How US actions are affecting health security across Ukraine & Europe
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Hello and welcome to The Lancet Voice. It's April 2025, I'm Gavin Cleaver and together with my co-host Jessamy Baganel we've got the pleasure of welcoming back Oksana Pysyk from UCL who's becoming a frequent guest on this podcast.

With this conversation, we wanted to examine the European impacts of the actions of the Trump administration, the repressing concerns about the health infrastructure in Ukraine, and what the ongoing conflict which Trump has pledged to stop means more broadly for health in Europe. We hope you enjoy this conversation with me, Jessamy, and Oksana Pizek. Well, thank you so much, Oksana, for being with us. And I know that you've joined us before and you are a bit of a regular now on The Lancet Voice.

And I think we wanted to talk to you because there's obviously huge geopolitical instability and you have enormous expertise in Ukraine and with things that are happening around Ukraine. But there are also the impacts more broadly around health in Europe that have been the sort of fallout from Trump's executive orders. And Gavin and I were talking and saying actually that we haven't heard very much about what that type of fallout is.

is going to be and going to look like. And I know that you're very tapped into the sort of European health and pharmaceutical infrastructure. That's kind of what we wanted to cover today and talk to you about. And I wondered whether perhaps we might start with you kind of just briefly giving us a kind of update on what's going on in Ukraine from a health perspective and where we are on that front. Well, again, given since January all the executive orders have

I think most people have been glued to the news to find out what house is going to affect not just Ukraine, but Europe, many other countries as well. And there has been a lot of flip-flopping. We saw that disastrous interview in the Oval Office with Zelensky after that spectacle.

military funding, intelligence sharing, all of that was stopped. And then it has since restarted after the private peace talks in Saudi Arabia.

Now, what hasn't been resumed and which is going to be not yet, and things are changing at such speed. And we see, you know, from the Trump administration, you don't know what to expect from one day to the next. But at time of recording, what still remains true is that USAID funds have been gutted and this affects globally globally.

many countries, but particularly Ukraine, on two main areas. So a lot of other programs and projects receive funding from other institutions, but HIV and their HIV AIDS program and TB both significantly rely on this. And

In Europe, Ukraine is only second to Russia in terms of rates of HIV, so very high. There's also still a large percentage of people who don't know their status, over 30% don't know that they're active carriers.

And so everything from diagnostics to medicines themselves, PEPFAR again, which was created by the Bush administration in the early 2000s, was also one of the programs that supported access to these medications. And it's not just the medicines themselves, because there have been some loose promises that, no, no, we're not going to stop all of the flow of access, but when you need access

the funding for contractors and other people to actually move the products across borders when they're still stuck in ports.

you have not only huge medicines wastage, but all of the sort of the infrastructure around getting the medicines to the people that need them ends up being affected. So there is no clear solution to how this is going to be worked out. It's a very large funding gap. So we don't know where those funds are going to come from. And it's unlikely that it's something that the European Union alone would be able to address, even though, again, this is

in terms of the health security lens, something that directly a health threat to the rest of Europe, if we have sort of uncontrolled spread in that way. So I think there's a lot of concern in those particular areas within the healthcare system.

Second to that, again, with sort of whether aid is going to stop or start based on Trump's mood, we know that the health infrastructure has been largely damaged. So over 2,300 hospitals, clinics, medical facilities, pharmacies have been attacked. This figure is larger than any other conflict to date.

So again, more hospitals, clinics, and medical centers have been attacked. Again, this is a war crime in Ukraine than in any country to date. This averages out to be what, like over two attacks a day, every day since the start of the invasion. So this is very much a targeted approach. And this is again, where we look at

How do you start to operate across a country so large where civilians at any point can be harmed by either drones or missile strikes and that where we see health workers and health facilities being strategically targeted? And this serves a greater purpose in the sense that to win a war, especially a war of attrition, we're looking at how can we

almost tire out the population or make it harder for people to recover. And if you have your basic infrastructure, and that goes including energy infrastructure targeted, it makes very hard for the civilian population to continue to carry on. You have an unhealthier population. And Ukraine was already, prior to the full-scale Russian invasion, facing a health care workforce shortage. So all of these things, including the internal displacements of people,

Many people fleeing into Poland and all across Europe meant that a long part of that, you saw brain drain, people with expertise, health care workers also leaving. So very challenging from a health systems point of view. And I think very naive to think that that's not going to affect the rest of Europe in the long term. And very much still ongoing, right? I mean, for all the bluster since Trump took over about ending the...

