TB and the Ukraine War

Not only does the current Russia-Ukraine pose unique risks of regional and global military escalation, it is also creating historic levels of population displacement and military mobilization of convicts, in one of the world's foremost multi-drug-resistant tuberculosis hotspots.

TB, or "consumption" is an ancient disease, closely associated with malnutrition and overcrowding. It is the disease that killed Chekhov, Chopin, Emily Bronte, Orwell, Kafka, Keats, Thoreau, and many others at the height of their creative years.

TB is caused by the bacteria 'Mycobacterium tuberculosis'. Mycobacteria have evolved a waxy coating which allows them to survive and reproduce inside macrophages, thus evading our immune system's first line of defense. Tuberculosis can remain latent within the body for many years, becoming active once the immune system is sufficiently weakened by factors such as malnutrition, diabetes, HIV, or smoking. A patient with latent TB has a 5-10% lifetime chance of developing active TB. Classic symptoms of active pulmonary TB include night sweats, weight loss, and a cough that produces blood-tinged sputum. Untreated, pulmonary TB eventually destroys the lungs in a "swiss cheese" pattern, and leads to patient death. TB bacteria may also disseminate throughout the body, creating a variety of symptoms, such as cutaneous nodules, engorged lymph nodes (scrofula), meningitis, and an array of internal organ problems. 

TB is the world's top infectious disease killer, and fully 1/4 of the world population currently carries latent tuberculosis. Infection rates vary locally, ranging from as low as 3% in some developed countries, to 90%+ in parts of Africa. Only patients with active TB can pass the bacteria on to others, and may infect 15 other individuals per year. Conflict and other social disruption events can have a major impact on spread. Firstly, conflict subjects individuals to physical hardships, such as poor nutrition, inadequate housing, and exposure to other infectious diseases. Second, conflicts displace populations, and lead to overcrowding, poor sanitation, and breakdown of healthcare systems. Studies suggest that war increases annual TB incidence up by up to 20%. The 2022 Russian invasion of Ukraine has resulted in the fastest mass refugee migration since WWII. In 2022, the world-wide number of displaced persons hit a new record of over 100 million souls.

Social disruptions do not have to be conflict-based to facilitate the spread of TB. Russia and other former USSR members have the developed world's highest TB rates, due to social disruptions that occurred during the decade after the fall of the USSR. The 1990's reversed a huge amount of Soviet progress on TB control, which had been achieved via xray detection, isolation, and treatment in sanitariums. Infection rates in Russia fell from 1910 levels of 400/100,000, down to a rate of 17.3/100,000 (in men) and 1.9/100,000 (in women) in 1990. But post-Soviet poverty and healthcare system collapse caused Russian TB rates to double between 1991-1998. During the same time period, incarceration rates tripled in most post-Soviet states. By the late 1990's, TB had become a raging epidemic within the overcrowded Russian prison system, with prisoner infection rates averaging 4,000/100.0000, and in some regions reaching 7,000/100.000.

Mycobacterium tuberculosis's ability to hide from the immune system means that treatment regimes, even for cases that are susceptible to first-line antibiotics, are lengthy. If, due to treatment costs, disruptions in health services, or poor patient education, a patient stops treatment early, evolutionary forces favor the growth of antiobiotic-resistant bacteria within that patient's body. This resistant bacteria can then be passed on to others, garnering new opportunities, with each unsuccessful treatment course, to become resistant to additional medications. The result is multi-drug-resistant TB, or "MDR-TB"- one of today's major public health challenges. Treatment regimes for MDR-TB last up to two years, may cause uncomfortable side effects, and have a significant failure rate. To reduce risk of MDR-TB, DOTS, or Directly Observed Treatment, has become the gold standard for TB treatment worldwide.

