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There is a fascinating tension in the British attitude to war and military matters. When he wrote about England in 1941, George Orwell said his home country was defined by the gentleness of its civilisation, and such a hatred of war and militarism that flag-waving and patriotic boasting were always the preserve of a small minority. Events over the past 40 or so years have perhaps proved him wrong: from time to time, a widely shared jingoism has been brought to the surface of our national life, focused either on actual conflict as happened when Britain fought for the Falkland Islands or some hare-brained proxy for it, such as Brexit. But there is something about Orwells portrayal of people with an innate distaste for bellicose posturing that still rings true, across all the countries of the United Kingdom.

Among certain politicians, by contrast, there is far too little of that kind of thinking. Over the past three weeks, the unimaginable awfulness of what has happened in Ukraine and the fact that Vladimir Putins invasion is such a matter of moral clarity has encouraged a lot of rhetoric and posturing that has been shrill, banal and full of a misplaced machismo. The war, says one Tory MP, is Boris Johnsons Falklands moment. The vocal Conservative backbencher Tobias Ellwood a former soldier in the Royal Green Jackets, and now an active reservist insists that the wests response shows weve lost our appetite, weve lost our confidence to stand up: to stand tall. And while he and other Tory MPs including zealous believers in Britain breaking from the EU, suddenly holding forth about the urgent need for international unity have been making sense-defying demands for Nato to impose a no-fly zone, some of the cabinet have come out with their own very unsettling pronouncements, seemingly thinking that if Putin talks tough, they should talk tougher. When Sajid Javid was asked about the recent Russian attack on a Ukrainian military base only about 10 miles from the countrys border with Poland, we saw the strange spectacle of the health secretary apparently embracing the prospect of nuclear war: Lets be very clear if a single Russian toecap steps into Nato territory, there will be war with Nato.

With the chancellor Rishi Sunaks spring statement arriving on Wednesday, a familiar sound is getting louder: Conservatives demanding more money for the military, even though the UK currently spends the fifth-largest annual sum in the world (after the US, China, India and Russia). For well over a decade now, most Tories have been united in the belief that just about every public service is best cut to the bone and subjected to endless lectures about inefficiency. But defence is suddenly a glaring exception: Labour may have credibly identified 13bn of departmental waste since 2010, but that seems to be no barrier to calls for a spending rise of about 25%.

If you want a flavour of the thinking at work, a good place to start is a recent piece in the Sunday Telegraph by the former Brexit minister David Frost. He reckons that western muscle memory is returning and we are getting back to the principles that helped us to win the cold war. He says: We are going to have to spend more on defence and that will mean tough choices. We all know what those are likely to be: the price of our supposedly central role in a reshaped world may well be paid in social care, education, childrens services and all the rest.

Though he would presumably express opposition to cuts elsewhere, Keir Starmer has joined in the calls for more military cash, which snugly fits the Im not Jeremy Corbyn narrative of his leadership. Given Starmers apparent determination to follow the example set by his New Labour forebears, and Tony Blairs recent offer to help his old party with policy advice, we should be listening hard to what the latter has to say. Last week, he published an essay about the Ukraine crisis. Its most sobering passage ran thus: When Putin is threatening Nato and stoking fear of nuclear conflict, there is something incongruous about our repeated assurance to him that we will not react with force. Naturally enough, Blair also wants more money for the armed forces. We are awake, he says. Now we must act. This the same register he used at the start of the war on terror, when he talked about shaken kaleidoscopes and the need to reorder this world around us. Hearing it again is not exactly reassuring.

As is usually the case, Boris Johnsons tone swings between the serious and utterly crass. At this weekends Tory spring conference, he and his colleagues parroted the familiar argument that the war demands an end to woke ideas and criticisms of British history (which actually sounds like a milquetoast version of Putinism), and he made that grotesque comparison of Ukrainians to Brexit voters. When caught in a more sensible mood, he has also counselled a measure of caution and level-headedness. Its very important that we dont get locked into any kind of logic of direct conflict between the west and Russia because thats how Putin wants to portray it as a fight between him and Nato, he told the Economist last week. It isnt. This is about the Ukrainian people and their right to defend themselves. This line was repeated on Sunday. But around him, there still swirl very dangerous currents.

