Assessment Report Improving the Health and Safety of Miners in Eastern Ukraine Published by the United Nations Development Programme (UNDP) in Ukraine

Home , Krasnodon, Metinvest, Rovenky

Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Published by the United Nations Development Programme (UNDP) in Ukraine

The mention of specific companies does not imply that they are endorsed or recommended by UNDP in preference to others of a similar nature.

UNDP does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

United Nations Development Programme in Ukraine 1, Klovsky Uzviz Str. Kyiv, 01021, Ukraine Contents Contents

EXECUTIVE SUMMARY...... 5

KEY FINDINGS . 6 1. INTRODUCTION...... 8 1.1 Miners...... 8 1.2 Mining Industry...... 8 1.3 National Priorities...... 8 1.4 Gender Considerations ...... 9

2. COMMUNITY MEETINGS...... 10 2.1 Methodology. 10 2.2 Factors Affecting the Health and Safety of Miners ...... 10

3. HEALTH DATA ON MINERS...... 11 3.1 Key Findings from the Medical Exams of Miners. 11 3.2 Methodology for Conducting and Analysing the Medical Exams...... 11 3.3 Health Data on Miners...... 11

4. Safety data on Miners . 17 4.1 Key Findings...... 17 4.2 Safety Data on Miners...... 17

5. OPINION SURVEYS OF MINERS IN ROVENKY AND SVERDLOVSK. 18 5.1 Key Findings from Rovenky and Sverdlovsk ...... 18 5.2 Miners’ Opinions on Health . 18 5.3 Miners’ Opinions on Safety...... 22

6. GENERAL RECOMMENDATIONS. 25

7. KRASNODON ACTION PLAN . 26 7.1 Key Findings...... 26 7.2 Community Health Profile. 26 7.3 Krasnodonugol...... 27 7.4 Priorities . 28 7.5 General Recommendations. 28 7.6 Action Items...... 29 7.7 Budget . 33

8. ROVENKY ACTION PLAN...... 34 8.1 Key Findings...... 34 8.2 Community Health Profile. 34 8.3 DTEK Rovenkiantratsit...... 34 8.4 Health and Safety of Miners ...... 36 8.5 Priorities . 36 8.6 General Recommendations. 37 8.7 Action Items...... 37 8.8 Budget . 41

3 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine 9. SVERDLOVSK ACTION PLAN . 42 9.1 Key Findings...... 42 9.2 Community Health Profile. 42 9.3 DTEK Sverdlovantratsit. 43 9.4 Health and Safety of Miners ...... 43 9.5 Priorities . 44 9.6 General Recommendations. 44 9.7 Action Items...... 45 9.8 Budget . 49

10. REGIONAL CONSIDERATIONS...... 50

11. APPENDIX...... 52

12. BIBLIOGRAPHY. 55

13. ENDNOTES. 58

4 EXECUTIVE SUMMARY Executive summary

The “Improving the Health and Safety of Miners in Eastern Ukraine” project aims to identify and address the health and safety needs of miners in Krasnodon, Rovenky and Sverdlovsk. This report summarises the results of the first or assessment phase of this project, while the second phase will focus on implementing the recommendations set forth in this report.

To begin, UNDP partnered with DTEK and Metinvest, two of the largest energy and mining companies in Ukraine, to implement this project. UNDP also received endorsements from the mayors of Krasnodon, Rovenky, and Sverd- lovsk, as well as the governor of the Luhansk Oblast State Administration to proceed with the effort.

UNDP then conducted dozens of interviews, focus groups, and community workshops to understand the health and safety needs of miners. UNDP also worked closely with DTEK Rovenkiantratsit, DTEK Sverdlovantratsit, and Metinvest Krasnodonugol to examine the working conditions of miners. Over the course of three months, UNDP had engaged over 250 miners, miners’ spouses, health workers, and government officials to discuss the miners’ needs and priorities.

In addition, UNDP contracted GfK Ukraine, the country’s largest market research firm, to conduct a study on the health and safety of miners based on the medical exams and opinion surveys of 373 miners. The results of this study helped shape the proposed action plans for each of the three target communities.

Overall, UNDP found the most pressing health and safety issues of miners to be respiratory diseases, cardiovascular diseases, and occupational traumas. While DTEK and Metinvest have done much to improve the health and safety of miners, there is still much work to be done.

Each community has specific and unique needs, but in general, the proposed action plans focus on upgrading medical equipment, improving emergency transportation, and conducting preventative health work. The following sections describe the process, results, and proposed actions in greater detail.

5 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Key findings

The following list summarises the key findings from the health and safety assessment of miners in Krasnodon, Rovenky and Sverdlovsk. Subsequent sections explain the findings in further details.

Health Issues • The most prominent health issues of miners in Krasnodon, Rovenky, and Sverdlovsk are respiratory diseases, cardiovascular diseases, occupational injuries and musculoskeletal conditions. • More than 37 per cent of miners in Rovenky and Sverdlovsk suffer from respiratory diseases. Chronic bronchitis alone affects 330 per 1,000 miners—a rate seven times higher than the general adult populations in Rovenky and Sverdlovsk. • About 18 per cent of miners in Rovenky and Sverdlovsk suffer from cardiovascular diseases. For example, 57.6 per 1,000 miners suffer from ischemic heart disease compared to the national average of 53.1 per 1,000 people or the European average of 36.3 per 1,000 people.1 • In Rovenky and Sverdlovsk, the most common musculoskeletal conditions of miners are osteochondrosis (68 per 1,000 miners) and lower back pain (42 per 1,000 miners). • The Luhansk Clinic of the Ministry of Internal Affairs classified miners into three health groups: I) generally healthy, II) those who have had acute and/ or chronic disease(s) in the past, and III) those who currently have a chronic disease. Of those who took part in the study, 33 per cent were classified into Health Group I, 13 per cent into Health Group II, and 54 per cent into Health Group III. • Still, miners are rather optimistic about their heath: 61 per cent are satisfied with it even though 54 per cent are classified in Health Group III. In fact, only 8 per cent are dissatisfied with their health. • At the same time, 70 per cent of miners worry that their health might deteriorate because of harmful working conditions, and 46 per cent worry that it might deteriorate because of unhealthy habits (e.g., smoking, alcohol consumption). • For the most part, miners consult doctors for their health problems (64%). They also consult health professionals at their enterprise (34%), acquaintances and relatives (27%), pharmacists (23%), and the Internet (10%). • A large number of respondents prefer self-treatment or to do nothing in treating some of their health issues. For example, only 64 per cent of respondents consulted a doctor to treat bronchitis, 44 per cent for backaches, and 40 per cent for sore throats over the last 12 months (August 2011-August 2012). • Fifty-nine per cent of miners (63% of underground workers and 47% among aboveground workers) consider that the health care system in their city satisfies their needs. • Eighteen per cent of miners are unsatisfied with the quality of medical care, 16 per cent with inconvenient schedules of medical institutions, 15 per cent with expensive medicines, and 12 per cent with expensive medical services. • Miners’ families and pharmacists play an important role in the health and wellbeing of miners. At least 15 per cent of miners use medical products advised by a pharmacist, 9 per cent use medical products advised by family members or acquaintances, and 8 per cent use folk remedies.

6 KEY FINDINGS

Safety Issues • The rates of occupational injuries have decreased at all three enterprises since 2007: by 66 per cent at Krasno- donugol, 21 per cent at Rovenkiantratsit, and 20 per cent at Sverdlovantratsit.

• In 2011, the national average for occupational injuries of miners was 9.3 per 1,000 miners. During the same period, Krasnodonugol, Rovenkiantratsit and Sverdlovantratsit reported 6.87, 12.98, and 7.63 occupational injuries per 1,000 miners, respectively.

• Even though 50 per cent of miners are satisfied with their working conditions, 75 per cent of miners are worried about the possibility of work-related accidents.

• About half of all miners are satisfied with safety conditions at the workplace, 11 per cent are dissatisfied, and 40 per cent are satisfied only partially.

• Miners are generally satisfied with their working conditions, but 75 per cent of miners (79% of underground workers and 65% of aboveground workers) worry that occupational injuries might happen.

• Most miners recognise their enterprises’ efforts to improve occupational safety; only 19 per cent think that existing measures are not effective enough.

• The vast majority of miners (69%), especially underground workers, believe that improving workers’ safety requires tightening control over maintenance of equipment and carrying out timely maintenance and replacement of equipment.

7 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine DTEK’s subsidiary mining companies are DTEK Roven- 1. Introduction kiantratsit and DTEK Sverdlovantratsit. Metinvest is the largest company in Ukraine and is an international, Ukraine’s coal mining industry has one of the highest vertically integrated steel and mining company with rates of occupational casualties, injuries and diseases in over 635 million tonnes of coal in reserves.8 Its subsid- the world. In 2011, the State Committee on Statistics of iary mining company is Krasnodonugol. Both compa- Ukraine reported 161 casualties in the mining industry, nies are part of Ukraine’s largest financial and industri- an average of one casualty every 2-3 days.2 The rate of al group, System Capital Management (SCM).9 occupational injuries was 9.3 per 1,000 employees3 — more than five times the rate of the construction indus- Most of Ukraine’s mining activities take place in the try, which had an injury rate of 1.7 per 1,000 employees. Donetsk coal basin of Eastern Ukraine, where about In addition, miners suffer unusually high rates of occu- 225 mines produce 90 per cent of the country’s hard pational health diseases, with one study showing min- coal.10 The remainder of the hard coal comes from ers being seven times more likely to suffer from chronic about 18 mines in the Lviv-Volynskiy basin in Western bronchitis than their adult counterparts.4 Thus, UNDP Ukraine.11 Ukraine’s mines are among the deepest in partnered with energy and mining companies DTEK and the world with some more than 1,000 metres deep. Metinvest to improve the health and safety of miners in the mining cities of Krasnodon, Rovenky and Sverdlovsk. 1.3 National Priorities The Government of Ukraine has reaffirmed its commit- At the project kick-off event, the governor of the ment to create safer, healthier working conditions for its Luhansk Regional State Administration, mayors of miners on numerous occasions. In 2010, the Ministry of Krasnodon, Rovenky and Sverdlovsk, executives from Coal Industry of Ukraine began a process of restructur- DTEK and Metinvest, and UNDP agreed to an approach ing its mining industry, citing inefficient production and which would focus more on community health services hazardous working conditions. Subsequently, Ukraine rather than mining safety standards. The project, which began privatising state-run sites, signing deals with Chi- comprises of two phases, first focused on assessing na to revamp some of them, while also working with the the health and safety needs of miners. This assessment European Union to shut down its non-productive ones.12 report summarises the results of the first phase and provides a foundation for the upcoming second or In 2011, Ukraine became the 25th country to ratify the implementation phase of this project. International Labour Organization (ILO) Convention 176, the Safety and Health in Mines Convention. Two unions, 1.1 Miners the Coal Industry Workers’ Union of Ukraine (PRUPU) For this project, the term “miners” includes employees who and the Independent Trade Union of Miners of Ukraine, work in mines, whether it is underground or aboveground. spearheaded the effort to ratify Convention 176.13 Once This includes stope miners, sinkers, administrative staff enacted, Ukraine’s national laws on mine safety are ex- and others. The project only considered current or retired pected to be updated to comply with international miners in Krasnodon, Rovenky and Sverdlovsk. standards. The Convention describes responsibilities for government, mining companies, and miners, and also 1.2 Mining Industry gives miners the right to report dangerous conditions The mining industry, particularly of coal, plays a central and accidents, as well as the right to refuse unsafe work.14 role in Ukraine’s economic and social development. With around 500,000 employees, Ukraine’s mining industry The State Service of Mining Supervision and Federa- workforce ranks among the biggest in the world.5 In ad- tion of Trade Unions of Ukraine (FPU) also signed an dition, the mining industry is projected to grow by 5.1 per agreement, in force until 31 December 2015, to joint- cent to an estimated value of UAH 97.81 billion (USD 14.19 ly monitor the implementation of labour protection billion) by 2015.6 For mining communities such as Krasno- laws.15 Under the agreement, the parties are required don, Rovenky and Sverdlovsk, mining activities account to jointly investigate accidents, work together on im- for the majority of the communities’ economic activity. proving labour laws, and consult each other in matters of labour safety. The parties agreed to revisit and eval- Two energy and mining companies—DTEK and Metin- uate their progress on an annual basis. vest—own the mines in Krasnodon, Rovenky and Sverdlovsk. DTEK is the largest privately owned, verti- In addition, Ukraine will begin reforming its health- cally integrated energy company in Ukraine. The com- care sector in 2014, according to the Ministry of pany employs more than 100,000 people, controls Health. Citing lack of funding, equipment and med- about 45 per cent of the country’s mines, and has an ical staff, the Ministry of Health plans to overhaul its annual coal mining capacity of 36.8 million tonnes.7 healthcare system, including the addition of a unified

8 INTRODUCTION state emergency medical service. The reform process minority of women who work at mines have specific needs has started with pilot projects in the communities of that may be overlooked by managers who are predominantly Donetsk, Dnipropetrovsk, Kyiv and Vinnytsia. men. In addition, widowed wives and their children are disproportionately affected when the breadwinner of the 1.4 Gender Considerations family was someone lost in a mining accident. Thus, this Gender considerations are vital in the mining industry where project examined the different needs of males and females an overwhelming majority of miners are men. Conversely, the through gender-sensitive interviews and focus groups.

9 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine process, community members reaffirmed their com- 2. Community meetings munities’ needs for upgrading medical equipment, improving emergency transportation, and implement- 2.1 Methodology ing public health programmes. They also edited their The assessment process consisted of three main steps: community action plans, primarily by adjusting the preparation, assessment and agreement. The figure quantity or type of medical equipment needed (see provides an overview of the steps, although the process the sections on Action Plans for specific details). was not always linear, as steps were rearranged, repeat- ed, and modified as necessary to fit the local context. 2.2 Factors Affecting the Health and Safety of Miners Figure 1. Conducting a health and safety risk assessment The main health and safety ailments of miners are respira- Preparation tory diseases, cardiovascular diseases, occupational inju- • Meet with key stakeholders ries (trauma), and musculoskeletal conditions. The reasons • Collect secondary data • Define the work plan miners get sick or get injured include a multitude of factors, including genetics, personal choices, living and working conditions, access to health care, and general social, Assessment economic and environmental conditions. The following is • Collect primary data • Examine work and health facilities a list of the main factors that are affecting the health and • Discuss and prioritise needs safety of miners in Krasnodon, Rovenky and Sverdlovsk: • Health care services: The availability, accessibility and quality of health care services. Agreement • Meet with key stakeholders • Health care facilities: Staff and resource capacities • Discuss findings and draft report to meet the health needs of miners. • Agree on ways forward • Lifestyle and behaviours: Lifestyle choices (e.g., eating, exercise, drugs and alcohol) of miners. First, the preparation process focused on building rela- • Locus of control: The extent to which a person be- tionships with local stakeholders and conducting back- lieves he or she can influence his or her own life. ground research. To begin, UNDP partnered with mining companies DTEK and Metinvest to establish the param- • Mining conditions: Mine depth, methane gas lev- eters of the project. This included discussions with key els, temperature, dust levels and other conditions. leaders from Krasnodonugol, DTEK Rovenkiantratsit and • Mining equipment: Quality, quantity and func- DTEK Sverdlovantratsit. Then, UNDP, DTEK, and Metinvest tionality of mining equipment. met with the governor of the Luhansk Regional State Ad- • Safety regulation compliance: Compliance of safe- ministration and mayors of Krasnodon, Sverdlovsk and ty regulations by employees. Rovenky to officially launch the project. In the meanwhile, • Safety training programmes: The frequency and UNDP collected secondary data, mostly from reports pro- quality of safety training programmes. vided by the cities, hospitals and mining companies. • Legal frameworks: The implementation of policies, such as ILO Convention 176. Second, UNDP conducted the health and safety risk as- • Governance: Ownership structure and allocation sessments to examine prevalent health and safety issues, of subsidies. identify barriers to quality health services, and assess the health and safety needs of miners. This was done pri- • Coal pricing: Coal prices affect incentive structures marily through interviews, focus groups, walkthrough and pressures to produce. evaluations and community workshops. To ensure a • Pressures of production: Pressures to meet de- well-rounded perspective, UNDP included a range of mands of management. participants, including above- and underground work- • Incentives for profit making: Incentives to make ers, miners’ spouses, labour unions, and other communi- money, especially when miners are paid by volume ty members. The process also included workshops where of minerals extracted, as opposed to an hourly wage. community members examined data, explored possible • Insurance policies: The availability of adequate solutions, and prioritised community action points mov- policies for miners and their families. ing forward. In total, UNDP engaged over 250 miners, • Unions: The effectiveness of unions to advocate doctors, community, and government representatives for miners’ health and safety. to discuss the health and safety problems of miners. More specific findings and recommendations are de- Third, community members reviewed the draft as- scribed in the individual action plans in subsequent sessment report and action plans. During this review sections.

10 Health data on miners

To begin, GfK Ukraine collected secondary data from lo- 3. Health data on miners cal hospitals, DTEK, Metinvest, and the Luhansk Oblast Department of Health. This data included demographic 3.1 Key Findings from the Medical Exams information, as well as health information on the adult of Miners populations of Krasnodon, Rovenky and Sverdlovsk. • More than 37 per cent of miners in Rovenky and GfK Ukraine then organised 373 independent medical Sverdlovsk suffer from respiratory diseases. Chron- exams of miners from Rovenkiantratsit and Sverdlovan- ic bronchitis alone affects 330 per 1,000 miners—a tratsit to be conducted at the Luhansk Clinic of the Min- rate seven times higher than the general adult istry of Internal Affairs. GfK Ukraine determined that a populations in Rovenky and Sverdlovsk. research sample of 373 miners was sufficient for pro- ducing a maximum sample error of 5 per cent. Roven- • About 18 per cent of miners in Rovenky and Sverd- kiantratsit and Sverdlovantratsit helped choose the lovsk suffer from cardiovascular diseases. For ex- miners for this study based on four criteria areas: age, ample, 57.6 per 1,000 miners suffer from ischemic gender, place of work, and job position. heart disease compared to the national average of 53.1 per 1,000 people or the European average of Each miner was examined by a physician, otolaryngol- 36.3 per 1,000 people.16 ogist, neurologist, dermatologist and ophthalmolo- gist. Each miner also received a fluorography, electro- • In Rovenky and Sverdlovsk, the most common cardiogram, and general blood and urine tests. In ad- musculoskeletal conditions of miners are osteo- dition, GfK Ukraine conducted surveys to better un- chondrosis (68 per 1,000 miners) and lower back derstand the opinions of miners regarding their health pain (42 per 1,000 miners). and working conditions. UNDP shared the final results • Fifty-three per cent of miners smoke, close to the of this study with key stakeholders to help them guide 17 average of Ukrainian men aged 18-59. In addi- community planning efforts. tion, 39 per cent of smokers suffer from bronchitis in comparison to 26 per cent of non-smokers. Miners did not receive any compensation, monetary or otherwise, to participate in the study. All parties • The Luhansk Clinic of the Ministry of Internal Af- involved in the medical exams—UNDP, GfK Ukraine, fairs classified miners into three health groups: and the Luhansk Clinic of the Ministry of Internal Af- I) generally healthy, II) those who have had acute fairs—all guaranteed that individual medical results and/ or chronic disease(s) in the past, and III) those of miners would remain confidential. The parties also who currently have a chronic disease. Of those agreed that UNDP would only use medical results in who took part in the study, 33 per cent were clas- aggregated form to understand the general health sified into Health Group I, 13 per cent into Health trends of miners in Rovenky and Sverdlovsk. The Lu- Group II, and 54 per cent into Health Group III. hansk Clinic of the Ministry of Internal Affairs notified miners about their individual health results in person 3.2 Methodology for Conducting or by special courier service. and Analysing the Medical Exams In addition to meeting with key stakeholders, UNDP 3.3 Health Data on Miners contracted GfK Ukraine, the country’s largest market GfK Ukraine’s study shows that miners from Rovenki- research company, to organise and analyse the medi- antratsit and Sverdlovantratsit suffer disproportionate cal exams of 373 miners in order to better understand health problems in comparison to the general popula- the health needs of miners. The study examined the tions of Rovenky and Sverdlovsk. In particular, miners health of miners in Rovenky and Sverdlovsk (Metin- suffer disproportionately from respiratory diseases, vest/ Krasnodonugol declined to participate in the cardiovascular diseases and musculoskeletal condi- study because they did not feel the need to collect tions. For example, more than 37 per cent of miners more data than they already possessed). The study in Rovenky and Sverdlovsk suffer from respiratory dis- was aimed to answer the following questions: eases. Chronic bronchitis alone affects 330 per 1,000 • What are the specific health and safety ailments of miners — a rate seven times higher than the general miners? adult populations in Rovenky and Sverdlovsk. In addi- • What are the specific health and safety needs of tion, 57.6 per 1,000 miners suffer from ischemic heart miners? disease compared to the national average of 53.1 per 1,000 people or the European average of 36.3 per • How do those problems and needs differ from the 1,000 people.18 The following table shows the compre- rest of the population? hensive results from the medical exams.

