Kost Elisevich

The road to a better health care system for Ukraine will be best accomplished with the removal of Russian forces from its designated sovereign territory. But first the threat of winter must be overcome. Well into its eleventh month, Russia’s invasion of Ukraine began a new chapter with the realization that its military campaign has floundered and winter has further hampered its progress. A shift in strategy now has concentrated upon terrorizing the entire nation by undermining its civilian infrastructure and threatening its means of survival in the cold of winter. For a nation entrenched in its desire to emerge ultimately with its sovereignty intact and its language and culture preserved, Ukraine faces a bitter struggle, seemingly to the end.

The past year’s conflict has left its mark on Ukraine. As of January 9, 2023, 6,952 civilians have been killed, including 431 children with an additional 11,144  civilians and 810 children injured. Almost a third of the population has been displaced internally or across neighboring borders. Housing infrastructure damage has well exceeded the September 2022 estimate of $50.5B (USD), as it has with transportation that was set previously at $35.3B. Similarly, a comparatively greater destructive focus has been placed upon industry and utilities in the past four months so that the September estimate of $41.3B will be dwarfed. Of particular concern has been the injury to medical infrastructure. More than 1,100 facilities have been damaged with 144 destroyed, compromising care not only for the civilian and non-civilian physical injuries of war but for those with ongoing medical and mental health concerns. Russian war crimes relating to mass executions, rape, forced prostitution, child abduction, indiscriminate shelling and other atrocities, now numbering over 58,000 incidences according to the Attorney General of Ukraine, add to the psychological trauma inflicted upon the nation. Independent reporting has verified more than 600 instances of war crimes, some including massacres of hundreds of civilians which, in sum, total thousands of individual crimes.

The winter brings its own grief with mean temperatures from December through March of -4.8°C (23.4°F) to 2°C (35.6°F); the coldest month being January with temperatures in Kyiv dropping as low as -13.5°C (8°F) at times. Repeated Russian targeting of energy infrastructure has resulted in reductions by 50% of overall power-generation capability with over 40% of energy facilities damaged to date. A dynamic process of destruction and restoration is in play leaving, at times, as many as 10,700,000 households without power for extended periods. With upwards of 7,000,000 people internally displaced, sheltering itself has become a problem for lack of housing leading to crowding in fewer places.

Many aspects of health, acute and chronic, are affected by the Russian invasion of Ukraine. Outright war began in the winter of 2022 and has entered another winter. There are two health-related conditions that typically come to the fore in the winter months and, particularly in the circumstances of war, can be made worse. These are transmissible respiratory diseases and mental health.

Spread of communicable disease is worsened by forced sheltering conditions attributed to the intentional destruction of housing, utilities and energy infrastructure. Compounding the concern has been a lack of suitable immunization programs because of obstacles to distribution, and the lack of medical facilities and personnel. Before the invasion, 20% of Ukrainian children were not fully vaccinated against measles and 13% lacked protection against poliovirus. The latter was detected in more than 20 Ukrainian children in 2021. A national vaccination program begun in response was interrupted by the Russian invasion. The incidence of tuberculosis has been rising, affecting children, in particular. An estimated incidence of 94 cases per 10⁵ people was determined but about a quarter of the cases remained undetectable.

In the two-year period from January 3, 2020 to January 13, 2023, 5,354,738 cases of COVID-19 were confirmed with 110,920 deaths. By late February 2022, 31,668,577 vaccine doses had been administered, although fewer than 35% of the general population had received their second dose. A new variant, BA.5.2.6, a derivative of the Omicron variant BA.5, appears resistant to standard COVID treatment and has spiked in Ukraine accounting for as much as 10% of cases at present. Unfortunately, disease surveillance has been disrupted; moreover, the Russians are not bothering with COVID testing in the occupied areas of Ukraine. Demonstrably poor logistical planning by the Russian military and inept governance within separatist regions of eastern Ukraine may give rise to epicenters for the outbreak of new resistant strains where laboratory infrastructure is compromised or absent.

