Ukraine’s Military Medicine Is a Critical Advantage

Russia’s ongoing invasion of Ukraine has prompted more than $100 billion in aid since February, several votes at the United Nations, and the transfer or sale of high-tech weapons systems from the United States to Ukraine, including the HIMARS rocket launch system, Switchblade 600 drones, and MANPADS air defense systems. But another, more prosaic part of the West’s aid to Ukraine is having a significant effect on the conflict: medical supplies. Military medicine is a largely overlooked contributor to military effectiveness, but its effects are playing out in real time on the battlefield.

From better field sanitation to mechanized and air evacuation, as well as modern body armor, armies today that take advantage of these changes can not only save lives but also preserve the strength of their forces. In World War I, for example, injured U.S. soldiers could wait hours to be evacuated to a field hospital just a few miles away; during the war in Afghanistan, by contrast, injured U.S. military personnel would be evacuated to the U.S. military hospital in Landstuhl, Germany, or even back to the United States within a day or two.

By all accounts, Ukraine has much better military medicine than Russia. Ukrainian forces, for example, are well trained in Tactical Combat Casualty Care (TCCC), a set of prehospital guidelines developed by the U.S. military in the 1990s and revised and widely adopted in the early years of the Afghanistan and Iraq wars. U.S. military medical practitioners found that 87 percent of preventable battle deaths occurred in the prehospital setting; among these, the most by far were dying from hemorrhage. Thus, the TCCC guidelines focus heavily on hemorrhage, with advice on when to apply tourniquets, hemostatic dressings, and clamps to stem blood loss. Aid from the West has included exactly these kinds of supplies, as well as related equipment such as body armor. Western advisors have also been pushing for the use of whole blood in far forward settings. One reason for Ukraine’s medical advantage is that it has welcomed such aid not just since this February but over the past eight years. Since the invasion of Crimea in 2014, Ukraine has been prepping for all-out war with Russia, including on the medical front.

Russia’s ongoing invasion of Ukraine has prompted more than $100 billion in aid since February, several votes at the United Nations, and the transfer or sale of high-tech weapons systems from the United States to Ukraine, including the HIMARS rocket launch system, Switchblade 600 drones, and MANPADS air defense systems. But another, more prosaic part of the West’s aid to Ukraine is having a significant effect on the conflict: medical supplies. Military medicine is a largely overlooked contributor to military effectiveness, but its effects are playing out in real time on the battlefield.

From better field sanitation to mechanized and air evacuation, as well as modern body armor, armies today that take advantage of these changes can not only save lives but also preserve the strength of their forces. In World War I, for example, injured U.S. soldiers could wait hours to be evacuated to a field hospital just a few miles away; during the war in Afghanistan, by contrast, injured U.S. military personnel would be evacuated to the U.S. military hospital in Landstuhl, Germany, or even back to the United States within a day or two.

By all accounts, Ukraine has much better military medicine than Russia. Ukrainian forces, for example, are well trained in Tactical Combat Casualty Care (TCCC), a set of prehospital guidelines developed by the U.S. military in the 1990s and revised and widely adopted in the early years of the Afghanistan and Iraq wars. U.S. military medical practitioners found that 87 percent of preventable battle deaths occurred in the prehospital setting; among these, the most by far were dying from hemorrhage. Thus, the TCCC guidelines focus heavily on hemorrhage, with advice on when to apply tourniquets, hemostatic dressings, and clamps to stem blood loss. Aid from the West has included exactly these kinds of supplies, as well as related equipment such as body armor. Western advisors have also been pushing for the use of whole blood in far forward settings. One reason for Ukraine’s medical advantage is that it has welcomed such aid not just since this February but over the past eight years. Since the invasion of Crimea in 2014, Ukraine has been prepping for all-out war with Russia, including on the medical front.

Russian forces, on the other hand, lack medical training as well as supplies. A recent video shared widely on social media reportedly showed Russian officers telling new conscripts to purchase tampons to plug bullet wounds. Russia has suffered from shortages in military medical staffing for years. Russian morale is also reportedly quite low, as seen from both field reports and the flow of Russian men leaving the country so as not to be drafted into the army. One reason for low morale is likely reports of poor medical care and supply, including the use of Soviet-era first-aid kids and limited pharmaceuticals. While Russian personnel have had some training in TCCC, they appear to lack crucial modern equipment—such as the combat application tourniquet—to implement these guidelines.

