The War Rheum Save

February 24, 2025 marks three years since Russia launched the massive aerial attack on Ukraine with 122 missiles and 36 drones, fueling the Russo-Ukrainian War that began in 2014. The effects on rheumatologists and their patients living in Ukraine largely have been unseen by the world. At ACR Convergence 2024, I met Dr. Marta Dzhus who practices at St. Michael's Clinical Hospital in Kyiv; she shared her story with me about the humanitarian crisis in rheumatologic care in Ukraine because of the ongoing war. Here is an excerpt of our conversation.

Me: Dr. Dzhus, please tell us more about yourself.

Dr. Dzhus: I am a professor of  rheumatology and Chief of Internal Medicine at Bogomolets O.O. National Medical University. I also head the EUSTAR center (EUropean Scleroderma Trials And Research group) and supervise transitional medicine, helping patients with JIA into adulthood. I also supervise rheumatology department at St Michael Clinical Hospital, Kyiv, Ukraine. 

Me: What happened when the war began and how has it disrupted your life?

Dr. Dzhus: When the war began, my husband and I moved to Lviv while at the same time my children went abroad for their safety. We were all in different countries and could only see one another on video calls. I saw patients remotely and performed consultations in a mobile hospital or at my flat. I work from early morning until late at night without weekends, trying to respond to everybody who contacted me. For patients who left Ukraine, I wrote letters to the EULAR secretariat, who gave me contacts of foreign colleagues rheumatologist from different countries, trying to help our patients to find a rheumatologist.  At night, alarms sound several times to warn us of missiles attacks and to urge us to shelter! Most of us stopped responding to the alarms. When you are tired, you want to sleep in your own bed, not in a shelter. You want to rest after working all day and not think about what is flying in the sky and whether it will strike your house. We became experts on night sounds and were able to distinguish the sound of a missile from the Shahed drone or sounds of our air defense. My husband and I returned to Kyiv in August 2022 and since then I have been working mainly in the hospital, taking care of our patients. 

Me: What was Ukraine like before the war started, and what is it like now?

Dr. Dzhus:   Before the war, Ukraine had a population of approximately 45 million people. We had a relatively stable healthcare system. The war has had a dramatic impact as there have been nearly 2000 attacks on healthcare facilities. Hospitals were bombed, and doctors and healthcare workers killed. We were operating under constant threat. Additionally, over 50 attacks were directed towards children’s hospitals, and 40 attacks affected maternal health facilities. Our hospitals are barely functioning. Critical health services like laboratory testing, cancer screening, gynecological services, and rehabilitation programs have been reduced by over 20%. Some areas are reporting even higher losses including disruptions in the supply chain for essential equipment and pharmaceuticals, shortages of laboratory test kits, delays in the delivery of crucial medications, and problems around appropriate medication storage due to power outages. In many regions, hospital staff has been drastically reduced. 

Me: How has the war affected medical education and research?

Dr. Dzhus:  Academics suffered. Medical students in Ukraine have hybrid education (online and in-person), but this, too, has been disrupted due to frequent air raid alarms, loss of internet connection, and blackouts. Scientific activities in Ukrainian Universities have decreased due to similar reasons, but in addition, the majority of researchers indicate that negative emotional state and adaptation to the new reality have negatively affect scientific activity.  An unpublished cross-sectional study of medical students in Ukraine and Croatia showed, "Despite the challenges, nearly 60% of medical students have engaged in volunteer work, assisting in hospitals, working with children, and collecting data on the war’s impact on health." The same study found that over 50% of students reported worsening mental health since the start of the war. It revealed high rates of moderate to severe depression and anxiety among medical students, with over 40% reporting these symptoms. The war will have a dire impact on the future of Ukraine's healthcare system.

Me: Tell me how the war has affected rheumatologic care in Ukraine.

Dr. Dzhus:  Care for rheumatic disease patients has been severely disrupted. Ukraine had 350 rheumatologists in 2022 when the population was 41 million. Today we have less than 300, mainly due to doctors leaving Ukraine. In comparison, the number of rheumatologists in France is 2600 and in Italy is 1800 with similar populations. The lack of medical professionals has affected the treatment of chronic diseases such as arthritis, lupus, and other autoimmune conditions. My colleagues, especially women, who are mothers of children, fled abroad for safety reasons. Even before the war, Ukraine had high rates of rheumatic diseases. The full-scale invasion has made these conditions harder to manage with fewer doctors and limited access to necessary treatments. There has been an increase of some rheumatic diseases such as JIA in adults, SSD, gout (especially among soldiers), and spondyloarthritis.

