Dr. Jarno Habicht, WHO Representative in Ukraine

According to the World Health Organization, more than 1,000 attacks on the Ukrainian healthcare system have taken place since the beginning of the full-scale war, which is a violation of international humanitarian law.

As of today, 1067 attacks on the healthcare system have been verified: 952 attacks on medical facilities were carried out, 74 medical workers and 27 patients were injured, and 124 medical vehicles were damaged.

This is the highest number of attacks WHO has ever recorded in any humanitarian emergency.

Attacks on the healthcare system have also led to the closure of pharmacies. Every fifth person in the country has problems with access to essential medicines, while in the areas of occupation and active conflict - every third.

So, what is the situation with medicines in Ukraine? What is the situation in the temporarily occupied territories? What epidemics threaten Ukraine because of Russia's full-scale war?

Jarno Habicht, WHO Representative in Ukraine, spoke about these issues, as well as about WHO educational programs and initiatives to train Ukrainian doctors and work in wartime, in an interview with Ukrinform.

THE WAR IN UKRAINE HAS PROVOKED AN UNPRECEDENTED HUMANITARIAN CRISIS

- Over the past 15 months of the full-scale war in Ukraine, more than 1,000 strikes on the healthcare system have been recorded. How can Russia be forced to stop such attacks and compensate for the damage? What mechanisms does the WHO have?

- This is the highest number of attacks WHO has ever recorded in any humanitarian emergency. The war in Ukraine has brought immense challenges to the lives of all Ukrainians, triggering a humanitarian crisis of unprecedented scale. It is very important that there is an official platform for reporting attacks on health and the methodology in place for all the attacks not to be unnoticed and it is the only source that goes to UN Security Council. Can you imagine that without this platform everyone can report attacks on health in the way they understand it and to what level off mess and probable misinformation it could lead?

Here WHO’s role is to verify that attacks on healthcare have occurred to highlight their impact on people in the community and their access to health services.  Other bodies within the United Nations system such as the Security Council, or mechanisms such as the International Criminal Court, have the mandate to investigate attacks on health care and WHO cooperates with them where appropriate and following established procedures. 

- What is the situation with medicines in Ukraine? What is lacking the most? Do you know about the situation in the temporarily occupied territories?

- As I have seen including during recent visits close to the frontline and other war-damaged zones – attacks on health have profoundly impacted the population’s access to essential health services and medicines in addition to the closure of pharmacies. One in five people throughout the country is struggling to access essential medicines, while in areas of occupation and active conflict, that number increases to one in three. Despite significant improvement from the early days of full-scale invasion, high price of medicine and availability remains to be barriers to get necessary medicine, households reported pain, heart and high blood pressure-related are the top three medicines that as they couldn’t get.

WHO health needs assessment revealed that the proportion of those who had difficulty with the rising cost of the medicines increased, also only 7% of respondents reporting that they were unable to obtain the necessary medicines in April 2023 compering to 22% in September 2022. From financial protection studies we also know that medicines are a major driver of financial hardship for Ukrainians and are a major cause of out-of-pocket spending of the population. It’s important to involve all actors to cooperation, such as pharmacies which are mostly private in Ukraine – but their recovery and re-launch of operations, especially in areas recently re-taken under the control of Government of Ukraine, is crucial for population to be able to access medicines, including through governmentally-funded Affordable Medicines Programme.

Also WHO organized number of convoys and donations to newly-accessible and Ukraine government controlled affected areas with medicines, supplies for emergency care ensuring that health facilities continue to deliver life-saving and essential health services. WHO has delivered about 3300 metric tonnes of medical supplies to Ukraine since 24 February 2022.

- Please tell us about the consequences of the Kakhovka dam explosion. What will happen to water supply, the environment, and infections?

- The tragedy at the Kakhovka Dam caused mass destruction and human suffering, significant damage to infrastructure and the environment. Some areas are left with no electricity or potable water. As the Kakhovka reservoir served as a crucial water source for numerous major and smaller cities located to the north, west, and south of the country, the destruction of the dam has disrupted or contaminated the water supply in all these regions with the risk of waterborne diseases. The flooding is occurring in a highly industrialized zone with chemical release into water, which could result in contamination and severe impact on people and animals for several years with heightened risk of waterborne diseases, including cholera, diarrhea, and others.

