01 April 2022: Editorial
Editorial: The Public Health Implications for the Refugee Population, Particularly in Poland, Due to the War in UkraineMateusz Jankowski1CDEF*, Mariusz Gujski23BCDEF
Med Sci Monit 2022; 28:e936808
ABSTRACT: On February 24, 2022, the Russian Federation initiated a military invasion of Ukraine, resulting in a significant armed conflict in Europe. Large numbers of refugees and asylum-seekers have left Ukraine. As of March 29, more than 4 million refugees, including over 1.5 million children, have left Ukraine, while about 7 million individuals have become displaced within Ukraine. Most refugees have gone to bordering countries, with 60% coming to Poland. This large number of refugees in such a short time requires urgent public health measures to ensure their health and safety. Refugees to Poland must receive access to healthcare, social care, and education. Those who have chronic disease and malignancy must continue to receive treatment. Medical students’ continued education and training in their host countries should be prioritized to provide needed healthcare resources. Epidemiological disease surveillance and disease prevention are required at this time. The continuation of the current conflict in Ukraine also poses a potentially severe risk to the global environment and long-term food security. This editorial aims to highlight the public health implications for the refugee population, particularly in Poland, due to the current war in Ukraine.
Keywords: Editorial, Public Health, Refugees, Armed Conflicts, Poland, Ukraine
On February 24, 2022, the Russian Federation initiated a military invasion of Ukraine, resulting in a significant armed conflict in Europe. The United Nations estimates that at least 30% of the Ukrainian population will require life-saving humanitarian assistance . As of March 29, over 4 million refugees have left Ukraine, including over 1.5 million children, and about 7 million people have become displaced . Most of the Ukrainian refugees sought shelter in one of Ukraine’s bordering countries, including Poland (over 3 million), Romania (609,000), the Republic of Moldova (387,000), Hungary (364,000), and Slovakia (281,000) . The current refugee situation in Europe is the largest since World War II. Healthcare professionals, especially those from neighboring European countries, are professionally and ethically obliged to prepare a response to public health and healthcare-related issues resulting from the movement of refugees.
Access to healthcare is a basic human right. Protecting the health of all, including refugees, has become a priority during the humanitarian crisis in Ukraine . Medical care is to be provided both immediately and in the long term. All refugees must be granted access to healthcare when crossing the border from Ukraine and while resident in their country of safety. Common medical problems from the extended time taken to travel and poor access to drinking water and hot meals include dehydration, exhaustion, and hypothermia. These conditions require immediate basic medical care. The refugees are also at risk of developing respiratory tract infections due to the low temperatures experienced when traveling on foot [4,5]. Also, older refugees with those with chronic diseases may experience an exacerbation of their illness [4,5]. There are also problems with the effects of lack of access to drugs, such as insulin and antihypertensives, with cardiovascular diseases, diabetes, and kidney disease requiring immediate medical attention when crossing the border [4,5].
Most bordering countries have organized reception centers that provide migrants with shelter, food, health care, information, training, specialized interventions, and other essential services [6,7]. Refugees can legalize their status as refugees or asylum-seekers [6,7]. Also, they can receive primary medical care and information on access to healthcare in the hosting country [6,7].
The predominant demographic groups amongst the refugees include women, children, and the elderly since men aged between 18 and 60 years are not allowed to leave Ukraine . Refugee children require medical attention from pediatricians, while seniors will need support from internists or general practitioners . In previous experience from war zones, immigrants tend to seek medical assistance in hospital emergency departments, which may become overwhelmed even in medium-sized and large cities . Therefore, it is crucial to provide refugees with access to primary healthcare within national health systems .
Poland is experiencing the most significant number of Ukrainian refugees. Poland has passed a law that guarantees legal permission to stay and work for 18 months, with access to social security and healthcare systems and funds made available for children’s schooling . It has been estimated that providing healthcare access to one million refugees amounts to PLN 200 million per month (USD 47 million) [8,9]. Host countries need support, so an international effort is required to remove financial barriers, which prevent helping those in need.
Healthcare systems across the European Union (EU) are adjusting to deal with the massive influx of arrivals from Ukraine. It is essential to provide treatment for oncological patients, patients with renal failure, those who have undergone transplantation, and those who require immunosuppressive treatment . The EU has been mediating the relocation of Ukrainian oncology patients to its member states . However, mental and psychosocial support services should also be provided within the host country due to the high burden of psychological distress and trauma experienced by many refugees . These services may be provided online and using video consultations.
Approximately 2.7 million persons with disabilities are registered in Ukraine . Individuals with disabilities face a greater risk of abandonment, violence, and death, while their access to safety and recovery support is limited. Actions need to be undertaken by public health and social care institutions to provide the disabled with access to professional care.
