Joe Elia:
We are asking again, what’s the situation of clinicians in Ukraine and what can we do to help them? 

You’re listening to Clinical Conversations. I’m Joe Elia, and I’m joined by my cohost, Dr. Ali Raja, an emergency physician from Mass. General Hospital and Harvard Medical School. 

Our guests include Dr. Natalia Shevchuk, who is the chief narcologist of the Donetsk region in eastern Ukraine. Ana Meteliuk, the coordinator of a program with Yale School of Medicine called Expanding Medication Assisted Therapies in Ukraine. She works for the Alliance for Public Health based in Kyiv and she’s actually speaking to us from the Republic of Moldova.
 
We wanted to thank Dr. Fredrick Altice, Professor of Medicine and Public Health at Yale, the program’s principal investigator for connecting us with the people in Ukraine. 

Our translator is Oleg Lutsenko. 

Ali Raja:
Welcome, all of you. We really appreciate you agreeing to talk to us. We will keep this short. To all of our listeners, please, how are you doing there in the Donetsk region? 

Dr. Shevchuk / Translator:
Well, now in the Donetsk region, so from today, so from 18:00, we’ve dimmed our lights inside, so in the apartments we put out the lights and really from 6 p.m. until 6 a.m. -- so curfew -- so we’re not supposed really to put on the lights in any rooms in the apartment, so we are under shelling. So, the siren’s blaring and we’ve got to go down to the bomb shelter wherever it is available. So, in just my block of flats there is a bomb shelter and I try really go down there. Sometimes I’m really sick and tired of it and I really stay back at home but it is something that you must do. Some people don’t have bomb shelters, and that is why the people really are flocking from the other homes into this bomb shelter, running at high risk. 

So, from time to time, we are off to work because we have really seven substitution-therapy sites working in various towns in the Donetsk region and to the best of our luck until the warfare had started we had enough shipment of the medication [opioid substitutes] coming into our region. So, we were just guided by instinct. So, we approached the distributor asking them really for an ad hoc shipment of the medication. Thank God we have it really. It is now sitting in the warehouse in Kramatorsk town and in the other towns of the Donetsk region. So, we had really shipments during the hostilities, during the warfare, but now all of the towns have enough stock of medications or they have enough really stock to see them through two months or two months and a half. 

So, in this regard, we are doing pretty good, but we can’t say the same thing about the other regions in Ukraine just because we are in a very high exposure to very active warfare. We do not have any other refugees from the other state-run or private addiction sites. That is why we don’t have any burden to bear. So we will have enough of our medication to see us through another four months. So, if we are not bombed out of course and if we are not occupied and if we are not squandered and plundered. 

So, we have 612 patients in substitution therapy. This is really for the whole of the region-wise in the Donetsk region and just two people have migrated -- one really traveled to Germany and we haven’t heard from him and someone else to Lviv. Everyone else is back here, so that means everyone really takes home [their] doses. We dispense medications depending on specifics in each town but at least really for 10 days in a row and really 20, 25 days take-home doses to see them through. We try really to schedule a group of clinicians so as not really to [have to] report to the office every day. So, for instance, twice a week or three times a week [there’s] a clinician on duty in the office to dispense medications, and we have really temporary detention facilities here as well. 

So, before the war started, we really brought along those inmates every day to the health facilities and now we dispense the lump amount of this medication to them. So, to facilitate dispensing to the five people there in the temporary detention facilities. Now we’ve been faced with the challenge when clinicians really are trying to flee from our region and we are looking for their replacement. As of now, the substitution-therapy scheme in this Donetsk region is ongoing and in this Donetsk region it is more or less quiet and calm and we have enough groceries in the stores and we are getting our salary fine with that. What else?

There’s some also more comorbidity and concomitant diseases and all of them -- really to the full extent -- really have their access to antiretroviral therapy and they also get their TB medication dispensed to them in the TB clinics as well. 

Joe Elia:
According to The Lancet, Dr. Shevchuk, the treatment for substance use disorders stopped in that region -- in the occupied region -- back in 2014. Did you have many patients migrating from the occupied zone to your zone?

Dr. Shevchuk / Translator:
Yes, indeed. So, we were in the project. So to facilitate patients’ transfer from Donetsk, Horlivka, and Makiivka. Those are the towns really in the breakaway regions from Ukraine and [in] Russia’s control. We ended up having as many as 70 patients. So they traveled here and they got their housing and so someone rented their flats and they were given some allowance so as really to facilitate them really to settle in. All of them were just received and so a few of them really [went] back there. Just really two people because of some family challenges, so they had to leave. But other than that everyone’s really staying here. We are kind of developing very close relationships. 

Now the situation is really bursting out here with this active warfare waged against us and in 2014. So, we had for two months and a half the occupation, but the substitution therapy was ongoing and after liberation. So the frontiers of borderline, so it was moved further afield and we found ourselves back in the Ukrainian territory and the substitution therapy over the border, so it just didn’t stop overnight but it was just nipped in the bud. So, it just really persisted for five, eight months and then it stopped. So, we’re at the mercy of the remaining supply of the stock of their medications and then the other ones really traveled here. 

From the other regions of Ukraine, those patients really tried really to migrate to our place, so it was really to stay closer to the borderline. So, it was really to have more frequent meetings with their next of kin. 

Ali Raja:
Dr. Shevchuk, you mentioned that your patients in the Donetsk region are -- thanks to your care and your preparation -- they’re doing okay in terms of medication availability, but what about the other patients? Everybody fleeing the Ukraine right now. Have there been efforts to get them seen, for instance, in Poland or Moldova or somewhere else to continue their care?