11 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine

Table 1. Table 1. The differences between weighted and actual samples

Weighted sample Actual sample

Rovenkiantratsit Dzerzhynskogo 33 36 Office Rovenkovskoye 29 42 No. 81 Kievskaya 26 21 M.V. Frunze 50 35 Vakhrusheva 33 28 Kosmonavtov 37 41 Sverdlovantratsit Dolzhanskaya-Kapitalnaya 54 32 Ya.M.Sverdlova 18 35 Tsentrosoyuz 17 37 Kharkovskaya 14 33 Krasnyi Partizan 62 33 Category Underground worker (not including stope miners and sinkers) 199 191 Aboveground worker (not including administrative personnel) 78 72 Stope miner 47 50 Sinker 32 30 Administrative personnel 16 30 Age 18-30 108 182 31-40 120 111 41-50 76 56 51+ 69 24 Gender Male 299 294 Female 74 79 Source: GfK Ukraine, September 2012

Table 2. Results of the medical exams (per 1,000 miners)

Age Category Health group

Underground Aboveground 18- 30 31-40 41-50 51+ І ІІ ІІІ Total worker worker

Bronchitis 115.80 326.71 444.82 550.68 328.05 337.08 26.11 78.40 573.16 330.33 Presbyopia 0.00 25.19 278.34 326.26 77.02 265.38 32.39 35.92 201.14 124.60 Deviated nasal septum 115.61 156.14 167.53 30.24 142.60 66.52 117.10 129.29 125.75 123.38 Myopia 86.18 68.18 92.71 34.39 66.79 88.06 8.90 192.84 81.42 72.16 Osteochondrosis 6.84 25.57 141.60 159.69 38.40 156.84 8.68 28.19 113.72 68.32 1st degree hypertension 14.89 47.52 141.95 100.03 56.45 97.37 0.00 61.07 108.28 66.79 Ischemic heart disease 0.00 24.18 46.15 219.28 43.23 99.95 0.00 0.00 105.86 57.56 Cholecystitis 10.03 7.77 71.98 134.23 32.65 80.55 0.00 0.00 82.31 44.75 Vertebrogenic lumbalgia 16.10 32.14 50.70 95.71 20.22 110.16 0.00 44.92 68.27 42.94 A slight form of hypermetropia 4.54 0.00 50.74 165.47 37.08 57.04 0.00 69.01 61.02 42.12 Pulmonary fibrosis 0.00 24.35 82.73 79.68 39.24 39.31 0.00 0.00 72.20 39.26 Cardiosclerosis 0.00 0.00 46.15 161.27 32.84 57.58 0.00 0.00 71.90 39.09 Tonsillitis 78.39 10.44 0.00 42.03 35.12 30.69 0.00 141.62 28.79 34.00 Adiposis 0.00 11.16 56.66 97.63 24.63 57.99 0.00 53.23 48.12 33.06

12 Health data on miners

Age Category Health group

Underground Aboveground 18- 30 31-40 41-50 51+ І ІІ ІІІ Total worker worker

Allergic dermatitis 9.36 27.82 62.89 21.44 31.36 19.43 43.26 0.00 26.14 28.35 Peptic ulcer disease (PUD) 9.10 39.99 0.00 69.23 34.63 9.45 0.00 0.00 51.99 28.27 Neurocirculatory dystonia 55.75 26.51 0.00 0.00 29.84 9.87 0.00 0.00 45.60 24.79 Chronic pharyngitis 0.00 27.01 6.99 69.30 8.27 66.08 0.00 47.70 30.70 22.87 Pollinosis 0.00 16.19 30.21 60.14 18.33 34.48 0.00 22.16 35.93 22.41 Retinal angiopathy 0.00 0.00 18.43 97.63 9.29 58.57 0.00 36.29 31.34 21.74 Myocardiodystrophy 7.50 15.13 70.27 0.00 8.32 59.57 0.00 10.77 36.55 21.27 Groin erythrasma 2.46 13.63 38.28 42.03 16.22 33.53 23.71 5.54 22.31 20.60 Rhinitis 16.04 5.11 42.32 30.24 14.92 36.89 6.21 10.80 31.34 20.47 Pigmented nevus 4.83 3.48 12.05 84.02 25.89 4.42 0.00 38.33 28.51 20.47 Chronic pancreatitis 5.67 0.00 39.84 56.29 23.95 8.71 0.00 0.00 36.97 20.10 Diabetes mellitus 0.00 0.00 0.00 105.50 0.00 77.05 0.00 0.00 35.80 19.46 Angiosclerosis of retinal vessels 0.00 0.00 0.00 98.45 9.29 44.40 0.00 0.00 33.40 18.16 Calculi of the kidney 9.49 14.45 6.92 47.86 2.00 63.91 0.00 10.80 29.87 17.64 Pyelonephritis 9.49 14.45 6.92 47.86 2.00 63.91 0.00 10.80 29.87 17.64 Cochlear disorders 0.00 0.00 0.00 84.02 20.74 0.00 0.00 0.00 28.51 15.50 Atheroma of the auricle (ear) 0.00 0.00 0.00 84.02 20.74 0.00 0.00 0.00 28.51 15.50 Tinea versicolor 12.46 25.37 14.01 0.00 15.77 11.22 0.00 90.99 5.22 14.62 Gastritis 0.00 40.95 0.00 0.00 14.15 10.19 0.00 0.00 24.18 13.15 Otitis 0.00 5.01 42.92 12.94 11.62 15.82 0.00 0.00 23.32 12.68 Diabetic Retinitis 0.00 0.00 0.00 63.47 0.00 46.35 0.00 0.00 21.54 11.71 Vertebrogenic cervicocranialgia 0.00 16.60 28.25 0.00 5.86 26.40 0.00 20.17 15.51 11.05 COPD 0.00 0.00 0.00 53.09 13.11 0.00 0.00 0.00 18.01 9.80 Hypochromic anaemia 21.20 11.16 0.00 0.00 10.19 8.54 0.00 43.29 7.66 9.77 Chronic laryngitis 0.00 9.13 14.01 21.44 3.92 26.89 0.00 22.64 12.49 9.72 2nd degree hypertension 0.00 5.20 0.00 42.03 0.00 37.31 0.00 0.00 17.33 9.42 Fibromatosis of the uterus 0.00 5.20 34.01 0.00 0.00 33.85 0.00 0.00 15.73 8.55 Amblyopia 18.68 8.10 0.00 0.00 10.78 0.00 4.31 10.23 9.79 8.06 Diabetic polyneuropathy 0.00 0.00 0.00 42.03 0.00 30.69 0.00 0.00 14.26 7.75 Hepatitis 0.00 0.00 10.88 30.08 0.00 30.68 0.00 0.00 14.26 7.75 Myopic astigmatism 4.54 19.51 0.00 0.00 8.88 3.77 0.00 41.01 4.19 7.59 Vasomotor allergic rhinitis 0.00 6.07 0.00 30.24 0.00 29.80 0.00 7.22 12.12 7.53 Isolated systolic arterial hypertension 0.00 0.00 0.00 37.65 9.29 0.00 0.00 0.00 12.77 6.95 Iris coloboma 0.00 0.00 0.00 37.65 9.29 0.00 0.00 0.00 12.77 6.95 Psoriasis 0.00 20.75 0.00 0.00 6.76 6.37 15.46 0.00 2.96 6.66 Dyssomnia 7.64 0.00 0.00 21.44 2.98 15.66 0.00 0.00 11.38 6.19 Stomach cancer 0.00 0.00 0.00 30.08 0.00 21.97 0.00 0.00 10.21 5.55 Posttraumatic plexopathy 0.00 16.24 0.00 0.00 6.98 0.00 15.96 0.00 0.00 5.21 Tuberculosis of the lung 5.85 10.44 0.00 0.00 6.77 0.00 0.00 25.87 3.14 5.06 Varicose dermatitis 0.00 15.74 0.00 0.00 6.76 0.00 0.00 0.00 9.29 5.05 Source: Luhansk Clinic of the Ministry of Internal Affairs, September 2012 (calculations by GfK Ukraine)

13 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Hospital Visits older in age. In addition, 22 per cent said that they were not Of the surveyed miners, 48 per cent received treatment ill during the last 12 months (27 per cent of underground at a public hospital during last 12 months (not including workers and 9 per cent of aboveground workers) and for dental issues or preventive medical exams). About 14 only 3 per cent did not get treatment even though they per cent received treatment at their enterprise’s medical knew that they needed it. The survey also showed that centre, 3 per cent at a private hospital, 2 per cent at a miners used medical products and treatments based on public hospital in another city, and 1 per cent at a private the advice of doctors (22%), pharmacists (15%), relatives hospital in another city. It is notable that this rate of or acquaintances (9%), and folk remedies (8%). Miners hospital visits among underground and aboveground classified in Health Group III and aboveground workers workers is similar, even though the latter group is much were more inclined to exercise self-treatment.

Table 3. Survey data in response to the question, “Which of the following methods of treatment have you used over the last 12 months apart from dental issues and preventive examinations?”

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker You visited a public hospital in your city 46% 52% 43% 49% 38% 63% 46% 39% 50% 48% You exercised self-treatment using medical products advised by a doctor during your 18% 31% 14% 23% 22% 31% 18% 18% 24% 22% previous visit You exercised self-treatment using medical products advised by a pharmacist at 11% 28% 15% 15% 23% 8% 12% 20% 16% 15% a drugstore You visited the medical centre of your 10% 26% 10% 8% 16% 27% 13% 11% 15% 14% enterprise You exercised self-treatment using medical products advised by relatives, friends, or 6% 16% 8% 9% 14% 3% 6% 13% 9% 9% other informational sources You exercised self-treatment using folk 5% 17% 8% 7% 15% 3% 5% 11% 9% 8% remedies You visited a private hospital in your city 2% 4% 3% 2% 1% 5% 2% 1% 3% 3% You consulted a folk healer 3% 0% 2% 3% 3% 0% 3% 5% 1% 2% You visited a public hospital in another city 1% 2% 3% 0% 1% 2% 0% 4% 2% 2% You visited a private hospital in another city 0% 5% 0% 1% 1% 5% 0% 2% 2% 1% You were not ill 27% 9% 26% 25% 16% 18% 30% 16% 19% 22% You were not treated 2% 5% 2% 1% 3% 6% 1% 2% 4% 3% Source: GfK Ukraine survey

The following table shows the breakdown of miners who have received outpatient or inpatient hospital care.

Table 4. Survey data in response to the question, “Have you been treated in the past 12 months?” (per cent of miners who received treatment as an outpatient and/or impatient)

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker

Only as an outpatient 63% 59% 76% 69% 66% 33% 81% 46% 56% 62% Both as an outpatient 21% 21% 10% 16% 23% 37% 3% 34% 27% 21% and an inpatient Only as an inpatient 16% 20% 14% 15% 11% 30% 16% 20% 17% 17% Source: GfK Ukraine survey

Aside from general practitioners, miners most commonly receive treatment from otolaryngologists (8%), traumatologists (7%) and neurologists (7%).

14 Health data on miners

Table 5. Survey data in response to the question, “What doctors or other healthcare professionals have you visited in the past 12 months apart from dental issues and preventive examinations?”

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker

General practitioner 28% 26% 18% 27% 31% 38% 18% 29% 33% 27% Otolaryngologist 7% 10% 6% 8% 6% 10% 6% 8% 9% 8% Traumatologist 8% 2% 5% 7% 8% 7% 5% 8% 8% 7% Neurologist 5% 10% 5% 7% 8% 8% 5% 6% 8% 7% Surgeon 5% 4% 3% 5% 3% 12% 4% 6% 6% 5% Oculist 3% 11% 2% 3% 9% 10% 2% 5% 7% 5% Urologist 2% 8% 3% 4% 1% 8% 1% 2% 5% 4% Gastroenterologist 1% 6% 0% 1% 4% 5% 1% 1% 3% 2% Cardiologist 0% 8% 1% 1% 0% 9% 1% 1% 3% 2% Dermatologist 2% 2% 1% 2% 0% 6% 2% 2% 2% 2% Gynecologist 0% 7% 1% 0% 3% 5% 0% 2% 2% 2% Endocrinologist 0% 6% 0% 1% 0% 6% 0% 0% 3% 1% Pulmonologist 0% 5% 0% 0% 0% 6% 0% 0% 2% 1% Allergologist 0% 3% 0% 1% 0% 4% 0% % 2% 1% Rheumatologist 0% 3% 0% 2% 2% 0% 1% 1% 1% 1% Psychiatrist 1% 0% 1% 0% 0% 3% 1% 0% 1% 1% Proctologist 0% 2% 0% 0% 0% 3% 0% 0% 1% 1% Occupational Physician 0% 2% 0% 0% 0% 2% 0% 0% 1% 0% Oncologist 0% 1% 0% 0% 1% 0% 0% 0% 0% 0% Narcologist 0% 0% 1% 0% 0% 0% 1% 0% 0% 0% Infection disease doctor 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% Haematologist 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Venereologist 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Sexologist, sexual pathologist 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Other 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% No Answer 8% 3% 18% 6% 0% 0% 15% 3% 3% 7% Source: GfK Ukraine survey, September 2012

Smoking Fifty-three per cent of miners smoke, about the same rate as the average of Ukrainian men aged 18‑59.19 According to the medical exams, 39 per cent of smokers suffer from bronchitis in comparison to 26 per cent of non-smokers.

Table 6. Survey data in response to the question, “How many cigarettes do you smoke per day?”

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker

Under 5 4% 4% 9% 4% 1% 0% 8% 3% 2% 4% 5-10 23% 8% 22% 25% 16% 9% 22% 24% 16% 19% 11-20 32% 9% 28% 27% 27% 20% 27% 25% 25% 26% 21-40 5% 2% 1% 5% 8% 4% 0% 0% 8% 4% More than 40 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% I do not smoke 36% 77% 39% 39% 48% 67% 42% 47% 49% 46% Source: GfK Ukraine survey, September 2012

15 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Health Groups Table 7. Classification by health groups Physicians of the Luhansk Clinic of the Ministry of Internal Health group

Affairs analysed the results of the medical exams and І ІІ ІІІ classified the miners into one of three health groups: Gender Males 36% 13% 51% • Health Group I: The first group includes persons Females 17% 13% 70% in good health, who do not have any chronic diseases, complaints about their health, or history of Age 18-30 62% 16% 22% dysfunctional organs and systems. 31-40 34% 16% 50% • Health Group II: The second group includes per- 41-50 18% 15% 67% sons who have no appreciable diseases but have 51+ 0% 2% 98% had an acute or chronic disease in the past. Category Underground workers 37% 14% 49% • Health Group III: The third group includes persons Aboveground workers 19% 11% 69% with chronic diseases, who require systematic Work experience Under 5 years 54% 16% 30% medical observation. 6-10 years 33% 7% 60% According to the weighted results of the medical 11-15 years 23% 20% 58% exams, 33 per cent of miners were classified into 16 year and over 18% 11% 71% Health Group I, 13 per cent into Health Group II, and Total 33% 13% 54% 54 per cent into Health Group III. Source: GfK Ukraine, September 2012

16 Safety data on Miners

Falling objects 1.59 1.77 1.00 1.41 1.14 4. Safety data on Miners Falls 1.34 1.65 2.42 1.35 1.08 Underground transport 0.79 1.04 0.65 0.47 0.60 4.1 Key Findings Cardio vascular insufficiency (CVI) 0.00 0.06 0.00 0.06 0.06 Drilling and blasting operations 0.00 0.06 0.00 0.00 0.00 • The rates of occupational injuries have decreased (DBO) at all three enterprises since 2007: by 66 per cent Gassing 0.00 0.00 0.00 0.00 0.00 at Krasnodonugol, 21 per cent at Rovenkiantratsit, Electrocution 0.06 0.00 0.00 0.06 0.00 and 20 per cent at Sverdlovantratsit. Effects of elevated temperatures 0.00 0.00 0.00 0.00 0.00 • In 2011, the national average for occupational inju- Other 0.67 0.12 0.47 0.18 0.30 TOTAL 9.59 9.94 9.22 7.64 7.63 ries of miners was 9.3 per 1,000 miners. During the Source: DTEK and Metinvest (calculations by GfK Ukraine) same period, Krasnodonugol, Rovenkiantratsit and Sverdlovantratsit reported 6.87, 12.98, and 7.63 oc- According to a GfK Ukraine survey, 2.6 per cent, or 26 per 1,000 cupational injuries per 1,000 miners, respectively. miners, at Rovenkiantratsit and Sverdlovantratsit reported an occupational injury during the last 12 months. However, the • In Rovenky and Sverdlovsk, the most common real number of injured persons could be lower due to sampling musculoskeletal conditions of miners are osteo- errors. Approximately the same number of underground and chondrosis (68 per 1,000 miners) and lower back aboveground workers (2.6% and 2.5% respectively) reported pain (42 per 1,000 miners). an occupational injury during last 12 months. • Even though 50 per cent of miners are satisfied with As for the number of occupational casualties, only their working conditions, 75 per cent of miners are Sverdlovantratsit has experienced a decreasing trend worried about the possibility of work-related accidents. in this regard (from 0.18 per 1,000 miners in 2007-2009 to • Most miners in Rovenky and Sverdlovsk (59%) be- 0.12 per 1,000 miners in 2010-2011). At Krasnodonugol, lieve it is impossible to complete their work (e.g., this rate slightly increased in 2011 due to a mining meeting coal extraction quotas) without deviating accident in July. Likewise at Rovenkiantratsit, the rate has from safety and health rules. fluctuated over the past five years. In comparison, the average rate of casualties in the mining industry in 2011 4.2 Safety Data on Miners was 0.34 per 1,000 employees.21 In 2011, the rate of occupational injuries was 6.87 per 1,000 miners at Krasnodonugol, 12.98 per 1,000 min- Table 9. Factors of occupation-related casualties at Krasnodonugol, ers at Rovenkiantratsit, and 7.63 per 1,000 miners at Rovenkiantratsit and Sverdlovantratsit (per 1,000 employees) Sverdlovantratsit, according to statistics from DTEK and Krasnodonugol 2007 2008 2009 2010 2011 Metinvest. In comparison, the average rate of occupa- TOTAL 0.46 0.49 0.23 0.30 1.44 Rovenkiantratsit 2007 2008 2009 2010 2011 tional injuries in Ukraine’s mining industry was 9.3 per Landslides and collapses 0.09 0.15 0.00 0.05 0.15 20 1,000 miners. Furthermore, the rates of occupational Underground transport 0.05 0.00 0.05 0.00 0.05 injuries have decreased at all three enterprises since Machine-related 0.09 0.10 0.05 0.00 0.05 2007: by 66 per cent at Krasnodonugol, 21 per cent at Cardio vascular insufficiency (CVI) 0.05 0.20 0.00 0.00 0.05 Rovenkiantratsit, and 20 per cent at Sverdlovantratsit. Falls 0.00 0.00 0.00 0.00 0.00 Falling objects 0.00 0.00 0.00 0.00 0.00 Table 8. Factors of occupational injuries at Krasnodonugol, Drilling and blasting operations 0.00 0.00 0.00 0.00 0.00 Rovenkiantratsit and Sverdlovantratsit (per 1,000 employees) (DBO) Gassing 0.00 0.05 0.00 0.00 0.00 Krasnodonugol 2007 2008 2009 2010 2011 Electrocution 0.00 0.00 0.00 0.00 0.00 TOTAL 15.52 10.95 8.33 7.22 6.87 Effects of elevated temperatures 0.00 0.05 0.00 0.00 0.00 Rovenkiantratsit 2007 2008 2009 2010 2011 Other 0.00 0.00 0.00 0.20 0.00 Landslides and collapses 5.13 5.44 6.02 5.75 3.32 TOTAL 0.28 0.54 0.10 0.25 0.29 Falls 2.49 4.26 2.54 3.12 2.44 Sverdlovantratsit 2007 2008 2009 2010 2011 Falling objects 1.43 2.08 2.15 1.83 1.71 Machine-related 0.06 0.00 0.06 0.00 0.06 Machine-related 0.46 0.84 0.54 0.84 0.39 Cardio vascular insufficiency (CVI) 0.00 0.06 0.00 0.06 0.06 Underground transport 0.88 0.20 0.44 0.30 0.34 Underground transport 0.06 0.06 0.12 0.00 0.00 Drilling and blasting operations 0.00 0.00 0.24 0.00 0.10 Falls 0.00 0.00 0.00 0.00 0.00 (DBO) Falling objects 0.00 0.00 0.00 0.00 0.00 Gassing 0.00 0.15 0.00 0.00 0.00 Drilling and blasting operations 0.00 0.06 0.00 0.00 0.00 Electrocution 0.00 0.00 0.05 0.05 0.00 (DBO) Effects of elevated temperatures 0.00 0.00 0.00 0.00 0.00 Landslides and collapses 0.06 0.00 0.00 0.06 0.00 Cardio vascular insufficiency (CVI) 0.00 0.00 0.00 0.00 0.00 Gassing 0.00 0.00 0.00 0.00 0.00 Other 6.14 7.28 5.09 4.76 4.69 Electrocution 0.00 0.00 0.00 0.00 0.00 TOTAL 16.53 20.24 17.08 16.65 12.98 Effects of elevated temperatures 0.00 0.00 0.00 0.00 0.00 Sverdlovantratsit 2007 2008 2009 2010 2011 Other 0.00 0.00 0.00 0.00 0.00 Landslides and collapses 3.54 3.66 3.01 1.88 3.06 TOTAL 0.18 0.18 0.18 0.12 0.12 Machine-related 1.59 1.59 1.65 2.23 1.38 Source: DTEK and Metinvest (calculations by GfK Ukraine)

17 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine at their enterprise (34%), acquaintances and relatives 5. OPINION SURVEYS OF (27%), pharmacists (23%), and the Internet (10%). MINERS FROM ROVENKY • Miners’ families and pharmacists play an important role in the health and wellbeing of miners. At AND SVERDLOVSK least 15 per cent of miners use medical products advised by a pharmacist, 9 per cent use medical 5.1 Key Findings from Rovenky and Sverdlovsk products advised by family members or acquaintances, and 8 per cent use folk remedies. Health Issues • Miners are rather optimistic about their heath: 61 Safety Issues per cent are satisfied with it even though 54 per • About half of all miners are satisfied with safety con- cent are classified in Health Group III. In fact, only 8 ditions at the workplace, 11 per cent are dissatisfied, per cent are dissatisfied with their health. and 40 per cent are satisfied only partially. Under- • Miners stated that their most common health ground workers show higher dissatisfaction with problems are backaches (289 per 1,000), сolds safety than aboveground workers (14% vs. 6%), (269 per 1,000), headaches (194 per 1,000), bron- while younger miners are more satisfied than their chitis (169 per 1,000) and myalgia (162 per 1,000). older counterparts regarding safety conditions. • At the same time, 70 per cent of miners worry that • Miners are generally satisfied with their working their health might deteriorate because of harmful conditions, but 75 per cent of miners (79% of under- working conditions, and 46 per cent worry that ground workers and 65% of aboveground workers) it might deteriorate because of unhealthy habits worry that occupational injuries might happen. (e.g., smoking, alcohol consumption). • Most miners recognise their enterprises’ efforts to • A large number of respondents prefer self-treatment improve occupational safety; only 19 per cent think or to do nothing in treating some of their health is- that existing measures are not effective enough. sues. For example, only 64 per cent of respondents • The vast majority of miners (69%), especially un- consulted a doctor to treat bronchitis, 44 per cent for derground workers, believe that improving work- backaches, and 40 per cent for sore throats over the ers’ safety requires tightening control over mainte- last 12 months (August 2011-August 2012). nance of equipment and carrying out timely main- • Fifty-nine per cent of miners (63% of underground tenance and replacement of equipment. workers and 47% among aboveground workers) 5.2 Miners’ Opinions on Health consider that the health care system in their city According to the results of the survey, miners satisfies their needs. stated that their most common health problems • Eighteen per cent of miners are unsatisfied with are backaches (289 per 1,000), сolds (269 per 1,000), the quality of medical care, 16 per cent with incon- headaches (194 per 1,000), bronchitis (169 per 1,000) venient schedules of medical institutions, 15 per and myalgia (162 per 1,000). Of the respondents, cent with expensive medicines, and 12 per cent 22 per cent of miners recognised that they suffered with expensive medical services. from respiratory diseases during the last 12 months • For the most part, miners consult doctors for their health and 4 per cent recognised that they suffered from problems (64%). They also consult health professionals circulatory diseases.

