Unimaginable Tragedy – Uncommon Opportunity
Until recently, the U. S.’s Federal Emergency Management Agency (FEMA) was only allowed to respond to disasters by replacing damaged infrastructure with nearly-identical pre-disaster equipment. So when Hurricane Maria crippled Puerto Rico’s fragile and outdated electrical grid in 2011, that vital service could only be replaced by newly-made fragile and outdated equipment. The result was as tragic as it was predictable with the island subsequently losing power after Hurricane Beryl (2018), Hurricane Dorian (2019), Tropical Storm Karen (2019), Tropical Storm Isaias (2020), Tropical Storm Laura (2020), and Hurricane Fiona (2022). Rather than envisioning and building a power grid that was hardened, distributed, and renewable, Puerto Rico’s power grid remains vulnerable, centralized, and only 3% renewable. [ 1 ]
Though there have been some recent changes to FEMA’s regulations [ 2 ], the urge –and sometimes the requirement– to rebuild what was damaged exactly as it was before is understandable. Governments don’t want to pay for gold-plated replacements and individuals can see such rebuilding as an act of strength and defiance.
Unlike the U.S., as far as I know, Ukraine is unfettered by regulations requiring disaster responses to be limited to replacement but not improvement. And not withstanding the tragic circumstances of the war and the personal costs to its citizens, rebuilding that nation’s health infrastructure could be an unprecedented opportunity; imagine designing a health care system that meets both present and future needs, is unburdened by the history of how western (or even Soviet) health care developed over the years, and incorporating technology to deliver better care to more of its people.
Ukraine and its many allied nations are already committing to rebuilding the nation’s damaged infrastructure. [ 3 ] This article will focus specifically on how Ukraine’s health care system, broadly defined, might be re-envisioned and rebuilt. Here are just a few ideas.
Integration of Mental and Behavioral Health
It is hard to imagine that anyone living in Ukraine today does not suffer from anxiety, depression, trauma, grief, survivor’s guilt, psychosis, suicidal thoughts, or any number of other, similar conditions. And it’s just as easy to imagine that many people suffering from these feelings will adopt self-medicating and self-destructive behaviors as well. The loss of family, home, and income layered upon constant uncertainty and fear about the future, will indelibly mark many of Ukraine’s citizens for years to come if not throughout their lifetimes.
Recognizing the toll that these health challenges are inflicting on its people could encourage Ukraine to integrate mental and behavioral health services more tightly with traditional medical services. And if a majority of Ukrainians are so afflicted, it might lessen the stigma often associated with mental illness, making treatment more acceptable and reintegration more likely.
The links between mental and physical well-being have long been known. Depression, for example, “increases the risk for many types of physical health problems, particularly long-lasting conditions like diabetes, heart disease, and stroke,” [ 4 ] “while mood disorder diagnosis was associated with higher rates of infectious diseases, respiratory problems, and weight problems.” [ 5 ]
Crucially, I think every school should have a nurse or social worker with mental/behavioral health training as schools will be the venues for a generation to learn the skills of socialization and where personal traumas may most easily come to the fore. And I would not be surprised if the way the war is taught in schools –in history, political science, and sociology classes– helps set the collective character, the collective mental health, of that generation. Will they see the war as one of a long list of hardships and adopt a pessimistic, Russian-style fatalism leading to widespread depression, alcoholism, and other limiting health conditions, or will they learn the enabling capacity of resilience and the power of personal agency? [ 6 ]
The opportunity for Ukraine is to build a new health services system that doesn’t partition mental/behavioral and physical health apart from each other, as so many western societies have done, but rather sees them as related parts of a full spectrum of health.
A Proactive Approach to PTSD
The U. S. Department of Veterans Affairs estimates that “about 30 out of every 100 (or 30%) of Vietnam Veterans have had PTSD in their lifetime” and “[a]bout 6 out of every 100 people (or 6% of the population) will have PTSD at some point in their lives.” [ 7 ] Those are stunning figures. But unlike Ukrainian fighters, these Vietnam veterans and civilians didn’t fight in their home country and witness its destruction, and did not experience the death and injury of family and friends. So it seems likely the percent of members of the Ukrainian military who have or will experience PTSD is likely much higher than just 30% and similarly the overall population number is likely to be much higher than just 6%. (Even 6% would be some 2.6 million people –43.81 million x .06– not at all an insignificant number.)
