In Ukraine, the Covid-19 pandemic is just beginning to unfold. I witnessed the start of it in Kostiantynivka, a town in Donetsk region where I was recently hospitalised together with a colleague. We had just returned from a work trip to Germany to another town in the region, Sloviansk, where the crisis was quickly evolving, and my colleague felt some of the symptoms.

We had travelled separately, but our work trips were both timed around 11 March. That day, the World Health Organization declared the outbreak a global pandemic – and the Ukrainian government introduced a quarantine. Initially planned to last three weeks, this quarantine was later extended until 24 April.

A few days later, more measures were announced in Ukraine, such as the closure of all educational facilities, limits on public transport, closure of border crossings, suspension of all inter-city trains and city subway systems, and cancellation of all flights, except specially organised flights for Ukrainian citizens abroad. Since 28 March, access to and from Ukrainian-controlled Donetsk and Luhansk regions has been limited in order to curb the spread of the virus among military personnel stationed along the line of contact. Ravaged by six years of armed conflict, with hospitals in a disastrous state and an aging population, the regions of Donetsk and Luhansk are at particular risk.

In order to isolate ourselves from our surroundings, my colleague decided to move in with me. A few days later, he showed symptoms – and we decided to call the emergency phone number. After a two-day isolation in hospital, we tested negative and were released home.

Based on our official place of residence in Sloviansk, we were taken to a designated infection hospital in Kostiantynivka, around 50 kilometres away. At the time, this was the only hospital in the whole Donetsk region capable of taking samples for Covid-19 tests and sending them to Kyiv for test results. By the end of March, it is promised that laboratories in Mariupol, Donetsk oblast, and Sievierodonetsk, Luhansk oblast, will be equipped and permitted to test people for coronavirus infection. The number of officially confirmed infections is growing steadily. As of 31 March, more than 500 people have been diagnosed with Covid-19 across the country, with the number of suspected cases around 2,600.

In comparison to Italy and Germany, this number still looks low. But the figures are deceptive when it comes to assessing the serious risks Ukraine is facing.

First, laboratory tests have only been conducted in Kyiv so far, and new laboratories are being equipped gradually. Yet comprehensive nationwide testing as in countries with stronger healthcare systems seems far from feasible at the moment. Thus, the official numbers are likely to be the tip of the iceberg. And without reliable data, Ukrainian epidemiologists are struggling to track the actual spread of the virus.

Second, as I experienced firsthand, the Ukrainian healthcare system and medical infrastructure are woefully unprepared. If Ukraine reaches a similar number of infections to Germany (where there are more than 61,000 registered cases), Ukraine – and particularly its war-torn east – will face an additional humanitarian disaster since the ongoing war started in 2014. Current estimates for Ukraine published by the United Nations Office for the Coordination of Humanitarian Affairs predict that up to 50% of the population could be infected with the virus.

If this figure turns out to be even close to accurate, under the current circumstances the pandemic might lead to a devastating number of deaths in Ukraine. Even in comparison to other post-Soviet states, the Ukrainian healthcare system is notoriously weak and caught in the midst of an ongoing reform. Hospitals are massively underfunded, and technical equipment is outdated. In addition, hospitals, particularly in frontline locations, suffer from shortages of medicines and medical supplies, understaffing and limited access to referral hospitals. According to Deputy Health Minister Viktor Lyashko, the number of ventilators in the country is currently around 3,500. In comparison, currently Italy, which is most affected by the pandemic in Europe, has around 5,000, and the United Kingdom has more than 8,000.

Research about war zones suggests that the challenges faced by pandemics can exacerbate the effects of armed conflict. Both put pressure on healthcare systems, eventually leading to a larger number of deaths than would be expected in peacetime. And there is no sign yet that the shooting might be interrupted due to the pandemic: exchanges across the contact line carried on throughout March.

Therefore, one crisis is about to arrive on top of another in Ukraine, and there is a grave risk that they will mutually reinforce each other. The International Crisis Group points out some of the conditions that increase the vulnerability of a state and its population towards pandemics, such as “weak institutions, communal tensions, lack of trust in leaders and inter-state rivalries” – sadly, these are all applicable to the current Ukrainian context.

