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Donetsk: ‘Did they come to an agreement?’ Sergey, my driver, asked anxiously as soon as I got into the car at 8 a.m. on Thursday. We had several hours of driving ahead of us so I read aloud from my Twitter feed to him during the trip. ‘Looks like they did … oh, wait … they went back. Proposed terms are not acceptable, Poroshenko says.’ Sergey’s face fell. He crossed himself, swore out loud, then apologised. ‘I just want this to be over. Can’t they have some vodka in Minsk, shake hands and stop doing this to the people?’

By the time we reached our destination, the agreement was reached and the peace deal signed. Some people I spoke with by phone in Donetsk on Sunday said they were thrilled to wake up in the morning and not to hear the booming of shells. But whether and how long the ceasefire will hold is a different question.

In the meantime, residents of Donetsk and other conflict-affected areas of eastern Ukraine have been hiding from daily shelling and rocket attacks in basements and outdated bomb shelters, and starting their day by calling relatives and friends to find out if they made it through the night. Fighting has damaged or destroyed many houses, apartment buildings, schools and medical facilities, some of which have stopped operating.

The UN estimates that 5.2 million people are living in the midst of conflict in eastern Ukraine. The protracted fighting is not the only difficulty they face. The Ukrainian government stopped providing services, including pensions, to rebel-held territories in November, and rebel forces controlling these areas did not step in to close the gap. Travel restrictions introduced by the Ukrainian government in January make it complicated to move in and out of rebel-held areas.

People trapped in active conflict zones rely on humanitarian groups and volunteers to deliver food and medical supplies, but in the Donetsk region the needs are growing faster than they can be met. While we didn’t travel to Luhansk due to security concerns, the humanitarian situation is reportedly much worse there.

When I discuss the humanitarian situation in the east with people living in other parts of Ukraine, they often ask: “Why don’t they just leave? Why not go to Kiev – or anywhere else where there is no shelling?” The thing is, many can’t. Close to a million people did leave eastern Ukraine; they fled the hostilities to other parts of Ukraine, and many have left the country. But among those left behind are the most vulnerable: the elderly, people with disabilities, women with children – those who have been relying on pensions and benefits from the government that they haven’t received for months.

I’ve met people who are so poor they can’t afford to travel to see a doctor or purchase necessary medicines let alone travel to a checkpoint to apply for the special pass required to go in and out of rebel-controlled territories. In reality, these people are trapped.

Those living close to the front lines have been hiding in basements or bomb shelters in unsafe and unsanitary conditions for months, sometimes with no electricity or clean water. Forty-five people, including five children, have been living since August in one of the bomb shelters I visited last week in Donetsk. They said they had no electricity for three weeks. Several women, all in their 70s, said they have not received their pensions for eight months. Volunteers have tried to evacuate people and help them relocate but many are too traumatized and frightened to leave – and some have children or elderly relatives they cannot leave behind.

Svetlana, who has an 18-month-old baby and a 5-year-old, and is seven months pregnant, has been living in another nearby bomb shelter for months. When asked if she wanted to leave Donetsk, she said she had nowhere to go and was terrified of even stepping outside.

This constant and profound fear is common and understandable. Indiscriminate attacks on residential areas have been a daily occurrence for months, and almost no areas in Donetsk are safe. A bridge between Tekstilshiki and Petrovsky districts was hit less than an hour after we drove across it last week on the way to the shelters. On the way back, we stopped and watched men in orange vests extracting charred body parts from a burned car and put them into a body bag. After they finished, they moved on to the body of a man who had been riding his bicycle on the bridge and was apparently killed by a fragment.

Most doctors and medical staff we spoke to in rebel-held areas of Donetsk region said health services in those areas are on the brink of collapse. Medical workers have not been paid for months. Medical facilities are struggling with acute shortages of staff, medicines, and medical supplies. Many hospitals, including in Donetsk, Horlivka and other places, have been badly damaged due to intensive fighting.

The health crisis is affecting some of the most vulnerable groups of patients, in particular those receiving treatment for tuberculosis (TB), HIV and drug dependence. These patients are facing a growing risk of their live-saving treatment being interrupted.

The chief doctor of the Donetsk regional TB centre, where over 500 patients, including about 40 children, currently receive treatment, said that while the centre has enough first-line medications in stock to provide uninterrupted treatment to patients for another month, the supply of second-line treatment – used for patients who are resistant to first line therapy – and medications to treat related conditions is almost depleted. In December the centre ran out of rapid diagnostic tools for TB, and diagnosis can now take months instead of days. Rapid diagnosis and initiation of treatment are essential to containing drug-resistant tuberculosis, which can otherwise continue to spread.

