What Makes Ukraine’s Refugee Crisis So Different

As the WHO’s emergency coordinator for the Ukrainian refugee response, Paul Spiegel, MD, MPH recently returned from 6-and-a-half weeks in Europe, where he visited 4 countries hosting Ukrainian refugees—Slovakia, Poland, Romania, and the Czech Republic.

Spiegel, director of the Johns Hopkins Bloomberg School of Public Health’s Center for Humanitarian Health, shared some reflections with GHN on the many ways that the Ukrainian emergency differs from other humanitarian crises, including the response’s strengths—and concerns like the West’s failure to treat emergencies in all parts of the world equally.

How is the response to this emergency different than others you’ve worked on?

The governments are really taking the lead. Apart from Moldova, the host nations are all European Union countries, with very competent and strong governance. And so the international community’s role in this response is very different than in many other humanitarian emergencies.

The WHO’s mission is to, number 1, support those governments with technical advice and any support they need. But even with nearly 6 million refugees so far, hosts’ health systems have been able to cope; ministries are saying that hospitals are not overwhelmed at this point. That may be because we’re seeing a lot of physically healthy women and children coming across the border.

What are the main needs, then—is it responding to the trauma the refugees have endured?

The big problem is with mental health. In most countries, including the US, there aren’t enough psychiatrists and psychologists for even the national population. And now you’ve got people who have dealt with extreme, serious trauma who need support. On top of that, with mental health, a lot of the treatments are talk therapy, cognitive behavioral therapy and other methods where providers need to speak the language and understand the culture.

Another important area that’s often difficult to address sufficiently is gender-based violence.

Are the host countries including the refugees in the national health care systems?

That’s right—it’s extraordinary. In any of these countries, if you’re a Ukrainian refugee, you can work. You can send your child to school, and you have access to national health systems the same way that nationals have, so it’s very generous.

This was not the same for the migrants and the refugees from Turkey and from Libya. So we know there are some double standards here, which is a pity, and I hope that something like this will be used as a model for the future.

Are many of the refugees staying with families?

Yes, most are staying with host families, or hotels opened up by governments or hoteliers; sometimes these hoteliers are getting compensated, sometimes not. The generosity is quite extraordinary. And so refugees aren’t in classic refugee camps or big convention centers, with beds and beds across as far as you can see. I hope this will become the standard we see everywhere.

But 1 concern is that this generosity may dry up, because I don’t think that when people opened up their hearts and their houses they were thinking it would be a year, or even months—they were thinking weeks. In 3, 4 months, are people still going to be hosting? If not, what are the alternatives; what are we going to do for these people? Just as we saw with Syrian refugees in Jordan and Lebanon, there’s an outpouring of goodwill at the beginning—but that doesn’t last forever and resentment can set in. So I’m very worried that we haven’t seen the end of this by any means.

How are you measuring and tracking needs when people are so spread out?

That’s another complicated aspect: there are 5 contiguous countries involved, but most—Moldova, Hungary, the Slovak Republic, Romania—are primarily transit countries. Some people are staying there, but many are moving on to the Czech Republic, Germany, Sweden—all over. They say over 3.25 million people have crossed into Poland, but we don’t know exactly how many are staying there, because they are free to leave and travel within Western Europe’s Schengen zone—and we can’t track that easily.

On top of that, there’s a lot of anxiety because people want to go back; most of these are young women with partners back home fighting. We know many people are crossing back; whether that’s permanent or temporary isn’t clear.

How do you prepare these refugees to return to a country that’s been so devastated?

There’s so much more than just physical destruction … there’s the economy, and agriculture, and then the men are fighting. So there’s a lot for the refugees to decide: Even if their house is still standing, should they go back? Do they put their kids in school now, in the local language in Poland or wherever they are—or enroll them in online classes in Ukrainian offered by the Ukrainian government?

What would you tell people in the public health community who want to help?

Again, what makes this different is that we don’t need the UN and the international NGOs as much as in other settings. We don’t need to send a huge amount of people to this crisis because the EU has got the people and they’ve got the expertise.

We still need better data, even in this crisis, because currently the data are insufficient to make really good, strong decisions—either because systems aren’t in place, or people are not using the care, or the care may not be sufficiently disaggregated by host and refugee at this point.

But in the longer term, I think it’s helpful to look at equity issues. It’s going to be important for public health practitioners to be aware of the political aspects of these humanitarian crises, but from the public health point of view—to really try to get the data and analyze the data in terms of greatest need and advocate for that – ensuring care for all vulnerable people, whether host or refugee.

Everyone’s paying attention to Ukraine, and we are forgetting about places like Afghanistan and Syria. And it’s not just the media; it’s also the funding. Geopolitically, Ukraine is huge in terms of what it means for the world. From a humanitarian point of view, we need to treat these emergencies equally, according to the greatest need—and that’s not what’s happening.

Is the Ukraine response draining resources from other emergencies?

First, I would say that it’s very expensive; it’s going to take many billions of dollars. But the positive thing is that much of the funding is and will flow directly to the [host] governments, rather than through the UN or other organizations.

In some ways, this is what we’ve all wanted, which is national countries taking responsibility for refugees on their soil. But I am finding it’s hard for the UN and the international NGOs because they’re so used to doing things a certain way, using coordination models and assessment models designed for other refugee settings.

We often talk about “One UN,” trying to do things in a more integrated manner. But it’s not always easy. One of the things that [our team] developed that I’m most proud of—that I hope can serve as a model—is the Refugee Health Extension in Poland. By the time I left, we had professionals from UNHCR, from UNICEF, and from the European CDC working in the same office with the WHO. The idea was to try to work more closely to ensure that we’re giving consistent advice to all the governments, and to ensure that, in terms of monitoring and evaluation, the indicators are coherent and contextually specific for this environment—because it is so different.

What do you wish people realized about the needs of the Ukrainian refugees?

I think it’s important for us to look at how we see these situations compared to, let’s say, Afghanistan. With Ukraine, some in the West think … well, if that can happen there, it can happen here—which is true. When Westerners see people who look like us, who dress like us, who are walking across the border with dogs, from an emotional point of view that could be difficult. But from a humanitarian point of view, there is no difference between them and people with different colors or different religions walking across this border. I think it’s important for us to recognize our biases.

Somehow Ukraine brings it all home to us [in the West]. Maybe because it’s a western country, maybe because it relates to Russia. And it’s Europe. So I think Americans can somehow relate to it … which is just, it’s so unfair.

This interview has been edited for length and clarity.

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