COVID in a warzone: Ukraine’s dual crisis

Most of us could be forgiven for thinking there were glimmers of light at the end of a very long pandemic tunnel. We are not out of the pandemic yet, but with vaccines, advances in therapeutics and a wealth of knowledge on how the COVID-19 virus works and spreads, things have been improving.

However, Russia’s recent invasion of Ukraine has opened up a dark chapter, one which will likely drive COVID infections up – not just in Ukraine but in surrounding countries.

As people flee war, there is always a concern that they may bring infectious diseases with them, aiding the spread of illness through no fault of their own.

And history tells us warzones can provide the ideal conditions for infectious diseases to spread. Distracted government institutions, faltering health services, and the congregation of large numbers of vulnerable people, alongside environmental degradation, can create the perfect storm of conditions for an outbreak of a catastrophic infectious disease.

We saw this in the Democratic Republic of the Congo (DRC) during the 2018-2020 Ebola outbreak, particularly in the eastern part which has been engulfed in civil unrest and conflict. It is no coincidence that the DRC had a devastating and prolonged outbreak of Ebola, despite the efforts of government and foreign aid organisations.

A study looking at how the conflict affected public health measures to stem the spread of Ebola concluded that violence within the country – specifically attacks on health care settings and clinical staff – significantly affected vaccination efforts, isolation periods required for those infected, and health-seeking behaviours of those affected for some time after the attack took place, prolonging outbreaks.

In the Middle East and North Africa, years of war in Syria, Iraq, Yemen and Libya – including attacks on hospitals and clinics – left large parts of each country without a workable health infrastructure. And many healthcare professionals have been killed during conflicts, leaving a lack of trained professionals. Syria has seen a resurgence of preventable diseases like measles, polio and tuberculosis, as well as the spread of infectious diseases such as cutaneous leishmaniasis – known in Syria as “Aleppo Evil” – a disease spread by sandflies that causes disfiguring skin lesions.

Yemen, the region’s poorest nation, has been under constant attack from the Saudi-led coalition since 2015; leading to the destruction of infrastructure, including healthcare, as well as the displacement of millions. UNICEF said a child dies from a preventable disease every 10 minutes in Yemen.

As the world watches the conflict between Russia and Ukraine unfold, people are being forced into conditions where already high levels of COVID are likely to be made worse. Both countries experienced a significant rise in COVID cases this winter – Russia peaked at more than 180,000 positive cases on February 17, just days before it invaded Ukraine.

With such a high prevalence, there is every chance soldiers could bring the virus with them as they invade Ukraine, adding to its woes.

According to the latest available information in Ukraine, more than 4.8 million COVID cases have been reported and 105,500 deaths, with new cases increasing significantly in January-February 2022 and a peak in early February of more than 43,000 positive cases. Since the invasion, cases have dropped but this is most likely due to not testing, given the competing priorities for residents of both countries.

Against the backdrop of the invasion and high infection numbers is the fact that only 34 percent of Ukrainians have been fully vaccinated against COVID, and the invasion is very likely to thwart efforts to vaccinate more.

Vaccine supply chain issues in Eastern Europe have been a problem, but misinformation about the vaccines could make it worse. A study has looked at Russia’s role in the spread of misinformation about COVID-19, and it is not a stretch to say some of this could have found its way into Ukraine.

Since the invasion, fleeing people seeking safety have found roads backed up with vehicles and opted instead for public transport. Social media has been awash with images of large crowds at train stations and on trains departing major cities.

It is understandable that the primary focus of the people of Ukraine is to escape danger, but the sad reality is that the combination of large crowds and people rammed into train carriages all breathing the same air is the ideal situation for an airborne virus like COVID to spread.

Some people have taken refuge in subway stations to escape the dangers of the war; once again, this will mean large volumes of people in close proximity, many of whom do not have the added protection of the vaccines, leading to an increased risk of infection. As groups of people reach the borders of neighbouring countries, another bottleneck is likely to form – once again increasing the risk of infection.

COVID remains a dangerous infection, particularly for the elderly and clinically vulnerable. Many people fleeing war zones suffer from lack of sleep, no access to their usual medicines, and poor nutrition – all of which can increase the risk of serious infection due to the negative impact these things can have on the immune system.

Beyond the immediate spread of the virus, the longer the war goes on, the more it will impact health systems and disrupt surveillance and response systems.

Attacking infrastructure is a tactic often used in war to disable transport and supplies, aiming to weaken a country into submission, and this will have inevitable consequences for medical supplies in Ukraine. A weakened infrastructure will hinder both civilian and military populations’ access to healthcare and other emergency services.

Russia is reported to have built field hospitals for their own sick and wounded in areas surrounding Ukraine while at the same time, there have been reports of its military shelling maternity units in Ukraine’s Kyiv, and hospitals being forced to move staff and facilities to makeshift locations underground.

The World Health Organization (WHO) said on Sunday that trucks are unable to transport oxygen from plants to hospitals around Ukraine.

The country has an estimated 1,700 COVID patients in hospital who will probably need oxygen treatment, and there are reports of some hospitals already running out of oxygen.

As Russia invaded, the WHO warned that Ukrainian hospitals could run out of oxygen supplies in 24 hours, putting thousands more lives at risk. The WHO is working with partners to transport urgent shipments through Poland. If the worst was to happen and there was a national oxygen shortage, this would not only have an impact on those sick with COVID but multiple other health conditions as well.

As the war rages on, there will be a threat to the supply of electricity and power and even clean water to hospitals.

It is often said that in war there are no winners, but it is clear that disease and illness stand to benefit from human conflict. Coordination amongst international aid organisations will now be key to keeping essential health services going as the crisis deepens.

Organisations such as Doctors Without Borders (MSF), already in Ukraine working on other projects, say they are now mobilising a general emergency-preparedness response to be ready for potential needs and are working on medical kits for rapid dispatch. The British Red Cross is also in the country, supporting healthcare facilities with medicines and medical equipment as well as providing clean water and helping rebuild the country’s infrastructure.

Efforts should be put into vaccinating refugees as they arrive in surrounding countries. But equally important will be the international diplomatic efforts needed to end the war so healthcare systems can rebuild and get back to treating those in need.

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