Tertishnik’s village was once a backwater, best known for smuggling petrol and cigarettes across the poorly guarded border. But, in 2018, a tall barbed wire fence was erected by Russia along a street named Friendship of Nations, splitting the community into two: Milove in Ukraine and Chertkovo on Russian territory. The smuggling has stopped, and now relatives and neighbors on opposite sides of the street have to travel to border checkpoints to visit each other. 

The divisions in the village, and the country, have imposed a heavy economic and social cost on Milove, but when asked how his life has changed, the first thing Tertishnik mentions is the coronavirus — and vaccination in particular. The 73-year-old is angry because Ukraine does not use Russia’s Sputnik V shot, so he has to receive one of the several Western formulas registered for use in Ukraine.    

“I think Sputnik is better, because it’s been through so many tests and is being used in lots of countries,” he said. “These others, their quality is questionable. Even the media often says so.”  

The pandemic has created a tidal wave of disinformation in nations across the world. But in Ukraine, the conflict over lockdowns and vaccinations has been deepened by the fault lines of a war between government forces and Russia-controlled separatists in the east of the country since 2014. So far, the conflict has claimed 14,000 lives. It has also entrenched divisive narratives over whether Ukraine should look west towards Europe or east to Russia, that have led people like Tertishnik to favor an unobtainable Russian vaccine over the ones freely available at their local hospital. 

Tertishnik’s preference for Sputnik V is strongly linked to nostalgia for the Soviet era, which he remembers as a time of order, certainty and harmony. Economic hardship, the new borders separating him from neighbors and family, and conflicting media messaging — he says he watches both Russian and Ukrainian TV — have exacerbated his sense of grievance. Conversations with him are peppered with assertions that Russians and Ukrainians were friends for centuries before the West interfered, and that Ukraine is little more than a Western puppet state. 

To date, less than 10% percent of the population have had one or two coronavirus shots. Pandemic conspiracies and vaccine hesitancy can be found across the nation’s social and political spectrum. A survey by the Kyiv International Institute of Sociology in April found that 53% are not willing to be vaccinated, mainly because they fear that the shots have not been sufficiently tested. 

However, the biggest numbers of those uncertain or unwilling to be vaccinated were in the eastern and southern regions which are traditionally more Russia-oriented. A March survey by the independent research organization Rating Group Ukraine found consistently more vaccine hesitancy and refusal among supporters of the three main pro-Russian opposition parties in Ukraine. Those respondents were also more likely to trust Sputnik V than other vaccines.  

Ukrainian politicians don’t have to be pro-Russian to criticize the government’s pandemic response and vaccine policy. But research published in April by the European External Action Service, the EU’s diplomatic service, has detailed how Russia’s “vaccine diplomacy” drive has used state-controlled and proxy news outlets, along with social media, to undermine trust in Western-made vaccines, EU institutions and vaccination strategies. A report from the Ukraine Crisis Media Centre identifies how this disinformation campaign in Ukraine aligns with broader attempts to divide society and turn the country’s vector from west to east.

In February this year, the Ukrainian government announced it would not register Russian Sputnik V. Most of the EU, including France, Germany and Italy, had also not approved it, citing missing clinical trial data. But the Ukrainian government ruling explicitly bans Covid-19 vaccines developed or produced in an “aggressor state.”  

The ban provided a prime opportunity for Russian media, and pro-Kremlin media in Ukraine, to accuse the government of committing “genocide” of its people for political purposes. It also tied neatly into the long-term disinformation narratives that divide the country, accusing the West of pushing Ukraine into war in 2014 and, now, of experimenting on Ukrainians with vaccines, to the benefit of big business. 

While Ukraine negotiated for vaccines from the EU and the World Health Organization’s Covax program, Russia scored a propaganda goal by providing Sputnik V to separatist territories in east Ukraine.

The pandemic had already damaged increasingly tenuous ties between Ukraine and the eastern and Crimean territories it lost to Russia in 2014. Pre-Covid-19, more than a million people, mostly residents of separatist territory, crossed the de facto border in east Ukraine every month. When politicized quarantine restrictions restricted crossings, those people were largely deprived of family contact, jobs, Ukrainian pensions and other benefits, in addition to a shared information space.   

Ukraine initially closed all the de-facto borders with what it refers to as its “temporarily occupied territories” in March 2021, as part of a strict nationwide Covid lockdown. The government was keen to emphasize the alleged disastrous level of coronavirus infections in Russian-controlled territories, although real figures were impossible to come by. Restrictions were lifted after three months, but immediately imposed by separatists in the east and Russian-annexed Crimea, who cite Ukraine’s inability to cope with the coronavirus crisis. 

The separatist-imposed restrictions have remained in place ever since. Currently people must provide numerous documents to justify their trip over the de-facto border in order to obtain permission to cross at a set date and time. Just one crossing there and back is allowed a month. 

Konstantin Reutsky, who heads the Ukrainian NGO Vostok-SOS providing assistance to residents on both sides of the frontline, believes there is no epidemiological justification for the separatist-imposed restrictions. Instead, he says, they are just another tactic in the information war. Ukrainian media is blocked on separatist-controlled territory — and even in some adjoining Ukraine-controlled areas — and Russian and separatist media portray Ukraine as on the verge of economic and social collapse. With access closed, people have no opportunity to see that in fact Ukraine is rebuilding and developing areas close to the frontline. 

Russia and separatist authorities “don’t want people to see that things are better on this side,” said Reutsky. “Covid was an excuse.” 

