EUROPE’S FRONTIER COUNTRIES READY THEIR HOSPITALS FOR WAR From stockpiling trauma kits for mass casualties to kitting out medics with body armor, wartime health planning is no longer hypothetical on NATO’s eastern flank. By GIEDRĖ PESECKYTĖ Illustration by Wayne Brezinka for POLITICO Speeding along Fabriko Street in an ambulance toward Lietavos school, Martyna Veronika Noreikaitė felt unprepared. She could feel her heart pounding. It was a sunny Tuesday morning in mid-May when Noreikaitė was radioed about an explosion in Jonava, a city of 30,000 people in central Lithuania. In her three years as a paramedic, her calls would, on a normal day, involve high blood pressure or chest pains. This was Noreikaitė’s first mass casualty event. As they pulled up to the school, sirens wailing, the building was obscured by smoke. “People were running around, lying on the ground, screaming,” Noreikaitė said, recalling the chaos at the school’s stadium. Police, firefighters and military personnel were already on site. Noreikaitė and her colleague were the first paramedics to arrive.“When you see what happened — the panic, the screams — you don’t know what to do, or where to go. You forget everything. It throws you off balance.” The novelty of such a disaster in a peaceful European state was precisely why the Lithuanian authorities had set up the two-day “Iron Wolf” (“Geležinis Vilkas”) military exercises. The goal was to steel the military, police, firefighters, hospitals and paramedics to operate under exceptional circumstances — as Lithuania braces for the worst-case scenario: an attack on NATO’s eastern flank. Since Russia’s full-scale invasion of Ukraine, the threat of military conflict has loomed large. “When the media reported the war had started in Ukraine, it was terrifying,” Noreikaitė said. “It was frightening at work because we didn’t know if we had enough resources or if we were prepared if it happened here.”  Noreikaitė now feels calmer. She focuses on training and mastering triage protocols. Exercises, like the one in Jonava, help. Indeed, she believes they “should happen more often.” Lithuania is no outlier: All NATO’s eastern flank countries are revisiting crisis response protocols for health-care facilities, organizing training exercises, investing in ballistic helmets and vests, and shifting operating theaters underground. Since the conflict in Ukraine has shattered the illusion that Europe is safe from war. “It’s not a question of if [Russia] will attack,” said Ragnar Vaiknemets, deputy director general of the Estonian Health Board, which oversees preparedness for crises from pandemics to war. “It’s a question about when.” Ukrainian medical personnel transport a wounded soldier to a medical evacuation (Medevac) airplane, in Rzeszow, Poland. | Petter Bernsten/AFP via Getty Images Formerly under Soviet occupation, the countries on Europe’s eastern frontier know only too well how quickly troops can arrive. “We have bad neighbors here: Russia and Belarus,” Daniel Naumovas, Lithuania’s deputy health minister, said at an event in February. His country links NATO to the Baltics via the Suwałki Gap — a narrow, vulnerable corridor seen as one of the likeliest targets of a future Russian attack. While all EU countries are “in the same boat,” some are in the vanguard “where the water is cold,” Naumovas said. “Water is splashing on our face; water of war.” For countries on NATO’s east, war readiness isn’t optional — it’s urgent. “Few EU countries are frontline countries,” said Katarzyna Kacperczyk, undersecretary of state at Poland’s health ministry. “For them the issue is more pertinent.”  Poland has elevated the issue of health security during times of conflict throughout its rotating presidency of the Council of the EU, where Europe’s security has been the central theme. “We cannot prepare a contingency or strategic plan for the military sector or economic sector or energy sector, and exclude the health sector,” Kacperczyk said.  HOSPITALS UNDER FIRE Russia’s invasion of Ukraine has shown that modern conflicts no longer spare health services — or the civilians they serve. Eastern European countries are taking note. Located just 50 kilometers from the EU’s external border with Belarus, Vilnius University Hospital Santaros Clinics is developing underground infrastructure, shelters, helicopter landing sites and autonomous systems that would allow it to function even if electricity or water supplies were cut off. Santaros is not unusual. In Estonia, in addition to body armor for ambulance crews, satellite phones would be distributed to maintain communications if traditional networks fail. Plans are even in place to generate an independent internet network if necessary. European countries average 11.5 intensive care beds per 100,000 population. | Omar Marques/Getty Images Electrical generators are being installed across the health-care system, following Ukraine’s experience with Russian strikes that routinely cut off civilian power. “We know for certain that Russia targets the civilian infrastructure and energy structures, and that means that you cannot have these kinds of situations where the hospital doesn’t work because there are some power plant problems,” Vaiknemets said. Many hospitals in Eastern Europe — relics of the Soviet era — are particularly vulnerable. “We have high buildings, we have large buildings. They are in one complex, one area,” Vaiknemets said. Hospitals are now looking at how to repurpose basements to be operating theaters in case of need. “I can’t imagine working on a top level … of the hospital just waiting to get hit,” he said.  