Gain, wait: Ukraine’s tentative push

Hello and welcome to The Intelligence from The Economist. I'm Jason Palmer.

And I'm Ora Ogunbiyi. Every weekday, we provide a fresh perspective on the events shaping your world.

Cervical cancer is one of the world's deadliest diseases, killing hundreds of thousands of women each year. But vaccinations make it almost entirely preventable. Our correspondent looks at the data to see where those jabs are and aren't being given.

And last week, many of the world's biggest airlines met up for their annual jamboree. They had lots to whinge about, especially how much money they all have trapped in Nigeria. We speak with one frequent flyer about the very real impacts of these blocked funds.

But first— It's now official. Ukraine's long-awaited counteroffensive is underway, as President Volodymyr Zelensky confirmed over the weekend. "It is important that Russia always feels this," Mr. Zelensky said, "that they do not have long left." But he gave no further details. What's clear is a renewed push in Bakhmut, a city that's been reduced to rubble as a psychological, if not tactical, focus of the war. Small Ukrainian gains are becoming apparent, most of all in 3 villages in the eastern region of Donetsk. The Ukrainian spokesman said he'd been authorized to declare the villages liberated from Russian occupation. All this so far is probing, what are called shaping operations. Most of both countries' armies remain in reserve as the actual full-scale battle lines are decided.

So we're now a week into the Ukrainian long-awaited counteroffensive.

Oliver Carroll is our Ukraine correspondent.

So far, it's been a mixed picture. The reports from the front lines straddle a whole range of emotions from upbeat to downright gloomy. But it's important to understand that the picture we're seeing now is still a relatively small, relatively not massive force stretched along various locations on the front. And what everyone is telling me is this is still a very early stage.

So you said the moods range from upbeat to gloomy. Let's, let's start on the positive side of the ledger. What has been going well?

So the most important of these expected offensives is a southward push to break the so-called land bridge, which is the road and rail landmass which is linking Russia to Crimea. And that's the really strategically sensitive point, both for Russia and for Ukraine. It's the only major strategic gain of Vladimir Putin's for the whole war. So let's start there. We're certainly seeing some breakthroughs, but still before the main Russian defence lines in a push which is essentially on the border of Donetsk and Zaporizhzhia. It's essentially in Donetsk, but it's really on the border. And yesterday there was certainly a stream of good news for Ukraine. It was confirmed that they'd taken at least two important villages along that axis, Vlagodatne and Makiivka. And crucially for Makiivka, it's in the high ground, which essentially means that the next stage is then a assault on the main Russian defensive lines. In terms of other good news stories, Ukraine has for the last 2 weeks been making progress around Bakhmut, further northeast. And for Ukraine to essentially take back that city in a very short time, that would be a major win psychologically and politically.

And what about the gloomy side of things? What isn't going so well?

Well, this would have to be the other major push southward in what's essentially the axis which we've been expecting for the most predictable line of attack that essentially goes from Zaporizhzhia region and Ukrainian positions around a village called Orikhiv, going further down towards Melitopol, which is an important strategic city near the Azov Sea. So what we've been seeing there is full frontal fighting from Orikhiv down to Tokmak, which is a strategic railway hub. And obviously, Because of all the stakes involved, because of the time that Russia has had to prepare these defensive positions, it's been hard going. There have been serious losses in top-notch Western equipment and personnel. We know that they've lost mine-clearing vehicles, German Leopard tanks, and half a dozen at least Bradley infantry vehicles. We did certainly at one point think this was going to develop into the main effort. But that's now a question, and we'll see how that develops.

And so in terms of trying to divine what the actual major axis of this counter-offensive is, is that getting any clearer?

It's very early. The full shape of Ukraine's plans aren't clear yet. If there were plans initially, they're being improvised upon. What I was told by a General Staff source was that both sides, both Russia and Ukraine, are involved in what they described as a chess game to draw out each other's reserves. And it's when we start seeing the really big guns committed, we'll see some really interesting things. We've seen perhaps 3 out of the 12 Western-built brigades committed. There may be more brigades we don't know about, but when we start seeing a mass commitment down 1 or 2 axes of attack, that's probably the stage to make an assessment. That might be some time. A military intelligence source told me there was certainly some sense they had been pushed into the counter-offensive before necessarily having all the proper support they needed, especially with regards to fighter jets. His point to me was, you know, Ukraine does need to hurry, but it needs to hurry slowly.

And you briefly mentioned the Kharkovka Dam, which was the big story from last week. How does that play into all of this?

