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First comes civil war, then comes polio. Ukraine and its child population are threatened by a polio epidemic due to years of neglect by the government and health authorities in vaccinating children.
The representative of the World Health Organization in Ukraine, Dr Dorit Nitzan, and the agency as a whole have been sounding a warning for more than a year. The story came to Canadians' attention on October 7 when Nitzan was interviewed on the As It Happens radio program of the Canadian Broadcasting Corporation.
Nitzan and the WHO say that Ukraine is in the midst of a polio outbreak that has a "real threat" of worsening. In late June and early July of this year, two children contracted the polio virus in western Ukraine. They became paralyzed. They are ten months and four years old and were the first reported case of polio in Europe in five years.
Breaking news on Oct 13, 2015: The Dutch Safety Board has issued its report on the crash of Malaysian Airlines Flight 17 on July 17, 2014. Read a commentary on the report by veteran U.S. investigative journalist Robert Parry of Consortium News, here.
Dr. Nitzan says that, typically, for every reported case of polio there are 200 other carriers. "There is no doubt we will see more cases.
"The outbreak is here, and it’s going to be huge – if nothing is done," she is quoted in The Guardian on October 7.
Vesti.ru reported on Sept 25 the story of a frightened mother, Ivanna Lakatos, who tried without success to have her infant vaccinated. "I went to our doctor, asked for a polio shot, but she said 'There is a problem. We're out of the vaccine.' I'm scared that there is no vaccine."
The two confirmed cases are in Zakarpattia oblast, the western-most region of Ukraine. The region borders Hungary, Poland, Romania and Slovakia. The Guardian reports there are fears that the virus could find its way into unvaccinated communities inside the EU, such as refugees fleeing conflicts in Syria and Afghanistan.
The two children became infected by vaccine-derived poliovirus type 1. That's a rare occurrence, when weakened polio strains used in oral polio vaccine (OPV) mutate. According to a September 2, 2015 bulletin by the European Center for Disease Prevention and Control on the situation in Ukraine, "The risk of cVDPV strains emerging from OPV is higher when polio vaccination coverage is low, as has been the case in Ukraine for several years."
"Polio virus is very good at finding susceptible children, no matter where they live," says Oliver Rosenbauer, communications officer for the Global Polio Eradication Initiative, part of the WHO.
The overall vaccination numbers are disturbing. As of 2014, only 50 per cent of Ukraine's 14-and-under population was vaccinated against polio. Only 14 per cent of children born in the past year were vaccinated, according to Dr. Nitzan.
"That's terrible. Even without an outbreak, we have to move. But now that we have an outbreak, we have to move, and fast," she told CBC.
"Some of those who are powerful and who have access to the media are confusing [the situation]. That's why we are saying what we believe very strongly. This is an outbreak and we will not let them rest. We have to take care of the children."
Ellyn Ogden of the United States Agency for International Development told reporters last week, "No other country in the world is in such a dire situation or shows such disregard for protecting children against childhood diseases."
"Children in Ukraine have not been vaccinated against polio since 2008," she said.
Speaking to the Associated Press on October 8, WHO's European director, Zsuzsanna Jakab, said it is crucial that a vaccination campaign start next week to protect Ukrainian children from polio. She is concerned that Ukraine's health ministry might suspend immunization efforts.
"If the ministry of health is not empowered to start vaccinating, then we need to reach a higher level of government," Jakab said. "If the vaccination campaign doesn't start on Monday, then I will get on a plane and go to Ukraine personally to speak to the president."
Interests become involved
Ukraine's polio emergency has come to the fore in Ukraine and in some international media because of conflicting interests between the Ukrainian government, its health ministry and the country's private health care industry.
Last April, the Canadian government quietly funded the purchase by UNICEF of 3.7 million doses of polio vaccine from a manufacturer in France, Sanofi Pasteur, the vaccines division of Sanofi-Aventis Group. Polio vaccine is frozen once it is produced and packaged. Controversy arose over the Canadian-funded shipment when the frozen vaccine partially thawed in transport from France to Ukraine.
