War amid a Pandemic: The Public Health Consequences of Russia’s Invasion of Ukraine
Michaela Simoneau and Humzah Khan. "War amid a Pandemic: The Public Health Consequences of Russia’s Invasion of Ukraine." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, April 22, 2022. Accessed February 13, 2023. https://healthsecurity.csis.org/articles/war-amid-a-pandemic-the-public-health-consequences-of-russia-s-invasion-of-ukraine/
Russia’s invasion has inflicted extreme physical and psychological trauma inside Ukraine. As a renewed Russian assault against Ukraine’s southeast begins, Ukrainians are likely to face persistent and intensifying public health challenges as a direct result of the conflict, compounding the impact of the Covid-19 pandemic. The security and safety of healthcare facilities, workers, and supply lines remain paramount concerns. Disruptions to surveillance and treatment programs risk an eruption of infectious disease outbreaks. Interruptions to chronic care and routine health services threaten to increase mortality and decrease life expectancy. The long-term mental health consequences of war-related trauma will be considerable. Over 5 million people have fled the country, while an estimated 7 million or more are internally displaced out of a pre-war population of 44 million. Fleeing populations have been met with a surge of support, but receiving health systems, both within and outside Ukraine, are under stress.
The disruption of health services has not been universal, and it has been difficult for authorities to assess the scale of destruction of health infrastructure, with damage only becoming apparent as fighting recedes. At the same time, civil society programs have proven resilient, and some areas of the country have managed to sustain routine services.
Now, as the war shifts geographically and strategically, there may be a possibility of resuming services around Kyiv, even as a concentrated onslaught in southeastern Ukraine wreaks new levels of destruction. Areas with functioning healthcare facilities will have to expand services to include internally displaced and mobile populations. While Ukrainian authorities and international players alike start to plan for reconstruction, they must contend with the diverse health impacts of the war across the country.
Q1: How has the invasion disrupted public health services in Ukraine?
A1: Ukraine’s post-Soviet health system has seen significant but fragile improvements thanks to recent reform efforts to combat corruption and improve public trust. In a matter of weeks, the Russian invasion has imperiled this progress, disrupting disease surveillance, immunization, and treatment programs already stressed by the Covid-19 pandemic. The impact of the disruptions on infectious and chronic disease programs is anticipated to be severe and durable.
Ukraine suffers from low immunization rates across several infectious diseases. Rampant misinformation and the politicization of vaccines have deepened an enduring legacy of distrust in the healthcare system and widespread existing vaccine hesitancy or outright refusal. The national Covid-19 vaccination rate—for one dose—is estimated to be 36 percent. Routine immunization rates for measles continue to be troublingly low and have been exacerbated by Covid-19-related disruptions—the national average is too low to prevent dangerous outbreaks and is less than 50 percent in regions seeing high levels of population displacement, including eastern Ukraine. In 2018, Ukraine saw Europe’s biggest measles outbreak since the vaccine became widely available. And an ongoing outbreak of vaccine-derived poliovirus makes the risk of increased polio transmission particularly alarming. Since October 2021, at least 22 cases of polio have been found in Ukrainian children, including two paralytic cases. A “catch-up” polio immunization campaign, introduced by the Ukrainian Ministry of Health and the World Health Organization (WHO) in early February 2022, has now been suspended following the invasion.
Insecurity and instability engendered by the invasion have impeded access to treatment programs for chronic and infectious diseases. Active conflict, disrupted supply lines, and unreliable communications restrict movement between care centers and access to medicines. Continuity of care is essential to treat noncommunicable diseases, which are a leading cause of premature death in Ukraine. Disruptions in treatment for chronic cardiovascular and respiratory diseases are likely to increase immediate-term mortality. Many Ukrainians, including 120,000 living with Type 1 diabetes, rely on regular doses of life-saving medicines to survive.