Ukraine-Russia conflict. In 24 hours. In 24 hours, yes. Not a huge amount has changed, really. No, in terms of the ceasefire, but I think many people had advised the administration that every single ceasefire or peace accord that was signed by Putin had been previously broken. His attitude, though, was that Putin is my buddy. He respects me. It'll be different when I strike the deal. He will listen to me.

So far, that's not yet to be the case. And it means that it's very difficult for planning for the future. Last time we spoke, we talked about Ukraine becoming the most disabled country in Europe due to the scale of amputees, again, both from the soldier, civilian and veteran population, children included in that figure, over 100,000 amputees.

There was not that type of expertise in Ukraine in terms of the forms of reconstructive surgery, everything from facial to prosthetics to limbs. But only in six months did it take for the surgeons in the country to see more patients.

and cases than all of the conflicts that Americans had previously been involved in. And they were the Brits and the Americans were the ones primarily doing the training for these types of surgeries, both in person and online, to help meet the need

Part of this issue is that with new type of drone warfare, more soldiers are being left out. So you have a shorter transit time to pick them up, get them to hospital, get them treated. So higher dangers compared to, let's say, more historical forms of warfare. So when we've talked to military,

those that specialize in this. So there's the Superhuman Center in Lviv, and they're also expanding to other sites across Ukraine. They talked about the problems that they face specifically with that transit time, because typically you have something called the golden hour window in which you can have the best chances for the patient, including saving limbs, reconstruction, etc. But with the use of

This more modern warfare with drones, it means that it's extremely dangerous to pick up the soldiers who have fallen. So they don't know, you know, what kind of technology can they do to provide cover to extract those that have the soldiers that have been injured. So we've got unbroken as well, which is a similar type of like holistic recovery.

rehab center that incorporates having the adjustment towards limb loss. Again, there's a lot of psychological effects that are attached to that, as well as the fact that for children who are growing, you have to come back often and get that fitted. One of the other threats that this is linked to is AMR and the antimicrobial resistance that we're seeing at a huge scale in Ukraine.

You laid out the problems really clearly there. And it was a really comprehensive and great summary, Oksana. And I was just wondering whether we could kind of dig into it a bit more in terms of what are the international institutions or what are your insights about the international institutions, WHO, European organizations, NGOs even, and their response in the last three months? What have you found positive and engaging? What have you been disappointed by? What are your reflections?

Well, I think there is severe challenges that a lot of the NGOs are facing in terms of the funding constraints. So much of it, again, was coming from U.S.-associated sources.

sources. And even in Europe, what we see both in the UK and in France, the budgets that have gone towards foreign aid have now been reduced in the need for enhanced defense budgets. And so because there is this trade-off, as a result, this means that I think many internationally focused NGOs and those that also operate in Ukraine have to get by with less. Now,

Now in Ukraine specifically, yes, there has been the presence of WHO and other UN agencies, but they have a very robust civil society response and maybe a more informal network. And this was extremely important.

in the bombing of Mariupol and in the further eastern regions where it was deemed too dangerous for actually UN agencies to send their own staff on the ground. So what you had in response is sort of in the safer regions, these groups on the ground, they supported things like mobile clinics,

Again, in a way to try to compensate for or if you're moving target rather than a fixed target, because we know that health centers face higher risks of being attacked. So in that aspect, it was is very useful.

