This article was initially published on March 28^th, 2022 on the Souk, the MSF associative website.

In a country with a solid medical infrastructure and faced with a large-scale international mobilisation, what is the place of MSF in Ukraine and beyond? "We are not currently in the front line of emergency care provision," write Thierry Allafort Duverger and Michael Neuman, who see our work in limited areas, particularly with those "left behind," and in the longer term.

The scenes are as common as they are extraordinary. The bombings followed by population movements, the first efforts by humanitarian organizations to help the displaced people as well as those who have remained in the war zone. Tragic scenes already seen in other wars, and that have now accompanied us for more than a month following the Russian invasion of Ukraine on February 24.

Yet these scenes are exceptional. Both because of the reappearance of large-scale war on European soil, and because of the intensity and speed with which millions of people have moved towards the West to flee the fighting and destruction. Another exceptional sight is the massive European solidarity with the affected people. The political mobilisation, of course, as well as the reception of refugees in the countries of the European Union in a remarkably benevolent way, but also the massive donations for Ukraine and its population, refugees or not. Although unverifiable, the figure of 70,000 tons of humanitarian aid that the Ukrainian government reports receiving in the last two weeks gives an idea of the scale of the effort.

For Médecins Sans Frontières, the conflict in Ukraine is also an opportunity to confront the norm and the exception. The organization is accustomed to war zones, to caring for its victims, as well as for the displaced and refugee populations that are the product of war. It also draws its resources from the emotions and popular solidarity that events such as war provoke.

However, for MSF there are also singular elements in what is currently taking place "at the gates of Europe", which raise questions about the response we can provide.

Firstly, we must remember that Ukraine had a strong medical system before the conflict, with high-quality university training.

Secondly, the Ukrainian war effort has also taken on the task of providing relief to civilians: the health staff has not fled and they are taking care of the wounded produced by the war without much need, for the moment, of foreign personnel. Ukraine is a reminder of a reality that has been observed many times: in disaster situations it is the state, the local community, and local organizations that regularly provide most of the first aid. Moreover, the international mobilisation is of a truly phenomenal level. This is not only military, but also economic and infrastructural – the Ukrainian electricity network has just been connected to the European network, for example, and the response is also helping to replenish the medical stocks needed by hospitals.

To a considerably lesser degree, we had already seen the strength of the Ukrainian medical system and its support networks: during the conflict in the Donbass region in 2014, finding our place was not easy for the MSF teams mobilised. As we did then, we see today that it would be most useful to focus on those left behind by the conflict: all those, especially the elderly and the poorest, who did not want to or simply could not flee the conflict; the mentally ill; and people in institutions, including children. In collaboration with Ukrainian partners we can try to provide care to these people, some of whom are already deprived of care because of the reorientation of the health system towards the care of the wounded. We may be able to ensure the continuity of their treatment for chronic diseases, for example. We may also be able to help alleviate the lack of family support that these people will suffer because of the displacement of their loved ones. Many people will have difficulty accessing drinking water and food. Social support is an aspect that will also undoubtedly be important to consider in the context of the severe socio-economic disruptions that war entails.

In addition, the intensity of the fighting and the tactics used means that the windows for MSF to provide assistance in zones of active combat are limited, albeit real. Like they were during the intense fighting in the cities of Aleppo and Raqqa in Syria, or Mosul in Iraq, MSF's emergency medical operations in combat zones, including for the wounded, remain limited or non-existent. In Mariupol, the shelling of the city does not spare medical structures. It is extremely dangerous to get teams in and to evacuate the wounded because of the difficulty of negotiating cease-fires and the mines laid on the roads. The problem of supplying medical facilities is now linked to the difficulties of access due to the siege and shelling of the cities by the Russian army. Here again, the Ukrainian teams are very committed to providing the necessary medicines and medical equipment.

However, unlike the Syrian and Iraqi situations mentioned above, these limitations come into tension with the imperative to do something for Ukraine, and preferably to do something big and visible. As in some natural disaster situations - the Indian Ocean Tsunami in 2004-2005 for example - MSF's leaders and operational managers are under significant internal and external pressure to act. This is evidenced by the large amount of spontaneous fundraising and applications from people wanting to join our teams in Ukraine.

The war in Ukraine is indeed a major crisis. A political crisis, of course, but also an emergency: the huge recent population movements and the large number of dead and wounded require rapid and decisive action from local and international institutions. Nearly a quarter of the Ukrainian population has been displaced in the space of three weeks, which is unprecedented.

It is likely that the conflict will continue, causing the solidarity with the displaced and refugees to wane and the local health system to become more fragile. The longer the war lasts, the more the local health system will need external support to cope. We must therefore be invested in the long term and be clear about our immediate assistance.  We are not currently in the front line of emergency care provision, but we can and must be active in other sectors, especially with the marginalised people mentioned earlier. In addition, the dramatic situation of certain cities, Marioupol and Kharkiv in particular, which have been partially or totally destroyed, will require a larger participation on our part in a second phase. This will also be the case for the Ukrainian populations who find themselves in areas under Russian control, and who must not be forgotten despite the probable difficulties we will have in negotiating access. We are also aware of the difficulties Poland, Romania and Moldova will have in accommodating, for the long term and in good conditions, the refugees who have recently arrived on their soil.

Moreover, we already know that this war will have worldwide repercussions. We know the importance of Ukraine in the world production of wheat, corn, and sunflower oil, and that of Russia in the production of oil and gas. The price increases already observed will most likely continue. Moreover, until the outbreak of the war, 40% of Ukrainian wheat and corn exports were directed to the Middle East and Africa.

What will be the impact of the coming inflation and underproduction on many of the countries where we work? We must remember the popular uprisings caused by the rise in prices in 2008 following the financial crisis. Political consequences and social upheavals are not to be ruled out.

This general deterioration comes in a year that we had already predicted was going to be particularly difficult. As the FAO recently reminded us, 26 developing countries depend on Ukraine and Russia for more than 50% of their wheat imports. They are warning of the risk of famine.

To take just two examples from the many places where MSF is working: Afghanistan is facing an extremely difficult situation both financially and in terms of food security, while the continuous rise in the price of cereals is accelerating the fragility of the nutritional status of the population in the Sahel. Ukraine is also a major supplier of grain to the World Food Program, which poses a risk to the countries currently receiving this aid.

Thus, while a large part of the world's attention is focused on Ukraine and the consequences of the war, we must not forget the rest of the world.