Combining efforts in medical support for Ukraine

As parts of support to Ukraine are to be considered sensitive, this article will focus on publishable information and will exclude details e.g. locations where support and especially training are taking place, reflecting the need to protect personnel involved.

Russia’s war of aggression against Ukraine continues to impose significant human suffering and high material costs on Ukraine and has wide-ranging repercussions both for Europe and globally. Russia’s aggression still poses an existential danger for the population and infrastructures of Ukraine but also has implications on the European and global security and prosperity.Democratic nations and their organisations of cooperation like EU and NATO have reiterated their resolute condemnation of Russia’s war of aggression against Ukraine which constitutes a manifest violation of the UN Charter. Therefore, they recalled their unwavering support of Ukraine’s independence, sovereignty and territorial integrity within its internationally recognised borders

Since the beginning of the war in Ukraine, the MMCC/EMC has been active in various areas of Ukraine support (source: MMCC/EMC)

and its inherent right of self-defence against the Russian aggression. To this end, these nations stated they will support Ukraine to defend itself against Russia’s aggression as much as needed and for as long as it takes.
Among all the efforts nations and organisations like EU and NATO are committed to support Ukraine, there are mainly three fields in which the Multinational Medical Coordination Centre/ European Medical Command (MMCC/EMC) is involved. 1. The development and implementation of support options in the field of medical support with possibilities for multinational cooperation and coordination, 2. Back-up assistance in the medical evacuation of Ukrainian citizens mainly to western European nations and 3. Offering support to planning and conducting training of the Ukrainian armed forces (UAF) especially in the field of medical support.
All this is performed in fulfilment of MMCC/EMC’s vision: COMBINING EFFORTS IN MEDICAL SUPPORT – a common aim of its 18 participating nations which declared Full Operational Capability (FOC) of the MMCC/EMC in May 2022. As already declared at the 49th COMEDS Plenary in 2018 (biannually meeting of the Chiefs of Military Medical Services of NATO and partner nations), the changing NATO security environment requires effective medical coordination and organisation to support NATO core tasks and readiness. There is a clear need to improve medical coordination and cooperation among NATO and EU medical stakeholders in order to strengthen the interface of civilian and military healthcare. MMCC/EMC’s primary mission is to aim at this.

Planning of support options
As a coordination entity with a well-defined network within the field of medical support with its 18 participation nations and links to military and civilian medical stakeholders of NATO and EU, the monitoring of developments related to RUS war preparations began as early as in autumn 2021. MMCC/EMC staff began to accumulate information about the expected escalation of tensions towards a more and more inevitable conflict. At this time, MMCC/EMC began to focus resources in order to increase situational awareness and closer monitoring of the developments via open and classified information, e.g. Russian medical training preparations and indicators for blood sampling to increase the stocks at the Russian border. The comprehensive analysis of the development, carried out by the expertise of the different branches of the MMCC/ EMC, led to the development of possible scenarios and the development of support options or Courses of Action (CoA). The CoA were discussed with internal and external experts and continuously adapted and tested regarding their feasibility and practicability by including the current developments of the worsening crisis. The scope of support options that were developed included, for example, the coordination of material support, support with regards to organising MEDEVAC or assisting it. Other tailored support options depending on the needs of Ukraine but also on our participating nations’ engagement in support of Ukraine or being prepared to support organisations like EU on their request. Although many of these options were discussed they did not materialise due to different reasons including political implications, reasons of feasibility and missing clear signals of demand from the Ukrainian side. However, various support options have been implemented or are currently being implemented and supported by MMCC/EMC. The implementation of all support options always happens in a flexible and outputoriented, professional and silent manner for the benefit of Ukraine.
An essential part of contingency planning from the medical support point of view is the continuous assessment of the medical situation with a particular focus on the military medical situation. This happens in close cooperation with respective stakeholders, nations and entities and of course most importantly with Ukrainian stakeholders. The development of a comprehensive picture of Ukraine’s medical needs and demands is difficult to generate due to the circumstances and different counterparts of the deeply interconnected military and civilian health care system of Ukraine.
Building up, maintaining and extending a network of relevant stakeholders is key for supporting Ukraine’s fight in the medical domain, however, this is much easier said than done due to the changing responsibilities, individuals and the great uncertainty that a war entails. In the meanwhile, as a result of this engage- ment facilitated by MMCC/EMC, a medical support layer of the medical liaison network of nations and organisations has been formed – spanning NATO and EU nations, organisations and other like-minded partners, which is proving significant in terms of improving coordination and cooperation in military medical support to Ukraine.
Finally, two things need to be said about the part “planning of support options”:

1.  The ongoing planning of support options has proven to bea field of work that needs to be constantly worked upon. The following factors count here: a good awareness of the situation, a broad network and expertise that enables the development of alternative courses of action, although their respective feasibility cannot be taken for granted and is highly dependent on circumstances, time, space and willingness – or to quote Dwight D. Eisenhower: “Plan is nothing, planning is everything.”