But where they fell short, I think, is actually in giving the manpower that was needed. And we see this in other conflicts as well, where these agencies really rely on the sort of in-country representation because...

because of just the risks are so high. So if you think of Gaza as an example, where they've had the highest number of aid workers who have been killed, and this is pretty much only those that are locally hired rather than from other organizations.

I do think that the WHO has been very good in the sense of supporting for some of the technical things, particularly around medicines donations, getting vehicles, but it's kind of like a drop in the ocean for the overall need.

And now with greater pressure, since the US has withdrawn from the WHO, they also have other pressures to fill sort of that funding gap. But I think the overall concept of how health security and global health has been kind of merged into one kind of started in the 80s, where there was a more of an idea that

conflict, infectious diseases, these go hand in hand. There's sort of a security risk, and we need to contain it elsewhere so that it doesn't flow into high-income settings where there is this regional instability. And so out of that, I think the first time the UN Security Council had even highlighted that issue,

a disease could be a security risk was for HIV/AIDS in the 90s. And as a result of that, that sort of built the philosophical foundations for things like the PEPFAR program and others to emerge. And I think this is very much how Ukraine is being viewed.

this point, which is obviously there are the direct impact of the conflict itself, the health consequences of that, but also continued regional instability where we know this could also

affect Georgia. Russia already occupies 20% of Georgia. It could also then stream into Moldova. Do we really have sufficient architecture to support these countries in a way to meet those health needs in a conflict zone? And I think that the reality is, there's so many gaps in the system that there's a lot of kind of volunteer-driven efforts to plug those holes. There

There are lots of issues with that as well. You have duplication, you have wasting of resources, you have sometimes not transparency. Ultimately, you don't have a kind of centralized understanding of what is happening. And so I think the response in Ukraine has been fragmented, but the local people and organizations have been very savvy in their response. And we have seen other groups volunteer and participate

otherwise kind of fill those holes. Now, since the COVID pandemic, there has been this concept of the European Health Union trying to get that to

support in terms of pharmaceuticals, like access to medicine, strategy filters under that. In reality, what I'm seeing is that a majority of that need was being driven by, if not USAID, which is now off the table, then other kind of informal actors.

That's helpful. But I suppose just kind of taking it a bit deeper, do you see that the community is mobilising and active around here? Or is it that organisations are just too stretched in multiple different directions that they can't really focus on Ukraine, they can't necessarily focus on the sort of health security actions, aspects of things? Or what's your sense of that?

Well, I think part of, I agree that there has been, and that this is typical, this is now over three years of conflict. And with all the upheaval that we're seeing in the US and the anticipation of that, even before Donald Trump entered the office, there has been almost let's wait and see aspect. And even this

forced into action only by the fact that there was an active stepping away from supporting of Ukraine from the US administration. So this concept of the coalition of the willing, etc. You know, there was this almost like long delay of, well, we've done this much and these are the different schemes that are available. But let's wait and see if we have to give so much up already for defense.

a lot of the other humanitarian budgets were coming from other countries. And as a result of that, I think, kind of seeing where the cards will fall before revealing a hand. And I think this is, again, due to the nature of this very, well, I hate to use the cards analogy, because that's

That seems to be Chuck's notion. Feel free to use whatever analogy helps you the most. But his famous line to Zelinsky about you're not holding a strong deck of cards and that his response was like, I'm not playing cards and that this is serious.

And so I think we've seen European leadership emerge from unexpected places, in particular, you know, having Macron kind of before being as out of line with the rest of European leaders now stepping up. In this instance, it really is kind of military and humanitarian aid that go hand in hand.

in this type of conflict. But apart from that, a lot of other countries have reduced their spend alongside the decision to remove USAID. So Norway, for instance, being one of those countries, they followed

the the Americans in that decision yeah it's interesting isn't it because just as we're talking I'm kind of thinking about it and thinking you know on the one hand we've had some very strong political leadership people standing up coming together uh you know there's lots of people in England saying oh this is going to align us closer to Europe this could you know there could be a new type of collaboration between the UK and Europe that you know moves beyond Brexit um that that is sort of

particularly in response to Trump and Ukraine and security threats.