It’s not often that a government knows some time in advance that a large number of its citizens will suffer from a known and treatable condition, so the Ukrainian government should take advantage of this advanced warning and implement programs now to deal specifically with PTSD. These would most obviously include training medical and social service personnel in diagnosis, counselors and therapists in treatment, pharmaceutical manufacturers to produce sufficient supplies of medications like SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors), as well as public service campaigns to counter any stigma attached to the condition or its treatment.
Intentional Siting of Facilities
As of April 2022, “324 [Ukraine] hospitals were damaged, of which 24 were completely destroyed.” No doubt, since that time, many more have suffered similar fates. A press release from the Ministry of Healthcare of Ukraine states:
“…the Ministry has already started planning the rehabilitation and reconstruction of hospitals. The Ministry of Health is currently working on a comprehensive plan of where hospitals will be built, in what shape they will be restored and what services they will provide.” [ 8 ]
The first sentence of that quote suggests something akin to the old FEMA approach of one-for-one replacement, while the second sentence hints at a more promising whole-of-country perspective. Given the widespread population displacements (some even forcibly out of country) and the disproportionate destruction in the country’s eastern regions, demographics and geography should be major considerations in selecting sites for new hospitals. In addition, Ukraine might consider innovative “nesting” of facilities in hub-and-spoke configurations where hospitals and trauma centers are ringed at progressively greater distances and sparser populations by urgent care facilities and then clinics. Such an approach could help ensure better health care access in Ukraine’s more rural areas, predominantly in the country’s west (e.g., the oblasts of Rivne, Ternopil, Ivano-Frankivs’k, Transcarpathia, Chemivtsi, and Vinnytsya).
Regardless of the facility siting approach selected, all facilities should be interconnected with a robust telemedicine capacity, so expertise is not overly concentrated in the larger cities and people in rural regions can benefit equally from specialists’ care. (The U. S. could benefit greatly from this approach, too.)
Of course, one advantage of a high-speed internet network is that it’s not geographically limited. Ex-pats, refugees, and others who are trained in medicine, who speak Ukrainian and/or Russian, and who understand the country’s culture could be valuable supplements to a telemedicine network.
Robust Public Health Surveillance
In the years just prior to the war, Ukraine was working with WHO and the U. S.’s CDC and USAID to enhance its primary health care and public health infrastructures. [ 9 ] But even without the burdens of war, bringing the delivery of health care in Ukraine up to EU standards would have taken years of effort and significant increases in spending. Ukraine has
High mortality rates, with considerable “excess mortality” of people dying of preventable causes.
Low vaccination rates, both for children and adults, for typical contagions as well as COVID.
High infection rates of HIV/AIDS and multi-drug resistant TB.
A lack of drugs to treat diseases like “diabetes, cancer, heart and kidney disease.” [ 10 ]
…all of which would rightly demand immediate attention and resources. But a system of robust public health surveillance should also be a high priority. With a population slightly larger than that of Texas (41.4 million in Ukraine compared to 39.2 million in Texas) and covering an area somewhat smaller than Texas (232,000 square miles versus 269,000 square miles), creating such a system will be a heavy lift. Where to start?
One option would be to start with the schools. Again, for comparison, Ukraine has half again as many schools as Texas (12,800 versus 8,000), so they would constitute a fairly large network. [ 11 ] If the nurses or health professionals in those schools were to report centrally nothing more than regular counts of absences, that could act as an early tripwire to outbreaks. And if they were able to further report some characterization of symptoms, even without quantifying them, (e.g., most sick children had fevers, many of those who had to leave school had dry, hacking coughs, etc.), this might be enough to alert public health officials to new outbreaks. Quantifying outbreaks and characterizing them via laboratory testing would be the obvious follow-on steps as the surveillance system grew and improved.
A critical element of such a surveillance system would be the requirement to report observations and data. Here in the U. S., most public health data reporting from states to the CDC is done on a voluntary basis. For example, states must report infant deaths due to influenza, but not adult deaths. Fortunately in this regard at least the Ukrainian oblasts are not as autonomous as the U. S. states.
