Professor of public health, Andrew Lee, speaks to Health Europa about the devastating impact of the war in Ukraine on population health.
It is hard to imagine how affected countries will recover from the impact of Russia’s invasion of Ukraine, especially when health systems are already buckling under the pressure of the COVID-19 pandemic. The war in Ukraine has placed over 15 million people in the country in desperate need of humanitarian aid.
As huge numbers of people seek help both at home and beyond their borders, what will be the impact on both domestic and neighbouring health infrastructures and the provision of long-term care? To discuss this, Health Europa reached out to Andrew Lee who is a professor of public health at the University of Sheffield’s School of Health and Related Research.
You have said that ‘war affects people’s health beyond bullets and bombs’. What are some of the potential long-term impacts of the conflict on the Ukrainian population?
The long-term consequences of the war in Ukraine will depend on what each affected individual’s experience of war is. Some will have experienced a mixture of trauma, not just physical harm, but also potentially mental, psychosocial, sexual harm, and/or economic loss. The severity of each trauma experienced will again be varied. Much will also depend on whether they have been displaced from their homes, or abroad, and the traumas they will have experienced in that process.
The longer the war in Ukraine drags on, the greater the trauma the population will have experienced. There is also quite a bit of literature on survivors’ guilt, and post-traumatic stress disorders related to conflict.
We should also not forget the significant impact this will have on a generation of Ukrainian children, at a vulnerable and formative period of their development – they will undoubtedly be experiencing disruptions to their education and learning opportunities but may also be mentally scarred by the loss of loved ones, seeing the horrors of war, or the loss of home and country in the exodus.
When the war ends, there will also be the challenge of reintroducing battle-hardened veterans back into the normality of civilian life. This transition and demobilisation process can be quite difficult. Indeed, we know veterans often struggle to reintegrate and return to normality. Suicides, substance misuse, and domestic violence are unfortunately more likely in veterans. Injured and disabled veterans will also have long-term rehabilitation needs.
How could large population displacement impact health systems and infrastructure in other countries?
Firstly, these large population displacements could present considerable pressure on health systems in receiving countries. This includes increased demand for health services at all levels (from primary care to specialist hospital care and mental health services). Bear in mind often the host countries’ health systems were probably already operating under significant stress pre-crisis, as they emerged from the COVID-19 pandemic with backlogs in care to address. As such, adding in tens of thousands more patients for them to deal with (or in the case of Poland, more than three million) will compound matters. This could lead to longer waiting times for specialist services, reducing the accessibility of care for both the host and refugee populations. Initially, the demand will be for minor ailments and emergency care, but over time there will be demand for chronic disease management (such as diabetes, chronic lung conditions, etc).
For the host country, there will be concerns about potential infectious disease risks, so they may try to introduce health screening, disease surveillance, and immunisations for these diseases. Again, this requires both manpower and healthcare resources to deliver. If significant outbreaks were emerging, this may not just be limited to the refugee population but also spill over to the host population. Outbreaks will again require more resources to manage and stamp out.
What long-term strategies will need to be put in place to support neighbouring countries who have taken in refugees but also to support and protect the health and wellbeing of refugees?
A long list of actions is needed. Firstly, an assessment of the health needs of refugees is required. This has to be broad and comprehensive, covering both infectious and chronic non-communicable disease needs. And it has to be done quickly and repeated periodically as refugee needs are likely to evolve over time. Secondly, the refugees will somehow need to be registered with the host country’s health system and helped to navigate the system and access services appropriately.
Paradoxically, whilst infectious diseases may have the highest concern (and hence the need for urgent vaccination programmes, and disease screening), in reality, it is the chronic non-infectious diseases where the needs are. Think of disrupted care for people with asthma, diabetes, cancer, and heart failure, where they may have run out of medications, or their conditions were not fully investigated, and treatment plans implemented before they had to flee. There may also be cultural differences, and not just language barriers, between the host and refugee populations. Local health providers will need to learn about this so that they can deliver culturally appropriate care.
And as I mentioned earlier, it would be important to anticipate the long-term consequences of the war in Ukraine that will start to manifest later, such as post-traumatic stress, substance misuse, domestic violence, and other mental health and psychosocial issues.
Can you outline some of the potential health implications incurred as a result of the sanctions that have been imposed on Russia?
A poorer Russia may struggle to manage and deliver high-quality technology-dependent health services. It may struggle to afford expensive drugs that are imported from abroad, and consequently, the range of treatments available to its citizens may be curtailed. But ultimately, the health impacts will depend on how much economic damage Russia takes as this will, in the end, affect the ordinary citizens. We know poverty leads to poorer nutrition, fuel poverty, links with damaging health behaviours such as alcohol and smoking use, and less access to healthcare.
Do you think there is a clear sense of global solidarity in terms of protecting the health of those civilians affected? How have different countries responded?
No, I do not think there is global solidarity on this issue. Neighbouring countries have thus far shown great magnanimity in accepting refugees and the EU has made some promising noises of support. However, countries further afield such as the UK have been more hesitant to take in refugees. Many have also been reluctant to contribute to the costs of the refugee response that tend to be disproportionately borne by the neighbouring countries receiving the refugees. This is not a new phenomenon – the same happened with the Syrian war where neighbouring countries like Turkey and Lebanon were left shouldering both the influx and costs of caring for refugees. Another barometer of this is what percentage of funds have been received by the UN for its humanitarian flash appeal to support refugees. So far $2.25bn was asked for, and $1.38bn was pledged by countries, but from experience, we know these pledges are unlikely to be fulfilled and can lead to massive shortfalls (see: Ukraine Flash Appeal 2022 | Financial Tracking Service (unocha.org)). Also, public and media interest will wane and move on to the next crisis elsewhere.
Rebuilding a country from war takes years and the heavy load tends to be left to the affected country to bear. So, in this regard I am pessimistic – there is never enough, many needs will go unmet, and nice words will not fill a gap in services.
Dr Andrew Lee MB ChB MSc (Dist) MRCGP MFPH FHEA FRSPH DCH DTM&H DLSHTM CILT
Professor of Public Health
University of Sheffield
www.sheffield.ac.uk/scharr/people/staff/andrew-lee
https://twitter.com/andrewleedr?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
This article is from issue 22 of Health Europa Quarterly. Click here to get your free subscription today.