Let's start with the humanitarian picture. It's one thing on the Ukrainian-controlled side, which is being assisted and helped by a pretty competent government response from the Ministry of Infrastructure and so on, but there's very limited things they can do in the Russian-controlled areas, and the picture there is pretty disastrous. There certainly seems to be a picture where the military themselves disoriented, not seeing, not expecting what happened, we're not in a position and certainly not willing to help the local populations. We have issues with water, with disease, and just with general devastation. It's a very grim picture there.

And what about in terms of the counter-offensive though? How has it changed things there?

In terms of how the Kharkovka Dam have changed the military geography of the region, well, it's important to say that the destruction of the bridge alongside the dam has almost certainly put an end to any crossing of heavy weaponry. But importantly, it's not just Ukraine that has to adapt here, because the flooding has also washed away Russian defences, Russian minefields on the eastern side of the Dnieper. Because of the complexity of the military operation, while it was never considered to be a main axis of offensive operations, it was certainly hinted to me that there's now more potential arguably for Ukrainian units to assault using speedboats, perhaps special forces divisions.

And what's the sense that you get of how the Russian side looks? Are they coping well?

Again, this is really early. It seems that they've had some successes halting that most important advance along the Tokmak axis. They have a number of inbuilt advantages, and their artillery, for example. So main major focus still for Ukraine is reducing that Russian artillery advantage. And also disrupting logistics. So in a way, we're still very much in a shaping phase of this counter-offensive. There are a few really key questions that, you know, we still haven't got an answer to. Again, we're very early on in this process. On the artillery front, is the Ukrainian setup of very limited but more exact firepower better than, you know, the Russian mass inexact artillery force? The other thing as well is aviation. You know, on paper Russia has a clear advantage, but Ukrainian air defences are deterring Russian pilots. Will that continue? Many of the Russian pilots are inexperienced. There were massive losses in the first phase of fighting above Kyiv and in Ukraine last year. And there's a similar question for Ukraine: can they win this counter-offensive with brigades of relatively inexperienced but Western-trained soldiers and Western equipment? It's still very early on, but the answers to these three questions will in large part determine the outcome of this counteroffensive, and thus by design, the shape of European geography for years, if not decades to come.

Oliver, thanks very much for joining us.

It's a pleasure.

Most illnesses for which effective vaccines for children are widely available no longer threaten public health. That is unfortunately not the case for cervical cancer.

Daniela Raz is a data journalist at The Economist.

There's a vaccine that prevents almost all cases, and it was first approved for use in 2006. And if more people got that vaccine, we could actually eliminate cervical cancer. But in 2020, the most recent year for which we have data, cervical cancer still killed over 340,000 women. That makes cervical cancer one of the world's deadliest vaccine-preventable diseases. But there's no reason to be optimistic that this could change.

Okay, before we get into that, tell us what actually causes cervical cancer.

So human papillomavirus, which is also called HPV, is a group of sexually transmitted viruses. HPV is so common that nearly every sexually active person contracts a strain of it over the course of their lifetime. Some of these strains cause cancer, others cause non-fatal but really unpleasant things like genital warts. Most people don't know they've contracted HPV. Their immune system will quietly flush it out, usually within about 2 years, and they have no symptoms. But for a small minority of women, the virus lingers and it can form these lesions on the cervix. And for some women, those lesions can then become cancerous. HPV causes over 95% of cervical cancer cases, so that's almost all cases of cervical cancer.

And you said it's one of the most deadly vaccine-preventable diseases.

Cervical cancer is the second most common cancer among women aged 15 to 44. And one of the really horrible things about cervical cancer is that it strikes younger women. So among the world's top 10 most common cancers, cervical cancer has the youngest median age of diagnosis.

Diagnosis.

Now, in rich countries, 5-year survival rates are around 70%. In poor countries, fewer than 1 in 5 women with the disease survive 5 years. So Malawi, for instance, which has the highest rate of cervical cancer in the world, the 5-year survival rate is estimated to be less than 3%. Poor countries also account for 90% of deaths from cervical cancer. That's because in poor countries there's worse health infrastructures and the cancer is diagnosed at later and therefore deadlier stages. Treatment for women with the cancer is worse, and for women who are dying of the cancer, palliative care is worse as well. And so much of this is avoidable or preventable. If the HPV vaccine is given before people become sexually active, it provides full protection against HPV and therefore against the cancer-causing strains of HPV as well. The problem we're facing is that some 17 years after the vaccine was first approved, hardly any girls are getting vaccinated globally.

I find that quite surprising because here in Britain, for example, we've got a school vaccination program. I mean, I remember getting vaccinated with a series of jabs when I was about 14. Isn't that the norm in the rich world, at least?

