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The Russian invasion of Ukraine on February 24, 2022 created a largescale humanitarian crisis that is intensifying as the conflict persists. Millions of Ukrainians, mostly women and children, have fled the country in what the United Nations calls the fastest-growing refugee crisis in Europe since World War II. Tens of thousands of people still in the country are finding themselves without access to food, water, power, or heat. And the World Health Organization has confirmed more than a dozen attacks on Ukrainian healthcare facilities and services since the start of the conflict.

Even though armed conflicts like the one currently taking place in Ukraine are known to create far-reaching harm to public health, the issue is not well studied.

“There is no National Institutes of Health on this,” said Amy Hagopian, a UW professor of global health and of health systems and population health, and a founding member of the Global Alliance on War, Conflict, and Health. “That would require acknowledging that armed conflict is a public health problem and that there are public health solutions to this problem. Many would like to leave these issues out of the field of public health.”

Complications of armed conflict, such as forced migration, exposure to violence, supply shortages, destruction of infrastructure, and interruption of essential services, will have short- and long-term consequences for the health and wellbeing of Ukrainians living through the invasion and its aftermath.

“The most immediate public health concern is loss of life as the result of bombings, shooting, and displacement. Other concerns include gender-based violence, disruption of livelihoods, poor access to income or cash for maintaining basic needs, and disruption in medical services for people with chronic conditions,” said Pamela Collins, professor of global health and of psychiatry and behavioral sciences, and executive director of the International Training and Education Center for Health at the University of Washington. I-TECH has been working in Ukraine since 2011, supporting the Ministry of Health to improve service provision for people living with HIV.

It’s not only Ukrainians suffering the public health effects of the invasion. Ukraine and Russia are breadbaskets, supplying 29 percent of the world’s wheat and barley. Already countries in the Middle East and Northern Africa, such as Lebanon and Tunisia, are rationing flour and wheat and reducing bread production. Food shortages and disruptions in global food supplies can contribute to malnutrition, undernutrition, or even death.

The danger is even greater in areas where water becomes contaminated due to the destruction of water purification and sewage treatment facilities.

“The combination of malnutrition and waterborne diarrheal illness, that's a vicious cycle that's well described in public health. It doesn't usually kill an adult, but it can very well kill a child,” explained Evan Kanter, a UW clinical assistant professor of health systems and population health and of psychiatry and behavioral sciences who specializes in the mental health effects of war.

To better understand the public health implications of armed conflicts like the ongoing Russian invasion of Ukraine, we spoke to Pamela Collins, Amy Hagopian, and Evan Kanter.

Indirect deaths due to infectious disease outbreaks, water contamination, and malnutrition, injury caused by damaged infrastructure, increases in domestic violence, sexual violence, and maternal and infant mortality, these are some of the biggest public health concerns typically associated with armed conflict. What other public health concerns are you seeing in Ukraine that aren’t commonly reported?

PC: This conflict is happening in the context of a global pandemic. Mass migration, unstable housing, and group sheltering all contribute to COVID-19 transmission.

EK: The percentage of elderly people in Ukraine is much greater than in other recent conflicts like Iraq and Syria. It could be that in some areas we see higher rates of death and disability, because of the population skewing elderly. Older people have more chronic illness and they're more dependent on health services that might be disrupted. They're also less mobile. This would be an important thing to follow.

Something else that’s new that we haven’t faced before is we’re having war going on around nuclear reactors. It’s a very dangerous situation.

What impact will the violent conflict have on the mental health of people living through the crisis?

PC: Exposure to war—destruction of one’s property and environment, violence, witnessing loss of life, experiencing fear for one’s own survival—all of these are psychologically traumatizing. The good news is that the majority of people exposed to trauma do not develop mental disorders as a result. However, they may experience severe stress reactions, anxiety, and depressive symptoms in the immediate term, and these are responsible for considerable suffering.

There are a lot of citizen soldiers fighting in Ukraine. Are we going to see different mental health impacts on them versus on someone who has military training?

EK: Yes, more symptoms and more severe symptoms. Studies have been done on National Guard personnel that have been deployed in Iraq and Afghanistan compared to regular military and those individuals suffer disproportionately.

Ukraine is experiencing one of the fastest-growing HIV epidemics in the world. How will the invasion impact the care and support of people living with HIV?

PC: One of my concerns for people living with HIV in Ukraine is that many are members of UNAIDS-defined key populations (e.g. people who inject drugs), who are very socially marginalized in peace time. We know that the most vulnerable communities experience greater risk of illness and death during humanitarian emergencies. We’ve seen this with COVID.

Medically speaking, access to antiretroviral drug supplies, access to opiate substitution therapies and other harm reduction services will be disrupted in different areas of the country. These disruptions, combined with the deprivations of war can also put people in increasingly high-risk situations that endanger their safety, increase their likelihood of poor viral suppression, and increase opportunities for transmission of HIV. A study of HIV transmission in Ukraine after the 2013-2014 conflicts [the Maidan Uprising in late 2013, the Crimean Peninsula annexation in early 2014, and military conflict in eastern Ukraine, in the Donetsk and Lugansk regions] showed an increase in HIV incidence by 15-54% in areas affected by war.

What can the public health community do to reduce the harm caused by armed conflict?

EK: Right now, we need to do everything we can to protect civilian infrastructure and assure that humanitarian assistance can get to the population. There has to be every kind of international pressure.

AH: There are primary, secondary, and tertiary prevention principles in public health aimed at reducing risks or threats to health that have great application to war and armed conflict. Many of these topics should be investigated, researched, and explored.

EK: Just the idea that you can approach war as a problem in public health is not quite accepted in the United States. The tools and approaches of public health can be very powerful. We want to bring them to bear on war and conflict both to prevent the damage that war does and to prevent war to begin with.

The Department of Global Health stands in solidarity with Ukraine, including our colleagues and their communities. Please consider donating to the I-TECH Humanitarian Fund to support I-TECH Ukraine during this crisis.

By Amy Frances Goldstein