Table 10. Survey data in response to the question, “What diseases have you experienced in the last 12 months?” (per 1,000 miners)

Age Category Health group

Underground Aboveground 18-30 31-40 41-50 51+ І ІІ ІІІ Total worker worker

Backache 175.92 278.07 502.62 254.27 272.98 337.51 225.30 388.40 304.10 289.28 Cold 331.94 276.25 334.79 86.53 270.72 265.35 293.60 274.70 253.50 269.36 Headache 121.42 180.41 324.96 194.12 134.76 373.05 103.20 252.50 236.40 194.96 Bronchitis 103.41 147.80 199.00 277.48 164.93 181.54 118.10 168.90 199.80 169.12 Myalgia 85.30 117.89 246.72 269.44 125.92 270.32 139.10 184.40 171.10 162.40 Painful joints (rheumatism) 26.92 118.08 226.43 316.18 114.85 253.70 87.80 156.40 185.70 149.93 Feeling of fatigue and tiredness 86.58 183.69 257.34 71.92 152.03 142.45 94.30 91.30 196.70 149.61 Toothache 143.31 163.16 156.17 85.51 150.24 116.13 155.00 136.70 134.80 141.62 Heartburn 142.78 148.09 96.88 117.26 131.25 128.24 95.80 188.00 137.60 130.49

18 Opinion surveys of miners

Age Category Health group

Underground Aboveground 18-30 31-40 41-50 51+ І ІІ ІІІ Total worker worker

Injuries (outside of work) 165.62 77.59 151.72 125.01 167.05 8.71 146.90 84.50 125.20 127.05 Herpes 81.02 143.47 165.98 30.24 91.01 161.81 77.60 161.50 115.20 108.90 Sore throat 166.95 123.60 94.00 0.00 109.39 101.80 134.20 133.80 85.20 107.47 Flu 80.31 120.31 175.29 47.86 118.70 69.96 72.10 163.80 113.30 106.39 Angina 64.95 136.17 53.15 82.13 87.38 92.21 96.80 97.00 81.70 88.60 Eye diseases 24.92 37.25 131.84 160.32 64.09 109.25 3.10 110.40 110.70 75.50 Chronic respiratory diseases 0.00 43.98 49.21 238.83 56.42 102.83 15.20 40.30 106.60 68.14 Hypertension (high blood pressure) 6.92 35.52 65.17 193.41 15.89 199.58 15.30 79.10 86.50 62.30 Heartache 5.67 81.20 74.84 69.79 21.33 157.57 18.60 56.80 77.80 55.75 Chronic rhinitis 57.87 44.38 28.72 72.27 32.25 103.69 26.90 50.40 64.30 50.30 Diarrhea 42.28 26.69 45.64 104.15 44.41 64.03 45.90 52.40 50.80 49.37 Maxillary sinus 47.27 68.65 52.30 0.00 52.07 29.74 73.10 87.40 20.60 46.43 Insomnia 57.58 23.10 70.95 42.03 37.25 73.24 22.20 69.50 55.30 46.34 Allergy 13.76 41.28 59.57 91.24 15.80 135.97 0.00 65.00 69.40 46.16 Digestive disorder 22.96 36.68 10.88 134.23 36.17 72.89 6.20 45.80 68.90 45.45 Skin diseases 21.85 38.98 99.37 21.94 44.20 39.67 65.90 18.20 35.20 43.05 Overweight 6.84 50.64 29.73 89.89 12.16 125.78 15.20 20.20 61.20 40.86 Prostate diseases 16.00 45.59 20.87 90.23 40.23 40.04 18.00 61.90 48.40 40.18 Kidney stones 14.21 53.77 42.40 47.86 25.38 78.60 0.00 71.60 54.40 38.83 Nervous disorder, depression 35.82 24.83 52.86 42.03 29.24 59.51 12.10 21.40 55.50 36.89 Gastritis 4.37 23.87 71.93 47.86 20.17 68.27 19.20 7.40 46.10 32.33 Varix dilatation 13.55 10.72 40.15 69.79 11.86 77.32 0.00 11.40 49.50 28.40 Cardiovascular diseases 0.00 6.06 10.88 129.99 11.06 78.61 0.00 0.00 51.70 28.13 Occupational injuries 8.28 53.98 0.00 34.39 26.43 25.11 23.40 19.50 29.30 26.09 Pancreatic diseases 0.00 23.69 62.29 30.08 11.43 68.16 0.00 18.80 42.90 25.76 Pneumonia 0.00 10.72 100.51 0.00 26.11 16.90 29.70 33.00 18.00 23.78 Gastric ulcer or duodenal ulcer 0.00 13.63 23.83 43.03 9.12 40.85 7.50 0.00 27.00 17.14 Hearing loss 2.86 0.00 36.17 47.86 7.78 44.21 15.20 6.50 20.50 16.99 Vibration disease 0.00 18.46 14.01 42.03 7.93 41.92 0.00 0.00 30.40 16.52 Liver disease 0.00 11.00 32.14 30.08 12.07 25.98 7.70 0.00 24.00 15.59 Pneumofibrosis 0.00 0.00 38.56 42.03 10.44 30.69 15.20 0.00 19.50 15.56 Potency disorder 20.24 0.00 9.17 42.03 7.91 38.04 11.30 0.00 21.80 15.52 Atherosclerosis 0.00 0.00 10.88 69.79 0.00 59.68 0.00 0.00 27.70 15.08 Thyroid gland diseases 4.54 16.24 32.31 0.00 5.72 34.85 0.00 10.70 21.50 13.08 Diabetes 0.00 0.00 0.00 63.47 0.00 46.35 0.00 0.00 21.50 11.71 Memory impairment 0.00 0.00 14.01 47.86 0.00 46.17 0.00 0.00 21.50 11.66 Constipation 4.29 9.36 14.57 21.94 3.94 32.87 4.90 16.00 13.90 11.25 Psoriasis 0.00 25.70 14.01 0.00 8.89 17.59 20.30 0.00 8.20 11.09 Neurological disorders 3.42 9.82 25.79 0.00 1.34 33.13 8.70 19.20 7.50 9.37 Oral diseases 15.51 14.62 0.00 0.00 5.42 20.47 5.70 11.40 10.80 9.22 Shoulder joint periarthritis 0.00 4.99 36.17 0.00 6.66 15.61 15.20 0.00 7.30 8.92 Gallstone disease 3.33 4.91 28.97 0.00 7.84 10.09 3.00 0.00 13.70 8.41 Hypotension (low blood pressure) 0.00 17.35 8.20 0.00 3.48 18.33 9.10 12.80 4.80 7.23 Chronic obstructive lung disease 0.00 0.00 0.00 37.65 9.29 0.00 0.00 0.00 12.80 6.95 Asthma 0.00 3.48 25.73 0.00 3.78 13.85 0.00 0.00 11.60 6.32 Cystitis 5.12 4.86 0.00 0.00 2.00 6.18 0.00 0.00 5.60 3.05 Coxarthrosis (hip joint arthrosis) 0.00 0.00 12.05 0.00 3.26 0.00 0.00 18.80 0.00 2.44 Migraine 4.83 0.00 0.00 0.00 1.89 0.00 0.00 10.90 0.00 1.41 Tuberculosis 4.78 0.00 0.00 0.00 1.87 0.00 4.30 0.00 0.00 1.40 Source: GfK Ukraine survey, September 2012

19 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Miners were also asked whether they have chronic Miners are rather optimistic about their heath: 61 per cent diseases connected with their professional activities. are satisfied with it even though 54 per cent are classified Twenty-five per cent of respondents believed that they in Health Group III. In fact, only 8 per cent are dissatisfied did, but only 13 per cent had been officially diagnosed with their health. Aboveground workers are less satisfied by a doctor. Another 8 per cent of respondents with their health, possibly since they are older on average thought that doctors did not want to confirm their and thus more susceptible to illness and poor health. diagnosis on an official basis. Only 17 per cent of At the same time, 70 per cent of miners worry that their health miners recognised that they suffered from bronchitis, might deteriorate because of harmful working conditions, even though medical exams showed that 33 per cent and 46 per cent worry that it might deteriorate because of of miners actually suffered from bronchitis. unhealthy habits (e.g., smoking, alcohol consumption).

Table 11. Survey data in response to the question, “Do you have any chronic diseases connected with your professional activities?” Category Age Health group

Underground Aboveground Total 18-30 31-40 41-50 51+ I II III worker worker

No 76% 75% 95% 77% 66% 52% 90% 80% 65% 75% I believe I do, but doctors have not confirmed 8% 9% 1% 7% 9% 22% 3% 6% 12% 8% my diagnosis officially Officially diagnosed: Bronchitis 9% 4% 2% 8% 7% 16% 3% 6% 11% 8% Officially diagnosed: Other 5% 4% 1% 2% 9% 11% 2% 5% 7% 5% The diagnosis has been confirmed 2% 8% 0% 6% 9% 0% 2% 3% 5% 4% Source: GfK Ukraine survey, September 2012

Table 12. Survey data in response to the statement, “How satisfied are you with your health?”

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker

Completely satisfied 42% 19% 60% 35% 27% 10% 58% 29% 24% 36% Rather satisfied 27% 19% 29% 26% 14% 27% 24% 32% 23% 25% Somewhat satisfied, somewhat dissatisfied 27% 41% 11% 35% 45% 39% 16% 39% 38% 31% Rather dissatisfied 3% 10% 0% 4% 10% 10% 2% 0% 8% 5% Completely dissatisfied 1% 11% 0% 0% 4% 14% 0% 1% 6% 3% Source: GfK Ukraine survey, September 2012

Table 13. Survey data in response to the question, “Do you agree with the statements given below?”

Category Age Health group

Under- Above Total ground ground 18-30 31-40 41-50 51+ I II III worker worker

You worry that your health might deteriorate because of harmful 72% 63% 69% 74% 75% 58% 65% 63% 74% 70% working conditions You worry that your health might deteriorate because of your 50% 36% 52% 49% 42% 36% 51% 44% 44% 46% harmful habits (smoking, alcohol, etc.) You often feel unwell, experience low energy level, attacks of 17% 36% 2% 21% 31% 44% 9% 22% 30% 22% chronic diseases, etc. that do not require a sickness certificate You often suffer from stress, anxiety, depression 10% 23% 3% 16% 18% 20% 4% 20% 18% 14% You often drink more than 50 g of strong alcoholic beverages or 9% 2% 6% 8% 13% 0% 8% 2% 7% 7% half a litre of beer a day You often have to get a sickness certificate because of different 2% 12% 2% 1% 7% 12% 2% 3% 7% 5% diseases, injuries Source: GfK Ukraine survey, September 2012

20 Opinion surveys of miners

A large number of respondents prefer self-treatment Eighteen per cent of miners are unsatisfied with the quality or to do nothing in treating some of their health of medical care, 16 per cent with inconvenient schedules issues. For example, only 64 per cent of respondents of medical institutions, 15 per cent with expensive medi consulted a doctor to treat bronchitis, 44 per cent cines, and 12 per cent with expensive medical services. for backaches, and 40 per cent for sore throats over Despite complaints about the quality of health care, the last 12 months (August 2011-August 2012). most miners evaluated the work of their doctors pos- Fifty-nine per cent of miners (63% of underground itively: 58 per cent were satisfied and only 7 per cent workers and 47% among aboveground workers) were dissatisfied. Most of those who were dissatisfied consider that the health care system in their city complained that the treatment was ineffective and satisfies their needs. that it was too expensive.

Table 14. Survey data in response to the question, “What conditions of chronic diseases have you experienced in the last 12 months (since August 2011), and how would you describe your usual behaviour when these problems arise?” (per cent of those who suffered from described disease) I prefer self-treatment I prefer self-treatment and I do nothing I prefer I consult a because I’ve already con- buy medical substances and wait for self-treatment professional sulted a doctor about this according to friends’ ad- the disease to or treatment by doctor im- problem and know what vice, information from ads, disappear on a healer using mediately they prescribe Internet, etc. its own folk remedies Toothache 67% 13% 8% 5% 7% Bronchitis 64% 11% 10% 14% 2% Backache 44% 21% 9% 18% 8% Sore throat 40% 28% 20% 4% 7% Myalgia 33% 19% 21% 20% 7% Cold 27% 37% 27% 7% 2% Headache 25% 20% 37% 14% 4% Feeling of fatigue and tiredness 12% 5% 25% 53% 5% Heartburn 6% 35% 31% 21% 6% Source: GfK Ukraine survey, September 2012

Table 15. Survey data in response to the question, “Does the existing healthcare system in your city satisfy your needs?” Category Age Health group Total Underground worker Aboveground worker 18-30 31-40 41-50 51+ I II III Yes 63% 47% 65% 52% 56% 66% 64% 52% 58% 59% No 37% 53% 35% 48% 44% 34% 36% 48% 42% 41% Source: GfK Ukraine survey, September 2012

Table 16. Survey data in response to the question, “Why does the existing network of medical institutions in your city not satisfy your medical needs?” Category Age Health group

Underground Aboveground Total 18-30 31-40 41-50 51+ I II III worker worker Low quality of medical care 16% 22% 16% 22% 21% 8% 13% 25% 18% 18% It is difficult to get an appointment because of 14% 23% 14% 18% 22% 9% 19% 13% 15% 16% queues, inconvenient schedule Medicines are expensive 14% 18% 14% 19% 18% 7% 14% 20% 14% 15% Medical services are expensive 11% 16% 10% 17% 15% 5% 11% 16% 12% 12% Doctors take bribes 4% 7% 1% 8% 6% 5% 5% 5% 5% 5% There is no required equipment 3% 2% 1% 4% 2% 6% % 10% 3% 3% There are not enough beds in in-patient hospitals 3% 1% 1% 3% 5% % 4% 4% % 2% There are no required specialists 1% 6% 1% 3% 1% 5% 2% % 3% 2% It is difficult or impossible to get necessary 1% 5% 2% 4% 2% % 4% 3% 1% 2% medicines in the city Other 4% 10% 5% 5% 2% 9% 5% 6% 5% 5% Source: GfK Ukraine survey, September 2012

21 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine For the most part, miners consult doctors for their health while younger miners are more satisfied than their problems (64%). They also consult health professionals older counterparts regarding safety conditions. at their enterprises (34%), acquaintances and relatives (27%), pharmacists (23%), and the Internet (10%). Miners are generally satisfied with their working conditions, but 75 per cent of miners (79% of underground workers and 65% of aboveground 5.3 Miners’ Opinions on Safety workers) worry that occupational injuries might happen. About half of all miners are satisfied with safety conditions at the workplace, 11 per cent are Miners also responded to a series of statements describing dissatisfied, and 40 per cent are satisfied only partially. various safety issues on a scale from 1 (complete Underground workers show higher dissatisfaction disagreement) to 5 (complete agreement). GfK Ukraine with safety than aboveground workers (14% vs. 6%), then calculated averages based on these responses.

Table 17. Survey data in response to the question, “How satisfied are you with the medical care provided by the doctor you last visited in your city?” (per cent of respondents who visited a doctor in their city during last 12 months) Category Age Health group Total Underground worker Aboveground worker 18-30 31-40 41-50 51+ I II III Completely satisfied 38% 38% 29% 40% 28% 56% 35% 39% 40% 38% Rather satisfied 25% 9% 18% 31% 24% 5% 19% 19% 21% 20% Somewhat satisfied, somewhat dissatisfied 14% 32% 15% 9% 30% 29% 12% 29% 21% 19% Rather dissatisfied 5% 4% 5% 5% 11% 0% 4% 5% 6% 5% Completely dissatisfied 2% 4% 1% 3% 2% 3% 3% 0% 3% 2% Source: GfK Ukraine survey, September 2012

Table 18. Survey data in response to the question, “Whom do you ask advice from most, or what sources of information do you seek in case of health problems?” Category Age Health group

Underground Aboveground Total 18-30 31-40 41-50 51+ I II III worker worker Doctor in a hospital 65% 64% 65% 65% 55% 72% 65% 63% 64% 64% Doctor or nurse in a first-aid post of your company 34% 36% 36% 31% 36% 36% 28% 39% 37% 34% Friends, acquaintances, relatives 26% 30% 32% 31% 28% 14% 33% 41% 21% 27% Pharmacist/ chemist at the pharmacy 20% 34% 19% 29% 28% 16% 19% 29% 25% 23% Information from the Internet 9% 12% 6% 12% 16% 5% 10% 14% 9% 10% Press 1% 5% 2% 4% 2% 0% 3% 5% 1% 2% Information from TV 2% 1% 3% 1% 2% 0% 2% 3% 1% 2% Traditional healers, herbalists 1% 1% 2% 1% 1% 0% 2% 2% 0% 1% Information from radio 0% 0% 0% 1% 0% 0% 1% 0% 0% 0% Other 3% 0% 1% 2% 2% 6% 1% 6% 3% 3% Source: GfK Ukraine survey, September 2012

Table 19. Please assess how satisfied you are with the safety levels of your working conditions? Category Age Health Total Underground worker Aboveground worker 18-30 31-40 41-50 51+ I II III Completely satisfied 22% 24% 33% 16% 18% 21% 30% 17% 19% 22% Rather satisfied 28% 21% 31% 26% 21% 24% 25% 27% 27% 26% Somewhat satisfied, 37% 50% 27% 41% 50% 48% 32% 51% 42% 40% somewhat dissatisfied Rather dissatisfied 9% 2% 7% 10% 3% 5% 8% 2% 8% 7% Completely dissatisfied 5% 4% 1% 7% 7% 2% 6% 2% 4% 4% Source: GfK Ukraine survey, September 2012

Table 20. Survey data in response to the question, “Do you agree with the statement given below?” Category Age Health group

Underground Aboveground Total 18-30 31-40 41-50 51+ I II III workers workers Do you worry that there a job-related accident might 79% 65% 78% 77% 70% 73% 76% 69% 76% 75% happen? Source: GfK Ukraine survey, September 2012

22 Opinion surveys of miners

Table 21. Survey data in response to the question, “How much do you agree with the following statements about adherence to occupational safety and health (OSH) regulations at your enterprise? Write “1” if you completely disagree and “5” if you completely agree.” Category Age Health

Underground Aboveground Total 18-30 31-40 41-50 51+ I II III workers workers

Drills on OSH are carried out in a responsible manner. These drills not only explain how to adhere to OSH rules 4.3 4.4 4.4 4.5 4.0 4.5 4.3 4.4 4.4 4.4 but also why it is vital to

I understand the OSH goals, regulations, and methods of 4.3 4.4 4.4 4.2 4.2 4.7 4.4 4.2 4.3 4.3 their implementation

My manager helps me with choosing safer methods of 4.2 4.4 4.3 4.1 4.1 4.5 4.2 4.2 4.3 4.2 reaching production targets I can easily inform the management on a breach of occupational health and safety regulations if I become 4.0 4.2 4.0 3.9 4.0 4.4 4.0 4.1 4.1 4.1 aware of them OSH system at the enterprise enables me to get new 4.0 4.1 4.1 3.9 3.9 4.3 4.0 4.0 4.1 4.0 knowledge and skills Punishment for breaching OSH regulations is fair and 3.8 4.0 3.9 3.8 3.7 4.2 3.8 4.1 3.9 3.9 justified The enterprise provides opportunities for workers to 3.7 4.0 3.8 3.6 3.6 4.3 3.7 3.6 3.9 3.8 participate in improving the OSH system The enterprise’s health and safety procedures are too 3.6 4.0 3.9 3.8 3.4 3.8 3.7 3.5 3.8 3.7 strict The enterprise values health and safety of workers 3.4 3.7 3.8 3.1 3.2 4.0 3.5 3.5 3.5 3.5 higher than operating performance I am satisfied with the recognition (non-monetary) and commendation by the management, which I get for 3.3 3.5 3.5 3.2 3.0 4.0 3.2 3.1 3.5 3.4 adhering to OSH regulations Bonuses for adhering to OSH regulations are fair and 3.3 3.5 3.5 2.9 3.4 4.0 3.2 3.2 3.5 3.4 justified I am satisfied with material incentives I get for adhering 2.8 3.3 3.0 2.4 2.6 4.0 2.7 2.8 3.1 2.9 to OSH regulations Source: GfK Ukraine survey, September 2012

Table 22. Survey data in response to the question, “What are the main reasons for deviating from OSH standards when performing work functions?”

Category Age Health group Total Underground Aboveground 18-30 31-40 41-50 51+ I II III worker worker

If you follow all the safety standards, it is impossible to 65% 43% 64% 62% 57% 50% 58% 52% 62% 59% perform the tasks you are charged with Workers can ignore safety standards because of the 28% 16% 26% 28% 18% 27% 28% 21% 24% 25% desire to receive incentives for labor results Management requires implementation of work plans 25% 24% 17% 25% 35% 24% 20% 19% 29% 24% at any cost Existing measures are not effective enough and do not 15% 29% 14% 19% 12% 33% 17% 17% 20% 19% guarantee injuries are eliminated Too many requirements: it is not possible to memorize 20% 12% 26% 18% 15% 10% 20% 22% 16% 18% them all Reluctance to spend time and efforts on organizing 19% 13% 14% 18% 19% 20% 12% 32% 17% 17% work on a safety basis (laziness) Poor knowledge of the technological process 16% 12% 11% 13% 13% 25% 13% 14% 16% 15% Not enough attention is paid to occupational safety 7% 5% 9% 4% 1% 13% 7% 10% 6% 7% training Other 4% 3% 3% 3% 4% 8% 7% 3% 3% 4% Don’t know 5% 20% 7% 7% 12% 11% 8% 11% 9% 9% Source: GfK Ukraine survey, September 2012

23 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Most miners (59%), especially young underground in the table below to be good motivating factors to workers, believe it is impossible to complete their adhere to OSH rules. It is notable that bonuses for all daily work tasks (e.g., meeting coal extraction quotas) workers in a division are preferred motivating factors without deviating from occupational safety and health over individual bonuses. (OSH) safety rules. Most miners recognise the efforts of Sixty-nine per cent of miners, especially underground their enterprises in adhering to OSH standards; only 19 workers, believe that improving workers’ safety per cent think that existing measures are not effective requires tightening control over maintaining enough. The following table shows what miners think equipment in good condition and carrying out timely are the main reasons for deviating from OSH standards. maintenance and replacement of equipment. The The majority of respondents, both aboveground and following table shows what miners believe need to be underground workers, consider the incentives listed done to improve workers’ safety.