2.  Medical indicators and warnings are predictive of war – the comprehensive analysis of the available information from the pre-conflict phase provided an increasingly solid picture of the inevitability of the conflict, particularly with regards to the evaluation of the medical support indicators but correlated with other information. As a consequence, it is necessary for the medical services to deal with this area as well: an analysis of open and especially classified data, in an intelligence context.

MEDEVAC assistance
In the early beginning of the war, the Ukrainian Ministry of Health requested assistance first from the European Union regarding the evacuation of patients who were either seriously ill or suffered from chronic diseases due to rapidly increasing numbers of patients that were expected as a result of the war. Moreover, it was to be expected that the possibilities to treat these patients adequately would be considerably limited under the conditions of the Ukrainian health care system.
Following this request for assistance, the European Commission has set up a transfer mechanism for Ukrainian patients in need of continued treatment or urgent medical assistance in Europe. On short notice, the European member states offered a high amount of treatment and bed capacity to Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG ECHO) – European Commission’s department for overseas humanitarian aid and for civil protection.
To serve the most vulnerable patients and relieve the burden from the healthcare system, DG ECHO EU Member States and Union Civil Protection Mechanism (UCPM) Participating States have established the Medical Evacuation System (MEDEVAC) for assistance of Ukraine in close cooperation with the Directorate- General for Health and Food Safety (DG SANTE) – European Commission’s department for the monitoring and implementation of European Union policies and laws on health and food safety, utilising already existing IT networks (used for patient allocation and for exchange of patient data) and adapting procedures established for emergency assistance in place to the new needs emerging from this request.
Shortly after this request was distributed in early March 2022 by the Ukrainian Ministry of Health towards European Union, a second request for assistance was submitted by the Ukrainian Ministry of Defence towards NATO later in March 2022. Here especially the Euro-Atlantic Disaster Response Coordination Centre (EADRCC) – NATO’s principal civil emergency response mechanism in the Euro-Atlantic area – was requested to support Ukraine with the setup of a system for MEDEVAC of patients, filling up Ukraine healthcare facilities quickly. Both requests were seemingly aiming in the same direction but were slightly different in their respective scope. Making this happen in parallel would have required the same medical resources of nations and would have been ineffective if impossible due to the scarcity of resources required.
Due to the early awareness of both individual requests within the MMCC/EMC – underlining the importance of situational awareness–, coordination work with respective stakeholders towards a coordinated and complementary approach started in early April 2022. A work that proved to be diplomatically sensitive and not at all easy since it touched on the field of cooperation between EU and NATO.
Until mid-May 2022, the roles and responsibilities for the coordinated MEDEVAC assistance to Ukraine have been developed and defined in the following way:

• Ukraine Ministry of Health (MoH) is single point of contactfor all MEDEVAC related matters and ensures the transport of patients from Ukraine to within the bounds of its neighbouring countries;
• A mainly civil driven process, with military medical resources as the last resort;
• The European Union’s Emergency Response Coordination Centre (ERCC) – which leads and coordinates the overall MEDEVAC effort for patients to be evacuated from Ukraine, Moldova Poland, Rumania and Slovakia based on the Union Civil Protection Mechanism (UCPM)-, Union Civil Protection Mechanism is a system established in 2001 for coordinating rescue and humanitarian assistance in the event of natural and man-made disasters whose scale or nature exceeds the response capabilities of the affeced country participating nations. For this, established communication procedures and means already in place will be utilised for coordinating MEDEVAC and exchange of medical data; The EADRCC strives to compliment already ongoing efforts by other International Organisationsand to offer flexible, sustainable and scalable solutions;
• MMCC/EMC acts as the coordination element and interface for non-UCPM participating nations of NATO and their partnernations willing to support the MEDEVAC and treatment effort;
• The procedures of cooperation between ERCC as single point of contact and MMCC/EMC acting as interface towards nations offering military medical options as last resort with regards to the following cases: exceeding treatment and/or transportcapacities;
•  communication means to ensure these were tested in end of May 2022, thereby simultaneously marking the operational ready status.

