Hematologists have been on the front lines in the battle against cancer and debilitating hematologic conditions for decades. But when fighting of another sort breaks out and countries are thrown into war or conflict, a new danger threatens patients with chronic or life-threatening blood diseases.
Suddenly, these patients are not only forced to find ways to survive, seek shelter, and find food amid constant bombing and air raids, but they also must find ways to continue their treatment even as hospital infrastructure may be damaged, electricity may be lost, or critical staff are called to fight in the war effort.
These challenging conditions are a reality for those living in the midst of the ongoing war in Ukraine as well as the war plaguing the Israel and Gaza region. But as physicians and patients in these war-torn areas find themselves in undesirable circumstances, the international medical community has stepped up to help.
Whether its finding innovative ways to get these countries the medical supplies, drugs, and mentorship they need to continue providing treatment within their own country or helping critically ill patients evacuate to other countries to receive care, numerous medical organizations have been doing what they can to ensure no patient is left behind.
War Presents Unique Challenges for Patients and Physicians
One of the biggest challenges many physicians in areas of conflict face is maintaining treatment, despite frequent attacks on hospital infrastructure. In May, The Washington Post reported there had been about 90 documented incidents involving hospitals in Gaza since the war broke out in October 2023.1 In the first year after the Russian invasion of Ukraine, a report in the BMJ found there had been more than 700 attacks on hospitals, health workers, or other medical infrastructure in Ukraine.2
Arnold Ganser, MD, chair of the American Society of Hematology’s (ASH) Crisis Management Work Group and a professor of medicine at Hannover Medical School in Germany, told ASH Clinical News that most of Ukraine’s radiation therapy units “were destroyed by bombing” and many of the laboratories in the country were run by private companies that moved out when the conflict began.
The frequent bombings could mean that physicians suddenly had to change course if part of a hospital was damaged. For example, a hematopoietic cell transplant (HCT) may have started in the ward and been finished in the bomb shelter.
Even before the war, Ukraine had struggled with drug shortages, but those shortages were made more severe as the fighting broke out.
“It was difficult to get drugs into the country,” Dr. Ganser said.
Dr. Ganser explained that after the Russian invasion began, many drug suppliers left Ukraine, and the public hospitals often had to adapt treatment protocols to meet the needs of patients, unless the patient themselves or a relative brought in their own drugs.
Ukrainian physicians also struggled to keep track of their patients.
“Their neighborhoods were being bombed, so patients were by themselves, leaving the area to go somewhere else. How do we keep track of them so they are still getting the care they need?” said Lorna Warwick, chief executive officer of the Canada-based Lymphoma Coalition.
Ms. Warwick added that many hospitals were also dealing with staffing shortages. Although physicians were exempt from being conscripted in Ukraine, other medical staff and technicians were not and could be called to join the fighting.
In Gaza, Duha Shella, MD, wrote in Intensive Care Medicine that the lack of electricity and fuel as a result of the attacks endangered patients on ventilators or monitors.3 As wounded patients continued to flood the overtaxed hospitals, one physician described the scene as a “vision of hell.”
Treatments Interrupted
For patients with chronic blood disorders or cancer, significant delays in treatment can be the difference between life and death.
“Especially with the aggressive types, if their treatment doesn’t continue, they are just not going to live,” Ms. Warwick said.
To receive the best outcomes for adult patients with lymphoma, Dr. Ganser said the treatment interval must be “very close,” while there is a little more flexibility in the timing of the leukemia treatment schedule.
“If you could not continue, you’d have time to transfer the patient, maybe even to western European countries. It is still an option,” he said.
In the pediatric setting, patients with acute lymphoblastic leukemia benefit today from high survival rates, but Alexandra Müller, MD, executive director of the SAFER Ukraine program, said those outcomes depend on patients getting the treatment they need.
“Even if you’ve already started, we know that significant delays in treatment can compromise the overall outcome, and this is timely, needed treatment in the beginning,” said Dr. Müller, who also works in the Department of Pediatric Hematology and Oncology at the University Medical Center Freiburg in Germany.
Not only that, but because hematologic conditions may be acute, patients may need intensive care treatment or support during the course of their treatment.
“It almost always requires inpatient treatment because the therapy you are applying is highly toxic, and therefore you need a good set of supportive treatment,” Dr. Müller said.
Finding Solutions: Organizations Step Up to Help
Providing care in a time of war is no easy task, but numerous medical organizations, associations, and nonprofits have stepped up to answer the call.
