The Public Health Impacts of the War in Ukraine

A longtime physician and faculty member at Tufts University School of Medicine is the author of a new book about how war affects health

At the start of the 20th century, the number of military deaths in war far exceeded the number of civilian deaths. In contrast, today’s wars kill far more civilians than military personnel, largely because military forces often target civilians, like the current war in Ukraine.

Russian attacks on civilians and civilian infrastructure in Ukraine, which have been widely reported by the media and the United Nations, represent a type of military strategy used with increasing frequency in recent decades. This strategy has been used against noncombatant civilians in wars in South Sudan, Yemen, Syria, Chechnya, and many other countries.

Russia’s invasion of Ukraine has commanded the world’s attention, says physician Barry Levy, A66, a longtime faculty member in the Department of Public Health and Community Medicine at Tufts University School of Medicine and author of From Horror to Hope: Recognizing and Preventing the Health Impacts of War, recently published by Oxford University Press. With reporters and U.S. government officials on the ground in Ukraine, he notes, the world has witnessed the devastating impacts the war has had on Ukrainian citizens.

As heinous as the bombings and executions have been in Ukraine, just as horrendous have been the number of people who have died or become seriously ill by lack of food, water, and medical care,” says Levy. “The deaths of people sheltering in basements and elsewhere, without food and water for long periods of time, may never be fully recognized.”

Levy, who teaches the Environmental and Occupational Health course for MD/MPH students and is a former president of the American Public Health Association, sat down with Tufts Now to talk about the war in Ukraine from a public health perspective. 

Tufts Now: What are the biggest public health concerns during a war like this?

Barry Levy: The immediate concern is for people who are at risk of being killed or severely injured by bullets or bombs during indiscriminate or targeted attacks. But, in addition to deaths and injuries from these attacks, there are five categories of war-related illness, which usually get less attention:

  1. Malnutrition. Infants and young children are at high risk of malnutrition during war, with resultant cognitive impairment and abnormal development. Often, as in Ukraine, food has been used as a weapon of war.  
  2. Communicable diseases. These include respiratory disorders, like COVID-19, measles, and tuberculosis, which spread easily in crowded settings, and diarrheal diseases like cholera, which can easily spread where safe drinking water is not available and there is poor hygiene and sanitation. Multidrug-resistant bacteria often develop during war.
  3. Adverse effects on mental health. The mental health impacts of war are widespread and often last long after war has ended. These include posttraumatic stress disorder, depression, substance abuse, and suicide. 
  4. Impacts on reproductive health. Because of inadequate prenatal care, women are more likely to have complications during pregnancy and childbirth. Newborns are likely to have higher risks for prematurity, low birthweight, and death during the first month of life.
  5. Non-communicable diseases. Many people with hypertension, coronary artery disease, chronic lung disease, or cancer will not be able to get their medications during war because of attacks on health workers and healthcare facilities. Some of them will die from preventable and treatable disorders. And war-related exposures cause respiratory, neurological, and cardiac disease and many types of cancer.

Before the war began, Ukraine had a fairly sound healthcare system, much of which has since been damaged or destroyed. Before the war, its infant mortality rate was 7 per 1,000 live births, which is about the same as the United States, and its life expectancy was about 72, a few years less than in the United States.

A subway station serves as a bomb shelter for thousands of people in Ukraine during an attack by Russian forces.

A subway station served as a bomb shelter for thousands of people in Ukraine during an attack by Russian forces in February 2022. Photo: Drop of Light / Shutterstock

Is Ukraine thinking about COVID-19 with everything else going on?

While people are displaced and struggle to meet their basic needs like food and water, COVID is not a priority. Nevertheless, some people there, particularly older persons and immunocompromised people, are at high risk for dying or having serious complications from COVID. There has been no systematic reporting of COVID cases in Ukraine since the war began, and most of the population has not received two or more doses of vaccine.  

How does the war’s impact on the environment affect public health?

It's hard to think of factors that are more damaging to the environment than war—and the preparation for war, which contaminate air, water, and soil and adversely affect animal habitats and ecosystems. However, the greatest environmental hazards in Ukraine now are the thousands of landmines that Russia has planted as well as unexploded ordnance, such as bombs and cluster munitions, the total removal of which may take many years.

Ukraine is a highly industrial country, particularly in its eastern and southeastern regions. Fires and explosions set off by bombs and shells have contaminated the air with toxic gases and particulate matter. Destruction of factories has contaminated soil and water with heavy metals and other hazardous chemicals. Military maneuvers have damaged the environment and have emitted greenhouse gases that contribute to climate change. And with much of the built environment—residences, office buildings, and schools—destroyed, people have been left without homes, work, and education.

You’ve written about war and public health for decades. How do you maintain any sense of hope or optimism?

I titled the book From Horror to Hope because, despite all the horrors of war, there are reasons for hope. These include many disputes being settled without violence, widespread international support to protect civilians during war, and increased efforts to protect human rights. International treaties have done much to control chemical weapons and restrict the global trade in weapons.

My book includes profiles of 18 individuals who have helped to reduce the health impacts of war. For example, some clinicians have treated civilians in war zones and then advocated for measures to protect civilians during war and to promote peace.

Reasons for hope also include measures developed to prevent war and promote peace, as outlined in the final chapter in my book. These include resolving disputes before they become violent, addressing the underlying causes of war, and strengthening the infrastructure for peace.

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