Me: How have you and other Ukrainian rheumatologists been providing care? What challenges do you face?

Dr. Dzhus: Telemedicine has been a vital tool, especially during COVID, but it’s not always feasible during war. Internet access is unstable, and many patients cannot get online. Even when they can see their doctor medical supplies and treatment are limited. The Russian invaders have repeatedly demonstrated a complete disregard for the rules of war by shelling humanitarian convoys. In the biggest frontline cities of Ukraine, the stores of DMARDs are already insufficient. Lack of medication results in flares and damage from chronic active disease. Unfortunately, our patients must buy most of their medications themselves. There is a NATIONAL list of basic medicines and medical products which are covered by the Government, but there are no biologics except for Rituximab. Biologics are extremely expensive; only a few of our patients can afford them. Because of this, many patients start to increase intervals between doses as soon as they get a good response. A lot of patients in frontline areas also are increasing their steroid doses due to flares; they stay on high dose of prednisolone as they do not have the opportunity to consult with a rheumatologist or have followup visits.  Trying to achieve treat to target (T2T) cannot be achieved. The only program that has state funding in our country is a program for the treatment of resistant patients with JIA, and they receive biologics for free. But such treatment has not been available in occupied territories, and JIA patients who were internally displaced due to active hostilities have difficulties finding a rheumatologist who could provide free access to biological treatment.

Me: What kind of support have you received?

Dr. Dzhus: Since February of 2024, EULAR has adopted a series of measures to support Ukraine. These measures so far include coordinating support through EULAR Members and countries bordering Ukraine to identify opportunities for people with rheumatic diseases in Ukraine and among the refugees. EULAR also provided free access to the On-Demand virtual Congress platform  and online courses for the applicants from Ukraine.  Further, to the request by the Ukrainian Association of Rheumatologists, EULAR provides speakers to the virtual Ukrainian conferences on requested topics. I was the first rheumatologist in Ukraine who applied for help from EULAR.  When full-scale war broke out, many of our patients fled abroad. I wrote letters to EULAR asking for help for the patients; I indicated the city and country of the patient's stay, a few days later I received a reply from EULAR that they found a rheumatologist in the nearest city and gave me a contact. Most rheumatologists I contacted responded and accepted our patients. In the beginning, it was invaluable for patients, when in a foreign country without knowledge of the language, without understanding how the system works, without social protection, to receive such support! Thanks to EULAR, we have found doctors for our patients all over Europe in Germany, France, Italy, Portugal, and Austria, just to name a few countries. Such coordination took a lot of time, but it worked and has been tremendous for our patients.  I am also grateful for the ACR for providing free registration to Convergence for Ukrainian delegates, making it possible for me to come to Washington, DC.

Me: What kind of impact do you think the war will have on the future of rheumatologic care?

Dr. Dzhus:  I predict with many of the younger people leaving the country, we will have a large number of elderly and disabled people. We will have a significant burden on our medical system due to hospitals being understaffed.  Rheumatic diseases and other stress-related conditions are already on the rise and will continue to increase. Due to limited access to modern treatment and cost, we won’t be able to achieve timely T2T strategies, which will lead to worse outcomes for our patients. 

Me: What are your needs now and how can the world community help?

Dr. Dzhus: We need the support of the world community to provide our patients with medical supplies, disease modifying agents, including biologics and JAK-inhibitors. We need equipment – mainly musculoskeletal ultrasound machines and laboratory equipment. I am actively searching for a musculoskeletal machine for my clinic but having a difficult time obtaining one.

Ukraine needs financial support to educate our patients, nurses and young rheumatologist about rheumatic diseases and to survive and recover from this war. Without support, rebuilding will take significantly longer and put more lives at risk. Finally, we also want justice to prevail and the right to live and work on our land with freedom.

Dr. Dzhus can be reached by email.

Editor's note: This blog was written at ACR 2024 in November. To contribute to medical relief in the Ukraine, also consider

• Direct Relief
• Help Ukraine|Operation Palyanytsya