There is no good time for a war, but there are certainly bad ones. Even as Russia’s full-scale invasion of Ukraine enters its second month and the civilian death toll nears 1,000, the pandemic churns on. In Europe and parts of Asia, cases have shot up in recent weeks. A new and seemingly more transmissible variant has emerged, as we always knew it eventually would. The World Health Organization has expressed worry that the war could not only supercharge transmission within the region but worsen the pandemic worldwide.
With its 35 percent vaccination rate, Ukraine was especially vulnerable even before the invasion forced 10 million people from their homes. That much of the population must now cram together in packed train cars and basement bomb shelters will not help matters. For many in Ukraine, though, such concerns are not top of mind. “Their priority is just to flee and survive,” Paul Spiegel, the director of the Center for Humanitarian Health at Johns Hopkins University, told me. In his research, Spiegel has found a strong connection between conflicts and epidemics. But assessing the interplay between disease and violence in Ukraine is difficult right now: After the invasion, reporting on case counts slowed to a trickle.
To get a better sense of how the pandemic is affecting the war and vice versa, I spoke with Spiegel, who is currently in Poland as part of a WHO team helping to receive the flow of refugees. Our conversation has been edited for length and clarity.
Jacob Stern: How does the situation look on the ground?
Paul Spiegel: I’m currently with the WHO on a surge team based in Poland. We’re establishing a refugee health hub. Then there’s a whole other group working on Ukraine. And I want to distinguish that, because what we’re seeing right now in Ukraine is the destruction of cities and supply chains, and so it would not be surprising for an epidemic of some sort to occur there. On top of that, this is happening in the middle of a pandemic. Having people live underground for days at a time in bunkers, having people so close together, likely less concerned about some of the masking and social distancing, given that their priority is just to flee and survive—it would not be surprising if something like COVID were exacerbated.
The other thing that I think is really important in any situation is history. What is the childhood immunization rate for measles, polio, diphtheria in Ukraine compared to the surrounding countries? We have to think about COVID, and that’s very concerning. We have to think about some of the vaccine-preventable diseases, and then we have to think about water- and sanitation-borne diseases, particularly diarrhea, given the destruction of what’s happening in Ukraine.
Stern: You distinguished right at the beginning there between what’s going on in Ukraine and what’s going on with the refugees. How are these dynamics playing out among the refugees?
Spiegel: So far, at least from what we’re seeing, we’re not yet aware of an increase in epidemics with the refugee movement. It’s often characterized—really stigmatized and stereotyped—as “refugees spread diseases.” And it’s not the refugees. It depends on what the prevalence may have been where they’re coming from. But if there is spread, it’s because of the conditions and the vulnerabilities and risk factors that they’re exposed to.
I’ve rarely in my life seen such an outpouring of generosity among the surrounding countries. You have millions of people moving in an extremely short period of time, but in Europe right now, there are no camps. There are reception centers, but people are accepting them from all over Europe, and so they’re not going to be put into this position of very high-density camplike settings that we’ve seen in other situations, which are problematic for epidemics because of the proximity. So I’m hopeful at least that given the current situation, the chances for outbreaks is reduced.
Stern: That’s an interesting connection you’re making between the tolerance and welcomingness of these countries and how that, aside from being the right thing to do, can actually benefit public health.
Spiegel: Right now I’m in Kraków, and there are at least a couple hundred thousand refugees in Kraków, but you can’t really see that. Amazingly, even in my hotel there are Ukrainian refugees. It’s extraordinary to see. They are dispersed and they are being welcomed into a hospitable and sanitized environment.
Stern: Either in Ukraine or among the refugees, what are some of the greatest health challenges your team is facing right now?
Spiegel: In Ukraine itself, with the actual bombing and the conflict itself, we’re seeing a lot of trauma cases, and the WHO and other organizations have been sending in emergency medical teams to help. With the refugees, for the most part we’re not seeing many conflict-related wounds from people thus far, at least with people crossing over. What we are seeing is a challenge to continuity-of-care of diseases, particularly serious diseases and/or diseases that can spread, such as HIV and TB. We need to make sure that those people who were receiving treatment are going to continue to be able to receive treatment.
The WHO and many other groups have been working in Ukraine to refer patients, and so there’s been over 350, maybe 400, pediatric cancer patients that have been referred from Ukraine to Poland and elsewhere. This is extraordinary to see, and the resources here are so much more than we’re used to in other places. However, what we’ve seen in other countries is that over time, there may be concerns, because even in a country that’s used to a certain amount of treating dialysis or cancer patients, or neonatal intensive-care units, when suddenly you have a million more people, it still may be a strain or a choke point.
Stern: One kind of influx of cases that you didn’t mention there is COVID cases. Is that because that hasn’t been the primary issue, or is that also something that these health systems are dealing with right now?
Spiegel: The health systems at the moment are not yet overwhelmed. When the invasion occurred, Ukraine and the rest of the surrounding countries actually had had their Omicron peak and cases were falling, but certainly there will be a number of people that are going to be hospitalized, there’s no question. But at this point, from what I’ve been hearing, there’s not an overwhelming of the hospitals. Unfortunately, it’s a stay-tuned moment.
Stern: As we see cases start to tick up across Europe, given the lack of testing data coming out of Ukraine right now, what metrics or trends will you be looking at to gauge how and to what extent this conflict is affecting pandemic dynamics?
Spiegel: It’s going to be hard because of what’s happening in terms of access and danger. But one of the key areas, when you have either poor data or you have a new variant, is going to be looking more at the hospitalizations and the ICU beds.
Right now we’re seeing a surge in some parts of Europe, and therefore we might see an increase in certain countries where the Ukrainians are now, and there’s no evidence whatsoever that that’s occurring because of the Ukrainian refugees.
Stern: Stepping back for a minute, the big question that I think people are asking here is really: How bad is this? And that question is really two different questions. The first is: How bad is the pandemic for the situation in Ukraine? The second is: How bad is the situation in Ukraine for the global state of the pandemic?
Spiegel: Certainly it would not be unreasonable to think that transmission would increase when people are fleeing and they’re in bunkers, they’re in trains, they’re not necessarily using PPE and masks. So it wouldn’t be surprising, but again, it depends where we are in the epidemic, how many people have actually been infected, the vaccination rate, and where this new subvariant of Omicron is.
I would not think that this crisis will change the trajectory of the pandemic given the levels of the previous Omicron surge, but it is always difficult to predict. I am more concerned about China/Hong Kong due to their previous strategy of containment, the large number of people who could get infected, and the possibility of another variant. The answer is: It’s hard to tell what happens next, but there’s probably no positive side you could see.