However, in post-Soviet states, corruption and economic woes interfered with successful TB programs. Physicians opposed DOTs, feeling that it threatened their already precarious livelihoods. TB medications were re-purposed and sold in markets by crooked pharmacists, or traded for other items by prisoners in treatment programs. Until fairly recently, antibiotics were widely available without prescription at pharmacies in both Russia and Ukraine. It was quite common to self-prescribe an inappropriate course of antibiotics, for example, for a viral cold infection. By 1998 20% of Russian prison cases were MDR-TB. As prisoners were released mid-treatment, this trend spread into the general population. Eastern Europe now accounts for the largest MDR-TB burden in the world. 

In recent years Russia, along with many former Soviet states, has resumed making progress on TB control. Between 2010-2020, Russian TB mortality halved, and general population infection rates fell to 45-50/100,000 (48% MDR-TB). WHO estimated 2021 TB incidence in Ukraine to be 71/100,000 (31% MDR-TB in new cases and 45% in relapse cases). In contrast, average 2021 TB incidence in the EU was 8.4/100,000 (33% MDR-TB). Thus, TB infection in refugee populations moving from Eastern to Western Europe is a major public health concern.

Despite progress within prisons, as well as amongst the general population, TB remains a major problem in Russian prisons. Russia has one the world's highest incarceration rates, with overcrowding and poor living conditions extremely common. A 2017 study estimated that 1 in 10 Russian prisoners have active TB, and that the majority of remaining prisoners have latent infections. A 2019 study found that Russia had the world's second-highest number of new active TB cases amongst prisoners (~13,000 cases, second only to 15,000 cases in Brazil). A 2-3 yr prison sentence leads almost inevitably to TB infection. 48% of Russian prison cases are multi-drug-resistant. Russia also has one of the highest rates in the world of "extensively drug-resistant TB", which is even more difficult to treat than MDR-TB. Russia's heavy reliance on convicts as soldiers, low health standards for enlistment, difficult frontline living conditions, unreliability of medication supplies, potential for injury or capture, and inter-mixing with and displacement of civilian populations all create a major risk for wartime transmission of TB, MDR-TB, and XDR-TB.

In the Ukraine war, post-Soviet health challenges are potentiated by the melange of convict soldiers, frontline conditions, and mass displacement of civilians. The result is a myriad of spread opportunities for the world's new diseases of disruption: MDR-TB, MDR wound infections, and potentially also novel respiratory viruses (think a new wartime COVID variant or a 1918-style influenza). 

Spread of MDR-TB is not the only concern. TB comes in a variety of strains. Interestingly, the prevalent strain in Russia is the "Beijing" type. The Beijing TB strain, first described in 1995, has unique proteins. These potentially make it more infectious and more resistant to treatments. A 2020 literature review of studies involving 7,000 patients found strong support for correlation between the Beijing strain and more unfavorable treatment outcomes. Despite global implementation of DOTS, TB incidence seems to be declining at only 1-2%/yr- far slower than math models predict. The reasons for this include prevalence of HIV coinfection, diabetes, malnutrition, drug resistance, crowding, and poor control infrastructure. Arguably, another reason is the spread of Bejing subtypes- which will also likely be further facilitated by the disruptions of the Ukraine war.     

There is hope on the horizon for TB control. A currently approved vaccine, the BCG TB vaccine, does not prevent TB, but it does serve to lessen risk of some severe forms of disseminated disease in children. Several vaccines designed to prevent pulmonary TB in all ages are currently under development. The most promising is M72. M72 was dropped by its original creator due to low profit potentials, but has recently been picked up by the Gates Foundation and has entered Phase III trials. M72 may be able to prevent pulmonary disease in 54% of infected adults. And for a disease that can take years to treat, and becomes active in 5-10% of patients, who go on to infect 15 other people per year, 54% prevention be a game-changing statistic.

