Better Health For All

Russia invaded Ukraine on Feb 24^th 2022, this act has had a direct and devastating impact on the country’s healthcare system as a whole, compounding the impact of Covid-19. In any circumstance conflict tends to exacerbate existing public health concerns and place strain on all systems currently in place. Destruction of infrastructure, disruption of supply chains, displacement of people and changes in funding priorities all act to create difficulties. 

Threats to Health and Access to Healthcare

The leading cause of premature death in Ukraine in 2020 was non-communicable disease, with cardiovascular disease accounting for 66% of this burden.[1] Ukraine has the second highest number of newly diagnosed HIV cases in Europe and the fifth highest number of confirmed cases of extensively drug-resistant tuberculosis in the world. These conditions all require regular medications to prevent complications and routine monitoring for disease progression, access to primary healthcare is therefore vital. Ukraine has one of the highest maternal mortality rates in Europe and infant mortality is also relatively high compared to its neighbours.[2] The risk of communicable disease increases with conflict due to damaged infrastructure, limited access to safe water, over-crowding and unsanitary conditions.

The WHO verified 715 attacks on healthcare settings from 24^th Feb to 30^th Nov 2022 resulting in 129 reported injuries and 100 deaths of healthcare personnel and patients.[3] This damage alongside the shelling and occupation of territory has led to limited access to medical care for the population. The WHO and other NGO’s are working within Ukraine to support the delivery of healthcare and to rebuild the public health system.

A health needs assessment completed in September 2022 by the WHO reported that despite a deterioration in the level of access to health care, this is not universal and the system as a whole remained resilient.[4] Although more than half of people attempting to access primary care faced at least one barrier, only 4% were unable to get the care required. The biggest barrier reported was cost, followed by time constraints involved in getting to and from health facilities and limited transportation options. Cost is particularly a problem for women as they do not earn as much as men and also access more routine healthcare. Lack of availability of medication affected 25% of respondents and 19% reported that required treatments were unavailable to them. In areas under Russian control and close to active hostilities the difficulties accessing healthcare are far greater, 15% report no access at all to a family doctor. This population is also harder to reach so it is likely that the difficulties are higher than reported by those surveyed. Displaced individuals are also more likely to struggle to access family doctors and medication with one in five saying they have no access at all and 46% saying they have no access in person. Since this data was collected in September 2022 the situation has deteriorated in several areas and the winter temperatures have created an additional burden on the healthcare system.

Displacement

By October 2022 around 14.3 million exits from Ukraine had been registered, the speed and scale of this mass exodus makes it the largest and quickest displacement of people in Europe since World War 2.[5] The majority of these refugees are women and children and a significant number will carry a mental health burden from the trauma of the invasion and family separation.

The International Organization for Migration (IOM) reports that as of January 2023 5.4 million people are internally displaced within Ukraine, this is a reduction from around 7 million in August 2022.[6] 58% of these individuals have been displaced for 6 months or more yet the situation remains dynamic with 12% displaced in the last few weeks, nearly a third have been displaced more than once. This mass displacement of the population includes medical workers and staff responsible for the running of medical facilities, creating challenges for the maintenance of the healthcare system. Displacement of the population creates temporary overcrowding, particularly in collective centres, increasing the spread of communicable disease and making it more difficult to maintain care for those with chronic medical conditions. Displaced individuals are also less likely to have the clothes and kit required to keep warm through the winter months.

Mental Health

Ukraine is facing a mental health crisis, it is reported that nearly a quarter of the country’s population is at risk of developing a mental-health condition,[7] with 5.7 million school-aged children impacted directly.[8] A WHO public situation analysis has labelled mental health as one of the country’s most urgent public health risks. Evidence shows that the seven year war in the Eastern Donbas region significantly increased alcohol and substance misuse amongst veterans, displaced people and civilians.[9] There will be an increased healthcare need moving forwards for those suffering with substance misuse and other mental health disorders as a result of the conflict, exacerbated by the Covid-19 pandemic. A WHO supported roadmap on mental health and psychosocial support sets out priority actions for different sectors.[10] The aim is to build a mental health system in line with the best global practices to ensure provision of mental health services to individuals in Ukraine.

Winter

Winter in Ukraine is harsh, with temperatures dropping as low as –20°C. This extreme cold increases morbidity and mortality from both acute and chronic disease. Damaged buildings with inadequate insulation and attacks on the energy infrastructure have posed huge challenges this winter. Electricity cuts affect the whole country and are reported to last 8-12 hours per day.[11] There have been power cuts lasting up to three days, leaving homes and healthcare facilities without essential power. In desperation people are turning to alternative heating methods, which themselves pose health risks. The Ukrainian Government have set up ‘invincibility centres’ as warm spaces for people across the country, these also have mental health support workers. Despite this many continue to suffer in life threateningly cold conditions.

Vaccination

Prior to the invasion Ukraine had a vaccination programme but many people remain at risk from vaccine preventable diseases due to years of vaccine hesitancy and low coverage.[12] In 2018 Ukraine had Europe’s largest outbreak of measles since the vaccine became widely available and in 2021 there was an outbreak of vaccine-derived polio. Roll out of Covid vaccination was slow with only 39.7% of the population receiving one dose by February 2022.[13] Disruption to logistical chains and supply lines has made vaccination more difficult since the invasion, particularly in active conflict areas and for displaced people. For adult Covid vaccination (23%) and childhood vaccines (14%) of displaced people were unable to access a vaccine compared with 13% and 6% respectively of those who remained in their homes.[14] Mobile vaccination teams have been set up to try and address the issue but the numbers seeking vaccination remain low resulting in low levels of herd immunity. Many of those who have fled Ukraine have entered countries who also have low vaccination coverage, increasing the risk of outbreaks in overcrowded settings. The European Centre of Disease Prevention and Control recognised this soon after the invasion and recommend that all Ukrainian refugees without evidence of previous vaccination should be offered vaccinations with the priority being COVID-19, measles, and polio, ideally within 14 days of arrival in a host country.[15]

Technological and Industrial Emergencies

Ukraine has four operational nuclear power plants and many industrial chemical sites. These are potentially at risk from damage due to the conflict and could lead to public health emergencies of international concern should radio-nuclear or toxic chemicals be unintentionally released.[16] The WHO is working to increase preparedness and response capacities relating to these threats that could cause devastation should an incident occur.

