Human Suffering, Mutual Aid, Public Health, and Future Struggles in Ukraine

Sam Friedman

FOLLOWING RUSSIA’S INVASION of Ukraine last February, the political left in the United Stares country and much of the world has been divided about whether to support the Ukrainians in defending their right to self-determination, the Russian invaders in their efforts to “defeat Ukrainian fascism” or “restore the Russian homeland,” or whether to seek an abstract “peace.”

I have taken part in many such discussions as a supporter of the right of the Ukrainian people to determine their own destiny, and thus as a supporter of the defeat of the Russian invasion. What I have rarely noticed in these discussions, however, is any deep understanding of the current realities and future lives of Ukrainian people as people.

I feel this in part because I have worked closely with many Ukrainian friends since 2010 in efforts to prevent the spread of HIV/AIDS among people who use drugs, sex workers and gay men and other men who have sex with men.

In many of these years, I have traveled to Ukraine two or three times, for up to three weeks a visit. Most of that time has been spent in or near Kyiv or Odesa, but I also spent some time setting up projects in Simferopol and Sevastopol (the two largest cities of Crimea), Kriviy Rih in central Ukraine, and Lviv in the western part of the country.

In the course of these trips, I have made many friends. In many ways they were comrades in struggle, with the struggle in question being the effort to protect people against infection and related efforts to get these people the best possible medical care. I also recognize that in spite of this involvement with them, and in spite of my own Ukrainian Jewish ancestry, my understanding of Ukraine and of the suffering of its people is only partial.

During the Maidan Revolution of 2013-2014, and the months thereafter, some of my friends took an active part. Others did not. My interviews with them were the basis for a paper I wrote on these struggles (Friedman, Sam. “What happened in Ukraine?” Z-Net. July 6, 2015. Reprinted in New Politics; and (with footnotes) at International Marxist Humanist Organization & at Ukraine Solidarity Campaign).

Pandemic, Then War

The pandemic disrupted my ability to travel to Ukraine, and disrupted the lives of my friends. Nonetheless, they continued their work trying to reduce the spread of HIV and to help people get good care.

The invasion of Ukraine seriously disrupted their efforts. Much of their energy has gone into driving what had been AIDS prevention vans around the country to deliver medical supplies and food to hospitals and other organizations that needed them, including in frequently shelled areas. These supplies included medicines for the HIV infected and methadone for people who use drugs.

I have had several zoom conversations with my Ukrainian friends and exchanged many emails with them about conditions in the country. Some of what I will describe may be known or assumed by readers, but much may not.

First, even for those not in the military, the war has led to massive amounts of overwork and burnout. Some of this is due to a commonplace of class struggle: During wartime, governments and employers prevent strikes and routine workplace self-defense efforts, and get a degree of worker support for this based on cries for national unity. (This was much of the motivation for the revolutionary struggles in Europe at the end of WW I, and the wartime strikes and post-war strike wave in the United States in the 1940s.)

In Ukraine, overwork and burnout are increased by volunteer efforts to help in war-related tasks and by volunteering to help those in need. In addition, the frequent need to deal with the aftermath of damages caused by bombs or shelling adds both to stress and overwork.

Importantly, however, much of this volunteering is conducted and led by people who mobilize themselves independently of governments or employers. It is a social mutual aid response to meet each others’ needs and to build their own destiny. As such, it is one important seed from which later social struggles may grow.

Second, medical conditions have deteriorated. Hundreds of health facilities have been destroyed by Russian attacks and many others looted by Russian troops. COVID vaccination was paused, increasing vulnerability to disease and death.

Ukraine had high tuberculosis rates before the war. TB and COVID spread has probably increased due to the time people spend crowded in subways/bomb shelters, and overcrowded housing due to the destruction of many buildings, with a partial and lesser mitigation due to the decline of nightlife and similar crowded gatherings. Water supplies have been disrupted in many regions, and there has been unconfirmed news of a cholera outbreak in Mariupol.