But then on the other side, I feel that there have been institutions that you would have expected to be more vocal and to be involved in the conversations that have sort of been absent. And I guess my question is, how do we break out of this cycle in Europe where we are just purely reactive and we're in this sort of paralysis of just responding to whatever is going on in the US? And there's some short term things that we can do. There's some long term things that we can do.

But I'd love to kind of hear your thoughts about it. Yeah, I mean, I think part of it is the fear of people, again, within the EU thinking about national priorities and that this turning into something that's not, you know, the initial shock and outrage, I think, has long passed.

And at this stage, I do think that they're worried about that populist type of mentality spilling over from the United States. And we've seen an attempt to export that into other countries, you know, where we did see Elon Musk addressing far-right parties in Germany. And I think from their perspective, like Ukraine is not at the top of their priority list because they're worried about the direction of Russia.

where their own countries are going to end up? Are they going to be influenced by the same outcome of what we saw in the United States? And so those national priorities, we have the cost of living crisis. People are not really connecting the dots that, you know, this through that lens of health security, that this is also our problem. We face that situation.

Same issue when we were in the pandemic, right? When we were talking about vaccine inequity, about how nowhere is safe until everywhere is safe. But national priorities and vaccine hoarding was that response. And I think that's what we're seeing here is that Europe and the UK are facing cost of living crisis on a scale that...

is causing a lot of concern for politicians based on the current bizarre policies around tariffs, which I understand have also been only now scaled back. By the time this podcast airs, we could have any number of tariffs in or out. In or out. But the point being is that there's so much global uncertainty and that if we're worried about tomorrow, the exact same policy being announced

completely different and there's a new enemy or a new line that there's zero predictability, it makes it very difficult to plan. And so I think in a way they have said, well, the Ukrainians have managed to push the Russian army back to this extent, uh,

at great cost to Ukraine because they are really fighting for the rest of Europe. You know, let them carry on. But we have to sort out the demands of now people not being able to afford groceries or putting their heating on. And they don't really want to hear about how HIV and TB and AMR coming from Ukraine is going to impact them in five, 10 years.

And so it's a very difficult political message, just in the same way that during COVID we really tried to explain how we are all connected. I think politically failed to do that in an effective way. How fragmented is health security across the European Union generally?

So interestingly, post-COVID, because Europe came out, and again, this was politicized, there's a lot of comparisons between rate of being able to purchase vaccines, which vaccines they had access to in comparison to the UK. You know, some then...

using it as ammunition to say Brexit was a success for this reason. But it did identify that greater coordination was needed. So as a result of that, we touched on it earlier, but sort of the European Health Union, the extension of powers of the European CDC, the Center for Disease Control. But this is just like another body in these attempts to almost

streamline, coordinate, have faster responses across all member states, in a way, makes it more difficult to coordinate. So they have tried to address those obstacles, but that fragmentation will take some time to overcome. So

Sometimes the response to just create new bodies isn't always the answer. It is sometimes the one that gets the flashy headline. That's what we're seeing so far. But there is a, you know, through the pharmaceutical strategy that falls under that is to help to increase access to medicines. And again, in a way at a more affordable pricing. So all of that came out of, I think, the view that the European Union performed in a way that was

to other countries, specifically on medicines procurement to be not as fast and not at the scale that they needed and that they were almost like hindered by the fact that they had to do it as a block instead of it being in theory, if you have a larger, you know, negotiating chip, you know, larger block, you can get a larger amount of vaccines, the more vaccines you can buy, the lower the price, right? Which is also why the UK bought eight times more than what they needed, right? So...

So maybe per vaccine lower, but overall at greater cost. So but that was a very the point on that is to show that even when we're in the facing something like a pandemic that affects all of us versus a regional conflict in Eastern Europe, that it's difficult to say actually no.

This will affect all of us in real tangible ways that now, three years later, the immediacy of the cost of living has squashed the political, I would say, support that we originally saw across Europe for Ukraine. And you...

