War is a normal state of man

George W. Crile, 1917

The word war comes from the German werran and the old English werre, meaning confusion or to confuse. In addition to being the living species that has caused the most damage to the planet, humans are warlike by nature, some more than others, but at the end warriors. The word "war" infiltrates our common language, for example, the war on poverty, drugs, cancer, corruption, violence, COVID-19 and the war on terror.¹ For centuries nations arise and are changed through wars and Humanity does not learn to live together in peace. Individuals, governments, and/or political or religious tendencies have been conquering territories, subjugating their inhabitants using violence, creating new sovereign countries that have been modifying nations, traditions, habits, religions, economy, science, and much more. Since prehistory there are indications that man was a warrior, as shown by the cave figures in "les Coves del Civil" (Figure 1). Thousands of historical war conflicts such as the one in ancient Mesopotamia where the chronicles relate continuous internal struggles, even after Sargon the Great of Akkad 2334-2278 BC unified the region under the Akkadian empire. The bloodiest warriors in history were the Spartans, Samurais, Vikings, Roman legionnaires, Persians, Aztecs, Maoris, Mongols, Templars and Ninjas, among others. The new continent was conquered by several countries including Spain, England, France, Holland, and other European nations that brought war, destruction, progress, religion, and disease to the American continent. Throughout the planet there are records of regional war conflicts as a forced routine and the planet has already experienced two world wars with millions of deaths and severe residual damage in all imaginable areas.

Figure 1 Representation of the archers of the Civil cave (Castellón). Of extraordinary interest is the set of human figures with arches that represents a possible war dance, also interpreted as a battle scene.

From the beginning of the 20th century to the present, more than thirty wars have been fought that have resulted in 187 million casualties.² Despite the lessons derived from centuries of war confrontations, and from the efforts of international non-governmental organizations, wars continue to be a cardinal part of Humanity.

In an interesting monograph published in 1917,³ George Crile described what he called the phenomenon of war: "The inhabitants of the warring countries are divided into two classes – those who are killing man: and those who, inactive, wait at home for the return from the front. Railways are hauling food, ammunition, and men to the battle line, and hauling back to the wounded. Factories are turning out uniforms and guns, powder and shot. Telegraphs and telephones speak only of war. The printing press describes battles and records the names of the dead. Hotels and schools are hospitals, and parks are drilling grounds. Iron and steel, copper and lead, are implements of injury and death; while the universities and scientific laboratories are deserted …." Crile continues his brutal description of the effects of war, results that at this era are similar, but seasoned with modern technology which produces more death, more destruction, with severe damage to the environment and Humanity.

Each leader -person or government- that starts a warlike conflict has their own personal, political, religious, economic, and/or historical motives, interests that harm the planet and Humanity and interfere with our progress, including the multiple scientific aspects.

As the world goes through the catastrophic impact of the COVID-19 pandemic in which, according to the WHO, in the first 2 years almost 15 million people died as a direct or indirect result, including health workers who fought to care for patients affected by this small but deadly virus;^4,5 now, Humanity is facing a new and irrational challenge in Russia's war on the territory of Ukraine. The conflict between these two countries is a long history of disputes involving Eastern European countries⁶ dating from World War II and especially after the Russian fragmentation that resulted in the so-called post-Soviet countries. On February 24, 2022, Ukraine was invaded by Russian troops that until today have not only had negative effects in both countries, but also collateral damage throughout the planet with the threat of a third world war. This large-scale invasion surprised everyone, especially to the Ukrainians and to the whole of Europe. The now refugees who managed to leave the Ukranian territory lost not only relatives, but also their belongings, their houses and above all, they lost their freedom.

The countries that have sheltered millions of people, especially the regions bordering Ukraine – Poland (76% of refugees), Slovakia, Hungary, Romania, and Moldova that are supplying humanitarian support to the evacuees, have had to face sudden massive migration and the results that this implies on education, work, social and medical needs. Those with chronic diseases or cancer should continue their treatment. Epidemiological aspects are vital, sanitary barriers for the prevention of communicable diseases such as tuberculosis, which is endemic in Ukraine, COVID-19, HIV/AIDS, etcetera.^7-9 Countries farther away in Western Europe and the American continent have also been affected by this abrupt migration.

