Public Health Catastrophe Looms in Ukraine, Experts Warn – The New York Times

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Even before the war, the country struggled with epidemics of H.I.V., tuberculosis and hepatitis. The conflict threatens to undo decades of progress.
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By Apoorva Mandavilli
A convoy of five vans snaked slowly on Friday from the battered Ukrainian capital, Kyiv, toward Chernihiv, in the northeast of the country. On board were generators, clothes, fuel — and medications needed to treat H.I.V.
With a main bridge decimated by shelling, the drivers crept along back roads, hoping to reach Chernihiv on Saturday and begin distributing the drugs to some of the 3,000 residents in desperate need of treatment.
Organizers of efforts like this one are rushing to prevent the war in Ukraine from morphing into a public health disaster. The conflict, they say, threatens to upend decades of progress against infectious diseases throughout the region, sparking new epidemics that will be nearly impossible to control.
Ukraine has alarmingly high numbers of people living with H.I.V. and hepatitis C, and dangerously low levels of vaccination against measles, polio and Covid-19. Overcrowded and unsanitary living conditions for refugees are breeding grounds for cholera and other diarrheal diseases, not to mention respiratory plagues like Covid-19, pneumonia and tuberculosis.
“If they don’t get the medicines, there is a high risk that they will actually die because of the lack of therapy, if they don’t die under the shelling,” said Dmytro Sherembei, who heads 100% Life, the organization delivering medications to Chernihiv residents with H.I.V.
Mr. Sherembei, 45, learned he had H.I.V. 24 years ago. He is one of more than 250,000 people in Ukraine living with the virus, a huge epidemic driven largely by the sharing of contaminated needles among intravenous drug users.
Ukraine and the surrounding region also make up a world epicenter of multi-drug-resistant tuberculosis, a form of the disease impervious to the most powerful medications.
The Ukrainian health ministry in recent years had made progress in bringing these epidemics under control, including a 21 percent drop in new H.I.V. infections and a 36 percent decline in TB diagnoses since 2010.
But health officials now fear that delays in diagnosis and treatment interruptions during the war may allow these pathogens to flourish again, with consequences that ripple for years.
“Last year, we were working to differentiate between different TB mutations,” Iana Terleeva, who heads tuberculosis programs for Ukraine’s Ministry of Health, said in a statement. “Now instead, we are trying to differentiate between aerial shelling, raids and other military hardware.”
The fighting also has damaged health facilities throughout the country and spawned a refugee crisis, imperiling thousands of people with chronic conditions like diabetes and cancer who depend on continuing care.
“Everything is at very high risk, as it is always in the battlefield,” said Dr. Michel Kazatchkine, a former U.N. secretary general envoy for Eastern Europe.
“We should anticipate major health crises with regard to infectious diseases and chronic diseases across the region that I expect to be severe and durable,” he added.
The war “will have a huge impact on health systems that are already very fragile,” Dr. Kazatchkine said.
More than three million Ukrainians have fled to neighboring countries, most of them to Poland, and nearly seven million are internally displaced. The refugees are arriving in countries unprepared for an onslaught of patients with medical needs, experts said.
Moldova, for example, is one of the poorest nations in Europe, ill equipped to care for refugees or to stem infectious disease outbreaks. Countries like Kyrgyzstan and Kazakhstan buy drugs and vaccines produced by Russia and are heavily dependent on its economy.
Russia itself has more people with H.I.V. than any country in Eastern Europe, and Western sanctions are likely to interrupt the already low levels of funding for services in the country.
Within Ukraine, nearly 1,000 health care facilities are close to conflict zones or areas no longer under government control. The World Health Organization has recorded at least 64 attacks on such facilities, including 24 in which the buildings were damaged or destroyed.
The hospitals that are still operational struggle to care for the sick and wounded, and are crippled by dwindling medical supplies, including oxygen and insulin, and a shortage of lifesaving equipment like defibrillators and ventilators.
Hundreds of children with cancer have fled their homes, according to the World Health Organization. The armed conflict has even derailed routine childhood vaccinations.
Only about 80 percent of Ukrainian children were immunized against polio in 2021, and the country had detected a few polio cases even before the war began. The vaccination coverage for measles in Ukraine is likewise too low to prevent outbreaks.
These are the ingredients of a public health calamity, many experts fear. The W.H.O. and other organizations are deploying medical teams and shipping supplies, vaccines and drugs to Ukraine and to neighboring countries. But the aid may never reach areas of active conflict.
During the pandemic lockdowns, the Ukrainian government began disbursing three-month supplies of medications for H.I.V. and tuberculosis. But many Ukrainians forced to abandon their demolished cities were able to take only limited supplies of the medications needed to keep them alive.