The chief doctor of the regional drug treatment centre in Donetsk told us that while the facility sporadically receives supplies and medicines from humanitarian convoys, the supply of medications for opioid-substitution therapy stopped in September. Buprenorphine, a medication used in opioid-substitution therapy, ran out in January and methadone supplies will last only till March. Buprenorphine and methadone are readily available in Ukraine but are not being delivered to rebel-held areas.

The Ukrainian government has still not signed a document, drafted in January, to allow humanitarian groups to deliver both medicines to rebel-held areas. People receiving opioid substitution treatment include many vulnerable patients, such as people with HIV, tuberculosis or hepatitis, the doctor said. Discontinuing this treatment could have dire, possibly deadly, consequences.

According to the chief doctor for the Donetsk regional AIDS centre, travel restrictions have severely impeded the delivery of both diagnostic test kits and antiretroviral medicine. Antiretroviral medicines are available in government-controlled territory but are not being supplied to rebel-held areas. Three weeks ago the centre’s medical staff applied for passes that would allow them to cross to government-controlled areas to collect the medications themselves, but when I spoke to them they had still not received the passes.

The doctors estimated that over 6,000 people live with HIV in Donetsk region’s rebel-controlled territory, and currently receive antiretroviral therapy. Current supplies are expected to last until mid-March. Interruptions in treatment may result in worsening health of patients, including death, and development of resistance to antiretroviral medicines.

A range of other factors – including dire security conditions – combine to cause severe shortages in other medicines. The chief of the transplants and dialysis department of the Kalinina hospital – the largest hospital in the Donetsk region – said that patients with chronic renal failure receiving hemodialysis and immunosuppressive medicines after kidney transplants may face interruptions in their life-saving treatment due to shortages of medicine, supplies and equipment for hemodialysis. ‘It is like this,’ he said. ‘If there is a Ukrainian flag, there is life. If there isn’t – you are on your own. When did we stop being Ukrainian citizens?’

The chief of the neurosurgery department at Kalinina hospital – the only hospital department that performs neurosurgery in the region – said that the provision of urgent medical services in his department is collapsing: “Not only life-saving medicines but basic supplies used in surgery such as gauze, bandages are almost gone. We had to introduce a very strict economy regime but even so, if there is another shelling attack and we have a lot of patients needing surgery, we will not be in the position to provide help. We are one step away from a catastrophe.’

Viktoria, a Kalinina hospital pharmacist in Donetsk, echoed that sentiment. She showed us a list of 49 essential medicines the hospital is about to run out of. A separate list for essential medical supplies and consumables included needles and syringes, bandages, gauze, tape, surgical sutures, dressings and x-ray films. ‘We are desperate here’, she said. ‘Some of these medicines will run out in a few days and unless help comes soon, patients will not get the treatment they need.’

Some of the problems that civilians in eastern Ukraine are facing today are the horrid and inevitable consequences of war, but some could be fixed. The Ukrainian authorities could approve and implement the decree that would allow humanitarian groups to deliver opioid-substitution therapy to rebel-held areas. They could also speed up the process of issuing passes needed for the delivery of antiretroviral and other medications and diagnostic equipment.

Neither side in the conflict appears to be systematically blocking international and domestic groups from delivering aid to conflict-affected areas. But these groups, already struggling to meet the growing needs in the war-torn region, have faced a range of obstacles: from intensive fighting that makes it difficult to reach hardest-hit areas to travel restrictions that complicate efforts to scale up the response. There have also been reported cases of arbitrary refusals and delays by both Ukrainian and rebel forces at checkpoints to let people through with medical aid, even when they have the required paperwork.

The new Minsk agreement calls for both sides to guarantee access to humanitarian assistance. This is desperately needed so civilians trapped in war zones in eastern Ukraine can get help.

Lastly, indiscriminate warfare has to stop. While travel restrictions and lack of state-provided services create terrible conditions for people in rebel-held areas, it is the indiscriminate attacks on civilian areas on both sides of the front lines that is affecting civilians most severely. As one doctor in Donetsk told us: ‘They put a red tape around regions where people, citizens of Ukraine, are still living. It is horrible for us, but perhaps, we will be able to survive that. What we can’t survive is civilians being killed every day by shells and rockets from both sides.”

Yulia Gorbunova is a Researcher at Human Rights Watch.

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