Russia invades Ukraine again: how can the health community respond?

Dear Editor

We note with concern that in the article published 2 March 2022 entitled ‘Russia invades Ukraine again: how can the health community respond?’ Professor Martin McKee supports an increase in defence spending. (1)

We write on behalf of the Nuclear Weapons Group of Medact which is the UK affiliate of International Physicians for the Prevention Nuclear War (IPPNW), winners of the Nobel Peace Prize in 1985. It is also an affiliate of the International Campaign to Abolish Nuclear Weapons (ICAN), winner of the Nobel Peace Prize in 2017. (2)

We admire the work of Professor McKee to draw attention to the public health implications of the war in Ukraine and we agree with his analysis of public health ramifications regarding Ukraine, Covid 19, polio, mental health and agricultural disruptions. We strongly endorse his call for an immediate ceasefire. (1)

We, however, respectfully disagree with his following point:

‘The end of the cold war brought a financial dividend as defence budgets were cut. However, it is now clear that in many cases this went too far, and, as in Germany, spending is likely to rise substantially. We cannot call for more money to prevent threats from microorganisms but criticise spending to protect against actions by hostile states.’ (1)

We are concerned that such increased military spending could all too easily escalate. A new cold war or potentially worse situations involving further wars could lead to scenarios involving nuclear weapon use. And nuclear weapon use is never acceptable and must be avoided.

The major threats to our security involve global issues, such as the climate crisis and lack of pandemic vaccine justice. Addressing them in a meaningful fashion requires diverting money away from arms budgets to climate change mitigation and health budgets. (3) (4) While declaring a ‘climate emergency’ the UK government spending on carbon reduction is less than half the increase in military spending in the recent Integrated Strategic Defence and Security Review (4). And ‘European NATO members already spend almost 5 times as much as Russia on their militaries’. (5)

The UK is already the second largest arms dealer in the world (6) and arms manufacturers and dealers view this war, and all wars, as huge opportunities for vast profit. The only real winner in the war is and will be the arms companies.

It is so very important to offer a public health perspective about the war - and Professor McKee’s voice is valued and respected. We, however, found it disappointing that he did not mention the greatest potential public health risk of the war: the possible escalation to the use of nuclear weapons. As in other cases in medicine we must prevent what we cannot cure, and the use of nuclear weapons is the most pressing example of that.

There is no possible way to have a meaningful medical response to the use of even one nuclear bomb as the Journal of Public Health published in 2020 made clear. (7) A limited war risks famine killing 2 billion people. (8) A likely escalation to full nuclear war risks the end of our civilisation. (7) A needed ceasefire now, yes, and real negotiations. However also needed now is recognition that for most countries, nuclear weapons already are illegal under international humanitarian law and pressure should now be put on the UK government to attend the meeting of nuclear ban treaty states' parties in Vienna in June. (7)(9)

As the World Health Organisation has stated, nuclear weapons pose the greatest immediate threat to human health and welfare. They are primed to unleash a final epidemic for which there could be no effective treatment. (10) These warnings have been echoed by the Bulletin of the Atomic Scientists (11), the International Campaign to Abolish Nuclear Weapons (ICAN) (11) and the International Committee of the Red Cross (12). We need a new non-militarised paradigm of security. (13)
Yours sincerely,

Michael Orgel, MD

1) https://www.bmj.com/content/376/bmj.o548
2) https://www.medact.org/
3) https://www.opendemocracy.net/en/oureconomy/the-eu-is-wrong-to-arm-ukrai...
4) https://caat.org.uk/news/2020-03-02-2/
5) https://caat.org.uk/news/statement-on-the-war-in-ukraine/
6) https://caat.org.uk/news/new-stats-show-uk-government-is-the-second-bigg...
7) https://doi.org/10.1093/pubmed/fdz102
8) https://www.ippnw.org/programs/nuclear-weapons-abolition/nuclear-famine-...
9) https://www.icanw.org/ican_condemns_russia_invasion_of_ukraine_an_escala... aine&utm_medium=email&utm_source=ican
10) https://peaceandhealthblog.com/2022/03/10/global-medical-and-public-heal...
11) https://thebulletin.org/2022/03/bulletin-science-and-security-board-cond... ampaign=DoomsdayClockMarchStatement
12) https://www.icrc.org/en/document/icrc-appeals-nuclear-weapons-never-used
13) https://rethinkingsecurityorguk.files.wordpress.com/2019/05/rethinking-s...

Dear Editor,

In their article, Martin McKee and Adrianna Murphy, among the threats to public health posed by the war launched by Russia against Ukraine, casually mention the COVID-19 pandemic. Meanwhile, the world community must understand the threats associated with COVID-19 for the population, primarily in European countries, where Ukrainians fled to escape the war. As of March 20, 3.5 million people have left Ukraine [1].

We are now in the city of Kharkiv, which is daily subjected to airstrikes, rocket attacks, artillery strikes, and are witnessing a humanitarian crisis that the population of the city is experiencing. More than 700 multi-storey apartment buildings have been destroyed, and people live for many days in the subway, basements, bomb shelters. They are subject to significant psycho-emotional impact. In some areas of the city, there is no electricity, water, or heating. The temperature outside is below 0 degrees Celsius. The food they eat is stored improperly due to the lack of refrigerators in shelters or electricity in homes. This leads to intestinal infections. Putin's troops are destroying residential buildings, medical facilities, the city's infrastructure, and life support systems, which affects people's health.