Table 23. Survey data in response to the question, “How does each of the following methods encourage you to personally adhere to OSH regulations? On a 5-point scale, write ‘1’ for ‘least encouraging’ and ‘5’ for ‘most encouraging.’” Category Age Health group Underground Aboveground Total 18-30 31-40 41-50 51+ I II III worker worker Travel accommodations to sanatoriums and health 4.1 4.6 4.2 4.2 4.3 4.2 4.3 4.2 4.2 4.2 resorts at discounted prices Fear of job loss, reduction in skill-category, re- 3.9 3.9 4.1 3.8 4.0 3.9 3.9 3.9 4.0 3.9 examination in safety regulations Full or partial payment of paid medical services 3.9 3.8 4.0 3.8 4.1 3.6 4.1 3.9 3.7 3.9 Denial of a personal bonus (workers are denied their 3.7 4.0 3.9 3.7 4.2 3.4 3.9 4.1 3.7 3.8 bonus if they do not adhere to OSH regulations) Bonus for all the workers of the division for advances in 3.6 3.7 3.7 3.4 3.6 3.8 3.7 3.5 3.6 3.6 the sphere of OSH Valuable presents for advances in OSH 3.6 3.5 3.9 3.4 3.8 3.4 3.6 3.4 3.6 3.6 Denial of a bonus for all the workers of the division for non-observance of OSH regulations through the fault of 3.2 3.5 3.1 3.1 3.6 3.3 2.9 3.6 3.4 3.3 one or several workers of the division Personal bonus for observing OSH regulations (the bonus 3.3 3.0 3.3 3.2 3.2 3.0 3.4 3.4 3.0 3.2 is received by workers themselves not by a division) Public recognition of one’s achievements in OSH, commendation by management in front of colleagues 3.1 3.6 3.3 3.2 3.1 3.1 3.2 3.0 3.2 3.2 (e.g., letters of commendation, awards, honours board, newspaper) Competition between divisions for achievements in the 2.9 3.2 3.2 2.9 2.9 3.1 3.0 2.8 3.1 3.0 sphere of OSH Letters to family members stating that a worker strictly 2.6 3.1 2.9 2.5 2.9 2.8 2.7 2.6 2.8 2.7 follows the regulations Letters to family members stating that a worker often 2.6 2.6 2.6 2.5 2.6 2.8 2.5 2.5 2.7 2.6 breaches the regulations Source: GfK Ukraine survey, September 2012

Table 24. Survey data in response to the question, “What needs to be done in the first place in order to improve workers’ safety?” Category Age Health group Underground Aboveground Total 18-30 31-40 41-50 51+ I II III worker worker To tighten control over maintenance of the equipment in good condition, carry out timely maintenance and 71% 64% 68% 64% 78% 70% 73% 55% 71% 69% replacement of the equipment To tighten control over maintenance of occupational 36% 34% 27% 48% 35% 27% 27% 43% 38% 35% safety and health regulations by workers To increase provision of information to workers on occupational safety and health regulations, measures 26% 34% 27% 31% 25% 29% 32% 27% 27% 28% aimed at teaching workers to follow the regulations To improve living conditions 16% 19% 15% 21% 14% 13% 13% 22% 17% 16% To increase the operating efficiency of rescue services 13% 10% 12% 14% 12% 8% 14% 10% 12% 12% To increase the operating efficiency of a resuscitation- 4% 9% 6% 6% 4% 5% 5% 3% 6% 5% antishock group To improve ventilation system 1% 1% 1% 3% 0% 0% 1% 4% 3% 1% To improve heating system 0% 0% 0% 0% 0% 0% 3% 0% 1% 0% Other (please explain) 4% 5% 5% 6% 4% 2% 0% 0% 0% 5% No answer 1% 3% 0% 1% 4% 0% 8% 5% 2% 1% Source: GfK Ukraine survey, September 2012

24 General recommendations

• Upgrade medical equipment and training for 6. General screening services and emergency care. recommendations • Nutritional policies and planning should balance traditional cuisine with nutrition guidelines outlined in the “Health of the Nation” (2002-2011), In general, the most prominent health and safety which was adopted by the Cabinet of Ministers in problems of miners are respiratory diseases, 2002, or with World Health Organization guidelines. cardiovascular diseases, occupational injuries (traumas), and musculoskeletal conditions. While the majority of • Sports and sports facilities should be included in miners expressed satisfaction with their health (61%) and health planning efforts. health care options (59%), most of them were diagnosed with a chronic disease (54%). Thus, the following Improving the Occupational Safety of Miners recommendations focus on prevention, diagnosis • During safety drills, ask miners to provide exam- and treatment of those diseases, as well as improving ples of how and when it is impossible for them emergency transportation and medical services. to follow OSH rules and regulation. Management should implement changes accordingly. Improving the Health of Miners • Ensure timely maintenance and replacement of • Train health workers to recognise and treat the most mining equipment. prevalent diseases among miners (i.e., respiratory • Consider bonuses for teams of workers who meet and cardiovascular diseases). Also train health work- specified OSH goals (according to survey data, miners ers who are most frequented by miners: general stated that they would be more interested in receiv- practitioners, otolaryngologists, trauma surgeons, ing bonuses as a group than on an individual basis). neurologists, pulmonologists and cardiologists. • Remind miners about the consequences of violat- • DTEK and Metinvest should maintain health data ing OSH rules, such as rates of injuries and casualties. of their employees in electronic databases as op- • Remind miners that they may be fired, be reassigned, posed to just keeping paper records. or be denied bonuses if they violate OSH rules. • Provide positive reinforcement for those who comply • Consider involving miners in setting realistic and with OSH rules and regulations. Consider monetary fair daily quotas for coal extraction. bonuses for meeting certain OSH goals and/or sup- • Include miners in selecting equipment. In one case, port more visits to sanatoriums and health resorts. miners complained that newly purchased goggles • Implement a public health campaign, including infor- (protective eyewear) were not compatible with their mation about smoking, alcohol, healthy eating and respirators. Thus, miners had to choose between exercise. The campaign should include information wearing their goggles or respirators while working. on preventing and treating cardiovascular diseases, • Of course, implementing these recommendations respiratory diseases and musculoskeletal conditions. depends on changes from both management and • Include pharmacists and miners’ spouses in discussions miners. True, lasting changes will require time, about miners’ health. commitment, and effort from both sides.

25 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine

Figure 2. Number of physicians per 10,000 people 7. Krasnodon action plan 35 32 30 23,04 7.1 Key Findings 25 23 • In Krasnodon, the top health problems of min- 20 ers are respiratory diseases, occupational injuries 15 (trauma), heart diseases and musculoskeletal conditions. Respiratory diseases account for 74% of all 10 reported occupational diseases (mechanic bron- 5 chitis — 46% and anthracosilicosis — 28%). 0 • From 2007-2011, occupational injuries at Krasnodon WHO Minimum Krasnodon Ukraine ugol have decreased by 66 per cent. • In 2011, Krasnodonugol endured 6.87 occupa- The following charts illustrate data regarding hospital tional injuries per 1,000 miners. In comparison, beds and hospitalisation rates in Krasnodon. the national average for occupational injuries was 9.3 per 1,000 miners, while neighbouring Figure 3. Hospital beds per 10,000 people Rovenkiantratsit and Sverdlovantratsit endured Figure 3. Hospital beds per 10,000 people 120 12.98 and 7.63 occupational injuries per 1,000 98,17 miners, respectively. 100 89,3 80 70,86

• Key stakeholders named the community’s top pri- 60 52,37 orities as the need to improve emergency trans- 40 portation and upgrade intensive care units. 20 0 2010 2011

7.2 Community Health Profile City Oblast Krasnodon, along with its seven neighbouring towns, Figure 4. Hospitalisation per 100 people has a combined population of 117,730 people, Figure 4. Hospitalisation per 100 people whereas the city itself has a population of 49,921 30 22 25 24,41 people. The city has eight healthcare institutions, 25 18,7 including five hospitals, a dental clinic, an ambulance 20 16,77 station, and an urban health centre. According to the 15 central hospital, the planned capacity for outpatient 10 care was 2,245 visits/ shift with an actual capacity of 5 1,933 visits/ shift. 0 2010 2011 City Oblast Table 25. Select data from Krasnodon’s central hospital

2010 2011 The following table shows the rate of registered Patients treated (number) 19,763 17,734 diseases per 1,000 inhabitants in Krasnodon.

Average length of stay (days) 11.80 11.38 Table 26. Rate of registered diseases per 1,000 inhabitants in Krasnodon Ambulance outpatients (number) 948,384 912,861 Group 2005 2006 2007 2008 2009 2010 2011 Infectious diseases (cases) 16,588 15,246 of diseases All diseases 1509 1558 1584 1690 1569 1728 1749 Diseases of As of January 2012, there were 242 physicians or the circulatory 769 790 799 823 826 841 860 23.04 per 10,000 people, with 164 vacancies for system doctors and 92 vacancies for nurses. While there is no Diseases of the respiratory 220 212 223 210 210 226 217 international standard for assessing the sufficiency system of a health workforce, the World Health Organization Diseases of the musculoskeletal estimates that countries with fewer than 23 healthcare 47 52 53 51 50 48 48 system and professionals (i.e., physicians, nurses and midwives) connective tissue per 10,000 people will be unlikely to achieve primary Diseases of the 10 12 10 10 10 10 11 healthcare interventions described by the UN nervous system Millennium Development Goals.23 Source: Lugansk Oblast Department of Health (calculations by GfK Ukraine)

26 Krasnodon action plan

7.3 Krasnodonugol of defibrillation happening in the first minute, gives a Krasnodonugol is the second largest coking coal survival rate of nearly 100 per cent, whereas the rate producer in Ukraine. It ships coking coal primarily drops to about 1 per cent after 10 minutes. to Avdiivka Coke and Azovstal Iron and Steel Works. Krasnodonugol has a goal of training all medical per- Krasnodonugol currently produces coking coal from sonnel (about 935 of them) in emergency cardiac and its underground mines, which are nearly 1,000 metres trauma care procedures. As of October 2011, Kras- deep at its deepest point, before processing the coal at nodonugol had trained about 109 of these medical its two on-site washing plants. In 2009 Krasnodonugol’s professionals. Krasnodonugol also aims to provide total coking coal output was 5.4 million tonnes. at least 8 hours of training to every single miner in first aid support (with defibrillators), advanced cardiac In 1914, Krasnodonugol started as a group of life support and advanced trauma life support, even Sorokino coal mines. These 25 coal mines united in though the industry standard is only 10 per cent. As 1935 to establish the Sorokinocoal trust. During its of October 2011, some 1,000 non-medical employees 93 years history (1914-2007) the company mined had received the one-day training. The company has about 370 million tonnes of coal. In 2007, mine a goal of under 5-minute response times for adminis- closures (and therefore lack of maintenance) led to tering first aid, dependable emergency communica- major environmental and geological problems. For tion, efficient medical transportation, and competent example, water accumulated in the mines quickly, medical personnel. causing flooding throughout the city. The inactive mines posed a significant disaster risk to Krasnodon. Occupational Health Krasnodonugol’s health clinics keep records of every Today, Krasnodonugol has been reinvigorated ever miner. These records contain information such as since it became part of the mining division of Metinvest. whether the miner is medically cleared to work under- Krasnodonugol is now one of the top 10 largest mining ground and past results of blood, hearing, dermatol- companies in Ukraine. The company consists of five coal ogy, fluorography, and electrocardiogram tests. There units, two coal preparation plants, and maintenance, are also recommendations for what kind of work each transport and energy divisions. The company has its miner is suited to doing in relation to his or her physical own medical service, as well as programmes on social health. These health clinics provide therapy, massag- development. Krasnodonugol employs about 15,500 es, and health services to around 200 miners per day. people in the mining and service departments. There are also underground health clinics, about 850 metres deep, which provide health care as necessary. Occupational Safety According to Krasnodonugol, the top five occupational Krasnodonugol was one of the first in Ukraine to health ailments of miners are respiratory diseases, introduce an international standard for the protection trauma, heart diseases, musculoskeletal conditions and safety of workers (OHSAS 18001). In order to and skin diseases. Respiratory diseases account for reduce occupational injuries, the company has an 74 per cent of all occupational diseases (mechanic occupational health and safety programme, which bronchitis—46% and anthracosilicosis—28%). includes training and funds to purchase personal protective equipment, control devices, and other Figure 5. Occupational diseases of miners from 2007-2011, safety equipment. Miners also are equipped with as reported by Krasnodonugol, June 2012 individual control devices to measure the levels of 160 145 140 methane in the mines. Each miner goes underground 135 120 with an oxygen can, which provides 1-4 hours of 121 100 100 98 oxygen depending on the person’s rate of breathing. 93 80 77 74 Miners are warned by phone, sounds, and lights in case 61 60 60 59 of an emergency. The underground health clinic has 42 40 29 38 33 been upgraded within the last year with modern first 26 20 18 13 18 11 8 13 8 aid kits, inflatable splints, plastic and steel stretchers, 0 5 6 2007 2008 2009 2010 2011 defibrillators, and other life-saving equipment. Mechanic Bronchitis Anthracosilicosis Radiculopathy (Nerve-Related) Vibration Diesease Other In 2010, the average emergency response time, or the time it took a doctor to arrive at the scene of an accident, was 31 minutes. The range of emergency Krasnodonugol sends miners to occupational health response time was between 5 and 90 minutes. centres if further medical analysis is needed. These visits Minimising response time is invaluable as the are paid by the company if the ailment is work-related. percentage of survival goes down dramatically with For non-professional diseases, each miner must pay for each passing minute. According to Metinvest, the start his health-related costs through social insurance.

27 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Figure 6. Cancer rates per 100,000 people 7.4 Priorities 326,9 302,8 Key stakeholders — miners, doctors, and government 300 318,7 311,8 officials — discussed the top health and safety 250 issues affecting miners. In particular, the group

200 discussed respiratory diseases, workplace trauma,

150 cardiovascular diseases, musculoskeletal conditions, and skin diseases as the top problems. Then, the 100 group listed five priority areas to address: pre-hospital 50 stage, primary prevention, transportation between 0 home and work, rehabilitation of injured miners, and 2010 2011 hygienic conditions in the mines. City Oblast 1. Pre-hospital stage (high priority) Figure 7. Tuberculosis rates per 100,000 people 2. Primary prevention (high priority)

120 108,6 3. Transportation between home and work (medium priority) 98,1 100 4. Rehabilitation of injured miners (medium priority) 82,5 79,9 80 5. Hygienic conditions in the mines (medium priority)

60 Among this list, the stakeholders stressed the importance 40 of improving pre-hospital stage and primary prevention

20 efforts. They further explained that that improved emergency response vehicles and intensive care units are es- 0 2010 2011 sential in light of recent coal mining accidents.

City Oblast Next Steps The city of Krasnodon and Krasnodonugol both pro- Health and Safety Efforts vide strong leadership to make things happen. Com- Krasnodon has several promising developments in bined with support from the central government improving its health and safety services. For example, the and international community, Krasnodon has an op- city provides scholarships to a number of its residents, portunity to improve pre-hospital stage and primary who study at Luhansk Medical University, in return for prevention efforts. The following is an outline of pro- a commitment from the students to return to their posed next steps: community as health practitioners upon graduation. Figure 8. Outline of proposed next steps As of January 2012, the programme was sponsoring 14 students and 6 interns at Luhansk Medical University, as Steps Responsible Parties well as 7 students who are enrolled in biomedical classes. 1. Review, adjust, and agree upon the action City of Krasnodon, The city also has a programme where it provides housing plan Metinvest, UNDP to young medical specialists. While the programme has 2. Engage the Luhansk Regional State Admin- UNDP not kicked off, it will provide 15 apartments for young istration, Ministry of Health, and other govern- medical professionals in the near future. ment bodies 3. Contact potential financial partners, such as UNDP At Krasnodonugol, the company has implemented the EU and neighbouring government donors a first aid training programme for its employees 4. Proceed with the implementation plan City of Krasnodon, UNDP with great success. As of June 2012, 825 employees (managers and team leaders) have received two-day 7.5 General Recommendations training courses and over 1,100 miners have received The following are general recommendations for the a one-day training course. While industry standards community to consider moving forward. Details for promote at least 10 per cent of its workforce to be the recommendations are described in more details in trained in first aid, Krasnodonugol is aiming for 100 the proceeding section. per cent of its miners to be trained. In addition, • While the city purchased a new ambulance in Jan- Krasnodonugol recently equipped its mines with uary 2011, the city could use an additional two modern immobilisation devices, automatic external modern ambulances to meet minimum emer- defibrillators, and other life-saving equipment. gency response standards (McSwain, N.E. (1991) These aforementioned developments provide a solid proposes 1 ambulance per 50,000 residents. Oth- foundation to develop further health and safety efforts. ers argue that this number should be closer to 1

28 Krasnodon action plan

ambulance per 10,000 residents. For Krasnodon, ambulance to service mining communities in the with a population over 100,000, the city should Luhansk oblast. have between 1 and 10 ambulances. And since Krasnodon recently received a new, modern am- 7.6 Action Items bulance, two additional ambulances would be a The following action items provide the framework for good starting point). the second phase of this project. These action items • The city should upgrade its medical equipment focus on pre-hospital care (i.e., ground ambulances, an (e.g., automated external defibrillators), particular- air ambulance, and intensive care units) and primary ly for its intensive care units. (preventative) health (i.e., health promotion and • The Krasnodon City Council should help keep disease prevention programming). and attract talented medical professionals by providing at least 15 apartments for young medi cal 7.6.1 Pre-Hospital Stage professionals. • In general, the city could use at least one additio 7.6.1.1 Ground Ambulances nal anaesthesiologist, two pediatricians, an urol- Background: Time is a critical factor in saving victims ogist, a surgeon, and two general practitioners. of cardiac arrest, trauma, and other life-threatening The Sukhodolskaya city polyclinic could also use at health conditions. For example, the survival rate from least one obstetrician and gynaecologist. The Kras- a cardiac arrest is nearly 100 per cent if defibrillation nodon City Council should consider these needs is started within the first minute of the incident. That within the context of their scholarship programme. rate drops to about 1 per cent after ten minutes. • Krasnodonskoye, or city hospital number 2, needs Equipping ambulances with automated external 20 nursing care beds. defibrillators (AEDs), oxygen supplies, ventilators, • Data on the health and safety of miners should be and electrocardiograms (ECGs) can literally mean the systematised into an electronic database. This will difference between life and death. make the data more robust, accessible and usable. Thus, community leaders stated a need to improve • Krasnodon should conduct a community-wide pub- its pre-hospital treatment, or emergency medical lic health campaign to promote healthy lifestyles. response before or during transportation of a patient to the hospital. Other than one fully equipped, • Krasnodonugol should simulate real-life situations modern ambulance acquired last year, 25 Krasnodon’s in its first aid trainings in both aboveground and ambulances are actually old, refurbished military underground contexts. The company should con- vehicles that lack life-saving medical equipment. sider doing the trainings more frequently and in Moreover, because of the depths of the mines and poor fewer hours. conditions of the roads, it may take up to 90 minutes • Pharmacists should be included in health strate- to get an injured miner from the bottom of a mine to gies since miners depend on them heavily. a hospital. If a patient needs to go to a special care • Likewise, miners’ spouses should be included in centre (e.g., burn unit) in Luhansk or Donetsk, it would health strategies since they play a functional role take about 1 hour and 3 hours, respectively. Having in the health of miners. fully equipped ambulances for these long rides would • Sports and sports facilities should be used as a be essential to sustain lives en route to the hospital. platform to support health planning efforts. Recommendation: The community’s rescue services • Nutritional policies and planning should balance would be greatly enhanced by adding two fully- traditional cuisine with nutrition guidelines out- equipped modern ambulances and upgrading lined in the “Health of the Nation” (2002-2011), existing ambulances with medical equipment. which was adopted by the Cabinet of Ministers in N.E. McSwain (1991) proposes 1 ambulance per 2002, or with World Health Organization guidelines. 50,000 residents, while others argue that this • Miners should have access to 2.0-2.5 litres of clean number should be closer to 1 ambulance per 10,000 drinking water every day, as recommended by the residents. For Krasnodon, with a population of over European Food Safety Authority (2.0 litres for wom- 100,000 people, this means there should be between 24 en and 2.5 litres for men). Water intake should be 1 and 10 ambulances. And since Krasnodon received staggered throughout the day, as even one per a new, modern ambulance in January 2011, two cent of loss in bodyweight due to fluid deficiency additional ambulances would be a good starting can impair a person’s ability to concentrate. point. In addition, old vehicles should be equipped • Metinvest, Krasnodonugol, and neighbouring with emergency medical supplies, including AEDs, communities should consider obtaining an air intravenous lines and fluids, essential medicines,

29 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine cervical collars, stretchers, spinal boards, first aid kits, • Work with procurement specialists to ensure le- radios and oxygen deployment kits. gal compliance and technical specifications of the In the future, the entire fleet of vehicles should be ambulances and equipment (Responsible Parties: replaced with fully-equipped, modern ambulanc- UNDP and Rescue Services) es. Moreover, according to international standards, • Conduct internationally competitive bidding pro- ambulances should have three-member crews, all of cess to ensure best value (Responsible Party: UNDP) whom have passed emergency medical technician (EMT) courses. Such a course usually lasts more than Activity Two: The second activity is to conduct cascade 3 weeks and at minimum, teaches how to adminis- trainings for using the newly acquired equipment. The ter cardiopulmonary resuscitation (CPR), pass a chest steps involved in this activity include: tube, and introduce an intravenous line. • Draft training agenda for members of the Res- cue Services unit (Responsible Parties: UNDP and Activity One: The first activity is to procure two ful- heads of Rescue Services) ly-equipped modern ambulances, as well as equip- • Train staff members of the Rescue Service to use new- ment to upgrade the existing fleet of ambulances. The ly acquired equipment (Responsible Party: UNDP) steps involved in this activity include: • Monitor, review, and adjust procedures as neces- • Review and revise the proposed procurement list sary (Responsible Party: Rescue Services) as necessary (Responsible Parties: UNDP, City of Table 27. Proposed procurement list to improve emergency transport Krasnodon, Rescue Services) (to be revised with Rescue Services unit) Item Description Quantity Unit Price Total

Ambulances Modern, fully-equipped ambulance will include defibrillator, intravenous lines and 2 $65,000 $130,000 fluids, stretcher, cervical collar, spinal board, first aid kits, oxygen kits, etc. Equipment to upgrade Automated external defibrillators (AEDs) 7 $1,500 $10,500 existing ambulances Intravenous lines and fluids 7 $1,000 $7,000 Cervical collars 7 $100 $700 Spinal boards 7 $300 $2,100 Stretchers 7 $300 $2,100 First aid kits (e.g., burn pack, bandages, dressings, gauze rolls, adhesive tape) 7 $200 $1,400 Two-way radios to be use between the dispatcher and emergency medical technician 7 $250 $1,750 Oxygen deployment kits 7 $400 $2,800 Misc. (e.g., stethoscope, thermometer, cold packs, disinfectant, blankets, gloves) 7 $250 $1,750 Total: $160,100

Table 28. Proposed fees for consultant to conduct cascade trainings doctors in Krasnodon, as well as guidelines set forth Item Description Quantity Unit Price Total by the World Health Organization.27 The list focuses on Consul Fees for 12-day consultation 12 $500 $6,000 medical equipment rather than everyday medicines tant Travel costs 1 $1,000 $1,000 (e.g., antiseptics) or protective clothing (e.g., gloves). Miscellaneous (e.g., 1 $1,500 $1,500 The final procurement list will be reviewed and adjust- internet, printing) Total: $8,500 ed with Krasnodon medical institutions. Activity One: The first activity is to procure medical 7.6.1.2 Intensive Care Units equipment for the hospitals in Krasnodon. The steps Background: The standardised death rate in Ukraine due involved in this activity include: to injuries is almost three times that of countries in the European Union.26 Thus, improving intensive care units • Review and revise the proposed list of medi- makes sense in an injury-prone mining community like cal equipment (Responsible Parties: UNDP and Krasnodon. In fact, coal mining traumas represent the Central Hospital) most prominent disaster risk in the area, yet Krasnodon • Work with Technical Advisor to ensure technical and neighbouring Sverdlovsk share a local trauma centre. compatibility of new equipment (Responsible Par- ties: UNDP and Central Hospital) Recommendation: The following list of proposed • Conduct internationally competitive bidding pro- trauma care equipment is based on discussions with cess to ensure best value (Responsible Party: UNDP)