The expected number of MEDEVAC requests was difficult to predict, especially at the beginning of the process. To be prepared and ready to support, MMCC/EMC activated its situation centre (SITCEN) on short notice. Also, on short notice, the Medical Servicesof Canada, Great Britain and United States of Americaprovided a liaison officer for the SITCEN to ensure afocused and streamlined communication with their nation’s respective relevant entities and POCs to speedup the communication process, if required. Urgency isalready determined by the need regarding the activation of the military back-up option due to non-sufficientcapabilities within the system. Integration was smoothand mission support successful where it was required. Starting early with a lot of willingness by all participatingnations and entities, the MEDEVAC assistance for UKR un-der the lead of the ERCC developed and stabilised in such a way that based on the average number of requestsfor MEDEVAC of patients 30-40 patients per week weremoved on a regular basis and distributed to nations voluntarily offering treatment for these patients. For nearlyevery MEDEVAC and treatment request an offer of an UCPM nation could be identified by the ERCC in a timely manner. All offers from nations require an approval by the UKR MoH including the prioritisation of patients and acceptance of an offered treatment facility that was offered. For military patients, the UKR Ministry of Defence (MoD) coordinates with the UKR MoH which stays single point of contact. MEDEVAC coordination centre within UKR MoH organises and ensures the transport of patients from within Ukraine to its neighbouring countries. MEDEVAC with specialised airplanes are receiving patients to be transported to offering nations on airports close to the border. The system is highly dependent on the willingness of nations and their respective health care systems, particularly with regards to taking patients with complex diseases and injury patterns, often connected with contaminated wounds for their treatment and rehabilitation.
The medical evacuation scheme includes two regular MEDEVAC flights a week with max 2-3 destinations / day. These regular, pre-planned MEDEVAC movements are more sustainable. The air MEDEVAC capability is provided by a NATO member state and UCPM participating nation – Norway. A civilian Boeing 737 is converted into a MEDEVAC platform with different configurations; in general max. 20 stretchers including 3 full ICU beds plus 15 seats. The medical crew consist of military personnel: physicians (emergency medicine / anaesthesia / ICU), nurses (anaesthesia / ICU), paramedics and a translator. The MEDEVAC equipment and personnel is provided by the Norwegian Military Medical Services. The on-route treatment during the flight mostly consists of pain relief, oxygen, fluids, antibiotics.
For evacuation, the western pathway is mainly used from UKR to POL with the possibility to use a Medical In-transit Evacuation Facility which is financed through the UCPM and managed by Polish Centre for International Aid (PCPM). This facility offers a safe space for patients arriving from Ukraine. At the facility, patients will be granted 24/7 nursing care and screening for diseases. Additional Airports of Embarkation are in ROU and SVK. The World Health Organisation (WHO) in coordination with the UKR embassies is supporting the repatriation of UKR patients from the host countries.
Currently, the offers of receiving nations are sufficient in com- parison to the requested number of MEDEVAC so that the military reach back option is not needed but still valid. Therefore, MMCC/

A network for coordinated patient evacuation enables the MMCC/EMC to benefit together with various international stakeholders (source: MMCC/EMC)

EMC downsized its activities in the SITCEN and the medical liaison officers were redeployed to their respective nation. MMCC/ EMC monitors the developments in the system and is involved in special cases.
First observations and lessons identified from a military medical viewpoint:
• UKR MEDEVAC Assistance gives Ukrainians confidence thatallies stand alongside them;
• Importance of contingency planning;
• Connection and communication of all actors is key (civ-mil);
• Human dimension of assistance – bureaucracy and proceduresreduced to a minimum;
• It’s crucial to have a reliable, regular and sustainable MEDEVACsolution;
• Regular pre-planned MEDEVAC movements are moresustainable;
• More Bulk MEDEVAC capabilities are required;
• Software for patient regulating/tracking requires a civ-milinterface;
• Possibility for the exchange of medical records with civ-milinterface is crucial.

To sum-up: the basic principle of patient acceptance by UKR MoH before the start of MEDEVAC determines the overall process. The UKR MEDEVAC assistance is no blueprint but a source for study to gain experiences for Art 5 Mission preparation. It can support the development of NATO and EU patient flow procedures, particularly the experiences regarding the civil-military interac- tion which proved itself as a solid foundation for the MEDEVAC support of Ukraine.