You can see it in terms of the way that people are talking about it. I think a frustration about the length of time. But this has always been Putin's endgame is that the West will eventually tire. They will not stay together. There won't be solidarity in that same way in the early days. And he can achieve those sort of colonial imperial ambitions.

It occurred to me as you were speaking that we mentioned tariffs. What sort of effect would tariffs have on the pharmaceutical industry, like a broad kind of tariff war? Yeah, so it's interesting because Trump has been alluding to the fact that he is imposing a pharmaceutical tariff. Yes, we're recording this on April the 10th. I believe he mentioned it on April the 9th. So by the time this gets to air, any number of things could happen. But that's where we currently sit. That's where we're currently at.

Well, interestingly, the boss of Novo Nordisk, so this is in Denmark, right, has been brought in by the Danish government to advise their political leaders on how to negotiate with Trump. How should they take him on?

Because again, Denmark and Greenland, all these other, you know, quite complex geopolitical things that the government needed to deal with. But they went to their pharma boss to say, do you have any advice on how to interact with people?

from a business perspective. Now, pharmaceuticals have a global supply chain and most active pharmaceutical ingredients or APIs come from India, China. Those are the largest suppliers in the world, including things like generics. India is known as the pharmacy of the world. They supply one third of global vaccine supply.

They are critical in terms of providing alternative for cheaper medicines. And so it's very rare to see an entire pharmaceutical product to be manufactured only in using excipients and other even medical devices, et cetera, coming from just one place.

However, once it is assembled, then very typically in high income settings, you have maybe one or two wholesalers max before it's purchased by a pharmacy. Whereas in low income settings, you see many more middle actors throughout that supply chain. And that's where things can get a bit dicey from a security perspective. But all of that is, again, because as I said,

It's very unusual for sourcing all of the ingredients that go into a medical device or a vaccine or tablet means that it'll become much more expensive. And I cannot imagine that pharmaceutical industry is not going to push back against this. And in the end, the U.S. market is the most expensive market in the world. It's the one that the pharmaceutical industry cares the most about because it's where they recoup all of their profits kind of

Europe and the rest are sort of secondary. They're happy to negotiate at a lower prices, right? Because every country will have a different price for the same medicine. And that's really comes down to the ability of that government to negotiate a deal with the pharmaceutical industry. So, you know, usually you can have regions purchase as a block because then again, higher volume, lower price.

Yes, I always hear from my US friends traveling over to Europe how blown away they are by the price of pharmaceuticals over here. I had a friend who was traveling over to Italy, I think, from the US.

and they needed some medication for you know some infection or something i think and um they didn't have specific health insurance on them and so the doctor said this i'm afraid because we're out of you're not under insurance this is really going to cost a lot and they were braced for the worst and it was 35 euros and they were they were a bit like i mean oh god yeah uh it's it's a

part of the reason why we see the extreme reactions to the US healthcare system and industry. So because many people just cannot afford basic healthcare. And that has led to some pretty dramatic events in recent in the recent years, I suppose. But if we even think of how different

pharmaceutical companies are based in different countries. And so it's very, I think it's gonna be very complex to work out if the tariffs is gonna be based on the

country model, semaglutide being one of the most popular medicines in the US, because if we counter in both overweight and obese population, it's like over 70%. So that's a huge market. And it has, I don't know if you have recently been to the US, but the US and New Zealand are the only countries that allow direct to consumer advertising. And I had never in my life seen so many

Back-to-back TV adverts. Yeah, all over TV channels in the US. And so much specifically on Zempik being the brand for semaglutide, which is indicated for diabetes,

Wigo-V is, of course, the one indicated for weight loss, same drug, kind of brand recognition. I mean, from the layperson's perspective, everyone just says Ozempic regardless of why they're using it. So I think that will drive the cost up of that further, and it's already in the thousands range in the U.S. and hundreds of pounds here. So let's see what the global ramifications will be, but...