30 Krasnodon action plan

• Work with procurement specialists to ensure le- Table 29. Proposed procurement list to enhance intensive care units in Krasnodon gal compliance and technical specifications of the Item Description Quantity Unit Price Total ambulances and equipment (Responsible Parties: Portable ultrasound machine Diagnoses traumas and illnesses (e.g., cardiovascular disease); UNDP and Rescue Services) 1 $50,000 $50,000 inclusive of supporting software costs • Conduct internationally competitive bidding pro- Electrocardiographs (ECG) Interprets electrical activity of the heart, including the presence of 5 $1,000 $5,000 cess to ensure best value (Responsible Party: UNDP) any damage Heart monitors Tracks heart functions and alerts staff to any sudden changes in 3 $5,000 $15,000 Activity Two: The second activity is to conduct cascade vital heart functioning trainings for using the newly acquired equipment. The Defibrillators Electric-shock, life-saving apparatus for victims of heart attacks, for 3 $3,000 $9,000 steps involved in this activity include: patients in intensive care • Draft training agenda for members of the Res- Portable x-ray machines Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 cue Services unit (Responsible Parties: UNDP and Fluorography machine Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 Crash carts Serves in emergency situations with defibrillator, pulse oximeter, heads of Rescue Services) 4 $3,000 $12,000 etc. • Train staff members of the Rescue Service to use new- Hospital beds Beds for rehabilitation and acute care patients with attachments 6 $500 $3,000 ly acquired equipment (Responsible Party: UNDP) for respirator apparatus, oxygenators, and other life-saving devices • Monitor, review, and adjust procedures as neces- Sphygmomanometer kit with stethoscope Measures blood pressure, heart beat rate 10 $40 $400 sary (Responsible Party: Rescue Services) Total: $194,400 Table 27. Proposed procurement list to improve emergency transport (to be revised with Rescue Services unit) Item Description ActivityQuantity Two: TheUnit second Price activityTotal is to improve the quality 7.6.2 Preventative (Primary) Health of intensive care and maximise the use of the newly acquired equipment. International trainings for trauma care 7.6.2.1 Health Promotion and Disease exist throughout the European Union and other regions of Prevention Programme the world. The Advanced Trauma Life Support (ATLS) pro- Background: In 2011, Krasnodon reported 860 cases gramme, organised by the American College of Surgeons, of cardiovascular diseases and 217 cases of respiratory is one of the longest standing education course in trauma diseases per 1,000 inhabitants. These health problems are 28 care worldwide. However, courses are not currently avail- linked to changeable lifestyle patterns, including smoking, able in Ukraine or neighbouring CIS countries. Moreover, poor diets, stressful working conditions, and alcohol abuse. start-up costs for such trainings would be around $80,000 per country. There are other courses offered through the Recommendation: Half of all deaths before the age of Primary Trauma Care (PTC) Foundation and the International 75 can be prevented through targeted programmes to Association for Trauma Surgery and Intensive Care (IATSIC) as modify behaviours and improve environmental condi- well. However, Ukraine and its neighbouring countries have tions.29 Moreover, the Institute of Occupational Health plenty of individuals who can conduct trainings to improve in Kyiv estimates that compensation costs are approxi- the level of intensive care in Krasnodon. Thus, individual mately six times higher than what it would cost to pro- trainers should be brought in as a cost-effective alternative tect workers or treat them at earlier stages of occupa- to improve the quality of intensive care in Krasnodon. tional diseases.30 The European Agency for Safety and Health at Work also states the investments in occupa- The steps involved in this activity include: tional health and safety have very high returns on in- • Select hospital staff members to participate in cas- vestment in terms of earning, improvement of a com- cade trainings (Responsible Party: Central Hospital) pany’s image, and reducing insurance and compensa- • Conduct cascade trainings for hospital staff (Re- tion costs.31 Thus, Krasnodon needs a comprehensive sponsible Party: UNDP) health promotion campaign to change habits, as well • Have hospital staff members conduct trainings to as change the fatalistic mindsets of miners who do not their staff members think they can affect their own health and wellbeing. (Responsible Party: Central Hospital) Activity One: The first activity is to conduct health promotion campaigns and trainings. Such a campaign Table 30. Proposed fees for consultant to conduct trainings would focus on the primary health ailments affecting Item Description Quantity Unit Price Total miners: respiratory and cardiovascular diseases. Consultant Fees for 12-day consultation 12 $500 $6,000 A good model to consider is Krasnodonugol’s train- Travel costs 1 $1,000 $1,000 the-trainers programme, which trained 35 retired Miscellaneous (e.g., internet, 1 $1,500 $1,500 miners in occupational health and safety procedures, printing) who in turn trained 6,959 managers and supervisors Total: $8,500 later on. The steps involved in this activity include:

31 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine • Conduct tri-annual health promotion meetings • Principles of Health Promotion and workshops to discuss community-wide strate- • Evidence-based Methods of Health Promotion gy on health promotion (Responsible Parties: City • Prioritisation and Planning of Interventions of Krasnodon, Metinvest, UNDP) • Health Promotion Evaluation • Select at least 10 participants representing the pri- • Methods of Structural and Individual Behaviour vate sector, government, education, and other rel- Change evant sectors for the cascade training (Responsible Party: City of Krasnodon) • Assessment of Health Impact and Investment • Conduct the cascade trainings on health promo- Activity Two: The second activity is to conduct a diet tion (Responsible Party: UNDP) and nutrition programme for miners. UNDP will exam- • Participants conduct trainings at their place of ine the diet and nutrition of miners. Nutritional exams work (Responsible Party: Participants) would begin by asking miners to keep a “food diary” to understand what miners consume on a daily basis. The core curriculum for this health promotion training UNDP will then conduct interviews and focus groups would include: to complement information gathered from the food diaries. Simultaneously, UNDP will conduct a nutritional • Salutogenesis: Health, Illness and Wellbeing analysis of menus from the canteens in the mines. Final- • Determinants of Health ly, UNDP will provide suggestions for alternative diets.

Table 31. Proposed budget for strengthening primary (preventative) health efforts Item Description Quantity Unit Price Total Consultant Fees for 12-month health promotion campaign 1 $32,000 $32,000 Fees for diet and nutrition programme 1 $8,000 $8,000 Total: $40,000

32 Krasnodon action plan

7.7 Budget Table 32. Proposed budget to implement Krasnodon’s action plan Ground Ambulances

Item Description Quantity Unit Price Total Ambulances Modern, fully-equipped ambulance will include defibrillator, intravenous lines 2 $65,000 $130,000 and fluids, stretcher, cervical collar, spinal board, first aid kits, oxygen kits, etc. Equipment to upgrade existing Automated external defibrillators (AEDs) 7 $1,500 $10,500 ambulances Intravenous lines and fluids 7 $1,000 $7,000 Cervical collars 7 $100 $700 Spinal boards 7 $300 $2,100 Stretchers 7 $300 $2,100 First aid kits (e.g., burn pack, bandages, dressings, gauze rolls, adhesive tape) 7 $200 $1,400 Two-way radios to be use between the dispatcher and emergency medical 7 $250 $1,750 technician Oxygen deployment kits 7 $400 $2,800 Misc. (e.g., stethoscope, thermometer, cold packs, disinfectant, blankets, gloves) 7 $250 $1,750 Sub-total: $160,100

Proposed Fees for Consultant to Conduct Training

Item Description Quantity Unit Price Total Consultant Fees for 12-day consultation 12 $500 $6,000 Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., internet, printing) 1 $1,500 $1,500 Sub-total: $8,500

Intensive Care Units

Item Description Quantity Unit Price Total Portable ultrasound machine Diagnoses traumas and illnesses (e.g., cardiovascular disease); inclusive of 1 $50,000 $50,000 supporting software costs Electrocardiographs (ECG) Interprets electrical activity of the heart, including the presence of any damage 5 $1,000 $5,000 Heart monitors Tracks heart functions and alerts staff to any sudden changes in vital heart 3 $5,000 $15,000 functioning Defibrillators Electric-shock, life-saving apparatus for victims of heart attacks, 3 $3,000 $9,000 for patients in intensive care Portable x-ray machines Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 Fluorography machine Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 Crash carts Serves in emergency situations with defibrillator, pulse oximeter, etc. 4 $3,000 $12,000 Hospital beds Beds for rehabilitation and acute care patients with attachments for 6 $500 $3,000 respirator apparatus, oxygenators, and other life-saving devices Sphygmomanometer kit with Measures blood pressure, heart beat rate 10 $40 $400 stethoscope Sub-total: $194,400

Preventative (Primary) Health

Proposed Fees for Consultant to Health and Nutrition Programme

Item Description Quantity Unit Price Total Consultant Fees for 12-month health promotion campaign 1 $32,000 $32,000 Fees for diet and nutrition programme 1 $8,000 $8,000 Sub-total: $40,000

TOTAL: $411,500

33 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine • Community members prioritised the following 8. Rovenky action plan actions: to upgrade medical equipment, primary health prevention efforts, and balance the de- 8.1 Key Findings mands of coal production and miners’ safety. • In Rovenky, the top health ailments of miners are respiratory diseases, occupational injuries (trauma), 8.2 Community Health Profile heart diseases and musculoskeletal conditions. The city of Rovenky has a population of 53,609, • More than 37 per cent of miners in Rovenky and whereas the population of the entire municipality is 33 Sverdlovsk suffer from respiratory diseases. Chron- 91,558. The municipality’s population receives health ic bronchitis alone affects 330 per 1,000 miners — services by Healthcare Rovenky, a network of medical a rate seven times higher than the general adult institutions, including the central hospital, four city populations in Rovenky and Sverdlovsk. hospitals, and several other specialty clinics. The central hospital has an emergency ward of 345 beds. • About 18 per cent of miners in Rovenky and Sverd- Rovenky also has an ambulance station that employs lovsk suffer from cardiovascular diseases. For ex- five teams per shift. There are also two medical schools ample, 57.6 per 1,000 miners suffer from ischemic within the city limits. heart disease compared to the national average of 53.1 per 1,000 people or the European average of 36.3 per 1,000 people.32 Table 33. Number of beds and visits per shift in Rovenky’s health institutions • In Rovenky and Sverdlovsk, the most common Institutions Beds Visits/ Shift musculoskeletal conditions of miners are osteochondrosis (68 per 1,000 miners) and lower back Central Hospital 345 --- pain (42 per 1,000 miners). City Hospital № 2 70 150 • In 2011, the rate of occupational injuries at Roven- City Hospital № 3 70 100 kiantratsit was 12.98 per 1,000 miners. In compari- Yasenovskoy Hospital 40 100 son, the national average for occupational injuries City Hospital № 4 Infections 90 --- of miners was 9.3 per 1,000 miners and was 6.87 St. Michael’s Clinic --- 50 and 7.63, respectively, for neighbouring Krasnodo- Rural Clinic Blagovskoy --- 15 nugol and Sverdlovantratsit. Dental Clinic --- 150 • The most common causes of injuries include col- TB Hospital 90 --- lapses (105.6/ year), falls (61/ year), falling objects Bone TB Sanatorium 50 --- (37.8/ year), machine related (12.6/ year), and un- Source: City of Rovenky, June 2012 derground transport related (9/ year). • Even though 50 per cent of miners are satisfied with The city also has multiple sports venues to help their working conditions, 75 per cent of miners are promote healthy lifestyles, including Avangard worried about the possibility of work-related accidents. stadium, 2 swimming pools, 7 children’s playgrounds, • Most miners (59%) believe it is impossible to com- 58 athletic fields, 1 tennis court, 9 soccer fields, and 27 plete their daily work tasks (e.g., meeting coal ex- gyms of at least 162 square meters. traction quotas) without deviating from occupational safety and health (OSH) safety rules. 8.3 DTEK Rovenkiantratsit • Miners’ spouses and pharmacists play an impor- In July 2010, DTEK invested in to the state-owned tant role in the health and wellbeing of miners. At Rovenkiantratsit, an investment approved by the least 15 per cent of miners use medical products Ministry of Coal Industry of Ukraine. Since then, DTEK advised by a pharmacist, 9 per cent use medical has invested in to construction, machinery and technical products advised by family members or acquaint- equipment to improve the company’s operations. ances, and 8 per cent use folk remedies. Simultaneously, the city of Rovenky joined the DTEK • The Luhansk Clinic of the Ministry of Internal Af- Social Partnership Declaration in order to develop better fairs classified miners into three health groups: living and working conditions. DTEK Rovenkiantratsit I) generally healthy, II) those who have had acute has six mines and three ore processing plants, and and/ or chronic disease(s) in the past, and III) those other structural units that cater to coal production. As of who currently have a chronic disease. Of those August 2012, Rovenkiantratsit employs 13,067 people, who took part in the study, 33 per cent were clas- or about 19 per cent of the adult population of Rovenky. sified into Health Group I, 13 per cent into Health Of the total, the company has 10,756 male employees Group II, and 54 per cent into Health Group III. (82%) and 2,311 female employees (18%).

34 Rovenky action plan

Table 34. The distributions of miners Figure 11: Distribution of employees by occupation, as of August 2012 by gender and age at Rovenkiantratsit 7000 Including: Mine Total 6000 Men Women 18-30 31-40 41-50 51-60 60+ 5000 Dzerzhynskogo 2058 1679 379 668 691 484 200 15 Office 4000 1826 1430 396 526 516 450 302 32 Rovenkovskoye 3000 No. 81 Kievskaya 1655 1352 303 440 526 443 221 25 M.V. Frunze 3133 2704 429 984 1011 769 344 25 2000 Vakhrusheva 2054 1690 364 654 670 440 284 6 1000 Kosmonavtov 2341 1901 440 773 739 531 279 19 0 Total Mines 13067 10756 2311 4045 4153 3117 1630 122 Total Dzerzhynskogo O ce No. 81 M.V. Frunze Vakhrusheva Kosmonavtov Source: DTEK, August 2012 Rovenkovskoe Kievskaya Stope Miners Sinkers Underground Workers Aboveground workers Administrative

Figure 9: Distribution of employees by gender, as of August 2012 Rovenkiantratsit’s Health Records of Miners 12 000 10 756 Employees of Rovenkiantratsit undergo annual medical

10 000 exams in accordance with Ukrainian law № 246, “Proce- dure for conducting medical examinations of workers 8 000 certain categories” (21 May 2007). According to the com- 6 000 pany, 98.6 per cent of employees have gone through pe-

4 000 riodic medical exams in accordance with the abovemen- 2 704 2 311 1 901 tioned law. Employees undergo exams with neurologists, 2 000 1 679 1 690 1 430 1 352 ophthalmologists, ENT doctors, psychiatrists, as well as 379 396 303 429 364 440 0 specialists in x-rays, laboratory tests, electrocardiography, Total Dzerzhynskogo O ce No. 81 M.V. Frunze Vakhrusheva Kosmonavtov Rovenkovskoye “Kievskaya” pneumatic tachometry, and spirography. Based on these Men Women exams, the top three health ailments affecting employees The company has 4,043 workers from 18-30 years old, in 2011 were respiratory disease (48.37%), trauma (7.98%) 4,151 workers from 31-40 years old, 3,116 workers and skin and subcutaneous tissue diseases (7.89%). Ex- from 41-50 years old, 1,629 workers from 51-60 years ams also revealed that alcoholism continues to be prob- old, and 122 workers over 60 years old. lematic as it affects at least 27.16 per 100,000 people.

Figure 10: Distribution of employees by age, as of August 2012 Figure 12. Total number of occupational diseases at Rovenkiantratsit,

4500 2007-2011 200 4000 179 178 180 170 3500 160 3000 140 132 116 2500 120

2000 100 80 1500 60 1000 40 500 20

0 0 Total Dzerzhynskogo O ce No. 81 M.V. Frunze Vakhrusheva Kosmonavtov 2007 2008 2009 2010 2011 Rovenkovskoe “Kievskaya” Number of Occupational Diseases 18-30 years old 31-40 years old 41-50 years old 51-60 years old 60+ years old Occupational Injuries (Traumas) at Rovenkiantratsit Table 35. The distributions of miners by occupation in Rovenkiantratsit Occupational injuries represent a serious concern Under Above Administra at DTEK Rovenkiantratsit. For 2011, the company Stope Mine Sinkers ground ground tive support miners averaged 203.6 injuries per 10,000 workers. workers workers staff Dzerzhynskogo 327 211 993 453 74 Office Figure 13. Total number of traumas at Rovenkiantratsit, as of June 2012 253 147 707 437 282 450 Rovenkovskoye 406 No. 81 Kievskaya 222 111 900 335 87 400 358 352 M.V. Frunze 483 396 1565 556 133 350 336 300 Vakhrusheva 231 209 1123 396 95 266 Kosmonavtov 288 373 1060 525 95 250 Total Mines 1804 1447 6348 2702 766 200 Source: DTEK, August 2012 150 100

The company has 6,348 underground workers, 2,702 0 aboveground workers, 1,804 stope miners, 1,447 2007 2008 2009 2010 2011 sinkers, and 766 administrative support staff. Number of Traumas

35 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine Figure 14. Comparison of traumas per 10,000 workers at Rovenkiantratsit III) those who currently have a chronic disease. Of those and the average of traumas to miners across Ukraine (2011) who took part in the study, 33 per cent were classified 250 into Health Group I, 13 per cent into Health Group II, 203,6 200 and 54 per cent into Health Group III. In Rovenky, the top health ailments of miners are respiratory diseases, 144,8 150 cardiovascular disease, occupational injuries (trauma), and musculoskeletal conditions. 100 In fact, more than 37 per cent of miners in Rovenky 50 and neighbouring Sverdlovsk suffer from respiratory diseases. Chronic bronchitis alone affects 330 per 0 Rovenkiantratsit Average of Traumas to Miners Across Ukraine 1,000 miners — a rate seven times higher than the

Rovenkiantratsit Average of Traumas to Miners Across Ukraine general adult populations in Rovenky and Sverd- lovsk. Furthermore, about 18 per cent of miners in Rovenky and Sverdlovsk suffer from cardiovascular Over the past five years, the most common types of diseases. For example, 57.6 per 1,000 miners suffer trauma were as follows: 576 “other” cases (115.2 per year), from ischemic heart disease compared to the nation- 528 collapses (105.6 per year), 305 falls (61.0 per year), 189 al average of 53.1 per 1,000 people or the European falling objects (37.8 per year), 63 machine-related (12.6 average of 36.3 per 1,000 people.34 As for musculo- per year), and 45 underground transport (9.0 per year). skeletal conditions, the most common conditions of Figure 15. Traumas at Rovenkiantratsit by type, as of June 2012 miners in Rovenky and Sverdlovsk are osteochon-

160 147 drosis (68 per 1,000 miners) and lower back pain 133 (42 per 1,000 miners). 123 116 120 111 110 104 The rate of occupational injuries at Rovenkiantratsit in 96 96 86 2011 was 12.98 per 1,000 miners. In comparison, the 80 68 63 national average for occupational injuries of miners 54 52 50 42 44 was 9.3 per 1,000 miners and was 6.87 and 7.63, 37 35 40 31 respectively, for neighbouring Krasnodonugol and 19 17 17 10 11 9 8 4 6 7 Sverdlovantratsit. The most common causes of the 0 2007 2008 2009 2010 2011 occupational injuries include collapses (105.6/ year), Other Collapses Falls Falling Objects Machine-related Underground Transport falls (61/ year), falling objects (37.8/ year), machine related (12.6/ year), and underground transport related Rovenkiantratsit reported 6 work-related deaths (9/ year). In an opinion survey conducted by GfK in 2011, an average of about 4.6 deaths per 10,000 Ukraine, 50 per cent of miners from Rovenkiantratsit workers. Across all of the mines in Ukraine in 2010, and Sverdlovantratsit stated that they are satisfied there were about 3.9 deaths per 10,000 workers. with their working conditions, even though 75 per cent of miners also stated that they are worried about Figure 16. Casualties at Rovenkiantratsit as reported the possibility of work-related accidents. by the company in June 2012 12 8.5 Priorities 10 Key stakeholders — miners, doctors and government

8 officials — prioritised the following as most pressing issues to address. 6 1. Improvement of medical equipment and emergency 4 transportation (high priority) 2 2. Programmes on health education (high priority)

0 3. Balancing the demands between coal production 2007 2008 2009 2010 2011

Casualties and miners’ safety (high priority) 4. Transportation to mining site (medium priority) 8.4 Health and Safety of Miners 5. Quality of underground air (medium priority) After conducting medical exams of miners in Roven- Among this list, stakeholders prioritised improving ky and Sverdlovsk, the Luhansk Clinic of the Ministry medical services, programmes on health education, and of Internal Affairs classified miners into three health balancing the demands between coal production and groups: I) generally healthy, II) those who have had miners’ safety as the most important issues to address. acute and/ or chronic disease(s) in the past, and

36 Rovenky action plan

Next Steps choosing safety equipment so that management Rovenky has community resources (e.g., health and understands the workers’ needs. sports facilities) to help advance health promotion • DTEK Rovenkiantratsit should consider providing efforts community-wide. Upgrading human and clean and heated means of transportation to and medical capacities, while also improving working from work. conditions, are a step in the right direction for • The city’s medical equipment and training should improving the health and safety of miners in Rovenky. be upgraded to improve screening and emergen- This action plan focuses on reducing the risk factors cy medical services. that make miners’ susceptible to cardiovascular disease, respiratory disease and trauma. • A comprehensive health education and promotion campaign should be advanced within the However, improving the health and safety of miners framework of this project. Sports and sports facili- will require engagement of the public and private ties should be used as a platform to launch such an sectors. Thus, UNDP has contacted the Ministry effort. In addition, schools and other educational of Health, Ministry of Emergencies, and State institutions should be used to promote healthy Committee of Ukraine on Industrial Safety, Labour living. Protection and Mining Supervision and will seek to engage them in the implementation phase • Nutritional policies and planning should balance of the project as well. traditional cuisine with nutrition guidelines outlined in the “Health of the Nation” (2002-2011), In phase two of the project, UNDP will conduct a which was adopted by the Cabinet of Minis- roundtable discussion between DTEK, Metinvest, ters in 2002, or with World Health Organization and representatives from government entities, in- guidelines. cluding the Ministry of Health, Ministry of Emer- gencies, State Committee on Mining Supervision • Miners should have access to 2.0-2.5 litres of clean and Industrial Safety. Once representatives are en- drinking water every day, as recommended by gaged, UNDP will facilitate further discussions with the European Food Safety Authority (2.0 litres for the abovementioned ministries and representatives women and 2.5 litres for men). Water intake should from the Luhansk Regional State Administration and be staggered throughout the day, as even one per cities of Krasnodon, Rovenky and Sverdlovsk. Con- cent of loss in bodyweight due to fluid deficiency currently, UNDP will contact potential partners, in- can impair a person’s ability to concentrate. cluding the European Union and interested parties • Promote the use of the prophylactic sanatori- (e.g., neighbouring government donors), about join- um during miners’ second vacation by allowing ing this effort. miners to bring their families with them to the sanatoriums. 8.6 General Recommendations • Pharmacists should be included in health strate- • Rovenky needs at least two modern and ful- gies since miners depend on them heavily. ly-equipped ambulances to meet minimum emer- • Likewise, miners’ spouses should be included in gency response standards (McSwain, N.E. (1991) health strategies since they play a functional role proposes 1 ambulance per 50,000 residents. Oth- in the health of miners. ers argue that this number should be closer to 1 • DTEK, Rovenky, and neighbouring communities ambulance per 10,000 residents. Rovenky, with a should consider obtaining an air ambulance to population of over 91,000 people, should have be- service mining communities in the Luhansk oblast. tween 2 and 10 modern ambulances). • Data on the health and safety of miners should be 8.7 Action Items systematised into an electronic database. This will 8.7.1 Improvement of Medical Equipment make the data more robust, accessible and usable. Background: Rovenky has a central hospital, four city • DTEK Rovenkiantratsit should consider installing hospitals, several other specialty clinics, and an am- radiation therapy rooms and aerosol inhalation bulance station. Rovenky also has 755 hospital beds rooms for their health units. compared to neighbouring Sverdlovsk which has 720 • DTEK Rovenkiantratsit should purchase washing beds. Still, much of the medical equipment in Roven- and drying machines to clean miners’ work clothes ky is obsolete and needs to be replaced. Doctors and on its premises. miners alike know that medical equipment needs to • DTEK Rovenkiantratsit should provide workers with be upgraded throughout Rovenky’s network of health sufficient amount of respirators and interchange- institutions. The following highlights some of the able filters. Workers should also be included in problems with the outdated equipment, as well as

37 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine recommendations of what purchases should be made equipment (i.e., crash carts, electrocardiographs, heart moving forward. monitors, AEDs). Health consultants determined the • Diagnostic Equipment: Diagnostic equipment numbers of each equipment based on volume of that could have led to early detection (e.g., x-ray patients and professional opinion. machines, spirometers, pulse oximeters, fluorography machines, ultrasound machines) are mostly Activity One: The first activity is to procure medical outdated and in some cases obsolete. Many pre- equipment for the hospitals in Rovenky. The steps ventable diseases have gone undetected or de- involved in this activity include: tected too late in the process. Last year, respiratory • Review and revise the proposed list of medical diseases led to 17 per cent of all deaths, and car- equipment (Responsible Parties: UNDP and Cen- diovascular diseases led to 47 per cent of deaths. tral Hospital) Recommendation: At least four portable x-ray • Work with Technical Advisor to ensure technical machines, two fluorography machines, and one compatibility of new equipment (Responsible Par- portable ultrasound machine are needed based on ty: UNDP and Central Hospital) the number of patients who visit the hospitals. These • Conduct internationally competitive bidding machines are critical in diagnosing and evaluating process to ensure best value (Responsible respiratory and cardiovascular diseases. Party: UNDP)