Crossing points and vaccines

After a peak in spring this year, when coronavirus infections were reaching 15,000 per day, it is hard to see how Ukraine’s currently low rates of less than 1,000 new cases a day can justify the ongoing restrictions. Ukraine’s extensive building program in the east includes a whole new crossing point on the de facto border, with banking and postal services and a center for processing Ukrainian documents and benefits. This crossing, however, has never been opened due to disagreements for which each side blames the other. 

Meanwhile, Stanitsia Luhanska in Ukraine is one of only two crossing points with separatist territories now open. Queuing to navigate the jumble of fences and kiosks on the Ukrainian-controlled side, travelers have to contend with a number of coronavirus-related complications on Ukraine-controlled territory too. A free bus service to the Ukrainian checkpoint stopped when the crossing temporarily closed last year, and has not been reinstated. Until recently, Ukrainian authorities required that inhabitants of the separatist territories take a Covid test on arrival, but took months to provide free tests.  

In June, Ukraine hit back in the Covid vaccine propaganda war. It began a long-promised government program of free vaccination for inhabitants of annexed Crimea and the separatist “republics,”, describing the move as a response to “medical genocide” against Ukrainians living under Russian occupation. 

People can book an appointment by registering online or calling a hotline, and can choose locations near the front in east Ukraine and Crimea. Those who have registered for vaccination are allowed to skip the queue at the Ukrainian checkpoint. By mid-July, 393 people had registered for the program, according to the Ukrainian Ministry for Reintegration of the Temporarily Occupied Territories. 

In Stanitsia Luhanska, vaccination with the Chinese CoronoVac is available for people from the separatist “Luhansk People’s Republic” (LPR) twice weekly in the primary medical center. Located in Stanitsia Luhanska hospital, the center is an island of bright new renovation in a building otherwise much in need of repair. On a recent swelteringly hot day, a family had traveled over 100 km from Alchevsk in the LPR, to renew their Ukrainian bank cards and for their 28-year-old daughter, Yelena, to be vaccinated.

“I’ve been waiting for this program,” Yelena said. The announced supplies of Sputnik V to the LPR ran out in April, she said, when priority groups such as medics and police were vaccinated. Since then, the only option was to travel to Ukrainian government-controlled territory, or, for Russian passport holders, to Russia. 

“I don’t like the propaganda around it,” she added. “But there’s propaganda on both sides.” 

Yelena found out about the Ukrainian program from the social media page of a Ukrainian NGO. “Those who want to find information discover ways of finding it,” she said. “And those who are okay with Russian propaganda don’t need alternative sources of information.”

Yelena said that there was a good deal of anti-vaccine sentiment in Alchevsk, as well as theories that the virus was artificially created or doesn’t exist, and distrust of the Ukraine program. 

“None of my relatives, except my parents, think it’s a good idea to come here,” she said. “Even my father was, like, ‘How do you know they’ll give you a vaccine? There’s a shortage of vaccines in Ukraine’. He’s skeptical, he doesn’t trust the government.”

Yelena’s experience at the clinic did not change her father’s mind, but by the end of their visit her mother, trembling with nerves, also got her first shot. 

While people like Yelena make the complicated journey west over the frontline to get a vaccine in Ukraine, Natalia Kravchenko, a doctor administering the program in Stanitsia Luhanska, would prefer to look east. She yearns for Soviet-era health care and research which she considers to still be effective and strong in Russia.

“I, personally, would like to be vaccinated with Sputnik V. I was born in Russia and have a Russian mentality,” said Kravchenko, who is in her 50s. “But we inject with what they give us. It’s all politics. We were friends and now we’re enemies. What can you do?”       

One village, two vaccine drives

Back in Milove the local hospital, which is being renovated as part of a $235 million European Investment Bank program for east Ukraine, had vaccinated just 410 people by mid-July from a population of 5,800. A mobile brigade from a nearby town is also providing shots.

“Everyone reads on the internet,” said Iryna Smyrnova, the hospital’s head of secondary medicine. “They all call now and ask, ‘What vaccine is it?”

The majority who do get vaccinated in Milove are keen to get Pfizer or AstraZeneca shots manufactured in the U.K. or Europe, according to Smirnova. Not because they think those vaccines are any more trustworthy than others, but because the vaccination certificate will allow them to leave both government and separatist Ukraine and travel abroad. 

Even Tertishnik has registered to get a Western vaccine. “I don’t think it’s better, I think Sputnik is better, but those up top decided,” he said. 

When asked for the reasons behind his decision, he replied, “I want to live a bit longer, and see my grandchildren.”  

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The post Russian vaccine propaganda is deepening divisions in conflict-riven Ukraine appeared first on Coda Story.

“Everyone has a right to their own philosophy,” she says of her decision. 

International organizations and governments responsible for public health would disagree. Because of falling vaccination rates, infectious diseases like measles are making a global come-back. Ukraine is one of the hardest hit countries, with the fastest recent rise in measles in the world — more than 115,000 cases and 40 deaths since an outbreak started in 2017. 

The acting Ukrainian health minister described the crisis as a national security threat. The World Health Organization has identified “vaccine hesitancy” as one of the world’s top ten health threats for 2019. And the U.N. children’s fund UNICEF has named misinformation, mistrust and complacency as the “the real infection” behind the re-emergence of preventable diseases.

The conflict between state health programming and misinformation that fuels vaccine hesitancy is not unique to Ukraine. But Ukraine is in the midst of another war over its geopolitical and ideological position between Russia and the West. With Western-backed health reforms introduced by a U.S.-born health minister, vaccines and measles play into that larger conflict. 