According to WHO guidelines and those of the manufacturer, only vials of the vaccine that have been opened for use are considered unsafe to refreeze and reuse. The manufacturer has assured that the shipment in question is safe. Dr. Nitzan told CBC that a commission of the Ukrainian Ministry of Health has agreed, but it's now up to Prime Minister Arseniy Yatsenyuk to accept the commission's recommendation.
Resistance to accepting the shipment comes in part from a civic organization in Ukraine, the All-Ukrainian Council for Patients' Rights and Safety. It wants the Canadian-funded shipment tossed. Viktor Serdyuk, the president of the council says, "We must absolutely destroy the vaccine, or pass it on to some poorer countries."
Deputy Health Minister of Ukraine Ihor Perehinets is cited in The Guardian saying that lobbyists in the country are fighting to control vaccine procurement. "Someone doesn’t want to have procurement outsourced to international organisations, which are much more transparent while conducting procurement in Ukraine and abroad."
The aforementioned Vesti.ru report says that doctors in Ukraine dismiss the claims of government officials that vaccination rates in the country are not their fault but are due to misguided fears by parents of vaccination. It cites pediatrician Dr. Yevgeny Komarovsky telling Ukrainian television, "We are not told the whole truth. You cannot imagine how many children are at risk. We have a catastrophic problem."
Ukrainian media is reporting the story worryingly. Minister Kvitashvili announced on October 9 that a vaccination program would begin on October 12. He said two million doses received some weeks ago via the UNICEF have already been distributed to the regions of the country. A remaining one million doses received in May are undergoing testing.
Kvitashvili acknowledges that Ukraine still lacks 6.5 million vaccine doses. He says his government is seeking donor countries to fill the need.
Kyiv television network TSN reported on September 12 that general vaccination in western Ukraine would begin in a week, starting with newborns up to age six, then on to children up to ten. All children would eventually be vaccinated, regardless of what past records might state. TSN said ten million doses are required for all of Ukraine.
One month later, Dnepro Evening reported on Oct 2 that the the chief medical officer of Dnepropetrovsk region in central Ukraine, Andrei Kondratyev, considers the region to be in a state of emergency. Whereas 366,000 doses of polio vaccine are required, there were 170 available.
City Morning in Kirovgrad, central Ukraine, published a public warning on October 8 saying that Ukraine has an outbreak of polio and the only prevention is vaccination.
The director of public health for Kharkiv city, Ukraine's second largest, and region is reported on October 8 as warning that the immunization rates of children in that region are very low: for infants up to 18 months of age, 11.5 per cent; above two years, 44 per cent; above six years, 31 per cent; and above 14 years, 24.6 per cent. The region recently received 200,000 doses of vaccine.
A 2013 article in the medical journal The Lancet said that "public mistrust in vaccinations" along with "poor vaccine supply" and "corruption in the health system" had left Ukraine with "worryingly low rates" of immunization.
The WHO is asking Ukraine to follow internationally agreed outbreak response guidelines and declare a public health emergency. The Guardian reports that Bill Gates, a leading campaigner for the global eradication of polio, has phoned President Petro Poroshenko to make the case for distribution of the life-saving vaccines.
One year ago, Dr. Nitzan and the WHO warned that Ukraine was running dangerously low or had entirely exhausted its supplies of vaccine for viruses such as polio, mumps, measles and diphtheria. "Ukraine has no vaccines... They don't have any vaccines in their storage," Nitzan told reporters in Geneva.
She said that an international appeal in mid-August 2014 for $14 million to assist Ukraine in purchasing vaccines had only netted $40,000 one month later.
PharmaLetter reported in August 2014, "Due to the current economic crisis in the country, Ukraine may face shortages of drugs in the near future.
"According to [Health Minister Oleg Musy], the Ukrainian Ministry of Health does not have resources for the purchase of drugs for state needs. According to him, the government currently has only 2.1 billion hryvnia (around $190 million) available, which will allow it to purchase only 30 per cent of drugs for the country’s overall needs."
Among the challenges facing the health ministry is the steep devaluation of the Ukrainian currency following the violent overthrow of the country's elected president in February 2014.