So the UK has one of the highest HPV vaccination rates in the rich world. Among girls in the UK who turned 15 in 2021, 81% were fully vaccinated. That is probably in large part thanks to those school vaccination programs you mentioned, but the UK is definitely not the norm even among rich countries. So for instance, in the U.S., among girls who turned 15 in 2021, 64% were fully vaccinated, and that's comparably high. In Japan, they stopped recommending the jab back in 2013 because of pressure from vaccine skeptics who had these unfounded safety concerns about the vaccine. The Japanese government only resumed recommending the vaccine in 2022, and its ability to do this is thought to be because of increased faith in vaccination more generally because of the COVID vaccine. But because of this break in vaccination, Japan has essentially had a 0% HPV vaccination rate for nearly a decade. And then globally, just 12% of eligible girls got a second dose of the vaccine in 2021. That's down from 14%, an already very low number in 2019. And no routine immunization saw more backsliding during the pandemic than the HPV vaccine. Takeup of the first dose fell by 25% between 2019 and 2021.

Now, Daniela, let's talk a bit more about preventing it. If there is a safe and effective vaccine, then why are vaccination rates so low?

Yeah, so there are several barriers to explain why uptake of the HPV vaccine has been so slow. The first is the age of vaccination is quite atypical. Usually childhood vaccines are given to babies and younger children, and countries, especially poor countries, will have these existing infrastructures to deliver vaccines to those age groups. They don't necessarily have a system in place to deliver vaccines to preteen girls. Another reason is that the vaccine has historically been expensive. There's also the issue with dosage. Historically, the vaccine was administered in either 2 or 3 separate doses a few months apart. And as you can imagine, follow-up and tracking of girls to ensure they get the second or sometimes third dose is really an added complication. Another issue is sort of how the vaccine was billed originally as a vaccine that prevents a sexually transmitted virus. This is true, but it's also a cancer-preventing vaccine. However, the issue is that there are parents and more conservative cultures that are generally squeamish about encouraging vaccination in young girls against what is ultimately a sexually transmitted disease. And then lastly, there's this delayed realization of benefits from the HPV vaccine. Lots of vaccines are given for immediate benefit. You know, you get vaccinated against measles or COVID to protect you from getting measles or COVID now. And with HPV, you're getting vaccinated to prevent ultimately a cancer that you might not get for decades down the line. Now, despite that long list of potential obstacles, there's definitely a lot of cause for renewed optimism.

Finally, some optimism. Tell us why.

A few big barriers are being cleared right now, and that's great news. In December, based on new research, the World Health Organization said that just a single dose of the HPV jab will offer full protection. That's going to make vaccinating a lot easier. It means there are more vaccines available per person. And the cost of vaccinating will be less given you need only one dose. The other roadblock being cleared also has to do with cost and vaccine availability, and that's that firms in China and India are now producing their country's first domestic HPV jabs. So the Serum Institute of India, which is the largest vaccine maker in the world, has said they plan to make 200 million doses of the HPV vaccine in the next 2 years. The price of those vaccines is also expected to be well below the current market rate. And this should supply the Indian government's first national HPV vaccination effort. So in sum, we've got more vaccines, cheaper vaccines, and easier to deliver dosage, which are all reasons to be very, very optimistic.

Okay, so in light of that optimism, how many more girls do you reckon will be vaccinated in the coming years?

The World Health Organization, along with UNICEF and a few other partners, have set this really ambitious target vaccination rate of 90% by 2030. That means by 2030, they want 90% of eligible girls to be vaccinated. That entails a sustained increase of 9 percentage points per year. Researchers at the London School of Hygiene and Tropical Medicine designed a statistical model that estimates how many cervical cancer cases can be prevented under various vaccination scenarios. Using their model, we found that reaching this WHO target of 90% vaccination rate by 2030, we can prevent 3.7 million cervical cancer cases. That is over 2 million more than what we would prevent if we stayed at the current vaccination rate.

Wow. Okay, so this could really have a game-changing impact then.

So not only are we in a situation where we could cut cervical cancer cases by the millions, we can also get to the point of eliminating the disease.

Well, fingers crossed. Daniela, thank you so much for coming on the show.

Thanks for having me.

Hi, Mom.

Hi, babes, how are you?

I'm fine, how are you?

I'm all right.

Quick one, when are you coming to London again?

In a couple of weeks, I think.

Okay, have you actually booked your ticket yet?

Gordon Bennett. Yes, pain, agony. Yes, I have.

How bad was it?

Peak season normally is bad, but with all that's going on at the moment, it's like about ��2 million, just under something. That's over $4,000.

So this is my mom, Wumi, and like me and countless other Nigerians, she's a frequent traveler between Lagos in Nigeria and London.

