War, Escalating Vulnerabilities, and Service Delivery in Ukraine
By Sarah D. Phillips, Indiana U and Jill Owczarzak, Johns Hopkins U
This piece was originally published in the October 2015 NewsNet. Please click through for additional content.
Before the war in Ukraine began in mid-April 2014, considerable headway was being made in the development of programs and initiatives to protect the rights of—and provide social and health services and employment opportunities to—Ukraine’s vulnerable populations, including people with disabilities, people who use drugs, and people living with HIV/AIDS and/or other chronic illnesses (tuberculosis, Hepatitis C). As anthropologists interested in health and society, we have been tracking these initiatives in a series of research projects on disability issues since 2006 and HIV prevention since 2012 . Now we find ourselves documenting how the war in Ukraine has not only disrupted existing services for already-vulnerable populations; it has created new forms and new crises of vulnerability.
Approximately 7,000 people have been killed and over 17,000 injured in Ukraine during the war. The war has displaced more than 2.3 million people. As of July 31, 925,500 persons had sought asylum, residence permits or other forms of legal stay in neighboring countries, mostly Russia. By September 7, 1,460,000 internally displaced persons (IDPs) were registered by the Ministry of Social Policy across Ukraine in the government-controlled areas (GCAs). The true number of IDPs is likely much higher, since centralized registration for IDPs was launched only in October 2014; some IDPs may not have proper documentation required to register; unaccompanied children cannot register; and IDPs within non-government controlled areas have not been counted. It is not known how many people are living in non-government-controlled areas (NGCAs, areas under separatist control) in Donetsk and Luhansk oblasts. According to the United Nations High Commissioner for Refugees, people living in these areas lack access to public services previously provided by central authorities, and the situation is exacerbated by the restrictions to the movement of people and goods.
According to the Ukrainian Ministry of Social Policy, 12.6% of IDPs in Ukraine are children, 4.2% are people with disabilities (PWD), and 59.1% receive some sort of social pension. Women and children comprise the majority of the IDP population, as men stayed behind to protect property, to fight in the conflict, or were prevented from leaving by armed groups. International organizations such as the UNHCR, UNICEF, and others are helping Ukrainian state institutions coordinate relief efforts for war-affected populations in Ukraine. They are joined by a robust cadre of civic activists and associated non-governmental organizations that, since the EuroMaidan protests, have engaged in fundraising and service efforts to assist IDPs and supply the Ukrainian army with equipment and provisions. These citizens’ initiatives are locally referred to as a “state within a state,” a formulation that highlights the extent to which private citizens are stepping in to fill the gaps in the Ukrainian state’s safety and security net. At the same time, IDPs are not always welcomed by host communities; as often happens, local populations may see IDPs as competitors for jobs and scarce resources, and blame them for bringing social and health problems with them.
These challenges are exacerbated by Ukraine’s attendant economic down-spiral—Ukraine’s currency (the hryvnia, UAH) crashed in February 2015, GDP fell by 18% during the first quarter of 2015, and inflation topped 60% in April 2015. The Ukrainian government was woefully unprepared for the humanitarian crisis, and international and local organizations are struggling to cope as well. In this context of economic decline, sharpened marginalization of vulnerable groups, and an IDP crisis, already over-burdened health and social service agencies—many of them non-governmental organizations with very limited resources—must rapidly adapt to serve new populations and provide new services. Here we highlight a few cases that illustrate some of the vulnerability crises produced or exacerbated by the war in Ukraine.
Acute vulnerabilities in non-government-controlled areas
People living in NGCAs—including those with disabilities who may have chronic medical conditions that require medicines, therapy, and other special care—face acute shortages of medicines, personal hygiene products, safe drinking water, and food, including infant formula and baby food. Food security is a serious concern, due to shortages and high inflation in the NGCAs. The existing permit system for crossing the “contact line” from GCA to NGCA includes no provisions that would allow people with disabilities, the elderly, and those with acute health crises and health care needs to quickly leave the conflict zone, and the restrictions on freedom of movement impede people in NGCAs from accessing social entitlements and healthcare. The UN Office for the Coordination of Humanitarian Affairs (OCHA) and NGOs report difficulties in carrying out humanitarian work due to regulations on the free movement of civilians and goods imposed by Government authorities. Notary services have been discontinued in the NGCAs, which impedes some pensioners (including people with disabilities) from accessing their social benefits. Disability rights activists who left the NGCAs are struggling to provide aid to people with disabilities still living in the separatist-controlled territories, either by periodically undertaking risky travel there, or by sending aid through couriers.
