The Russian attacks on Ukraine are having a devastating impact on civilians. But the health consequences extend far beyond the effects of bombing and shelling.

Although it may not be the most urgent threat Ukrainians face, COVID remains a serious risk. Crowded trains, bomb shelters and refugee processing facilities provide ideal conditions for COVID transmission. In the country, Russian attacks have destroyed health care facilities and cut off humanitarian aid routes, and those hospitals that are still operating are running out of resources such as oxygen and vital medical supplies.

“The war in Ukraine is having devastating consequences for the health of Ukraine’s people ... that will reverberate for years or decades to come,” said World Health Organization Director General Tedros Adhanom Ghebreyesus at the United Nations Security Council meeting on Ukraine on March 17.

When Russia invaded Ukraine on February 24, COVID cases in the country had been declining from their early February Omicron peak of more than 37,000 per day. But since the war began, COVID testing has decreased, and the number of new cases Ukraine’s health authorities are reporting is likely an undercount. Ukraine also has a relatively low vaccination rate: only about 36 percent of Ukrainians are estimated to have received shots, making it likelier that at least some of those who contract the disease will have a severe case.

COVID is still a threat. “It hasn’t gone away..., but priorities certainly changed,” says Paul Spiegel, director of the Center for Humanitarian Health at Johns Hopkins University. For those who were concentrating on COVID before, “now you’re worried about your life. You’re worried about leaving the country, your children, your partner.”

Spiegel says the conditions many refugees are facing are likely to increase transmission of SARS-CoV-2, the virus that causes COVID. While he worries this could lead to an uptake in cases among refugees, he says that host countries should be careful not to blame them for spreading disease. Many European countries are already seeing another wave in cases caused by Omicron’s subvariant BA.2, so the influx of refugees may have little effect on total cases. The millions of refugees entering surrounding European countries will need treatment, however, and those countries should be prepared to handle the demands on their health systems.

In recent days Russia has intensified its attacks on civilians and civilian infrastructure, including hospitals. According to the WHO’s Surveillance System for Attacks on Health Care, there were 73 attacks on Ukrainian health care facilities between February 24 and March 28.

A tragic and widely shared Associated Press photograph that circulated recently depicts a pregnant women on a stretcher amid the bombed-out remnants of a hospital in the eastern Ukrainian city of Mariupol'. Neither the woman nor her fetus survived.

International health agencies have called for Russia to stop these attacks on health care facilities. “These horrific attacks are killing and causing serious injuries to patients and health workers, destroying vital health infrastructure and forcing thousands to forgo accessing health services despite catastrophic needs,” read a March 13 joint statement from the WHO, UNICEF and the U.N. Population Fund (UNFPA). “To attack the most vulnerable—babies, children, pregnant women, and those already suffering from illness and disease, and health workers risking their own lives to save lives—is an act of unconscionable cruelty.” The statement also called for an immediate cease-fire to allow access for humanitarian assistance, a demand that has clearly gone unheeded.

Beyond COVID, the war could increase the risk of other infectious diseases, such as tuberculosis (TB), measles and polio.

Ukraine has a high rate of death and disability caused by TB, including from drug-resistant TB. “The situation in Ukraine before the war was not great,” says Lucica Ditiu, executive director of the Stop TB Partnership, a Geneva-based organization hosted by the U.N. Office for Project Services. But Stop TB had been working with Ukraine to address the problem and procure medicines to treat people with the disease. The country was committed to making progress, Ditiu says. Then the war began.

“What is happening right now is horrific,” Ditiu says. Hospitals and dispensaries that provide critical TB treatments are being destroyed. “It took years to build this [system]. It will take tens of years to rebuild this,” she says. TB’s symptoms are very similar to COVID’s—they both can cause cough, fever and night sweats—and both diseases spread easily under the crowded conditions many refugees are experiencing.

Apart from calling for an end to the war, Ditiu recommends several other measures to address the crisis. Countries that are receiving refugees need support, including medical care and staff. And humanitarian corridors must be created to allow health care workers and medical supplies to reach Ukrainians in hard-hit parts of the country.

Polio could also see a resurgence because of the war. The disease is vaccine-preventable and had been nearing eradication in most of the world. But a handful of cases were reported in Ukraine starting last fall. The country responded to that outbreak with a vaccination drive, but the war has disrupted those efforts, raising the risk of further outbreaks.

There is a well-established link between war and disease outbreaks extending back centuries. The civil war in Syria and the refugee crisis it spurred led to measles outbreaks. And the violent conflict in the Democratic Republic of the Congo, which included direct attacks on health care workers, exacerbated the recent Ebola outbreaks there.

“What we know from studying war [is that] there are two kinds of trauma,” says Rohini Haar, an epidemiologist at the University of California, Berkeley, School of Public Health. There is direct or violent trauma, which results in death and casualties from the fighting itself, and there is indirect trauma, which persists for years and may never be fully documented. “Usually direct trauma is the major source of death in the first few days and weeks,” Haar says. “But by months and years, it pales in comparison to the indirect deaths.”

She and her colleagues conducted a study of measles cases in Syria based on data starting in 2015, but the country’s civil war itself started in 2011. “We don’t even know what happened before because nobody was counting,” she says. Haar worries indirect deaths and diseases are likely to be underestimated in Ukraine, too. And the health effects of the war in Ukraine will likely last many years. “This is just the very early days of what will end up being a protracted crisis,” she says.