In the future, there should be a gradual shift to Activity Two: The second activity is to train staff to use digital machines (instead of film-based ones) when the newly acquired equipment. The steps involved in the hospital has the technical and staff capacity to this activity include: absorb the changes. For example, the hospital should • Select 10 hospital staff members to participate in cas- be upgraded with computer stations and software cade trainings (Responsible Party: Central Hospital) programmes in each department to handle the technological shift to digital equipment. • Conduct cascade trainings for hospital staff (Re- sponsible Party: UNDP) • Emergency Room Equipment: Rovenky is lacking necessary equipment for emergency situations, in- • Have hospital staff members conduct trainings to cluding crash carts, electrocardiographs, heart mon- their staff members (Responsible Party: Central itors and automatic external defibrillators (AEDs). In Hospital) Rovenky, where heart diseases kill the majority of Table 37. Proposed fees for consultant to conduct trainings people (over 47 per cent of deaths last year), equip- Item Description Quantity Unit Price Total ment to monitor heart conditions and to stabilise victims of emergency situations is critical. Consultant Fees for 12-day consultation 12 $500 $6,000 Recommendation: Proper medical equipment Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., internet, during emergency situations can make the difference 1 $1,500 $1,500 printing) between life and death. Thus, minimum additions should be made, including the abovementioned Total: $8,500

Table 36. Proposed list of medical equipment to procure (to be revised with the Central Hospital as necessary)

Item Description Quantity Unit Price Total

Crash carts Serves in emergency situations with defibrillator, pulse oximeter, etc. 4 $3,000 $12,000 Defibrillators Electric-shock, life-saving apparatus for victims of heart attacks, for patients in in- 3 $3,000 $9,000 tensive care Electrocardiographs (ECG) Interprets electrical activity of the heart, including the presence of any damage 6 $1,000 $6,000 Fluorography machine Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 Heart monitors Tracks heart functions and alerts staff to any sudden changes in vital heart func- 4 $5,000 $20,000 tioning Portable ultrasound machine Diagnoses traumas and illnesses (e.g., cardiovascular disease); inclusive of support- 1 $50,000 $50,000 ing software costs Portable x-ray machines Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 Pulse oximeters Measures oxygen levels and diagnoses patients’ breathing and circulatory problems 5 $200 $1,000 Spirometers Diagnoses chronic obstructive pulmonary disease (COPD), a.k.a. chronic obstruc- 8 $250 $2,000 tive lung disease (COLD)

Total: $200,000

38 Rovenky action plan

8.7.2 Improve Emergency Transport Activity Two: The second activity is to conduct cascade Background: Rovenki’s Rescue Services’ ambulances are trainings for using the newly acquired equipment. The actually old, refurbished military vehicles, which lack ba- steps involved in this activity include: sic emergency medical equipment. The lack of modern • Draft training agenda for members of the Rescue vehicles and equipment severely limits the effectiveness Service (Responsible Parties: UNDP and head(s) of of the Rescue Services. Moreover, because of the depths Rescue Services) of the mines and poor conditions of the roads, it may take • Train staff members of the Rescue Service to use new- up to one hour to get an injured miner from the bottom ly acquired equipment (Responsible Party: UNDP) of the mines to a local hospital (15 km drive). If a patient needs to go to a special centre in Luhansk or Donetsk, • Monitor, review, and adjust procedures as neces- it will take 2 hours and 4-6 hours, respectively. Poorly sary (Responsible Party: Rescue Services) equipped vehicles and long commute times to hospitals Table 39. Proposed fees for consultant to conduct cascade trainings make it imperative to improve emergency transport ser- Item Description Quantity Unit Price Total vices as medical services provided — or not provided — Consultant Fees for 12-day 12 $500 $6,000 in the minutes en route to a hospital can be the difference consultation between life and death. In addition, half of the 124.3km of Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., municipal roads in Rovenky are in need of urgent repair. 1 $1,500 $1,500 internet, printing) Recommendation: Rovenky needs at least two modern Total: $8,500 and fully-equipped ambulances to meet minimum emergency response standards (McSwain, N.E. (1991) propos- 8.7.3 Programmes on Health Education es 1 ambulance per 50,000 residents. Others argue that Background: The top health problems in Rovenky— this number should be closer to 1 ambulance per 10,000 cardiovascular and respiratory diseases—are linked to residents. Rovenky, with a population of over 91,000 peo- changeable lifestyle patterns, including smoking, poor ple, should have between 2 and 10 modern ambulances). diets, stressful working conditions, and alcohol abuse. In the future, the entire fleet of vehicles should be replaced Yet miners in Rovenky suffer disproportionate rates of with modern ambulances. Moreover, according to chronic bronchitis, ischemic heart diseases, and other international standards, ambulances should have three- cardiovascular and respiratory disease. member crews, all of whom have passed emergency Recommendation: Half of all deaths before the age medical technician (EMT) courses. Such a course usually of 75 can be prevented through targeted programmes lasts more than 3 weeks and at minimum, teaches how to modify behaviours and improve environmental to administer cardiopulmonary resuscitation (CPR), pass conditions.36 Moreover, the Institute of Occupational a chest tube, and introduce an intravenous line. Health in Kyiv estimates that compensation costs are Activity One: The first activity is to procure two fully- approximately six times higher than what it would cost equipped modern ambulances, as well as equipment to protect workers or treat them at earlier stages of oc- to upgrade the existing fleet of ambulances. The steps cupational diseases.37 The European Agency for Safety involved in this activity include: and Health at Work also states the investments in oc- • Review and revise the proposed procurement list as nec- cupational health and safety have very high returns on essary (Responsible Parties: UNDP and Central Hospital) investment in terms of earning, improvement of a com- • Work with procurement specialists to ensure le- pany’s image, and reducing insurance and compensa- gal compliance and technical specifications of the tion costs.38 Thus, Rovenky needs a comprehensive ambulances and equipment (Responsible Parties: health promotion campaign to change habits, as well UNDP and Central Hospital) as change the fatalistic mindsets of miners who do not • Conduct internationally competitive bidding pro- think they can affect their own health and wellbeing. cess to ensure best value (Responsible Parties: UNDP) Activity One: The first activity is to conduct health promotion campaign and trainings. Such a campaign Table 38. Proposed list of equipment to procure to improve emergency would focus on the primary health ailments affecting transport (to be revised with Rescue Services unit) miners: respiratory and cardiovascular diseases. A good Quan- Unit Item Description Total tity Price model for DTEK to consider is Metinvest’s train-the- Ambu- Transports patients to health trainers programme in Krasnodon, which trained 35 lances centers; fully equipped ambu- retired miners in occupational health and safety proce- lance will include defibrillator, dures, who in turn trained 6,959 managers and supervi- intravenous lines and fluids, es- 2 $75,000 $150,000 sential medicines, cervical col- sors later on. The steps involved in this activity include: lar, stretcher, spinal board, first • Conduct tri-annual health promotion meet- aid kits, radios, oxygen kits, etc. ings and workshops to discuss community-wide Total: $150,000

39 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine strategy on health promotion (Responsible Par- Rovenky has an impressive array of underutilised sports ties: City of Rovenky, DTEK, UNDP) venues, including “Avangard” stadium, 2 swimming • Select at least 10 participants representing the pri- pools, 7 children’s playgrounds, 58 athletic fields, 1 vate sector, government, education, and other rel- tennis court, 9 football fields, 27 gymnasiums, 25 rooms evant sectors for the cascade training (Responsible for sports and recreational activities, and other fitness Party: City of Rovenky) spaces. These resources provide a foundation to develop a comprehensive health promotion programme. • Conduct the cascade trainings on health promotion (Responsible Party: UNDP) Table 40. Proposed budget for programmes on health education

• Participants conduct trainings at their place of Item Description Quantity Unit Price Total work (Responsible Party: Participants) Fees for 12-month health 1 $32,000 $32,000 promotion campaign The core curriculum for this health promotion training Consultant Fees for diet and nutri- would include: 1 $8,000 $8,000 tion programme • Salutogenesis: Health, Illness and Wellbeing Total: $40,000 • Determinants of Health • Principles of Health Promotion • Evidence-based Methods of Health Promotion 8.7.4 Balancing the Demands between Coal Production and Miners’ Safety • Prioritisation and Planning of Interventions Background: This is a vital, yet difficult, action item to im- • Health Promotion Evaluation plement. Miners stated that the need to make a living, to- • Methods of Structural and Individual Behaviour gether with the pressures from management to produce, Change led to risky behaviour. Thus, this action item is about pro- • Assessment of Health Impact and Investment moting safer working conditions and ultimately, balancing the demands between coal production and miners’ safety. Activity Two: The second activity is to conduct a diet Recommendations: This is an enormous task that and nutrition programme for miners. will take years of persistence and reform to achieve. Canteen supervisors at DTEK Rovenkiantratsit explained However, there are intermediate steps that can that menus were based on high-calorie diets established improve morale and limit risky behaviours by miners. during Soviet times. After interviews with miners and • Include Miners in Decision-Making: Miners know miners’ wives, it was also clear that miners ate high calorie, their working conditions better than anyone else. high fat diets at home as well. Thus, a diet and nutrition Including them in decision-making processes will programme would help to keep track of diets, as well as improve efficiency, safety and morale. For example, provide guidance for miners to change their eating habits. one miner stated that he appreciated that DTEK This activity begins with a “food diary” to keep track of Rovenkiantratsit purchased new protective eyewear what miners consume on a daily basis. Food diaries recently. However, the upgraded eyewear did not help track how many calories one is consuming, as fit on their faces with the old respirator masks. Thus, well as if one is consuming enough fruits, vegetables, miners had to choose between wearing the eyewear and whole grains. Participants list their current weight, or wearing the respirators. Such a situation could height, goal weight, and any other health goals the have been avoided if miners were more intimately he or she might have (e.g., blood pressure, cholesterol involved in choosing their own protective gear. levels). In addition, food diaries allow one to write • Conduct Comprehensive Risk Assessments: down how he or she feels after changing his or her Currently, risk assessments are conducted sepa- diet. UNDP will then conduct interviews and focus rately by different departments at DTEK Rovenki- groups to complement information gathered from antratsit. While conducting assessments at each of the food diaries. Simultaneously, UNDP will conduct the mines is helpful, a comprehensive assessment a nutritional analysis of menus from the canteens in must also be conducted. Again, miners should be the mines. Finally, UNDP will provide suggestions for included in this process. alternative approaches for meeting their dietary needs. • Improve Underground Hygienic Conditions: Dust Concurrently, UNDP will facilitate discussions with city control is a major issue at DTEK Rovenkiantratsit. officials and DTEK Rovenkiantratsit about how to increase There are many dust suppression techniques, in- usage of the vast network of sports and health facilities in cluding water-based ones that could really decrease the area. While DTEK Rovenkiantratsit already organises dust levels, as well as the risk for getting respiratory sports days and programmes for its employees, further diseases. In addition, miners regularly commented health and fitness programmes could be easily developed. about the lack of clean drinking water as a concern.

40 Rovenky action plan

Providing clean drinking water not only improves hy- but focus on ways to balance the demands between gienic conditions, it also will improve worker morale. coal production and miners’ safety. Activity One: The first activity is to fund an advisor Activity Two: The second activity is to establish to help guide health and safety procedures at DTEK a health and safety working group to ensure the Rovenkiantratsit. Such an advisor could provide sustainability of the project. regular advice to DTEK Rovenkiantratsit, while also advocating local and national government bodies Table 41. Proposed budget for promoting safer working conditions Unit to improve and enforce laws that protect miners. Item Description Quantity Total Price The advisor also could conduct trainings on risk Advisor Funding for full-time 1 $50,000 $50,000 assessments, dust control and other best practices advisor for 12 months in mines, with a goal of training at least 10 per cent Project Funds to conduct 1 $50,000 $50,000 of the workforce or about 1,954 employees. These management trainings training will not only impart skills to improve safety, Total: $100,000

8.8 Budget Table 42. Proposed budget for Rovenky’s action plan Action Item 1: Improvement of Medical Equipment

Item Description Quantity Unit Price Total Crash carts Serves in emergency situations with defibrillator, pulse oximeter, etc. 4 $3,000 $12,000 Electric-shock, life-saving apparatus for victims of heart attacks, for Defibrillators 3 $3,000 $9,000 patients in intensive care Interprets electrical activity of the heart, including the presence of any Electrocardiographs (ECG) 6 $1,000 $6,000 damage Fluorography machine Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 Tracks heart functions and alerts staff to any sudden changes in vital Heart monitors 4 $5,000 $20,000 heart functioning Diagnoses traumas and illnesses (e.g., cardiovascular disease); inclusive Portable ultrasound machine 1 $50,000 $50,000 of supporting software costs Portable x-ray machines Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 Measures oxygen levels and diagnoses patients’ breathing and circulatory Pulse oximeters 5 $200 $1,000 problems Diagnoses chronic obstructive pulmonary disease (COPD), a.k.a. chronic Spirometers 8 $250 $2,000 obstructive lung disease (COLD) Sub-total: $200,000

Proposed Fees for Consultant to Conduct Trainings

Item Description Quantity Unit Price Total Fees for 12-day consultation 12 $500 $6,000 Consultant Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., internet, printing) 1 $1,500 $1,500 Sub-total: $8,500

Action Item 2: Programmes on Health Education

Item Description Quantity Unit Price Total Fees for 12-month health promotion campaign 1 $32,000 $32,000 Consultant Fees for diet and nutrition programme 1 $8,000 $8,000 Sub-total: $40,000

Action Item 3: Balancing the Demands between Coal Production and Miners’ Safety

Item Description Quantity Unit Price Total Advisor Funding for full-time advisor for 12 months 1 $50,000 $50,000 Project management Funds to conduct trainings 1 $50,000 $50,000 Sub-total: $100,000

TOTAL: $348,500

41 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine least 15 per cent of miners use medical products 9. Sverdlovsk action plan advised by a pharmacist, 9 per cent use medical products advised by family members or acquaint- 9.1 Key Findings ances, and 8 per cent use folk remedies. • In Sverdlovsk, the top health ailments of miners are res- • The Luhansk Clinic of the Ministry of Internal Af- piratory diseases, occupational injuries (trauma), cardi- fairs classified miners into three health groups: ovascular diseases and musculoskeletal conditions. I) generally healthy, II) those who have had acute • More than 37 per cent of miners in Sverdlovsk and and/ or chronic disease(s) in the past, and III) those neighbouring Rovenky suffer from respiratory dis- who currently have a chronic disease. Of those eases. Chronic bronchitis alone affects 330 per 1,000 who took part in the study, 33 per cent were clas- miners — a rate seven times higher than the gener- sified into Health Group I, 13 per cent into Health al adult populations in Sverdlovsk and Rovenky. Group II, and 54 per cent into Health Group III. • About 18 per cent of miners in Sverdlovsk and Rovenky • Community members prioritised the following ac- suffer from cardiovascular diseases. For example, 57.6 tions: upgrade medical equipment, improve emer- per 1,000 miners suffer from ischemic heart disease com- gency medical transportation and conduct prima- pared to the national average of 53.1 per 1,000 people ry health prevention efforts. or the European average of 36.3 per 1,000 people.39 • In Sverdlovsk and Rovenky, the most common 9.2 Community Health Profile musculoskeletal conditions of miners are osteo- The city of Sverdlovsk has a population of 72,611 chondrosis (68 per 1,000 miners) and lower back people, whereas the population of the entire munici- 40 pain (42 per 1,000 miners). pality is 110,107 people. The most common diseases in Sverdlovsk include cardiovascular diseases and • In 2011, the rate of occupational injuries at Sverdlovan- respiratory diseases. tratsit was 7.63 per 1,000 miners. In comparison, the national average for occupational injuries of miners Table 43. Rate of registered diseases per 1,000 inhabitants in Sverdlovsk was 9.3 per 1,000 miners and was 6.87 and 12.98 for Group of diseases 2005 2006 2007 2008 2009 2010 2011 neighbouring Krasnodonugol and Rovenkiantratsit. All diseases 1580 1603 1598 1676 1659 1641 1694 Diseases of the • In Sverdlovsk, the central hospital treats an average of 710 714 720 730 741 754 781 circulatory system 201.7 traumas per year. DTEK Sverdlovantratsit’s health Diseases of the 214 207 204 234 253 218 246 clinics report an average of 231.2 injuries per year. respiratory system • The most common causes of injuries include col- Diseases of the musculoskeletal 68 74 69 67 67 59 61 lapses (105.6/ year), falls (61/ year), falling objects system and con- (37.8/ year), machine related (12.6/ year), and un- nective tissue Diseases of the derground transport related (9/ year). 26 25 20 19 20 19 20 nervous system • Even though 50 per cent of miners are satisfied with Source: Luhansk Oblast Department of Health (calculations by GfK Ukraine) their working conditions, 75 per cent of miners are worried about the possibility of work-related accidents. Occupational Diseases in Sverdlovsk • Most miners (59%) believe it is impossible to com- According to health officials, the top health ailments plete their daily work tasks (e.g., meeting coal ex- of the general population of Sverdlovsk include dust traction quotas) without deviating from occupa- bronchitis (48%) and pneumoconiosis (38%). In fact, tional safety and health (OSH) safety rules. over the past 10 years, respiratory diseases have • Miners’ spouses and pharmacists play an impor- accounted for 1,388 of 1,543, or nearly 90 per cent, of tant role in the health and wellbeing of miners. At all reported cases of occupational diseases.

Table 44. Occupational diseases reported by the Sverdlovsk Central Hospital, June 2012 Occupational Diseases Reported by the Central Hospital, 2002-2011 Occupational Disease 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Dust Bronchitis (Lungs) 30 36 61 65 19 59 121 105 110 138 744 Pneumoconiosis (Lungs) 66 78 64 43 56 40 68 67 54 54 590 Vibration Diseases 7 6 10 9 1 4 10 18 6 21 92 Nerve-related 1 4 7 4 2 5 8 2 5 8 46 Tubercolosis (Lungs) 3 6 4 5 6 3 4 2 2 3 38 COPD (Lungs) 0 0 0 0 0 0 0 3 7 6 16 Hearing Loss 0 1 0 1 1 0 1 2 0 6 12 Joint-related 0 1 0 0 1 0 0 0 1 1 4 TOTAL 107 132 146 127 86 111 212 199 185 238 1543

42 Sverdlovsk action plan

Traumas in Sverdlovsk Figure 18: Distribution of miners by gender, as of August 2012 While not categorised as an occupational disease, 12000 traumas also affect a large number of the general pop- 10000 ulation in Sverdlovsk. Since 2002, the central hospital 8000 treated an average of 201.7 traumas per year. Over the 6000 same period, DTEK Sverdlovantratsit’s health clinics re- 4000 ported an average of 231.2 injuries per year. 2000

0 The abovementioned data is complicated, as some of Dolzhanskaya- Ya.M.Sverdlova Tsentrosoyuz Kharkovskaya Krasnyi Partizan Total the miners who are injured at the workplace are sent Kapitalnaya for follow-up visits to hospitals, leading to duplicative Total Men Women data. However, in other cases, miners stated that they are forced by their managers to report workplace inju- Figure 19: Distribution of miners by age, as of August 2012 ries as household injuries in order to make the compa- 2000 ny’s safety statistics look better. Still, the figures below 1800 1600 provide a basis to examine traumas in Sverdlovsk. 1400

1200 Figure 17. Traumas reported by the Sverdlovsk Central Hospital and 1000 DTEK Sverdlovantratsit, June 2012 800

500 600

390 400 400 200 377 304 282 280 300 0 Dolzhanskaya- Ya.M.Sverdlova Tsentrosoyuz Kharkovskaya Total 218 Kapitalnaya 252 179 183 179 200 243 18-30 31-40 41-50 51-60 60+ 224 149 148 187 174 164 152 100 133 111 Table 46. The distributions of miners by occupation in Sverdlovantratsit 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Under- Above Adminis- Stope Sink- Central Hospital DTEK Sverdlovskantratsit Mine ground ground trative sup- miners ers workers workers port staff Dolzhanskaya- 353 182 2396 911 57 Kapitalnaya 9.3 DTEK Sverdlovantratsit Ya.M.Sverdlova 184 98 922 211 33 In July 2010, DTEK invested in to the state-owned Tsentrosoyuz 104 47 806 202 35 Sverdlovantratsit, an investment approved by the Kharkovskaya 151 57 784 49 31 Ministry of Coal Industry of Ukraine. Since then, DTEK Krasnyi Partizan 368 180 2968 817 93 has invested in to construction, machinery and tech- Total Mines 1160 564 7876 2190 249 nical equipment to improve the company’s opera- Source: DTEK, August 2012 tions. Simultaneously, the city of Sverdlovsk joined Figure 20: Distribution of miners by occupation as of August 2012 the DTEK Social Partnership Declaration in order to 9000 develop better living and working conditions. DTEK 8000 Sverdlovantratsit has five mines and three coal wash- 7000 6000 ing facilities. As of August 2012, Sverdlovantratsit 5000 employed 10,315 miners or about 12 per cent of the 4000 adult population of Sverdlovsk. 3000 2000

1000

Table 45. The distributions of miners by gender and age in Sverdlovantratsit 0 Dolzhanskaya- Ya.M.Sverdlova Tsentrosoyuz Kharkovskaya Krasnyi Partizan Total Including Kapitalnaya Mine Total Stope Miners Sinkers Underground Aboveground Administrative Men Women 18-30 31-40 41-50 51-60 60+

Dolzhanskaya- 9.4 Health and Safety of Miners 3364 2614 750 580 1296 460 960 68 Kapitalnaya After conducting medical exams of miners in Sverd- Ya.M.Sverdlova 1166 900 266 462 176 250 211 67 lovsk and Rovenky, the Luhansk Clinic of the Mini Tsentrosoyuz 1043 783 260 480 69 234 202 58 stry of Internal Affairs classified miners into three health groups: I) generally healthy, II) those who have Kharkovskaya 864 585 279 550 19 198 49 48 had acute and/ or chronic disease(s) in the past, and Krasnyi Partizan 3878 3111 767 712 1795 472 817 82 III) those who currently have a chronic disease. Of those Total Mines 10315 7993 2322 2784 3355 1614 2239 323 who took part in the study, 33 per cent were classified Source: DTEK, August 2012 into Health Group I, 13 per cent into Health Group II,

