Even before Russian forces invaded Ukraine in March 2014, Ukraine had been struggling to manage the COVID-19 outbreak. It was slower to launch its COVID-19 vaccination campaigns than other European countries, and while the government encouraged citizens to get immunized, most people struggled to find a way to get the shot, didn’t feel the need to get vaccinated, or didn’t trust the safety and efficacy of the vaccine.
Before the February 24 invasion, only 35% of Ukraine’s population was vaccinated. This puts Ukraine in line with the majority of neighboring countries. However, some other countries such as Poland and Hungary have higher coverage. While different health systems and varying attitudes about vaccination in those countries are contributing to those contrasting rates, Ukraine’s relatively low vaccination rate could have implications for how large additional surges of cases, both in the country and in the region become as a result of the war. Like many other countries, Ukraine experienced a surge in cases due to the Omicron variant in November and another peak in the first week of February—most likely due to its low level of vaccination. The country had 60% positive COVID-19 results by the middle February.
Such low vaccine coverage isn’t enough to control a highly transmissible virus like SARS-CoV-2, say public health experts. Add in a war—with the political and social upheaval it causes—and not only are spikes in infections inevitable, but there is also the potential for new variants to emerge, which puts the whole world at risk.
SARS-CoV-2 spread can be controlled by vaccination and other mitigation measures, such as wearing masks, social distancing and maintaining basic hygiene. However, these are difficult to do when the country is under siege. The humanitarian group Doctors Without Borders has been distributing trauma kits and training health care providers in Mariupol, Ukraine—a target of the Russian attack—as well as providing shelter and basic health needs for those crossing the border into other countries like Poland. But it’s not enough.
“War is an infectious disease’s best friend,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It challenges every public health program you can possibly have. It reduces access to medical care for the seriously ill. And it often encourages transmission of disease when people crowd into shelters and train platforms. This is going to be the perfect storm of one serious challenge after another.”
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Researchers from the World Health Organization discovered that 65 percent of all major epidemics in infectious diseases occurred in 1990s conflict-zone populations. Les Roberts, professor emeritus of Columbia University’s Mailman School of Public Health who has spent time in war zones addressing outbreaks, notes that these populations are especially vulnerable to viral diseases like COVID-19. “It turns out when you are under stress, your immune system does not work as well. You are not eating as well, and you cannot fight disease as well,” he says. “And in times of conflict, you move around a lot, and end up in bomb shelters or basements or on trucks that are way more crowded than normal and have bad air circulation. I don’t think people fully understand how war is like the breeding ground of disease.”
More than 670,000 people have left Ukraine since the war began, and this increased travel will almost certainly lead to a spike in cases in the country and those bordering it—like Poland, Hungary, Slovakia, Romania, and Moldova—while straining their health care systems. According to U.N. High Commission for Refugees, almost half the Ukrainians fled to Poland. This is a concern that health experts have been particularly worried about. “SARS-CoV-2 spreads like lightning right now,” says Jeffrey Shaman, professor of epidemiology at Columbia University Mailman School of Public Health. “For places like Poland and places in western Ukraine where people are fleeing, there is enormous opportunity for this virus to do damage that it wouldn’t have had the opportunity to do otherwise.” Prior to the influx, nearly 60% of Poland’s population was vaccinated, which will help protect it against a surge, but new infections will likely spike there as well, increasing demand for health care services.
“We have warned for years about the potential convergence of conflict and epidemiology—bad things happen when those things converge,” says Dr. Eric Toner, senior scholar at the Johns Hopkins Center for Health Security. “Certainly, in the dire circumstances in which the population is right now, mask-wearing, distancing, and quarantine are not going to be possible. As people flee the affected parts of the country, crowding on buses, trains, and cars and ending up in hotels or living with relatives or in refugee settlements—those are not conditions for good control of a transmissible disease like COVID-19.”
According to public health experts, hospitals are likely to be the hardest affected by the sudden influx of people fleeing the outbreak. COVID-19 will not be considered as a priority because of war injuries. This will make the spread of the virus easier. That disruption will in turn lead to more health care workers who will get infected, and won’t be able to perform their duties.
“There will be runs on hospitals and facilities and resources because of injuries associated with the conflict,” says Shaman. “In the longer term, I imagine it will result in deterioration of the ability to deliver health care at the level that people in the Ukraine are used to having.” And if surges occur in neighboring countries as well, that puts additional pressure on health care services in the entire region. “The world community would be advised to provide supplies and facilities to buffer the displaced Ukrainians and Polish populations from those consequences.”
Shaman and other health professionals are also worried about long term COVID-19 control effects. Research consistently shows that vaccination-based immunity begins to decline after approximately five to six month. To maintain protection from severe diseases, booster shots are vital. If the conflict in Ukraine goes on, even those who have been vaccinated will be unable to receive boosts as war trauma and other injuries will prevail over vaccine efforts.
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The global biodefense system against high-infectious coronaviruses is weakening as a result. Even without a military conflict, stark inequities in health resources have led to profound differences in countries’ ability to control COVID-19; developed nations have been able to purchase and distribute vaccines, while poorer countries, mostly in Africa and parts of Asia, still struggle to contain the virus since they lack access to the shots. The lack of coordination between public health resources and countries makes a situation like the one in Ukraine more dramatic. “I can’t begin to tell you where the solution is,” says Shaman. “The World Health Organization doesn’t have the authority or the resources in terms of money to deal with this. This is a very large issue that involves development, nation sovereignty, and the ability of nation states to get along and support one another in a trusting way rather than in ways that we’ve seen the world devolve into over the last 20 years.”
What’s truly needed is a global coordinating body for public health, Toner says, which isn’t likely, given challenges posed by issues of national sovereignty. However, the principle of global coordination could still be applied in limited ways.
COVAX was an example of such an effort. This program allows countries with developed economies to buy vaccines and lower the prices for those in developing countries. However, it is not fulfilling its promise. The 2 billion doses that COVAX promised to deliver by the 2021 end were not delivered. According to the group, it is likely to take well into 2023 before enough vaccines are available to all countries. “After the pandemic is over, I think we need to take a real look into COVAX and why it didn’t work as well as we had hoped, and what we could have done to make it better,” says Toner.
Many public health professionals have suggested alternatives such as supporting vaccine manufacturers to establish manufacturing plants in countries where they have previously struggled to obtain the most recent vaccines. They also advocated encouraging greater sharing of intellectual property so that poorer countries can access the technology needed to make shots.
Roberts stresses that it is possible to reduce and control the spread of viruses as Ukrainians flee from their homeland to seek refuge in other countries. Vaccinating and boosting people who enter these communal settings—especially those who are particularly vulnerable, such as the elderly or people with underlying health conditions—is an important start.
However, that’s still mostly out of reach. The World Health Organization doesn’t have enough resources to quickly direct vaccine supplies and personnel to crisis zones such as Ukraine, and lacks political authority to address questions of national sovereignty. Doctors Without Borders (and other humanitarian groups) also have critical roles. However, they can only provide localized help. “If we continue to be reactive in crisis after crisis, then we will not get at the systemic, underlying issues that need to be solved,” says Shaman.