How Ukraine rehabilitates its war wounded will define it at a nation

Telegraph

2 days ago

With complex negotiations to end the Russo Ukrainian stalemate now underway, one of the few things which can be said with certainty is that both sides will carry the legacy of conflict for decades to come, physically represented by the huge numbers of limbless former soldiers.
Estimates of the number of Ukrainian amputees vary widely – a commonly accepted median figure is approximately 40,000. To put that number in context, it is roughly similar to the number of British servicemen who lost limbs in the First World War.
As the population of Britain in 1914 stood at just 40 million the proportionate loss is also comparable, as is the similar ratio of amputees to population in the American Civil War – the first large scale conflict of the industrial age.
Such an ongoing burden of injury has not been seen in modern times – although Gaza may provide competition where an estimated 4,700 have lost limbs from a population of 2.3 million.
For comparison, the total number of British amputees in the Second World War was approximately 12,000. And just over 5,000 Americans lost limbs in Vietnam.
It shouldn't need saying, but the challenges facing Ukrainian society in adapting to this burden of injury are immense.
First there are the follow up surgical costs to consider. It is common for initial amputations carried out in field hospitals to require revision surgery to achieve a residual limb capable of accepting a prosthetic limb.
Using a rough estimate of $50,000 to rehabilitate one patient, suggests an estimated cost of $2 billion for the initial phase of treatment, not taking into account substantial ongoing costs for prosthetics replacement over time.
Yet the socio-economic arguments in favour of providing high quality rehabilitation for wounded speak for themselves. Failure to reintegrate wounded servicemen back into the workforce and wider society risks creating a generation prone to depression and substance abuse, to say nothing of the wasted potential of productive lives.
The principles of rehabilitation have not changed greatly since the First World War. Sport is a common means of combining physiotherapy and psychological group support – as was well known to the patients of Roehampton Hospital in 1917 as to modern day participants in the Invictus games.
Similarly, the requirements of war accelerate technological change in many areas including rehabilitation. The astonishing advances in 'bionic limbs' driven by the needs of amputees from conflicts in Iraq and Afghanistan are a contemporary example.
These devices are of particular significance in cases of very short amputation limbs not capable of accommodating standard prosthetics.
Significant technical advances in prosthetic design first occurred after the America Civil war. With typical entrepreneurial zeal, prosthetic manufacturers Franklin Palmer and Amasa Marks made considerable fortunes linked to astute marketing and political lobbying.
In Britain in the wake of the First World War, the lightweight Desouter prosthesis, made of the alloy 'duralumin' instead of wood, was eventually provided free to limbless ex-servicemen after substantial political pressure.
Duty to provide high quality care
The political dimension of rehabilitation services in Ukraine needs urgent consideration. Simply put, the citizen soldiers of Ukraine will reasonably consider that the country has a moral obligation to mitigate the consequences of their sacrifice, especially as many amputees will have been subject to compulsory conscription.
The unintended adverse consequences of battlefield tourniquet misuse highlighted recently in this newspaper will rightly add to political pressure on the Ukrainian state to provide high quality care for their veterans.
The political power of a mobilised veteran community in democratic states has been clearly demonstrated after most major conflicts. The ability to organise and advertise this potent message is amplified in the information age. Some of the financial obligation will undoubtedly be transmitted to other European nations as the reconstruction phase commences. Ukraine's allies should help it to plan for it now.
The geopolitical payoff for the financial cost may lie in the juxtaposition between how Ukrainian and Russian war wounded are looked after once the fighting stops.
The number of Russian amputees is also unknown, but it is reasonable to assume it is on a similar scale to that of Ukraine. Open sources have noted significant activity in production of Russian prostheses and wheelchairs and reports in the Russian press have highlighted complaints about the availability and quality of support for disabled soldiers.
It is widely accepted that the discontent of Soviet veterans of the Afghanistan conflict contributed to the disintegration of the Soviet Union.
In the battle of ideas that underlie most wars, the most persuasive political argument for supporting rehabilitation in Ukraine may be by viewing it as an opportunity to demonstrate the difference between Western democratic values compared with those of autocratic governments.
Effective physical and psychological rehabilitation graphically demonstrates what this war is fundamentally about – the nature of the relationship between citizen and state, for good or bad.
Dr Eddie Chaloner is a Consultant Vascular Surgeon practising in the UK; Shehan Hettiaratchy is London's Major Trauma Director, Consultant Plastic and Reconstructive Surgeon, for Imperial College Healthcare NHS Trust