WHO TB page
WHO TB Surveillance and Monitoring in Europe, 2023
The 2020 clinical update by the Global Tuberculosis Network
2020 Stanford-China study: Mycobacterium tuberculosis Beijing genotype strains and unfavourable treatment outcomes: a systematic review and meta-analysis
2017 literature review: Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review
 

Ukraine: A Quiet Night at the Stabilization Point- with Kittens

 

Ukraine has seen 20,000-50,000 War-related Amputations

 

On 2 August 2023, a Wall Street Journal investigation found that Ukrainian amputations in the war came to between 20,000 and 50,000- including both military and civilians. WSJ's estimate is based on data from the world's largest prosthetics manufacturer, Ottobock. In comparison, during World War I, 41,000 British and 67,000 Germans needed amputations. For background, the US (population 330mil) experiences 185,000 amputations per year. If Ukraine (population 44 million) had a similar pre-war all-causes amputation rate, this would amount to approximately 25,000 amputations/yr. So wartime amputations would represent a 50-100% annual surge over normal amputation events (i.e. those caused by trauma, medical conditions, etc). While WWI featured a larger scale of combatant forces and casualties, modern-day antibiotics, surgical techniques, and frontline medical interventions allow a greater portion of those who experience loss of limb to survive their injury.

After WWII, the USSR took pains to hide war amputees from social spaces and official media images. In modern Ukraine, various governmental, civil society and international groups are beginning the long process of addressing the war's legacy of amputees. Ukrainian public spaces are generally not engineered to be handicap-friendly. Major conversations about legislating equal access measures for the disabled do not seem to have emerged yet; these may be forthcoming as war wounded become increasingly visible in the public eye. 

There are currently over 80 prosthetics fitters in Ukraine, many of these having opened since the 2022 Russian invasion.  In much of Europe and the US, a prosthetic leg can cost between $3,000-$24.000, and a bionic arm may cost $20,000-80,000 USD. The maximum Ukrainian government coverage for a prosthesis is about $50,000, and compensation amounts for military service members are three times higher than for civilians.  A Ukrainian information center for amputees, Protez Hub, finds that 'current government funding for prosthetics is sufficient in the predominant number of cases, however providers said that additional funding was required in civilian cases'. Protez's polls also found that the approximate ratio of upper limb to lower limb amputations is 35% to 65%. Prosthetics require a lifetime of maintenance and parts replacement/prosthetic updates. Protez find that the Ukrainian prosthetics industry is well-developed, and there is healthy competition. The industry continues to develop further, and is coping with the current higher-than-normal number of amputees.

 

Some Ukrainians injured early in the war have received advanced prosthetics, and have won medals in competitions such as the international Invictus Games and US Warrior Games.

Anastasia Shestopal, athlete, Tiktok and Instagram influencer, lost her leg in the 

Kramatorsk railway station bombing in April 2022. Photo by Ukrainian Vogue Visible social project

Nov 2023: Vogue: Visible: Amputees in Vogue Shoot

Porter, Tom (2 August 2023), "Amputations in Ukraine are as widespread as in the Trenches of World War I due to Russia's heavy use of mines and artillery: report" Business Insider.

1 Aug 2023, Wall Street Journal: In Ukraine, Amputations already evoke scale of WW1

Nov 2023: Vogue: Visible: Amputees in Vogue Shoot

Ketamine in War, including use in TBI patients

Fast-acting, easy to deliver, and respiratory-drive-sparing, ketamine is becoming an increasingly popular solution for pain control and/or sedation in emergency and combat medicine.

Traditional anesthetic and analgesic medications pose several challenges during wartime conditions. Opiates and benzodiazepines come with side effects, such as hypotension and respiratory depression, which can increase patient-management workload.

In 1958, the search for a safer anesthesia agent yielded PCP. However, severe psychological recovery effects quickly ruled out high-dose PCP as an anesthetic (non-schizophrenic patients tended to experience 1-2 days of artificially-induced withdrawal psychosis, while in schizophrenics existing symptoms were profoundly exacerbated).

200 derivatives of PCP underwent further testing. One of these, ketamine, was found to have a short duration of action and produce less stimulant effects than PCP. Ketamine could be delivered by multiple routes (IV, IM, IN) and spared patients' breathing and airway protection reflexes. Ketamine was first synthesized in 1962, and after testing on animals and volunteer prisoners, was approved for use in humans in 1970.