Shortages of vaccines and of trust

Instability, corruption and complacency have all led to gaps in vaccine availability and coverage in Ukraine. Infectious diseases like measles need a vaccination rate of 95% or above for ‘herd immunity’ to limit their spread. After mass programs were introduced in the USSR in the 1960s, measles was limited to small outbreaks. Most people in Ukraine forgot the disease could have potentially fatal consequences. 

Official statistics show national coverage of the MMR (measles, mumps and rubella) shot began falling from the late 2000s after vaccine shortages in 2008 and 2014-16. By 2016, just 45% of children had had the MMR jab, a vaccine against measles, mumps, and rubella. 

Lack of availability was accompanied by declining trust. Many trace the lack of confidence back to the 1980s. That’s when a Russian “professor” (according to Russian Wikipedia, she does not have any medical certification) began campaigning against vaccination. She became the guru of Russian-language anti-vaxxers, still referenced by some who oppose vaccines in Ukraine. 

By 2019, a global study on attitudes to health and science by the Wellcome Trust found that just 29% of Ukrainians think vaccines are safe, and half think they are effective (in Russia the figures are 45 and 62%). 

Julia, 35, began doubting vaccines when she was expecting her first child, Sofia. The views of her yoga teacher and of a relative amplified her opposition. Julia has never doubted her decision not to vaccinate. Her second child Zoryana was born at home, outside the state health system altogether. 

I meet Julia and her daughters in a fashionable vegetarian cafe in Kyiv. “I brought the children, so you can see they are alive and healthy despite being unvaccinated,” Julia says, cheerfully.

Four points led Julia from doubt to certainty: questions about the source and quality of vaccines; the ineffectiveness of the tuberculosis vaccine in Ukraine; pressure put on post-natal women to vaccinate with no proper explanation, and her discovery (not confirmed by medical tests) that Sofia has contra-indications in the form of allergies to vaccination. “I think it all happened as it was meant to happen,” she says.

Some of Julia’s doubts can be easily resolved. Vaccines currently used in Ukraine are produced in Belgium and procured by UNICEF. The TB vaccine, developed almost a century ago, is indeed only partially effective, but those for other diseases such as measles which were developed much later have up to 97% effectiveness.  

However, many overworked and underpaid medical staff in Ukraine do not discuss such doubts with patients. “Most of them just want to get people out of the clinic, so they can get more people in,” says Lotta Sylwander, UNICEF’s Ukraine representative.   

Julia found that medical staff followed up with daily calls after Sofia was born – but only to insist on vaccination. “It’s all scare tactics,” she says. “If a nurse hasn’t persuaded you to vaccinate then she hasn’t done her job.”

To guarantee herd immunity, and protect those few whose medical conditions prohibit vaccination, MMR and other vaccinations are mandatory in Ukraine, as in many countries. Children should have a certificate showing they are vaccinated in order to attend school. In practice, many parents buy fake certificates from doctors.  

Julia's first source for vaccine and health information is the internet. She seeks information that fits her worldview, which values self-sufficiency, nature and a holistic approach to health.   

Globally, doubt in science-based, state public health programs is fed by exposure to an apparently unlimited amount of information which can confirm or disprove every bias. Julia admits that the information is overwhelming, and her attitude to vaccines is often, in the end, based on intuition. 

“It’s more on an energetic, deeper, even spiritual level,” she says.

Conspiracies, lies and propaganda

The current measles outbreak has claimed 40 lives in Ukraine since 2017 — deaths which could have been prevented. Accurate information, and national statistics, are widely available. But Julia is not convinced by statistics. 

“If the government gets vaccines then it needs to use them, and so the few cases [of measles] are exaggerated to a level of national importance,” she says. “It’s all marketing and information wars.” 

Mistrust in governments, health systems and big business informs vaccine hesitancy everywhere. In Ukraine it’s exacerbated by almost three decades of social, political and economic upheaval. Many Ukrainians feel that the only thing they can rely on is themselves.   

“How can I rely on the government that is changing its position and direction all the time?” says Julia. “Why is the government responsible for my kids? Really, it is not. It pretends to be but actually it doesn’t help.”   

Yuri, 35, a Kyiv shop owner, and his wife have decided not to vaccinate their ten-month-old child. Yuri says he doesn’t trust any governments or international health organizations which “hide a lot from us,” he says. “It’s profitable for them to keep people stupid, because they’re easier to control. It’s not just vaccines, it’s our whole lives.”      

In Ukraine it’s not only people like Yuri who see government conspiracies. When I asked the then acting Ukrainian health minister, Ulana Suprun, what was the key reason for the measles outbreak she had a simple answer: Russia, through its propaganda spreading false vaccine information, and its domestically-produced vaccines which were used in Ukraine in the 1980s, and which she says were ineffective. 

A vocally patriotic diaspora Ukrainian, who started her career in Kyiv supplying medical kits to the army when war broke out with Russian-backed separatists in east Ukraine in 2014, Suprun claimed that “Ukraine is facing the primary assault from Russia's comprehensive hybrid war including in the field of healthcare,” in a speech to the UN last year. She stepped down as acting minister in late August. 

Suprun, along with much Western media, cited research which found that Russian trolls and bots may help spread anti-vax messages online. However, the study analyzed only English-language Twitter, and its findings are far from conclusive. 