Back in the 1980s, as Ronald Reagan speculated about a limited nuclear war in Europe and we were warned about the prospect of an accidental nuclear exchange, I grew up with a cold sense of fear. Now a new generation has to face not just those same anxieties, but the existential threat of the climate emergency and the prospect of regular global pandemics. Not surprisingly, there is a growing crisis in childhood mental health: a sign not just of failing public services, but arguably of a system of power and politics that does not ease such visceral fears, instead endlessly inflaming them.

In a situation as fragile as this, belligerent talk can have terrifying consequences. It also tends to highlight the way Westminsters armchair generals neglect their duty of care to their own citizens. I am now having conversations with my 12-year-old daughter about the prospect of nuclear annihilation. I tell her itll be all right, but her and my fears are hardly helped by the reckless words we sporadically hear from some of those supposedly in charge.

Yes, the world has clearly changed. Even if liberal values are always damaged and compromised by people in power, that does not mean that they are not still the best hope we have, something Putins passage into something close to fascism makes plain. But those same values not to mention the delicate stuff of geopolitics and diplomacy demand nuance and calm. Moreover, there is one thing we overlook at our peril: that however much we spend on our military, our social fabric needs to be resilient and secure enough to cope with a new reality of constant shocks and disruptions, and at the moment it is anything but. In this dreadful moment, these seem to be things in danger of being forgotten. I worry about that. I think we all should.

John Harris is a Guardian columnist. To listen to Johns podcast Politics Weekly UK, search Politics Weekly UK on Apple, Spotify, Acast or wherever you get your podcasts. New episodes every Thursday

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The Tories bellicose posturing on Ukraine is dangerous - and unfair to us - The Guardian

ODESSA, Ukraine Ukrainian forces carried out counter-offensives against Russian positions on Wednesday, seeking to inflict what one official called maximum losses, even as the invading Russian military stepped up its lethal attacks on cities.

In Mariupol, an airstrike destroyed a theater where about 1,000 people had taken shelter, according to city and regional administrators, and photos and videos posted online showed the burning wreckage of the building.

Officials in Mariupol, the besieged southern city that has suffered the most intense bombardment, said they could not yet estimate the number of casualties among civilians, who might have been in a bomb shelter beneath the theater. The strike came as 11,000 residents evacuated the city on Wednesday, according to its City Council.

In a video address to Ukrainians early Thursday morning, President Volodymyr Zelensky of Ukraine called for more sanctions against Russia and said it was a terrorist state.

Our hearts are broken by what Russia is doing to our people, he said, to our Mariupol.

After falling back under a relentless pounding over the wars first weeks, Ukrainian troops tried to gain some momentum with counterattacks on Russian positions outside of Kyiv and in the Russian-occupied city of Kherson, in Ukraines south, a senior Ukrainian military official said.

Rather than seek to regain lost territory, Ukrainian forces tried to cause as much destruction and death as possible, attacking Russian troops and equipment with tanks, fighter jets and artillery, the official said, speaking on condition of anonymity to discuss sensitive military information.

In the task of inflicting maximum losses, weve done excellently, the official said.

American intelligence officials said their conservative estimate of Russian troop deaths was at least 7,000, a staggering number that carries implications for both combat effectiveness and morale. Western defense and intelligence agencies estimate that Ukraine also has suffered thousands of combatants killed.

Mr. Zelensky addressed Congress via video link on Wednesday, asking for more aid, and President Biden promised more weaponry. The administration plans to provide Ukraine with high-tech defensive weapons that are easily portable and require little training or logistical support to use, according to U.S. and European officials.

Meanwhile, President Vladimir V. Putin of Russia falsely accused Ukraine of seeking weapons of mass destruction and asserted that what he called an economic blitzkrieg by the West, aimed at destroying Russia, had failed.

Mr. Putin also sneered at Russians who oppose the war, saying the Russian people could distinguish true patriots from the scum and the traitors, and just to spit them out like a midge that accidentally flew into their mouths.

In a televised videoconference with top officials, he once again falsely described the government in Kyiv, led by a Jewish president and prime minister, as being pro-Nazi and on its way to acquiring nuclear weapons. Their aim, of course, would have been Russia, he said.