Ukrainian civil society organizations orchestrate the bulk of HIV and tuberculosis programs in Ukraine. These services have proven to be resilient—one month into the invasion, only 36 out of 403 antiretroviral treatment sites had suspended services entirely. The stakes are high, with decades of hard-earned progress to be lost. Ukraine has the second-highest burden of HIV/AIDS in Europe, with an estimated prevalence rate of 1 percent among Ukrainians between the ages of 15 and 49. An estimated 59,000 people on antiretroviral therapy are in areas affected by the war, and missed doses raise the risk of resistance. Multidrug-resistant tuberculosis (MDR-TB) is a serious concern as well—Ukraine has the fifth-highest number of confirmed cases of extensively drug-resistant tuberculosis in the world. The Covid-19 pandemic halved tuberculosis case detection in Ukraine in 2020, and as the invasion further degrades tuberculosis surveillance capacity, interruption to treatment regimens will likely result in increased spread of drug-resistant variants. Furthermore, prolonged Russian control of pieces of eastern Ukraine could disrupt the provision of services to the most vulnerable populations, as it did following the invasion of Crimea and the Donbas in 2014.
An estimated 80,000 Ukrainian women are expected to give birth within the next three months, but it is unclear how many of these women are in conflict zones or in areas with disrupted access to maternal care. Of the 70 specialized perinatal care centers in Ukraine, at least 15 have suspended operations. Women have been forced to give birth underground in bomb shelters and metro stations. Preliminary reporting by Ukrainian doctors indicates an increase in stress-related premature births.
Q2: What are the immediate needs of health systems in Ukraine? How are health organizations responding?
A2: Ukraine’s health system has demonstrated the capacity and fortitude to rise to wartime needs. Hospitals pivoted to trauma care, suspending routine surgeries and restructuring staff. A nationwide hotline created by the government for Covid-19 response was retooled as a general medical hotline. In Kharkiv, in eastern Ukraine, hospitals could see up to 60 to 80 wounded people per day. In the Kyiv region, urban hospitals were so close to the frontlines that the wounded were brought in straight from the battlefield, bypassing field hospitals. International health organizations have lauded the performance of Ukraine’s hospital system.
The fundamental priority for the health system is protection and security. An estimated 1,000 health facilities are near conflict areas or in contested territory. The WHO has verified at least 162 attacks on healthcare facilities since the start of the invasion, resulting in 73 deaths. The number of attacks continues to rise. Most of these strikes involve heavy weaponry, such as the March 9 bombing of a maternity hospital in Mariupol. Although Russia insists that its targets are legitimate, Russia has a history of deliberately destroying civilian infrastructure in besieged territories, as seen in Syria. Razing civilian infrastructure—particularly healthcare infrastructure—is a calculated form of subjugation intended to terrorize and catalyze population flight. General Alexander Dvornikov, an architect of Russia’s Syria campaign, is Russia’s top commander for the new phase of the invasion.
In terms of material needs, urgent priorities include surgical supplies, anesthetics, transfusion kits, intensive care unit equipment, and essential medicines. These supplies are difficult to deliver to territories under siege or heavy fighting. Supply lines are complicated by unreliable distributors and inaccessible stockpiles. In at least one incident, a warehouse storing tuberculosis treatments was bombed, forcing a reallocation of supplies from other regions. Many supply lines rely on rail transport, and although Russian forces have not systematically targeted railways, the April 8 airstrike on Kramatorsk train station may change risk assessments.
As their advances stalled, Russian forces increasingly turned to siege tactics, relying on blockades and artillery. Hospitals saw fewer gunshot wounds and more shrapnel wounds, which tend to require more intensive surgery and carry a higher risk of infection. Russia’s announced intent to focus on territories in the southeast may further disrupt material access.
