As the first snows fall across Ukraine, World Health Organization officials in Kyiv warn the coming winter will be “life-threatening for millions” of Ukrainians.

At a press conference in Kyiv on Monday, WHO’s European Regional Director Dr Hans Kluge called the Russian airstrikes on Ukraine’s energy and medical infrastructure “the largest attack on health care on European soil since the Second World War.”

“This winter will be about survival,” Kluge said. “Today 10 million people – a quarter of the population – are without power, and cold weather can kill.”

Russian forces have conducted 703 attacks on Ukrainian healthcare infrastructure since the start of their invasion in February. As of 16 November, 144 medical facilities have been reduced to rubble, according to Ukraine’s Ministry of Health. 

“This is a clear breach of international humanitarian law and the rules of war,” Kluge told reporters. “This war must end before the health system and the health of the Ukrainian nation are compromised any further. Access to healthcare cannot be held hostage.”

Kluge called on Russian forces to immediately open humanitarian corridors to the remaining occupied regions. Russia has so far blocked efforts by international organisations to deliver aid to the territories it controls, leaving many Ukranians cut off from the more than 9 thousand tons of medical supplies delivered by 35 countries from around the world since February. 

“This is an unacceptable situation,” Kluge said. “What’s happening in Mariupol, what’s happening in Donbas. We know there are 17,000 people with HIV in Donetsk alone who may soon run out of the critical antiretroviral drugs that help keep them alive.”  Donetsk is one of two major subregions in the historical Donbas in the eastern part of Ukraine, the other being Luhansk, where large parts of territory remain under Russian military control. 

In his appeal to the international community for further financial support for the Ukrainian health sector, Kluge outlined the actions being taken by the WHO and international partners to help Ukraine’s health system prepare for the coming winter months. 

These include repairs to health facilities, heating infrastructure and energy lifelines, and the provision of portable heating devices, medical supplies, diesel generators, and ambulances. 

“Ukraine’s medical system saves the lives of our citizens every minute – sometimes it takes minutes, so increasing the number of such machines increases the chances of providing timely and high-quality care and saving the lives of patients,” Ukrainian Minister of Health Viktor Lyashko said of the delivery of two ambulances to the Sumy region this week. 

The Government of Ukraine, WHO and key international organisations will hold a series of high level meetings to discuss support for Ukraine’s health care system over the coming days. 

“No primary health care centers” in war-torn east

The most urgent mission facing the WHO and its international partners is getting aid to newly liberated territories like Kherson and Mykolaiv. Russian troops fleeing the cities left health, energy, water and sanitation infrastructure in total disrepair, spurring Ukrainian authorities to begin voluntary evacuations in the region amid fears of a humanitarian crisis brought on by arrival of the harsh Ukrainian winter. 

“In the newly liberated territories there is the big challenge non-communicable diseases, chronic diseases – diabetes, hypertension, chronic respiratory infections – because there is quite an elderly population,” said Kluge.

In Kherson, people did not have hot water or electricity for over two weeks leading up to its liberation by Ukrainian troops recently following a Russian withdrawl from the city. The Russian blockade of medical and humanitarian supplies has left food stocks running low, pharmacy shelves empty, and medical facilities without medicine. 

“In the liberated areas, there are no pharmacies,” Kluge said of his contacts with authorities and volunteer organizations on the ground. “There are not any primary health care centers functioning.”

Rolling blackouts hit homes and hospitals as winter approaches 

Meanwhile, rolling blackouts caused by the continued Russian assault on Ukraine’s energy grid are threatening the ability of medical facilities to continue operating, and depriving civilians of heat for their homes, access primary and urgent care, clean water, and essential humanitarian services.

“Without electricity the machines in intensive care units stop working, surgeries cannot continue, and cold chain facilities needed for vaccines and medicines will be disrupted” said WHO Ukraine Representative Dr Jarno Habicht. “One can only imagine the impact on civilians across Ukraine.”

The latest WHO estimates put the average number of patients treated in the healthcare facilities forced offline by attacks across Ukraine at 421 thousand patients per month. Already short on capacity, the threat of the remaining maternity wards, blood banks, and intensive care beds not having access to the electricity needed to run incubators, refrigeration units and ventilators to Ukraine’s health systems is generating fears of a deadly winter.  