And then he went deeper into unreality, accusing the government in Kyiv of disregard for the suffering of the Ukrainian people that his own forces were bombing every day.

The fact that people are dying, that hundreds of thousands, millions have become refugees, that there is a real humanitarian catastrophe in cities held by neo-Nazis and armed criminals, he said. Theyre indifferent.

Ukrainian and Russian negotiators held a third consecutive day of talks on a possible settlement to the conflict, and in typical fashion, the Kremlin left a muddy picture of its intentions. Mr. Putins bellicose, often false statements, larded with World War II references, clashed with more conciliatory comments from his underlings.

But little appeared to have changed on the battlefield. The war in Ukraine, about to enter its fourth week, has become a grinding daily slog with little evidence of significant gains for either side.

Details of the Ukrainian offensive could not be fully established independently, though several top Ukrainian officials, including key aides to Mr. Zelensky, confirmed that the counterattacks were underway.

In Kyiv, missile strikes and heavy artillery sounded overnight and in the early morning on Wednesday in exchanges in the outlying suburbs that were notably heavier and louder than in previous days. Two people were wounded and a residential building was damaged in a strike that landed near the city zoo, the second time in two days that shells have landed close to the city center.

Satellite pictures from Tuesday showed heavy black smoke above the Kherson airport, where the senior military official said Ukrainian forces had targeted parked Russian military aircraft.

Kherson was the first (and so far, only) major city to be fully taken over by Russian forces, which have turned it into a forward military base from which they have launched attacks on surrounding cities and villages, according to Ukrainian officials. On Tuesday, the Russian Defense Ministry announced that it had taken control of the entire Kherson region, giving Russian forces a significant foothold in southern Ukraine that Ukraines military will have difficulty dislodging.

Even so, neither side can be said to have made much progress militarily. The Institute for the Study of War, which has been tracking developments closely, noted in a Tuesday evening assessment that, for nearly two weeks, Russian forces have not been conducting extensive simultaneous attacks that would allow them to seize control of multiple areas at once in Ukraine. And they are unlikely to do so in the next week, it said.

In the absence of significant military gains, Russian forces on Wednesday continued a campaign of terror against Ukrainian civilians.

At least 10 people were killed when a Russian strike hit a bread line in Chernihiv, a city north of Kyiv that has been subject to intense shelling by Russian troops seeking to move on the capital. Ukraines prosecutor generals office said in a statement that the attack occurred at about 10 a.m. as people were lined up at a grocery store. Photos released by the prosecutors office showed several bodies scattered around a dirt yard.

Using heavy artillery, cruise missiles and fighter jets, Russian forces have systematically targeted civilian areas with no military presence, striking apartment buildings, schools and hospitals in cities and villages all over a broad front in the north, east and south of Ukraine. The attacks may have killed thousands of civilians, though reaching a precise count of the dead has been impossible.

Saying it was profoundly concerned by Russias use of force, the International Court of Justice ordered Russia on Wednesday to suspend its military operations immediately, pending its full review of a case submitted by Ukraine last month. However, the order was not expected to lead to any immediate cessation in the onslaught.

According to the United Nations, at least 726 civilians have been killed, including 64 children, since the invasion began on Feb. 24, though its figures do not include areas where fighting has been heaviest, like Kharkiv and Mariupol. In Mariupol alone, which has been turned into a hellscape of burning and decimated buildings, local authorities say at least 2,400 have been killed, and probably far more.

In Kharkiv, Ukraines second largest city, the municipal emergency services agency first reported on Wednesday that 500 civilians had been killed since the war began, but then revised that number to 100 later in the day. In any case, the agency said in a statement on Facebook, the true number of deaths could be much higher, noting that emergency workers were continuing to scour the rubble of residential neighborhoods for more bodies, often under fire.

Mr. Zelenskys appeal to Congress on Wednesday was in part a desperate effort to obtain the weaponry and defenses capable of fending off such attacks. Central to this appeal was a call for a no-fly zone to be imposed over Ukraine, aimed at preventing Russian fighter jets, which cause severe destruction, from operating over Ukrainian territory. Close the sky has become a rallying cry for Ukrainian officials and regular citizens.