Ukrainian civil society organizations are adapting quickly—and effectively—to meet evolving needs amid volatile levels of access. The Alliance for Public Health (APH), Ukraine’s largest health-focused nongovernmental organization (NGO), continues to provide at least limited services in most regions, including HIV prevention, antiretroviral therapy, opioid substitution therapy, and anti-tuberculosis drugs, as well as humanitarian goods. Between March 23 and April 6 alone, APH delivered 140 metric tons of medical supplies to hospitals across Ukraine. 100% LIFE, Ukraine’s largest organization of people living with HIV, is working with Ukraine’s health ministry to distribute an initial delivery of 18 million doses of antiretroviral medicine procured by the President’s Emergency Plan for AIDS Relief (PEPFAR), enough to cover a six-month supply for all people living with HIV on first-line treatment. Repurposed APH mobile clinics transport humanitarian aid into conflict zones, and armored vehicles originally procured to transport opioid substitution therapies have been used to evacuate vulnerable populations. Networks of volunteers coordinating over WhatsApp and Facebook move medicines from distribution centers to healthcare providers near the frontlines.Though services continue in blockaded and Russian-occupied Kherson, APH has been unable to deliver medicine replenishments. Access to besieged Mariupol continues to be impossible.
Larger, international NGOs (INGOs) have a small operational footprint in Ukraine but have expanded somewhat, with a focus on alleviating supply shortages. The International Committee of the Red Cross sent 140 additional staff to bolster operations in more than 10 different locations in Ukraine. Médecins Sans Frontières swapped out its HIV and tuberculosis teams and sent in trainers and supplies to prepare hospitals to respond to mass casualty incidents. The WHO is standing up an operations center in Poland to support humanitarian health delivery and surveillance operations in Ukraine. Coordination between INGOs and Ukraine’s ministry of health is ongoing.
Q3: What is the health outlook for Ukrainians fleeing the country? What is the capacity for surrounding countries to provide for their care?
A3: The scale and speed of population exodus from Ukraine has been shocking, surpassing five million refugees in just eight weeks, while displacing millions more internally. This mass movement has created a regional health security challenge, raising concerns of how to ensure adequate care while also mitigating the threat of wider disease transmission throughout the region.
Low vaccination rates among Ukrainians put them at increased risk of outbreaks of vaccine-preventable disease, particularly for refugees in crowded conditions or with limited access to clean water, where unsanitary conditions may allow pathogens to spread more easily. Neighboring countries have inconsistent vaccination coverage among their own populations, including for Covid-19, where pockets of transmission may occur. Many European countries are already experiencing an unrelated surge in Covid-19 infections from the Omicron sub-variant BA.2.
Mobile populations may have difficulty finding a consistent supply of drugs, as is critical to the proper management of chronic infections such as HIV and MDR-TB or for cancer care, particularly as many neighboring countries have insufficient supply of these expensive medicines.
The short- and long-term mental health effects of the conflict are also likely to be severe for the general population and healthcare workers in particular. Acute psychological trauma care is in short supply, and extreme stress can manifest physically, disrupting sleep, exacerbating cardiovascular and chronic respiratory diseases, and contributing to elevated levels of depression. Without access to sufficient care, the overwhelming number of child refugees are likely to suffer these psychological effects long into the future, including if and when they can return to Ukraine, impeding their ability to learn, work, and form relationships.
Many refugees are being housed in single-family homes in neighboring countries rather than camps, which reduces some of the risk of infectious disease transmission. But this decentralization makes performing needs assessments and connecting individuals with chronic care or infection prevention and control services more challenging, especially as visa-free travel throughout the European Union means that many refugees have already left their first country of arrival. In each new country, refugees have to navigate a complicated new system and language, where, absent sufficient support, a lack of understanding about where to find services may cause them to forgo routine care, and they may be unable to find services, especially mental healthcare and psychosocial support, in their native language. Resettled Ukrainian providers may be able to work under the supervision of certified host country doctors, but it will take time for them to secure their own qualifications.
National and local authorities and civil society organizations have led the health response to the refugee crisis across EU member states. INGOs have provided limited assistance to non-EU Moldova and concentrated their support in EU countries along the heaviest travel routes. Many INGOs have had to build programs from scratch, and even organizations with long-standing presence in Eastern Europe have faced legal, logistical, and financial challenges in shifting to support the acute care needs of the wider war, including permissions to secure or transport emergency medicines and supplies that are unregistered or unsubsidized outside of Ukraine.