To worsen the situation, anti-vaccine sentiment, enhanced by widespread disinformation, has resulted in a reduction in vaccinations within neighboring countries where refugees have now entered en masse. The European Centre of Disease Prevention and Control has recommended that all Ukrainian refugees without proof of vaccination be given vaccine coverage for COVID-19, measles and polio, preferably within two weeks of arrival.

The incidence of influenza and pneumonia had begun to rise sharply in 2019 but appeared stalled by the COVID-19 pandemic. It will be difficult to predict under the current circumstances of overcrowding and reduced sanitation. Only 164,939 Ukrainians had been vaccinated by late February 2022, a not-too-surprising result given a recent study in which 72.9% of 1,852 Ukrainians reported having never been vaccinated for influenza. Tobacco smoking in Ukraine has brought about 130,000 deaths annually and enhances an unneeded susceptibility toward influenza-induced pneumonia. The tobacco habit has declined over the past two decades although still 31% of Ukrainians remain daily smokers. A new tobacco control law was signed by President Zelensky in January 2022 but implementation has been threatened again by the war and anxiety related to the conflict can only worsen the habit.

The United States Centers for Disease Control and Prevention (CDC), through its Global Health Security Agenda (GHSA), has engaged with Ukraine with its efforts to prevent, detect and respond to infectious disease outbreaks. These include disease surveillance, laboratory capabilities, biosafety and biosecurity, immunization policies and personnel development. Central to the surveillance effort has been the creation of a Field Epidemiology Training Program (FETP). Achieving the competencies outlined by the GHSA and FETP must be expedited despite the disruption of the war as disease spread pays no attention to human conflict.

Although the current open warfare, beginning with the invasion of Ukraine on February 24, 2022, has become recognized as the most significant chapter in the conflict, hostilities actually began in earnest in 2014 when Russian military operatives infiltrated eastern Ukraine and became entrenched with separatists in the region. By 2016, 1.5M internally displaced persons (IDPs) were suffering the consequences. A nation-wide survey examining the mental health of 2,203 IDPs identified a prevalence for post-traumatic stress disorder (PTSD) of 32%, for depression of 22% and for anxiety of 18%. Sadly, 74% who likely required mental health and psychosocial support never received it, demonstrating a substantial treatment gap that can only worsen under the current circumstances.

The winter, of course, brings its own seasonal affective disorder that impacts those vulnerable with a prior history of mental disorder. The same holds true for another aspect of mental health as it pertains to eastern Europe, alcohol use disorder. In the first large population study of alcohol use in Ukraine, published in 2005, the rate of heavy users varied a good deal among regions but averaged 22% (38.7% male, 8.5% female) across the country. The highest rate was in southeast Ukraine which was heavily populated by Russian migrants of the Soviet era. The rate, in fact, was over 10% higher than any other region. A cross-sectional study of 32 regional mental health facilities in 2022 showed the greatest reductions in hospital admissions occurred in those same regions currently occupied by Russian forces. Perhaps as a consequence, mental health facilities outside the occupied regions saw the highest increases in admissions related to ‘war trauma.’ Some regions saw as much as a 30% increase.  Equally concerning, has been a 9.1% reduction in medical staff, particularly clinical psychologists, again largely in the eastern regions.

A 2019 published meta-analysis of mental disorders (i.e., depression, anxiety, bipolar disorder, PTSD, schizophrenia) among residents in global conflict zones demonstrated a 22.1% increase in prevalence. The lack of sufficient attention given to mental health within eastern Ukraine, in particular, should raise concerns over the current situation of Russian occupation as the occupiers appear insensitive to the matter. A mental health Gap Action Program Humanitarian Intervention Guide (mhGAP-HIG) has been designed by the World Health Organization (WHO) and the United Nations High Commissioner for Refugees (UNHCR) to provide some foundation for managing such situations. Remote access psychological support and consultation through telemedicine services in non-occupied regions of Ukraine and neighboring countries would offer needed care in the absence of the standard inpatient care delivered. Likewise, the WHO has provided a guide entitled, “Essential Skills in Times of Stress” which is integrated into their “BetterMe” mobile app. Stress management methods thus become much more accessible in a mobile format.