Russia has turned the Ukrainian sky into a source of death for thousands of people, Mr. Zelensky said.

Knowing that the request had little chance of being approved, given that it would thrust American pilots into direct confrontation with the Russians, Mr. Zelensky quickly pivoted to something to which Republicans and Democrats have been far more receptive: asking for more weapons to enable his people to keep up the fight themselves.

Mr. Biden announced $800 million in new military aid to Ukraine, including antiaircraft and antitank missiles, body armor, vehicles, drones and small arms, bringing to $2 billion the amount delivered or pledged since early last year. But as expected, he did not offer to deliver warplanes or enforce a no-fly zone.

The United States and its allies have relied primarily on financial sanctions that are already devastating the Russian economy.

Russian officials close to the talks said Wednesday there had been signs of progress, though even there, the picture was unclear. They said the idea of a neutral Ukraine, with a status like that of Sweden or Austria, was on the table, which their Ukrainian counterparts disputed.

Sergey V. Lavrov, Russias foreign minister, told a Russian television network that the status of the Russian language and Russian news outlets in Ukraine were under discussion, and that there are concrete formulas that are close to being agreed on.

Michael Schwirtz reported from Odessa, Ukraine; Valerie Hopkins from Lviv, Ukraine; and Carlotta Gall from Kyiv. Reporting was contributed by Anton Troianovski and Ivan Nechepurenko from Istanbul, and Richard Prez-Pea from New York.

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What Happened on Day 21 of Russias Invasion of Ukraine - The New York Times

Cryptocurrencies have taken on an unprecedented role in the war in Ukraine, helping the government raise millions of dollars to fund its fight against the Russian invasion.

Why has Ukraine turned to cryptocurrencies, and how is the nascent crypto industry changing its reputation and having an effect amid the clouds of war?

At the outset of the conflict, Ukrainian officials posted addresses for two crypto wallets on their Twitter account, giving donors a direct and clear address to which to send contributions.

The wallets attracted more than $10.2m (9.2 million euros) just four days after the start of the invasion.

Since then, more than $100m worth of crypto has been raised, with the Crypto Fund for Ukraine run by Michael Chobanian the founder of the Ukrainian crypto exchange Kuna accounting for 60 percent of all donations.

We are still collecting crypto. It is being spent on aid like daily rations and bullet-proof vests and helmets, the 37-year-old Ukrainian told AFP.

Initially, two funds were set up, one for humanitarian purposes and the other to support the Ukrainian military.

However, after the violence escalated across Ukraine, the funds were merged and focused fully on supporting the military, said Chobanian.

He said that the majority of crypto donations came in the form of Bitcoin, Ethereum and the stablecoin Tether a coin pegged one-to-one to the dollar.

Aid packages sent to Ukraine in fiat money from the United States and the European Union dwarf cryptocurrency donations, but the latter allow individuals to get involved.

US crypto charity, The Giving Block, told AFP that cryptocurrency donations have the potential to attract younger donors who are looking to support various causes.

Another reason crypto donations are of value to Ukraine is because they are less influenced by geopolitical or macroeconomic factors. Chobanian points to the depreciation in the value of the Ukrainian hryvnia as a result of inflation.

An extra advantage of donating in cryptocurrencies is the speed of the transfers. Bank wires may take up to 24 hours to be validated between two countries. However, cryptocurrency transfers typically take less time.

Despite the success of crypto in aiding the Ukrainian war effort, it has not always been a smooth ride.

In the early days of the conflict, the deputy minister for digital transformation wanted to issue Ukraines own crypto as a symbolic gesture for Kyivs cause, but the project was eventually cancelled.

To make matters worse, people seized the opportunity to mint and market fake versions of the planned government-issued crypto.

There was a lack of communication within the government, said Chobanian, who now works closely with the ministry.

It was the first day of the war, he recalls.

Moreover, cryptocurrencies have become a staple part of Ukraines shadow economy used as a medium of exchange in online crime, tax avoidance and capital flight.

According to data analytics firm Chainalysis, transactions from Eastern Europe to other regions are particularly high, and the company suggests that capital flight could account for some of the crypto movement in the area.

Despite the risks associated with crypto, Chobanian is confident that it will become a core part of the Ukrainian economy.

