There are no good times for war, but there are definitely bad times. Even Russia’s full-scale aggression in Ukraine entered its second month and the number of civilian deaths was close to 1,000, chilling the epidemic. In some parts of Europe and Asia, cases have increased in recent weeks. A new and seemingly more transferable variant has emerged, as we always knew it would be in the end. The World Health Organization has expressed concern that war could not only supercharge infections in the region but also exacerbate global epidemics.
With its 35 percent immunization rate, Ukraine was particularly vulnerable even before the invasion forced 10 million people out of their homes. The fact that most of the population now has to ride together in packed train cars and basement bomb shelters will not help matters. For many Ukrainians, though, such concerns are not at the top of their minds. Paul Spiegel, director of the Center for Humanitarian Health at Johns Hopkins University, told me, “Their only priority is to escape and survive.” In his research, Spiegel found a strong connection between the conflict and the epidemic. But it is now difficult to assess the interaction between disease and violence in Ukraine: after the attack, reporting of the number of cases slowed down.
To better understand how the epidemic is affecting the war and vice versa, I spoke with Spiegel, who is currently part of the WHO team that is assisting in the flow of refugees to Poland. Our conversations have been edited for length and clarity.
Jacob Stern: What does the situation on the ground look like?
Paul Mirror: I am currently with WHO on a surge team based in Poland. We are setting up a refugee health center. Then a whole other group is working in Ukraine. And I want to differentiate this, because what we are seeing now in Ukraine is the destruction of cities and supply chains, and so it would not be surprising to see any kind of epidemic there. On top of that, it’s happening in the middle of an epidemic. People live underground for a few days at a time in the bunker, people are very close, probably less concerned about some masks and social distance, because their priority is just to escape and survive – it would not be surprising if something like COVID Was either extended.
The other thing that I think is really important in any situation is history. What is the rate of childhood vaccination against measles, polio and diphtheria in Ukraine compared to neighboring countries? We need to think about Kovid, and this is very worrying. We need to think about some vaccine-preventable diseases, and then we have to think about water- and sanitation-related diseases, especially diarrhea, because of the devastation that is happening in Ukraine.
Stern: You know the difference between what happens in Ukraine and what happens to refugees. How is this mobility playing into the refugee?
Spiegel: So far, at least from what we see, we are still not aware of the growing epidemic with the refugee movement. It is often identified – really stigmatized and stereotyped – that “refugees spread the disease.” And it is not a refugee. It depends on the type of circulation they are coming from. But if spread, it is because of the situation and the vulnerabilities and risk factors that they are exposed to.
I have rarely seen such generosity in my life in the neighboring countries. Millions of people are leaving in a very short time, but there are no camps in Europe right now. There are reception centers, but people are receiving them from all over Europe, and so their very high-density camp-like settings will not be in this position as we have seen in other situations, which is problematic for epidemics because proximity so I am at least hopeful considering the current situation. The chances of an outbreak are reduced.
Stern: It is an interesting connection that you are making between the tolerance and welcome of these countries and how it can benefit public health in addition to being the right thing to do.
Spiegel: I’m in Krakow right now, and there are at least a million refugees in Krakow, but you don’t really see that. Surprisingly, even my hotel has Ukrainian refugees. It’s awesome to see. They are dispersed and are welcomed in a hospitable and sanitized environment.
Stern: Either in Ukraine or among refugees, which of your team is facing the biggest health challenges right now?
Spiegel: In Ukraine itself, with actual bombings and conflicts, we are seeing a lot of trauma cases, and WHO and other agencies are sending emergency medical teams to help. With refugees, for the most part we don’t see many conflict-related wounds from humans so far, at least with the passing of humans. What we are seeing is a challenge to the continuity-care of diseases, especially serious diseases and / or diseases that can spread, such as HIV and TB. We need to make sure that those who are receiving treatment are able to receive treatment.
The WHO and many other groups are working in Ukraine to refer patients, and so more than 350, possibly 400, pediatric cancer patients have been referred from Ukraine to Poland and elsewhere. It’s amazing to see, and the resources here are much more than we’re used to. However, what we have seen in other countries, over time, can be a concern, even in a country that is accustomed to a certain number of dialysis or cancer patients, or neonatal intensive care units, when suddenly one more million of you, it is still a strain or May be a suffocation point.
Stern: One type of case is influx which you have not mentioned. Is it because it wasn’t the primary problem, or is it something that these health systems are dealing with right now?
Spiegel: At the moment the health system is not yet overwhelmed. When the attack took place, Ukraine and the rest of the surrounding countries actually had their Omicron peaks and cases were declining, but of course there will be many people who are going to be hospitalized, no question. But at the moment, from what I’ve heard, the hospital has nothing irresistible. Unfortunately, this is a permanent moment.
Stern: As we now see cases from Ukraine due to a lack of test data on the rise across Europe, what metrics or trends would you look for to determine how and to what extent this conflict is affecting epidemic dynamics?
Spiegel: This is going to be difficult because of what is happening in terms of access and danger. But one of the key areas, when you have bad data or you have a new look, is the more attention will be paid to hospitalization and ICU beds.
At the moment we are seeing waves in some parts of Europe, and so we are seeing an increase in some countries where Ukrainians are now, and there is no evidence that this is happening because of the Ukrainian refugees.
Stern: Going back a minute, I think the big question people are asking here is: How bad is it? And that question is really two different questions. The first is: How bad is the epidemic for the situation in Ukraine? The second is: How bad is the situation in Ukraine for the global epidemic state?
Spiegel: Certainly it would not be unreasonable to think that when people run away and they stay in bunkers, they stay on trains, they do not use PPE and masks the infection will increase. So it wouldn’t be surprising, but again, it depends on where we are in the epidemic, how many people are actually infected, the vaccination rate and where this new submarine of Omicron is.
I don’t think this crisis will change the course of the epidemic because of the level of previous Omicron growth, but it’s always hard to predict. I’m concerned about China / Hong Kong’s previous control strategies, the large number of people who could be infected, and the possibility of other forms. The answer is: It is difficult to predict what will happen next, but there is probably no positive side to what you see.