Health care was an early casualty of the conflict in the Donbass. The Ukrainian government, saying it wished to ensure that national resources did not fall into the hands of armed groups, cut off funding in November to all facilities in the region, including hospitals, and told patients who remained in the conflict zone that they could travel to government-controlled territory to receive medicines. Unsurprisingly, this has proved impractical for many people who are sick, poor or simply frightened. Mechanisms to monitor and respond to disease outbreaks are no longer functional in the territory; immunization coverage is low, and health experts now fear possible outbreaks of polio and for the safety of blood supplies.
People at risk for, or living with, H.I.V. are already suffering. Ukraine has one of the highest rates of H.I.V. infection in Europe; the majority of patients were infected with the virus through contaminated drug injections. Before the conflict, Ukrainian programs helped control H.I.V. infections in the Donbass by providing sterile needles and syringes and methadone, a medicine the World Health Organization recommends to reduce use of and craving for heroin. Ukraine successfully reduced H.I.V. infections, particularly among young people who inject drugs, for whom infection rates decreased more than fivefold between 2007 and 2013.
Unfortunately, the Donbass conflict now jeopardizes that progress. According to the International H.I.V./AIDS Alliance in Ukraine, a nongovernmental organization based in Kiev, more than 1,000 patients in the Donbass have either had their methadone stopped or reduced to substandard doses, forcing men and women to undergo painful withdrawal or return to street drugs. Requests to the Ukrainian government to replenish methadone supplies, accompanied by an offer by Doctors Without Borders to oversee distribution, were met with the response that the medicine — distributed routinely to hundreds of thousands of patients across Western Europe — could be transported, under Ukrainian law, only by armed convoys. In June, a number of patients sent a video appeal to government officials, saying they feared for their lives because their treatment had been interrupted. It is not known how many people have succumbed to overdose or suicides after methadone treatments were ended, though the video reported nine deaths.
People living with H.I.V. in the Donbass now face a similar interruption in life-saving antiretroviral treatment. The W.H.O. estimates that supplies of H.I.V. medicines will last only until mid-August in some parts of the Donbass. The Global Fund to Fight AIDS, Tuberculosis and Malaria has offered to pay for more antiretroviral treatments, and Unicef is willing to procure them. However, no humanitarian convoy has delivered medicines into the territory since February. Thousands of men and women, many of whom overcame discrimination and financial barriers to secure access to H.I.V. medicines, are now watching their antiretroviral pill supplies vanish, and with them, their hopes for survival. The W.H.O. reports that medicines for multidrug-resistant tuberculosis, diagnosed at high levels in the region, are also running low.
For their part, those in control of the self-proclaimed Luhansk and Donetsk People’s Republics in the Donbass have shown little interest in protecting the lives of people with H.I.V. A number of reports have documented violence against people who use drugs and other marginalized groups. The People’s Republic of Luhansk has indicated that it does not want to continue opioid-replacement therapy (consistent with Russian policy), and has announced that United Nations agencies must register with them prior to provision of any humanitarian aid. The Ukrainian Parliament has exempted itself from culpability for the Donbass, passing a resolution in May that the rights of those remaining are the responsibility of the “occupier.” At the same time, the authorities in Luhansk or Donetsk have not moved to fill the H.I.V. treatment gap, leaving patients in a desperate limbo.
No one should be forced to choose between fleeing their home and stopping life-saving treatment.
This is a humanitarian crisis that can be easily solved. The Ukrainian government, even if reluctant to commit resources in the “temporarily occupied” region, should permit passage of a United Nations convoy with medicines funded by international donors. Those controlling the Donbass could also give the green light for the convoy. The government of Ukraine should work on an interim procedure to provide assistance to the population in these territories and facilitate the passage of humanitarian aid.
The Minsk Group, which is led by France, Russia and the United States and tasked with finding a peaceful resolution to the conflict, should urge immediate action to restore the medicine supply in the Donbass.
Silence and inaction will only bring more suffering. Nothing is gained by making patients hostage to geopolitical disputes. Both the Ukrainian government and the leaders of the separatist Donbass region should ensure that, as a matter of medical ethics and human decency, innocent and vulnerable medical patients do not join the list of casualties in this conflict.
Michel Kazatchkine, a French physician, is the United Nations secretary general’s special envoy for H.I.V./AIDS in Eastern Europe and Central Asia.