For many decades, concerns over misuse and hallucinogenic side effects discouraged use of ketamine in mainstream medical practice. However, the drug was used with some success in a number of conflicts during the 70's and 80's. Ketamine's first wartime use was by a composite team of UK, French, and US doctors during the 1970 Jordan-PLO civil war. This team used ketamine to sedate children during treatment of burns. IM administration simplified delivery, and having a sedation option with minimal airway impact freed up caregivers in a resource-poor setting. 

Another early use of ketamine was during the Falklands conflict. Fifty burn patients were given ketamine during wound treatment on the Hospital ship Uganda. The patients came in in a wave of 150 casualties, after the bombing of two landing ships.

By the late 90's and early 2000's, research had disproved many misconceptions surrounding

ketamine. Emerging as one of the safest and most versatile battlefield medicines, the drug

saw renewed interest from the US military and from EMS systems. Various US special

operations teams added ketamine to their protocols during the Afghanistan and Iraq wars. In

2012, the US Defense Health Board added ketamine to TCCC protocols as a primary pain

control option (50mg IN or IM, of a 20mg slow IV/IO push). Various military studies from

this period suggest that ketamine administration had either a neutral or protective action against development of PTSD in injured soldiers.

Use of ketamine for pain control is an off-label use; however it seems to be a highly effective alternative to opiates. Ketamine antagonizes NMDA receptors. It interferes with the brain's chemical ability to receive incoming pain stimuli, and at the same time reduces the emotional reaction to pain. Pain control is achieved at a fraction of an anesthesia dose.

Several other factors make ketamine an ideal pain control+ sedation option in EMS,

wilderness medicine, and combat situations. Rather than dropping respiratory drive and

blood pressure, like opiates and benzodiapines ketamine produces hyper-adrenergic effects.

It stimulates the release of dopamine, norepinephrine, and serotonin, and blocks re-uptake of catecholamines. This leads to a slight increase in blood pressure and heartrate. Additional

benefits include a long shelf life, a wide storage temperature tolerance, low cost, good safetybprofile, ability to administer via IN, IM, IV or IO route, fast action onset, and a variety of dose-dependent effects. Recent studies have dismissed concerns about use of ketamine in TBI patients, showing that the drug does not have a negative impact on cranial perfusion pressure. Ketamine is recommended by the Wilderness Medical Society for use in remote environments, and is on the WHO essential medications list. In resource-poor countries, ketamine is sometimes used as a sole anesthesia agent during surgeries.

Ketamine is general very safe, but some considerations must be taken for patient safety.

Emergence reactions are not uncommon and may include hallucinations, disorientation,

nausea, and anxiety. Keeping the patient in a quiet room with low lighting can help avoid

emergence reactions. Use with caution in combination with other drugs, including sedative

agents, or in patients who have taken street drugs. Ketamine may worsen schizophrenia

symptoms, and may cause hypotension in severely catecholamine-depleted patients.

Although a major benefit of ketamine is its tendency to leave patient respiratory and airway

protective drives intact, patient level of consciousness and breathing should be

carefully monitored, especially with higher doses. This has recently been demonstrated in

the newsstories about the death of actor Matthew Perry, and the manslaughter trial of two Aurora, CO paramedics, whose patient died after being given ketamine.

2018 JEMS: Should Ketamine Be Contraindicated for Patients with Traumatic Brain Injury?

"The_Drug_of_War"--a_historical_review_of_the_use_of_Ketamine_in_military_conflicts 

"The potential of ketamine for posttraumatic stress disorder: a review of clinical evidence"

2008 US Military Study: "The correlation between ketamine and posttraumatic stress disorder in burned service members". Found a lower incidence of PTSD amongst burned soldiers who were given ketamine, in a 147-patient sample.

2014 US military Study: "The intraoperative administration of ketamine to burned U.S. service members does not increase the incidence of post-traumatic stress disorder"  larger retrospective data analysis of ketamine use and PTSD development in 298 burn patients serving in the US military. This study did not find that ketamine offered PTSD-protective effects seen in previous smaller studies, but ketamine also did not worsen likelihood of PTSD development. 

2021 US military study: Ketamine Use in Operation Enduring Freedom - shows increasing usage of ketamine within the US military during the Afghanistan/Iraq campaigns.