It is unknown how many people with disabilities (PWD) are still living in the NGCAs. For instance, although the prewar population of PWD in Luhansk oblast was estimated at 250,000, as of mid-July only 24,000 PWD from Luhansk oblast were registered as IDPs living in GCAs. It is not known how many PWD have requested asylum or permanent residence in neighboring countries, but disability rights activists estimate that at least 22,000 PWD are still living in the city of Luhansk, with thousands more throughout the NGCAs.
IDPs with disabilities—doubly vulnerable
Although there are no reliable statistics available, it is estimated that of the approximately 1.4 million IDPs registered in the GCAs, almost 60,000 are PWD. Although it is widely recognized among those involved in humanitarian efforts that IDP populations are comprised of many PWD and elderly persons, very few targeted programs to assist PWD and the elderly have been developed. Although in recent years significant strides had been made in accessibility and social integration of PWD, the post-Soviet social safety net for those with disabilities was always severely inadequate. The situation has only gotten worse with the influx of IDPs with special needs. According to a prominent disability rights activist and PWD from Luhansk, herself an IDP, “the state budget doesn’t even cover the local PWD, not to mention the IDPs with special needs now.”
PWD receive an average monthly disability pension of 1,200 UAH ($60), and IDP PWD are entitled to additional assistance of 1,000 UAH ($50). Unemployment rates are extremely high for IDPs, and IDP PWD find it nearly impossible to get work. PWD are often excluded from trips and programs arranged for IDPs; organizers find it too difficult to accommodate their special needs (transportation, communication, etc.). Unable to afford the customary 4,000 UAH ($200) monthly apartment rent, PWD displaced by the war face housing insecurity. Many PWD IDPs are being housed collectively in repurposed buildings (sanatoria, schools, dormitories, hospital wards). These buildings are not handicapped accessible and many are in need of repairs. A UNDP official in the GCA of Donetsk oblast reports that these collective centers for IDPs have become “dumping grounds” for the disabled and elderly by family members unable or unwilling to care for them. Food insecurity is also a mounting problem for PWD and other vulnerable populations displaced by the war.
Case management overload
Since 2012 we have worked closely with eight HIV service agencies in eight Ukrainian cities that use harm reduction strategies to reduce HIV risk and improve health and social outcomes for at-risk populations, especially people who use drugs (PWUD) and commercial sex workers (CSWs). In the context of the IDP crisis these agencies are compelled to absorb new target groups, provide new services, and adapt existing services to the needs of IDPs. In Poltava, for example, the agency Light of Hope (Svitlo Nadiyi) has opened their small shelter to people they call “transit refugees” (temporarily homeless, most of them IDPs). They identify “transit refugees” as a new target group for their services, as well as the elderly and the chronically ill. Light of Hope is adapting its alreadyexisting model of case management for PWUD to evaluate the needs of and deliver services to new client groups. They have received very little financial support to do so, however, causing a “case management overload” for the agency. The agency also has incorporated IDPs into its small job training-apprenticeship program. Light of Hope has been compelled to create new services as well: to better serve the very ill and elderly, the agency is developing hospice services, for example.
The HIV service agency Our Help (Nasha Dopomoha) in Slavyansk is also extending its services to IDPs, especially the elderly, who, it is reported, are being “dumped” in temporary IDP housing facilities by family members eager to move on and seek work. These elderly IDPs have chronic and acute health conditions that Our Help—as one of the most organized, respected, and agile NGOs in the city—is struggling to address. As a formerly separatist-occupied city just outside the NGCA, Slavyansk hosts a large number of Ukrainian troops. Our Help is extending its services to offer Hepatitis C testing to troops, and so far reports a 4.27% prevalence rate. Our partner agency in Dnipropetrovsk faces a different adjustment due to the war: the agency’s long-standing director has been serving in the Ukrainian National Guard since February 2014 and is fighting in the war, resulting in significantly scaled-back programs and services.