Media and social media coverage of measles and vaccination in Ukraine does relate to the Russian-Ukrainian information war, however. As Suprun has blamed Russia, Russia and its proxy separatist ‘republics’ in east Ukraine blame America, in the person of Suprun (who has an American passport) and her Western-backed medical reforms. Suprun and her shake-up of the corrupt, inefficient health system is controversial in Ukraine — her opponents call her ‘Doctor Death’. Russian media outlets, widely read or watched in Ukraine, repeat and amplify attacks on the reforms, feeding distrust of state healthcare. They use the measles outbreak to bolster propaganda that the Ukrainian state is a Western puppet. 

Passive victims of the information war

Yuri, the shop owner, is an extreme anti-vaccine conspiracy theorist — during our conversation he tells me that many of the laws of physics are wrong. He chats to locals in his shop next to a playground in a Kyiv suburb, where he sells ecologically friendly food, cosmetics and cleaning products. Many customers are parents, and the subject of vaccination often comes up. One mother told me about such a conversation. “When I said I had just vaccinated my son for measles, the atmosphere changed; it was as if the temperature dropped several degrees,” she said. “I had to slowly retreat towards the exit. Really parents are divided into two camps, and it’s a war.”

According to Lotta Sylwander, UNICEF’s Ukraine representative, committed opponents to vaccination like Yuri are the exception in Ukraine. “It’s not anti, it’s more a passive kind of not understanding” that drives vaccine hesitancy, she says. The issue for the health system is how to reach these people and convince them.

Tatiana Kulakova, 40, would be a prime target for positive vaccine messaging. Her daughter Maria, eight, has never had any jabs. She has had several serious health problems, but according to doctors there is no current reason why she cannot be vaccinated. But Tatiana, who gave birth to Maria several weeks prematurely after having two miscarriages, is too worried to go ahead. 

“It’s scary to live without vaccination, but what about the consequences?” she says. “It’s not clear how my child will react.” 

Tatiana bought a fake certificate — at the suggestion of staff in her local clinic, she says –— so that Maria could attend kindergarten. For school she has another certificate saying she has refused to vaccinate her daughter. In fact, she hasn’t refused, she just hasn’t been able to bring herself to agree, or found anyone she trusts enough to allay her fears.

Clinics in Ukraine display vaccine information posters, and the health ministry has started vaccine drives to reach parents and children through schools. It plans to stamp out the practice of fake certificates, and a recent court ruling confirms that schools have the right to turn away unvaccinated children. Meanwhile MMR coverage among children aged one is now 91 percent, and annual UNICEF research shows 88 percent of mothers of young children feel positive towards vaccinating in 2019, compared to 28 percent in 2008. 

Yet measles infection rates are still rising, at over 100 new cases a week. All the parents I spoke to in Kyiv thought that a large percentage of pupils in their children’s schools had not been vaccinated. And none of them who had not vaccinated, including Tatiana, could be persuaded to change or make up their minds.

“I just can’t come to a decision,” Tatiana says. “I understand that I need to do vaccination. But on the other hand, no one can properly tell me whether I should do it or not.” 

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The post Disinformation and vaccine hesitancy grips Ukraine appeared first on Coda Story.

It started on August 23 with “a strong chemical smell,” Lena, a young lab assistant from Armyansk, remembered when we spoke. She thought it must have come from the Titan plant on the edge of town, which makes titanium dioxide, a whitening agent for paints and cosmetics. “At first I didn’t take much notice, because we often have chemical emissions here,” she said. But by the time she got home from work her eyes and throat were swollen and burning. “Next morning I fainted in the bath. I had an allergic reaction all over.”

Armyansk lies a short drive from the so-called Administrative Boundary Line (ABL) that has divided Crimea from Ukraine ever since Russia occupied and annexed the peninsula in 2014.

But as reports spread of what appeared to be a major health and environmental incident, authorities on both sides of the divide, in Russia and Ukraine, seemed more concerned with using the leak as a propaganda tool than addressing the needs of those affected or investigating the cause.

“No one said what was happening,” Lena recalled, as she sat smoking with a friend outside an empty Armyansk kindergarten. “The Ministry of Emergencies should have said to close the windows and stay inside. But lots of people went out and opened windows, and there was mass poisoning.” “Lots of people went out and opened windows, and there was mass poisoning.” Lena, Armyansk resident

Since Crimea’s annexation, the new Russian-backed authorities have imposed strict controls on the media, which now generally paints a positive, uncritical picture of events in the peninsula. What is reported is weighed not for factual accuracy, but to exclude dissident content and maximize propaganda value.

Fines and arrests for public dissent are a further disincentive to voicing alternative views. Lena and her friend, like everyone I met in Armyansk, would not tell me their surnames. After Yekaterina Pivovar, another local resident, spoke out about her concerns to the media using her full name, she was cautioned by the police and publicly pilloried on Crimea’s main television station.

There are no independent bodies left on the peninsula that can investigate. Neither can international agencies, with Crimea cut off from the outside world by sanctions and its disputed status.

When some local and Russian outlets picked up the Armyansk story on August 27, they reported only that there had been an emission of an “unknown substance.” The next day, Sergei Aksyonov, the man appointed by Russia to run Crimea, finally mentioned the leak. All he could say was that it was harmless, and “according to preliminary data” was emitted from the Titan factory.

The factory is owned by Ukrainian oligarch Dmitry Firtash, currently in Austria fighting an extradition request from the U.S., where he faces charges of attempted bribery.