Ukraine’s Humanitarian Response Plan (HRP) for the Covid-19 Pandemic highlights three key factors that put people in eastern Ukraine at a particularly high risk. First, six years of armed conflict has left the healthcare system in a derelict state. Second, more than one third of the total population of the Donetsk and Luhansk regions consists of pensioners (36%), which the WHO has identified as a major risk group. This is significantly higher than the national percentage – roughly 23% of Ukraine’s population are retirement age. In isolated settlements in the conflict region, many of which are cut off from healthcare services, the number of elderly people is as high as 41%, according to HRP. Furthermore, elderly account for almost one third of the 3.4 million people in need of humanitarian support – which means that there are more than a million elderly people who are particularly vulnerable to the new coronavirus in this conflict region.

Third, because of the nature of the virus, and how highly contagious it is, mobility and human interaction increases the spread. In 2019, the number of people regularly crossing the contact line was up to 1.2 million per month. The checkpoints have been shut to reduce this risk – which puts the elderly population in the non-governmental controlled regions at severe risk of poverty. Their main reason to undergo the cumbersome queuing system to enter Ukrainian-controlled territory is to withdraw their modest pensions on the governmental-controlled side.

Kostiantyn Rieutsky, executive director of the Vostok SOS charity foundation, conducted a monitoring trip in Luhansk region with his team in the third week of March to evaluate how hospitals are preparing. “The situation is very serious,” Rieutsky tells me over the phone. “Only four departments in the whole region are prepared to take patients.” Crucial equipment for receiving patients – such as masks, full-body gowns or contactless clinical thermometers – are scarce. Officially the whole region should have 64 ventilators. But, Rieutsky says, medical staff could not locate all of them.

The hospital in Rubizhne, Luhansk region, is preparing to take the largest number of patients. It was recently modernised after receiving Japanese development aid. Currently, they have four ventilators and 30 beds where patients can be isolated. When I asked Rieutsky about his opinion of this hospital, he said that the regional governor “exaggerates the capacities of the hospitals massively, saying that this hospital could take up to 200 coronavirus patients.” As soon as the hospital in Rubizhne is full, patients will be relocated to other hospitals in the region, in Sievierodonetsk, Lysychansk and Starobilsk. All of them lack trained medical staff and ventilators, according to Rieutsky.

Another hospital, the one at Stanytsia Luhanska, an urban settlement directly on the contact line, is in a particularly bad state. According to Rieutsky, this hospital is severely underfunded, and has almost none of the necessary equipment. “The doctors there told us very clearly that they are absolutely unprepared to take patients infected with coronavirus,” Rietusky reports, before saying that the first suspected cases have already been hospitalised in Luhansk region.

Doctors, emergency staff and nurses lack information about Coronavirus or share contradictory information, Rieutsky says. His description matches my and my colleague’s firsthand experience in the hospital in Kostiantynivka.

As we spent two days waiting for test results locked in a 16 square metre prison-like room, we had plenty of reasons to feel uncomfortable. Starting from freezing at night due to the lack of proper heating, to the fact that we were being watched by the police and could have been punished in case we left the premises. However, the greatest cause of anxiety was the shared cluelessness between us and the hospital’s medical staff. We had hardly any information about when our results would be available or what the next steps could potentially be. Medical staff in Kostiantynivka seemed no less anxious and insecure than us about what was going to happen.

Following their monitoring visit, Vostok SOS published a policy paper, recommending the Ukrainian government conduct a comprehensive monitoring of available health services and access in conflict-affected regions. Furthermore, they suggested mobilising volunteers equipped with relevant skills to ensure, on the one hand, the delivery of basic goods or social benefits for vulnerable people, and, on the other, to facilitate comprehensive testing. In addition to this, stronger coordination with the Ukrainian armed forces could facilitate the allocation of medical equipment, transportation and medical specialists from the military.

Rieutsky and his team, based in Sievierodonetsk, suggest coordinating an information exchange between doctors working in the conflict region with virologists and other experts in other parts of the country, as well as rapid translations of up-to-date international research findings about symptoms, diagnosis and treatment options related to the Covid-19 virus for the medical stuff, and efficient dissemination of this material respectively.

To finance these measures, they say the government should increase their efforts to raise money for the health sector from public, private and commercial donors, and to cooperate with civil society in their decision-making processes. As a crucial precondition for this, their report states, the Ukrainian authorities need to be transparent about the real state of affairs, in order to know where to allocate direly needed resources.