Nevertheless, especially the current situation worsens the situation with aerosol infections. There is a high crowding of people in places where they hide from bombs. Physical distance, mask mode in these conditions are not respected. People with respiratory symptoms are not isolated. Meanwhile, the war, which began on February 24, 2022, coincided with an increase in the incidence of COVID-19 in Ukraine associated with the Omicron variant BA.1. On February 23, 2022 (Wednesday), 25,062 cases of COVID-19 were registered in Ukraine. A week later, on March 2, 2022 (Wednesday), the number of registered cases of COVID-19 was 6,879, which is much lower than the predicted incidence calculated the day before by our group using a combined intellectual model implemented within the framework of the project of the National Research Foundation of Ukraine 2020.02/0404 [2].

According to the model, about 30,000 new cases were predicted in Ukraine every day at the beginning of March. The low number of registered cases is due to their incomplete registration. In areas with active hostilities, people can mainly seek medical help online or by phone. However, communication is not available in all areas of the city. Furthermore, in this case, diagnostic testing is not performed. In severe cases, people go to the emergency room and are hospitalized. The infectious diseases hospital has a diagnostic laboratory, and tests are being carried out. However, it should be noted that 2.5-3% of the capacities of laboratories providing COVID-19 diagnostic services are operating in areas where active hostilities are taking place. Events in the epidemic foci of COVID-19 are not held, contacts are not traced. Isolation and self-isolation of contact persons are not carried out. In addition, it should be taken into account that the coverage of two doses of the vaccine against COVID-19 of the population of Ukraine is low and amounted to 34.5% before the start of the war. Immunization with the third booster dose has just begun. Children under 12 in Ukraine are not subject to vaccination, and vaccination of children over 12 began only in January 2022. At the same time, children make up the majority of refugees.

Conditions in which refugees leave areas with active hostilities also contribute to the spread of the virus. There are large crowds of people waiting for evacuation trains at the stations. The trains are overcrowded, the occupancy of trains is up to 200%. There are no conditions for physical distancing. People get to the border after more than a day being in unventilated overcrowded wagons.

There is a high risk of spreading the SARS-CoV-2 virus among the population of European countries. This is especially dangerous because many countries are easing or ending restrictive measures - canceling the mask regime, physical distancing, etc. Thus, among refugees leaving Ukraine, there is a high probability of the emergence of sources of COVID-19 infection, especially among children.

The Omicron variant BA.2 remains highly likely to spread, and new, more dangerous variants of the coronavirus will emerge. When revising covid laws and regulations to prevent the spread of the Omicron variant BA.1 COVID-19, countries need to consider the existing risks associated with the war in Ukraine to provide access to testing, medical care, and vaccination for refugees from Ukraine.

Dmytro Chumachenko – PhD, Associate Professor, Associate Professor of Mathematical Modelling and Artificial Intelligence department, National Aerospace University “Kharkiv Aviation Institute”, Kharkiv, Ukraine

Tetyana Chumachenko – DSc, MD, PhD, Full Professor, Head of Epidemiology department, Kharkiv National Medical University, Kharkiv, Ukraine

References
1. Ukraine Refugee Situation. United Nations High Commissioner for Refugees. 2022. https://data2.unhcr.org/en/situations/ukraine
2. Yakovlev S, Bazilevych K, Chumachenko D, et. al. The concept of developing a decision support system for the epidemic morbidity control. CEUR Workshop Proceedings. 2020, 2753: 265-274.

Dear Editor

It is good to hear from you, Sergei, when hearts are breaking in Russia as well as Ukraine and all over the globe most of us can only look on in horror and pack another truck load of goods to send over.

As far as developing countries should get together I would sadly say that the response has been so varied. Would they struggle to be top dogs? Some countries have activated immediately, some dragged their heels as long as possible. I don't want to see yet another set of leaders and representatives set up by only developed countries when those who suffer in any war are the so called 'ordinary people' and those sent to sacrifice their lives. . Those with the expertise not experienced by 'leaders' need to be involved as well as those who have lived under dictatorships in 'developing' countries. How to stop that becoming mere tokenism as it was in the climate change gatherings would need a diferent inclusive formula. With all respect and sadness to those on both sides who are going through another hell not of their making.

Dear Editor,

McKee and Murphy (2022) have described a potential response of the health community towards the invasion of Russia to Ukraine. Their article stresses that the health community should call for stronger global political and financial governance to address the consequences of the crisis and prevent similar events in the future. While this consideration is thoughtful and touches upon the bigger picture, we believe that the health community should also step up to support the education of trainee doctors and health professionals in Ukraine.

As of the 24th of February 2022, the assault on Ukraine’s hospitals by unrelenting air raids and indiscriminate bombardment has put Ukraine’s trainee doctors in grave danger and severely compromised their education. It has also led to the discontinuation of clinical research, which was the main source of support for their involvement in research and continuous medical education. This situation is expected to plague medical education in the country for a long time after the cessation of the hostilities, harming both physicians and patients in the country.

Currently, physicians who obtained their qualifications in Ukraine are not able to practise Medicine in other countries, unless they clear a number of qualification exams. The amount of time, expenses and diplomatic paperwork required for this purpose makes their participation in such an arduous process virtually impossible under the present circumstances. However, medical students and young doctors in Ukraine can greatly benefit from resuming their clinical and scientific training abroad. The knowledge and experience they will gain can play a crucial role in restoring and improving the provision of healthcare in Ukraine.

The health community can address this need in two manners, a formal and an informal one. Formally, health professionals should call upon governments and health bodies to facilitate clinical training for medical students and young physicians from Ukraine abroad under emergency - temporary license to practice. Informally, health professionals should volunteer time and resources in educational activities (webinars, workshops, internships etc) targeted towards colleagues in Ukraine whose education and training was interrupted.