Bloggers in Crimea joined in the information battle. Those with pro-Ukrainian views posted emotional interviews with alarmed, angry locals. Others took Russia’s side and blamed the “Ukrainian terrorist government” — recycling what the Crimean authorities now said was the cause of the incident: Ukraine cutting the water supply to the factory’s waste reservoir.

Most of Crimea’s water needs used to be supplied from mainland Ukraine via a canal. After the 2014 annexation, Ukraine stopped the flow. Four years of falling water levels, coupled with a very hot, dry summer, were allegedly causing accumulated sulfur dioxide in the factory reservoir to evaporate into the atmosphere.

On September 4, some two weeks later, Aksyonov finally visited Armyansk. Distressed residents had gathered in the town’s square — a rare occurrence since under Russian laws now in force any gathering can be considered an “unsanctioned meeting” and participants detained or fined.

Aksyonov admitted that pollution levels were above normal, but insisted there was no serious health threat. The Titan factory was ordered to shut down for two weeks, and 4,000 children and their mothers were evacuated – although Aksyonov, and the government-controlled media, called it an “extended holiday.”

With the mass evacuation, Ukrainian media picked up the story. If Crimea-based outlets now report only good news, Ukraine’s media — with no accredited journalists in Crimea — now prefers only bad news casting Russia in a negative light. Ukrainian media claimed that Russian military exercises had caused the leak. Reports dubbed the incident a “second Chernobyl,” in reference to the devastating Soviet-era nuclear accident in 1986.

For the state-controlled Crimean media, this was a gift, allowing them to ridicule Ukrainian coverage instead of investigating what had happened. With many Ukrainian internet sites blocked, it is hard for people in Crimea to get any alternative news. One Armyansk resident who spoke about her concerns to the media using her full name was cautioned by the police and publicly pilloried on Crimea’s main television station.

About the only thing the two sides agreed on was to blame Firtash, the factory owner. For Russian and Crimean outlets, his nationality made him an easy target, ignoring his ties to Moscow that allow him to continue operating the plant. Pro-Ukraine outlets on the other side of the divide portrayed Firtash as selling out his nation and breaking international sanctions.

Hoping to get past the disinformation, I visited Armyansk in early September. After heavy rain, the heatwave had broken. Adults were on the streets. There was one sign of an official response: roads and buildings had been hosed down. But the air had a distinctly acidic flavor. Vegetation, especially on the northern side of town close to the factory, had turned brown or lost its leaves altogether, while a few miles south it was still green.

Nonetheless, some locals accepted the official line. “What happened? Autumn happened,” said Denis, a young man drinking coffee on a bench.

“The apples and pears are still there [on the trees], I just wash them before eating them. Just all the leaves fell off,” said Valya, a woman in her fifties selling soft drinks on the main street. She had no doubt the cause was the Titan plant, but she was apparently unconcerned.

“I was born here and I knew what it was right away,” she said. “For us, this is just normal.” Most of what she had read in the news, Valya said, was “exaggeration.” She was grateful to “our leadership for reacting in a timely manner.”

“It’s horrible, and why should we lie about it?” countered an elderly woman next to her, selling peppers from her allotment. But, she added, “Who can we complain to? We’re nothing; we’re just pawns.” One report dubbed the incident a “second Chernobyl.”

The Crimean health authorities had reportedly said there had been no increase in patients in Armyansk, and no cases of chemical poisoning. There were no patients to be seen in the hospital, nor anyone willing to talk. A group of nurses fell silent when I approached. An administrator told me only Crimea’s health ministry could comment.

I left Armyansk with a sore throat and the distinct impression — common in Russia-controlled Crimea — that people were afraid to tell the truth. The signs of pollution were obvious, although not as bad as some social media and Ukrainian reports had suggested. Locals said the evacuated children were due to return in three days.

Instead, three days later the authorities declared a state of emergency in Armyansk. Apparently another toxic gas — hydrogen chloride — had been detected.

At a news conference, Igor Mikhailichenko from the Crimean Cabinet of Ministers said that top of the list of the six likely causes was now “an emission of unknown chemical substances from the territory of the neighboring state”.

Ukrainian officials pointed the finger back. Among three possible causes they were considering was a “deliberate release of chemicals by Russia,” which they portrayed as a tactic to pressure Ukraine into resuming water supplies to Crimea. Monitors from Kherson administration bordering Crimea on the Ukrainian side said the pollution had most likely come from a one-off discharge. “We’re nothing; we’re just pawns.” Armyansk woman

There is no way to independently verify what had happened or its effect on health. A Crimea-based environmental NGO, the “Centre for Environmental Well-being”, told me it didn’t have the right expertise. Greenpeace International said there was not enough reliable information for it to be able to comment.

The state of emergency was lifted a week later, on September 23. Armyansk’s children returned to school. But earlier this month, Armyansk residents again complained of bad smells and allergies. The authorities in Crimea cracked down, and Yekaterina Pivovar was one of those who felt the effect.

She spoke to French television and the independent Russian outlet “Novaya Gazeta” about her children’s health problems, and her plan to visit the town mayor with other concerned mothers. Soon afterward, police came to her home to warn her against organizing an “unsanctioned meeting.”

That evening Crimean state TV named her as a provocateur and self-publicist spreading disinformation on behalf of Ukraine.

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The hospital in his hometown of Vuhledar, a small, shabby mining town in the Donbas region of eastern Ukraine, lacked the necessary specialist care. Viktor found other facilities further away where doctors offered to operate, but they wanted to charge him 5,000 Ukrainian Hyrvnia (about $190) — a commonplace act of corruption in a country where healthcare is supposed to be free.