2015 Emergency Physicians Monthly article: Battle Tested: Ketamine Proves its Worth on the Front Line

2014 study: The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review
A review of available literature found that ketamine did not produce significant changes in
cerebral perfusion pressures, neurologic outcomes, length of ICU stay, or mortality.

Two Aurora paramedics charged in Elijah McClain’s death defend actions, say police officers hurt their efforts to treat him

Soldier and Civilian Deaths: Comparing Recent Wars to Ukraine

CONFLICT	DURATION	ESTIMATED MILITARY DEATHS *	ESTIMATED CIVILIAN DEATHS	AVERAGE CIVILIAN DEATHS / MONTH	DEATHS: MIL VS CIVILIAN	SOURCE
US POST - 9/11 WARS:
Afghanistan	Oct 2001 - Aug 2021	US and Allies: 76,486 Opposition: 52,893	46,319	195	280%	Brown University, Watson Institute, https://watson.brown.edu/costsofwar/figures/2021/WarDeathToll
Pakistan	Oct 2001 - Aug 2021	US and Allies: 9,518 Opposition: 32,838	24,099	101	176%	Brown University, Watson Institute, https://watson.brown.edu/costsofwar/figures/2021/WarDeathToll
Iraq	March 2003 -March 2023	US and Allies: 56,925-60,925 Opposition: 36,806 - 43,881	186,694 - 210,038	784 - 883	50%	Brown University, Watson Institute, https://watson.brown.edu/costsofwar/figures/2021/WarDeathToll
Syria / ISIS	Sept 2014 - March 2023	US and Allies: 62,502 Opposition: 67,065	138,947	1,349	90%	Brown University, Watson Institute, https://watson.brown.edu/costsofwar/figures/2021/WarDeathToll
Yemen	Oct 2002 - Aug 2021	US and Allies: 2 Opposition: 99,321	12,690	56	780%	Brown University, Watson Institute, https://watson.brown.edu/costsofwar/figures/2021/WarDeathToll
GAZA	Oct 7 2023- Dec 14 2023	Israel: 444 Hamas: 6000	19,800	9,000	30%	Israeli MOD, Gaza Healthy Ministry https://www.aa.com.tr/en/middle-east/gaza-death-toll-tops-18-600-as-israeli-attacks-continue/3081566
UKRAINE: DONBAS WAR	6 April 2014 - Jan 2022	Ukraine: 4,400 Separatist / Russian: 7,000	3,404	36	330%	UN and US State Dept https://en.wikipedia.org/wiki/Casualties_of_the_Russo-Ukrainian_War#cite_note-OHCHR-8, https://en.wikipedia.org/wiki/Casualties_of_the_Russo-Ukrainian_War#cite_note-russiansoldiers-16
UKRAINE: FULL-SCALE INVASION	Feb 2022 - Sept 2023	Ukraine: 70,000 Russia: 120,000	9,701	485	1960%	US Estimate https://en.wikipedia.org/wiki/Casualties_of_the_Russo-Ukrainian_War#cite_note-NYT_August_2023_Estimate-107

Ukrainian Defense Ministry Expands Medical Eligibility Rules for Military Service

 On Sept 3, the Defense Ministry of Ukraine amended its list of medical conditions which exempt citizens from military service. Individuals with the following conditions are now considered fir for service: 

- clinically cured TB

- clinically cured hepatitis

- slowly progressing blood diseases

- slowly progressing CNS disorders

- minor thyroid issues

- HIV+ and asymptomatic

-mild mental and neurotic disorders

Prelude to Medic Work in Ukraine, part 2

#3:  "Do Not Kill or Torture Prisoners"

- From the United States Marine Corps Common Skills Handbook, Core Principles of the Law of War

Late January 2022 

Things are mostly packed and ready for the yearly journey to Africa. More and more frequently, my daily work occurs with "Comprehensible Russian" podcasts and Ukrainian news playing in the background. Included in these is Bellingcat's investigative series on Flight MH17. This Malaysian Airlines flight was shot down by a Buk surface-to-air missile in 2014, as it passed over a then-freshly-ignited conflict area in East Ukraine. 298 civilian passengers died in the crash.

