Author: Sangeetha Srinivasan
As former Vice President Biden’s journey through the Democratic 2020 presidential campaign began, Ukraine became a hot topic in the American news, making it a relevant country for further review. Ukraine, a country the size of Texas, has recently been flagged for political and health reasons. The political conflicts include a long-standing Ukrainian enemy – Russia, as well as the United States with President Trump allegedly and criminally targeting his domestic political rival. Political conflict is not a new issue for Ukraine, as the country has been amidst political tensions with Russia for decades. It would be safe to say that the average American is blissfully unaware of the dispute between the former Soviet Union country and Russia. Besides health, Ukraine has recently been in the news for its measles outbreak. Travelers who entered the United States after visiting Ukraine were among the most likely to transmit the measles virus. This past year “close-knit Orthodox Jewish communities” who participated in a religious pilgrimage to Ukraine consisted of 75% of the 1249 measles cases in the US. The CDC also put a precautionary warning for those attending the Rosh Hashanah Pilgrimage to Uman, Ukraine this past year as a mass gathering of 30,000+ unvaccinated people could accelerate the spread of infectious diseases like measles. The best way to limit future measles cases within the US is to examine and understand the conflicts preventing proper public healthcare in countries like Ukraine.
Background on Measles
Measles (rubeola) is an infamous preventable viral disease that, despite being eliminated in the US back in 2000, has made a shocking return as the disease continues to persist in travelers from other countries who bring this respiratory disease into the US. Measles contains an airborne risk component making the disease highly contagious especially since the measles virus can last in the air for up to 2 hours after a patient coughs or sneezes. Unlike many other contagious diseases, the measles virus has no zoonotic element and is purely spread through humans. The virus resides in the upper respiratory barrier epithelium – the nose and throat mucus.
The symptoms take about a week to two weeks to show in the infected patient. The patient can pass the disease on from about four days before the measles rash shows up on the body to four days after the rash has subsided. Starting with the normal fever, cough, runny nose, watery eyes, the patients infected with measles jump to more serious symptoms such as Koplik spot in the mouth and the rash. The measles virus is most associated with it’s rash symptoms which appear 3-5 days after the initial symptoms. The flat red rash spots start at the head hairline and make their way down to the rest of the body to the legs. Due to the recent influx of anti-vaxxers around the globe, measles has a high probability of thriving in communities where vaccination is unpopular even in developed countries. A country needs to have 93-95% of its population successfully vaccinated for measles virus for herd immunity to kick in. Herd immunity refers to the percent of a population that needs to be vaccinated in order to protect the whole population including those who could not vaccinate themselves for any reason. In 1954 Dr. Thomas Peebles isolated the measles virus from a student named David Edmonston. The measles vaccine that is currently used is the weakened version of the Edmonston-Enders strain developed by Maurice Hilleman in 1968. This vaccine has not been changed since. Like in most cases of infections, infants under 12 months who are too young to get the vaccine and the elderly are at the highest risk of contracting “measles-related complications and death”. It is important to note unvaccinated people have a higher susceptibility for the measles virus in general.
Ukraine Country Profile
Ukraine is a fairly new country as it only gained independence from the Soviet Union in 1991, less than 30 years ago. This novel quality of the country definitely plays a role in the political and health related turmoil brewing within Ukraine. The majority religion is Orthodox Christianity. The Netflix documentary “Winter on Fire: Ukraine’s Fight for Freedom” is a great starting point for Americans who want to understand the civil rights movement of 2013-2014 and the Ukrainian’s citizens’ mistrust of the government that used excessive violence on peaceful students and citizens. Roughly 1 out of every 44 citizens participated in the Euromaidan protests in Kyiv fighting against the corrupt Ukrainian government, ultimately forcing the then President Viktor Yanukovych (Party of Regions) to step down and the former prime minister Yulia Tymoshenko to be freed from jail. The citizens wanted Ukraine to be a part of the European Union, while Yanukovych pushed his agenda towards aligning with Russia, which enraged the newly liberated citizens who did not want a repeat of Soviet Ukraine. While it seems like the protests had a happy ending, the big war with Russia was just brewing. After the protests ended in February 2014, the Russian military occupied Crimea in March 2014. Eventually the Crimeans voted to secede from Ukraine and join the Russian Federation. Crimea is still considered disputed territory as Ukraine has not let Crimea go to Russia and the pro-Russia separationists who control the territories in eastern Ukraine (Appendix A). Following suit of Crimea, the pro-Russia separatists of the Donetsk and Luhansk regions of eastern Ukraine have also voted to be independent of Ukraine. With Ukraine preoccupied with its internal conflict, Russia had the chance to channel its ulterior motives through the Ukrainian pro-Russia separatists without having to get its hands dirty.
