Russian-backed attempts to sabotage Ukraine's economic, political, and health developments have left the country fighting a measles outbreak and continuing a bloody, undeclared war. The situation is emblematic of increasing tension between the ideologies of President Vladimir Putin and countries of the pro-democratic, neoliberal west.

The measles outbreak—affecting other countries including Serbia, Georgia, Greece, and Italy—has hit Ukraine hardest, with the country's 23 000 cases accounting for more than half the European regional total. Kremlin-supported social media accounts spreading discredited theories about the measles, mumps, rubella (MMR) vaccine, combined with shortages and underfunding, have been blamed for the outbreak. Research published on Aug 23 concluded Russian trolls promoted discord and, masquerading as legitimate users, created a false impression that arguments for and against vaccination were equipoised. The result has been an erosion of public consensus on the value of vaccine programmes. The precipitous fall in vaccination level began after 2008, when 95% of eligible children in Ukraine received their second (and final) recommended dose of the MMR vaccine. By 2016, the rate was 31%, among the lowest in the world. Although now rising again, the latest 85% measles vaccination rate recorded by WHO remains below that needed for herd immunity. Records in 2016 show poor vaccination rates for other diseases: only 19% of children received the third recommended dose of the diphtheria-tetanus-pertussis vaccine and 56% received the third recommended dose of oral polio vaccine. Hepatitis B vaccination was low, with coverage with hepatitis B birth-dose and third-dose vaccines at 37% and 26%, respectively. WHO estimates between 3% and 5% of the Ukraine's 45 million population has been infected with hepatitis C. Ukraine bears the second largest HIV epidemic in eastern Europe and central Asia.

The proxy war in the country's eastern Donbas region, which began mid-April, 2014, had claimed 10 090 lives by May 15, 2017, including 2777 civilians killed, and at least 23 966 injured. These are conservative estimates based on available data, and the actual figures are likely to be higher, stated a UN report in 2017. More than 1·6 million people have fled their homes and become internally displaced, while some 3 million remain in territory controlled by armed groups. The region designated a non-government controlled area is made up of large parts of the two oblasts—or regions—of Donetsk and Luhansk and separated from the rest of Ukraine by a line of contact that has five entry–exit checkpoints. On May 29, the UN Security Council (UNSC) held the first briefing on Ukraine in 15 months. It was followed by an unprecedented UNSC Presidential Statement expressing “grave concern about the recent deterioration of the security situation in eastern Ukraine and its severe impact on the civilian population”. The Office of the UN High Commissioner for Human Rights (UNHCR) makes note of summary executions reported on both sides of the contact line earlier on in the conflict. Special attention is paid by UNHCR to the allegations of systematic use of torture and ill treatment by the Security Service of Ukraine against conflict-related detainees to extract confessions. Sanctions imposed on the Kremlin at the time of Russia's invasion and annexation of Ukraine's Crimea region in 2014, coming in the wake of Ukraine's so-called revolution of dignity or Euromaidan and the removal of President Viktor Yanukovych from power, have done little to improve matters.

The health-care reforms, led by US-born Uluana Suprun, profiled in this week's issue, include the introduction of an internal market structure, a shift of care from a hospital to a community-based service, and the elimination of corruption and bribery. Patients currently make up the 45·6% shortfall of the 7·6% of GDP spent on health with out-of-pocket and informal payments. Bed numbers and patients' average length of hospital stay will be reduced. Western-backed support for the reforms comes from the UN Development Programme, UNICEF, and the UK procurement agency, Crown Agents, now responsible for purchasing 5·9 billion Ukrainian hryvnia (about US$ 212 million) of medicines for the country. The service—developed from the Soviet Semashko system—is seen by many as inefficient and inequitable; nevertheless some politicians and doctors remain opposed to the changes. More generally, the World Bank has also endorsed Ukraine's efforts to achieve lasting economic recovery.

The situation in the Ukraine involves many facets but western leaders and Ukraine's Government must stay focussed and committed to driving through the latest plans to improve the country's health. However, more zeal is needed to resolve the bloody conflict in the eastern region.

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