My old favorite Russian songs of my teens have been resurrected as workout tunes. When the war starts, I'll come to be surprised at how many of my favorite bands make the risky move of coming out as anti-war. And what about the Russian friends I danced with? Will they protest the war? It will remain a lingering mystery- even in 2021, my letters to Russian acquaintances have begun to go unanswered. I'm probably just writing to the FSB now.

A favorite of mine, "Prosvistela" ("Whistled by") comes on. I realize I've never paid enough attention to the lyrics to understand them. I listen now, and pick out a confusion of something falling on the table, a hug, heaven, being prisoners of the motherland. It doesn't really make sense, so I finally google the meaning. It turns out my favorite song was written by Yuri Shevchuk, after a visit to soldiers fighting in Chechnya. Scarred by the horrors he saw, Shevchuk penned an unsubtle composition about a grenade falling into an armored personnel carrier. Everyone inside is killed, but in heaven they reunite with friends, find freedom and happiness, and reflect on the meaninglessness of the war. I'm shocked that this song, which blended seamlessly with the teeny pop discoteca sounds of my youth, had such a deep and dark meaning. You can here it here, and my translation of the full lyrics is below: Prosvistela/ "Whistled By", DDT https://www.youtube.com/watch?v=inG69xYWROw

The music draws me back into memories of Russia. I'm 16 again, and it's my first week in southern Russia. My host family doesn't speak a word of English, which is tremendously exciting for me. I've chosen Russian because I believe Russia will cause trouble one day, and I'll want to know Russian very well. Complete immersion is the best way to learn. I'm constantly thumbing through the heavy Russian-English dictionary I carry everywhere in my backback (no Google Translate or Kindle app in 1998!). Everything- "I'm hungry", "Good morning", "Where is the bathroom?" requires a consult with the book. Unfortunately I had an orange juice explode in my bag on the plane, and the dictionary remains decorated with tiny black mold stains for the year-long duration of my visit. Every morning I select 50 new words and write them down three times, in order to commit them permanently to memory.

During my first few days, southern Russia sees an oppressive August heat wave. My host family retreats to the beach, and I promptly become very ill with food poisoning. My host mother wisely sees me through with a treatment of two shots of heavily salted vodka, followed by bed rest.

By the time my second week in Russia rolls around, it is time to return to school. I'll be accompanying my host sister to the equivalent of a K-12 public school. At 14, she is two years younger, and immensely more wordly than I. "Irina" (name changed for her safety) has it all planned out: on her 15th birthday, she'll try Ecstasy; on the 16th, she'll lose her virginity. At the end of her 16th year, she'll enroll in college, preparatory to Law School. I'm placed in Irina's grade, and she helps me understand the lessons, which are of course all in Russian.

The heat wave, if anything, has grown more intense on our first day back at school. The class swelters, as the teacher conducts what I come to realize is a surprisingly in-depth review of World War II history. My host sister knows far more than the average American college student about 20th century European wars. I half-follow vaguely familiar battle names and dates, thumbing through my trusty, moldy dictionary.

Before math class, I join my host sister and her friends outside, politely declining their proffered cigarettes. Sweating and swatting at flies, we seek refuge under the only shade available, but don't stay too long. They must not have taken out the trash since spring; the air stinks of rotting meat.

We return to class, math this time. Suddenly, a woman comes in and draws the teacher from the room. A growing wave of whispering begins: "Samo-ubitsvo!" I feverishly flip the pages of my moldy dictionary, seeking this new term which has caused such a stir.

It means "suicide".

In the next two hours, I will be introduced to the real Russia, and the reality that, in most of the world, the strong devour the weak. In the next week, at 16 years old, I'll build two key emotional foundations. One is for dealing with Americans who turn a willful blind eye to the evils of the world (as with many future ugly international realities, my American compatriots cope with the alien violence and ugliness of this first day of Russian school, by simply refusing to believe in it). The second foundation is for recognizing and navigating the special mix of 'anything-is-possible and nothing-is-real', which underpins every twist of the marionnette strings, by which the Russian government controls the Russian population.