The private donors that president Volodymyr Zelenskyy has approached so far have stirred another controversy. In an attempt to fundraise private resources, president Zelensky asked the country’s richest oligarchs to invest in the fight against the pandemic. In a meeting called by the president, Ukrainian oligarchs were allocated oblasts in which they are to coordinate the anti-covid-19 efforts. Through his private charity foundation, controversial billionaire Rinat Akhemotov donated 300 million hryvnya (£8.6 million) towards supporting healthcare in Ivano-Frankivsk, Lviv, Donetsk and Luhansk regions. He also promised 300,000 rapid tests for coronavirus and at least 200 respiratory medical devices.

In their policy paper, Vostok SOS asked Ukraine’s Ministry of Reintegration of the Temporarily Occupied Territories to monitor the provision of medical facilities along the contact line as well as the situation for staffing, medicine, medical equipment and protection equipment. This programme should also monitor access to health services for citizens residing in settlements along the demarcation line.

“The entry/exit points should be closed,” Rieutsky says, with obvious dismay in his voice. He’s referring to the checkpoints that regulate movement between Ukrainian-controlled territory and non-governmental controlled territory. “In order to prevent the worst from happening, we need to restrict the mobility of people as much as possible.”

Rieutsky’s distress likely concerns the state of the healthcare system in the non-governmental controlled territories. It’s been damaged in the six years of protracted conflict and, subsequently, by economic blockades and international sanctions. Healthcare infrastructure has been disrupted by its complete disconnection from medical supply chains in governmental-controlled territory. This has caused a continuous shortage of medicine, equipment and staff, as quite a few specialists have left because of the war.

In mid-March, almost at the same time as the Ukrainian government, the de-facto authorities of non-government controlled territories proclaimed “high alert” regimes. This implied that the “border” between the two so-called “Donetsk People’s Republic” and “Luhansk People’s Republic” was closed, medical staff were deployed at the entry/exit point and checkpoints in order to identify people with relevant symptoms, such as high fever, and to send them to the relevant infection hospital. The de-facto authorities have started cooperating with UN agencies to ensure provision of necessary Covid-19 material and equipment, but the concern that the restricted access to the regions increases a massive outbreak remains.

The first Covid-19 case in non-governmental controlled Luhansk was announced on 28 March. But as of 29 March “they are still not keeping the quarantine and not cancelling mass events, or clubs,” says Pavel Lisyansky, representative of Ukraine’s human rights ombudsman in Donetsk and Luhansk regions. “Judging from this and their media environment, you could get the impression that they are not afraid of the virus at all.”

The main reason to hide the pandemic outbreak in the non-governmental controlled territory is to avoid public panic and a rush towards the border with Russia. As soon as people are aware of the pandemic risks, Lisyansky explains, they might demand proper medical treatment which the grim medical infrastructure in these regions cannot provide.

Tests taken in non-government controlled Luhansk are taken to the bordering Russian region of Rostov. The city of Donetsk has a laboratory capable of running the tests but it seems highly questionable whether it will be capable of dealing with an influx of tests from several hundreds of patients as soon as the pandemic unfolds. The Eastern Human Rights Group reports that hundreds of people have already been hospitalised with suspected pneumonia in non-governmental controlled territory. Meanwhile, Russia, which normally controls each and every political step in the region, is absorbed with its own pandemic outburst. “This is why the curators in the Kremlin have decided to maintain silence on this topic in these regions,” Lisyansky explains.

When it comes to hospitals under Ukrainian control, Lisyansky is more optimistic. The NGO he founded, the Eastern Human Rights Group, is in touch with hospitals in the region and aware that many of them lack equipment and relevant material. Yet help from Kyiv is coming, he says, with funds and masks allocated to various local hospitals. Due to their exposure to regular shooting, hospitals in frontline cities like Svitlodarsk have established strong ties with international organisations and NGOs. Now the doctors working in Svitlodarsk are doing their best to prepare for the pandemic. “In the course of six years of war, people have developed the skills to survive in extreme situations,” Lisyansky says.

On 18 March, my colleague and I were released from hospital in Kostiantynivka before we received our results. Forty eight hours after our hospitalisation, medical staff received an order to free the beds for patients suffering from more severe symptoms. They did not know when our results would be available, but promised to inform us via phone. Because we were among the first suspected cases in Sloviansk, local media followed our treatment closely. When we returned to town, the information that our tests were negative went viral over social media – two days before we received confirmation by phone from the hospital.

Will the medical systems in Ukraine’s conflict-affected regions be able to adapt quickly enough to contain the outburst of the crisis? The fact that no one knows remains the greatest cause of anxiety.