War in Ukraine: public health, rehabilitation and assistive technologies

The Russian invasion already has and will continue to amass an enormous additional burden of disease in Ukraine. Its sources include the direct effects (such as the traumatic injuries and psychological disturbances sustained by participating in or being subjected to violent hostilities), indirect impacts (including those secondary to sheltering and fleeing from aggressive attacks, and disruption to the health system’s infrastructure and workforce), and migratory consequences [1,2] of kinetic warfare in twenty-first century Europe. One of the greatest health needs created by the conflict is the surge in those requiring rehabilitation services [3], which is likely to affect tens of thousands of people and thereby amount to a public health problem.

WHO defines rehabilitation as “a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment.” [4] Along with preventing and minimising the impact of complications, rehabilitation improves an individual’s functioning, reduces the costs of their ongoing care, and supports their participation in a flourishing life [3]. Conflict not only inflicts the direct physical harm that increases demand for rehabilitation, but also reduces the health system’s ability to provide this care through disruption to or destruction of the relevant infrastructure, workforce and clinical services. Consequently, not only those with conflict-related rehabilitation needs (such as fractures, amputations, and spinal cord injuries), but also those with pre-existing functioning impairments and long-term rehabilitation requirements face barriers to accessing essential health services. In the absence of early and continuous specialist rehabilitation interventions, the likely result is severe, debilitating and long-lasting physical and psychological impairment that reduces functioning and quality of life while increasing the risk of serious complications [5]. Since the war in Ukraine has to-date wounded 5,900 civilians (which is deemed to be a considerable underestimation) [6], and thousands of troops have been injured on the battlefield, the burden of rehabilitation need from conflict-related injuries alone is of adequate scale to constitute a public health problem.

Prior to the war, Ukraine’s progress towards the health-related SDGs required urgent acceleration to achieve UHC [7], and drastic improvements in the adoption and usage of assistive technologies was deemed central to these efforts [7]. Assistive technologies are embedded in assistive products, which WHO considers to be “any external product (including devices, equipment, instruments or software), the primary purpose of which is to maintain or improve an individual’s functioning and independence, and thereby promote his/her well-being” [8]. A 2020–2021 survey found that 45% of Ukrainians have at least some difficulty in one or more domains of mobility, vision, hearing, communication, cognition, and self-care (16% have a lot of difficulty or could not function at all in one or more domains), and 40% need at least one assistive product [8]. Concerningly, 80% of those using assistive products other than spectacles paid out-of-pocket or received them from others, while 8% have an unmet need for at least one assistive product. The on-going war is now likely to exacerbate these pre-existing discrepancies.

Multiple weaknesses in and opportunities for the development of Ukraine’s assistive technology sector have been identified: (Policy) only those registered as disabled are eligible for government-funded assistive products, while duplicate systems exist for provision of these technologies; (Products) many available assistive products are low-quality, while few options exist outside mobility and self-care domains; (Provision) assistive products are often provided without rehabilitation services; (Personnel) few assistive technology professionals are trained to international standards [3]. Deplorably, efforts to improve this suboptimal landscape are now being hampered by the Russian invasion, as resources are redirected towards national defence spending [9], and the necessary health facilities and workforce are disrupted.

The on-going conflict has both increased the demand for and reduced the supply of assistive technologies for Ukrainians in need of rehabilitation services. As such, those with greatest health needs now face the largest barriers to accessing care – a conflict-induced variant of the inverse care law [10]. In response to this humanitarian crisis, WHO has produced two priority assistive technology product lists (based on the findings of the 2020–2021 survey), the first of which (AT6) includes wheelchairs and cushions, elbow and axilla crutches, walking frames, and mobile toilet and shower chairs, and were included in deliveries of WHO Trauma Emergency Surgical Kits to Ukrainian healthcare facilities. The second list (AT10), which targets internally displaced people and refugees, includes two types of wheelchairs and cushions, elbow and axilla crutches, walking frames, static toilet and shower chairs, absorbent products, and three different types of catheter kits [11]. In addition, a list of assistive products for children and people with disabilities in emergencies has been developed by UNICEF [12].

Without urgent remedial action, a substantial burden of severe, debilitating and long-lasting impairment is likely to ensue, which will severely diminish the quality of life of tens of thousands of Ukrainian people, and widen the country’s health inequalities. Accordingly, multisectoral action involving public health professionals is urgently required to deploy relevant assistive technologies that meet international standards (including those donated by international partners), along with the necessary professional training for their appropriate prescription, fitting and subsequent follow-up [13]. The procurement and provision of both the WHO AT6 and AT10 list products is the first step towards achieving this goal [11], but their ubiquitous distribution throughout the conflict-stricken country, and meaningful incorporation into the existing (and severely overstretched health system), are essential steps to avoid the enormous burden of morbidity that will otherwise be created. While many growing health priorities compete for resources in Ukraine, the scale, severity and duration of ill-health caused by unmet rehabilitation needs creates an essential target for public health action.

Disclosure statement

No potential conflict of interest was reported by the author(s).