When we win the war, we will rebuild Ukraine using blockchain technology. All of us were helped by crypto, he said.

While Chobanians aspirations may be very ambitious, they are based on real developments.

On Wednesday, President Volodymyr Zelenskyy passed a law that would provide a legislative framework for crypto platforms and users to operate within the country.

Caroline Malcolm, head of international public policy and research at Chainalysis, told AFP that the conflict in Ukraine is forcing governments to develop their understanding of cryptocurrencies and their regulation.

She believes that such discussions can be beneficial to the crypto industry, leading to proportionate and effective regulatory policies.

As of last week, US President Joe Biden signed an executive order seeking further clarification and guidance on crypto regulation showing Washingtons willingness to contend with an ever-growing and new asset class.

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Bitcoin to the rescue: Cryptocurrencies role in Ukraine - Al Jazeera English

Recently, at a closed ski resort in Ukraines Carpathian Mountains, Roman Davydov leaned into a microphone and announced the latest news from the war. Kryvyi Rih, in southern Ukraine, was being attacked; a U.S. journalist had been shot; and the British Foreign Secretary had announced new sanctions on Russian oligarchs in London. Davydov, who is forty-three, with dark hair and an oft-furrowed brow, is the voice of Kraina FM, an independent radio station that, after Russian bombing began in Kyiv, relocated to an undisclosed location. (The staff of Kraina FM asked me not to identify the village, for security reasons.) Outside Davydovs improvised booth, a corner office lent to Kraina FM by a local accountant, an odd sense of normalcy reigned. Beyond the ski-rental shop, where a cluster of sandbags had been piled, a man in a blue jacket and ski goggles operated a small lift for a childrens slope in the bright sunshine.

The area, which is several hours south of Lviv, has become a shelter for displaced people, Bogdan Bolkhovetsky, Davydovs colleague, told me. Bolkhovetsky, Kraina FMs station general manager, said that he and Davydov had arrived in the village by pure chance. The west of the country is full of refugees, and there are few places for families to stay as they make their way toward the borders of Europe. We found this place because it was the only place vacant, Bolkhovetsky said. They arrived in the evening on February 27th; just days later they were setting up the station in a sloped-ceilinged, wood-panelled space that barely fit their two desks. They acquired laptops and a mixer from the supply of aid making its way from the rest of Europe to Ukraine. We called our friends in Austria and they were so quick, Bolkhovetsky said. Guys weve never met just sent us the equipment, and a friend of ours brought this equipment in. I mean, they brought us these German laptops and the mixing console and weve never seen these people before.

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Kraina FM is an independent radio station that grew out of a now defunct channel called Radio EU. Until the Russian invasion, the station mainly played Ukrainian rock and pop, although it also featured childrens programming and occasional news flashes that, when the channel was launched, in 2016, Davydov said would be the most independent among Kyivs radio stations. Kraina FM was more funny and easy, Davydov told me later, in an e-mail. Now its mostly just rock and not happy information. Like millions of other Ukrainians who have fled their homes, most of the stations staff left Kyiv after the fighting began. Everyone was scattered for two or three days, Bolkhovetsky told me. You look at Google Maps, you see the name of the city and you just start calling hotels to stay overnight.

Bolkhovetsky, who is forty-nine, had awoken from a terrible nightmare on February 24th, when he saw a news alertPutin addresses the nationand heard the first low thuds of Russian bombs exploding around the capital. I just started packing the bags, throwing everything in, he said. With his wife and nine-year-old son, he fled to a summer house outside Kyiv. Within days, Russian helicopters were attacking nearby. Some flew low enough for him to see the pilots in the cockpit. The faces look like you, he said. Just people on the job, like fucking robots. His son spent most of the day in the basement, still in his pajamas. At one point, when the helicopters flew off, Bolkhovetsky piled his family into the car. Once he had reached a town that was not being attacked, he called Davydov, and together they searched for a safe place to set up the station.

