https://orcid.org/0000-0002-0630-8394
This manuscript was handled by Deputy Editor Charalambos Antoniades.
Refugee crisis dynamics
With the onset of the Russian invasion of Ukraine on February 24, a constant inflow of refugees fleeing their homeland has occurred. By 1 May 2022, over 10 million people have been displaced in Ukraine, with over 5.8 million migrating as refugees. Approximately 55% of them migrated into Poland.1,2 This number does not include people who had crossed the borders illegally, without registration, which may account for an additional 10–20%. The dynamics of refugee inflow into Poland are presented in Figure 1.
(A) Daily dynamics of the number of refugees from Ukraine. (B) The number of patients admitted by Doctor Ukraine Teams depends on the reason for consultation: new symptoms vs. seeking help resolving chronic medical conditions.
According to the UN Refugee Agency (UNHCR), women are 88% of adult refugees, and a majority of them (95.3%) is the Ukrainian nationality. The elderly account for 14%, while children account for 36%.2 While numerous arrive with pre-existing comorbidities, their health condition is often exacerbated by the ordeal of the preceding days and weeks, unprecedented levels of stress leading to psychological challenges and depression. At the moment of arrival, at the border of the Republic of Poland, 18–30% of incoming refugees reported an urgent need for medical attention. Thus, approximately one million people urgently needed medical assistance in the last three months. In Poland alone, over 500 000 new Ukrainian patients were reported to need urgent medical aid.1
Cardiovascular health status in Ukraine before the war
When preparing to support the medical needs of refugees in the current crisis, it is essential to address cardiovascular epidemiology in Ukraine in the years preceding the war. According to the European Society of Cardiology, cardiovascular diseases account for 68% of total mortality in Ukraine in 2018.3,4 Based on World Health Organization (WHO) statistics, life expectancy in Ukraine in 2018 was 72.3 years3–and was lower than in the rest of Europe (Poland—78.2 y, Germany—81.3 y, UK—81.2 y). These discrepancies are particularly evident in child mortality, estimated to be 8.52 per 1000 born in Ukraine.5,6 This represents more than double the European average (e.g. Poland—4.58, Germany—3.05, UK—4.21). These health parameters are related to significantly lower GDP per capita (in USD), which in Ukraine was 8000 USD per capita (vs. Poland—28 k, Germany—45 k, UK—40 k USD).7 These factors are also likely linked to multiple environmental factors and global differences.8
Interestingly, cardiovascular risk factor profile appears to be relatively close between Ukraine and Poland and shows a much higher prevalence of cardiovascular diseases than in Western European countries.
For example, the prevalence of hypertension among adults is relatively similar in Poland and Ukraine (43.1 vs. 49.2%, respectively) but higher than in Germany and UK (29.7 and 26.4%).7 The dynamics of hypertension characteristics also present similar temporal trends. According to Imperial College and WHO GHO 2015, mean systolic blood pressure in men decreased over time, comparing 2008 to 2015: from 137 to 135 mmHg (comparing to other countries—Poland—changed from 135 to 134 mmHg, Germany—declined from 133 to 126 mmHg, UK—decreased from 131 to 126 mmHg. In women, mean systolic blood pressure was 132 in 2008 and fell to 128 mmHg in 2015. Similar changes were observed in Poland—130 vs. 123 mmHg, Germany—125–117 mmHg, and the UK—124–117 mmHg7
Prevalence of overweight and obesity among Ukrainian adults was estimated at 58.6% (vs. Poland—58.3%, Germany—56.8%, UK—63.7% in the 2016 WHO GHO report. The prevalence of elevated fasting blood glucose (>7 mM or on medication) was 7.3% (vs. Poland—7.7%, Germany—5%, UK—5.8%).7
In summary, these data clearly show that the people of Ukraine were already at high cardiovascular risk before the war. Consequently, the cardiovascular needs of the Ukrainian refugees must be identified, assessed, and treated, and continuity of care continues.
