The health needs of refugees from UkraineBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o864 (Published 05 April 2022) Cite this as: BMJ 2022;377:o864
- Adrianna Murphy, associate professor health systems and policy1,
- Daniela Fuhr, associate professor of mental health systems1,
- Bayard Roberts, professor of health systems and policy1,
- Christopher I Jarvis, assistant professor of infectious disease outbreaks and humanitarian emergencies2,
- Anna Tarasenko, crisis project manager3,
- Martin McKee, professor of European Public Health1
Since Russia’s reinvasion of Ukraine on 24 February 2022, more than 4 million people have fled the country. Seeking safety from escalating violence, most refugees have gone to the neighbouring countries of Poland, Slovakia, Hungary, Romania, and Moldova. By far the largest number are in Poland, which as of 29 March 2022 had welcomed over 2 million refugees.1 This vulnerable population will have both immediate and long term healthcare needs.
Martial law has prevented men aged 18-60 from leaving Ukraine so the vast majority of refugees are women, children, and older people. Many early refugees are staying with family or friends in host countries, but as the violence escalates, more refugees without connections are fleeing and require the most assistance.2 They often arrive cold and dehydrated, some having travelled for days. The harsh and overcrowded conditions endured during their journey and in reception centres make them susceptible to infectious diseases. Children are at particular risk of measles, polio, and other vaccine preventable diseases, including diarrheal diseases. Routine vaccination coverage in Ukraine was low before the war, and the rotavirus vaccine is not routinely given.34 Cramped conditions also make refugees vulnerable to covid-19. Before the war Ukraine had almost 25 000 new cases each day, with only 36% of the population fully vaccinated.5 As these diseases spread quickly in crowded settings, prevention measures including hygiene and masks, vaccination, and effective surveillance are priorities.
Women escaping Ukraine need access to sexual and reproductive healthcare. The World Health Organisation anticipates 2,000 births among refugees from Ukraine in the next four weeks, with numbers rising as more refugees arrive.6 They estimate that at least 15% will require emergency obstetric care. Women are also at high risk of gender based violence (GBV) and trafficking. The United Nations Population Fund is working hard to get refugee women to appropriate antenatal care, and provide other reproductive health services, including care for GBV victims, and supplies for menstrual hygiene and contraception.7
It is also essential to address the needs of refugees with the pre-existing chronic conditions. Chronic non-communicable diseases are the biggest contributor to disease burden among Ukrainian adults. About a third have hypertension8 and 7% have diabetes.9 Ukraine also has one of the highest burdens in Europe of chronic infectious diseases, especially HIV and tuberculosis.1011 Effective management is only possible if those affected have continuous access to medicines and care, both challenging for refugee populations.1213 Most refugees arrive without medical records or adequate supplies of medication. In some cases, this can be a matter of life or death, as with insulin for Type I diabetes or diuretics for heart failure. Those with chronic renal failure require immediate and ongoing dialysis. Refugees with cancer face particular challenges; breaks in care may allow cancers to spread, but management is often complicated and requires detailed knowledge of the progress of the disease, with the added challenge of differences in treatment across countries.14 Older refugees, many of whom will have multimorbidity and suffer from frailty, and those with disabilities are particularly vulnerable. These people are often given low priority and face many barriers to accessing care. A survey of older refugees from Ukraine in Moldova found that 28% required urgent medications, including for diabetes, hypertension, and pain relief, but over a third had no access to the money needed to purchase them.15
Finally, exposure to traumatic events and ongoing daily stressors means that one in five people affected by conflict are likely to experience mental disorders. These cover the whole spectrum of disorders and severity so those supporting them will need the skills to manage a wide range of mental health needs.1617 There is now considerable experience that can be drawn on, providing mental health and psycho-social support programmes (MHPSS) and integrating them with health, education, and social protection programmes, complemented by more targeted community mental health interventions.17 The key to a comprehensive, relevant, and sustainable MHPSS response is multi-sectorial coordination. Central to such efforts should be the involvement of Ukrainian refugees, particularly those with lived experience of mental disorders.
Responding to these health needs will require significant resources. The United Nations High Commissioner for Refugees coordinates the response with national authorities and other UN agencies and non-governmental organisations. But it is the host countries that will provide most healthcare, especially in the long term. Their responses thus far have been commendable. Two days after the Russian reinvasion, Poland offered all refugees escaping the war access to the same health care as Polish citizens under their National Health Fund.1819 Moldova, one of the poorest countries in Europe, has received the most refugees from Ukraine per capita and is offering them free access to health services, including vaccination against covid-19 and other vaccine-preventable diseases.20 The European Commission has enacted the Temporary Protection Directive, offering immediate protection, including medical assistance, to refugees from Ukraine.21
While difficult to accept, Russia’s aggression is unlikely to end soon. As the violence continues, there will be many more people forced to flee their homes. So far, Ukraine’s neighbours have willingly taken on most of the responsibility of supporting those fleeing the war. But they cannot do it alone. One lesson of the covid-19 pandemic was the importance of European solidarity. This is a test of whether we can turn this idea into a reality.
Competing interests: none declared
Provenance and peer review: commissioned, not peer reviewed
The authors are grateful to Michael Woodman, Senior Public Health Officer, UNHCR for his technical comments on the draft of this article.