Davydov had fled Kyiv with his wife and three-year-old daughter, heading to his wifes office in central Kyiv, where they thought they would be safe. But Russian shelling forced them to seek shelter underground for days. Davydov had a microphone and a connector in the trunk of his car, a setup that he had previously used to record soccer news late at night for early-morning bulletins. Despite the shelling, Davydov kept the broadcasts going, recording one-man news items and uploading them remotely during pauses in the explosions. For two or three days we broadcast only with my one microphone, he said. In the background of these first recordings, one can hear children and dogsDavydov was recording them in the crowded shelter with his head enveloped in a plaid shirt to muffle the sound.

Both Bolkhovetsky and Davydov have spent most of their careers working in radio. Davydov studied economics, but, when he was eighteen, he started doing humor programs for a station in what is now called Kamianske, a city of more than two hundred thousand people on the Dnieper River, and never looked back. He has worked just about every job on the air sincecopywriter, traffic manager, music director, brand voices, program director. In 2004, he moved to Kyiv. Bolkhovetsky, who was born in Luhansk, an eastern region of Ukraine claimed by Russia-backed separatists, worked as an English and French teacher before going into radio in the late nineteen-nineties. He moved to Kyiv in 2005 and worked at a succession of different radio stations.

Once they got Kraina FM up and running at their mountain location, a representative from the National Council of Television and Radio Broadcasting in Ukraine requested that they play a national broadcast. Everybody else switched to the national station, Bolkhovetsky told me. It was a continuous broadcast of just one program on TV stations and everywhere. Bolkhovetsky and Davydov decided to continue their own programming. I mean, you tune in to any station and it is the same, Bolkhovetsky told me. Whats the point? Lets have one which is different. They decided to re-create Kraina FM as the station of national resistance.

At the moment, Kraina FM is broadcasting to some twenty cities and online. During the first week, the programming was almost exclusively news about the Russian advance. By the second week, the station had morphed into something profoundly different, cordinating humanitarian logistics and explaining which towns needed what. And a lighter side also crept into the programming. In the first week, we didnt think about something funny, Davydov said. And now its humor about Russiansaggressive humorpoetry, patriotic poetry, some little features about Ukrainians. They broadcast a famous Ukrainian Father Christmas telling childrens tales at night and a psychologist who gives advice for how to care for children during days marked by shelling and air strikestalk to them kindly, show love, listen, and dont contradict what the child says.

A network of around fifteen people, in Ukraine, Poland, and Russia, helps them put out Kraina FMs programs remotely. They use Ukrainian news agencies and the app Telegram to source and put together bulletins. The Internet connection is awful, and theyre often unable to upload stories and recordings. Usually, Kraina FMs programming reaches about a million people, but these days they have no idea how many people are listening. The person who would normally monitor that is likely still in Kyiv, presumably with more urgent matters to contemplate. Perhaps the real measure of the stations popularity has been its drives to locate supplies for the Ukrainian military, first responders, and other humanitarian groups. One day a television producer in Kyiv told them that the military needed a hundred laptops. Davydov and Bolkhovetsky announced the request on air. We made the announcement, like, every fifteen minutes or twenty minutes, Bolkhovetsky said. About two hours later, the military called back; they had enough laptops. Nevertheless, laptops continued to flood in. When I asked why they continued to produce the show, Bolkhovetsky pointed to this experience. What other reason do you need in this moment?

The ski village is something of a transit hub for people fleeing across the border. People come, people go, Bolkhovetsky told me. Thats how it works here.At a certain point, the time came for their own families to leavetheir wives and children had been anxiously spending their days in the resorts hotel rooms while Bolkhovetsky and Davydov got the station running. Both families fled to other parts of Europe. Its better to be by ourselves, Bolkhovetsky told me. They will take care of themselves and well take care of business and ourselves. Still, saying goodbye, he said, was terrible, like never before. Its not compared to anything in my life, to anything.

Under Ukraines current martial law, military reservists between the age of eighteen and sixty have to register to be conscripted into the Army, and all other men in that age group are not supposed to leave the country. Even if Bolkhovetsky and Davydov wanted to leave, they would not be able to. I asked Bolkhovetsky and Davydov whether, if called up, they would fight against the Russians. On one of their first days in the village, Bolkhovetsky told me, We went to the local military station and we said, We are here. What do you want us to do?

What can you do? the local soldiers asked them.

We can do radio, Bolkhovetsky replied.

On hearing this, the unit chief looked at him. So go and make radio, he said.