The Lymphoma Coalition — which was awarded the inaugural Diversity, Equity, and Inclusion Award by the European Hematology Association for their efforts — jumped in after the war broke out to provide help to hematology patients and the Ukraine medical community.
“I’ll be honest. This was not our normal type of work, and we had zero idea of what we were doing, so it was a lot of learning as we go,” Ms. Warwick admitted.
The organization already had strong ties to the professional organizations within Ukraine, including the Ukraine Hematology Association, and relied on their established network to quickly determine the country’s biggest needs, including finding out which hospitals were still functional, what equipment and medication needs there might be, and which patients had the greatest need for urgent care.
They worked to bring in generators to help facilities function better amid unreliable power, worked to provide access to medication and other supplies, and helped move high-risk patients to other facilities in Ukraine or outside the country.
Although they had no trouble finding people with private planes or securing insurance, Ms. Warwick said, the Lymphoma Coalition struggled to find pilots willing to fly into a war zone for adult patients. Commercial flights were often not an option because many of the patients who needed care were also positive for COVID-19 or tuberculosis, two diseases with a higher prevalence in Ukraine.
Often, they relied on ground transportation. Because ambulances were viewed as bombing targets, the organization worked to find alternative types of transportation, like moving patients in a station wagon.
“We found a group who could help us with ground transportation,” Ms. Warwick said. “They are just a group of young people who wanted to do something to help and were willing to take the risk.”
One near constant was unpredictability, and the team had to be willing to adjust their plans at a moment’s notice, given that a facility may be safe one day and a target the next.
“We set up a very specific schedule of ‘we’re going to take this group of patients from this area and move them to somewhere where they can get the needed medical support,’ but even if there was no issue in the location where those patients were, there could be bombing on the roads that we had planned to move them through,” Ms. Warwick explained.
For the approximately 89 patients they helped move out of Ukraine, the Lymphoma Coalition coordinated with medical students who volunteered to translate medical records from Ukrainian to English and arranged for patients to have the support they needed in their new host country, whether it was securing housing or enlisting someone to help fill out paperwork.
St. Jude Children’s Research Hospital joined with the Western Ukrainian Specialized Children’s Medical Centre (WUSCMC) Tabletochki Foundation, the Polish Society for Pediatric Oncology and Hematology, Herosi Foundation, and the American Lebanese Syrian Associated Charities to form the Supporting Action for Emergency Response in Ukraine, or SAFER Ukraine, initiative in 2022 to help with the safe evacuation of pediatric patients with cancer and blood disorders in an effort to avoid any possible treatment delays.4
As Dr. Müller explained to ASH Clinical News, the initiative relied on a “two-step triage system.” Patients and their families were initially directed to WUSCMC in Lviv, Ukraine, to be clinically assessed to determine which patients were stable enough to go to the group’s dedicated triage hub in Poland, known as the Unicorn Clinic, or whether they needed immediate medical attention. Those who were sent to the clinic underwent a second assessment to determine where to send them based on their individual needs and specific disorders.
“If we got a patient with leukemia relapse, they were able to tell us, ‘OK, we have those centers on the ground that are able to provide immunotherapy, CAR T cells, and HCT,’” Dr. Müller said of how selections were made.
The World Health Organization (WHO), which has assisted in providing war relief by coordinating with its partners on humanitarian aid efforts, spoke with one child and her mother who benefited from the clinic after fleeing their hospital in Ukraine when it came under artillery fire.
“It was impossible to continue treatment with the alarms, the sirens, and the likelihood of the destruction of the capital,” the girl’s mother, Natalia, told the WHO.5 “I am very grateful to everyone who arranged the evacuation of children and those doctors who took us for treatment in Germany.”
Marta Salek, MD, MPH, served as the Unicorn Clinic’s first clinical director and said the team worked hard to ensure they adopted a system that was safe and fair, and distributed patients equally across Europe to avoid overwhelming anyone’s health care system.
“We had to make sure we were redistributing across the continent in a way that made sense, that was safe not only for the children from Ukraine, but also for the children who needed care within in each country because cancer care is so resource intensive,” she said.
Over time, the initiative has transformed to not only provide emergency evacuation response but also help build capacity and the local workforce within Ukraine to treat pediatric patients with cancer and blood disorders, Dr. Salek said.
Retaining Physicians and Providing Training
While some efforts focused on evacuating patients, Dr. Ganser and his team focused on keeping medical talent in Ukraine by establishing hematology centers and allogeneic HCT (alloHCT) programs.
Physicians from Ukraine institutions had asked for help to develop the transplantation programs shortly before the war broke out. Representatives from major hematology societies, including ASH, transplant organizations, and physicians from Ukrainian institutions, created a non-government initiative known as Help for Ukrainian Hematology Patients (HUP) to answer the request and kept the work going even as war raged on through weekly video conference meetings.