The drug treatment void in Russia-controlled Crimea
Historically, the HIV epidemic in Ukraine has been most acute in the country’s eastern and southern regions and concentrated among people who inject drugs and their sex partners. While the Ukrainian government’s response to the epidemic has been criticized by advocates within nongovernmental organizations, one success has been the introduction of opioid substitution treatment (OST). OST is recognized as an effective HIV prevention strategy for opioid-dependent drug users because it reduces injection risk behaviors and increases quality of life. While there have been ideological and practical challenges to OST access and provision in Ukraine its continuous implementation since 2004 contrasts with Russia, where OST is banned. Russian addiction specialists widely believe that OST is ineffective in treating addiction and increases mortality among drug users. When Russia annexed Crimea in March 2014, OST became illegal there as well. Stocks of methadone and buprenorphine on the Crimean peninsula were quickly depleted. As a result, in May 2014 eleven OST sites in Crimea shut down, leaving hundreds of patients without this addiction treatment option. In addition, OST clinics often provide a way to engage marginalized populations in other medical and social services. Without OST, these patients face the difficult decision of whether to travel to mainland Ukraine in order to continue receiving OST or remain in Russiancontrolled Crimea and face their addiction without this treatment and its attendant support services. The results are devastating: UN officials report that about 10 percent of the 800 Crimean OST patients have died, likely of overdoses. Nongovernmental organizations have also helped OST patients to leave Crimea (and Ukrainian regions still engaged in conflict) for other regions of Ukraine where they can continue to receive OST. Unfortunately, fewer than 100 patients were able to relocate, leaving hundreds of OST patients and thousands of drug users without access to evidence-based treatment. Instead, drug users in Russia must navigate of patchwork of treatment options that lack strong evidence of effectiveness, such as 12-step programs, or detoxification treatment within state-run narcology centers (sometimes within inhumane treatment that includes shackling and cells) that lack adequate rehabilitation support. 
For the agencies that work with drug users, the transfer of Crimea from Ukrainian to Russian control has been devastating as well. We had been working with one agency in Simferopol for several years when the conflict began. This agency provided harm reduction services to PWUD and CSWs (many of whom also use drugs), and connected them with addiction treatment services, including OST. Like most other HIV-related NGOs in Ukraine, this agency supported its programs with money from the Global Fund that was distributed through the International HIV/AIDS Alliance in Ukraine. This and other agencies are no longer certain about their programmatic or financial future. The programs they had developed over many years are no longer acceptable in the new HIV prevention landscape; harm reduction approaches including needle exchange are no longer tolerated. They are unsure how long the Global Fund will continue to support their work, and they have been unable to receive funds from Russian sources.
Discussion
Displacement of large numbers of people as the result of conflict or natural disasters has the effect of exposing the inadequacies of already weak social safety nets, the true extent to which vulnerable populations live in precarious situations, and how quickly new categories of vulnerability can be created. Prior to the current conflict in Ukraine, people with disabilities, drug users, and people living with HIV/AIDS were already precarious subjects. These exacerbated and new vulnerabilities present challenges for institutional actors involved in service delivery. There is commonly a proliferation of IDP-specific NGOs immediately following a crisis, which may lead to redundancy in services, duplication of existing services, and competition between agencies for clients and funding. In cases where each organization is specialized and provides a single type of service (e.g. legal aid, medical care, rights advocacy, social services) there is often a fragmentation of the service landscape, as well as breakdowns in communication, that hinders IDPs’ reliable access to services. In other cases, the immediate food, shelter, and clothing needs of IDPs are the primary focus of aid organizations and existing, non-IDP serving agencies that address other issues (e.g. HIV prevention and interpersonal violence) do not work with IDPs. Indeed, crises often generate an abundance of short-term services for provision of basic needs; less attention is focused on longer-term problems or the problems faced by particular vulnerable groups. This situation calls for new models of assistance, moving away from service-delivery to facilitating IDPs’ access to existing services. In the case of populations that have very specific needs, such as people with disabilities (whose numbers continue to increase in a context of war) and drug users, partnering with organizations with histories of working with and advocating for these groups is even more important. This approach will require new strategies to identify systems of collaboration, coordination, and referral between different types of providers; identify ways to deliver services that would increase clients’ comfort and sense of confidentiality; and identify organizations with strong and shared interests in working with IDPs.
Sarah D. Phillips is a Professor of Anthropology and Director of the Russian and East European Institute at Indiana University
Jill Owczarzak is an Assistant Professor of Health, Behavior and Society at the Bloomberg School of Public Health at Johns Hopkins University
All photos used by permission of Sergii Morgunov.