This review analyzes medical and psychological aspects of the war in Ukraine. The separation of Russia from Europe started in 1917 and has continued thereafter. If the power shifts to the East, it will come along with losses of values like liberties and human rights. Disregard for laws and regulations, corruption and collectivism will come instead. The quality of many services, products and foodstuffs will decline. The lack of knowledge about other countries, misleading propaganda, suppressed envy and shame contribute to hostility against other nations. In this connection, drawbacks of the healthcare are discussed here. The following distinctions are pointed out: comparatively low life expectancy, medical science not repelling falsification, inefficient medications advertised and prescribed, invasive procedures applied without indications. Autocratic or military management style discourages criticism. Attributes of this style include the paternalistic approach to patients, bossy management, harassment of colleagues if they do not follow instructions or not collaborate in dubious research. Under conditions of paternalism, misinformation of patients and compulsory treatments are deemed permitted. Military and medical ethics are not the same. The comparatively short life expectancy in Russia is a strategic advantage as less healthcare investments and pensions are needed. A constructive alternative is a global leadership concentrated in the developed parts of the world, based on humanism and modern science. Gigantic projects could be realized by united humankind instead of rivalries and military expenditures. Wars within Europe testify to the courage of soldiers and irresponsibility of some leaders.

This review analyzes medical and psychological aspects of the war in Russia and Ukraine. The separation of Russia from Europe started in 1917 and has continued thereafter [1]. If the power shifts to the East, it will come along with losses of values like liberties and human rights. Disregard for laws and regulations, corruption and collectivism will come instead. The quality of many services, products and foodstuffs will decline. The following distinctions should be pointed out: comparatively low life expectancy, medical science not repelling falsification, inefficient medications advertised and prescribed, invasive procedures applied without indications [2-5]. Autocratic or military management style discourages criticism. Attributes of this style include the paternalistic approach to patients, bossy management, harassment of colleagues if they do not follow instructions or not collaborate e.g. in dubious publications. Under conditions of paternalism, misinformation of patients and compulsory treatments are deemed permitted [6]. Finally, the environmental protection and energy conservation is less popular in Russia than in other industrialized countries.

Russian leaders may be the first movers of a new historic period. If the world becomes multicentric as per Vladimir Putin, armed conflicts of various magnitudes will be permanent. In a sense, it would be a return to the medieval times. Indeed, the leading Russian ideologist Alexandr Dugin has written: “The Middle Ages were the golden age of mankind” [7]. A constructive alternative is the global leadership centered in developed parts of the world, based on humanism and modern science. 

The declared reason of the Ukraine invasion was the anti-separatist activity in the Donbas since 2014. Apparently, this activity has been exaggerated. The coping with separatism within national borders is justifiable, exemplified by Russian activities in the Caucasus. The 1991 borders of Ukraine were recognized by all nations, including the Russian Federation (RF). Admittedly, a majority of residents in the southern and eastern parts of Ukraine are Russian-speaking whereas some people were disappointed that their region had not become a part of RF. Some residents of occupied territories voted for the unification with RF to avoid trouble as they don’t believe that the situation will be reverted. Many local inhabitants do not care much about liberties and human rights; what is important, is wealth and security. Therefore, significance of the referendums is limited. To be unbiased, such referendums must be performed not in conditions of occupation but under efficient international control e.g. within the framework of a peacekeeping mission. 

The main thing is to avoid a new East-West conflict. True winners would be those who stay outside, as it was through the 20th century. The war is distracting people from internal problems facilitating screw-tightening, postponing solutions in the public health and social affairs. All those participating (factually or on paper) will obtain the war veteran status thus acquiring privileges over fellow-citizens. This is a motive both to participate in the warfare and to exaggerate its dimensions. Overmanned militias both in the Donbas and in Chechnya were a remedy against unemployment due to the overpopulation in the latter and coal mines closures in the former [8]. 

