James' World 2

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In the early 1980s, military forces from the Soviet Union went to war in Afghanistan in an effort to prop up a failing Marxist regime. At the time, Ukraine was part of the union, and many of its people were conscripted. Plenty of soldiers ended up losing legs in the fighting – and back then, their options weren’t good.

Shockingly, the Soviet authorities’ response was to offer them a medical version of a skateboard to get around. “That was your only option,” says Antonina Kumka, a former adviser to Ukraine’s government. “They were just rolling on wooden boards with wheels around the cities.”

Fast-forward to today, and Ukrainians have again been thrust into a war they didn’t choose. This time, the conditions of modern warfare mean that unprecedented numbers of people are losing limbs, presenting the country with a huge challenge. The response, however, has been very different. Kumka, who is a co-founder of Protez Hub, an initiative to improve the lot of Ukrainians with amputations, has been stepping up her work. And her organisation is just one part of a sprawling network of clinics, start-ups and research labs that has sprung up to help the injured.

Thankfully, no skateboards are involved. But questions abound. Does Ukraine really have what it needs to help the legions of injured people – many of whom will need prostheses for decades to come? Is this newly created industry always acting in the best interests of those it assists? And it is worth asking what the rest of the world can learn from Ukraine’s booming prosthetics industry.

Unsurprisingly, statistics on the number of Ukrainian amputations are murky. Figures of up to 100,000 are often mentioned in news reports, apparently based on government estimates. But Ukraine has an interest in exaggerating this number to bolster international empathy and support. Kumka, who can access official statistics as part of her work, tells New Scientist the real number is around 24,100, counting from the beginning of 2021 to the end of 2025. (Neither the Ukrainian Ministry of Health nor the Ministry of Social Policy responded to requests to confirm this number.)

However, even that lower estimate represents a tragic loss for a whole generation of Ukrainians. For context, 12,000 UK service members lost limbs in the six years of the second world war, while around 1705 US service members had limbs amputated as a result of injuries sustained during 16 years of fighting in Iraq and Afghanistan. For Ukraine, which had one of the lowest incomes of any European country even before Russia’s invasion, the necessary medical response is an enormous challenge.

The nature of the war today means that not only are amputations more common – on both sides – but they also tend to be particularly difficult cases. The front lines are shrouded in a wide no-man’s-land, known locally as the Kill Zone, in which drones dominate and no vehicle can move without attracting deadly attention. Anyone from Ukraine injured in this zone faces a difficult extraction that is only partially being addressed with ground drones at the moment.

Yakov Gradinar works at Protez Foundation (which translates as Prosthetics Foundation), a non-profit clinic in Ukraine that supplies and fits prostheses (and which isn’t connected to Protez Hub). He says one person recently came in having been stuck on the front line wearing a tourniquet for 60 days. These devices stem blood loss in the short term, but create complications in the long term. They were simply never designed to be used for such lengthy periods. “Tourniquets are saving lives, but losing limbs,” says Gradinar. He estimates that as many as 95 per cent of these patients would be dead without the life-saving devices, but that they also lead to amputations much higher up the limb because the flesh below them rots once it is deprived of blood flow.

Payments for prosthetics

One of the reasons the prosthetics industry in Ukraine now extends far beyond Gradinar’s organisation comes down to money. Before Russia’s invasion in 2014, Ukraine had only a small number of prosthetics workshops dealing with cases from car accidents and medical amputations. The government would pay almost $700 per limb, which the individual could use as they saw fit. Since then, Kumka has been a leading figure in campaigning for greater investment and better legislation. Now, the Ukrainian government will pay $100,000 to soldiers for each lost limb, allowing them to go to any of the country’s increasingly numerous private clinics, or even abroad, and choose a limb that suits their needs. When limbs wear out after two to five years, they can receive the payment again. (It is a similar situation for civilians who lose a limb, albeit with less money available.) Over the coming years, this will cost the government “billions and billions and billions of dollars”, says Kumka.

This investment has catalysed the development of new clinics, labs and more. Former doctor Dima Gazda launched a company called Esper six years ago – before the full-scale invasion – to develop sensor technology that could be licensed to other companies for use with prostheses. But when the war ratcheted up, Gazda wondered whether this technology could be adapted so the company could create its own prosthesis for wounded soldiers. “The Ukrainian prosthetics market is definitely shaped by war. We as a company, also, we are shaped by war,” he says.

Since then, Esper has developed an advanced robotic prosthetic hand that has six motors controlled by sensors, allowing the wearer to move the hand faster or slower as needed. It is more dextrous and capable than most prosthetic hands. Around 60 per cent of its nearly 250 components are made in Ukraine. The Esper Hand is waterproof, can carry loads of up to 35 kilograms and is highly modular, so breakages can be easily repaired without having to ship it to a service centre. It is also 10 per cent lighter than a human hand – although Gazda says everyone who holds it thinks it is heavy, largely because they have never held a human hand in the same way.

Esper now employs 65 staff, and although its head office is in New York, most of them work in Ukraine. More than 600 soldiers have been fitted with at least one Esper Hand, and more than 50 of those are back on the front line. According to Gadza, one soldier called Volodymr, who lost both arms in a drone attack, has now been fitted with a pair of Esper Hands. He subsequently qualified on an elite sniper course, which he put down to the hands no longer having a pulse running through them, allowing him to be unnaturally still and precise. He also started to paint, and has held his first exhibition.

Another example of Ukraine’s burgeoning prosthetics industry is Gradinar’s Protez Foundation. Amputations higher up a limb generally lead to a harder rehab, and any prostheses with a knee, which are more difficult to learn to use, are more complex to build and fit, and therefore more expensive. We have long known that higher amputations also result in greater energy use when walking. Not only is Ukraine seeing huge demand for prosthetics care, but it is also seeing the most challenging cases imaginable.

Gradinar says that many new clinics take only the easier cases, but he prides himself on never saying no. He has fitted devices from Icelandic company Össur, which uses resin and glass fibre to mould a socket that fits the user closely, on shorter amputations than the company had ever previously seen done – pushing the boundaries of what was believed to be possible.

Other Ukrainian companies are emerging all the time. Kyiv-based Allbionics makes an electronic hand with 3D-printed construction, backed up by aluminium where needed, which runs for two days on a single charge. A smartphone app helps users learn to operate the device and track usage stats. Syla makes a prosthetic knee that uses AI to help the wearer control it intuitively and lets them walk at up to 10 kilometres an hour, with a battery life of 24 hours. There are also treatment clinics, such as Superhumans Center, which has three sites across Ukraine and more than 600 staff.

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