Paulo M. Buss, Ana Helena Freire and Santiago Alcázar*
The war in Ukraine has been thoroughly divulged, discussed, and explained on all social media platforms, in Brazil and abroad. Its geopolitical, economic, and social consequences have also been explored by specialists of all fields of knowledge and geographical position. However, there is one dimension that has been left out by this widely encompassing debate: the matter of health.
On the other hand, more attentive readers will certainly not have missed the term “others” in the title. It turns out that dozens of other wars are currently ongoing all over the world, in the Global South, but with much less appeal because they are not occurring in Europe, the heart of the western world, but in the peripheral areas of this vast world of ours, remarkably affecting global health.
But let us begin with the war in Ukraine. The conflict has been the subject of multiple interpretations by specialists in international geopolitics, from diplomat scholars, active or retired, activists and representatives of the civil society, who offer a range of possible interpretations and explanations. A return to the Cold War? Water under the bridge, because what we are watching now is a war with plenties of bombings and losses, anguish, personal suffering, associated with a deep hit taken by multilateralism, and, for some, the beginning of the design of a new world order in politics - which began pretty poorly, as it was not discussed around a table, but started with cannon fire.
The general consequences are already making themselves felt: several deaths among the military, but also among innocent civilians; a growing number of refugees and displaced people; racism made evident by the unequal treatment given to non-whites at the borders; great difficulties in providing suitable lodgings for these people; attacks against health clinics; the collapse of the Ukrainian health system and pressure on those of neighboring countries; increased global instability; strong impact on the economy, including higher prices of essential products, such as energy and food, all over the world; the threat of nuclear war and of chemical and biological weapons; and the unveiling of the bowels of a weakened multilateralism that had already become visible as such in the fight against the pandemic.
All this is taking place during the first pandemic of the 21st century, which has taken the lives of more than 6 million people and has produced more than 450 million cases all over the world - these are official figures of the WHO Coronavirus (COVID-19) Dashboard on 13-03-2022, figures that are known to be underestimated. According to a paper published in The Lancet on March 10, there have probably been about 18.2 million deaths. Approximately 10.5 billion doses of vaccines had been applied by then, with an impressive inequality between rich and poor countries, between those in the Global North and in the Global South.
As we write these lines, the World Health Organization (WHO) recorded more than 186 million cases and more than 1.9 million deaths in Europe since the beginning of the pandemic. The graphs for the upcoming waves of the epidemic in the Old World, available at the same source mentioned above, show that the daily average number of cases and deaths in March 2022 is very similar to what was observed in March 2021. To sum it up, the war in Ukraine is taking place during an extremely delicate moment of the epidemic in Europe.
In the countries directly involved in the conflict, the numbers displayed by the WHO Dashboard are also of great concern. In Russia, there have been more than 16 million cases and 350 thousand deaths since the beginning of the pandemic, with an average of 4,000 daily deaths in the past few weeks. In Ukraine, the same source reports 4.8 million cases and 105,000 deaths accumulated since the pandemic began, with an average of 25,000 daily cases and 300 deaths per day, on average, in the past few weeks. One should always keep in mind that the actual figures are probably much higher. This means the war is taking place during an extremely delicate pandemic moment in the two countries.
Russia has applied about 170 million doses of the vaccine on its population of 146 million people, while Ukraine has applied about 31 million doses on its 48.5 million inhabitants - the vaccination process is obviously stalled now, because of the war. In a war scenario, vulnerability due to lack of vaccine coverage is higher.
Mass human mobility is usually disorganized and potentially generates many different epidemic infirmities, such as outbreaks of infectious diarrheas, respiratory diseases - especially in the European winter - and severe mental conditions, not to mention the loss of control of chronic non-transmissible diseases, such as hypertension, diabetes, and others.