Then a former girlfriend told Viktor about a “special program” in the region offering high-quality surgery, for free.

There was a catch, though. The hospitals involved in the program were on the other side of the frontline of Ukraine’s grinding four-year-old war, in territory held by Russian-backed separatists. And they have been offering free medical care as a way of winning support in parts of Donbas under Ukrainian government control, thus turning patients into participants in an information war.

It is called the “Humanitarian Program to Unite the People of Donbas” and, in effect, it has turned healthcare — enshrined by the United Nations as a universal human right — into a propaganda weapon. It has turned healthcare — enshrined by the United Nations as a universal human right — into a propaganda weapon.

The war in eastern Ukraine still claims weekly civilian and military casualties, and both sides have been censured for using medical facilities as military bases and targets, in defiance of international humanitarian law. The conflict has disrupted day-to-day healthcare for the local population in more mundane ways too.

The 280-mile frontline chops the Donbas region in half, between areas under Ukrainian government control and those the government calls temporarily occupied territories, held by the separatists.

Crucially, the separatists hold the two regional centers of Donetsk and Luhansk, which they have declared the capitals of their unrecognized “republics,” created and sustained by Russian support. Places like Vuhledar are trapped in a precarious limbo, still under Ukrainian government control but cut off from key services like healthcare.

For their part, the separatists call these areas “territory temporarily occupied by Kiev” and have made them a priority target for their hearts and minds campaign. Having Donetsk in their hands gives them a clear advantage in the healthcare propaganda war.

The city was the region’s main medical hub before the conflict flared in 2014, providing tertiary, or advanced, care, for most of Donbas, including Viktor’s hometown. Donetsk had a nationally recognized medical university, and the largest cancer center in Ukraine, headed by the country’s chief oncologist. Donetsk surgeons were renowned for their “golden hands.”

Much of this expertise and infrastructure has been destroyed by the war, which has decimated staff and equipment and cut medical supply lines. But the city still has some of the best medical specialists and facilities in the region.

It was Donetsk that Viktor needed to reach. Just 40 miles from his home, it took him all day because of the obstacles thrown up by the conflict.

To cross the frontline — known as the “Line of Contact” — people need a special pass from the Ukrainian security services. To get it, “you have to say your aunt lives there or something,” Viktor explained. “Then it’s checkpoints, queues, waiting everywhere, it takes ages. But I needed to save money so I went to see if they could help me.”

At least one million people cross the line every month, according to United Nations figures, braving the risk of getting caught in crossfire, as well as the bureaucratic delays. Most make the trip for family reasons, or to claim pensions or other social support. The launch of the “humanitarian program” has added to this traffic. The “humanitarian program” refers to people living under government control as “hostages”

The two separatist “republics” jointly launched the program in February 2017, promising Donbas inhabitants on both sides of the Line of Contact free healthcare, as well as education, sport and cultural events and social benefits. And they say the message is getting through.

According to their website, more than 1,200 people from Ukrainian government-controlled Donbas have crossed over for treatment since the program began for services ranging from maternity and pediatric care to cancer surgery and vaccinations.

There is no way to confirm these figures. I was denied access to Donetsk and Luhansk, and no one there agreed to give an interview by telephone. On the Ukrainian government-controlled side, people are reluctant to admit crossing the contact line for treatment. None of the patients who agreed to talk to me would give their full names.

Despite being on crutches, Viktor agreed only to meet outside on a park bench. “You never know who’s listening,” he said. But from my own research, it is clear that there is now wide awareness of the program on both sides of the frontline, and many people from government areas continue to go to Donetsk for health services, while trying to stay out of the politics of the conflict.

Kiev has not outlawed receiving medical treatment in occupied Donetsk or Luhansk. But collaborating with the separatists — or supporting their propaganda efforts — is illegal. How exactly such charges are defined is not clear, but past experience has taught both individuals and organizations to be wary of such accusations.

The Ukrainian authorities have investigated non-governmental organizations (NGOs) based in Ukraine who have provided foreign-funded medicines and other supplies to occupied Donetsk and Luhansk. NGOs working there have been banned by the de facto authorities on similar charges. Doctors have found themselves placed on blacklists run by both Ukrainian officials and the separatists, accused of being “terrorist collaborators” by one side, or of being spies by the other.

Most Donbas residents and patients, who overwhelmingly have relatives and friends on the other side of the contact line, try to avoid openly taking sides. Words and categories such as “separatist,” “pro-Russian” or “pro-Ukrainian” are rarely mentioned. But the de facto authorities in Donetsk and Luhansk do not hide their political and propaganda goals in running the health program. The de facto authorities in Donetsk and Luhansk do not hide their political and propaganda goals in running the health program.

Its official website describes people in government controlled-areas as “Donetsk and Luhansk citizens living in territory temporarily controlled by Ukraine,” and calls them “hostages.”

It continues with what reads like a call to arms: “Brothers and sisters! Countrymen! Residents of [...] all cities, towns and villages held by Ukraine! Let’s unite our efforts for survival and peace. For the fight against those sitting far away in Kiev, Brussels and Washington, who are trying to set us against each other over who will get richer from this war.”

Would-be patients for the program from government-held territory are required to write a personal appeal to the de facto “minister of health” in Donetsk or Luhansk, thus legitimizing the separatist regimes.