Another often unrealized impact of mental stress brought on by conflict is its association with cognitive decline and the incidence of dementia in the longer term. A recent study by Sulkava et al (2022) of adults aged 25 to 74 years identified a 17% to 24% increased risk of all-cause dementia occurs with exposure to significant stress leading to depression and/or anxiety (doi:10.1001/jamanetworkopen.2022.47115). A greater concern may be the effect of the stress upon children exposed to continuous adversity, as witnesses to atrocities and the experience of absent adult support. Disrupted brain development, cognitive and emotional impairment with increases in psychopathology including PTSD, behavioral dysregulation, depression and suicidal thoughts or behaviors are the outcome. A study of children in the Middle East exposed to the toxic stresses of war, including sexual exploitation and abduction, by Samara et al (2020) has detailed many of the same features and conditions found in the conflict in Ukraine – lack of qualified personnel, financial concerns, limited community awareness, social stigma, disrupted transportation and limited triage capability. Their recommendations call for psychosocial intervention focused upon child resilience and coping strategies, parental support and education. Improved mental health resources should include training of paraprofessionals and frontline professionals, mobile mental health resources and digital technologies. Building and development plans for health care must include integrated mental health services.

Recognizing the need for mental health support in the early stages of the current national crisis and anticipating the need to avert more serious later psychiatric consequences, the First Lady of Ukraine, Olena Zelenska, with the support of the WHO Regional Director for Europe, Hans Kluge, and Ukraine’s Minister of Health, Victor Lyashko, launched the National Program of Mental Health and Psychosocial Support in Ukraine in May 2022. The program began with an audit of the existing system of care and will establish a service model to be vetted with a pilot project. It is intended to deal with the breadth of society, from childhood to the elderly, military personnel, those who have lost loved ones, their homes and the futures they had anticipated for themselves. Expertise and protocols developed by the U.S. military will be shared for rapid implementation. The system will be, in part, unique to Ukraine itself based upon its own experiences but will include international elements ideal to the circumstances. The intent will be to see “that psychological help becomes as common and accessible as regular medical help, and heals Ukrainians’ psychological wounds of the war.”

Another point to be made here concerns the impact of the war in Ukraine upon the mental health of people living in the neighboring nations of eastern and central Europe. Riad et al (2022) undertook an assessment of the mental health of adolescents and young adults in central Europe, specifically university students in the Czech Republic. Moderate to severe levels of anxiety and depression were noted in 34% and 40.7% of 591 participants, respectively. Higher scores were noted among females, those more avidly pursuing the news and those with higher frequency of social media use. Psychological disorders arising from these experiences will be cause for greater vigilance elsewhere.

Notable strides have been made in recent years to correct the health care problems of the past but much remains, particularly in the face of the setbacks suffered in the present conflict. On the positive side, expedited and focused plans of not only rebuilding but modernizing the delivery of health care within the country will afford Ukraine the creation of a model that integrates ideal practices identified by other nations with its own assessment of experiences. Some of this was underway prior to the invasion and some quickened by more urgent needs brought about by the conflict.

The winter is at hand now and the uncertainty of war persists. The present concerns must be attended. Air defense has become an important element of health care in preventing further damage to energy infrastructure and to residential areas. Provision of temporary modular housing will allay some of the fears regarding the spread of infectious disease and provide comfort to many who are destitute. Careful surveillance of disease and demographic trends will provide needed data to predict the spread of disease or identify a prominent regional disease pattern.

A decisive end to the war is needed with the reconstitution of Ukraine as it was prior to 2014 so that it may resume its path toward a unified health care plan that will afford its people the sort of welfare it has fought for.

Copyright @Kost Elisevich, MD, PhD, 2023. All rights reserved. Any illegal reproduction of this content will result in immediate legal action.