Dr. Shevchuk / Translator:
Now our patients didn’t leave here. Just one of them really left for Germany but he never sought clinical advice. He was supported by his relatives and by his family so managed really to get him any type of care, but he never referred to our care. Thanks very much to the Public Health Alliance. Thanks very much to the focal point on the ground and the NGOs are very much involved in this exiting activity, but thank God we do not have this active warfare going on here, and we don’t have very many people [hoping] to migrate. We are pleased to find out that the regions that have the influx of those people migrating from easternmost Ukraine, so they are faced with really the [shortage] of those medications. That is why the people fear that they might be denied access to their medications just because of [shortages]. So they don’t have enough. 

Joe Elia:
You had a colleague in Mariupol that you have lost contact with. Have you heard anything further from that region?

Dr. Shevchuk / Translator:
Well, for the town of Mariupol, it was really the drug addiction clinic -- a very large one. Alexander [?Bienko] was the regional substitution-therapy focal point for the Donetsk region and actually this is the last time that I kept in touch with him, communicated with him was on the first of March. So, there was very heavy bombardment and shelling and after the first of March [I have had no contact] neither with him nor with the other colleagues from that famous drug addiction clinic, so I never managed really to get in touch with, not by WhatsApp, not via Viber, none of them really showed up really in the network. All of the cellular phones really switched off, and I’m trying really to get some [news] around the place about him or his colleagues but I never succeeded there, unfortunately. I’m really scared really to think what’s going on in that place. 

Ali Raja:
You mentioned that you have enough medication to care for your patients. We can’t imagine what the morale of your patients and staff is in these circumstances. Are people able to get enough food and sleep? Electricity at the clinics -- is it stable? 

Dr. Shevchuk / Translator:
No, I can’t say really that we’ve got enough of all the stuff really to accommodate the needs actually. So, during those days I have been two times down in the bomb shelter. Sometimes, I have really spent overnight in the bomb shelter. So, the overnight was pretty much quiet and the sirens were just blaring not for a long time. So, sometimes during the night you have really to spend the whole night down in the bomb shelter. So, these two days we [keep] more or less quiet and still. So far, it’s really the availability as groceries in the stores. Actually, the staple foods are available. I can’t really compare really the groceries and its assortment now out in the shops as compared to the prewar times, but I can’t say either that we are starving. We’ve got groceries in place but it’s all kind of subsistence level, so whatever you need first. 

Joe Elia:
I was looking at the statistics of COVID-19 in Ukraine and it seemed that you were at a peak just as the invasion began. How are people doing with COVID-19 now? 

Dr. Shevchuk / Translator:
People do get sick and come down with COVID-19, but we don’t have really the surge of patients with COVID-19 as it was before the war. So, we have a lot of really {unintelligible} and from elsewhere who have migrated, who have left. Actually, it was really the mothers with children really who have traveled out. It was really the hotbed of coronavirus transmission. We ended up having fewer population here in place. I think a good half have left and people do get sick with COVID-19 but we have less people really clustering together and less mothers around and more people really sitting back at home and somehow it must have really brought down this COVID-19 incidence. Perhaps, the people must be very resilient because access to the medications and pharmacies are hard to get to because their personal income going down and everyone is trying really to care for themselves, so as not to come down with this disease. 

Public transportation here, so if the municipal shuttle buses and the trolly buses were overcrowded, now we keep walking on foot. Sometimes we have really social bus service and people now are keeping fit, are keeping more fit because of the coronavirus explosion. 

Ali Raja:
We’ve covered a lot of ground so far, but is there something else that you would like to say to our audience? How might the clinicians listening to this podcast, how might they help you? 

Dr. Shevchuk / Translator:
Do you mean what type of assistance, what type of help? I think we’ll appreciate some tips -- what it takes really to behave in such crisis situations. So both the patients and the health providers alike, not only the clinicians but also the medium personnel such as nurses and all the other support staff working for the health facilities right now are nervous. Really they are now scared and frightened. So, people are short tempered. A lot of people are concentrating on the OAT [opioid agonist treatment] side. So the substitution-therapy side, so a lot of people are really coming in and some people really come in because they no longer have enough stock of their medication. Some people really come in drunk and there are nervous breakdowns happening in the office at work. 

So, the health providers really push the security buttons every now and then. So it’s really to bring in the security guards to calm them down. We are trying really to communicate to the patients that they must not behave like this. Once again, you have really their family coming in to escort the patients to the site so it’s not really to have that patient along the way…so as not really to have someone really coming to the patient really to snatch that medication from them on the way. So, we have really to do a lot of communications that we have enough stock. Then we will have more shipment coming in so don’t be worried. 

What do they dream about, the patients? So this is a secret. They dream about humanitarian aid coming in, as in our heyday, and Canadian-made methadone and methadine from Germany. It is their dream. I just share their concerns about it to you. 

Joe Elia:
Well, Dr. Shevchuk, I want to thank you for being with us today from the Donetsk region. Many of us today listened to your President Zelensky talk to a joint session of the United States Congress. He gave an excellent speech. We hope this interview will bring help where it’s needed. We applaud you and your staff. We thank Anna and Oleg for their role in bringing us together with you today. 

Dr. Shevchuk / Translator:
A big thank you to you so that you’ve heard us out and you’re interested really to find out about our challenges. While I think it is very highly appreciated especially of the people from far off really take our problems close to heart. I will share this message with my colleagues so that we have this lovely conversation and it will make them happy, too. 

Joe Elia:
Let me just say that that was our 286th Clinical Conversation. It comes to you from the NEJM Group and the writers and eitors of NEJM Journal Watch. The executive producer is Kristin Kelly. I’m Joe Elia. 

Ali Raja:
And I’m Ali Raja. Thanks for listening and more importantly doing what you can to help these brave clinicians.