As the war in Ukraine continues, ongoing damage to infrastructure, limited access to medical supplies and the shelling of hospitals has caused concern about the provision of medicines and healthcare – not only for people fleeing the conflict but also for those left behind.
Sadly, the conditions of war and conflict – the mass movement of people, overcrowding, lack of access to clean water and food compounded by the difficulty in accessing even the most basic medical care – are conditions in which infectious diseases thrive.
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Recent reports from Humans Right Watch (HRW) say Mariupol, a Ukrainian city under siege, has not had access to running water, electricity or heat since March 2, when Russian forces surrounded it as part of a larger offensive. Prior to the war, Mariupol had a population of almost half a million. The city sits at the mouth of the Kalmius River, which has dangerously high levels of pollution, according to the World Wildlife Fund, and relies on water treatment plants that run on electricity to provide clean water to residents.
Staff working with Doctors without Borders (Médecins sans Frontières, MSF) in Mariupol reported that they were collecting snow and rainwater as a means of getting clean water to drink, as the queues for free clean drinking water were “huge”. MSF also said many grocery shops were destroyed by Russian missiles, food was scarce, and it was not clear when and where basic provisions of bread would be delivered.
To make matters worse, safe exit routes for civilians out of the city are also being targeted.
According to international law, those responsible for armed conflict must protect objects indispensable to the survival of the civilian population. They need to ensure civilians’ access to adequate water and sanitation. Starvation as a method of warfare is prohibited.
A humanitarian health crisis
In areas under attack, people are having to shelter underground in cramped conditions, while the COVID-19 pandemic continues.
The shortage of food may also lead to individuals suffering from malnutrition, while limited access to clean water can help diseases spread.
Water that is safe and readily available is important for public health, whether it is used for drinking, domestic use, food production or recreational purposes. Contaminated water and poor sanitation are linked to the transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, typhoid, and polio.
Diarrhoea is the most widely known disease linked to contaminated food and water. Those who are already dehydrated and poorly nourished who then drink unclean water run the risk of contracting a variety of bacteria and viruses. These can cause diarrhoea, which will then further dehydrate them and make them lose vital electrolytes and sugars. Children and the elderly are particularly at risk of severe illness from dehydration and diarrhoea. Without access to timely hospital care, they could die.
Additionally, those living with chronic health conditions like diabetes and asthma could be deprived of life-saving medication such as insulin and inhalers as pharmacies are emptied or unable to remain open.
At the same time, the war poses risks for the tens of thousands of existing patients in the country needing vaccinations, medicines or continuity of care for other diseases.
Before the war, Ukraine had just embarked on a nationwide immunisation programme to vaccinate more than 100,000 children who were unprotected against polio. This came after a case of paralytic polio was found in an unvaccinated 17-month-old girl in the Rivne region in October 2021. Then, a couple of months later, a second case appeared in the Zakarpattya region. After this, 20 more cases of polio were detected in children, though not all suffered paralysis.
Health authorities planned to ramp up vaccination efforts against polio for children in the country and the campaign got under way at the start of February. But it was brought to a halt a few weeks later when the war began.
Polio, or poliomyelitis, is a disabling and life-threatening infectious disease caused by the poliovirus. The poliovirus spreads from person to person through faeces and saliva, most often through dirty hands, infected food, and water. Most people with polio will not have any symptoms and will fight off the infection without even realising they were infected. A small number of people will experience a flu-like illness 3 to 21 days after they are infected. In a small number of cases, the poliovirus attacks the nerves in the spine and base of the brain. This can cause paralysis, usually in the legs, that develops over hours or days. If the breathing muscles are affected, it can be life-threatening.
Polio remains a serious public health hazard in countries including Pakistan and Afghanistan but was thought to have been eradicated in Europe, so the outbreak in Ukraine last year caused grave concern. Every unvaccinated person can get polio, but children under the age of five are most susceptible to the poliovirus. That is why it is recommended that all children are fully vaccinated.
With the invasion and as people flee the fighting, it will be impossible for healthcare workers to safely locate and vaccinate those who need it.
The concern now, with a population on the move, is that polio could move with them, particularly as many people have no symptoms at all. Efforts must now be made to vaccinate children as they enter surrounding countries, to protect them and those who are giving them refuge.
Ukraine has one of the highest rates of tuberculosis (TB), particularly multidrug-resistant TB, in the world. There are an estimated 30,000 new TB cases annually in Ukraine, and the World Health Organization estimates the country has the fourth-highest TB incidence rate in Europe.
TB is an airborne bacterial infection caused by Mycobacterium tuberculosis. It can be acquired by breathing contaminated air droplets coughed or sneezed by a person nearby who has active tuberculosis. The most common form of infection is pulmonary TB, which affects the lungs. In some cases, the bacteria can also attack the lymphatic system, central nervous system, urogenital area, joints and bones.
Health experts have said that the war could lead to a “devastating” TB problem in Ukraine. MSF, which has been treating drug resistant-TB patients there for years, previously said the disease “poses a significant public health challenge”.
During the 2014 conflict in eastern Ukraine, doctors said the TB situation worsened as a result of the fighting and associated disruptions to treatment and access to vital medicines.
This month, the NGO StopTB Partnership, which has been working in Ukraine to ensure people with TB get access to the medicines they need, tweeted about the Russian invasion, saying: “It’s clear we expect many more cases of TB.”
Interruptions in treatment or diagnosis can drive up wider transmission as well as risk patients' lives… It's clear we expect many more cases of TB – @StopTBhttps://t.co/eAMwVKlHAY @Reuters_Health @Reuters #endTB #Ukraine
— Stop TB Partnership (@StopTB) March 1, 2022
As bombardments continue in parts of Ukraine, access to essential medicines is becoming more difficult so people with existing TB may find their symptoms worsening, but also as they seek shelter in crowded underground bunkers, they run the risk of passing TB on to those around them.
HIV also remains a public health issue in Ukraine. According to UNAIDS, an estimated 250,000 people (the second-highest number of any country in Eastern Europe and Central Asia) are currently living with HIV in Ukraine – 156,000 of whom are on antiretroviral therapy.
Many of those diagnosed with HIV/AIDS in Ukraine are intravenous drug users, but there has been an increase in the number of people testing positive who are not drug users. According to Winnie Byanyima, UNAIDS executive director, people living with HIV in Ukraine only have a few weeks’ worth of antiretroviral therapy remaining with them and, without continuous access, they are at risk of developing AIDS, a life-threatening condition. It is therefore vital that supplies of medicine for these people continue.
UNAIDS has called for the protection of health workers and the uninterrupted continuation of HIV and health services for all people, including people living with and affected by HIV.
As the war rages on, the people of Ukraine will be increasingly relying on international efforts to help with the emerging health crisis. Neighbouring countries will need to be prepared for the new health needs that arrive with the refugees. Efforts must be made to ensure those left behind have access to clean water, food, medicines and vaccinations and the international community must help those wanting to exit the country to do so through safe corridors.
The prevention of disease and the safeguarding of healthcare provisions must be a priority in any war; if we do not take action, we may see a rise in deadly illnesses such as TB, polio and AIDS.