Public Health System and Recovery

The Ukrainian public health system has been through a period of transformation and development since 2015. In 2019 Ukraine ranked 94^th of 195 countries in its ability to fight epidemics due to suboptimal capabilities to prevent, detect, and respond to significant infectious disease outbreaks.[17] In September 2022, despite the outbreak of war, Ukraine adopted the law “On The Public Health System” providing a framework for building a public health system in Ukraine.[18] A National Recovery Plan is being designed to restore the health system’s infrastructure and technical, professional, and staffing areas.The WHO, the European Union Delegation to Ukraine, the U.S. Agency for International Development (USAID) Mission in Ukraine, and the World Bank have prepared a joint discussion paper to complement Ukraine’s National Recovery Plan and describe a common vision of key priorities for rebuilding capacity over the next two years.[19] The international community are key in supporting the rebuilding of a system able to manage the demands of both pandemic and war recovery. Initially emergency actions are required to stabilise the system whilst longer term recovery and rebuilding are planned.

The Faculty of Public Health Global Health Committee is currently involved in WHO efforts to strengthen the global public health and emergency workforce. The WHO Roadmap system aims to define essential public health functions, strengthen competency based education and map and measure occupations delivering public health functions to ensure that a unified global response to future public health threats is possible.[20] This work is crucial to ensuring that the public health world is prepared to manage any future pandemic threats and vital to support countries, such as Ukraine, that require the most help in establishing efficient and capable public health systems.

[1] https://ncdalliance.org/news-events/news/ukraine-humanitarian-crisis-ensuring-protection-and-health-services-for-millions-of-people-living-with-chronic-diseases (accessed 12/02/2023)

[2] https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_47b-en.pdf (accessed 13/02/2023)

[3] https://www.who.int/publications/i/item/WHO-EURO-2022-6172-45937-67791 (accessed 23/01/23)

[4] https://www.who.int/europe/publications/i/item/WHO-EURO-2023-6904-46670-67870 (accessed 02/02/2023)

[5] https://euaa.europa.eu/news-events/joint-euaa-iom-and-oecd-report-provides-new-insights-displacement-and-within-ukraine  (accessed 17/01/2023)

[6] https://dtm.iom.int/reports/ukraine-internal-displacement-report-general-population-survey-round-12-16-23-january-2023 (accessed 12/02/2023)

[7] https://www.who.int/europe/news/item/28-11-2022-who-supports-ukrainian-health-care-system-as-winter-approaches (accessed 02/02/2023)

[8] https://reliefweb.int/report/ukraine/war-leaving-invisible-scars-ukrainians-under-secretary-general-tells-security-council-noting-one-fourth-population-will-develop-mental-health-condition (accessed 13/02/23)

[9] Patel SS, Sukhovii O, Zvinchuk O, Neylan JH, Erickson TB. Converging Impact of the Ongoing Conflict and COVID-19 Pandemic on Mental Health and Substance Use Disorders in Ukraine. J Emerg Manag. 2021;19(9):63-68. doi: 10.5055/jem.0603. PMID: 35281482; PMCID: PMC8916750.

[10] https://www.who.int/europe/news/item/28-11-2022-who-supports-ukrainian-health-care-system-as-winter-approaches (accessed 02/02/2023)

[11] https://www.savethechildren.org.uk/news/media-centre/press-releases/ukrainian-families-girm-struggle-for-winter-survival0 (accessed 13/02/23)

[12] Addressing vaccine inequities among Ukrainian refugees

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00366-8/fulltext

[13] https://ourworldindata.org/coronavirus/country/ukraine#what-share-of-the-population-has-received-at-least-one-dose-of-the-covid-19-vaccine (accessed 13/02/2023)

[14] https://www.who.int/europe/publications/i/item/WHO-EURO-2023-6904-46670-67870 (accessed 02/02/2023)

[15] https://www.ecdc.europa.eu/sites/default/files/documents/Operational-considerations-Russia-aggression-towards-Ukraine-final.pdf (accessed 13/02/2023)

[16] https://www.who.int/emergencies/situations/ukraine-emergency/technological-hazards-and-health-risks-in-ukraine (accessed 15/02/2023)

[17] https://eurohealthobservatory.who.int/news-room/articles/item/ukraine-country-snapshot-public-health-agencies-and-services-in-the-response-to-covid-19 (accessed 13/02/2023)

[18] https://www.tdmu.edu.ua/en/2022/09/11/verkhovna-rada-of-ukraine-adopted-the-law-on-the-public-health-system/ (accessed 13/02/2023)

[19] https://www.who.int/europe/publications/m/item/priorities-for-health-system-recovery-in-ukraine-joint-discussion-paper (accessed 13/02/2023)

[20] https://www.who.int/news-room/events/detail/2022/05/18/default-calendar/phewf_roadmap_launch (accessed 13/02/2023)

Faculty of Public Health Global Violence Prevention Special Interest Group

February 2023