As a medic in the British Army during the late 1980s, I was taught that a war in Western Europe, started by the Soviet Union, would immediately result in hundreds of thousands of refugees, with that number escalating to millions in a matter of days. Because the region is one of the top three most densely populated subcontinents, battlefield casualties and medical management of refugees were expected to place enormous strain on military and civilian medical care in every area of Europe.
Forward military medical systems represent the most effective way to reduce death and severe injury from warfare; therefore, impairment of the function of frontline units because of such a mass exodus of civilians from the war zone was predicted to have a significant impact on all aspects of military effectiveness.
What we are seeing in the Russian invasion of Ukraine is this scenario writ large. Russia’s Vladimir Putin, like his supporter President Alexander Lukashenko in Belarus in December 2021, has weaponized refugees (particularly women, children, the elderly and infirm) as a potent way to destabilize neighboring nations — in this case, Poland, Romania, Moldova and, eventually, other Western European countries.
The destruction of civilian health care structures by the Russian Army is not a chance result — nor is it collateral damage. Rather, it is a deliberate military strategy to create massive waves of refugees that destabilize and overwhelm civilian and military structures, first in Ukraine and then in surrounding countries. To this extent, the war has already spread beyond Ukraine’s borders and into NATO-member countries. Meanwhile, Putin protests that any intervention from beyond Ukraine (e.g., the United States or the European Union) to impair his ability to reach Russian “military objectives” is effectively an act of war.
The first 12 days of this war and its humanitarian catastrophe have already produced an estimated 2 million Ukrainian refugees. Millions more are possible.
Since Putin clearly calculates refugees as part of his military operational plan, he is incentivized to create as much civilian chaos, terror and fear as possible. This includes creating the illusion of safe humanitarian corridors, the willful destruction of medical institutions and nuclear energy facilities in Ukraine, and potentially using chemical, biological or tactical nuclear weapons, all of which are in his armamentarium.
The use of chemical weapons happened in Syria, was sanctioned by Russia, and generated an anemic response, at best, by the West. Furthermore, in 2006, Russian defector Alexander Litvinenko was assassinated in London, dying weeks after drinking tea spiked with the radioactive compound polonium-210; in 2018, Putin’s agents attempted to assassinate another defector, Sergei Skripal, using an outlawed next-generation nerve agent, Novochok. This agent, developed after the Soviet Union had signed a global chemical-weapons treaty, was purposefully engineered to defeat NATO’s most advanced chemical weapons gear.
The Kremlin’s willingness to use outlawed nerve agents and radioactive isotopes to commit murder heralds the threat that Russia might go even further during its illegal invasion and deploy chemical or biological munitions among the Ukrainian people.
We also cannot ignore the fact that Putin launched his invasion during a pandemic — albeit, as the latest Omicron variant is waning in Europe. While all medical and psychological illness is amplified in refugee populations, it should be noted that Ukraine reported a 7-day average of more than 27,000 cases of COVID infection during the week prior to Russia’s invasion. The 1918 influenza pandemic commenced in Europe during the last nine months of the First World War, when Central Europe was in ruins. An extremely contagious virus spreading rapidly among vast numbers of people, displaced and suffering from food shortages and deprivation, is a deadly combination.
The monitoring of COVID infection in Ukraine is at a standstill as the medical infrastructure is paralyzed by the war. Civilians and refugees are crowded into bomb shelters, community halls, train stations and buses in Ukraine and Poland. In the West, we must recognize this and redouble our efforts to simultaneously monitor both the effects of the war and the pandemic while providing maximum assistance to bordering European nations to monitor, prevent and treat diseases, including COVID, among the rapidly growing, vulnerable and dispossessed refugee population.
Putin has cynically and mercilessly weaponized refugees as part of his military strategy to spread the impact of what he deceptively calls “a special military action” well beyond the borders of Ukraine and into the neighboring states of our democratic allies. NATO must acknowledge that the war has already crossed into NATO member nations. The severe consequences of a collapsing health care infrastructure in Ukraine and the enormous stress on bordering countries who are, for now, unreservedly taking in refugees must be part of the equation when Western allies decide how to respond to Putin’s war. Ignoring this allows an already hazardous situation for Ukrainian refugees and non-combatants who stay in their country as well as Polish, Romanian and Moldovan civilians to slip further out of control.
Steps to protect lives should involve the use of NATO forces to establish secure humanitarian corridors to help move refugees across safe borders. NATO-member nations must remain united in the face of this onslaught and pre-emptively draw and enforce clear redlines to protect the health of both civilians and refugees, including against the threat of attack from chemical or biological weapons.
We must presume Putin’s past actions will serve as his current playbook, or worse.
Mark C. Poznansky, M.D., PhD., FIDSA, is director of the Vaccine and Immunotherapy Center, Infectious Diseases Division, of Massachusetts General Hospital and professor of medicine at Harvard Medical School. He served as a captain in Great Britain’s Royal Army Medical Corps (V).
Jacqueline A. Hart, M.D., is director of the Bassuk Center on Homeless and Vulnerable Children, Families and Youth in Needham, Mass., which works with communities and organizations nationally to promote housing, health and other opportunities for individuals and families. She has more than 20 years’ experience working in lifestyle, behavioral and integrative medicine, applying those principles to vulnerable populations and marginalized communities.
Michael V. Callahan, M.D., DTM&H, MSPH, is former COVID special adviser to the Assistant Secretary for Public Health Preparedness at the Department of Health and Human Services. He has led seven disease outbreak deployments for Ebola, bird flu and SARS, directed the DARPA Biodefense Program, and is director for Clinical Translation, Vaccine and Immunotherapy Center at Massachusetts General Hospital.