The Impact of War on Public Health in Ukraine: Monitoring Tuberculosis, HIV, and Hepatitis C

The farming village of Dudachny in Kherson lived under occupation for months until it was liberated a year ago. Everything that was shot or blown up a year ago is still in pieces. Electricity and water are not flowing. Now the Russian forces still control the bank on the other side, seven kilometers away. Firefights can be heard every few days, residents say. Today only electric lawn mowers sound.

With two snow-white mobile clinics, the Ukrainian doctors and nurses of the Alliance for Public Health drive to villages along the front line in Ukraine where no other medical aid organization visits. Doctors are here to provide basic care, diagnose conditions like high blood pressure and diabetes, and provide medications. But they have a second agenda: monitoring infectious diseases. Screening for tuberculosis, HIV and hepatitis C. The buses barely stop and more than twenty villagers immediately rush over.

“TB is really a huge problem,” said Pavlo Smyrnov, the organization’s deputy executive director. He is trained as an epidemiologist. “That disease was the biggest problem in Ukraine even before the war.” Ukraine is on the World Health Organization’s ‘global tuberculosis watchlist’ along with 29 other countries. “The need for action has become even more urgent in the context of war in Ukraine,” the organization wrote in last year’s Global Tuberculosis Report.

Less access to care

Due to the war, fewer Ukrainians have access to medical care. The vaccination rate has fallen. “In Ukraine, due to the war and survival priorities, up to 20 percent of the population do not report to general practitioners with possible symptoms of tuberculosis,” Chief State Doctor Ihor Koezin said in March. Nevertheless, 18,510 cases of TB were diagnosed in Ukraine last year, an increase of 2.5 percent in a population that has shrunk considerably due to the departure of millions of war refugees.

Diagnosis is difficult, says epidemiologist Smyrnov. In his mobile clinics, when it comes to TB, they have to make do with questionnaires in which they ask about symptoms: persistent coughing, fever and a feeling of weakness. “Ukraine has one of the highest levels of tuberculosis in society worldwide,” says Smyrnov. “And also the multi-resistant strains xdr and mdr. You can’t treat that. That’s why you need regular screening. Every case you find now will spread in the future.”

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Infectious diseases in Ukraine are a potential threat to public health in Europe. In addition to the seepage of violence, governments outside Ukraine are concerned about the spread of infectious diseases as a result of the war. “Ukraine is not only a front in a military sense, but also in an epidemiological sense,” said a spokesperson for the Global Fund, the largest funder of the Alliance for Public Health. The multilateral health organization Global Fund raised a record amount last year. The Netherlands increased its contribution sevenfold, from 24 to 180 million euros.

The village of Dudachny, in the Cherson region liberated last year, is still heavily damaged. Of the fifteen hundred residents from before the war, almost two-thirds have left. Photo Kostyantyn Chernichkin

There has not yet been any worrying spread of TB due to the war. “The numbers of refugees from Ukraine who are diagnosed with tuberculosis do not yet give cause for concern,” the RIVM said. Twenty refugees from Ukraine were reported with TB in the Netherlands last year. That is not much: almost ninety thousand Ukrainians came to the Netherlands and the RIVM usually detects the disease in hundreds of people every year.

Especially children and men

Europe is helped epidemiologically by Ukrainian martial law, which stipulates that men of combat age are not allowed to leave the country. The refugee population consists mainly of women, children and the elderly. “In Ukraine, tuberculosis is less common in women and children than in men,” says the RIVM. “That most likely explains why we find less tuberculosis here than in Ukraine itself.” As the EU also requires, the Netherlands does not preventively screen for the presence of TB in new refugees, but only if there is reason to do so.

epidemiologistPavlo Smyrnov Every case you find now results in future spread

The mobile clinics in Kherson, Kharkiv and Zaporizhia are a start, but certainly not enough, admits epidemiologist Smyrnov, shaking his head. In addition to the lack of access to medical care, the war conditions themselves make the population vulnerable.

With two snow-white mobile clinics, Ukrainian doctors and nurses drive to villages along the front line where no other medical aid organization comes anymore. Photo Kostyantyn Chernichkin

The WHO estimates that almost 50 percent of TB infections in Ukraine are undiagnosed, and are therefore not treated but can spread. In addition, an unknown percentage of the population has ‘latent TB’. In the case of a latent infection with tuberculosis bacteria, a person carries the bacteria, but is not ill and not contagious. But as soon as resistance drops, a latent infection can still manifest itself. “If you get stressed, eat poorly, become malnourished, use substances such as alcohol, TB develops into its active form.” This active form, in which a patient characteristically coughs, is contagious.

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There is plenty of reason for stress during the war. Add to that the fact that people are being driven from their homes due to the war. Many people from the areas where fighting is taking place spent the winter huddled in poorly ventilated, unheated shelters. It happened to the 24-year-old son of Irina Babenko. He contracted tuberculosis in the city of Kherson, she says by telephone. “It was so hard during the occupation. I haven’t seen meat in all that time,” she says. “We haven’t seen any fish in all that time. Your health deteriorates.” Things did not get much better in the winter after the liberation. In June, her son suddenly started coughing really bad. “He had no fever, just a terrible cough.”

The man was soon diagnosed with TB in the hospital. And even though they all lived in one apartment; his fiancée, younger brother and mother did not receive it. “Fortunately we have good resistance,” Babenko explains.

Women go to the doctor

The fact that women in Ukraine get TB less often has to do with the division of roles within society. Men drink and smoke more often. They are also expected to remain strong. “Only women go to the doctor,” says Antonina (61) next to the mobile clinics in Dudachny. Almost everyone in line for the doctors is female. She has dyed red hair and bright blue eyes. Under her nails there is a thick black border from working in the garden. She tries to hide it.

The local nurse Olena Petjach receives a patient in her office in Dudachny. Photo Kostyantyn Chernichkin

The site of Dudachny is an old one kolkhoz; a collective farm from the Soviet era. Many watermelons are still grown and many residents are farmers. Thanks to this history, they have a decisive field sister close by who monitors their health. “Half of the people who come to the mobile clinic also visit me,” says Olena Petjach. “We have a healthy community. A few years ago there were a few with TB, but thank God not now.”

The population in Dudatsny is old. Of the fifteen hundred people who were there before the war, 520 are still left. There is an evacuation order for children here on the riverbank in Cherson: an urgent request to leave and a ban on travel. With the older population comes common health problems: high blood pressure and diabetes.

The population also lives under persistent stress due to shelling and other war discomforts. In the queue for the mobile clinics, an older woman with short hair dyed golden blonde looks nervously upwards. “I don’t know if it’s smart to stand here like this. Russians sometimes target groups of people,” she says. The enemy uses drones to monitor everything that happens on this side. Bystanders also look up. Nothing to see.

Antonina talks about neighbors who cry all day long, out of despair because they don’t know how long the war will last. “People have been through so much here, they are very happy when someone comes and asks how things are going,” says epidemiologist Pavlo Smyrnov. “It often helps if our doctors just talk to them.”

2023-11-19 19:20:16
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