At first glance, the hospital in the southwestern German city of Ulm looks much like any other. Patients sit in reception areas waiting to be called, doctors roam the halls looking at reports or their phones. Only the uniformed soldiers among the staff hint at military ties. Yet many meters beneath its busy wards lies a Cold War-era bunker that has suddenly become relevant again.
The underground medical facility was completed in 1979 amid the standoff between Moscow and the West. It was designed to let doctors continue treating injured soldiers in the event of a nuclear strike, and can house up to 2,000 people for 90 days. For the better part of three decades, the labyrinthine facility sat dormant. Now, the German military is considering reviving it.
Across the country, government bodies are surveying Germany’s healthcare systems and infrastructure to see how — or if — they would stand up in a defense scenario. Since Russia’s invasion of Ukraine, Germany has seen a surge in hybrid attacks, such as an attempted strike at an airport by an explosive-laden drone in Leipzig last month and various cyberattacks targeting hospitals. German Defense Minister Boris Pistorius has warned that Russia may be in a position to attack NATO territory by 2029. If that were to happen, Germany would be obligated to come to the alliance’s defense, and given its position in the heart of Europe, the country would likely become a key transit hub for soldiers — and a destination for their medical treatment.
In a report that gamed out potential scenarios should Russia invade NATO territory, the Bundeswehr calculated that as many as 1,000 wounded soldiers could arrive in Germany each day. As the country’s five military hospitals would quickly reach capacity — and the law requires that civilian hospitals help during wartime — the system would likely come under unprecedented strain, and could be forced to triage soldier and civilian care.
That, in turn, has focused attention on facilities like Ulm, which is a rare example of a military medical bunker in good enough shape to be brought back into use. But doing so would require spending millions of euros to modernize its decades-old ventilation and power systems, and would just be a drop in the bucket compared with what’s needed overall.
“Is our healthcare system prepared for this? The only answer is: No,” said Benedikt Friemert, chief medical director and commander of the Military Hospital hospital in Ulm. “What lies ahead of us is a marathon.”
Finding enough hospital beds is just part of the challenge. Germany’s leaders also need to reinforce medical supply chains and better coordinate the military and civilian hospital systems. Training is another concern: only a few hundred doctors in Germany are estimated to have experience handling war-related injuries. To improve these numbers, the Bundeswehr and the German Trauma Society DGU offer courses for civilian surgeons on treating mass-casualty events and wartime injuries.
When that collaboration was formalized in 2017, the world was very different, recalled Sascha Flohé, secretary general of DGU. “Back then, we still thought we were living in a safe world, apart from Islamist terrorism,” he said. “Nobody believed the security situation would change completely, or that we would be talking about collective-defense scenarios.” Now, demand is high, with some state governments booking out full weeks of classes, and spots are hard to come by. The most intensive programs, which utilize cadavers and anesthetized pigs, are only able to train between 50 and 100 surgeons a year.
Should war break out, the Bundeswehr’s medical forces would treat injured soldiers at the frontline before transporting them to Germany, where state authorities would send them on to civilian hospitals. That strategy was tested in March, when the military conducted its largest medical exercise in decades, simulating an attack on Lithuania and moving soldiers to hospitals in Berlin and parts of Brandenburg. The exercise went smoothly, Flohé said, but more practice is needed to ensure that the two systems can communicate effectively during an emergency.
The Health Security Act, which was expected to reach parliament this fall, is intended to do this by creating a real-time overview of beds, medicines and staff with war-relevant skills. But for now, it’s all piecemeal, making it difficult to know where specialists are available or if doctors and nurses who also volunteer for aid organizations or serve as reservists are being properly accounted for.
“At the moment we have these islands, the hospitals,” said Maria-Lena Weiss, a lawmaker with the Christian Democratic Union and a member of the Bundestag’s health committee. “Now it’s about connecting them to the overall system.”
Without government guidance, some companies have started to do their own calculations. Biotech company CSL found that as many as 20% of its employees in some areas could be called away as reservists or volunteers. Annegret Wittich-Höffer, the company’s head of Germany, Austria and Switzerland, also noted that truck drivers, many of whom come from Eastern Europe, could be called up by their home countries. The company is also figuring out how to continue producing critical medicines if demand suddenly soars. To make a drug used in trauma surgeries, CSL must first collect and process plasma donations. That, however, can take up to a year and the limited shelf-life of the finished products make it difficult to create strategic reserves.
“Without blood-clotting factors, things get really tight,” said Wittich-Höffer. Should wounded soldiers start coming into Germany for care at the scale that the Bundeswehr has laid out, she said, “nobody will be prepared — neither we nor our competitors.”
Hospitals, especially larger ones, are also seeking advice on resilience and emergency planning, said Michael Ey, a partner at PwC who specializes in healthcare. In addition to weighing physical protections such as bullet-resistant glass and protective barriers against drones, some are assessing how long medicines and surgical supplies would last in a crisis. “Our economy has largely been built around just-in-time supply chains. That may be good for efficiency and minimizing tied-up capital, but that’s not how resilience is built,” Ey said, arguing Germany needs decentralized stockpiles of masks, medicines and vaccines stored across multiple locations.
Russia’s 2022 invasion of Ukraine was a real-world example of how medical systems adapt to war. Kateryna Bielka, an anesthesiologist and professor in Kyiv, recalls how staff at her hospital improvised, moving patients to lower floors that were supposedly safer, barricading windows to protect against flying glass during air strikes and converting underground spaces such as changing or technical rooms into treatment areas. When Russia began attacking energy infrastructure, hospitals began diversifying their electricity sources, bringing in generators and solar panels. One of the biggest challenges throughout, she said, was dealing with uncertainty: “the high level of stress, lack of information, lack of understanding.”
Just across from the Military Hospital, the Ulm University Hospital is also preparing for worst-case scenarios. It has a dedicated crisis and resilience team that stages terror drills and is currently looking into whether the building’s underground parking garage could be converted into a long-term emergency shelter in the event of an attack.
Udo Kaisers, the university hospital’s chief medical officer, said that many German buildings were constructed at a time when resilience and crisis preparedness weren’t top priorities. And financing and grants generally cover only the most cost-effective construction or renovation measures, not the most durable ones.
He also worries about vulnerabilities in the medical supply chain. Germany, like much of Europe, is dependent on China for many critical ingredients needed in antibiotics and painkillers. While his hospital is increasing stocks of some essential drugs, budgetary concerns make this complicated. Hospitals in Germany are advised to stock only six weeks of intensive-care medicines.
There is broad political support for updating the country’s legal framework in order to keep the healthcare system functioning in a defense or wartime scenario. The previous government was working on this, but failed to complete it before collapsing in 2024. The current coalition was expected to present a draft of the Health Security Act this summer, but postponed it to fall — and it’s unclear whether that target will be reached.
Despite all the uncertainty, keeping hospitals functioning during turbulent times is at the heart of everything, said Kaisers.
“The healthcare system is central to the functioning of society,” he said. “Social cohesion, and ultimately also public morale, depend significantly on whether we can uphold the promise of healthcare for people.”
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