That's why I'm losing my hair.

I hope you're not losing your hair, but yeah, Nigeria has a huge diaspora. A lot of people go back and forth. Running away from the country has become so popular that it has earned its own Yoruba nickname, Jakba. And the artist Naira Marley even made a song about it. In 2022, about 3.5 million people flew in and out of Nigeria. And a lot of Nigerians who are leaving the country are driven by poor employment prospects at home. So according to one survey by Gallup, 53% of Nigerian adults would like to leave the country. But getting to and from the country is proving ever more complicated. Which airline did you end up going with?

British Airways, because I'm torn between loyalty and common sense, because I'd rather do like— you know, you can do the connecting ones, you know, the Air France, KLM, the Turkish and stuff, and have to lay over, and they'd probably be a bit cheaper, but the savings you do make, you kind of scarpered by the hours.

So I'm a regular on the Nigeria-UK route. I've been flying alone from Nigeria to the UK since I was about 5 years old. The flights are always full, the airports are always packed. It's just chaos. But I'm lucky to say that because of all these flights, I've never once had a cold Christmas because I've always spent Christmas in Lagos. But last Christmas, I had to take a more roundabout route. On my way back, I traveled via Qatar, and a journey that should have been a 6-hour straight flight directly south ended up being a 20-hour journey. That included a 7-hour layover. So yeah, not fun, but at least it was cheaper.

You know, we're trying everything that we can without breaking the bank.

Well, I'm glad you're coming because I'm not coming back for Christmas.

Why?

Because who can afford to pay that to come back for Christmas?

See, we're in the same boat. And how can you do Christmas on your own? I mean, as a family, Christmas meant to be family time.

This is all happening because plane tickets bought inside the country have to be purchased in naira. Which is the Nigerian currency, by law. So the only place that airlines are really able to then exchange the naira that they get from their ticket sales into their preferred currencies and secure those revenues against the staggering inflation of the naira is with the Nigerian Central Bank. But with dwindling oil revenues, meager exports, and currency interventions which have drained Nigeria's foreign exchange coffers, the Nigerian Central Bank basically has no dollars to sell. So what this all means is airlines have $812 million in total held up in funds trapped in Nigeria. That's more than airlines have trapped in all other countries put together, and it's one reason why flights are becoming more expensive.

People are not traveling. I mean, kids are not seeing their parents. It's a knock-on effect. We don't even have choice anymore, you know. It's just going to reach a point where people can't travel.

Every fortnight or so, the central bank promises airlines a tiny bit of all the dollars of their accumulated revenues in naira, and at an exchange rate that's almost 50% less advantageous than its official one. But even when the central bank promises them this money, it doesn't always come. I spoke to some of the airlines. KLM, for example, the Dutch carrier, which has been flying to Nigeria for 75 years, is still waiting for funds that the central bank promised it in September. They were faced with the prospect of reducing their Nigeria-bound flights, but instead resorted to selling only the priciest of tickets to Nigerians and then increased its prices in naira to make up for the added risk that they were taking on.

I understand the devaluation, I understand the exchange rate, I even understand what airlines are going through, because if our central bank doesn't have the money to give to them, then I can understand. But what do the people do?

Take another airline, Emirates, for example. They were fed up with waiting for the bank to pay its money. They just completely pulled out of Nigeria entirely last year, despite how popular the Lagos-Dubai route is. It's a strange but understandable move, and with so many people trying to fly out of Nigeria, it should be super lucrative. But airlines can't get their money, and they have to keep paying interest on their own debts. Even as they're chasing arrears that they're owed. So then they're not really gaining much from being there.

Remember, we don't have Emirates anymore, and if we're not careful, other airlines will follow suit because they weren't getting their money. Nigeria is one of the most lucrative routes. Something has to give.

In the long run, the larger airlines with bigger profit margins might be able to absorb the losses, but Nigerian passengers will almost certainly lose out. it doesn't look like prices are going down anytime soon. Unless Bola Tinubu, the newly minted president of Nigeria, finds a way to replenish reserves and disburse the cash to the airlines who really need it, foreign flyers may stop coming, and Nigerians might find themselves trapped.

So you're not coming for Christmas?

No, I'm not coming for Christmas.

But 50/50? Half? We go half? Maybe.

Maybe you can come here for Christmas.

No, it is cold.

Okay, no, I'm gonna, I'm gonna try. Come and get some home cooking and some sunshine.

All right, my dear, take care. Love to everyone. Bye-bye.

That's all for this episode of The Intelligence. Let us know what you think of the show. You can get in touch at podcasts@economist.com.

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