Many people have had their housing destroyed. Increasingly, as Russia has attacked infrastructure, millions of people have had their access to power or to heating fuels reduced or eliminated.

Homelessness or informal housing causes stress, overwork, and exposure to cold and the weather more generally. Moving in with others often causes massive stress for everyone. And winter makes these conditions worse — even in southern Ukraine, as in Odesa, winters can be cold and icy.

Displacement, Disease and Drugs

As mentioned above, my work with Ukrainians centered around HIV, particularly among people who use drugs and among sex workers. One effect of the war is likely to be massive increases in both drug use and sex work, and in the diseases like HIV, hepatitis C, and STIs that these spread.

There are already many signs that this is already occurring. Many displaced people — particularly women — are finding that sex work is their best available or only income source. Their potential clientele is increased because many women and children left the country, but this was forbidden for men.

Stress from having to leave your home and moving to another part of Ukraine may be leading large numbers of people to take up drug use. There is some preliminary evidence that this is happening in Odesa, for example. In addition, pain from war-related injuries or psychological trauma may lead some soldiers, ex-soldiers and civilians to begin to use drugs.(1)

There are of course many other health issues to be concerned about. I remember talking with some American veterans of the Iraq War in 2004 or thereabouts about their fear of exposure to depleted uranium from U.S. anti-tank shells. Undoubtedly, many forms of toxic exposure are affecting both civilians and soldiers in Ukraine. Their effects will become evident in future years.

So far, my discussion has focused on people living in areas controlled by Ukraine. Millions of Ukrainians, mainly women and children, have fled to various countries in other parts of Europe or to the Americas. They face many but varying problems (even if less severe than those faced by darker-skinned migrants or those from the global South.)

More ominously, many Ukrainians live in areas controlled by Russian forces, or that have been controlled by Russia and been reconquered by Ukraine. Others in large numbers have been forced to move to Russia.

Most or all of the members of these groups of people have faced various hardships that I know little about. Their traumas will play out in future years. Drug users and sex workers under Russian rule will have to endure the rigors of Russia’s highly stigmatizing environment that prohibits access to lifesaving drugs like methadone or buprenorphine, and is deeply hostile for all forms of harm reduction for people who use drugs or for sex workers.

Hundreds of people died in Crimea after Russia cut off access to methadone there. People who are queer, gay, lesbian, bisexual or transsexual will have to face the stigmatization and oppression embodied in recent laws against LGBTQ “propaganda” as enforced by a harsh state under constant pressure from homophobic religious and other rightwing forces.

Even if the war were to end tomorrow, Ukrainians will face difficulties for many years to come. PTSD will be widespread, as will be the effects of missed vaccinations for childhood diseases and for COVID-19.

Problematic Future Prospects

In addition, many people may be victimized by the future politics of Ukraine. Any postwar period is likely to see many potential struggles and the effort of government to limit them by divide and rule strategies.

Ukrainian politics is already quite right wing, oriented to neoliberalism and anti-unionism. As mentioned before, working people are likely to make demands and organize strikes and other struggles when the war ends — and financial constraints and the needs of corporations will force them and the government to resist.

Faced with social unrest, governments often respond by moralistic politics that scapegoat the vulnerable. This is what the Nixon forces did in the United States in the early 1970s with their wars on drugs and on crime. More generally, in many countries people who use drugs, sex workers, alcoholics, women who need abortions, and (e.g. in Iran) women who refuse to wear the hijab are examples of other people scapegoated by governments and corporations facing challenges to their power.

In a postwar Ukraine, efforts at scapegoating will be hampered by the extent to which the war has built many forms of solidarity among people of various backgrounds – and by the fact that any reactionary policy echoing “Russian values” or “Russian ways of doing things” will seem suspect or anathema to most Ukrainians.

Nonetheless there remains a strong right wing and moralistic strain within Ukrainian politics, and politicians’ and employers’ “need” to divide workers and communities seeking improved lives may lead to scapegoating to provoke such divisions.

