Healthcare infrastructure in eastern Ukraine has suffered a devastating blow over the course of the year-long conflict near the Russian border that was sparked by pro-democracy protests in Ukraine, according to a recent Human Rights Watch report. The U.N. estimates that up to 80% of local health workers have been evacuated from the area, and those who remain endure dire shortages of supplies that exacerbate the humanitarian crisis throughout the region.
Doctors in and around the Donetsk and Luhansk oblasts have warned that tuberculosis is an especial concern. The Kiev-based newspaper Sevodnya reports that in the areas surrounding the conflict, some 50,000 TB patients have been unable to access antibiotics since August. Large donations from international aid organizations finally began to arrive in the beginning of this year, but experts say the cash came too late to ward off a potential epidemic. “We are worried about tuberculosis, because it is endemic in this area,” Loic Jaeger, deputy head of Doctors without Borders in Ukraine, told The Guardian. “With people being displaced and living in crowded places, the risk of transmission is higher.”
Jeanette Olsson, Project Coordinator at Doctors without Borders, told Blouin News that “this has led to a number of patients stopping their treatment during the most intense periods of the war.” Olsson added that staff members have since closed these gaps, and are reporting high adherence rates among patients. (She did not mention whether or not drug-susceptibility tests have been run on patients whose treatment lapsed, or whether they are believed to have developed antibiotic resistance.) Doctors without Borders is also working to bolster the healthcare system in general, which will hopefully have a prophylactic effect.
In some cases, resuming antibiotic treatment for TB after a months-long hiatus may actually do more harm than good. The reasons why illustrate just how damaging civil unrest can be on TB management programs. Curing a typical case of TB requires a course of four different daily antibiotics for a period of six to nine months. But successful treatment requires patients to take medications diligently and properly — otherwise, the mycobacteria could develop resistance. Drug-resistant forms of tuberculosis are a particularly urgent global health issue. These strains are very difficult to treat, requiring far lengthier courses of medicine with severe side effects. They are also incredibly expensive and deplete a far larger share of resources for a disease that is already severely underfunded. In short, the treatment interruption at the end of 2014 stands to produce grave consequences for the region. If any of the estimated 50,000 patients did indeed develop resistance, they could easily infect others with a newer, stronger strain.
But curing TB is more complicated than a single patient taking their pills. Because treating patients with an airborne disease like TB is inarguably in the public interest, this care is typically coordinated by a nationwide program supported by public and private partnerships. As a result, a country’s level of stability is inextricably tied to its efficacy against infectious disease. Most regions in Ukraine provide treatment to patients on a regular basis at public clinics, which relies on an uninterrupted supply chain.
It isn’t hard to see how a conflict that has displaced millions of people could have a similarly devastating effect on state-run care. Ukrainian nationals weathered criticism for blocking the East’s access to essentials like food, water, electricity and medicine, and several TB treatment centers have been destroyed in combat. Other supplies have been lost to theft — a Doctors Without Borders van packed with aid was reportedly seized at gunpoint by pro-Russian separatists who wanted a vehicle, and Human Rights Watch has reported soldier-led takeovers of civilian medical facilities to clear the way for wounded fighters.
Furthermore, the unhygienic arena of war creates a hospitable environment for tuberculosis to spread. Poor nutrition weakens immunity systems, making it harder for citizens to fight off latent TB infections before the active disease takes root. And even if humanitarian aid workers provide antibiotics and facilitate proper nutrition, they can’t very well put it in the hands of the many patients who fled their homes. Even under optimal circumstances (let alone these ones) migratory workers are a significant risk group for TB throughout the world.
The aforementioned factors would lead to interrupted TB management programs anywhere, and TB outbreaks indeed coincide with practically every worldwide conflict. That said, this context is particularly worrisome as eastern Ukraine happens to have one of the highest rates of drug-resistant TB on the planet, predating the conflict. In fact, every country from the former Soviet Union qualifies as a high burden country by the WHO, thanks largely to the economic and social crises ushered in by the Soviet collapse. Eastern Ukraine, with its dense population and overcrowded prisons — notorious mycobacterial petri dishes — was hit quite hard by an epidemic in the 1990’s, and has yet to recover.
The trajectory of the inevitable TB epidemic in eastern Ukraine depends partially on the conclusion of the present conflict. If eastern Ukraine becomes — as some analysts suggest — another post-Soviet frozen conflict zone like Transnistria, Nagorno-Karabagh or South Ossetia, there is no uniform blueprint for how TB programs will proceed there. If the region falls permanently under Russian control, there could be serious consequences for one vulnerable TB risk group: intravenous drug users. In Ukraine, methadone replacement therapy is legal, whereas in Russia it is not. Studies have shown that methadone is positively correlated with TB treatment adherence, so patients who cannot access it are less likely to be cured. If the area falls to Kyiv, managing an outbreak will depend on adequate resources and the political will of an already overstretched government.
No matter what jurisdiction eastern Ukraine ends up in, bringing the TB outbreak under control – not to mention combatting the pervasive stigma against TB and those who have it — will require a combination of funding, humanitarian commitment and social initiatives. Unfortunately, all three will be hard to come by.