Social and environmental perspective

The conflict in Ukraine has impeded environmental policies in Europe and elsewhere. The war itself is damaging for the environment. The conflict between two major agricultural countries has negative impact on the global food supply. As food prices rise, some nations are likely to cope by converting forests to fields. International tensions and conflicts are among reasons to boost childbearing, which sometimes amounts to the reproductive coercion [9]. Pro-natalist policies are counterproductive in view of the global overpopulation. The demographic growth contributes to the shortage of food and energy in many regions. The energy could be supplied by nuclear power plants (NPPs). Well-managed NPPs pose less of a risk than those running on fossil fuels. Nuclear facilities practically do not emit greenhouse gases. By analogy with the Chernobyl accident, the war damage and shutdown of the Zaporozhie NPP (largest NPP in Europe) enhance demands for fossil fuels well in agreement with the interests of oil and gas producers. The weightiest argument against NPPs is that they are potential war targets. Escalation of conflicts contributes to boosting of fossil fuel prices. Apparently, this has been one of the motives to unleash and continue the war in Ukraine. Should the world become multipolar, armed conflicts will become permanent.

The worldwide use of atomic energy must be managed by a powerful international executive based in developed countries, albeit not in those threatening with nuclear weapon [10]. It would enable construction of nuclear facilities in optimally suitable places, notwithstanding national borders, considering all socio-political, geophysical conditions and reliability of local personnel. In this way, accidents like in Fukushima Daiichi due to the earthquake and tsunami, or Chernobyl, caused by violation of written instructions [11,12], would be avoided. Development of nuclear energy would create jobs for qualified workforce; otherwise, the know-how will be relocated to countries with less influential green movements. Probably not all writers and green activists exaggerating medical and ecological side effects of nuclear energy do realize that they serve the interests of fossil fuel producers. Citizens should be aware that their best intentions are exploited to disadvantage their own countries [13]. 

Medical Aspects

Since the 1980s, numerous former party and military functionaries, their relatives and protégées, have been introduced into educational, scientific and medical institutions in RF. Being not accustomed to hard and meticulous work, some of them have been involved in misconduct of various kind [3]. They will become more dominant thanks to the current war. Those participating in the conflict, factually or on paper, will obtain the veteran status and hence privileges over fellow citizens, occupy leading position without adequate training and selection. At the same time, some relatives of higher officers evaded mandatory military service under various pretexts [14]. 

Among mechanisms contributing to the persistence of suboptimal and outdated methods in medicine has been the lack of professional autonomy [15], autocratic or military managerial style discouraging criticism and polemics. Suboptimal practices have been used as per instructions of healthcare authorities and leading experts’ publications. To name but a few: the overuse of Halsted and Patey mastectomy with excision of pectoral muscles, electrocoagulation of endocervical ectopies without cyto- or histological check for precancerous changes, parabulbar injections of placebos, gastric resections for peptic ulcers, overuse of surgery for bronchial asthma, pediatric respiratory conditions, diabetes mellitus and tuberculosis [2-4], excessive use of bronchoscopy for research and practice e.g. in conscripts with supposed pneumonia: 1478 procedures in 977 patients 19,5±0,1 years old in one study [16,17]. The personnel training could have been one of the motives to overuse invasive procedures. The military needs experienced surgeons.

Military and medical ethics are not the same. The comparatively short life expectancy in Russia is a strategic advantage as less healthcare investments and pensions are needed. In conditions of legitimacy and high ethical standards, the market economy stimulates a competition of constructive ideas, innovations and treatment quality. In conditions of disrespect for laws and ethics, the competition turns to discrediting of the free healthcare, manipulation towards paid services, and harassment of non-paying patients. Actually, Russia needs international help in the field of healthcare. Obstacles to the importation of medical products have adverse consequences: domestic products are promoted sometimes despite lower quality and possible counterfeiting. Moreover, relatives of superior officers and functionaries have been involved in immoral and illegal activities. High social positions held by perpetrators prevented reporting [14].