For both data collection and analysis, Ukraine’s Main Center of Special Monitoring would be a good in-country model (even though their primary focus is on radiation monitoring), [ 12 ] while working with the U. S. CDC’s newly-formed Center for Forecasting and Outbreak Analysis would no doubt also be helpful. [ 13 ]
And aside from the obvious public health benefits of such a surveillance system, it may also bolster Ukraine’s full entry into the EU. Given the relative ease of border crossing within the EU, it seems likely that EU member states will want some reassurance that Ukraine’s population is vaccinated, healthy, and unlikely to be carriers of infectious diseases.
Medical Schools
Professor Judyth Twigg has written that “Ukraine still clings to the remnants of the Soviet system of health care. Twenty-six years after independence, it still prioritizes curative services over prevention, hospitals over ambulatory services, and specialists over primary care.” [ 14 - Her full article is well worth reading. ] Certainly cure and treatment claim a higher priority during wartime (and for some years thereafter) than preventive services. (See the discussions above about mental and behavioral health as well as PTSD.) But to make a 180-degree turn-around to the ethos of Ukraine healthcare, giving progressively more weight to preventive care, will be a years-long process, which might profitably begin now in the country’s medical schools. Training the next generation of Ukraine’s medical professionals to value and practice preventive medicine will require a wholesale rethinking of medical school curricula. It will also require communications campaigns to make Ukrainian citizens receptive to this change as well. But this is precisely the kind of challenge that could be addressed during this coming time of unique opportunity.
To make that transition easier and to increase the pipeline of doctors, nurses, and other caregivers, many more of which will be needed in the future, Ukraine could introduce a healthcare track as early as high school, focusing on chemistry, biology, physics, and statistics. And the government could do much more to encourage this path, perhaps providing summer internships at local hospitals and the institutes of the Academy of Medical Sciences, as well as a formal pre-med track as these students move on to their undergraduate education. It’s hard to think of a better investment and one that will continue to benefit the country for generations to come.
Vax and Vote
At the moment –and excepting some small portion of the population in the oblasts bordering Russia– the single most unifying sentiment among Ukrainians is a deep sense of unalloyed patriotism. A tried and true technique of advertising is to couple a positive (such as that patriotism) with a product. In the U. S., for instance, SUVs and pickup trucks are portrayed as expressions of freedom and rugged individuality. Ukraine might try associating their national pride with key health objectives.
The Sector for Strategic Communications of the Ministry of Information Policy could launch campaigns that said, in effect, “It’s patriotic to ABC,” where ABC could be anything from “seek help if you’re undergoing mental/emotional stress” or “get an annual check-up” or “tell your doctor if you get COVID,” or “get vaccinated.”
Specifically, only 36% of Ukraine’s population has received at least one COVID vaccination, which ranks it below other countries at war like Ethiopia, Somalia, and Burma. [ 15 ] One idea to increase that rate and couple vaccination to patriotism would be to make voting and vaccination possible at the same locations. I Voted! - I Vaxed!
Communications techniques like this might go some way to changing old attitudes and habits about healthcare.
Government Reorganization
As long as we’re thinking big, one final idea is to reorganize the Ukrainian government to collect all health-related functions and move them under the purview of the Ministry of Health of Ukraine. For example, move to the Ministry of Health some portion or all of the following: the Academy of Medical Sciences (which has 41 institutions and is currently under no ministry), the healthcare operations of the Ministry for Veterans Affairs, the Healthcare Department of the Ministry of Defense, pro-active health-related functions of the sub-department of State Emergency Services (under the Ministry of Internal Affairs), and others. The rationale, at least in part, for combining military health (Ministry of Defense and Ministry of Veterans Affairs) with civilian health is that those fighting make up a substantial proportion of the country’s population. The EU estimates that 1 million Ukrainian’s have been drafted, roughly 1 in 44 of the entire population (including infants, children, and the elderly) or 1 in 30 of those aged 15-64. [ 16 ] And as alluded to earlier, the health impacts (like PTSD) on civilians and fighters will present quite similarly.
A consolidation of this kind is not as unlikely as it might seem, given the near-constant reorganization of Ukraine’s ministries, which suggests another approach; if a permanent reorganization is out of the questions, implement a reorganization along these lines on a temporary basis, say, now through some period of time (two years?) after the war ends. [ 17 ]
Why Ukraine?