While the strain on neighboring countries is beginning to show, as some cities run out of accommodations, absorptive capacity has thus far proven sufficient as national health systems have stepped up to support refugee populations. The European Union has, for the first time, employed a temporary protection directive to allow Ukrainian nationals the right to live, work, and access services—including medical services—in the European Union for at least one year, although support for third-country nationals has been inconsistent. Multilateral and bilateral resources have been mobilized as well: EU donations of €550 million, plus additional stockpiled medical supplies; U.S. assistance of over $1.4 billion, with the deployment of a U.S. Agency for International Development (USAID) Disaster Assistance Response Team (DART); commitments from multilateral development banks; and a WHO appeal of $12.5 million to support the health needs of Ukrainians in surrounding host countries.
As the most intense fighting shifts to southeastern Ukraine, there have been calls for mass civilian evacuations in an effort to minimize atrocities. With a number of those evacuees likely to leave Ukraine entirely, and with the Russian entrenchment in the southeast threatening a more extended, protracted conflict, many refugees may require care in the long term, and neighboring health systems may require additional support.
Q4: What might the reconstruction of the health system look like as the scope of the war narrows geographically?
A4: While negotiations between Ukrainian and Russian interlocuters continue, it remains difficult to predict how the war will evolve in the coming days, weeks, or months, and to assess exactly what the outcome might mean for the reconstruction of the Ukrainian health sector. As some parts of the country begin to reopen, efforts to initiate a recovery may begin.
The concentration of attacks on healthcare facilities to date has been startling. It has been difficult for authorities to assess the scale and cost of the damage to medical infrastructure in the areas with the heaviest fighting, but many health providers have proven resilient and some parts of the country have been able to continue operating largely as they did before the war. As the geographic and strategic scope of the conflict narrows, it is likely that some parts of Ukraine will see a resumption of services as security improves. Meanwhile, areas in the east subject to more intense conflict, especially conflict that employs siege tactics and heavy bombing, could experience greater destruction and require a longer reconstruction.
Along with physical infrastructure, it remains unclear what the health workforce capacity might look like as the war progresses. Some healthcare workers have been displaced with the rest of the population while others have joined the territorial defense force, but many have decided to stay in their roles or have since returned after helping family members flee, particularly to liberated areas including Kyiv. And as millions of people have been internally displaced or left the country, it is difficult to reliably account for how many people remain in major urban centers, how many refugees may eventually decide to return—or have already returned—and what the needs of this redistributed population may be. Addressing the widespread physical and psychological trauma from the war will be a tremendous burden requiring sustained investments in long-term population rehabilitation and recovery.
Ukrainian providers have the best sense of their communities’ needs and will be integral to recovery planning. The Ministry of Health initiated ambitious reforms to the healthcare system in 2016 and will play an important role in the reconstruction effort. Large infusions of external assistance will also be required to ensure that the health situation does not deteriorate further after the acute phase of the crisis, as the Ukrainian economy is expected to contract by 45 percent this year. There have been promising signals of international support: the International Monetary Fund has opened a new account to channel donor funds directly to Ukraine, and international financial institutions have made sizable commitments to immediate liquidity, early reconstruction, and long-term recovery projects, within Ukraine and regionally. EU commitment to reconstruction is already apparent, particularly with the establishment of a forward-looking Ukraine Solidarity Trust Fund.
As the course of the war and true costs of reconstruction become clearer, there must be a dose of caution: after two years of intensive global spending on the Covid-19 response, public health and foreign assistance budgets are strained, if not exhausted. Even with more creative sources of funds and the extraordinary response to the Ukrainian cause to date, spending fatigue will be a looming concern, particularly as the cost of reconstruction efforts is expected to number in the hundreds of billions of dollars. Concerted effort will be required to sustain global solidarity and meet the ambition required for durable public health recovery in Ukraine.
Michaela Simoneau is a research associate with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Humzah Khan is a program coordinator with the CSIS Global Health Policy Center.
The authors would like to thank Maclane Speer for additional research support and our many colleagues who provided guidance throughout the drafting process, including Katherine E. Bliss, Thomas R. Cullison, Marti Flacks, Fred Khosravi, Jacob Kurtzer, J. Stephen Morrison, Leonard Rubenstein, Paul Spiegel, Judyth Twigg, and Erol Yayboke.
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