As we know, tariffs pass on the increased cost to the consumer. So I think there's going to be a pretty strong backlash to already incredibly expensive products.

and those that are in high demand, particularly in the United States. But if it's global, like circling back to Ukraine, if we have, again, these essential medicines, things for TB, there's a lot of drug-resistant TB cases in Ukraine, and these medicines are expensive. So anything that increases the cost of medicines will make a response to humanitarian conflicts even worse because...

were already short of funds to try and purchase these products. So that's why I'm saying that I think in Ukraine, there has been the heavy lifting has really been done from civil society at a local level, working with sort of international philanthropists, etc. And I'm not saying that's the best model, but it has been necessary. There has to be a model.

Well, I mean, your country's at war, you have to do something. And so I think there has been like a rough and ready response to it. And this is because just the amount that the more formalized groups, Red Cross, WHO Ukraine, I mean, it's a small team, they've done some good work, but it really isn't enough. It's just kind of scratching the surface.

And even if there are like from the European Union itself, there are some aspects around governments donating supplies, but it's like short-dated medications and stuff that's not even really needed. But then they get the PR moment to, you know,

clap for themselves and have a public statement that this was part of their overall aid contribution. So I think this is a very difficult circumstances due to the length of the time of the conflict, but also due to really global uncertainty kicked off by the Trump administration and the extremely...

And that's tied then to the cost of living crisis in the UK and in Europe, where the economic forecasting is not making countries feeling confident while also then having to cut on aid, spend more on defense,

And all of that then makes it very complicated to support in the way that's needed, in a way that I think will actually equip Ukrainians to win the war, but also in the interim for their society not to crumble.

So, Oksana, I think maybe the Ukrainian view of institutions like WHO is not as positive, say, as the rest of Europe. Is that accurate? Yeah, I think that the Ukrainian response to the support that they have received, you know, of course there is gratitude, but I think there is also quite a lot of frustration, especially when there is absence of UN agencies in occupied territories, when there are very few visible...

in some of the most dangerous areas as well. So overall, I think the Ukrainian view is that the WHO and the UN has let them down and that they're not reliable partners. I think even when the optics of some of the international organizations, famously Red Cross is a neutral organization,

However, they did bizarrely post a picture of the head of their institution shaking hands with the Russian foreign minister Lavrov. And at that time, it had really struck a chord with many Ukrainians who thought, hang on,

You've not met with our... There's no photo op with Zelensky. And this is after more healthcare sites have been targeted and attacked in Ukraine than any other conflict to date, you know, over two a day, over 2,000. And here this...

organization that's supposed to be giving medical aid to Ukraine is smiling for a photo and shaking hands. Now that could have been dealt with differently. Obviously the general population may not know the full extent of the IRC's neutrality position.

But even that does not visually convey neutrality. So I think sometimes in such high emotional context where

people are losing loved ones every single day. There has to be more like thought put into it when these organizations do try to broker between both parties such that both parties are represented if they take that route. And that you have to be visible. If people can't see you doing the work, they don't know about the work and they have to rely again so heavily on informal networks to be able to access their medicines.

So many people, over 50% in a recent survey from the Ministry of Health in Ukraine said that they still can't access essential medicines. So again, this is not going to be uniform, that some of the supply is going to be much more uninterrupted in larger cities further to the west. But if we look at the whole country, you have that's going to have significant impact on health outcomes.

And we've mentioned some of the other issues around AMR, TB, HIV, AIDS. And again, that one of the most effective actors in the region was USAID in terms of just fronting the funds. And that's no longer part of it. So I think there's a lot of fear in the moment about how is this going to be implemented?

And a bit of resentment, it's like almost. Well, there's a lot of rhetoric, you know, there's a lot of rhetoric and what Ukrainians want to see are action. And I think especially returning to sort of the Oval Office interview with Shulansky, you know, quite a lot of when they were claiming that

there was such unpopularity of the president that they all, you know, the nation really did stand behind him. He had kind of like an all time high in terms of popularity because he stood up for his people. And I think after over three long years of constant barragement of never really feeling safe and that UK statement will stand with you however long it takes.

