As of October 2022, more than six thousand people had been confirmed killed and about ten thousand injured in Russia’s invasion of and continuing war in Ukraine, according to the Office of the High Commissioner for Human Rights (OHCR). Overall numbers of deaths and injuries are likely higher, as gathering accurate information is challenging in conflict areas. In September 2022, just a month earlier, the World Health Organization (WHO) published an updated report on the growing health crisis as a result of the war. According to the report, 12.1 million people in Ukraine are in need of health care to treat acute conditions (including war-related injuries) and chronic health problems in a health care system that has been crippled by war and is lacking in medical equipment, supplies, and staffing. The country is also facing a constant threat from direct attacks by Russia’s military, with six million people located in the direct pathway of ground military operations or missile strikes.
Additionally, an estimated 7.4 million refugees from Ukraine are dispersed across Europe, placing immense burden on international relief programs and those countries receiving and hosting refugees.
In the new book From Horror to Hope: Recognizing and Preventing the Health Impacts of War (Oxford University Press 2022), public health physician and epidemiologist Barry Levy presents evidence-based, comprehensive information about the impacts of war on health, human rights, and the environment. The message is simple: “War causes death, disability, and disease. It damages the health-supporting infrastructure, displaces populations, violates human rights, and diverts resources. And it subsequently leads to more violence.” The WHO considers protecting civilians and health-care infrastructure a key priority. Civilian deaths must be prevented and health workers must be protected so they can continue to save lives. Health systems and facilities must be secured so that they remain functional, safe, and accessible to all who need essential medical services. Lifesaving medical supplies (e.g., oxygen) must reach those who need them.
Levy and another researcher, Jennifer Leaning, have already weighed in on the devastation of health and human rights in Ukraine caused by Russia’s invasion—and warned that “time is running out.” Their assessment follows established scientific knowledge (theory and empirical research) that connects various aspects of war and military conflict with population health impacts. Sadly, opportunities for studying this aspect of human societies are ample. War and armed conflict are so prevalent in contemporary times (a fact missed on many) that for decades medical experts and scientists have been studying the epidemiology of war-related morbidity and mortality, developing assessments of civilian suffering and health-care performance in wartime and defining needs and delivery of humanitarian response. Human rights and international legal dimensions of armed conflicts have also been hotly debated in medical and scientific circles. The knowledge that has emerged provides a framework for assessing the impacts of war in real time, as is currently being done with Russia’s war in Ukraine. One example is a recent study by Ubydul Haque and colleagues in which they use data on Russian military attacks to track the human toll and damage to the health infrastructure during the first 162 days of the war.
In my brief review of Ukraine’s health crisis below (per WHO and other sources), I will illustrate both the kinds of information typically gathered to assess war impacts on health systems and population health, as well as the gravity of the current situation.
A Crippled Health System
Ukraine’s health system has been significantly crippled in this war. Health facilities located in conflict areas have experienced damage and severe disruptions. As many as 631 attacks on Ukraine’s health infrastructure have by now been confirmed by WHO’s Surveillance System for Attacks on Health Care (SSA). However, the actual number of such attacks is likely to be much higher. Further data in SSA describe specific impacts on health-care facilities, patients, medical transport, supplies, and health-care workers and warehouses. Many Ukrainian health-care workers have been displaced or are unable to work. Consequently, there is limited or no access to medicines, hospitals, and health-care personnel in some areas.
In March 2022, international health agencies issued a joint statement calling for an immediate stop of all attacks on health care in Ukraine. Killing and causing serious injuries to patients and health workers is horrific and heartbreaking. Destroying health infrastructure results in forcing people to forgo essential health-care services and treatments. The most vulnerable are children, pregnant women, and health-care workers—who risk their own lives to save others. The WHO considers these attacks on vulnerable groups reprehensible and cruel.