WHO supports authorities and health workers prevent water-borne diseases and working to monitor for possible disease outbreaks since the first day after an accident. Our team provided cholera kits to Kherson and neighboring oblasts as it have proven to be invaluable in the current situation. Other medical goods also delivered to 4 hospitals to provide care for about 11 000 patients for several months to support generic needs, trauma and surgery, and also to treat the common childhood illness. These was done under weekly UN interagency convoys and our own missions to reach the most affected areas. Our team also helps MOH and Center for disaster medicine to coordinate more than 100 healthcare volunteers joined Kherson and Mykolaiv regions affected by the accident who will receive compensation for additional expenses, in addition to their salaries.

Also lasting mental health impacts on affected communities is one of risks we need to address jointly with MOH and partners. To assess the growing mental health needs, WHO conducted mission to Mykolaiv Oblast to visit primary health care centers, IDP centers and a psychiatric hospital. Preliminary finding of the assessment indicates that residents of the Kherson region living in IDP centers need more psychological and psychosocial support. Interviewed IDPs note anxiety, frequent mood swings, and sleep disturbances.  The support assistance from WHO side to this emergency continues.

THE NEED FOR MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT SERVICES IN UKRAINE IS HIGH

- What are the WHO educational programs and initiatives to train Ukrainian doctors? How do you work in a time of war? How does the WHO help, has it managed to attract specialists to work in Ukraine?

- Since the start of the war, WHO has supported the Ministry of Health to build the capacity of around 10,000 health care workers on a range of topics including mental health; trauma and rehabilitation; mass casualties; chemical exposure; infectious diseases; and outbreak detection and control engaging international and national trainers.

As well WHO reached more than 1200 healthcare trainees in Ukraine in a series of webinars on clinical management and medical staff safety in relation to Chemical, Biological, Radiological and Nuclear (CBRN) events. Then trainers have the possibility to share their knowledge with healthcare workers all over the country. Additionally, 726 EMS first responders and clinicians from referral hospitals in 11 oblasts were trained in chemical protection, decontamination and treatment.  So we have quite a busy schedule with trainings sharing best practices in various oblasts for Ukrainian healthcare workers were able to upgrade the skills during this challenging time to save people`s life and health.

- How do you provide psychological assistance to Ukrainian doctors and patients?

- According to WHO global estimates, one in five people (22%) living in an area affected by conflict at any time during the previous 10-year period is estimated to have some form of mental health condition. Applying these estimates to the population of Ukraine would mean that approximately 10 million people may have a mental health condition.These lead to the conclusion that needs for mental health and psychosocial support services in Ukraine are high. To meet these needs, WHO works in a few directions.

WHO with partners implement the Mental Health Gap Action Programme (mhGAP) to increase access to mental health services by involving primary health care workers (family doctors, pediatricians, therapists, paramedics, nurses). Overall, in Ukraine, almost 3000 primary health care workers have been trained on mhGAP. And almost 30,000 participants had completed the online self-paced course.

As well, 475 trainers will train representatives of different sectors (medical and social services, law enforcement, educators, NGOs, railway, enterprises) who help adults experiencing adversity to learn how to manage their stress.  Also, WHO supports the Ministry of Health in strengthening the capacity of Community Mental Health Teams (CMHTs) to provide specialized mental health care for people with severe mental health conditions in community as an alternative to institution-based care. Being the main technical partner for the All-Ukrainian mental health program initiated by First Lady of Ukraine Olena Zelenska, WHO provides support to this initiative, aimed at developing a system of provision of mental health and psychosocial support services.

- Are there programs to help women and children who have been sexually harassed during the war?

- There can be no tolerance of such acts of gender-based violence in Ukraine and all over the world. The health impacts of sexual (and other gender-based) violence on survivors are significant. These include physical, mental, sexual and reproductive health problems. As WHO we and partner agencies like UNFPA focus on survivors’ rights and need to access timely care. This care usually includes emergency contraception, tetanus and hepatitis B vaccination, STI prophylaxis, HIV post-exposure prophylaxis, and mental health support.