Estonia is procuring mobile medical units — pop-up treatment facilities deployable in emergencies — which should help address the currently limited critical care capacity in Europe. While European countries average 11.5 intensive care beds per 100,000 population, “wartime needs could require three to five times this capacity,” said Bjørn Guldvog, special adviser at the Norwegian Directorate of Health, at a health security event in April. Sustaining a high volume of operations for weeks or months would also be challenging: “Most facilities can sustain maybe 120-150 percent of normal surgical volume for 24 to 48 hours,” he said. Blood and oxygen supplies would also become critical. STOCKPILES AND SUPPLY CHAINS Even the best-prepared hospitals can’t function without medicines, supplies and equipment, and the Baltic countries are stocking up in preparation for mass casualties. Estonia, for example, has allocated €25 million for mass casualty supplies, including orthopedic gear, tourniquets and trauma kits — “the only heavy investment we have made,” Health Minister Riina Sikkut said at an event in February. Stockpiles would ensure that hospitals can run until supplies from allies reach them, Vaiknemets said, adding that NATO is crucial to securing supply routes.  In Latvia, health-care institutions have been required since Covid-19 to maintain a three-month supply of medicines. “I have never thought that I would say thanks to Covid, but thanks to Covid … we found financial resources,” said Agnese Vaļuliene, health ministry state secretary. The country is also working on national stockpiles. But the Baltics are too close to the front lines to keep emergency supplies safe, said Jos Joosten, a medical adviser at the European External Action Service, the EU’s diplomatic corps. As a result, other EU countries must “identify the things that are scarce, that are very difficult to organize, specifically for the small nations,” Joosten said. “And then we should give [up] some sovereignty, give it to the European Union to make decisions” on distributing what is needed. Stockpiles from the Red Cross, national reserves and rescEU, the EU’s emergency service, must all be ready to reach the front line — and civilian patients. “We have to have good crisis plans,” Sikkut said. STAFFING THE WAR EFFORT War readiness goes beyond policy — it needs people. Workforce shortages are a fundamental challenge for the Baltics, where day-to-day health staff are already stretched thin. Estonia, with a population of 1.3 million, has nearly half the health-care workforce per capita of Germany.  A Lithuanian survey found that over a quarter of health workers would likely flee during war, while fewer than 40 percent would stay and a third were unsure. | Mykhailov Dmytro/Global Images Ukraine via Getty Images As a result, patients “from the front lines” cannot expect the same care they would receive in times of peace, Vaiknemets said, which is “the main and underlying principle of our crisis-measure planning.”  But there’s another problem: Not everyone is prepared to stay. When Russia invaded Ukraine, Noreikaitė, like all paramedics, had to sign a declaration saying if war broke out in Lithuania she would stay on and work. “But how it would really be — who would come and who wouldn’t — I don’t know. Personally, I don’t have children or a family yet, so I think I would stay,” she said.  A Lithuanian survey found that over a quarter of health workers would likely flee during war, while fewer than 40 percent would stay and a third were unsure. Estonia anticipates similar patterns: “There are patriots, the first responders, the people that we know without question will stay,” Vaiknemets said. “Of course, there are naysayers that talk about going to Spain straight away.” He said around 50 percent to 60 percent of the population don’t yet know how they would respond. While he’s confident that most doctors and nurses would remain, Estonia’s authorities are working to ease concerns, especially about family safety. “It is very human: If I don’t feel safe, if I don’t have the confidence that my family is safe, I will not do it,” Vaiknemets said. In Latvia, pulmonologist Rūdolfs Vilde said some doctors he spoke to were considering fleeing if war breaks out — especially parents who “don’t see how it would be suitable for them to ditch the children somewhere and be in the hospital in times of military crisis,” he said.  