The language barrier constitutes another challenge that is currently being faced by European healthcare systems. Generally, refugees lack medical documentation, while those who possess it may have documentation only in the Ukrainian language. Healthcare specialists should also be provided with professional medical translators and translation assistance. The allocation of human resources should be optimized. Language barriers should be recognized as one of the main factors that limit healthcare access for refugees. It is also important to acknowledge that the medical professionals amongst the Ukrainian refugees could support the medical care of refugees within the host countries.
The World Health Organization (WHO) Regional Office for Europe calls for European countries to ensure the protection of all refugees . The WHO supports access to vaccinations . For example, in Ukraine, the overall vaccination rate for polio in 2021 was 80%, while in 2020, the overall vaccination coverage for measles vaccines (two doses) was 81.9% [11,12]. However, only 30% of the Ukraine population received at least one dose of a COVID-19 vaccine. All vaccination rates are considerably lower than those reported by the neighboring host countries [11,12]. There is increasing difficulty in determining the vaccination status of refugees due to a lack of access to childhood immunization records. The European Center for Disease Prevention and Control (ECDC) has called for all host countries to ensure vaccination coverage against poliomyelitis, measles, and COVID-19 among Ukrainian refugees .
Ukraine also has some of the highest rates in Europe for chronic infectious diseases, such as tuberculosis, HIV/AIDS, hepatitis B, and C . In recent decades, international health organizations and non-governmental organizations (NGOs) have supported capacity-building interventions for tuberculosis and HIV in Ukraine .
The war has disrupted the supply of antiretroviral drugs used for treating HIV and treatments for tuberculosis, which may lead to increased rates and severity of these diseases [12,13]. Access to diagnostic services and ongoing chronic communicable disease care, particularly for HIV and tuberculosis, should be facilitated by the healthcare systems of the hosting countries. To prepare for future mass migration, all European countries should ensure effective disease surveillance and reporting systems, including outbreak investigation, case management, and evaluation of response capacities.
Education has also been affected by the war outbreak. It is estimated that more than 750 schools have been damaged since the conflict began in Eastern Ukraine in 2014 . Sadly, the war has also affected the psychosocial well-being of an entire generation of children. All areas of higher education, including medical education, have been affected. Thousands of medical students have either fled their country or remained in Ukraine to serve in the military, including as paramedics. Ukraine’s medical universities have been popular for international students . It has been estimated that between 18,000 to 20,000 students from India were recently enrolled in 33 medical universities in Ukraine . Because most of these students will return home, medical education poses a challenge because it requires practical training and access to clinical facilities and patients. Ensuring the continuation of medical studies for Ukrainian refugees is a major challenge to the international community.
The WHO has documented at least 43 attacks on hospitals and medical facilities in Ukraine since the beginning of the Russian invasion . More than 300 health facilities are located along the conflict lines or in areas under Russian control . Healthcare professionals from Ukraine are also among refugees to European Union member states. Many countries have developed programs to facilitate the work of refugee doctors and nurses within their healthcare systems. There is also a need to establish internships and scholarship programs to aid Ukrainian scientists who have fled the war. Also, public health experts from Ukraine can provide a valuable resource. Training Ukrainian professionals in disease prevention and public health is an important consideration for the post-war era to facilitate the reconstruction of the Ukrainian healthcare system.
The ongoing conflict has highlighted the importance of updating postgraduate medical education programs in many EU countries. Postgraduate medical education programs should now extend their training to treat gunshot wounds, respond to crises, and provide radiation protection. The humanitarian, healthcare and education-related consequences of Russia’s military invasion of Ukraine are of major concern. However, the war has also had a devastating impact on the environment. Ukraine is a highly industrialized country whose infrastructure has been undergoing military attacks resulting in a high risk for environmental pollution, including water and soil pollution. Fuel and chemical spills and heavy metal contamination are a byproduct of war that pose a severe risk for the environment .
Finally, Ukraine is one of the world’s leading exporters of major grains and vegetable oils . The current war will have a global effect on food and agriculture. The limitations associated with lack of sowing cereals, infrastructure destruction, environmental pollution, and reduced export will significantly affect food supplies [18,19]. Food insecurity and famine may result in some world regions [18,19]. According to the World Food Programme (WFP), the impact of the war in Ukraine on food security will be global and requires an international response .
Russia’s recent military invasion of Ukraine calls for an international public health response. The international community must provide humanitarian aid, access to healthcare, social security, food security, and education for the entirety of the Ukrainian refugee population. Also, the public health systems of host countries must be adapted to meet the new challenges. National and international programs must ensure effective disease surveillance and reporting systems, disease outbreak investigation, case management, and response capacities well-prepared for the massive migration of Ukrainian refugees in Europe, particularly in Poland.