“If we sent all the patients with complicated, complex diseases to western European countries, then we’ll lose knowledge,” Dr. Ganser explained as to why it was so important to keep the efforts going. “The doctors will leave the country if they have no patients.”
To establish the HCT programs, medicines were donated from other places, and lab work was sent to a molecular lab in Munich. Despite the constant uncertainty, Ukraine was able to begin alloHCT programs for adults with the help of the HUP, which offered physicians virtual support and guidance through webinars and regular video conference meetings.
Dr. Ganser said the HUP also worked with the German Ministry of Health to open official channels in Europe to help with the drug shortages in the country. Ukraine can now submit a list of its most pressing needs through the EU Civil Protection and Crisis Management Mechanism.
In 2023, according to findings reported in a poster at the 50th Annual Meeting of the EBMT (formerly known as the European Society for Blood and Marrow Transplantation), 220 adult patients in Ukraine received autologous HCT, while 69 patients underwent alloHCT.6
“More and more patients, as you can see, are treated and transplanted in Ukraine with the same outcome as western European countries,” Dr. Ganser said, noting the program’s success.
Addressing the Psycho-Social Needs of Patients and Physicians
Patients facing serious blood disorders or cancer have significant psycho-social needs even in the best of times, but those needs are compounded in a time of war as patients struggle with the loss of their homes, loved ones, and sense of security.
As Dr. Müller described it, for her pediatric patients and their families, it was like getting hit by two tsunamis: one when a child was diagnosed with a life-threatening illness and the second when war broke out in their own country.
“For me, it’s still hard to imagine what those patients and families are going through,” she said.
To address these needs, the Unicorn Clinic had designated systems in place, like having a Ukrainian child life specialist with social support experience on hand to work with families and developing patient education materials that clearly laid out the program and what patients could expect.
“Families of children who are faced with these catastrophic illnesses are very resilient, and they were focused on the care of their child and where they would receive care, but these families were also grieving,” Dr. Salek said. “They were grieving the direct loss they had experienced with having lost family members, having to leave family members in Ukraine … and grieving the loss of their communities and just the uncertainty of the future of their country.”
Ms. Warwick said the Lymphoma Coalition anticipated that the patients they helped would be going through complex feelings about the war, but they didn’t anticipate the stress patients often felt about being thrust into another country’s medical system, even if it was more advanced and may have provided a better prognosis.
“The health care system in Ukraine and what you might find in Italy was so radically different that that was a challenge for patients,” she said. “In Ukraine, even though their hematologist may not have the latest therapy, they had a lot of time to spend with their patients, and they knew them very well.”
In the Western world, patients may only get a few minutes with the specialist, which, according to Ms. Warwick, left some feeling that the doctors “don’t care” about them.
Many organizations are now sharing what they’ve learned in academic papers in the hopes they might someday help others.
As these conflicts continue, experts say it’s important to remember the physicians on the front lines are still encountering extremely challenging working conditions and can use all the support they can get.
“The conflict is not over,” Ms. Warwick said.
References
- Vinall V, El Chamaa M. Mapping the damage to Gaza’s hospitals: battered, abandoned and raided. Washington Post. May 21, 2024. Accessed June 28, 2024. https://www.washingtonpost.com/world/2024/05/21/gaza-hospitals-attacks-bombed-israel-war/.
- Mahase E. Ukraine: over 700 recorded attacks on health facilities and workers in year since Russia invasion. BMJ. 2023;380:451.
- Shellah D. War on Gaza: the impossible duty to care for the critically ill. Intensive Care Med. 2024;50:311–313.
- Salek M., Muller A, Alanbousi I, et al. Development of a centralised triage centre for children with cancer and blood disorders in response to the humanitarian crisis in Ukraine. Lancet Oncol. 2023;24:1315-1318.
- World Health Organization. The impacts of war on children with cancer – ensuring continuation of care for those whose lives depend on it. March 17, 2022. Accessed July 1, 2024. https://www.who.int/europe/news/item/17-03-2022-the-impacts-of-war-on-children-with-cancer-ensuring-continuation-of-care-for-those-whose-lives-depend-on-it.
- Korenkova I, Klymenko S, Lysytsia O, et al. Help for Ukrainian Hematology Patients (HUP): a global initiative supporting the establishment of hematology centers and hematopoietic cell transplantation programs in difficult situations. Poster Session at 50th Annual Meeting of the EBMT. April 2024.