Some medical topics have been reviewed previously [2-5], where details and more references can be found. Here follow selected examples. According to the author’s estimates after temporary practice in Europe, an average size of malignant tumors in surgical specimens was larger in RF than abroad. Obviously, it reflects the efficiency of cancer diagnostics. Outside of the former SU, almost all mastectomy specimens were without muscle. The worldwide tendency towards more conservative breast cancer management remained unnoticed in RF for decades. The modified radical mastectomy of Patey with the removal of pectoralis minor muscle has been a standard treatment until recently; but the Halsted procedure with the removal of both pectoralis muscles was applied as well. The Halsted operation was presented as the main treatment modality for breast cancer in some textbooks edited in the 21st century [18,19], further references are in [4]. As the overtreatment had been realized, the chief surgeon of the Health Ministry, retired colonel Mikhail Kuzin recommended for less advanced cases the modified radical mastectomy of Patey with the excision of the pectoralis minor muscle. This latter procedure is also associated with adverse effects; it was extensively used in RF during last decades. Kholdin, Dymarskii and others recommended, patented and applied even more extended modalities of mastectomy, references are in [4]. Considering the breast cancer incidence, millions of women of different ages have undergone mutilating procedures with the muscle removal during the Soviet and post-Soviet times.

The cauterization or cryodestruction of endocervical ectopies (pseudo-erosions) independently of the presence of epithelial dysplasia have been applied routinely. Ectopies were found at mass examinations and treated by coagulation. This disagrees with the international practice. In particular, the recommended treatment of large ectropions by diathermoconization was noticed to cause complications. Destructive treatments of endocervical ectopies were patented recently. At the same time, Pap-smears have been rare and technically suboptimal, cervical cancer being detected averagely late; more details and references are in [20]. 

Even if a Pap-smear or cervical biopsy was performed, it did not always prevent the overtreatment, the more so as the difference between the terms metaplasia and dysplasia has not been uniformly understood. Pathologists e.g. at the Ostroumov Hospital in Moscow were discouraged from using the term ‘metaplasia’ to prevent remittance of patients to oncological institutions (dispensaries) and overtreatment. Of note, single-layered columnar epithelium beyond the external cervical orifice i.e. endocervical ectopy is generally considered normal. The cause was not (only) lack of knowledge: stressed women, needlessly redirected to an oncological institution, were easier to manipulate towards paid treatments. Furthermore, parabulbar and subconjunctival injections of carcinine, taurine and mildronate used in age-related ophthalmic conditions were seen to be complicated by hematomas. A benefit from a short-term enrichment of these substances in orbital tissues can hardly be understood, while parabulbar injections are associated with risk. Injections of cell suspensions obtained from abortion material into coronary vessels in cardiomyopathy [21] have been commented previously [22]. In conditions of suboptimal procedural quality assurance, endoscopic and endovascular manipulations can lead to infectious and thrombotic complications.

The “pancreatic blood shunting into the systemic blood flow” was applied as a surgical treatment of diabetes mellitus of both 1 and 2 types [23-26]. The physiological rationale sounds unconvincingly: “Creating a more optimal interaction of subcutaneously administered insulin and pancreas-secreted glucagon” [24]. Apart from several publications from the former SU, no reports on this treatment of diabetes were found. Thrombosis and peritoneal adhesions were observed post-surgery, while acidosis was a typical occurrence [25]. The anti-diabetic effect of the shunting was reported to be moderate both in humans and in preceded experiments with dogs. In the experiment, the majority of dogs did not survive the induction of diabetes by streptozotocin or pancreatic resection with subsequent shunting surgery [27]. Nonetheless, the porto-systemic shunting in diabetes was positively characterized until recently [25,26]. 