As well, the Ukrainian government announced last year it would ban the import from Russia of all but 20 drugs produced there. In 2013, Ukraine imported $74 million worth of drugs from Russia.
Since 1988, wild virus polio infections have declined globally by 99.9 per cent. Russia has been certified polio-free since 2002.
While the current efforts in Ukraine are focused on containing the virus, the WHO believes polio is likely to be just the first in a series of diseases to hit Ukraine if the government doesn’t start vaccinating immediately.
War and disease threats
The role of foreign governments in the polio crisis was inadvertently referenced in the CBC interview with Dr. Nitzan. Seemingly unaware of an answer to her question, As It Happens host Carole Off, one of Canada's leading journalists, asked Dr. Nizan whether the Canadian government has expressed any official concern about the polio threat.
No Canadian newspaper has done so, and reports in other media outlets in Canada have been scant to non-existent. Nizan said that the Canadian ambassador to Ukraine has been involved in encouraging that a vaccination program begin.
WHO published an analysis in December 2014 of the consequences for Ukraine's public health system of the government's civil war ('Anti-Terrorist Operation') in the east of the country. Dr. Nitzan reported in the article that her concerns for public health in the country were "profound".
The article explained, "As a doctor, she is particularly worried about the health of the sick, marginalized and vulnerable. This includes the very young and old, minorities such as Roma populations, the poor, persons with mental, physical or psychosocial disabilities, men who have sex with men and displaced persons. The very survival of these vulnerable populations is at risk when the right to health is forgotten…
"Access to health is a major issue in Ukraine. 'Universal health care exists only on paper,' says Dr Nitzan, referring to the general situation in Ukraine. 'People have to pay for a large portion of health services, procure their own medicines and there are no set prices for these essentials,' she says. The war and the financial crisis are making the poor even poorer, so they effectively have no access to health care, medicines or vaccines."
Ukraine's appointed minister of health is a foreigner, from Georgia. Alexander Kvitashvili was appointed minister of health in December 2014. He was minister of health in Georgia from 2008-2010, part of a team of neoliberal 'reformers' during the presidency of Mikhail Saakashvili (2004-2013). During Kvitashvili's two years in office, many hospitals in Georgia were privatized. (See this 2008 article on Georgia's health care privatizations.)
Mikhail Saakashvili is wanted in Georgia for financial crimes. He was appointed governor of Odessa region this past summer by Ukrainian President Petro Poroshenko.
In April 2014, WHO declared a "public health emergency of international concern" over the threatened spread of wild polio virus. It is only the second such declaration in WHO's history, the first being a 2009 declaration over the H1N flu virus.
WHO said polio is spreading from three countries-- Pakistan, Syria and Cameroon. "While polio is only endemic in three countries — Afghanistan, Nigeria and Pakistan — the highly infectious virus has been recently reintroduced into seven countries and 60 per cent of new infections last year were caused by international spread."
Other countries where the virus has appeared are Equatorial Guinea, Ethiopia, Iraq, Israel, Palestinian West Bank, Somalia, China and, particularly, Nigeria.
WHO says eradication of polio was tantalizingly close in 2012, with only 223 cases reported in the world. It reports most recently: "August 2015 marks one year since the last wild polio case was detected on the entire African continent. A polio-free Africa would leave only two countries where polio transmission has never been interrupted: Pakistan and Afghanistan.
"The Global Polio Eradication Initiative, spearheaded by WHO and partners, aims for a polio-free world by 2018."
So long as imperialist-driven wars are raging or breaking out in eastern Europe, southwest Asia, the Middle East and Africa, WHO's goal of polio eradication is impossible to achieve.
Health groups slam Ukraine for slow polio response, Agence France-Presse, Oct 9, 2015, published on Relief Web
Africa's year free of polio is giant step towards eradication, The Guardian, Aug 11, 2015
National Integrity System Assessement Ukraine 2015, by Transparency International Ukraine, 2015 (210 page report, pdf here),
Polio risk looms over Europe, by Declan Butler, Nature, October 29, 2013
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