The graphic above depicts the different disputed territories and conflict areas of Ukraine that are discussed in this memo. The UN is still split on who between Russia and Ukraine owns Crimea. The Minsk Accord ensured Ukrainian charge over Donetsk and Luhansk, as well as other conflict areas.
That said the US did not just sit back and watch Ukraine suffer. The Obama administration in 2014 released pictures showing rocket launchers fired from Russia striking Ukrainian forces, incriminating Russia while Russia still tried to feign innocence. Tensions built up when Russia launched a missile that was aimed for Ukraine, but instead shot down a Malaysian Airlines flight, killing 298 people on board. With the first Minsk agreement a failure, France, Germany, Russia, and Ukraine worked on a new Minsk Accord in February 2015. It resulted in “immediate and full bilateral ceasefire” in Donetsk and Luhansk, “withdrawal of heavy weapons,” “discussion of local elections,” release hostages and pardoning of opposition leaders, unimpeded humanitarian aid, and full Ukrainian government control over disputed territories and conflict zones. In June 2017 Ukraine faced a NotPeya ransomware cyberattack, courtesy of Russia. The Ukrainian government was not prepared for such an attack and until 2018 is still struggling to recover from the monetary damages incurred, setting the already poor nation further back8. The people of Ukraine thought it was time for a change; like Americans, they voted for a television personality with no political experience as their president – Volodymyr Zelensky. In the few months in power, Zelensky has been acting on the defensive towards Russia which angers some of the citizens who worked so hard to make sure Ukraine stays liberated, thus cycling the turmoil.
Epidemiology of Measles in Ukraine
At a population of 43 million (and declining), only 42% of Ukrainians are vaccinated against measles. The threshold percentage of the population that needs to be vaccinated in order to contain measles is 93-95% making Ukraine at its mere 42% an optimal breeding ground for this highly contagious disease. Between 2008 and 2016, 60% less Ukrainian children received their second MMR vaccine dose. With over 23,000 measles cases reported in 2017 and over 54,000 in 2018, Ukraine runs the highest numbers of cases in Europe. Ukraine is not the only European country with measles cases though. France, Georgia, Greece, Italy, Russian Federation, and Serbia all showed high measles counts as well, but just not to the extent of Ukraine.
Dr. Giuliano, an expert in Ethnic Politics in Post-Soviet Eurasia, believes that the perception of ethnic boundaries stems from the political leader and the stigmas they implement on certain cultural practices. In Ukraine’s case, in an effort to unify all populations Ukraine’s parliament passed a Law on Education in 2017 banning schools from teaching in a minority language . While this is great in theory, if schools did not adapt quickly enough certain populations wouldn’t have access to education. On the topic of education, the Ukrainian government raised its extremely low vaccination rates by providing free vaccinations and mandating children be vaccinated in order to be admitted to school in 2017 with the help of WHO and UNICEF. However, investigative journalist for The Lancet, Ed Holt speculates that parents might be getting fake certificates of immunizations as he is incredulous that parents with anti-vaccination sentiments would randomly change because the government told them to. He also mentions that even though vaccines are free, hospitals may not have enough in stock. For most Ukrainians, paying for a vaccine out of pocket would be more expensive than forging the certificate of immunization. Given that perspective, it would be hard to quantify whether there is a true increase in vaccination or whether it is just namesake.