Wedge biopsies from the pancreas and kidney were collected from diabetic patients intraoperatively. The histological descriptions included glomerulitis with mesangial interposition, double-contoured glomerular basement membranes and mesangiolysis, presented as typical features and consecutive phases of diabetic glomerulosclerosis [28]. These features are in fact characteristic of membranoproliferative glomerulonephritis, which, if found in a diabetic patient, should be interpreted as a superimposed condition possibly needing therapy. The kidney biopsy is generally indicated for diabetics only if a renal condition other than diabetic nephropathy is suspected. Of note, renal and pancreatic biopsies are associated with risks. The same can be said about renal and splenic venography, celiac arteriography and other invasive procedures performed within the framework of the diabetes surgery by the same scientists. The overuse of renal biopsy has been discussed previously [29]. 

Some surgical treatments of gastroduodenal ulcers in the former SU have been different from the international practice [30]. According to the author’s observations, resection of the stomach was rarely performed abroad for peptic ulcers, the volume being smaller, usually corresponding to antrectomy. For perforated ulcers, a local excision was usually performed; and a ring-shaped specimen was sent for histological examination. Laparoscopic procedures are currently on the rise. In the former SU, a primary gastrectomy (2/3-3/4 of the stomach), antrectomy with vagotomy, or a simple suture (depending on the patient’s condition) have been usually performed; references are in [4]. At least a fivefold decrease in gastric resection frequency among ulcer patients during last decades has been reported from some institutions, which indicates an overuse in the recent past; references are in [4]. However, the attitude delineated above is reappearing today, notably, in military-medical institutions [31]. The military needs trained surgeons. In recent publications, gastrectomy has been designated as the most frequent, main or singular surgical treatment of gastric ulcers [32-34], applicable for any ulcer location [31]. As before, appeals to “radicalism” can be heard, advantages of early surgery for uncomplicated ulcers being emphasized [31,34].

Another surgical procedure with no analogy in the contemporary international practice is the thoracotomy with the lung denervation for bronchial asthma referred to as “the most recognized method” in the guidelines by the Ministry of Health [35]. Thoracotomy with the pulmonary root skeletonization was called “the most recognized surgical procedure to treat severe asthma” [35]. The pulmonary root skeletonization method was patented and recommended both for “infectious-allergic” and steroid-dependent asthma. Lung denervations, segment- and lobectomies were advocated even for those asthma patients in whom the medical treatment “had a temporary effect”, especially in the presence of inflammatory lesions in the lungs. It was recommended that medical therapy prior to the surgery should be of limited duration [35]. Segment- and lobectomies were applied as an independent method of asthma treatment, even in those cases when medical therapy was effective. Indications for the surgical treatment included local pulmonary lesions such as bronchiectasis, pneumocirrhosis and bronchitis deformans (the two latter terms are used in RF) [36]. Resections were performed for extensive and bilateral lesions, also in remissions, deemed necessary for a radical healing of asthma. This concept was advocated by Fedor Uglov, who declared that “removal of infectious focus” is the main purpose of asthma surgery. Chronic pneumonia was claimed to be “the basis of bronchial asthma” [36]. Asthmatics were transferred from therapeutic departments for the surgical and bronchoscopic treatment. “After a course of therapeutic bronchoscopies”, Uglov and co-workers performed segment- and lobectomies [36], removing pulmonary tissues regarded by them to be abnormal. The same procedures were applied also in children with persistent cough and recurrent pneumonias. Some histological descriptions deviated from those in the standard editions of pulmonary pathology, being apparently adapted to the concept of surgical treatment details and references are in [4]. 