Our math teacher comes back inside, and acknowledges that there's no chance of us paying attention to the lesson. He releases us, and we join the entire student body outdoors. Kids from age five up through sixteen form a ring around the shade tree, where we had smoked earlier. The body hanging in the tree was discovered shortly after we left. The next group of smoking girls looked up when it dripped on one of them. It had probably been hanging, twenty feet up in the large oak, for the entirety of the hot weekend.

I saw my first body at age 14, when I discovered my mother had passed away from a mixture of cancer-induced hypercalcemia and pain medications. That was a peaceful and expected relief from pain, and I closed her eyes with more relief for her than grief.

This second body was much messier. At each of his slow rotations, his face was visible above us. It was plum-purple and bloated, and an impossibly swollen tongue stuck obscenely from his mouth. The military showed up with a pickup, and made a great show of obtaining his passport and reading his name out loud, then showing the passport around to the group of students. One of the soldiers then told the circle of assembled students to back up. He jabbed me in the abdomen with his AK when I was slow to respond. My host sister came to my rescue, saying I was "an Amerikanka, I didn't understand". I really wished she hadn't done more to make me stand out; even at sixteen I instinctively understood that what what happening here was outside the bounds of rule of law. Anything could happen. Being an American was crappy protection.

The soldier who had climbed the tree to get the dead man's passport proceeded to tie a rope around the waist of the corpse. The crowd of students parted to allow a pickup truck to drive in. One arm covering his nose, the soldier in the tree reached out and sawed though the rope around the corpse's neck. The circle of students, small and large, stood immmobile, barely glancing at the soldiers' AKs. They gazed upward, rapt, wordless. Neck-rope severed, the dead man described a slow-motion arc backwards. His torso came to an abrupt stop at its perigee, impossbily purple face now upside down, and oriented our way. An unexpected amount of what looked like black, clotted blood gushed out of his mouth and into the pickup bed below. I felt fortunate that my parents had enrolled me in many dissection and veterinary classes in grade school. Today's scene was no way to introduce oneself to the ugly side of mammalian biology.

The soldier in the tree undid a hitch, and slowly lowered the body, now essentially hanging upside-down, into the truck. With no further formalities, the soldiers left the scene and classes resumed. Being sixteen, abroad, and not having experienced the aftermath of a grisly suicide at school before, I accepted this as the normal process here. I told my dad about it next time we talked, and otherwise went on with life, and my observations of this very-different-from-American culture. It was ironic, comparing the complete lack of response from the Russian school system, to what would have happened at home in America. A scene like that on the grounds of a US school? The school would have been closed for a week, mandatory counseling for all the students! But, this was Russia. Counseling? Compared to watching the body of one's mother slowly destroyed by cancer, this really wasn't a big deal. As long as you're lucky, healthy formative-years coping mechanisms get built, and life goes on.

Only in retrospect, listening to Bellingcat and Prosvistela, did I begin to appreciate some of the political undercurrents of that day. Even in Russia, where life can be cheap, the man in the tree, so long ago, was probably not just a suicide. The army had taken far too much care to make sure all the students watched, and to make the name on his passport known. The man in the tree must have been someone... a political dissident, a rebel, an enemy of the mafia. He must have been someone worth making an example of. My dad, of course, believed every word of the story. The convenient denial of the other Americans- the other Exchange Program students and managers- was the first of many, many times that I would cope with this failing of my own culture. Outgoing President Obama would sum it up well in a 2015 speech: "If the American public cannot, or will not, differentiate fact from fiction, than we are in deep trouble".

Well, I'm just one member of that public. But, at sixteen, I surely appreciated my first lesson on what the breakdown of rule of law does to a society. My eyes and mind were wide open. I had expected that Russia would be challenging, romantic, sweet, and world-changing for me. It was all that. It was also ugly, corrupt, and violent.