43 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine and 54 per cent into Health Group III. In Rovenky, However, improving the health and safety of miners the top health ailments of miners are respiratory disea will require engagement of the public and private ses, cardiovascular disease, occupational injuries (trau- sectors. Thus, UNDP has contacted the Ministry of ma), and musculoskeletal conditions. Health, Ministry of Emergencies, and State Committee In fact, more than 37 per cent of miners in Sverdlovsk of Ukraine on Industrial Safety, Labour Protection and and neighbouring Rovenky suffer from respiratory dis- Mining Supervision and will seek to engage them in eases. Chronic bronchitis alone affects 330 per 1,000 the implementation phase of the project as well. miners—a rate seven times higher than the general In phase two of the project, UNDP will conduct a roundta- adult populations in Sverdlovsk and Rovenky. Fur- ble discussion between DTEK, Metinvest, and represent- thermore, about 18 per cent of miners in Sverdlovsk atives from government entities, including the Ministry and Rovenky suffer from cardiovascular diseases. For of Health, Ministry of Emergencies, State Committee on example, 57.6 per 1,000 miners suffer from ischem- Mining Supervision and Industrial Safety. Once represent- ic heart disease compared to the national average of atives are engaged, UNDP will facilitate further discus- 53.1 per 1,000 people or the European average of 36.3 sions with the abovementioned ministries and represent- per 1,000 people.41 As for musculoskeletal conditions, atives from the Luhansk Regional State Administration the most common conditions of miners in Rovenky and cities of Krasnodon, Rovenky and Sverdlovsk. Con- and Sverdlovsk are osteochondrosis (68 per 1,000 min- currently, UNDP will contact potential partners, including ers) and lower back pain (42 per 1,000 miners). the European Union and interested parties (e.g., neigh- The rate of occupational injuries at Sverdlovantratsit in bouring government donors), about joining this effort. 2011 was 7.63 per 1,000 miners. In comparison, the national average for occupational injuries of miners was 9.3 9.6 General Recommendations per 1,000 miners and was 6.87 and 12.98, respectively, for • Sverdlovsk needs at least two modern and ful- neighbouring Krasnodonugol and Rovenkiantratsit. In an ly-equipped ambulances to meet minimum emer- opinion survey conducted by GfK Ukraine, 50 per cent of gency response standards (McSwain, N.E. (1991) miners from Sverdlovantratsit and Rovenkiantratsit stated proposes 1 ambulance per 50,000 residents. Oth- that they are satisfied with their working conditions, even ers argue that this number should be closer to 1 though 75 per cent of miners also stated that they are ambulance per 10,000 residents. Sverdlovsk, with worried about the possibility of work-related accidents. a population of over 110,000 people, should have between 2 and 10 modern ambulances). 9.5 Priorities • The hospitals’ medical equipment and training should Key stakeholders—miners, doctors and government be upgraded to improve diagnostic and emergency officials—prioritised the following as most pressing medical services. At minimum, the hospitals should issues to address. get a portable ultrasound machine, x-ray machines, 1. Improve emergency medical transport (high priority) and arthroscopic surgery equipment (specific details are outlined in the subsequent section). 2. Upgrade hospital equipment to better diagnose occupational diseases (high priority) • Data on the health and safety of miners should be systematised into an electronic database. This will 3. Invest in personal and collective safety equipment, make the data more robust, accessible and usable. including warning signs (medium priority) • DTEK Rovenkiantratsit should purchase washing 4. Social services for injured miners (medium priority) and drying machines to clean miners’ work clothes 5. Underground medical equipment for miners (medi- on its premises. um priority) • DTEK Rovenkiantratsit should provide workers Among this list, the stakeholders prioritised upgrading with sufficient amount of respirators and inter- hospital equipment and improving emergency medi- changeable filters. Workers should also be includ- cal transport as the most important issues to address. ed in choosing safety equipment so that management understands the workers’ needs. Next Steps Sverdlovsk has strong community leadership and po- • DTEK Rovenkiantratsit should consider providing clean litical will to make things happen. Upgrading human and heated means of transportation to and from work. and medical capacities will go a long way to improve • A comprehensive health education and promotion the health and wellbeing of miners and the commu- campaign should be advanced within the framework nity at-large. This action plan focuses on upgrading of this project. Schools and other educational institu- both emergency and preventative health services to tions should be used to promote healthy living. reduce miners’ susceptibility to cardiovascular disease, • Nutritional policies and planning should ba respiratory disease and trauma. lance traditional cuisine with nutrition guidelines

44 Sverdlovsk action plan

outlined in the “Health of the Nation” (2002- vehicles and long commute times to hospitals make it 2011), which was adopted by the Cabinet of Min- imperative to improve emergency transport services isters in 2002, or with World Health Organization as medical services provided — or not provided — in guidelines. the minutes en route to a hospital can be the differ- • Miners should have access to 2.0-2.5 litres of clean ence between life and death. drinking water every day, as recommended by Recommendation: Sverdlovsk needs at least two the European Food Safety Authority (2.0 litres for modern and fully-equipped ambulances to meet min- women and 2.5 litres for men). Water intake should imum emergency response standards (McSwain, N.E. be staggered throughout the day, as even one per (1991) proposes 1 ambulance per 50,000 residents. cent of loss in bodyweight due to fluid deficiency Others argue that this number should be closer to can impair a person’s ability to concentrate. 1 ambulance per 10,000 residents. Sverdlovsk, with • Promote the use of the prophylactic sanatorium a population of over 110,000 people, should have during miners’ second vacation by allowing miners between 2 and 10 modern ambulances). In addition, to bring their families with them to the sanatoriums. existing vehicles should be equipped with emergen- • Pharmacists should be included in health strate- cy medical supplies, including AEDs, intravenous gies since miners depend on them heavily. lines and fluids, essential medicines, cervical collars, stretchers, spinal boards, first aid kits, radios and oxy- • Likewise, miners’ spouses should be included in gen deployment kits. health strategies since they play a functional role in the health of miners. In the future, the entire fleet of vehicles should be replaced with modern ambulances. Moreover, according • Nutritional policies and planning should balance to international standards, ambulances should have traditional cuisine with nutrition guidelines out- three-member crews, all of whom have passed emer- lined in the “Health of the Nation” (2002-2011), gency medical technician (EMT) courses. Such a course which was adopted by the Cabinet of Ministers in usually lasts more than 3 weeks and at minimum, teaches 2002, or with World Health Organization guidelines. how to administer cardiopulmonary resuscitation (CPR), • Miners should have access to 2.0-2.5 litres of clean pass a chest tube, and introduce an intravenous line. drinking water every day, as recommended by the European Food Safety Authority (2.0 litres for wom- Activity One: The first activity is to procure two ful- en and 2.5 litres for men).42 Water intake should be ly-equipped modern ambulances, as well as equip- staggered throughout the day, as even one per ment to upgrade the existing fleet of ambulances. The cent of loss in bodyweight due to fluid deficiency steps involved in this activity include: can impair a person’s ability to concentrate. • Review and revise the proposed procurement list as • DTEK, Sverdlovsk, and neighbouring communities necessary (Responsible Parties: UNDP and Central should consider obtaining an air ambulance to Hospital) service mining communities in the Luhansk oblast. • Work with procurement specialists to ensure legal compliance and technical specifications of the 9.7 Action Items ambulances and equipment (Responsible Parties: 9.7.1 Improve Emergency Transport UNDP and Central Hospital) Background: Sverdlovsk’s Rescue Services has 10 bri- • Conduct internationally competitive bidding pro- gades, along with 4 subdivisions, which are led by 2 doc- cess to ensure best value (Responsible Parties: UNDP) tors and 8 paramedics. The “ambulances” are actually old, refurbished military vehicles which lack basic emergen- Activity Two: The second activity is to conduct cascade cy medical equipment with only one working automat- trainings for using the newly acquired equipment. The ic external defibrillator (AED) among the entire Rescue steps involved in this activity include: Service unit. The lack of modern vehicles and equipment • Draft training agenda for members of the Rescue severely limits the effectiveness of the Rescue Services. Service (Responsible Parties: UNDP and head(s) of Moreover, because of the depths of the mines and poor Rescue Services) conditions of the roads, it may take up to one hour to • Train staff members of the Rescue Service to use new- get an injured miner from the bottom of the mines to ly acquired equipment (Responsible Party: UNDP) a local hospital (15 km drive). If a patient needs to go • Monitor, review, and adjust procedures as neces- to a special center in Luhansk or Donetsk, it will take sary (Responsible Party: Rescue Services) 2 hours and 4-6 hours, respectively. Poorly equipped

45 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine

Table 47. Proposed list of equipment to procure to improve emergency transport (to be revised with Rescue Services unit) Item Description Quantity Unit Price Total Transports patients to health centers; fully equipped ambulance will include defibrillator, Ambulances intravenous lines and fluids, essential medicines, cervical collar, stretcher, spinal board, 2 $75,000 $150,000 first aid kits, radios, oxygen kits, etc. Automated external defibrillators (AEDs) 10 $1,500 $15,000 Intravenous lines and fluids 10 $1,000 $10,000 Cervical collars 10 $100 $1,000 Spinal boards 10 $300 $3,000 Equipment to upgrade Stretchers 10 $300 $3,000 existing ambulances First aid kits (e.g., burn pack, bandages, dressings, gauze rolls, adhesive tape) 10 $200 $2,000 Two-way radio communication between emergency medical technician and dispatcher 10 $250 $2,500 Oxygen deployment kits 10 $400 $4,000 Misc. (stethoscope, thermometer, cold packs, blankets, towels, masks, gloves, disinfectant) 10 $250 $2,500 Total: $193,000

Table 48. Proposed fees for consultant to conduct cascade trainings machines in the central hospital, as well as one in each Quan- Unit Item Description Total of the surrounding health clinics. tity Price Fees for 12-day consultation 12 $500 $6,000 • Hospital Beds: Sverdlovsk has 720 hospital beds, Consul Travel costs 1 $1,000 $1,000 or 62 beds per every 10,000 people. This figure is tant Miscellaneous (e.g., internet, printing) 1 $1,500 $1,500 higher than the recommended number of 51 beds Total: $8,500 per 10,000 people. However, many of the beds in the central hospital need to be replaced, and Ward 9.7.2 Upgrade Hospital Equipment 2 does not have any functional beds at all. to Better Diagnose Occupational Diseases Recommendation: While hospital beds are not a priority, Background: Most of the medical equipment in Ward 2 could use five hospital beds at minimum. In the Sverdlovsk is from the 1980s and obsolete. Thus, many future, at least 20 more hospital beds for rehabilitation doctors make diagnoses based on intuition rather and acute care patients, with attachments for respirator than on hard evidence. Upgrading medical equipment apparatus, oxygenators and other vital life-saving would go a long way to improve much needed devices should be considered to replace older beds. early detection, prevention and treatment efforts. • Fluorography Machine: Polyclinics do not have The following highlights some of the problems with regular access to ultrasound or fluorography the outdated equipment, as well as recommendations equipment — both necessary for making accurate of what purchases should be made moving forward. diagnoses for illnesses and injuries. • X-Ray Machines: The x-ray department examines Recommendation: Fluorography machines are a type about 30 patients per day, conducting a total of of x-ray machine that are commonly used to diagnose 50-60 x-rays per day. However, two of the four sta- lung diseases. Considering the high number of miners tionary x-ray machines do not function properly. affected with respiratory diseases in Sverdlovsk, it Moreover, other departments (i.e., trauma) do not is crucial to have at least two of these machines to have working x-ray machines at all. properly diagnose and treat those affected with Recommendation: At least five portable x-ray machines respiratory diseases. are needed to replace outdated equipment and sustain • Arthroscopic Surgery Equipment: The trauma a minimum level of service. In the future, there should department states that over 30 per cent of its cas- be a gradual shift to programmes in each department es deal with miners. Yet the department is sorely to handle the technological shift to digital equipment. lacking equipment, including arthroscopic sur- • Ultrasound Machines: The central hospital has gery equipment, and some simple procedures are one stationary ultrasound machine for all of its delayed due to a lack of equipment. patients. The ultrasound machine, which is used to Recommendation: Arthroscopic surgery equipment diagnose traumas and illnesses, is limited in its ef- (e.g., cannulae, sterile tubing, arthroscopic resection fectiveness as it cannot be moved to where injured blades) is used for minimally invasive procedures to or sick patients are located. examine, diagnose, and treat joint problems. While there Recommendation: At least one portable ultrasound are many different types of equipment, five complete machine is needed to diagnose illnesses and injuries kits would greatly boost the department’s efforts. (e.g., abdomen, liver problems). In the future, there • Intensive Care Units (ICUs): Many wards, includ- should be more than two portable ultrasound ing intensive care units, lack necessary emergency

46 Sverdlovsk action plan

medical equipment, including crash carts, electro- • Conduct internationally competitive bidding pro- cardiographs, heart monitors and automatic exter- cess to ensure best value (Responsible Party: UNDP) nal defibrillators (AEDs). Recommendation: Equipment for ICUs is vital, Activity Two: The second activity is to train staff to use especially when treating heart attacks, strokes or other the newly acquired equipment. The steps involved in emergency situations. Thus, minimum additions should this activity include: be made, including the abovementioned equipment. • Select 10 hospital staff members to participate in cas- • Diagnostic Equipment: The central hospital and cade trainings (Responsible Party: Central Hospital) surrounding policlinics lack basic medical equip- • Conduct cascade trainings for hospital staff (Re- ment (e.g., fluorography machines, spirometers, and sponsible Party: UNDP) pulse oximeters) to diagnose diseases, including • Have hospital staff members conduct trainings to their those for commonly observed respiratory diseases. staff members (Responsible Party: Central Hospital) Recommendation: Equipment for early detection is vital to help prevent respiratory and cardiovascular 9.7.3 Strengthen Preventative (Primary) diseases. Many doctors and nurses are currently using Health Efforts their intuition to make diagnoses when relatively Background: While doctors in Sverdlovsk spend inexpensive diagnostic equipment (e.g., spirometers) 4 hours every week on preventative work, there is can make a big difference. no community-wide strategy that involves schools, Activity One: The first activity is to procure medical workplaces, and government entities to promote equipment for the hospitals in Sverdlovsk. The steps preventative health efforts. In addition, miners for- involved in this activity include: go preventative health measures such as sanatorium visits, mostly because they cannot take their families • Review and revise the proposed list of medical with them. For example, of 1,161 people of a particu- equipment (see Figure 9) (Responsible Parties: lar mine, only 323 miners went took advantage of the UNDP and Central Hospital) sanatorium in Crimea and only 37 went to the one • Work with Technical Advisor to ensure technical in Sverdlovsk. DTEK Sverdlovantratsit also provides compatibility of new equipment (Responsible Par- weekly health courses, but these are not part of a ties: UNDP and Central Hospital) larger, comprehensive effort.

Table 49. Proposed list of medical equipment to procure (to be revised with the Central Hospital as necessary) Item Description Quantity Unit Price Total Diagnoses traumas and illnesses (e.g., cardiovascular disease); inclusive of supporting Portable ultrasound machine 1 $50,000 $50,000 software costs Electrocardiographs (ECG) Interprets electrical activity of the heart, including the presence of any damage 5 $1,000 $5,000 Tracks heart functions and alerts staff to any sudden changes in vital heart Heart monitors 3 $5,000 $15,000 functioning Electric-shock, life-saving apparatus for victims of heart attacks, for patients Defibrillators 3 $3,000 $9,000 in intensive care Portable x-ray machines Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 Fluorography machine Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 Diagnoses chronic obstructive pulmonary disease (COPD), a.k.a. chronic Spirometers 8 $250 $2,000 obstructive lung disease (COLD) Pulse oximeters Measures oxygen levels and diagnoses patients’ breathing and circulatory problems 5 $200 $1,000 Crash carts Serves in emergency situations with defibrillator, pulse oximeter, etc. 4 $3,000 $12,000 Tools for minimally invasive surgical procedure to examine, diagnose and treat Arthroscopic surgery kits 6 $500 $3,000 joint issues (e.g., cannulae, sterile tubing, arthroscopic resection blades) Beds for rehabilitation and acute care patients with attachments for respirator Hospital beds 6 $500 $3,000 apparatus, oxygenators, and other life-saving devices Total: $200,000

Table 50. Proposed fees for consultant to conduct trainings Recommendation: Half of all deaths before the age Item Description Quantity Unit Price Total of 75 can be prevented through targeted programmes Consultant Fees for 12-day consultation 12 $500 $6,000 to modify behaviours and improve environmental Travel costs 1 $1,000 $1,000 conditions.43 Moreover, the Institute of Occupational Miscellaneous (e.g., internet, 1 $1,500 $1,500 printing) Health in Kyiv estimates that compensation costs are Total: $8,500 approximately six times higher than what it would cost

47 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine to protect workers or treat them at earlier stages of oc- The core curriculum for this health promotion training cupational diseases.44 The European Agency for Safety would include: and Health at Work also states the investments in oc- • Salutogenesis: Health, Illness and Wellbeing cupational health and safety have very high returns on • Determinants of Health investment in terms of earning, improvement of a company’s image, and reducing insurance and compensa- • Principles of Health Promotion tion costs.45 Thus, Sverdlovsk needs a comprehensive • Evidence-based Methods of Health Promotion health promotion campaign to change habits, as well • Prioritisation and Planning of Interventions as change the fatalistic mindsets of miners who do not • Health Promotion Evaluation think they can affect their own health and wellbeing. • Methods of Structural and Individual Behaviour Activity One: The first activity is to conduct health Change promotion campaign and trainings. Such a campaign • Assessment of Health Impact and Investment would focus on the primary health ailments affecting miners: respiratory and cardiovascular diseases. A good Activity Two: The second activity is to conduct a diet model for DTEK to consider is Metinvest’s train-the- and nutrition programme for miners. UNDP will exam- trainers programme in Krasnodon, which trained 35 ine the diet and nutrition of miners. Nutritional exams retired miners in occupational health and safety proce- would begin by asking miners to keep a “food diary” dures, who in turn trained 6,959 managers and supervi- to understand what miners consume on a daily basis. sors later on. The steps involved in this activity include: UNDP will then conduct interviews and focus groups • Conduct tri-annual health promotion meetings to complement information gathered from the food di- and workshops to discuss community-wide strate- aries. Simultaneously, UNDP will conduct a nutritional gy on health promotion (Responsible Parties: City analysis of menus from the canteens in the mines. Final- of Sverdlovsk, DTEK, UNDP) ly, UNDP will provide suggestions for alternative diets. • Select at least 10 participants representing the private sector, government, education, and other rel- Table 51. Proposed budget for strengthening primary (preventative) health efforts evant sectors for the cascade training (Responsible Unit Item Description Quantity Total Party: City of Sverdlovsk) Price Consult- Fees for 12-month health • Conduct the cascade trainings on health promo- 1 $32,000 $32,000 tion (Responsible Party: UNDP) ant promotion campaign Fees for diet and nutrition 1 $8,000 $8,000 • Participants conduct trainings at their place of programme work (Responsible Party: Participants) Total: $40,000

48 Sverdlovsk action plan

9.8 Budget Table 52. Proposed budget to implement Sverdlovsk’s action plan Action Item 1: Improve Emergency Transport Quan- Unit Item Description Total tity Price Ambulances Transports patients to health centers; fully equipped ambulance will include defibrillator, intravenous lines 2 $75,000 $150,000 and fluids, essential medicines, cervical collar, stretcher, spinal board, first aid kits, radios, oxygen kits, etc. Equipment to Automated external defibrillators (AEDs) 10 $1,500 $15,000 upgrade exist- Intravenous lines and fluids 10 $1,000 $10,000 ing ambulances Cervical collars 10 $100 $1,000 Spinal boards 10 $300 $3,000 Stretchers 10 $300 $3,000 First aid kits (e.g., burn pack, bandages, dressings, gauze rolls, adhesive tape) 10 $200 $2,000 Two-way radio communication between emergency medical technician and dispatcher 10 $250 $2,500 Oxygen deployment kits 10 $400 $4,000 Misc. (stethoscope, thermometer, cold packs, blankets, towels, masks, gloves, disinfectant) 10 $250 $2,500 Sub-total: $193,000

Proposed Fees for Consultant to Conduct Cascade Trainings Quan- Unit Item Description Total tity Price Fees for 12-day consultation 12 $500 $6,000 Consultant Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., internet, printing) 1 $1,500 $1,500 Sub-total: $8,500

Action Item 2: Upgrade Hospital Equipment to Better Diagnose Occupational Diseases Quan- Unit Item Description Total tity Price Portable ultra- Diagnoses traumas and illnesses (e.g., cardiovascular disease); inclusive of supporting software 1 $50,000 $50,000 sound machine costs Electrocardio- Interprets electrical activity of the heart, including the presence of any damage 5 $1,000 $5,000 graphs (ECG) Heart monitors Tracks heart functions and alerts staff to any sudden changes in vital heart functioning 3 $5,000 $15,000 Defibrillators Electric-shock, life-saving apparatus for victims of heart attacks, for patients in intensive care 3 $3,000 $9,000 Portable x-ray Diagnoses conditions in bones and soft tissues 4 $15,000 $60,000 machines Fluorography Diagnoses tuberculosis, lung cancer, etc. 2 $20,000 $40,000 machine Diagnoses chronic obstructive pulmonary disease (COPD), a.k.a. chronic obstructive lung disease Spirometers 8 $250 $2,000 (COLD) Pulse oximeters Measures oxygen levels and diagnoses patients’ breathing and circulatory problems 5 $200 $1,000 Crash carts Serves in emergency situations with defibrillator, pulse oximeter, etc. 4 $3,000 $12,000 Arthroscopic Tools for minimally invasive surgical procedure to examine, diagnose and treat joint issues (e.g., 6 $500 $3,000 surgery kits cannulae, sterile tubing, arthroscopic resection blades) Beds for rehabilitation and acute care patients with attachments for respirator apparatus, oxygen- Hospital beds 6 $500 $3,000 ators, and other life-saving devices Sub-total: $200,000

Proposed Fees for Consultant to Conduct Trainings Quan- Unit Item Description Total tity Price Fees for 12-day consultation 12 $500 $6,000 Consultant Travel costs 1 $1,000 $1,000 Miscellaneous (e.g., internet, printing) 1 $1,500 $1,500 Sub-total: $8,500

Action Item 3: Strengthen Preventative (Primary) Health Efforts Quan- Unit Item Description Total tity Price Fees for 12-month health promotion campaign 1 $32,000 $32,000 Consultant Fees for diet and nutrition programme 1 $8,000 $8,000 Sub-total: $40,000

TOTAL: $450,000

49 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine personnel required, airport landing fees, and distance 10. Regional considerations ground ambulances need to travel. In some cases, air ambulance services are provided on a 10.1 Air Ambulance fee-for-service basis. In others, companies may choose Background: Throughout Ukraine, most special to fund local air ambulance services as a donation to care centres (e.g., burn units) are located in major ur- the community. In the United Kingdom, Santander ban hospitals. For miners in Krasnodon, Rovenky and Corporate Banking and Virgin Group sponsor London’s Sverdlovsk, this means that some life-saving servic- Air Ambulance (LAA) operations.49 In New Zealand, es can only be obtained in large cities like Luhansk or several companies co-sponsor the Westpac Waikato Donetsk, which are 50km and 190km away, respective- Air Ambulance service.50 ly. These distances, combined with the area’s notori- Recommendation: An air ambulance makes sense ously poor road conditions, make emergency medical considering the number of miners who require transportation very difficult (for example, the city of special care following a coal mine explosion or Krasnodon has 50.3km of roads, 29.8km of which are in cardiac arrest. However, representatives from the disrepair). Still, travel time to specialised centres must cities of Krasnodon, Rovenky, and Sverdlovsk, be somehow decreased or medical services in Krasno- hospital officials, DTEK, Metinvest, and UNDP should don, Rovenky and Sverdlovsk must be improved. meet to discuss the feasibility of such a decision. To address the former point, some communities are Purchasing and maintaining an air ambulance obtaining air ambulances (e.g., helicopters) to reduce will take community commitment, as well as solid the time required to transport a victim to a special financial and logistical planning. The group should care centre and increase the patient’s chances for a also consider getting an air ambulance that covers successful recovery. Air ambulances not only avoid the entire Luhansk region, or possibly the Luhansk traffic and bumpy roads, they also travel much faster and Donetsk regions, to increase the feasibility and than land vehicles, flying at about 220-270km/ hour. practicality of such a plan. The group might also They also can take off from the ground within 2-5 consider talking to the Government of Ukraine minutes of receiving an emergency request. This all about purchasing an entire fleet of air ambulances equates to response times that are 3-5 times faster for the entire country, similar to what Romania’s than traditional land-based ambulances, possibly the Ministry of Health has done.51 difference between life and death for some patients. Activity One: The first activity is to consider the Still, air ambulances are popular within health systems procurement of an air ambulance. despite inconsistent evidence to support their use. Some • Discuss the interest of procuring and maintaining scholars state that air ambulances are both cost-effective an air ambulance (Responsible Parties: UNDP, Cen- 46 and life-saving. Others argue that the health outcomes tral Hospital, Luhansk Hospital, Metinvest) and costs of air ambulances are unclear; suggesting that what is important is early advanced life support (ALS), • Consult local authorities of Krasnodon, Rovenky, not the mode of transportation.47 There are also studies and Sverdlovsk about their interest of joining the that suggest that air ambulances make sense in the effort (Responsible Parties: Local authorities, DTEK, right location under the right circumstances.48 Before Metinvest, UNDP) investing in an air ambulance, Krasnodon, Rovenky, and • Consult air ambulance companies about financial Sverdlovsk should carefully consider the financial and and logistical procedures (Responsible Parties: UNDP, logistical requirements of owning one. Central Hospital, Luhansk hospital, DTEK, Metinvest) Financial Considerations: An air ambulance can • Consult the Luhansk and Donetsk oblast adminis- cost over $1.5 million, not including operational, trations about supporting the efforts (Responsible maintenance, or training costs. Each mission may cost Parties: Local authorities, DTEK, Metinvest, UNDP) up to $2,000 with annual maintenance fees possibly • Discuss preliminary plans of whom and how the costing over $165,000, although some operational air ambulance would be sustained after the pur- costs may be reduced by securing VAT exemptions chase. (Responsible Parties: Local authorities, on gas, for example. In addition, the air ambulance DTEK, Metinvest, Luhansk State Regional Adminis- will require trained pilots and should be staffed with tration, UNDP) an emergency medical technician (EMT), nurse and/ • Pursue potential donors about contributing to the or trauma doctor. The actual cost of each mission will effort (Responsible Parties: UNDP, local authorities, vary based on the distance flown, number of medical DTEK, Metinvest)