The following treatments were applied to alcoholics: prolonged intravenous infusions, sorbent hemoperfusion, endolymphatic and endobronchial drug delivery, pyrotherapy with sulfozine (oil solution of sulphur for intramuscular injections), endoscopic and surgical biopsies of internal organs, cholangiopancreato- and angiography without clear indications also for research [37]. The detoxification by intravenous infusions of sodium chloride, dextran, magnesium (Mg) sulphate, glucose solutions etc. have been recommended for various forms of alcohol dependence and alcoholism including the “moderately severe withdrawal syndrome” [38-40]. This is at variance with the international practice. Intravenous glucose and Mg are generally not recommended in the settings of alcohol withdrawal syndrome. Excessive infusions of Mg-containing solutions are associated with adverse effects. Repeated intravenous manipulations are associated with risks and discomfort. In conditions of suboptimal procedural quality assurance, endovascular and endoscopic manipulations can transmit viral hepatitis, which was known to occur to many alcohol-dependent patients. A combination of the viral and alcoholic liver injury is unfavorable. Compulsory treatments of alcoholics with tuberculosis included repeated bronchoscopies. Among others, vocal cord injuries were observed in such patients. Vigorous apomorphine- and mechanically induced vomiting as emetic (aversive) therapy of alcohol dependence induced hemoptysis in patients with tuberculosis [37]. It was reported in 1994 that ~60% of patients of a “phtisio-narcological” institution for compulsory treatment escaped while a half of them was returned with the help of the police [41]. Conditions in dentistry have been described elsewhere [5]. For example, in case of a tooth extraction, some dentists at state polyclinics offer a choice: “Do you want a paid or free injection?” The payment is unofficial i.e. under-the-counter. Anesthesia after the free injection is incomplete at best. According to the World Medical Association, the pain treatment is a human right.

Many above-cited experts or their relatives hold their positions now as before, reflecting the attitude to ethics in the healthcare and, by inference, in the society and its rulers [3]. It is known that the concept of informed consent has not been uniformly accepted in Russia. Today, patients are sometimes requested to sign in advance a form certifying their blanket consent to unnamed diagnostic and therapeutic procedures. Factors contributing to the persistence of suboptimal methods included the partial isolation from the international scientific community, authoritative or military management style, disapproval of criticism, disregard of the rules of scientific polemics, insufficient use of the foreign literature and unavailability of many internationally used handbooks even in central medical libraries. Disregard for the principles of informed consent together with authoritative and paternalistic attitudes towards patients contributed to the use of invasive methods with questionable indications. 

Psychopathological aspect

Psychological aspects of the war in Ukraine and bellicosity of some leaders have been discussed elsewhere [42]. Here is an updated summary. Vladimir Putin’s saying “If a fight is [perceived as] inevitable, you must strike first” may be a trace of juvenile ways of defending against bullies, presumably related to an intergenerational traumatic chain [43]. Physical abuse of children in families and bullying at schools are well-known problems in Russia, often neglected by teachers and authorities, who not always reacted to known cases of child abuse. It has been estimated recently that 14% of all children are exposed to violence, two million are regularly beaten by their parents, and 10% of them die from such treatment [44]. According to another source, 40% of children are beaten in families [45]. The prevalence of family violence in Russia during last decades has been estimated to be 45-70 times higher than, for example, in England and France [46]. Yet in 2017 some forms of family violence have been officially decriminalized in Russia. 

Both bullying and family violence have been described in biographies of Vladimir Putin. His father is said to have beaten the boy. There is evidence supporting an association between childhood trauma and bullying with various psychiatric symptoms, including persecutory delusions. Reportedly, the worse a child is treated, especially by his father, the more frequent are paranoid ideations in the adult life; details and references are in [42]. In fact, it is not so much the Russian population who perceive external threats as it is their leader who is re-enacting his puerile experiences [43]. Aggressiveness may be a way to defend self-esteem, blaming others in order to maintain a positive self. In regard to the demolition of the Ukrainian infrastructure including churches [47], Putin may be in grip of the idea that the “denazification” can be achieved through extensive devastation. There is an opinion that Putin’s phantasm of Ukraine’s denazification is an idée fixe based on entangled memories of what he has heard about the World War II. Putin wants to resist the imagined attack from the West; in the process, he may strive to become a new Stalin by completing the latter’s unfinished business of conquering Europe [48]. Many people subscribe to delusions at large. It is possible for a majority to be deluded and minority not to be deluded [49]. Homogeneity of thinking is a predictor of conformism that is conducive to dictatorship [50].