Unmet medical needs
In cooperation with local authorities, numerous non-governmental organizations (NGOs) initiated several response projects to support the medical needs of the refugees. The World Health Organisation (WHO), in collaboration with United Nations High Commitioner for Refugees (UNHCR) and United Nations Children's Fund (UNICEF), has attempted to estimate these health needs both in Ukraine itself and in refugee reception countries like Poland.9 At various levels of care, NGOs as well as government-based teams of volunteers work with refugees at their reception or relocation points, providing them with essential medical assistance in consultations and medications.9
The emergency medical services start on the trains, which bring refugees to Poland. The Polish Government has organized special medical trains. Each has a capacity of transporting 160 severely ill as well as wounded patients to evacuate patients from hospitals and the war frontlines. These medically staffed trains continue to operate daily between Ukraine and Poland despite imminent Russian attacks on Ukrainian railway infrastructure. At the same time, several NGOs, such as the Médecins Sans Frontiers, have worked on the passenger trains bringing refugees between key cities in Ukraine (i.e. Lviv) and Poland to provide immediate relief in this challenging environment. Upon arrival to Poland, access to broader medical care is immediately available to refugees at the reception and relocation points in border crossing areas and all major cities across Poland. Several medical charitable organizations, including Malteser International, Polish Medical Mission, International Medical Corps, and many others, are highly involved, along with numerous local and international volunteers arriving in Poland daily.
One of those initiatives has been organized by the Jagiellonian University Medical College in cooperation with the Doctors Charity Centre Foundation. Teams of medical students and academic physicians are providing immediate care in reception centres throughout Krakow, PL. This activity has provided an interesting outlook on the actual medical needs of refugees upon arrival in Poland (Figure 1B). When seeking acute help, the main complaint (in 68%) was an acute respiratory infection. The most common were upper respiratory tract infections, followed by gastrointestinal and urinary tract infections. Continuation of prior treatment was requested in 32% of cases, which is in line with WHO/UNHCR data1,9 and data from the published Moldova registry.10 Interestingly, as the refugee crisis continued, a gradual decrease in acute illnesses was observed, while the number of patients reporting chronic problems, including cardiovascular complaints, remained unchanged (Figure 1B). While these data provide a snapshot of the situation, they exemplify that cardiovascular care will likely remain a significant necessity for the continuously growing refugee population in the Ukrainian crisis.
Current large NGO initiatives focus mainly on support related to sudden illnesses. The WHO and UNHCR reports emphasize that the health need exceeds NGOs-provided aid, which is particularly important in relation to chronic conditions. The unaddressed fields include cardiovascular medicine, oncology, HIV, tuberculosis, gender-based violence, and human trafficking. An essential issue that is now coming into focus regarding refugees’ health needs that need urgent attention is the mental health and psycho-social support programmes. In several reception points and hospitality centres, psychologists and psychiatrists have regular visits to support the mental needs of refugees, but further structured interventions are urgently needed. The humanitarian system is put to a severe test. But even before the crisis, we struggled with different problems within the system, its financing and NGOs’ cooperation.11
While the number of refugees arriving in neighbouring countries decreases, the beginning of a new offensive in the Donbas region indicates that a new type of refugee is seen. This includes people escaping the warzone itself (as opposed to people fleeing the war). This will carry additional psychological and emergency military medicine-associated needs in all target countries. WHO provided Minimum Data Set for Reporting for Poland, which covers the most urgent needs to be assessed in the refugees. This data reporting form was already successfully implemented in Moldova.
Do we need a rapid assessment of refugees’ cardiovascular status?
Since the early days of April 2022, we have observed a decrease in the need for new medical attention, with a stable number of patients with chronic disorders seeking treatment continuation (Figure 1B). 21.6% of these chronic complaints were related to the cardiovascular system. These included hypertension, coronary artery disease, heart failure, and arrhythmia symptoms. Detailed characterization of their cardiovascular status is ongoing. Most of the refugees were made eligible for the free national medical service provided by the receiving countries, including Poland.12 Thus, one of the key reasons for the decrease in the number of patients observed in NGO-run medical support points is that patients with new symptoms are now well integrated and assessed within the healthcare system of the Republic of Poland. The second reason for this reduction is likely linked to a relative decrease in the influx of refugees to Poland after the initial wave (Figure 1A).
Assessing refugees’ cardiovascular status, especially the adults and elderly patients, seems a key to being able to help them avoid severe complications like myocardial infarction or stroke. Pre-existing, chronic, non-communicable diseases are the most significant contributor to the disease burden among Ukrainian adults. Setting priorities to address particular diseases and prioritizing care delivery in humanitarian settings is a key component of NCD care delivery.13
Assessment of medical needs supported by evidence combined with proper advocacy is essential to generate visibility and resource allocation.14 Only this could confirm the medical safety of refugees in their places of stay.15
Acknowledgements
The authors would like to acknowledge and appreciate the work of all volunteers in the current refugee crisis. These unprecedented times require unprecedented efforts. The local ethics committee approved the collection of the data for clinical characterization (OIL/KBL/19/2022).
References
Author notes
Conflict of interest: Authors have no conflict of interest.