In addition, the humanitarian crisis of the war-filled disputed territories/ conflict-areas in Ukraine have negatively affected about 10% percent of the population, of which more than a quarter fled their homes and became internally displaced persons (IDP’s). Humanitarian aid has been hindered by the armed troops in the conflict areas as they make it extremely difficult for them to pass through their extensive screening procedure or “accreditation system”. Police, servicemen, and other armed members in the conflict area are being extra difficult towards humanitarian organizations, making access to measles vaccines and cleaner, healthier living conditions unattainable. While the Ukrainian government is doing its best with providing free vaccinations and mandating children get vaccinated, the pro-Russian separatists in the conflict areas like Donbas, Donetsk, and Luhansk are stiff obstacles. As these armed troops continue to threaten the livelihood of the civilians, they are only making the public health situation worse. In poor, crowded living conditions with no access to vaccines, these citizens are at a higher risk for spreading measles. The political conflict is directly impeding vulnerable Ukrainians from accessing proper health care and public health aid when they need it the most.
With the lowest vaccination rates in Europe – 19% of the population for diphtheria, tetanus, and pertussis and 42% of the population for measles, mumps, rubella – Ukraine needs to push its citizens to value public health higher. According to the CDC vaccine preventable are not the only health concerns in Ukraine. Ukraine is at risk for HIV (PLHIV) and Polio. It is interesting to note that while vaccination and immunization rates are extremely low, the leading causes of death in Ukraine are primarily heart related. The American Heart Association published an article in 2018 stating that the inflammation response from when a patient gets sick can possibly be a trigger for heart diseases and stroke. This hypothesis could connect the low immunization rates to the leading causes of death in Ukraine. The CDC established an outbreak preparedness team called Field Epidemiology Training Program (FETP) in Ukraine to strengthen and sharpen the disease detecting skill-set in the local public health professionals. Hopefully as the FETP cohort sizes increase, Ukraine can become self-sustainable in disease control in the future.
The situation in Ukraine is very tricky as the conflict areas make the country vulnerable, especially since it does not stand a chance against the extensive Russian army. Perhaps if Ukraine mandated army service like South Korea and Israel, it would have more man-power. Regardless, the country does not have sufficient funds to take on Russia. This is where the United States comes in. Politico journalists Bryan Bender and Wesley Morgan state in their article that the “US has provided about $1.5 billion in military support to Kiev between 2014” and June 2019. Ukraine used that money to armor itself and stabilize its military/ territory crisis. With the sudden halt in military aid from the US to Ukraine, journalists speculate using evidence from the whistleblowers’ complaints that President Trump was providing money in exchange for information on his Democratic opponent – former Vice President Joe Biden.
The infographic above Ms. Inez Torre from CNN depicts how the Ukrainian army is likened to an ant compared to the Russian army.
Ukraine is dependent on foreign monetary aid if it will ever stand a chance against Russia and the militant pro-Russian separationists. Without stabilizing the conflict areas in Ukraine, humanitarian aid will continue to be limited. Without humanitarian aid, Ukrainians may not get access to health care and their public health needs. Without access to their public health needs, infectious diseases will continue to thrive and spread amongst unvaccinated communities and ultimately travel out of Ukraine. And with that we are back to square one. While it is a stretch to say without providing Ukraine foreign monetary aid, the US will see more cases of measles from those who traveled to Ukraine, it is not completely far-fetched. We see from case to case that political complications and war do lead to unhealthy living conditions for civilians caught in the cross-hairs, ultimately resulting in health risks from lack of access to affordable and effective health care. With cases like this, the Biblical Four Horsemen of the Apocalypse often come to mind – Pestilence (infectious disease), War (conflict areas), Famine (armed troops deciding rations), and Death. Now while we may not be directly dealing with an Apocalypse, this reference reminds me that the bad things we deal with are often intertwined.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
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