Population Health Needs
Although the number of deaths and injuries resulting directly from military operations is increasing, it is the noncommunicable diseases that are currently the leading causes of illness and death in Ukraine. As much as 84 percent of all morbidity is due to cardiovascular disease, diabetes, cancer, chronic respiratory disease, and mental disorders. Additionally, Ukraine has the highest rates of chronic infectious diseases (e.g., HIV, tuberculosis) in Europe. This indicates a tremendous need for continuous chronic care—and highlights the risks of not having that care available.
While shortages of medical supplies place limits on the provision of basic care, interruptions in prevention, diagnostic and treatment services increase the rate of harmful disease outcomes and put the most vulnerable populations at increased risk of severe illness and death. Reports on the precarious situation of Ukrainian children battling cancer went viral early in the war. Hundreds of these children have had to flee their homes and hospital beds and travel in challenging conditions to foreign places in search of safety and treatment.
Outbreaks of respiratory and diarrheal diseases also tend to be high in conflict areas due to disruptions in sanitation and other infrastructure. COVID-19 is especially threatening in Ukraine because vaccination uptake remains low, especially in vulnerable populations, and due to disruption in testing and treatment. Furthermore, there is a high concern about vaccine-preventable disease outbreaks, such as measles and polio, given low rates of routine vaccination coverage among Ukrainian children. Antimicrobial resistance also often increases during the war, exacerbating health problems. Another risk during the war is malnutrition, which is of particular concern for babies and young children. Lack of proper nutrition hinders physical and cognitive development as well as health problems in later life. Russian military forces have deliberately targeted and significantly damaged agriculture, food warehouses, and distribution systems, restricting access to food. The war in Ukraine is already causing a massive malnutrition crisis worldwide.
Furthermore, the psychological impact of war trauma on Ukrainians is expected to be severe, though recent data are sparse. Ekaterina Botchkovar and colleagues called attention to war trauma and mental health in Ukraine in the previous issue of Footnotes. An earlier study in Ukraine during Russia’s 2014 invasion showed that Ukrainians who were internally displaced by the War in Donbas were far more likely to report significant exposure to war trauma and exhibit symptoms of post-traumatic stress (PTSD) than those who did not have to relocate. Notably, those suffering from PTSD almost never sought psychological help, as has been documented in other research. The psychological impact of the war and the need for mental health and psychosocial support both on the ground in Ukraine and among Ukrainian refugees (see below) is expected to be high and continue to grow. Levy and Leaning identify a range of underlying factors contributing to the psychological impacts of war: trauma, family separation, deaths of loved ones, loss of employment and education, forced displacement, and witnessing of atrocities. Demographic shifts are also expected due to loss of men, displacement of women, and growth in single-head households, which will create further disadvantage.
International Response
International health and relief agencies have mobilized to deliver critical, multisectorial assistance to Ukraine, including access to emergency and essential health services and priority prevention programs, as well as resources for long-term health system recovery and growth. It is estimated that Ukraine needs $100 million to address its health needs, and the cost for refugee-receiving and hosting countries is estimated at $67.5 million. International response priorities include coordination of the health response (e.g., Emergency Medical Teams, or EMTs), strengthening health information management; provision of immediate emergency care, essential medical supplies, and equipment; and allocation of essential health care for priority causes of illness and death. Supply lines for a broad range of medical supplies—from trauma/surgery supplies to essential medications and rehabilitation equipment—have been established. There are significant needs for trauma and emergency care and lifesaving treatments, oxygen supplies, infrastructural hospital equipment (e.g., generators), and ambulances. EMTs are working with medical teams on the ground to provide trauma care, rehabilitation, mobile health interventions, patient transfer and medical evacuation, trainings, as well as the delivery of medicines, equipment, and supplies. International agencies have also been supporting medical evacuations from Ukraine to other countries, as well population health assessments and disease surveillance systems to detect outbreaks. International relief agencies have also constructed refugee health assistance out of neighboring countries (e.g., Poland) and coordinated interagency and intercountry refugee health assistance operations.
