Our global attention has skipped effortlessly from the dangers of COVID-19 to the war in Ukraine. Both global events have fostered fear, sadness, and death. And both are challenges to the world’s public health system.
On this week’s WhoWhatWhy podcast, we talk with Dr. Barry Levy, a past president of the American Public Health Association, an adjunct professor of public health at Tufts University School of Medicine, and author of From Horror to Hope: Recognizing and Preventing the Health Impacts of War.
Levy reminds us that war creates public health crises which last long after the bullets stop flying, such as lack of clean water and adequate sanitation, and the threat of communicable diseases, including tuberculosis, measles, and cholera.
Pregnant women and newborn infants are most immediately at risk from these conditions, but Levy points to the persistent and widespread suffering caused by post-traumatic stress disorder, depression, anxiety, alcoholism, and drug abuse.
Adding to all of this is the environmental degradation that is an inevitable consequence of war —- from landmines and unexploded munitions to toxic gasses and chemicals released from damaged industrial sites.
The terrible truth, Levy says, is that the costs of war, like that raging in Ukraine, do not end when one side or the other declares victory.
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Jeff Schechtman: Welcome to the WhoWhatWhy podcast. I’m your host, Jeff Schechtman. It’s as if we have slipped effortlessly from our focus on the COVID pandemic to war in Ukraine, both global events that have fostered fear, the threat of ever-spreading disease, and produced death and sadness. But that’s not where the comparison ends. Both are fundamental issues of public health.
When we see death and destruction in Ukraine and hear the statistics about refugees and the ups and downs of the battlefield, we often don’t see what it’s like for people actually living in a war zone. The threat of communicable disease is everywhere. Women having to give birth amidst the sirens of war, the trauma of children seeing a violent war up close and personal who are changed forever.
Add to this the long-term environmental consequences of human beings breathing the residue of bombs, buildings, and human destruction. These are all consequences that people will live with long after the war ends and even after Ukraine is rebuilt. We’re going to talk about those public-health consequences today with my guest, Dr. Barry Levy. He’s a physician and epidemiologist. He’s written and spoken extensively on the public-health impacts of war and terrorism.
He’s edited 20 previous books and authored more than 250 journal articles. He is an adjunct professor of Public Health at Tufts University School of Medicine and is a past president of the American Public Health Association. He’s the author of the recent book From Horror to Hope, recognizing the health impacts of war. It is my pleasure to welcome Dr. Barry Levy here to the WhoWhatWhy podcast. Barry, thanks so much for joining us.
Barry Levy: Thanks for having me. Good to be with you and your listeners.
Jeff: You’ve been studying war and the public-health consequences. You’ve been around war zones. In wartime, is anybody really thinking about these public-health consequences?
Barry: Yes, indeed. People are thinking about the public-health consequences. Of course, a lot of the focus is on treating the injured and ill, but mainly it’s focused on people who have been affected by bombs and bullets and explosions. And often, there isn’t a focus on people who are becoming ill as a result of the breakdown of the healthcare system, the difficulty in accessing food and water, the breakdown of the electrical grid often. And so people are often really in very desperate circumstances.
But the focus from the medical community and even the public-health community often has to be on those who are most immediately affected by bombs and bullets and explosions.
Jeff: Triaging those things is certainly critical and important, but some of these long-term impacts to public health really can be just as profound.
Barry: Yes, just as profound. And in many wars, the number of people who have died or become seriously ill as a result of these other effects – you mentioned communicable disease, mental-health impacts, malnutrition, and so forth – these effects may be, in fact, much more prevalent and longer-lasting, with effects that last far beyond the end of the war.
Jeff: Talk about some of the things that you’ve seen in communicable diseases and the way these things take root in a country at war.
Barry: Sure. And by the way, the Ukraine healthcare system was actually a very good healthcare system and the health status of the population was relatively good before the war began. So the health system is not without capability in dealing with a lot of these problems, although the healthcare facilities and health workers have been attacked. But in response to your question, with regard to communicable diseases, for example, one of the things that happen during war is that people cannot easily access safe water.