Although the Ukrainian government has been supportive of donor-funded harm reduction services both before the Russian invasion and so far during the war, these policies might become a critical political battle if the right chooses to focus on people who use drugs, gay men, and sex workers in the postwar period. (This of course assumes that Ukraine will continue to exist and will not be destroyed by a Russian annexation.)

I am continuing to work (from afar) with Ukrainians to protect public health there. As such, if scapegoating politics do become important, I will support efforts to maintain and strengthen harm reduction and other programs that keep people who use drugs, sex workers, sexual minorities and others relatively safe from disease and other harms.

Not only would cutbacks in these programs lead to disease spread, they would be deeply stigmatizing and hurtful of many groups of people. The politics behind such cutbacks would divide working class communities and people at work in ways that weaken their ability to defend themselves against attacks on labor and other demands by the powerful.

There are other ways, besides moralistic ones, to divide the working class and working class communities. If the pressures of neoliberalism and/or the International Monetary Fund for cutbacks in government spending and in workers’ wages and conditions become strong enough, and drive unemployment to high levels, this might lead to programs to reserve jobs for men (or perhaps women) who were soldiers.

The probably-unavoidable realities of starving and delinquent orphans and other street kids in the war’s aftermath could strengthen a scapegoating attack on “bad mothers” who do not supervise children adequately. Efforts to divide workers who are on strike from those who are not could become vicious. Scapegoating on the basis of language or of having radical politics also might be successful.

In short, we on the American left who support Ukrainian efforts against imperialist invasion and oppression should understand that any end of the war is likely to see heightened social struggle within Ukraine (and indeed in Russia). It will also lead to many major health problems within Ukraine. During the war, and afterward, we should work to strengthen the power of working class communities to battle their enemies and to support harm reduction and other approaches to disease prevention and mental health.

When the war ends — once again assuming that Russia does not succeed in taking over Ukraine — the experience that working class communities have had in self-organized mutual aid may be the ground for future successes. Even though this experience took place during a war for survival, large parts of the Ukrainian working class have learned how to organize themselves and then perform non-alienated labor. If postwar struggles over the future of the country become intense, workers may generalize this experience and try to build a new world “on the ashes of the old.”

Eugene Debs, the famous American labor organizer and socialist, once said, “Years ago, I recognized my kinship with all living things, and I made up my mind that I was not one bit better than the meanest on earth…While there is a lower class, I am in it, while there is a criminal element, I am of it, and while there is a soul in prison, I am not free…(2)

This statement of solidarity extends to us all and what we should do: During and after the war, support the struggles of the Ukrainian people, and of those Russians who resist the war; and during and after the war, to support the struggles of workers, including sex workers, of sexual minorities, and of people who use drugs in their efforts to defend their health and happiness and to transform the conditions of their lives.

Sam Friedman is a longtime socialist public health researcher and activist, particularly around HIV issues. He makes this important acknowledgment: I wrote this paper in interaction with Ukrainian colleagues who chose to remain anonymous. They fully deserve co-authorship, but under the circumstances chose not to make their names public. They also may not agree with elements of my political perspective.


  1. Major social crises often lead to increases in sex work and drug use and their associated diseases. After the break-up of the Soviet Union in the early 1990s, many of its former components — and perhaps particularly Ukraine and Russia — saw massive increases in drug use, alcoholism and sex work. These led to gigantic epidemics of HIV, tuberculosis and sexually transmitted diseases, and to many deaths. Similar increases in HIV took place in South Africa after the end of apartheid and in Indonesia after the overthrow of the Suharto regime. I have written many professional papers about this phenomenon as contingent (that is, it does not always happen) under the heading of “Big Events.” As the world increasingly is buffeted by climate change and pandemics of infectious diseases, such Big Events are likely to become more common, and it is important to think about how to prevent their effects of health. The most effective prevention effort is likely to be the overthrow of capitalism and its replacement by some form of socialism from below, but this will just provide the framework within which we will have to deal with the aftereffects of capitalism like climate change.
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for the January-February 2023 ATC 222