Elizaveta Grib, 16, fled her home in Kyiv with her mother and younger brother on Feb. 28, four days after the bombing began. They packed what they could in suitcases and made their way by train to Mykolaiv, a city near the southern port of Odessa that came under heavy bombardment by Russian forces.
Ms. Grib’s tuberculosis was diagnosed in September 2020 and she took some of her medicines with her, but now is unsure how she might obtain the drugs long-term. Without treatment, her disease could become resistant to all available therapies, perhaps even claiming her life.
“It’s very scary,” she said.
At least 1,200 people with tuberculosis are thought to have fled Ukraine. The Alliance for Public Health, a nonprofit organization, is helping more than 400 such patients in countries like Poland and Moldova. The W.H.O., too, has readied a stockpile of tuberculosis drugs in Poland for refugees from Ukraine.
A new phase of the war. Russia’s  fight to gain control over Ukraine’s industrial heartland in the east is underway. Both sides are trading artillery barrages as Russia tries to break through Ukraine’s defensive positions in multiple locations.
Saving civilian lives in Mariupol. Russia and Ukraine reached a tentative deal to evacuate some women and children from the city, though similar agreements have fallen through in the past. Ukrainian forces holed up at a large steel factory waging what appears to be the last defense of the city refused to surrender.
Sending military aid to Ukraine. Ukraine’s allies are scrambling to deliver more advanced weapons for the battle in the east, where its defense is expected to rely on weapons such as long-range missiles, howitzers and armed drones. President Biden said that the United States would send more artillery.
But most of the refugees are women and children, while the majority of Ukrainians with drug-resistant TB are men who must stay in the country and fight, said Andriy Klepikov, executive director of the alliance.
Within the country, staff members are delivering medicines to the sickest people in cities where it still is possible to travel, and mailing drugs to communities where post offices are still operational.
Dr. Klepikov himself had 20 minutes to fill a backpack and evacuate from a suburb of Kyiv to Lviv. When he returned to Kyiv on a short trip earlier this past week, he was devastated by the destruction of apartment complexes, kindergartens and shopping malls within a few minutes’ walk from his building.
“There are smell of heavy smoke, sound of bombing, artillery, sirens,” he wrote in a text message.
In Lviv, a city that has become a refuge for displaced Ukrainians, the alliance’s staff members are delivering condoms, syringes and tests. But in many other cities, there is little the organization can do to help.
Staff members have lost contact with colleagues in Mariupol, the southern city under siege by Russian forces; only the coordinator of the alliance’s mobile team called to confirm that she was alive. Staff members have also lost touch with 60 percent of their clients in the suburbs of Kyiv, which has been under attack for weeks.
“What has been gained over these 20 years can be destroyed in days,” Dr. Klepikov said. “We will not allow this — we will fight for sustaining these gains.”
More than one in four new H.I.V. infections in Ukraine occur among the country’s roughly 350,000 injecting drug users. Before the war, Ukraine’s policies on harm reduction enabled more than 17,000 of its citizens to receive so-called opioid substitution therapy.
The demand for treatment has increased as access to street drugs has decreased during the conflict. But now stocks of the opioid substitution drugs methadone and buprenorphine are unlikely to last beyond one to two weeks, experts said.
So the W.H.O. and other nonprofit organizations are requesting drug donations from the Czech Republic, Austria and other countries. The Global Fund, an enormous global health organization, has made more than $3 million available to purchase these treatments over the next year.
Some experts worried that if Russian forces prevailed, Ukraine’s drug users would be in grave jeopardy. Opioid substitution therapy is illegal in Russia. Within 10 days of its annexation of Crimea in 2014, Russia shuttered all of the methadone delivery centers, resulting in deaths from overdoses and suicides.
“You can’t just stop these treatments from one day to the next,” Dr. Kazatchkine said.
Women who use drugs face particular stigma and discrimination from state organizations and medical institutions, said Tetiana Koshova, regional coordinator in Kyiv for the Ukrainian Network of Women Who Use Drugs.
Before the war, the organization helped 50 to 70 women each month, but now that number has doubled, Ms. Koshova said.
Ms. Koshova got her diagnosis of H.I.V. in 2006, at age 27, and said she worried about the availability of H.I.V. drugs as the war grinds on. Although warehouses still hold stocks of antiretroviral medicines, “the situation can change in any moment, because rockets fly anywhere and destroy everything indiscriminately,” she said.
She spent much of Tuesday “sitting in the basement” because of a threat of rocket attacks.
“Explosions are constantly heard, and periodically there are problems with electricity,” she added. “All night and several times a day, I have to go in bomb shelter.”
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