And, for example, in some places where the Russian forces have restricted access to water, people have been draining water from their water-heaters and radiators of the car just to have some water to drink. So often, people are drinking contaminated water, water that’s contaminated with toxins or bacteria or viruses, and so they develop gastrointestinal diarrheal diseases, things like cholera or dysentery. And indeed, there could be large outbreaks of the disease as a result.
The other major category of communicable diseases we’re concerned about are respiratory diseases like COVID and also like tuberculosis. And so when people are uprooted from their homes and communities, when they’re without medical care, but [also] very importantly when they’re crowded in subways or other shelters to avoid the bombing and to protect their own safety and that of their children, they’re crowded together and diseases that spread by the respiratory route like COVID are more likely to spread.
And indeed, that’s likely what’s happening.
Jeff: Why haven’t we heard more about the spread of COVID in Ukraine?
Barry: For a couple of reasons at least. One is the news coverage focuses on the deaths and people who are injured by explosions and bombs and bullets and so forth, number one. But number two, COVID becomes less of a priority when war is going on. And so doctors are not necessarily giving it a higher priority because there are more immediate things that they need to attend to.
You used the word triage a little while ago, and indeed, doctors and nurses and other health care workers have to focus on those whose lives are threatened by the immediacy of war.
Jeff: Talk about the environmental degradation as a result of war and the health consequences of that.
Barry: Sure. And again, in midst of war, environmental degradation, so it takes a lower priority, unfortunately, but understandably. And so war damages, it contaminates the air, the water, the soil, destroys animals’ habitats and ecosystems. And with regard to Ukraine, keep in mind that Ukraine is a highly industrial country, particularly in the east and the southeast, where so much of the fighting has gone on.
So there are fires and explosions that contaminate the air with toxic gases and with particulate matter, which in turn causes respiratory problems, increases the risk of heart attacks, and so forth. There’s destruction of factories with chemicals and other hazardous substances leaking into the groundwater or surface water onto the soil. There are military maneuvers that damage the environment and create greenhouse gases that contribute to climate change.
And in Ukraine right now, perhaps the greatest environmental threat are the landmines and the unexploded bombs and missiles and cluster munitions that are strewn all over the environment. The Russians have consciously deployed landmines in so many areas. And so, even when the Russian forces retreat, those landmines are there until they’re systematically and very carefully removed, and they represent a major threat to people, especially children who might approach them or touch them and be killed as a result.
Jeff: You mentioned children. That’s another major part of this, obviously – just the mental-health consequences given what children are seeing.
Barry: Yes, absolutely. They’re witnessing atrocities. They’re uprooted from their homes and communities. They’re often separated from their families. Many children have become orphans as a result. Some of them, of course, with their parents or at least their mothers, cross borders into other countries where they also may be at risk. Particularly adolescent girls may be at risk of trafficking, adult women as well. So children are at risk in many ways.
The mental-health problems that children face may actually scar them for life no matter how much treatment or remediation occurs during and after the war. So the mental-health problems are really enormous and particularly for children.
Jeff: One of the things about all of these areas we’ve talked about – and you talk about it in the context of what the priorities are within a war – [is] that very little can be done, it seems, to address some of these problems while the war is ongoing.
Barry: Yes, that’s true. It varies, of course, with the war and the place in the war. Keep in mind that Ukraine is a country the size of Texas with a population, at least before the war began, the size of California, about 40 million people. And so the situation varies from one part of the country to the other. In Kyiv, where of course there have been attacks, but it’s a more, I want to say, normal situation.
But these problems, these other problems that we talked about – malnutrition, communicable diseases, mental health issues – can be addressed more easily than perhaps in the midst of the southeastern part of Ukraine where there’s [intense] fighting, where people have been sheltered, remember in the steel mill for weeks on end. And of course, an untold number of people are sheltered in the basements, in the forest, and there the priority is just on surviving and accessing enough food and water to survive.
So it depends on the stage of the war and the place of the country. And you’re right – in some places, little or no attention can be given to these other problems in the midst of the war.