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Ukraines Radio Station of National Resistance - The New Yorker

Refugees from Ukraine, which has a high rate of tuberculosis, are often screened for the disease. Above: Dr. Natalie Whrle analyzes the X-ray images of the lungs from a screening in Gauting, Germany, on March 12. Matthias Balk/picture alliance via Getty Images hide caption

Refugees from Ukraine, which has a high rate of tuberculosis, are often screened for the disease. Above: Dr. Natalie Whrle analyzes the X-ray images of the lungs from a screening in Gauting, Germany, on March 12.

"We have 20 patients we can't find, so we don't know if they are alive or not," says Dr. Olha Konstantynovska.

She's referring to the tuberculosis patients under her care in Kharkiv, where, as in much of Ukraine, the Russian war has disrupted lives including her own. She and her three daughters evacuated to her father's home about 20 miles away after a bomb hit a building down the street from their apartment.

Before she evacuated from Kharkiv because of Russian attacks on the city, Dr. Olha Konstantynovska treated tuberculosis patients at local hospitals. Olha Konstantynovska hide caption

Before she evacuated from Kharkiv because of Russian attacks on the city, Dr. Olha Konstantynovska treated tuberculosis patients at local hospitals.

TB a serious bacterial infection of the lungs is a big problem in Ukraine. According to the World Health Organization, the country has the fourth highest incidence of the disease in Europe. And it has one of the highest rates of multidrug resistant TB anywhere in the world.

In the tuberculosis hospital in Kharkiv, where Konstantynovska treats TB patients, about 70 of the 200 residential beds are filled. That's because at the beginning of the war, her team discharged as many people as possible to allow them to evacuate.

"I called to the hospital to speak with one doctor and she said that hospital has no potato and bread," says Konstantynovska. "We have drugs, but we have no food."

She says that before the war, "people from the whole city of Kharkiv two and a half million citizens [went] to this dispensary to be checked for tuberculosis." It's also where those with TB could receive medication, treatment and even surgery if necessary. Konstantynovska is a member of the small army of people in Ukraine who've mounted a stiff resistance against the disease, one that's been supported by the government.

But now, Konstantynovska says doctors are having a hard time getting to the hospital in Kharkiv. It's too dangerous to move about outside, and the roads are ravaged. One of the physicians walks a total of three hours each day to get to and from work. The head of a local dispensary is living in her office because her apartment was destroyed.

The view from inside the apartment of Dr. Tetiana Synenko, a TB specialist in Kharkiv, and a glimpse of the wreckage on her way to work. She's now living with 12 others in a nearby cellar. Tetiana Synenko hide caption

The view from inside the apartment of Dr. Tetiana Synenko, a TB specialist in Kharkiv, and a glimpse of the wreckage on her way to work. She's now living with 12 others in a nearby cellar.

Without intervention, people can live with tuberculosis and spread it, through the air for years. At some point, however, usually due to the stresses of hunger and injury; or a weakened immune system, it can turn fatal. Treatment consists of an antibiotics regimen that takes anywhere from six months to two years.

The contagiousness of TB is why Konstantynovska is especially worried about those missing patients. If they're on the move, she says, they're taking their TB with them, giving the disease more opportunities to spread through the air. "Eleven patients right now are in other regions of Ukraine," she adds. "They are trying to find the drugs because they stop[ped] treatment two weeks ago."

Interrupting an antibiotic regimen aimed at TB is worrisome for two reasons. First, drugs prevent someone from infecting others. So without meds, the disease has more opportunities to spread. And second, TB can become insensitive to the drugs if they're not taken regularly because insufficient dosing gives the tuberculosis bacteria time to mutate, selecting for populations of the bug that can dodge the meds. This is called multidrug resistant tuberculosis.

There's even extensively drug-resistant TB when the bacteria don't respond to the first or second lines of drugs. And once that form of resistant TB emerges, it can be passed from person to person, transmitted through the air just like regular TB. In 2020, a third of Ukraine's TB cases were drug-resistant, one of the highest rates in the world. And that number is likely to grow.

That's why Loyce Pace, the assistant secretary for global affairs at the U.S. Department of Health and Human Services, says her office is coordinating with the CDC and USAID "to track patients [within and beyond Ukraine] to understand where they are, what they need in terms of their meds and ensure that there's no gap."