The continuation of the current conflict in Ukraine also poses a potentially serious risk to the global economy, environment and long-term food security. People living through urban warfare have the risks of physical and mental harm in addition to the scarcity of basic health resources to treat all other diseases they may have or develop. The heroic resistance of Ukraine's troops and civilians has prolonged the war, and the invaders have been destroying vital infrastructure, including access to fresh water, food and medical resources. The threat of nuclear damage has been constant in this conflict; The world experienced this possibility when the Russians troops took control of the Zaporizhia nuclear plant and the Russian president's frequent threat to use nuclear weapons in the face of NATO's possible participation. The fragility of these types of facilities has turned them into a potential risk for a nuclear disaster with catastrophic, almost irreparable damage to the health of thousands of living species.¹⁰

As scientists, we work diligently to improve people’s lives; as doctors, we were created to safeguard life. Violence means frustration in our professional and moral task as human beings. Immediately after this war began, the international scientific community expressed its rejection of this invasion and solid proposals have been made to support not only the refugees, but also the patients, scientists and students of Ukraine and also the Russians who did not support the criminal behavior of their president.^11-16 The Russian Academy of Sciences, rectors of all Russian universities, and coworkers of numerous leading universities and academic institutes that all seemed not to support the war against Ukraine.¹⁷

Health workers in Ukraine continue to face not only the ravages of war, but also the restrictions and shortages to care for thousands of patients; people with kidney failure, cardiovascular diseases, cancer, HIV/AIDS, pregnancy, chronic diseases, COVID-19, and many more disorders,^16,18-24 as well as first level health care programs, especially child health care, including vaccination programs. The war crisis has damaged the rights and health of 7.5 million children; use of cluster munitions, bombing of schools, shelters, playgrounds, hospitals, and orphanages have devastated the health system. More than a hundred children have died during these attacks and thousands have stopped receiving care for their chronic illnesses. 4.3 million children -more than half of the country's population under the age of 18-have left their homes. According to UNICEF estimates, 1.8 million children have fled to neighboring countries as refugees and 2.5 million are internally displaced, which favors traumatic separation from their families, abuse, exploitation and human trafficking. All refugees, especially children, need food, fresh water, clothing, and warmth. Attending school prevents or decreases stress. Children are innocent victims of wars.^22,25

Fel et al.²⁶ studied a group of Ukrainian civilians during this war and found that the most important predictors for the development of post-traumatic stress disorder (PTSD) were loss of a loved one, place of residence, gender, continued education and health insurance. These authors found that having children is associated with a risk of more severe PTSD and that material security reduces PTSD, but only among people who do not have children. On the other hand, this armed conflict has endangered the research and production of the Sputnik vaccine, a biological that has been used in more than 70 countries.²⁷ Fortunately, it has been shown that boosters with other types of COVID-19 vaccines can be used in people who received Sputnik shot.

There is a debate among the editors of some scientific journals about not accepting manuscripts from Russian authors, temporary withdrawal of their already published research. Others have suggested suspending joint scientific research with Russian colleagues, as well as suspending grants, economic and technological support from the international scientific community,¹² while the majority of fellow editors maintain that this war crisis should not interfere with scientific aspects, and on the contrary, full support has been proposed to Russian scientists and students who outside and inside their country do not support Putin's policy.¹⁵

We, the health professionals who live in a free world, are concerned about our fellow doctors, nurses, technicians, scientists, academics, postdoctoral fellows and students in Ukraine and consider criminal the attacks on hospitals, shelters, communication routes, and academic institutions. We urge the international community to continue supporting Ukrainians inside and outside their homeland. At the time of writing this editorial, 152 days have passed since this invasion that has not only cost the destruction of cities and towns, but also the death of civilians and soldiers from both countries, the damage to hospitals, shelters, communication routes and of course, to the natural environment of Ukraine. A military conflict that once again puts Humanity in an inconvenient situation with a high matter of death; death resulting directly from injuries caused by war weapons that equally affect military and innocent civilians, death as a collateral consequence due to the almost total destruction of health services, death due to a late effect by interfering with medical research. In addition to death, the damage to freedom, the forced migration of 5.4 million Ukrainians and the catastrophic collateral damage in Ukraine and geographical regions not involved in this war, death, and damage to our planet due to an incomprehensible Putinesque genocide.

The damage to the people of Ukraine has been excessive. The international scientific community demands a peaceful solution and the restoration of all the activities of the Ukrainians in their country.

None.

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