COVID-19 infection rates are very high and there is great concern that the intense flow of refugees into neighboring countries can bring the virus with them. Refugees and displaced people are very vulnerable, as they gather in crowds, seeking shelter or moving in packed buses, trains, and cars, or in hotels or refugee camps, therefore more susceptible to infections. Social distancing is impossible and access to masks is not easy. There is also a secondary concern - that Russian soldiers, who are facing an even worse COVID-19 outbreak in their country, will spread the virus in Ukraine and in the neighboring countries that are receiving displaced people, resulting in a higher number of Covid cases and additional stress in the countries’ respective health systems.
Non-communicable diseases are the main cause of death in Ukraine, but infectious diseases are also a source of concern: recent outbreaks of polio and measles threaten infant health, and the rates of HIV and tuberculosis are among the highest in Europe. The Ukrainian health system is treating these conditions, although it was already overloaded by the COVID-19 pandemic and other conditions. Now it is also having to deal with a growing number of hurt and polytraumatized patients. Services are suffering from lack of maintenance of medical equipment, scarcity of medicines and medical supplies, insufficient staff and forced absence of personnel due to the conflict.
On the other hand, we know that 4,300 babies have been born in Ukraine since the beginning of the war, and 80,000 Ukrainian women are expected to give birth in the next three months. With an insufficient supply of oxygen, most hospitals no longer have any reserves left, which puts thousands of lives at risk, including these women and their babies. To make things even worse for patients, critical hospital services are being hampered by the lack of electricity, while ambulances transporting patients are at risk of getting hit in the crossfire.
The solidarity expressed by Western countries has been impressive, as well as the concerns and steps taken by international organizations towards Ukraine and its surrounding countries, including in the field of health, the Geneva headquarters, with Tedros Adhanom; the Europe division, located in Copenhagen; the European CDC; the UNHCR and its twelve global partners; the European Union; the IMF; International Red Cross; all working together to bring humanitarian help to Ukraine and its neighbors, who are receiving refugees and displaced people.
The first manifestation of the WHO general director took place on February 24th, by means of a statement in which he expresses profound concern with the health of the Ukrainian people as the crisis escalated. He warned that the health system must continue working to provide essential care to all health problems, from COVID-19 to cancer, diabetes and tuberculosis, and including mental health issues, especially to vulnerable people, such as migrants and the elderly.
On March 13, a joint statement by the WHO itself, together with UNFPA and UNICEF, points out that “attacking the most vulnerable - babies, children, pregnant women and those who already have underlying conditions, and health professionals who are risking their lives to save others - is an inconceivable act of cruelty”.
They are saying that since the beginning of the war, 31 attacks against health clinics or hospitals have been documented through the WHO’s Surveillance System for Attacks on Healthcare (SSA). Twenty-four of these structures were damaged or destroyed, causing at least 12 deaths and 34 hurt, and affecting access and availability of essential services. Attacks on healthcare services are a violation of humanitarian international health and of the Geneva Convention devices regarding war.
The UN Refugee Agency (UNHCR) has informed that the current number of people recently displaced within Ukraine is estimated to be around 1 million and that more than 2 million people, especially women and children and non-Ukrainian nationals, have already crossed into neighboring countries, fleeing the ongoing hostilities. This number continues to grow, intensely and rapidly. In this sense, the WHO joined its efforts to those recently launched by the UNHCR, which mobilized 12 international partners and on March 1, 2022 launched the plan Ukraine: Regional Refugee Response Plan Summary and Inter-Agency Funding Requirements, March-August 2022, in which it projects the expected number of refugees and the necessary inter-agency resources to provide them with adequate support.
This was so different from the European reception of refugees and displaced coming from wars in the Global South, such as Africa, the Middle-East, and other armed conflicts. It is an excellent thing that this is the current behavior regarding the conflict in Europe. It would be even better if they showed the same behavior towards the refugees who attempt to get to the Old World via the Mediterranean, which has been painfully turning into a cemetery of refugees and displaced people, or through land routes.