 Paranoid rulers tend to promote mentally abnormal individuals and rely on their opinions [51]. An example is Aleksandr Dugin, called the “Putin’s Brain” [52], who preaches Russia’s westward expansion resorting to religious and mystic vocabulary. His writings have been analyzed previously [42]. Dugin’s delusion-like ideas include the “Western plot to undermine Russia” and “Eternal struggle between Land and Sea”, the latter probably being a reminiscence of the novel “1984” by George Orwell. Admittedly, more recent Dugin’s writings contain reasonable conclusions. Criticizing globalization, he noticed that for a national bureaucracy (read: Nomenklatura) it would imply a loss of status. This seems to be the main motive of the anti-globalist ideology prevailing in the Russian officialdom these days. References are in the preceding paper [42].

Paranoid individuals are often self-centered, arrogant and vulnerable at the same time. In a sense, paranoid grandiosity is a shield for a fragile ego. The insecurity of a paranoid ruler may contribute to violence. A belief that others intend harm leads to aggression. Paranoia is generally characterized by a hostile disposition and aggressive behavior against perceived enemies. Paranoiacs are motivated to prove that they are right but have limited abilities to test whether their beliefs are realistic. Their thinking is characterized by jumping to conclusions. This bias may lead to mysterious and religion-related ideas. Certain war instigators and terrorists are paranoid in their tendency to present themselves as prophets and world saviors. Some of them are aggressive against delusional goals, as is the case with the “denazification” of Ukraine. Of note, such ideas are virulent. Mentally healthy people can be susceptible to appeals supported by mystic rhetoric, a predisposing condition being fear of strangers and projection of hatred upon them. This susceptibility is exploited by the propaganda. 

In the former Soviet Union, paranoia was recognizable both in authorities and in the whole society [53]. Paranoid politicians search for new enemies and resuscitate old hatreds. This is what we are observing in RF today. The more different a stranger, the more suitable is he or she as a target for externalization. The enemy becomes a reservoir for negated aspects of the self. A lack of knowledge regarding other countries, misleading propaganda, suppressed shame and envy contribute to hostility. Moreover, envious people blame those who make them feel ashamed by comparison. Some functionaries are descendants of the rural proletariat who burnt mansions in 1917 and committed violent crimes, envy being one of the motives. This tradition has evolved to kleptocracy.

The psychological projection in paranoid individuals is regarded to be an aberration of shame; being unable to tolerate shame, they project it onto others and thus disown. In its turn, intense shame confers vulnerability for paranoia [54]. Repressed shame may cause aggression [55]. Shame is associated with different psychiatric conditions and symptoms. There are reasons to be ashamed in today’s Russia, as reflected by a comparatively low life expectancy mainly due to the suboptimal healthcare.

Russian leaders are currently blamed for aggression. Should the world become multipolar, armed conflicts may become permanent. In some ways, this would be a return to the 20th century, or even earlier times. A constructive alternative is a global leadership concentrated in the developed parts of the world, based on humanism and modern science. Gigantic projects could be realized by united humankind instead of rivalries and military expenditures. Wars within Europe testify to the courage of soldiers and irresponsibility of some leaders. The winners are those who remain outside. Hostility toward the West is justified by the alleged “centuries of Western hostility toward Russia” [56]. The Tatar-Mongol yoke (1237-1480), the most effective “hostility towards Russia”, was not mentioned in the context, although it is a realistic perspective in view of demographic and economic developments. Ideally, peace should be achieved through negotiations.

The rhetoric around Ukraine conflict is going too far: obscenities, declarations of jihad and appeals to use nuclear weapon [10,57-59]. All the above is associated with shame. Repressed shame may cause aggression [55]. Some crew change seems to be necessary. Kleptocratic, corrupt, bigoted, and mendacious Putin-regime is to blame. Those responsible and wirepullers, deserve the death penalty not less than persons sentenced in the past as war criminals. In conclusion, Russian leadership should cooperate with European neighbors and other developed nations.

The author declares that he has no competing interests.