I think they want a little bit more of a realistic plan than that. I've heard various different things from various different people about the way that ministries of defence are thinking about potentially some kind of upscale in combat or fighting and what that would mean for hospitals and healthcare systems at home in terms of people being repatriated, in terms of types of research that would and sort of

that would need to go into it. And I just wondered whether you had any insights into that in terms of how European countries are...

thinking or preparing for different scenarios that could move forward from here? You know, I mean, hopefully not, but presumably governments are having to play through these different scenarios of, you know, what happens if we need more boots on the ground from different NATO countries or European countries? You know, we don't know. We're in limbo, as we've said. But what has been, what have you heard about this or what's been your experience about it?

Yeah, so I think defense already has a really strong integration of health within its oversight. So as I was saying earlier, from the 80s to 90s, we saw this sort of philosophical merging of global health security and defense in more and more overt ways.

you know, the UN Security Council saying, using languages of waging war on AIDS, HIV, AIDS, and then looking at the Ebola response in 2014, where it's fully boots on ground, you know, and it is international, like missions, a UN mission that gets sent there. And in that context, using quite heavy handed force to for lockdowns,

And the backlash that came from a kind of militarized response to the Ebola outbreak in West Africa. Now, I think the way that even in COVID, we had inclusion of the military personnel for setting up field hospitals, helping with test and trace. So to some extent, this is already built in in most nations. You know, they have an aspect where we know we can't train people

healthcare workers overnight. So we have kind of part of the reserve is already wrapped up within military so that they have some aspects of training, they can be ready to deploy when needed. I think now we also are looking at how countries are also considering, well, if there is going to be use of biological weapons or other types of

chemical weapons, how is that going to potentially impact neighboring countries? Or, you know, we've already had Chernobyl being a site Russians have attacked. So, you know, what is going to be then the response, not only in Ukraine, surrounding nations, again, if something like that were to happen, or if it was going to intentionally be larger than that, and beyond those borders within Europe. So...

What I foresee is that this already sort of integrated arm is going to get strengthened in a way. I think that they're going to have to try to do less with more. So it might be typically health comes second to things like military spend. And we just saw that, right, with the reduced foreign aid budget in the UK. So there is this sort of potential.

potential for it to be led by, rather than led from the health response, more led through the defense response.

Now, in terms of whether there's also more countries that look at mandatory military training, Poland has just said that that's going to be new policy for all of their men, greater use of reserves. I mean, there has been sort of some headlines about that here in the UK, although I certainly don't think there's a cultural appetite for that.

And I kind of defer to Gavin to also pitch into that. It was actually a policy suggested, wasn't it? Yeah, I know. So it is something that our... Last government during the election process and was immediately panned. Immediately panned, but it was raised. It was raised. It was raised and it was raised in parliament. And so...

Just me, you're absolutely right. All of these countries are coming together. They are thinking, you know, how do we how do we respond to the multitude of threats, whether they're it's like bioterrorism or cyber terror as well. I mean, we've had Russia attack do cyber attacks on the NHS, you know, and not just one. So the

We have to think about it not only in terms of how do we use personnel, how do we prepare against environmental disasters, things like ecocide, how that could potentially impact the environment surrounding not just Ukraine, but Ukraine as the breadbasket of Europe feeds the world. What is the global implication of that? And then also protecting the digital space. So I fear that governments have a very big job on their hands to deal with Russia in a way and effectively

a very soft-handed, appeasing approach is just going to invite more bold actions on the offensive, in my opinion. It's been really fascinating to have you in to talk about these things. What a wide range of chat. And thank you so much for coming once more onto The Lancet Voice to chat with Jessamy and I. It's a very cool setup you have here. So it's a privilege to talk to you both.

Thanks so much for listening to this episode of The Lancet Voice. Remember, you can subscribe to The Lancet Voice wherever you usually get your podcasts. And we hope to see you again next time.