“We usually celebrate the snow,” Habicht said. “But this winter will be different.”

Almost one in five Ukrainians are unable to obtain the medicine they need. In the east, this number increases to one in three, the WHO said. Across the country, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) estimates 9.3 million people require food and basic livelihood assistance, and 14.5 million are in need of health assistance.

COVID-19 threat heightened by arrival of winter

As of January, only one out of three Ukrainians remain vaccinated against COVID-19. It is during the winter season that respiratory infections are at their most dangerous, and coupled with the threats of pneumonia, influenza and a health care system under strain from the war effort, low-vaccination coverage poses a heightened risk. 

“Millions of Ukrainians have waning or no immunity to COVID-19,” said Kluge. “Couple that with an expected surge in seasonal influenza and difficulties in accessing health services, and this could spell disaster for vulnerable people.”

“Ukraine’s health system is facing its darkest days in the war so far,” he warned. “It is being squeezed from all sides, and the ultimate casualty is a patient.”

Elderly population at acute risk

At the onset of the war, hospitals and health facilities were asked to stop all non-emergency care in preparation for the burden of the wounded. This makes the elderly – especially those dependent on regular care for chronic diseases – acutely vulnerable. About 20% of the Ukrainian population is above the age of 60.

The reorientation of Ukraine’s medical system to wartime footing has left few staff available to provide primary healthcare for older people suffering from non-communicable diseases, and severely disrupted the availability of life-saving medications like insulin – especially in frontline regions.

“Access to healthcare, including primary care, has become extremely difficult,” Médecins Sans Frontières testified of their experience in Ukraine. “In combination with an already damaged and disrupted healthcare system, this creates serious issues for continuity of care [for patients suffering from chronic illnesses].” 

The social services relied on by many older Ukrainians have also been heavily impacted by the war, leaving many with no recourse to treatment.

The limited mobility of many elderly people also makes evacuation a more difficult task than for the young and healthy. Some choose to stay, unable to envision leaving the lives and cities they call home behind. 

Children caught in the cross-fire

War is particularly unkind to vulnerable populations, and the situation in Ukraine is no exception: children are caught in the cross-fire.

Today, some 3.4 million Ukrainian children need “child-protection interventions,” according to OCHA. These include services such as family tracing and reunification, psychological support and alternative care arrangements. 

As of 10 November, OCHA said 1.67 million children, parents and caregivers have received child-protection related support, with 650,000 children having received psycho-social support to cope with the traumatic effects of war and displacement. 550,000 caregivers – 71% of whom are women – who were provided sessions on supporting their children through the mental challenges of the war.

Caught between the mental weight of war and freezing temperatures, even warmth – absent access to clean electricity – poses its own set of dangers. 

“As desperate families try to stay warm, many will be forced to turn to alternative heating methods like burning charcoal, wood, or using generators fueled by diesel or electric heaters,” Kluge said. “These bring health risks, including exposure to toxic substances that are harmful for children.”

Many children have also been separated from their families as part of the thousands of Ukrainians forcibly deported to Russia and occupied territories since the start of the invasion. Exact numbers remain elusive, but the Ukrainian government has so far identified over 10,000 children matching this description.

Médecins Sans Frontières has reported treating patients as young as six-weeks old, and recent estimates count 437 children among the more than 8,300 civilians killed since February. The UN High Commissioner for Human Rights has confirmed an additional 505 children injured among the 10,000 injured civilians.

With no visibility on the situation in Russian occupied areas like Mariupol and casualty verification processes ongoing, the number is likely far higher.

October alone saw over 450,000 people flee to safety across Ukraine. Of these, 280,000 were people leaving the east of the country, according to the latest data from the International Organisation for Migration (IOM).

A total of 14.3 million Ukrainians have already been forcibly displaced by the conflict. As the harsh Ukrainian winter settles in, the WHO projects an additional 3 million will be forced to flee in search of warmth and safety over the winter.

Image Credits: Мstyslav Chernov, WHO, Mariusz Kluzniak, Ignatius Ivlev-Yorke, Ignatius Ivlev-Yorke.