To understand why Ukraine has so many TB cases, we need to rewind a hundred years.

For much of the twentieth century, when Ukraine was a republic of the former Soviet Union, tuberculosis was managed rather well, according to Tom Nicholson, executive director of the non-profit Advanced Access and Delivery. "The medical care system was quite comprehensive and was based on community medicine," he says. "It had a system of rural health posts, even in the most far-flung areas." There may not have been doctors on-site, but there were often nurses and medical technicians who could do a chest X-ray to screen for TB and dispense drugs to treat it.

The situation deteriorated with the collapse of the former Soviet Union in 1991. The economy in its republics tanked. Unemployment soared. Crime escalated, which sent a lot of people to prison. And that created a kind of "epidemiological pump," says Dr. Salmaan Keshavjee, director of the Center for Global Health Delivery at Harvard Medical School.

"Some people had TB," he explains. "It spread in the jails and in the prisons. And then they went back to their community, of course, when they were released. So the TB also went back to the communities." Tuberculosis rates soared, he says, including in some parts of Ukraine, which regained independence that same year.

During his work at a prison in Tomsk, Russia, Dr. Salmaan Keshavjee received this honey pot carved out of wood by a few of the prisoners. "It has a lot of meaning because this is where we showed that it was possible to bring [TB] mortality down close to zero if you got people the right treatment," he says. Salmaan Keshavjee hide caption

During his work at a prison in Tomsk, Russia, Dr. Salmaan Keshavjee received this honey pot carved out of wood by a few of the prisoners. "It has a lot of meaning because this is where we showed that it was possible to bring [TB] mortality down close to zero if you got people the right treatment," he says.

With government resources, Ukraine has since worked hard to build back its infrastructure for treating TB, registering a decade of declines between 2010 and 2020. But then COVID hit. Lockdowns early on in the pandemic shuttered hospitals where routine screening would take place.

Olha Konstantynovska's three daughters, afraid of an air attack, sleep in their apartment bathroom in Kharkiv. After an explosion down the street, the TB doctor and her family fled. Olha Konstantynovska hide caption

Olha Konstantynovska's three daughters, afraid of an air attack, sleep in their apartment bathroom in Kharkiv. After an explosion down the street, the TB doctor and her family fled.

"Sometimes it was impossible to check patients for TB," says Dr. Olha Konstantynovska, the physician currently living with her extended family outside of Kharkiv.

Without proper screenings and treatment, when tuberculosis did manifest and people came to the hospital, they'd be in bad shape severely underweight, a wracking cough, bleeding in the lungs.

In 2020, the percent of people receiving treatment fell dramatically from 75% the year prior to just over half. And now, in many parts of the country, the war's upended everything further.

In the chaos of battle, diseases find opportunity, disproportionately affecting people at the margins of society. Dr. Salmaan Keshavjee says, "In these moments of deprivation as a result of war, as a result of being refugees, as a result of being crowded in, not having enough food, et cetera, your TB rates go up." This isn't just true of Ukraine.

"I've spent many years working [with TB] with prison and other populations in Russia," says Keshavjee. "I have grave concerns that many of them are going to be dying. My guess is that they're trying to maintain their TB treatment programs. But Russia's under sanction. As funds and things get diverted to other efforts, you will see that the drug supply is going to drop."

Dr. Vasyl Petrenko visits a tuberculosis clinic in Kyiv before the war. Tatiana Butkivska. hide caption

Dr. Vasyl Petrenko visits a tuberculosis clinic in Kyiv before the war.

For now, Ukraine's stockpile of tuberculosis drugs is sufficient, provided they can be distributed. For instance, in Kyiv, Dr. Vasyl Petrenko, head of the physiatry and pulmonology department at Bogomolets National Medical University, says that Russian assaults on the city are limiting treatment options for patients.

When he's able to do his rounds, he tells his patients not to worry. "We are going to win," he reassures them. "The victory will be ours." He says it's crucial for morale. "It gives a lot of power, energy to every single person here."

The question is, how long will his optimism last?

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Russia's war with Ukraine is devastating for Ukraine's war on TB - NPR