In cooperation with MOH, WHO conducted trainings on service provision to GBV survivors for more than 200 healthcare professionals from 8 oblasts obtained knowledge and skills on provision of care including medical care, communication skills with survivor and referral to services available to GBV survivors outside of the health sector. More capacity-building activities are planned.

THE RISK OF INFECTIOUS DISEASE OUTBREAKS IS INCREASING DUE TO THE DESTRUCTION OF INFRASTRUCTURE

- What to expect this summer in terms of infectious diseases: what epidemics threaten Ukraine due to Russia's full-scale war? There has been a lot of talk about the possibility of a cholera outbreak in Mariupol. Are programs and vaccines being prepared? Are there any known cases of the disease?

- The risk of outbreak is known to be heightened when there is disruption and destruction to water, sanitation and hygiene infrastructure and the forthcoming warmer climatic conditions of spring and summer are favorable to transmission. According to public health situation analysis made by WHO in May the risk of cholera, for example, was non-zero, but the likelihood was low. The consequences of a cholera outbreak could, nevertheless, be severe were it to occur, so cholera is classed as presenting an overall moderate risk to public health.

The risk analysis was prepared prior to the Kakhovka dam explosion, the risk of waterborne diseases, including cholera could be higher particularly in areas affected by the flooding.

No cholera cases have been reported in Ukraine also the healthcare system is ready to act in case of such kind of threat appears. Here we can talk about Government controlled area, where the data is available. Early detection and treatment are crucial and WHO is supporting surveillance through epidemic intelligence and providing cholera test kits to high risk oblasts..

- There was an outbreak of polio in Ukraine. What is the current situation?

- An outbreak was first detected in the country in October 2021. WHO with MOH and partners, provided nationwide immunization catch-up campaign which has continued despite challenges such as mass movement of the population and the destruction of health-care facilities. Despite these barriers, as of 3 July 2023, a total of over 207,000 doses of inactivated polio vaccine (IPV) had been administered.

WHO with other Global Polio Eradication Initiative (GPEI) partners conducted a comprehensive evaluation of Polio disease surveillance, vaccination, vaccine logistics, laboratory capabilities and communication efforts to assess the situation on the ground and gather crucial insights to support the overall assessment of the polio response activities conducted.

Despite the immense challenges and uncertainties faced in Ukraine due to the ongoing war, the Outbreak Response Assessment (OBRA) team did not find any evidence of continued transmission of cVDPV2 in Ukraine. Based on their findings, a recommendation to WHO European region was to consider officially closing the polio outbreak in Ukraine in September if all the surveillance and vaccination recommendations are met.

- What is the situation with COVID-19 in Ukraine and the world?

- According to the data received, 6 WHO regions continue to report decrease in COVID-19 cases. In Ukraine incidence and hospital admissions continue to decrease at the national level as well. Daily COVID-19 hospital admissions fell from an average of 191 (02 June 2023) to 156 (19 June 2023). The proportion of ICU beds occupied by COVID-19 patients remains low.

The end of COVID-19 as a global health emergency declared earlier by the WHO Director General is not the end of COVID-19 as a global health threat. So we should continue to monitor the situation by integrating COVID-19 with broader respiratory infection surveillance and continue genomic sequencing for early detection of new strains and evolving health threats. In both areas Ukraine is doing good progress.

On the other side an effective architecture for health emergency preparedness and response helped us to start to address emergency of another kind when the full-scale invasion started.

DESPITE THE WAR, UKRAINE IS COMMITTED TO REFORM

- This year marks the 75th anniversary of the organization's founding. What are the main achievements and challenges? What needs to be improved?

- The work of WHO and its partners over the past 75 years to advance public health has impacted the lives of people worldwide. From the development of life-saving vaccines against deadly diseases like smallpox, polio, and measles, to the discovery of present-day antibiotics, and the global treaty to stop tobacco use, their accomplishments have made a significant impact on the world. Additionally, new diagnostics, medicines, and treatments for tuberculosis, HIV, cancer, dementia, and many other diseases and conditions have become available, further improving global health. However, as WHO Director-General Dr. Tedros Adhanom Ghebreyesus reminds us, it's not the past 75 years that matter, but the next 75. Our team aim is to continue to improve the health and well-being of all people in Ukraine, even in the face of adversity caused by war.

