March 21, 2016, BRITISH MEDICAL JOURNAL (BMJ)
The road to Donetsk from Kramatorsk, the last city in mainland Ukraine before the internal border, is beautifully lined with frosted trees. But its beauty belies the harsh reality of actually reaching Donetsk.
It is not a simple journey, as I discovered on a recent trip in January. Only one road crosses the so called “contact line” between government-controlled and non-controlled parts of the Donetsk province. That very road is also the only way to travel to Luhansk, which has no open road communication with mainland Ukraine anymore. Several Ukrainian army and Donetsk forces checkpoints need to be crossed along the way. People wait for hours to cross this internal border, with restricted access available only between 10 am to 5 pm. On top of it all, the environment conspires to make it an uncomfortable ride in the ceasefire zone: temperatures of -20C, destroyed high tension cables, no-go minefields, and the occasional bombed building.
Small mercy then that weapons have been laid down after 20 months of a war that has caused over 9000 deaths, driven over a million refugees to Russia and Belarus and beyond, and resulted in nearly 1.5 million people becoming displaced within mainland Ukraine.
East Ukraine remains split from the mainland and it is hard to predict just how long that situation will last. Equally uncertain is the future of organised free elections in the region, as stipulated in the Minsk Agreement.
An estimated five million people and most of the infrastructures of the region have stayed on in the now “self-proclaimed” People’s Republics of Donetsk and Luhansk. For over a year now, these territories have been declared “non-government controlled areas” by the Kiev authorities, meaning that financing for public infrastructure, government salaries, and pensions have been withdrawn by mainland Ukraine.
It is hardly surprising then that the health situation in Donetsk and Luhansk is particularly fragile.
Prior to the conflict, Donetsk and Luhansk both had some of the highest incidence and prevalence rates of both HIV/AIDS and multidrug resistant tuberculosis (MDR-TB) in Ukraine and Europe. The past year has seen a series of disruptions to the region’s healthcare—including interrupted supplies of medicines and diagnostic tools, physicians and social workers leaving the territories, and a reduced presence of non-governmental organisations dedicated to HIV prevention and treatment—which has left it teetering precariously.
The conflict’s ongoing dismantling of the health system threatened to lead to a virtual stockout of antiretroviral (ARV) drugs last October—a situation that was averted at the 11th hour after the drugs were procured by UNICEF through an emergency grant from the Global Fund and finally delivered to people living with HIV.
However, it must be said, the system has adapted to a degree: social workers continue to deliver services (some on a voluntary basis), laboratory reagents and some medicines are smuggled across the contact line, and some international (including Russian) humanitarian help has reached the territory. But it’s not enough.
Last year’s emergency procurement of ARV drugs threatens to repeat itself with 10 000 people living with HIV/AIDS in the region soon facing the risk of treatment interruption. Current ARV supplies are only funded until August 2016. In addition, the amount of procured ARV drugs has been calculated based on the number of patients on treatment a year ago, and does not include some 2000 newly diagnosed patients who will need to start treatment this year. This situation is compounded by a lack of some basic HIV and TB diagnostic tools.
There are no longer any reagents to perform CD4 cell counts in Luhansk and it also lacks the infrastructure to diagnose MDR-TB. Patients with MDR-TB in the Donetsk prison system are currently without treatment.
The time has well and truly come for the Minsk negotiators to prioritise HIV/AIDS, TB, and MDR-TB as urgent issues on the regional agenda that the world must address in these territories. But it is also long overdue for the authorities in Kiev, Donetsk, and Luhansk to accept that HIV/AIDS, TB and MDR-TB are regional and global concerns. The UN must also continue to play its part in fostering health and humanitarian diplomacy to avoid a European tragedy this year.