50 Regional considerations

Activity Two: If the aforementioned parties agree, the Table 53 Proposed procurement list to improve emergency transport second activity will be to procure an air ambulance. Item Description Quantity Unit Price Total Modern, fully-equipped dou- • Work with procurement specialists to ensure legal Air ble-engine ambulance with defibrillator, intravenous ambu- 1 $1,500,000 $1,500,000 compliance and technical specifications of the air lines and fluids, stretcher, ambulance (Responsible Parties: UNDP and Cen- lance cervical collar, spinal board, tral Hospital(s)) first aid kits, oxygen kits, etc. Con- Fifteen-day consultation on • Conduct internationally competitive bidding process sult- maintaining an air ambu- 1 $12,000 $12,000 lance service to ensure best value (Responsible Parties: UNDP) ant Total: $1,512,000

51 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine 11. Appendix

Appendix: extended lists of officially registered diseases among the population of surveyed cities

Table 54. Rate of registered diseases per 1,000 inhabitants in Krasnodon Diseases 2005 2006 2007 2008 2009 2010 2011

All diseases 1508.6 1557.9 1584.4 1690.3 1569.0 1727.8 1749.2 Diseases of the blood and blood-forming organs and certain disorders involving the 17.4 17.4 17.5 17.7 17.8 17.9 18.0 immune mechanism Endocrine, nutritional and metabolic diseases 36.5 38.1 37.6 40.2 41.0 43.0 45.7 Diseases of the nervous system 10.4 11.8 9.7 10.0 9.8 10.1 10.5 including diseases of peripheral nervous system 1.9 2.1 2.4 2.0 2.1 2.1 2.1 Vegetovascular dystonia 3.9 4.4 4.2 4.4 4.6 4.8 5.1 Diseases of the eye and adnexa 50.9 63.6 68.5 56.2 50.7 58.7 50.4 Hearing loss 6.0 5.2 6.5 5.9 5.3 4.9 4.9 Diseases of the circulatory system 768.7 789.8 799.3 822.9 825.5 840.6 859.8 Hypertensive diseases (all forms) 277.0 400.4 406.5 419.7 425.1 433.1 440.6 Other heart diseases 1.8 1.9 1.9 2.0 2.0 2.0 2.1 Paroxysmal tachycardia and heart arrhythmia 0.0 0.7 1.1 1.4 1.7 1.9 1.9 Cerebrovascular diseases 82.8 83.3 85.3 85.5 83.5 82.9 30.6 Strokes (all forms) 3.9 3.2 3.2 3.3 3.4 3.1 3.1 Atherosclerosis 1.4 1.4 1.6 1.6 1.5 1.4 1.5 Other peripheral vascular diseases 0.3 0.3 0.4 0.4 0.4 0.4 0.4 Phlebitis, thrombophlebitis, varicosity 0.6 0.8 0.9 3.6 3.1 3.0 2.9 Diseases of the respiratory system 219.8 211.9 222.8 210.1 209.9 225.6 217.2 including acute pharyngitis and acute tonsillitis 3.5 4.0 3.3 2.6 2.6 2.3 2.5 Acute laryngitis and tracheitis 1.9 2.5 2.4 5.3 3.3 4.6 4.3 Pneumonia 3.1 2.4 2.9 2.9 3.2 3.3 2.8 Allergic rhinitis 0.4 0.5 0.3 1.3 1.3 2.6 3.1 Chronic rhinitis, nasopharyngitis and pharyngitis 0.8 1.1 0.6 0.7 0.5 0.7 1.1 Chronic diseases of tonsils and adenoids 3.8 3.7 3.3 3.0 3.6 3.6 4.2 Chronic laryngitis and laryngotracheitis 0.5 0.7 0.6 0.6 0.6 0.6 0.7 Chronic bronchitis 59.2 58.8 57.5 57.2 42.0 42.1 43.3 Other chronic obstructive pulmonary diseases 0.0 0.0 0.0 0.0 16.5 17.1 17.3 Bronchial asthma 4.5 4.7 4.7 4.7 4.6 4.8 4.9 Pneumonomycosis 30.7 30.1 29.5 29.3 28.8 29.0 28.5 Diseases of the digestive system 176.5 173.9 179.6 180.2 184.4 187.9 191.5 including peptic ulcer 41.9 41.8 41.0 41.1 41.4 41.3 41.9 Gastritis and duodenitis 65.4 63.6 64.6 66.0 69.1 71.0 71.4 Gallstone disease 1.0 1.1 1.4 2.0 2.1 1.8 2.3 Diseases of the pancreas 9.6 10.4 11.1 11.8 12.3 12.7 13.2 Diseases of the skin and subcutaneous tissue 5.4 4.4 8.2 37.8 7.3 38.3 35.6 Diseases of the musculoskeletal system and connective tissue 47.1 52.1 53.1 50.8 49.8 47.6 47.5 Including rheumatoid joint inflammation and other inflammatory polyarthropathies 5.7 6.4 5.4 7.5 7.6 6.4 5.8 Arthrosis 22.6 23.3 23.6 23.7 24.4 24.1 24.9 Systemic lupus erythematosis 0.2 0.2 0.1 0.2 0.2 0.2 0.2 Ankylosing spondylitis 0.1 0.2 0.2 0.2 0.2 0.2 0.3 Cervical and other intervertebral disc disorders 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Other specified dorsopathies, spondylopathies 12.8 13.1 15.1 12.7 10.8 9.9 9.6 Diseases of the genitourinary system 50.2 50.7 50.0 47.2 45.9 47.3 54.6 Renal and ureteral calculi 1.3 0.0 1.8 1.4 1.5 1.3 1.2 Cystitis 1.0 1.3 1.4 0.9 0.8 0.6 0.7 Prostatic diseases 1.6 2.4 4.0 2.9 2.9 2.0 1.8 Injury, poisoning and certain other consequences of external causes 49.9 52.9 51.6 48.2 43.2 41.3 34.1 Source: Luhansk Oblast Department of Health, September 2012

52 Appendix

Table 55. Rate of registered diseases per 1,000 inhabitants in Rovenky Diseases 2005 2006 2007 2008 2009 2010 2011

All diseases 1489.8 1474.7 1475.5 1467.7 1574.4 1572.6 1613.4 Diseases of the blood and blood-forming organs and certain disorders involving 6.8 6.3 6.6 7.3 7.1 8.3 8.5 the immune mechanism Endocrine, nutritional and metabolic diseases 46.1 47.1 48.9 50.5 56.1 55.7 56.4 Diseases of the nervous system 14.6 13.0 12.8 11.2 12.4 14.2 15.6 including diseases of peripheral nervous system 1.3 1.1 0.6 0.3 0.4 0.6 0.8 Vegetovascular dystonia 7.5 7.0 6.1 6.3 6.3 6.9 6.9 Diseases of the eye and adnexa 73.2 80.3 71.2 80.6 87.5 108.1 114.7 Hearing loss 4.5 4.5 3.2 3.2 2.7 3.2 4.4 Diseases of the circulatory system 604.3 620.4 614.0 628.0 671.3 675.5 676.9 Hypertensive diseases (all forms) 270.6 279.0 278.9 285.2 307.1 305.1 303.5 Other heart diseases 0.7 0.7 0.8 0.6 0.6 0.4 0.6 Paroxysmal tachycardia and fibrillation atrial 0.0 1.0 1.9 1.3 1.3 1.0 0.9 Cerebrovascular diseases 93.4 89.2 84.6 82.1 83.7 85.8 85.9 Strokes (all forms) 5.1 4.8 4.3 4.6 4.7 4.4 3.9 Atherosclerosis 1.1 1.0 0.9 4.0 4.6 1.3 1.0 Other peripheral vascular diseases 0.2 0.2 0.2 0.2 0.3 0.6 0.2 Phlebitis, thrombophlebitis, varicosity 0.3 0.4 0.5 2.2 3.0 4.4 3.5 Diseases of the respiratory system 228.0 214.6 230.4 208.0 267.3 242.3 263.6 including acute pharyngitis and acute tonsillitis 10.5 12.5 16.3 13.9 13.7 18.0 19.9 Acute laryngitis and tracheitis 2.1 2.1 3.2 3.3 3.0 3.2 3.0 Pneumonia 7.6 6.4 6.7 5.2 5.3 7.9 7.7 Allergic rhinitis 1.0 1.6 1.4 1.7 1.5 1.7 1.5 Chronic rhinitis, nasopharyngitis, pharyngitis 2.7 2.7 2.6 2.9 2.6 2.3 2.4 Chronic diseases of tonsils and adenoids 1.9 2.1 2.3 2.1 2.2 2.3 2.0 Chronic laryngitis, laryngotracheitis 0.3 0.3 0.4 0.3 0.3 0.4 0.3 Chronic bronchitis 45.1 43.0 40.7 43.0 37.5 39.3 39.9 Other chronic obstructive pulmonary disease 44.1 0.1 0.2 0.2 10.9 4.7 15.2 Bronchial asthma 3.3 3.1 3.4 3.6 3.9 4.1 4.3 Pneumoconiosis 45.1 42.1 40.0 39.9 38.9 36.6 36.0 Diseases of the digestive system 115.5 111.6 111.8 110.8 109.3 110.6 106.1 including gastric ulcer and duodenal ulcer 21.9 21.8 21.2 19.7 15.8 17.8 17.3 Gastritis and duodenitis 25.4 24.1 22.7 22.5 19.2 23.6 24.0 Cholelithiasis 1.7 1.9 2.1 2.1 2.6 2.9 2.4 Diseases of the pancreas 17.7 18.0 17.8 18.7 16.5 18.3 18.1 Diseases of the skin and subcutaneous tissue 57.1 50.9 52.9 45.3 42.3 38.0 47.6 Diseases of the musculoskeletal system and connective tissue 58.6 56.9 51.1 48.1 51.9 50.4 52.6 including rheumatoid arthritis and other inflammatory polyarthropathies 4.3 4.3 5.3 5.1 3.0 4.3 4.7 Arthrosis 21.9 21.0 20.9 20.3 20.5 17.7 21.5 Systemic lupus erythematosus 0.2 0.1 0.1 0.1 0.1 0.1 0.1 Ankylosing spondylitis 0.2 0.2 0.3 0.3 0.4 0.4 0.6 Cervical and other intervertebral disc disorders 17.5 16.2 13.9 11.8 14.8 14.0 14.1 Other specified dorsopathies, spondylopathy 6.7 5.8 4.6 5.7 4.6 5.5 4.9 Diseases of the genitourinary system 37.6 38.6 40.7 39.2 42.7 43.2 48.8 Calculi of kidney and ureter 4.1 4.2 3.8 4.5 6.0 5.3 5.8 Cystitis 2.2 2.9 2.3 1.9 2.7 2.0 2.1 Prostate gland diseases 5.0 4.6 5.9 5.6 5.1 7.2 4.6 Injury, poisoning and certain other consequences of external causes 84.5 76.4 73.2 67.7 67.8 66.4 61.8 Source: Luhansk Oblast Department of Health, September 2012

53 Assessment report Improving the Health and Safety of Miners in Eastern Ukraine

Table 56. Rate of registered diseases per 1,000 inhabitants in Sverdlovsk Diseases 2005 2006 2007 2008 2009 2010 2011

All diseases 1579.7 1603.4 1597.8 1675.5 1658.6 1640.6 1693.7 Diseases of the blood and blood-forming organs and certain disorders involving 6.7 8.0 9.3 9.5 10.3 11.1 11.4 the immune mechanism Endocrine, nutritional and metabolic diseases 50.5 52.4 53.4 56.3 54.9 59.8 59.3 Diseases of the nervous system 25.5 25.1 20.0 19.3 19.7 18.6 20.3 including diseases of peripheral nervous system 3.0 3.2 2.9 2.7 2.6 2.1 2.4 Vegetovascular dystonia 4.9 4.8 5.0 4.6 5.0 4.1 4.6 Diseases of the eye and adnexa 47.9 50.3 42.2 40.4 38.4 34.3 31.7 Hearing loss 1.2 1.2 1.2 1.1 2.1 2.1 2.2 Diseases of the circulatory system 709.6 714.1 720.1 729.5 740.6 753.7 780.9 Hypertensive diseases (all forms) 310.8 318.4 322.8 326.3 333.5 341.6 349.9 Other heart diseases 5.3 5.4 5.6 5.8 5.5 5.5 6.0 Paroxysmal tachycardia and fibrillation atrial 0.0 1.2 1.2 1.2 1.3 1.3 1.3 Cerebrovascular diseases 85.1 83.8 82.2 83.1 81.5 80.3 84.6 Strokes (all forms) 3.7 3.6 2.8 3.9 3.6 3.8 3.9 Atherosclerosis 5.7 6.0 5.1 4.6 4.5 4.3 4.2 Other peripheral vascular diseases 0.3 0.3 0.3 0.3 0.4 0.4 0.4 Phlebitis, thrombophlebitis, varicosity 2.5 2.7 3.3 6.6 6.5 6.6 6.0 Diseases of the respiratory system 214.2 206.5 204.3 234.4 253.1 218.0 246.2 including acute pharyngitis and acute tonsillitis 7.9 7.8 7.3 12.9 8.5 8.5 9.8 Acute laryngitis and tracheitis 1.8 1.8 1.9 1.6 1.0 0.7 2.1 Pneumonia 5.5 5.0 4.6 5.0 7.1 9.7 13.6 Allergic rhinitis 1.4 2.5 1.6 2.6 1.2 2.8 1.5 Chronic rhinitis, nasopharyngitis, pharyngitis 1.4 1.2 1.2 0.8 0.9 1.0 0.9 Chronic diseases of tonsils and adenoids 1.2 1.1 1.2 0.8 1.6 1.4 0.9 Chronic laryngitis, laryngotracheitis 0.4 0.4 0.3 0.4 0.5 0.4 0.3 Chronic bronchitis 60.7 62.9 62.8 67.2 48.2 49.3 50.0 Other chronic obstructive pulmonary disease 0.2 0.1 0.2 0.0 21.0 22.8 24.3 Bronchial asthma 2.8 2.8 2.9 2.9 2.9 3.0 2.9 Pneumoconiosis 46.3 45.5 44.1 43.8 43.2 41.6 40.0 Diseases of the digestive system 130.1 132.3 134.9 137.1 138.5 136.1 141.0 including gastric ulcer and duodenal ulcer 36.6 36.9 36.8 36.9 36.4 36.5 36.8 Gastritis and duodenitis 28.4 28.8 29.1 29.5 29.5 29.9 30.3 Choleithiasis 2.1 2.2 2.5 2.4 2.5 2.7 3.0 Diseases of the pancreas 13.1 13.5 14.0 14.4 14.4 14.7 14.9 Diseases of the skin and subcutaneous tissue 17.8 18.8 19.1 34.0 16.1 18.2 13.7 Diseases of the musculoskeletal system and connective tissue 68.2 73.9 69.0 67.3 67.3 59.4 61.1 including rheumatoid arthritis and other inflammatory polyarthropathies 7.6 8.0 7.4 7.1 7.8 7.7 7.1 Arthrosis 27.6 28.1 27.9 28.9 28.8 28.9 29.8 Systemic lupus erythematosus 0.1 0.1 0.2 0.2 0.2 0.2 0.2 Ankylosing spondylitis 0.3 0.3 0.5 0.2 0.3 0.3 0.3 Cervical and other intervertebral disc disorders 0.5 0.4 0.0 0.1 0.0 0.0 0.0 Other specified dorsopathies, spondylopathy 22.8 27.2 24.5 22.1 22.0 13.7 15.2 Diseases of the genitourinary system 56.7 58.4 53.8 57.3 60.1 55.3 66.0 Calculi of kidney and ureter 4.0 3.7 4.9 6.2 6.7 6.5 7.0 Cystitis 5.5 5.2 4.0 4.1 3.0 2.1 2.3 Prostate gland diseases 6.8 6.4 5.7 6.9 5.6 4.8 4.9 Injury, poisoning and certain other consequences of external causes 122.0 122.0 132.8 122.1 124.2 136.8 121.0 Source: Luhansk Oblast Department of Health, September 2012

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58 Endnotes

31. European Agency for Safety and Health at Work. who.int/en/where-we-work/member-states/ukraine/ “Annual Report 2011.” (Bilbao: EU-OSHA, 2012), https:// publications3/10-health-questions-about-the-new- osha.europa.eu/en/publications/annual_report/ eu-neighbours-ukraine. 2011full. Accessed 3 July 2012. 42. EFSA Panel on Dietetic Products, Nutrition, and Al- 32. World Health Organization. “1o Health Questions lergies (NDA). “Scientific Opinion on Dietary Reference about the new EU Neighbours—Ukraine.” World Health Values for water.” EFSA Journal, 8(3):1459. Accessed Organization. Accessed 30 July 2012, http://www.euro. 10 July 2012, http://www.efsa.europa.eu/it/scdocs/ who.int/en/where-we-work/member-states/ukraine/ doc/1459.pdf. publications3/10-health-questions-about-the-new- 43. World Bank, “Combating Ukraine’s Health Cri- eu-neighbours-ukraine. sis: Lessons from Europe.” ECA Knowledge Brief. 33. Parliament of Ukraine, “City of Rovenky, Luhansk Accessed 1 July 2012: http://web.worldbank. Oblast.” Accessed 3 September 2012, http://w1.c1.rada.gov. org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/0,,- ua/pls/z7502/A005?rdat1=20.10.2003&rf7571=18997. contentMDK:22456440~pagePK:146736~piP- 34. World Health Organization. “1o Health Questions K:146830~theSitePK:258599,00.html. about the new EU Neighbours—Ukraine.” World Health 44. Billig, Patricia, Daane, Janelle, and Dobrovolsky, Organization. Accessed 30 July 2012, http://www.euro. Leondard. “An Assessment of Environmental and Oc- who.int/en/where-we-work/member-states/ukraine/ cupational Health Activities Conducted for the USAID publications3/10-health-questions-about-the-new- Mission to Ukraine.” (Washington, DC: USAID, 2000): eu-neighbours-ukraine. 62, http://pdf.usaid.gov/pdf_docs/PNACH064.pdf. 35. EFSA Panel on Dietetic Products, Nutrition, and Al- 45. EU-OSHA: Annual Report 2011. Accessed 3 July lergies (NDA). “Scientific Opinion on Dietary Reference 2012, https://osha.europa.eu/en/publications/ Values for water.” EFSA Journal, 8(3):1459. Accessed annual_report/2011full. 10 July 2012, http://www.efsa.europa.eu/it/scdocs/ 46. Taylor, CB, Stevenson, M, Jan, S, Middleton, PM, doc/1459.pdf. Fitzharris, M, and Myburgh, JA. “A systematic review of 36. World Bank, “Combating Ukraine’s Health Cri- the costs and benefits of helicopter emergency medi- sis: Lessons from Europe.” ECA Knowledge Brief. cal services.” U.S. National Library of Medicine, Nation- Accessed 1 July 2012, http://web.worldbank. al Institutes of Health, 41, no. 1 (January 2010): 10-20, org/WBSITE/EXTERNAL/COUNTRIES/ECAEXT/0,,- http://www.ncbi.nlm.nih.gov/pubmed/19853251. contentMDK:22456440~pagePK:146736~piP- 47. Kurola, J, Wangel, M, Uusaro, A, and Ruokonen, E. K:146830~theSitePK:258599,00.html. “Paramedic helicopter emergency service in rural Fin- 37. Billig, Patricia, Daane, Janelle, and Dobrovolsky, land—do benefits justify the cost?” U.S. National Li- Leondard. “An Assessment of Environmental and Oc- brary of Medicine, National Institutes of Health, 46, no. cupational Health Activities Conducted for the USAID 7 (August 2002): 779-784. Mission to Ukraine.” (Washington, DC: USAID, 2000): 48. Moradian, MJ, et al. “Helicopter emergency med- 62, http://pdf.usaid.gov/pdf_docs/PNACH064.pdf. ical service in Fars province: the referral trauma 38. EU-OSHA: Annual Report 2011. Accessed 3 center of South of Iran.” U.S. National Library of Med- July 2012, https://osha.europa.eu/en/publications/ icine, National Institutes of Health, 14, no. 5 (May annual_report/2011full. 2012): 300-304. 39. World Health Organization. “1o Health Questions about 49. Shephard News Team. “London HEMS se- the new EU Neighbours—Ukraine.” World Health Organiza- cures future funding.” Shephard. 10 February 2011, tion. Accessed 30 July 2012, http://www.euro.who.int/en/ http://www.shephardmedia.com/news/rotorhub/ where-we-work/member-states/ukraine/publications3/10- london-hems-secures-future-funding/. health-questions-about-the-new-eu-neighbours-ukraine. 50. Westpac Waikato Air Ambulance website. Ac- 40. Parliament of Ukraine, “City of Sverd- cessed 30 July 2012: https://www.rescue.org. lovsk, Luhansk Oblast.” Accessed 3 Septem- nz/westpac-waikato-air-ambulance/sponsors/ ber 2012, http://w1.c1.rada.gov.ua/pls/z7503/ associate-sponsors/. A005?rdat1=11.02.2012&rf7571=19031. 51. Helihub. “Romanian Ministry of Health orders two 41. World Health Organization. “1o Health Questions more EC135s.” 26 April 2012, http://www.helihub. about the new EU Neighbours—Ukraine.” World Health com/2012/04/26/romanian-ministry-of-health-or- Organization. Accessed 30 July 2012, http://www.euro. ders-two-more-ec135s/.

59 United Nations Development Programme in Ukraine

1, Klovsky Uzviz Kyiv, 01021, Ukraine