Sadly, it is not possible to ignore the racism in the welcome given to those displaced by the war in Ukraine, whose diplomatic climax was the emphatic declaration, by the African Union, stating that it is “shockingly racist” to see that African citizens are prevented from fleeing the conflict in Ukraine, and requests that countries respect the international laws for those who flee from wars, without looking at skin color.
But regardless of the attention the war in Ukraine deserves, as does the suppression of racism, one cannot forget war and health issues in the periphery of the world, the wars in the Global South: the prolonged conflict in Syria and the ones ranging from Afghanistan and Myanmar, from Yemen to Ethiopia, in Palestine, in Somalia, and in several countries in Sub-Saharan Africa (such as Burkina Faso, Mali, and Nigeria). At least 28 other countries are facing conflicts or have reported armed combats in these firsts months of 2022, according to the ACLED (Armed Conflict Location & Event Data Project). According to the latest figures released by the UN, there are currently about 70 million people displaced due to war.
These are very unfortunate realities in which conflict and diseases walk painfully hand in hand. They are much less visible than the conflict in Europe, the world center of capitalism, but they are by no means less important: the life of any human being, regardless of where in the world they are, should be worth the same.
It is not by mere chance that the worst numbers regarding health, pandemic lethality, or fragility of health systems in the response to the public health needs of their populations are located in these countries. The armed conflicts they face are certainly an important component of the causes of these issues.
After military personnel, innocent people are those most affected: children, women, and the elderly, who have no possibility of defense. The breakdown of health systems caused by armed conflicts is one of the most terrible consequences of war: it affects immediate healthcare (in health units, health centers and hospitals), and its recovery requires a long time and financial resources that are usually not available in the fiscal spaces of the countries involved, also because of the military expenses they face.
War also causes long-lasting environmental consequences. For instance, during the 10 years of the Vietnam war, between 1961 and 1971, American troops poured 80 million liters of toxic herbicides (Agent Orange and napalm bombs) that caused disease, deaths, deforestation and environmental contamination. Effects on human health can be seen to this day: due to their persistence in the environment and their high toxicity and teratogenicity, many generations of Vietnamese children were born with various kinds of deformities and neurological deficiencies.
Armed conflicts also affect biodiversity and ecosystems, and pollute and contaminate the air, the soil, and the water. In addition to causing the collapse of essential infrastructures, such as water, sewage and power systems, wars also paralyze environmental management systems, right at the moment when thousands of people are struggling to survive. The increased pressure for resources and the absence of controls are what make the environment a silent victim of wars.
Twenty years ago, the WHO published a historical (and to this day, the only) World Report on Violence and Health, in which it firmly stated that the highest number of deaths due to violence took place during the 20th century, throughout human history. In the category “collective violence”, or “institutional violence”, if we prefer, the report refers to social, political, and economic violence, deliberately produced by large groups of people or by States, with significant lethal impact. It exemplifies the concept of hate crimes against organized groups, terrorist acts, and mob violence. Political violence includes wars and violent conflicts, usually promoted by States; the category includes the war in Ukraine and most armed conflicts we mentioned before. The WHO should once again delve into this subject, due to the persistence of the so-called collective violence. It may end up concluding that the 21st century is likely to overtake the sad legacy of the previous century.
On the other hand, the WHO Constitution, from 1948, has always warned, in its foreword, about the relationship between health and peace: the health of all peoples is crucial to achieving peace and safety, and it depends on full cooperation of individuals and of nations. All public health actors in the world should keep this in mind and should include in their agendas of political fight the intransigent defense of peace and of conflict resolution through negotiation in all diplomatic spaces available, under the flag “health as a bridge to peace”. Because, unlike a disease that can be controlled by a vaccine, there is no vaccine against wars. The only remedy is to stop them.
*Paulo M. Buss, Ana Helena Freire and Santiago Alcázar are part of the Fiocruz Global Health Center (CRIS/Fiocruz). This article was first published at Le Monde Diplomatique Brasil