The program is promoted in multiple ways, including special booths on the separatist side of the Line of Contact. It has a hotline telephone number, and according to the website, gets many calls from Ukrainian government-controlled areas.

Russian and separatist-controlled media outlets also promote the program, with regular reports showing patients gratefully receiving free, high quality treatment — treatment, viewers are told, that is unavailable in Ukrainian government territory.

The reality for Viktor was not so simple. Once he finally reached Donetsk, he found himself ensnared in a kind of Catch-22 situation.

The hospital staff told him “they haven’t got the right to treat me without a doctor’s referral from Ukraine,” he recalled. But when he had asked for one before leaving Ukrainian government-controlled territory, doctors there had refused. “They said they haven’t got the right to give me a referral because it’s occupied territory,” Viktor said. “So it’s a closed circle.”

Viktor did finally get the surgery he needed for free — though only when he collapsed in Donetsk, and was taken to hospital by ambulance. Crossing over into separatist territory had possibly saved his life, and he had only good words for the medical staff there.

But in most respects, Viktor said it felt like he was being treated in the old unified Ukraine. The hospital conditions and food were terrible, he said, and patients had to provide and pay for their own medications.

“It’s just the same, and the people are the same as they were before,” he said.

When someone calls the hotline, they are asked to give their name and location, and say where they heard about the program. Then they are asked if they have a particular set top box which allows viewers in Ukraine to watch a digital package of six Russian TV channels and four channels run by the two breakaway Donbas “republics.” This is apparently a way of gathering data on the reach of these channels and their broader propaganda effect.

After that, the caller is transferred to someone introduced as a medical specialist, who advises what services are available. “Just come, and he’ll be checked and get what he needs straight away,” were the encouraging words one potential patient’s relative heard when she called the hotline.

According to the program website, around a quarter of calls to the hotline have come from people in Ukrainian government-controlled parts of Donetsk oblast or district.

Yet away from the glowing picture painted by their propaganda, the state of healthcare in the separatist-controlled territories is bleak.

According to the United Nations, the war has decimated services with a knock-on effect on health. Seventy percent of medical equipment has been put out of action. Rates of tuberculosis and HIV have risen to epidemic levels. There are an estimated 80,000 unvaccinated children and close to 100,000 cancer patients — with just three radiotherapy machines left in Donetsk.

Much of the limited medication touted as being free, such as some cancer treatment, kidney dialysis and insulin, is actually supplied by three NGOs and a handful of UN organizations still allowed by the de facto authorities to work there. Or it is provided by Russia.

But what the separatist program says about the lack of medical services in government-controlled Donbas is also true.

The frontline town of Mariinka is facing the same kind of problems as Vuhledar, cut off from the regional hub of Donetsk. It’s not a gap that can be filled quickly, explains Sergei Tkachenko, the head of Mariinka’s health department. “In my forty years in medicine, we worked in one team with Donetsk, and to start again from scratch is really hard.”

Mariinka’s understaffed clinic provides only primary healthcare. The nearest secondary healthcare facility still controlled by Ukraine was destroyed by shelling. Four of its departments, including intensive care, have been crammed into another hospital designed for a population of 20,000, but now serving at least 80,000 local and internally displaced people (IDPs).

Patients with more advanced needs are referred 85 miles away to Mariupol, where Ukrainian authorities are working to establish a regional-level hospital, or even further afield where they have to compete with local patients for services.

Or, a mere four miles away from Mariinka, there is Donetsk.

“Of course people go there,” said Tkachenko. “People go as they’ve been going for years. On their own initiative. And no one is turned away.”

Tkachenko said his staff cannot provide referrals for patients to get treated on the other side of the Line of Contact. But it’s clear that some medical specialists on the government-controlled side do help people make the trip.

Patients are required by the program to provide medical records and doctor’s notes. Several people from government-controlled towns like Mariinka, Vuhledar or Mariupol who had been to Donetsk for treatment said local doctors had “advised” them to go there, instead of providing an official referral.

“Yes maybe someone can give the advice: ‘go here’ or ‘go there’,” Tkachenko admitted. “But to send someone to an incomprehensible quasi republic — what if we send them and there’s shooting, or they say ‘you’re all separatists’ and get in trouble?” he went on. “Our doctors are very careful. You understand the consequences; to send them officially is practically a crime.”

What’s more, when patients return to Ukrainian government-held territory, their separatist-issued medical documents will not be recognized, meaning they can’t claim sick leave or disability benefits.

Viktor was given a Donetsk medical card after his surgery, but was told to hide it when he crossed the frontline on his way home. Whether this was for his own safety, or for the doctors who had signed it, he wasn’t sure. “Everyone’s afraid,” he said.

There are also cases of doctors in separatist-controlled areas advising patients to cross into Ukrainian government territory for healthcare — another sign of pre-conflict ties continuing.

Tatiana, 40 and four months pregnant, had just returned from a trip to her hometown of Donetsk to see a gynaecologist when I met her in government-controlled Mariupol. The doctor in Donetsk had referred her — unofficially — to a colleague from the city who was now living and working in Mariupol, calming Tatiana’s fears about having her child there.

“I felt relieved right away,” she said. “If my doctor says she knows him and they worked together, I know it’s alright.”

Her first two children were born in Donetsk. But she can’t have her third child there, because her husband, a policeman, was transferred to government-controlled Mariupol in 2014 and is now blacklisted in Donetsk.

Despite the potential consequences, Tatiana has crossed the Line of Contact regularly for medical services and has taken her oldest child, an eight-year-old with autism, to the Donetsk Yevtushenko Centre for Neuro-rehabilitation.