Just a week before the interview, Vilde and his colleagues at Pauls Stradiņš Clinical University Hospital were also asked to sign a document acknowledging they are critical personnel required to report to work if sirens sound.    Vilde himself plans to stay but stressed that he needs more information to feel confident should the worst happen.  “Should I be prepared … to provide some kind of military medicine, or should I be just prepared to come into my regular work and just have a bigger flow of patients?” Vilde asked. “Because those are two very different things and probably both of them would have to function during the wartime.” And Vilde doesn’t mind spending extra hours on top of his doctors’ job for training “because … I see this as a way to keep things the way they are.” A Ukrainian soldier being evacuated to Poland. | Petter Bernsten/AFP via Getty Images “If I want to be able to do my pulmonology job and maybe to try to develop things in Latvia, then there should be Latvian existence, right?” His hospital in Riga has also begun war-training sessions, Vilde said. Other hospitals and countries have begun ramping up war-readiness drills, too. Estonia is reinforcing its system-wide training. Hospitals, ambulance crews and health workers are instructed on how to switch to “crisis mode,” in which they must deal with large influxes of patients and treat wartime injuries — including blast wounds, gunshot trauma, burns, amputations and spinal or head injuries — that are rare in civilian settings. At Lithuania’s Vilnius University Hospital, “evacuation drills and preparedness exercises for receiving a large number of casualties are conducted for hospital staff” alongside the Lithuanian Armed Forces and Riflemen’s Union, hospital chief Tomas Jovaiša said. This year alone, Lithuania is planning seven exercises with the army and over 10 civil-security drills for medical professionals, according to health ministry spokesperson Julijanas Gališanskis. Lithuania is also forming an emergency medical team, and junior doctors last month hosted a forum dedicated to wartime health-care readiness. Some medics travel to Ukraine to learn firsthand how hospitals deal with missile strikes, mass casualties and power outages.  Vaiva Jankienė, a nurse and coordinator at Blue/Yellow Medical, which provides medical care to civilians close to Ukraine’s front line with Russia, has volunteered over 20 times in Ukraine since April 2022 — including in the atrocity-stricken town of Bucha shortly after its liberation. She said the best way to prepare health-care specialists is by volunteering in Ukraine.  She described the scale of injuries and illnesses in Ukraine as “difficult to comprehend” — many wounds are unlike anything seen before, owing to new wartime tactics. “After the drone attacks, the consequences are hard to imagine,” Jankienė said. “Injuries like these,” she sighed, “every single medical professional who saw them said the same thing: We couldn’t have imagined it would look like this.” While a trauma doctor in Lithuania might perform one amputation a year, in Ukraine, entire hospital wards are filled with patients suffering amputations of one, two, three, or even four limbs — plus a range of other severe injuries. “We have very little experience treating such complex, multiple traumas,” she said.  THE REFUGEE SURGE RISK The impact of war wouldn’t stop at national borders. Because of the use of advanced weaponry in Ukraine — including long-range missiles and military drones — the front line is no longer a fixed boundary. Attacks can now reach targets hundreds of kilometers away, endangering hospitals and civilian infrastructure far from combat zones and making evacuation plans essential.  Illustration by Wayne Brezinka for POLITICO As a result, countries further from the front lines must prepare to receive patients and refugees, Joosten said, warning that EU solidarity will be tested. “If Lithuania is overrun, who’s responsible for Lithuanians, because there’s no Lithuania anymore? But the European Union is (still there),” he said.  Joosten urged EU institutions to create funds to handle civilian and military casualties, as well as displaced populations. He added that casualties could be dramatically higher than in Ukraine. “Those 4,000 patients we moved away from Ukraine, that’s nothing, 4,000 in three years,” he said. “Let’s talk about 4,000 in two weeks, and then the next two weeks again, and the next two weeks … the numbers are so different when the real war starts.” No one knows when — or if — war will come. But as Vaiknemets put it: “Crisis never shouts when it’s coming.” That’s why the Poles and the Baltics “have to prepare for the worst,” Vaļuliene said. “But we hope it will not come.”