Better military medicine matters on the battlefield for at least three reasons. First, having better medicine means saving more lives; in other words, militaries with better medicine can bring more people to the fight. They will likely be healthier at the start of the war and, all else equal, will be more likely to receive treatment that allows them to return to duty sooner rather than later.

Second, having better medicine means a higher likelihood of maintaining unit cohesion; rather than being sent home (or worse, dying), injured soldiers can be treated and returned to their unit. Social bonds can be maintained. New troops do not have to spin up on training. And third, better medicine translates into higher troop morale. Knowing that you and your fellow soldiers will receive good medical care in the event of illness or injury will make you more willing to fight and take risks. It signifies a country unwilling to waste its soldiers’ lives—in stark contrast to the attitude on display in Russia’s mass mobilization of often untrained soldiers.

Many of these factors were evident in the United States’ most recent wars in Afghanistan and Iraq. The creation of a trauma registry in 2004 facilitated a revolution in military medical data collection, which, in turn, allowed for the research underlying guidelines like TCCC. The intense focus on stemming blood loss led to the invention and use of new kinds of tourniquets, hemostatic dressings, and catheters to maintain blood flow. And understanding the critical importance of delivering care as soon as possible prompted U.S. Defense Secretary Robert Gates to implement the “golden hour” rule in 2009, such that any injured U.S. military personnel would be evacuated to a higher-level medical facility within the first, most crucial hour of injury. Combined, these changed contributed to a tripling of the United States’ wounded-to-killed ratio, from the traditional 3:1 to 10:1 in Operations Iraqi Freedom and Enduring Freedom.

Of course, there are many ways in which these wars are not comparable. One key difference is that the United States fought counterinsurgencies in Afghanistan and Iraq. At least to date, the conflict between Russia and Ukraine has been a conventional war more reminiscent of past land wars in Europe—and with accordant levels of casualties. Artillery rather than roadside bombs have been the main mechanism of injury. Another important contrast has to do with air evacuation, a key part of saving the lives of the wounded. Neither Ukraine nor Russia has air superiority in this war. Thus, medical evacuation is compromised, although Ukraine is fighting closer to its own territory and with generally superior logistics. Given the importance of immediate care to the odds of survival, limited medevac helps make sense of the surprisingly low estimates of the Russian wounded-to-killed ratio at 3:1.

At the same time, there are important similarities, including around the politics of reporting casualty numbers. The best available estimates of Russia casualties, for example, are not coming from Russia. Instead, NATO and various Western intelligence agencies have been reporting these numbers. Ukraine’s own casualty reporting has been scanty at best. Part of the reason for both countries’ reluctance to report casualties is because such reporting can diminish morale—including among military forces, but also domestically. This practice speaks to the well-known “Dover effect”—referring to the images of military coffins draped with American flags being unloaded at Dover Air Force Base—in the United States. But it is also the case that casualty reporting has become part of the information warfare campaign. Ukraine, for example, reported 1,000 Russian fatalities after the first day of the war, while Russian media claimed that Ukraine had suffered 4,000 losses in a single week in September.

Actual casualty numbers—especially on the Ukrainian side—have increased as a result of Russian targeting of Ukrainian hospitals, in violation of international law. In addition to strikes on civilian medical infrastructure, such as that on a maternity hospital in March, Russian forces have also targeted Ukrainian medical evacuation rail lines.

Nevertheless, all signs point to Ukraine holding the medical advantage in this war. Medicine is of course not enough. The Finns likewise held the medical advantage over the Soviet Union in the 1939 Winter War. Finland used insulated medical aid stations, evacuated casualties by sled, and had generally better medical staffing and facilities. Although the war ultimately ended with a Soviet victory, medicine was nonetheless a force multiplier for the Finns, who had a much smaller population and were able to compromise the Soviet victory instead of being overrun. In a war where numbers matter, the side that has better medicine holds a distinct advantage.