So, twenty years later, when it came- Russia's wholesale violation of the Law of War in Ukraine, violation of "Do not kill or torture prisoners"? It was absolutely no surprise. Not after what I saw during my year in Russia.

Learning the structure and nature of Russia's ugly parts, and how to recognize their equivalents in other societies (including my own) was the greatest lesson of my time in the Russian exchange program.

Prelude to Medic Work in Ukraine, part 1

#4:  "Collect and Care for the Wounded, whether Friend or Foe"

- From the United States Marine Corps Common Skills Handbook, Core Principles of the Law of War

Early January, 2022

Grey clouds threaten to deliver a rare winter snow to my Western US mountain home. I hasten to relieve the springs of my old prius from their burden of medical supplies boxes- freshly donated by a local nonprofit partner. The collection of just-expired dressings, sutures, syringes, and IV sets are sure to save a few lives in West Africa over the coming year.

One by one, I lug the boxes in, adding them to the growing stack of supplies in the corner of my living room. Mission accomplished, I sprawl onto the couch to endulge my news-junkie compulsions. It's early January 2022. The US legal system continues to weigh in on vaccine mandates, and our societal pandemic response settles ever more firmly into dysfunction, setting the stage for future airborne disasters. But that's no surprise; the same thing happened after the Spanish Flu. As far as mainstream media goes, Trump has been tucked gratifyingly out of sight, as social media platforms and news outlets explore ways to navigate tech-revolution misinformation. Income-inequality fuels populism, while changing population dynamics fuel political extremism. All of these things together are making it feel a little bit like the 1920's and 30's. I turn on some Louis Armstrong and imagine I'm living in Huey Long's Louisiana.

Putin continues to insist that his military buildup along the borders of Ukraine is a mere exercise. Everyone else continues to do the convenient thing, which is to take him at his word. I listen to NY Times interviews, where dismissive Ukrainians refuse to be cowed by these latest Russian antics. Their tendency to replace hard 'Gs" with a soft "H" reminds me of the southern Russian accent I acquired, living near Sochi as a teenage exchange student. My time there was punctuated by the "Chechen" apartment bombings. Rumor has it, these were actually an FSB plot, orchestrated by then-Prime Minister Putin, in a bid to coalesce ordinary Russians behind him. Russian officials who raised the issue of a possible FSB plot? They developed a habit of dying under suspicious circumstances, and nothing was ever proven. The ensuing Chechen war cemented Putin's popularity, and made the new Chechen leadership into his puppets. Through lies, support of opposing fringe movements, and engineered political theater, Putin progressively undermined Russian society's ability (and will) to tell truth from fiction. Russia is the world's leader in government-by-disinformation. Since the 2016 debut of the Trump campaign, I have been hearing American echoes of Russian propaganda techniques every day.

Outside, the snow has started. Curled around a cup of Earl Grey, thousands of miles from European troubles, I mull over what the future may hold. I compare Putin's antics- his increasingly bold meanderings, first into Georgia, then Crimea- with the expansionist European strongmen of the 1930s. I don't dismiss the military buildup around Ukraine. Not at all.

That night, in my dreams, I shelter from bombs in the basement of a Ukrainian hospital. A chimeral Russian army sweeps, inevitable as gravity, through my Ukrainian dreamscape. They are certainly nothing like the real Russian army will turn out to be, because they mostly follow the Law of War. They fight only enemy combatants; they don't target civilians. Under a stern-but-fair Russian occupation, my dream-self works as a doctor-POW in the hospital, treating Russian soldiers and Ukrainians injured and taken prisoner in the fighting. Through this work, I gather intel and supplies for the Ukrainian resistance. The isolated case of true villainy is a Russian officer who attempts a rape; the hero is a second Russian officer who covers for me after I confront the villain and shoot him in a struggle over his firearm. Physically, the hero quite resembles Liev Schieber's Defiance character, Zus Belski, and it's all very romantic. In the end, I convince the Russian officer to join the Ukrainian resistance, the Russians are forced out by a NATO contingent, and all ends well for the Ukrainians. It's a very vivid dream, and I wake in the morning with Ukraine stuck indelibly into my subconscious.