Training assistance
Training has been provided by western countries to the Ukrainian Armed Forces (UAF) since the early days of the Russian invasion in Ukraine in 2014. After the start of the peak phase of the war in February 2022, the enduring commitment of western nations to support Ukraine with the material required is key to the capability to resisting and fighting back, aiming to regaining Ukraine’s independence, sovereignty and territorial integrity within its internationally recognised borders. But for using this material, it is essential that training is being employed effectively and success- fully. So, training efforts of most nations involved in support of Ukraine stepped up significantly.
In that respect, the European Union has agreed to the request of the Ukrainian authorities in October 2022 to train and equip soldiers within the frame of a European Union Military Assistance Mission Ukraine (EUMAM UA). The mission is led by the EU Military Planning and Conduct Capability (MPCC) as mission headquarter, while the coordination and integration of the training takes place in two multinational staffs, the Combined Arms Training Command (CAT-C) and the Special Training Command (ST-C). One of the fields of need explicitly requested by Ukraine is medical training. A field where training offers are highly suitable for MN coordination and mutual support due to scarcity and resource intensity of the training is being delivered.
Already during the development phase of the EUMAM mission, the intention was that training activities for the UKR should complement the successful training activities already underway in other nations and, where possible, be coordinated with bilateral efforts. With respect to medical training, MMCC/EMC acts as a coordinating and supporting body for nations and for organisations to ensure this complementarity and to increase efficiency wherever possible.
Besides EUMAM, the key actors involved in the delivery of training to the Ukrainian Armed Forces (UAF) are the US European Command, the US Army Europe and Africa, the UK Operations ORBITAL/ INTERFLEX and the Canadian Operation UNIFIER. The focal point for coordination of international military support to Ukraine is the US-led Security Assistance Group –Ukraine (SAG-U) in Wiesbaden, Germany, which was established on 16 November 2022 under the US European Command. SAG-U is the major coordinator of overall training needs for the UAF. A liaison network created between US-led SAG-U, EUMAM and the UK Operation Interflex and Ukraine’s General Staff (GS) was set up and proved effective regarding the overall coordination and synchronisation level. Regular interaction on the expert level due to the need of coordination and synchronisation of medical related support issues (training, material support) leads to a de facto establishment of a medical layer within this liaison network although it is not running on an exchange of personnel but on a closely linked frequent interaction, regular meetings and close coordination. MMCC/EMC is involved in generating the comprehensive operational picture for medical training activities. For this, it relies on its network and the trust of the participating nations and primary also on UKR military medical service build-up over time. SAG-U ́s Surgeon Cell – the medical branch of SAG-U – intends to optimise Medical Assistance to UKR and to do so acts as “primus inter pares” of all military medical stakeholders supporting UKR which are currently involved. To achieve this aim, a dedicated medical related multinational working group spanning nations and organisation was established and meets on a regular basis – TRIDENT MEDICAL –, representing the medical layer of the coalition in support of UKR.
Based on coordination efforts of MMCC/EMC, different nations supported medical training of DEU Specialised Training Command with personnel, knowledge and material. Eight nations are involved together. Among other things, for example NLD medical services, could support with medical equipment, reflecting the aim of the EU mission: train and equip. Additionally, MMCC/EMC facilitates donations for medical equipment, e.g. equipment for a blood bank.
The first observations of MMCC/EMC are as following: We are facing a complex and highly dynamic coordination process with a lot of different actors. Situational awareness is crucial and challenging, especially because the possibilities for medical liaison are limited. Multinational coordination increases sustainability and persistence of the training efforts.

Way ahead
Cooperation and coordination in the field of medical support for UKR will be continued – as much as needed and for as long as it takes. Especially European nations’ contribution to Ukraine’s self-defence is a crucial investment in these nations’ own security. Enduring determination and commitment are now required to safeguard the results already achieved and extend them until the final goal, recovery of Ukraine’s independence, sovereignty and territorial integrity within its internationally recognised borders, is achieved; a goal the coalition has committed itself to. MMCC/ EMC will continue to support.

Literature with the author.

Author:
LTC (OF-4) Alexander Jäckel (DEU)
MMCC/EMC Operations/Plans Branch,
Branch Head
Andernacher Straße 100, 56070 Koblenz

Date: 07/02/2024

Source: European Military Medical Services 2023