Why is this an article only about Ukraine? There are many other countries similarly afflicted by war and natural disasters (e.g., Syria, Eritrea, Pakistan, Haiti, and dozens of others) which might also benefit from a similar total reimagining of their health care systems, so why focus on Ukraine?
The answer is money. Of all these countries, Ukraine is most likely to receive massive sums of international assistance and foreign investment. Because a strong and growing economy will be advantageous to NATO and EU membership, because of the widespread dislike of Vladimir Putin (and admiration for Volodymyr Zelenskyy), and no doubt because of western and Eurocentric chauvinism as well, Ukraine, apart from all these other countries, can reasonably expect that it will receive the aid and investment necessary to implement reforms like those described here.
Final Notes
While the specific ideas suggested here may be impractical or overly-ambitious, what I do think is true is that at some point after the war’s end, Ukraine will be in a position to totally and completely reimagine its healthcare system, bolstered by its further integration with the west and the substantial aid it will receive to rebuild the country’s institutions. Imagining that future now would not be just a day-dream; it would be a prudent and thoughtful approach to securing a better, and healthier, life for its citizens.
The opening graphic is intentionally modeled on the UN’s Sustainable Development Goals program to suggest that Ukraine’s reimagining also be a highly integrated effort, supported by the international community, and (ultimately) tied to specific, quantitative goals.
Please share your comments below.
References
[ 1 ]
For storm-related power outages on the island, see:
https://en.wikipedia.org/wiki/List_of_Puerto_Rico_hurricanes
and embedded links to specific storms.
For the island’s power grid, see:
https://www.nytimes.com/interactive/2018/05/06/us/puerto-rico-power-grid-hurricanes.html
The remaining 97% of Puerto Rico’s electric power is provided by imported oil. See:
https://kleinmanenergy.upenn.edu/news-insights/puerto-ricos-path-toward-renewable-energy-development/
Adding insult to injury, and cost to their electricity, only U.S.-flagged ships can deliver that oil, unless the Jones Act is waived. See:
https://www.politico.com/news/2022/09/28/waiver-puerto-rico-energy-diesel-concerns-00059372
[ 2 ]
https://www.fema.gov/disaster/sandy-recovery-improvement-act-2013
and
https://eelp.law.harvard.edu/2021/01/a-new-approach-to-disaster-relief-funding-the-disaster-recovery-reform-acts-promise-for-pre-disaster-mitigation/
and
https://www.fema.gov/about/history
[ 4 ]
https://www.cdc.gov/mentalhealth/learn/index.htm
[ 5 ]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768339/
[ 6 ]
A national character is such a broad, collective average that it’s hard to generalize about 143+ million Russians, but I think Hendrick Smith paints a good picture here:
https://www.nytimes.com/1990/10/28/magazine/the-russian-character.html
[ 7 ]
https://www.ptsd.va.gov/understand/common/common_veterans.asp
and
https://www.ptsd.va.gov/understand/common/common_adults.asp
[ 8 ]
https://www.kmu.gov.ua/en/news/moz-rosijski-snaryadi-vluchili-u-ponad-300-ukrayinskih-likaren
[ 9 ]
https://www.euro.who.int/__data/assets/pdf_file/0006/413925/WHO_Health-Systems_support_Ukraine.pdf
[ 10 ]
https://www.csis.org/analysis/ukraines-health-sector
[ 11 ]
https://www.kyivpost.com/russias-war/thousands-of-schools-to-reopen-in-ukraine.html
and
https://ballotpedia.org/Public_education_in_Texas
[ 12 ]
https://gcsk.gov.ua/en/history.html
[ 13 ]
https://www.cdc.gov/forecast-outbreak-analysis/index.html
[ 14 ]
https://www.csis.org/analysis/ukraines-health-sector
[ 15 ]
https://coronavirus.jhu.edu/vaccines/international
[ 16 ]
https://ecfr.eu/article/no-partial-measures-how-ukraine-can-meet-the-challenge-of-russias-mobilisation/
and
https://en.wikipedia.org/wiki/Demographics_of_Ukraine
[ 17 ]
See here and the click-throughs to specific ministries to see the history of Ukraine government reorganizations: https://en.wikipedia.org/wiki/Government_of_Ukraine