Jeff: One of the other aspects of this is the refugee flow. In a country of 40 million people, as you mentioned before, a quarter of the population, about 10 million people, have moved out of the country, have spread elsewhere as refugees, and arguably carrying with them a lot of potentially communicable diseases.
Barry: Well, yes, that’s true. And imagine if any of us were suddenly uprooted from our homes, our communities, our friends and family to another country where a different language is spoken, where there’s a different healthcare system, where we’re often welcome, but there are dangers lurking. I mentioned trafficking already, and so it’s a very difficult situation for the refugees. In fact, I’ve heard reports in the media where some of the refugees actually have headed back to Ukraine because they think they’re safer there.
Now, again, that’s going to vary with their specific conditions and what country they’re in and so forth, but it’s a very difficult situation to be a refugee. Indeed the UNHCR, the UN agency on refugees, declared, I think it was about four days ago, that there are now 100 million uprooted people in the world – both refugees who have gotten to other countries and internally displaced people.
Like perhaps about 8 million Ukrainians who are within Ukraine, but still internally displaced, who often have a worse plight than those refugees who have actually gotten to the [supposed] safety of other countries.
Jeff: What’s being done in terms of vaccines or monitoring with respect to some of these communicable diseases as people are fleeing the country?
Barry: Efforts are being made to determine who has not been vaccinated and encourage people to be vaccinated, particularly against COVID but also other diseases like measles. Even before the war began, the vaccination rates for measles among children in Ukraine were relatively low, and so there had been measles outbreaks. There even had been a small polio outbreak in Ukraine about a year ago.
So efforts are being made particularly for children, but also with regard to adults, to make sure that they’re at least offered a COVID vaccine. That makes a big difference in preventing these preventable diseases. One of the great frustrations I think for a lot of people like myself who work in public health is that there are available preventive measures like these vaccines of proven effectiveness that people either don’t have access to, or they may have misinformation about the safety and effectiveness of the vaccine, so efforts do need to be made to [expand] public-health efforts to immunize people who have not been immunized against these known diseases.
Jeff: What are the concerns of diseases spreading far and wide around, certainly within Europe, as a result of the war?
Barry: Well, I think that’s probably less of a concern than some other issues that are secondary effects of the war. For example – and there’s been increasing coverage of this issue in recent days – one of the distant effects of a war, as you’re raising this issue, is the malnutrition and famine that will result in other countries, particularly low- and middle-income countries, that are dependent on grain, wheat, and corn coming from Ukraine
And so one of the distant effects of the war now, because Russia is blockading the ports, Russia is actually stealing a lot of the grain and shipping it back to Russia, and a lot of food crops will not be planted and effectively harvested this year. And so there’s going to be hunger and famine and malnutrition in other parts of the world. That’s even a bigger problem than the smaller risk of actually infectious diseases being spread by refugees.
Another concern just on that same note is that as countries respond to what’s going on in Ukraine and the war there, and the increased risks that they perceive, they’re going to be spending more money [on defense]. For example, Germany just a few weeks ago literally overnight doubled its military budget, and so money that otherwise might have gone for healthcare or public health or education or the social safety net in Germany is now going for military expenses.
That scenario is being repeated in many, many other countries. These are some of the other distant effects that yes, communicable diseases might spread, but these are some of the even greater concerns.
Jeff: This war, like all wars, will come to an end. Is there a system in place, a plan in place among the UN, NGOs, the World Health Organization to begin to deal with some of these issues once the war does end?
Barry: There’s a better understanding of what makes for a good peace, and there’s been better coordination among UN agencies and bilateral governmental agencies and non-governmental charitable organizations. But some of the things that need to be done are rehabilitating not only individuals but communities and trying to reestablish normalcy to the extent that that can be done. A very important thing in building and maintaining peace is engaging women in the process.
It’s often said that men make war, and unfortunately, men have often made ineffective peace agreements that often lead to a recurrence of war; so it’s been shown that when women get engaged in the peace processes, they’re more likely to be sustainable.
Jeff: Talk about how long it will take from your experience, what you’ve seen in past wars, for a lot of the country to be habitable again in terms of a breathable air and clean drinking water, et cetera.