1. United Nations Development Programme: The development impact of the war in Ukraine: Initial projections March 16, 2022 Available from: https://www.undp.org/publications/development-impact-war-ukraine-initial-projections
2. United Nations High Commissioner for Refugees, Operational data portal. Ukraine refugee situation: Continually updated Available from: https://data2.unhcr.org/en/situations/ukraine
3. World Health Organization (WHO) Regional Office for Europe. Migration and health: Access to vaccination for refugees from Ukraine needed to protect the most vulnerable among them from vaccine-preventable diseases March 10, 2022 Available from: https://www.euro.who.int/en/health-topics/health-determinants/migration-and-health/news/news/2022/3/access-to-vaccination-for-refugees-from-ukraine-needed-to-protect-the-most-vulnerable-among-them-from-vaccine-preventable-diseases
4. World Health Organization (WHO): Global Evidence Review on Health and Migration (GEHM): Strengthening information about health services related to NCDs for refugees and migrants to support evidence-based policy making on migration and health, 2022, World Health Organization Available from: https://www.who.int/news-room/events/detail/2022/03/01/default-calendar/global-evidence-review-on-health-and-migration-(gehm)-strengthening-information-about-health-services-related-to-ncds-for-refugees-and-migrants-to-support-evidence-based-policy-making-on-migration-and-health
5. Zenner D, Méndez AR, Schillinger S, Health and illness in migrants and refugees arriving in Europe: analysis of the electronic personal health record system: J Travel Med, 2022; taac035 [Online ahead of print]
6. European Commission: Migration and Home Affairs March, 2022, Task Force Migration Management Available from: https://ec.europa.eu/home-affairs/policies/migration-and-asylum/migration-management/task-force-migration-management_en
7. European Centre for Disease Prevention and Control: Handbook on implementing syndromic surveillance in migrant reception/detention centres and other refugee settings, 2016, Stockholm, ECDC Available from: https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/syndromic-surveillance-migrant-centres-handbook.pdf
8. Notes from Poland: Poland passes law expanding support for Ukrainian refugees March 14, 2022 Available from: https://notesfrompoland.com/2022/03/14/poland-passes-law-expanding-support-for-ukrainian-refugees/
9. World Health Organization (WHO) Regional Office for Europe: Policy brief on migration and health: mental health care for refugees, 2018, Copenhagen Available from: https://www.euro.who.int/_data/assets/pdf_file/0007/388069/tg-pb-mental-health-eng.pdf
10. European Disability Forum: Protection and safety of persons with disabilities in Ukraine February 24, 2022 Available from: https://www.edf-feph.org/protection-and-safety-of-persons-with-disabilities-in-ukraine/
11. European Centre for Disease Prevention and Control: Operational public health considerations for the prevention and control of infectious diseases in the context of Russia’s aggression towards Ukraine March 8, 2022, Stockholm, ECDC Available from: https://www.ecdc.europa.eu/sites/default/files/documents/prevention-control-infectious-diseases%E2%88%92Russia-aggression.pdf
12. World Health Organization (WHO) Regional Office for Europe, Ukraine crisis: Public health situation analysis: Refugee-hosting countries March 17, 2022 Available from: https://apps.who.int/iris/bitstream/handle/10665/352494/WHO-EURO-2022-5169-44932-63918-eng.pdf
13. World Health Organization (WHO) Regional Office for Europe: World Tuberculosis Day: supporting Ukraine in scaling up TB diagnosis and treatment March 23, 2021 Available from: https://www.euro.who.int/en/countries/ukraine/news/news/2021/3/world-tuberculosis-day-supporting-ukraine-in-scaling-up-tb-diagnosis-and-treatment
14. United Nations, UN News Global perspective Human stories: Conflict in Ukraine disrupting entire generation of children, says UNICEF February 18, 2022 Available from: https://news.un.org/en/story/2022/02/1112272
15. Kaushik M, War, apathy throw Indian medical students in Ukraine in disarray March 16, 2022, Forbes India Available from: https://www.forbesindia.com/article/take-one-big-story-of-the-day/war-apathy-throw-indian-medical-students-in-ukraine-in-disarray/74495/1
16. World Health Organization (WHO): WHO Director-General’s opening remarks at the WHO press conference March 16, 2022 Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-who-press-conference-16-march-2022
17. Lima DR, Bezerra ML, Neves EB, Moreira FR, Impact of ammunition and military explosives on human health and the environment: Rev Environ Health, 2011; 26(2); 101-10
18. Statista: Statistics about Agriculture in Ukraine Available from: https://www.statista.com/map/europe/ukraine/agriculture
19. World Food Programme (WFP): Ukraine emergency March, 2022 Available from: https://www.wfp.org/emergencies/ukraine-emergency
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