Refugee Health
As of September 2022, more than 7.4 million people have fled the war and violence in Ukraine. Of the refugee-receiving and hosting countries, Poland has accepted the largest number of Ukrainians—more than 1.3 million. The refugees have faced overcrowded conditions during transit and on arrival at transit sites or shelters. Poor access to water, sanitation, and hygiene, and low vaccination rates have raised concerns over the risk of spread of infectious diseases.
The immediate health priorities in receiving countries have included access to emergency medical care, medications, and mental health and psychosocial resources, and identifying and helping vulnerable groups—mothers and children, HIV and tuberculosis patients, and patients with noncommunicable diseases. Additionally, the increased transmission of COVID-19 and other seasonal respiratory infections and vaccine-preventable diseases in refugee populations needs to be addressed.
The International Organization for Migration (IOM) has mobilized resources to boost capacity in Ukraine and across Europe to respond to the Ukrainian refugee crisis. In these efforts, the safety and protection of refugees and their ability to access assistance at their destinations are the top priorities. Additional priorities include screening individuals and assessing them for potential short- and long-term vulnerabilities, including for human trafficking, child protection, health and mental health, as well as assessing special needs populations, such as elderly, wounded, or sick people. International organizations are also developing interventions focused on delivering quality health services to refugees and migrants from Ukraine in refugee-receiving and hosting countries (e.g., online training programs).
Environmental and Technological Hazards and Health Risks in Ukraine
Russian military operations have also caused massive environmental devastation and technological hazards. Explosions and fires pollute the air with toxic elements and threaten the integrity of nuclear reactors. The risks of radio-nuclear hazards are of critical concern. Ukrainian authorities are providing daily updates to the International Atomic and Energy Agency (IAEA) on the situation of the nuclear installations. In addition, deliberate destruction by Russian forces of industrial facilities is causing water and soil contamination. There is also a growing threat of nuclear weapons being used by Russians.
Human Rights Abuses
The war has also led to many documented violations of human rights and international humanitarian law. Russian forces have targeted civilian infrastructure and populations (e.g., health-care facilities, schools, neighborhoods), executed unarmed civilians, raped women, and deported 1.9 million Ukrainian civilians to Russia, including 307,000 children. As early as February 2022, the International Criminal Court (ICC) announced its jurisdiction over potential war crimes in Ukraine. Thirty-nine signatory states submitted formal requests (“referrals”) to the ICC to open an investigation into human rights abuse in Ukraine, and the Government of Ukraine accepted the ICC jurisdiction. However, prosecution of the crimes and resolution is likely to take years, and the outcome is unclear.
Conclusion
The depth of the Ukrainian health and health-care crisis cannot be overstated. The war has brought devastation on multiple fronts, and the worst may be still to come. Despite international humanitarian efforts to protect civilians and address the health needs of Ukrainian people and refugees, much remains to be done. Further systematic (scientific) assessments are also needed to guide interventions targeting short- and long-term health goals for Ukraine.
Conflict and war are recognized as one of the social determinants of health and drivers of health inequities. Per the WHO: “the social determinants of health are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” These forces, which include economic policies and systems, development agendas, social norms, social policies, and political systems, have already been severely disrupted in Ukraine by the war. Good health and well-being, which are considered human rights, have been shattered in the war, with many Ukrainians having already lost their lives or been injured or displaced by the war, and millions experiencing declines in health, lack of health maintenance, and stress and trauma due to the constant threat to their lives and well-being.
The social determinants of health in conflict settings also reinforce health disparities and push vulnerable populations even further into the margin. The poor, children, the elderly, and women in Ukraine have already been shown to be especially vulnerable in this war. Continuation of this armed conflict will further exacerbate the health and health-care crisis in Ukraine, and the health effects and trauma will be long-lasting and likely multigenerational.
Any opinions expressed in the articles in this publication are those of the author and not the American Sociological Association.