Barry: Well, again, I think a lot depends on how soon peace can be established, at least the cease fire, and what the elements of that peace agreement are. Again, Ukraine is a huge country with a large population, as you say, much of which has been displaced by the war. But I think with the support that Ukraine has received militarily and otherwise during the war, I have a lot of hope that, once the war ends, efforts will be on a major scale to try to return things to a sense of normalcy as soon as possible.
As you say, also the different parts of the environment, different parts of life in Ukraine will take different amounts of time to restore. The air may be cleared relatively quickly. It may take a longer period of time to clear the land of these landmines and unexploded weapons.
Jeff: Are there wars we can look to for best practices in public health-issues both during war and after the war?
Barry: When we think from a public-health perspective, there are some best-practice countries you might say that have shunned military and shunned war. For example, the country of Costa Rica in Central America has one of the highest rates of life expectancy, one of the lowest rates of infant mortality and maternal mortality. This has been a function largely of the fact that they don’t have a military and they haven’t engaged in war.
I did an analysis of the countries that spend more on health than on military, and they tend to be countries that have a higher health status of the population and are less likely to be engaged in war itself. I think it’s hard to make generalizations about best practices during war, and best practices in building peace [are] some of the best practices I’ve already mentioned.
During war, there are the Geneva Conventions that include the protection of civilians and civilian infrastructure, and of course, also protecting wounded military and prisoners of war. Those best practices actually, during war, are embedded in international humanitarian law and human-rights law to protect civilians, protect the civilian infrastructure, to protect healthcare facilities, hospitals, clinics, and so forth during war, which are being violated.
Those laws are being violated apparently by the Russians with the many direct attacks on health and healthcare. So the best practices I guess during war you could say are embodied in the Geneva Conventions and other parts of International Humanitarian Law. To a large extent, those have been followed in many wars where military have tried to avoid civilians and civilian infrastructure.
Jeff: Talk a little bit about the refugee camps. It just seems that they would be even more intense hotbeds for communicable disease.
Barry: Yes, that’s true in many wars. In this particular war, a lot of the refugees are actually being placed in living arrangements in cities rather than in camps, but indeed there are refugee camps; and within camps, as you say, people are crowded together. They’re away from their usual protections in many ways, not only in terms of disease protection, but protection against violence against women and so forth.
Refugee camps can be areas where there’s more easy spread of communicable diseases as people are crowded together – so respiratory diseases, measles is a big problem for children, particularly if they’re not immunized. And so if they’re not immunized, measles or polio or other diseases can spread quickly in a refugee camp. But one of the trends we’re seeing actually around the world is more and more refugees are actually being absorbed into cities and communities by the host countries, by the host cities; and, while there are still many refugee camps around the world, the trend is to try and integrate refugees into communities.
Jeff: Talk a little bit about the availability of doctors that are working in warzones.
Barry: Yes. So one of the things that happens in warzones, as we said already, is that the existing doctors may be attacked. They actually may be targeted as a strategy of war – and not only doctors, but nurses and healthcare workers – so their numbers may be fewer. Some of them may choose to flee for their own safety, some may be killed or injured, and, [as things are], some may be imprisoned in certain situations during war, particularly during civil wars.
One of the things that physicians and healthcare workers in other parts of the world try to do is to do whatever they can to help to protect those physicians and nurses and other healthcare workers by trying to build support for them in the international community. There are organizations like Physicians for Human Rights that have done a lot of excellent work by supporting physicians and other health workers in warzones.
Just expressing solidarity and doing what they can to advocate for their protection because their role is so vital in maintaining the health for the population and addressing the immediate needs of those who are wounded.
Jeff: Dr. Barry Levy. I thank you so much for spending your time with us on the WhoWhatWhy podcast.
Barry: Great to be with you and your listeners, Jeff. Thank you so much.
Jeff: Thank you. Thank you for listening and joining us here on the WhoWhatWhy podcast. I hope you join us next week for another radio WhoWhatWhy podcast. I’m Jeff Schechtman. If you like this podcast, please feel free to share and help others find it by rating and reviewing it on iTunes. You can also support this podcast and all the work we do by going to whowhatwhy.org/donate.