Before 2014 the Yevtushenko center was famous throughout Ukraine, with year-long waiting lists. Irina (not her real name) also recently took her autistic son to the center from Mariupol. The waiting time there is now reportedly down to a month, because of the fall in the number of patients. But she said she met other people there from government-controlled Donbas, and even from western Ukraine.

The political dimension to the program was explicit, she said, with the de facto authorities in Donetsk clearly encouraging patients to cross over. “The more people who go from Ukraine, the better. Those from Ukraine get free treatment or benefits.”

The clinic staff were different though, Irina said. Although they asked where she and her son were from and put Mariupol on the medical card “I think as far as treating people is concerned they don’t care where you’re from,” she said. “No one asked about our politics, they just wanted to help my child.” Healthcare as a tool of propaganda and soft power is not unique to Ukraine. In nearby Georgia the government offers free healthcare for people from the breakaway territory of Abkhazia

Nonetheless, Irina only agreed to talk about her trips sitting in her car with me. She plans to take her four-year-old son again on the 60 mile journey that can now take more than nine hours. “I’m a despairing mother,” she said. ”I’ll try anything.”

Healthcare as a tool of propaganda and soft power is not unique to Ukraine. In nearby Georgia the government offers free healthcare for people from Abkhazia, a breakaway territory it still claims but which is now under de facto Russian occupation. The government is building a new modern hospital in the nearest town to the boundary line, aimed at people from Abkhazia.

Ukraine is struggling to employ similar soft power since it lost its key medical institutions in the east. Government-controlled Donbas lacks not just facilities and equipment but staff, with military medics making up for 30 percent of personnel in some hospitals.

“Doctors are a problem in the whole of the east,” admitted Georgy Tuka, Ukraine’s deputy minister for Temporarily Occupied Territories.

Ukraine provides no financial or other incentives for medics to work in frontline areas. The separatist regions also suffer huge staffing deficits. But reportedly, they have a simpler solution: they just stop medical specialists trying to cross into government-controlled territory.

But it’s also a question of attitude. The Georgian government has adopted a conciliatory approach towards people in Abkhazia, distinguishing them from the Russian authorities who continue to exert control there. Ukraine tends to view all residents of Luhansk and Donetsk region that it doesn’t control as separatists and enemies. In December 2014, the government stopped pensions and other social and budget payments for people living on its temporarily occupied territories.

“There’s a wish to punish people,” Tuka acknowledged.

Those living in separatist-held Donetsk and Luhansk are entitled to claim Ukrainian pensions and other benefits only if they cross into government-controlled territory and register as an Internally Displaced Person (IDP). Even then, it’s difficult to access basic services, with IDPs last in line for medical treatment. As a result, the cross-border flow for healthcare is almost all one way — from government to non government-controlled areas.

Ukraine has offered one program of health-related assistance to people from its temporarily occupied territories. Also called the “Humanitarian Program”, it was introduced in 2014 to provide opiate substitution therapy (OST) and support for patients with long-term drug addiction from Crimea. Russia shut down OST services there after annexing the peninsula, and the same happened in Donetsk and Luhansk. The program was funded by international agencies and ended in 2016, having helped around 200 people.

The Ukrainian government is reluctant to talk about the separatist-run medical program.

“I’ve seen announcements about it. But I have no data about whether people use this program,” said Tuka, adding: “I don’t believe it works.”

International health workers familiar with the situation are similarly reticent. They would rather talk about the huge medical needs in separatist-held territory — unlike the de facto authorities there who “prefer to talk about [the ‘humanitarian program’] than the real problems they have at this moment,” said Christian Carrer from Association Internationale de Cooperation Medicale, a French foundation providing medical supplies to both sides.

But Carrer and many other aid workers agree with Donbas patients, that the remaining health specialists in separatist territory are caring professionals working in difficult conditions, and some of the services they provide — although far from all — are genuinely free.

“In Donetsk there is no corruption at least in terms of medicine,” said Carrer, describing how hospitals in Donetsk post lists at the entrance of medicines and equipment received from humanitarian organizations, so that patients know what they can get for free. “Corruption is when you have money, but they are all without money there.”

Even if there are doubts about the motives and the range of services offered under the program, simply attracting people to cross over can have an effect. Many people spoke wistfully about their experiences of being treated in Donetsk, mixed up with nostalgia for what they had lost.

“For a time I didn’t miss [Donetsk],” said Tatiana, the IDP originally from Donetsk. “I was hurt. They took away our home, people came with guns.”

But on her most recent visit she said she noticed how well-kept the city was, and the better quality of its roads compared to government-controlled parts of Donbas. “It’s such a lovely city, and people there have changed and become friendly again,” she said. “They used to be so enraged with Ukraine, or maybe some still are, but I didn’t meet them this time. Everything was easier — and now, maybe, I started to miss it.”

What both patients and doctors in Donbas miss most is the peace, normality and freedom of movement they had before 2014. And that is usually what they choose to talk about, rather than comment on the origins and geopolitics of a conflict that has split families, neighbors and work colleagues. “We have to finish this war and unite again and live as we did before: friendly and normal and everything comprehensible,” said health director Sergei Tkachenko in Mariinka.

There are few more stark examples of how the war has torn up the lives of Donbas people than the fact that, to get medical treatment, they have to accept becoming pawns in a propaganda war. “We’re just simple people and they ruined everything for us,” said Viktor. “Simple people who lived together before.”

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