, shattering glass and depositing shrapnel on the hospital grounds.
Amid Russia’s attack, there was no reprieve for people with diabetes – estimated at 2.3 million before the war – not least the littlest ones. These children’s daily battle to survive is playing out at Ohmatdyt, Ukraine’s main children’s hospital, which draws patients from across the country. Now Russia has unleashed a summertime wave of destruction with missile strikes hitting a shopping mall and its pharmacies in Kremenchuk on June 27, a resort village with a children’s rehabilitation center near Odesa on July 1, and numerous sites including a private medical clinic in Vinnytsia on July 14.
For both staff and patients, Russia’s war on Ukraine has added another layer to their constant medical struggle, one so pervasive that even air raids no longer send people scuttling to the basement shelter – instead, they simply shut the windows. But it’s also a time to take stock and reassess Ukraine’s medical needs, as the country was in a transitional period of healthcare reform even before the war began.
A medical system in transition
One of the government’s most significant accomplishments in overhauling the medical system was the 2018 creation of the National Health Service of Ukraine (NHSU), an agency of the Ministry of Health in charge of modernizing and managing payments. Previously, access to medication varied regionally due to discrepancies in local government financing, said NHSU spokeswoman Liliya Hudz. Thanks to the new streamlined system, as of October 2021 insulin distribution was administered by the NHSU and had more than quadrupled before the war.
“An endocrinologist writes out an electronic prescription that is filled by any participating pharmacy, which is then reimbursed by the National Health Service,” she said. Adjustments have been made for the war: family doctors can now give insulin prescriptions in old-fashioned paper form in case of internet disruptions.
The Ukrainian Diabetes Federation (UDF), which has lobbied the ministry to pay greater attention to the disease and attain World Health Organization standards of diabetes care, was critical of many aspects of the reform. Valentina Ocheretenko, the organization’s chairwoman, says the ministry’s new policies and financial restructuring as part of the pre-war healthcare reform destroyed years of work in creating a network of diabetes awareness and educational programs, but acknowledges that the NHSU’s takeover of the financing of insulin distribution “has worked much better than we expected” and that paradoxically the war made some treatments more accessible. At the same time, she cites statistics estimating that the demand for insulin has dropped by 30% due to people with diabetes leaving the country or living in occupied territories.
Meeting the needs of wartime
Displaced persons have flooded central and western Ukraine as eastern and southern regions, including parts of Donetsk, Kharkiv, Mykolayiv and Kherson, have been bombarded and occupied. Millions of refugees have left Ukraine, primarily women and children, since men aged 18 to 60 are legally barred from leaving.
The invasion initially led to a run on pharmacies, the health ministry reported, and resulted in initial insulin shortages, said Hudz, but the system is now back to pre-war benchmarks, partly due to large humanitarian aid donations, with 2,000 pharmacies prescribing 47 different kinds of insulin. Since the war began, insulin and a list of other medications for chronic illnesses have been provided to patients for free as part of the Affordable Medicines program introduced before the war and expanded since Feb. 24.
In regions where access to pharmacies has been cut off, supplies of medicines, including humanitarian aid, are directed to hospitals. As of June 27, the ministry says that it has received 145,555 ampoules, 146,387 vials and 763,238 injection pens of insulin as humanitarian aid.
“Gradually, humanitarian organizations supplied insulin,” said Dr. Pogadayeva of the situation at Ohmatdyt. “We then distributed it to other clinics, and children got the insulin they needed at our hospital.”
She said that the stress of war has already served as “a triggering factor” for new juvenile diabetes cases. While there are currently sufficient supplies (including donated supplies) of insulin, blood glucose meters and testing strips, Ohmatdyt would like to be able to provide children with skin sensors “so they don’t have to constantly prick their fingers” for blood sugar monitoring, a repetitive trauma for pediatric patients already feeling the psychic wounds of war.
Dr. Pogadayeva dreams of solving another shortcoming in diabetes treatment from pre-war times and ensuring that all children are supplied with free insulin pumps, which deliver insulin continuously through a catheter to patients with Type 1 diabetes. Pumps are supplied from regional healthcare budgets, which poorer regions cannot pay for.
While the bond forged between doctors, patients and parents in the bomb shelters at the start of the war is unique, Dr. Pogadayeva says close ties existed before the invasion and have continued with those who have had to flee Ukraine. Mothers consult with doctors at Ohmatdyt remotely to manage their children’s diabetes since it is much faster than seeing a doctor in Europe.
“It’s not like a doctor and patient relationship,” Dr. Pogadayeva said. “They trust us like their parents or relatives.”
Little Polina is still in Kyiv and visited the hospital on June 22, her second birthday. Dr. Pogadayeva said in July that the child’s diabetes is under control; she is in a good mood and talkative, like many children of her age.
“There are no words about war or illness in her vocabulary,” she said. “She perceives the disease as a way of life and probably doesn’t know yet that things can be different.”
Since the invasion of Ukraine, Direct Relief has secured and delivered 733,800 insulin pen needles, 188,833 10 ml insulin vials, nearly 25,000 glucose meters with 400,000 test strips, and over 3.2 million oral diabetes tablets equivalent to almost 1.5 million daily defined doses. In total, Direct Relief has provided more than 850 tons of medical aid to Ukraine and neighboring countries.
— Sophia Kishkovsky is a freelance journalist based in New York. She worked in the Moscow bureau of The New York Times and has written extensively for The Art Newspaper about the impact of Russia’s invasion on Ukraine’s cultural heritage. Olena Dubynskyi, a Direct Relief staff member in Ukraine, contributed reporting and translation to this story.