In Ukraine WHO remains committed to ensuring the health system is operational and that all possible efforts are made so that the system can recover quickly.

Health system recovery is one of WHO's priority in Ukraine, which goes beyond rebuilding physical medical facilities. We aim to support the country to restore essential services such as rehabilitation, primary health care, public health surveillance, and more, critical for overall national recovery. High-quality health services and medicines instil a sense of security, promoting trust in local and national government, and allowing people to return to their homes.

Further to this, we have made mental health a vital component of the health response. WHO, along with the First Lady of Ukraine, Olena Zelenska, the Office of the President, and the MoH, have launched a critical initiative for mental health and psychosocial support (MHPSS), prioritising numerous actions for a system-wide response to the mental health needs of Ukrainians.

Due to the ongoing invasion by the Russian Federation, WHO prioritize emergency health response in Ukraine. Through our health emergency response efforts, we have reached over 9 million people for now.

- What do you think about the healthcare system in Ukraine? What needs to be reformed and what can be a good example for the EU?

- WHO has been working in Ukraine for a long time, being involved in health system development, guiding the reforms directions and also providing humanitarian support since the war began back in 2014, which escalated in February 2022. Ukraine health system works in a very dynamic environment. It wasn’t even 6 years ago that the health reform law was adopted in 2017, and today the country has a whole new health system architecture with national purchaser set-up, providers obtaining much greater independence, transparent national procurement agency, new primary healthcare approach, drastically changing rehabilitation and mental health systems. The reforms are ongoing, despite the war, and we hope to see more political will and determination to continue making the health system more effective, people-oriented instead of facility-oriented, and with sound public health policies, which are also important in scope of achieving Ukraine’s EU aspirations.

In many parts of the world, when the war starts, everything else stops. But in Ukraine, what is unique is that we really see the aspiration for the reforms continuing, despite all the pressure. And it’s crucial for international organizations considering supporting Ukraine now and in the future – to see this commitment to reforms and making difficult, sometimes unpopular decisions, for the sake of long-term stability and performance of the system.

Despite facing over 1000 attacks on health care in Ukraine since 24 February 2022, WHO, alongside healthcare authorities and dedicated health workers, have been working tirelessly to ensure Ukrainians in the country receive essential health services. The entire health system has shown remarkable resilience and dedication during these trying times, which we believe is partly due to the reforms previously implemented. WHO remains committed to ensuring the health system is operational and that all possible efforts are made so that the system can recover quickly.

It's important to note that Ukraine plays a significant role in health and development, providing opportunities for other countries to learn from its experiences. Moreover, Ukraine is a member of the WHO governing system, including the Standing Committee of the Regional Committee (SCRC). Minister of Health of Ukraine Viktor Liashko, have also joined the Executive Board of the World Health Organization in May 2023.

- What was February 24, 2022 like for you? How did the full-scale Russian invasion begin for you personally?

- The day will stay in our memory for rest of our lives, when Russian Federation started invasion of Ukraine. That day it was important to be in touch with the team to know if everyone is ok and safe and also to contact health authorities to understand their needs and inform that we are operational as well ready to assist. We made preparations before to ensure medical supplies to be available, as well various trainings and materials. However last 500+ days have been intense to ensure response to public health needs and situation is constantly evolving.

- How is the work of the WHO team in Ukraine going now? What has changed since Russia's full-scale invasion? How have you reorganized the established processes? What difficulties did you face?

- Around the 24th of February 2022 we were a smaller team of 100 people, now we are about 300 people in various locations of Ukraine, including Kyiv, Dnipro, Odesa, Poltava, Lviv among others. Also, before WHO team were mainly based in Kyiv with few offices in Donets and Luhansk Oblasts. All of our work has continued with national authorities and with local authorities, as well as with the community. For WHO, as well as during the COVID-19 response, our role has been not only policy advice and dialogue or broader technical assistance, but also very much on the ground, like the situation analysis of what is happening in the hospitals, what happens in primary care centers, how do we work in public health for disease surveillance. This has continued with all of our work but scaled up.

Irina Drabok, The Hague