With the war in Ukraine already marking its one-year anniversary on 24 February 2023, a new report has called for the toll of destruction on the nation’s healthcare services to be treated as a war crime.
In the year that has followed the Russian Federation’s full-scale invasion, attacks on civilians and civilian objects have been a hallmark of the war, with violence against the Ukrainian health care system a prominent feature of Russia’s unlawful conduct.
Attacks on health care were a daily feature during the first weeks of the Russian full-scale invasion: for 35 days, Ukraine’s health care infrastructure was damaged every single day; there were 235 attacks in March alone; and over the entire period studied in the report (24 February – 31 December 2022), there was an average of more than two attacks on healthcare each day.
Yet targeting functioning health care infrastructure and workers in an armed conflict, and carrying out indiscriminate attacks that affect civilian infrastructure – including hospitals and clinics – are war crimes.
The report, Destruction and Devastation One Year of Russia’s Assault on Ukraine’s Health Care System, is a joint product of eyeWitness to Atrocities, Insecurity Insight, the Media Initiative for Human Rights (MIHR), Physicians for Human Rights (PHR), and the Ukrainian Healthcare Centre (UHC), and documents the staggering toll that Russia’s aggression has had on Ukraine’s health care system since February 2022.
It highlighted that the apparent targeting of the health care system is carried out through a variety of means, including attacks on health care facilities; attacks on ambulances; the destruction of critical health infrastructure and theft of supplies, and; assaults, torture, and the ill-treatment of health workers, including doctors, nurses, and paramedics.
The report drew on a range of sources: audio-visual evidence, open-source research, primary source interviews, and public reports from several international fact-finding bodies – including the Independent International Commission of Inquiry on Ukraine, established by the UN’s Human Rights Council in March 2022, the UN Human Rights Monitoring Mission in Ukraine, and the Moscow Mechanism of the Organization for Security and Cooperation in Europe – as well as NGOs.
Between February 24 and December 31, 2022, the research team documented a total of 707 attacks on Ukraine’s health care system:
▪ There were 292 documented attacks that damaged or destroyed 218 hospitals and clinics. Many health facilities were attacked more than once.
▪ There were 65 documented attacks on ambulances.
▪ There were 181 documented attacks on other health infrastructure (e.g., pharmacies, blood centres, dental clinics, research centres, etc.).
▪ 86 attacks on health care workers were documented, with 62 health workers killed and 52 injured.
Many others were threatened, imprisoned, taken hostage, and forced to work under Russian occupation.
The 707 attacks also included a range of additional incidents which met the World Health Organization’s (WHO) definition of attacks on health, including looting, denial of access to health care, disruption of access to utilities (water and electricity) and causing serious impacts on patients, such as having to move them out of hospitals for their own protection.
One in 10 of Ukraine’s hospitals have been directly damaged from attacks, with the heaviest destruction in the eastern oblasts of Kharkivska, Donetska, Luhanska, Khersonska and Kyivska.
In some cities and towns, nearly all the health facilities were harmed in some way, such as in Mariupol, in the southern part of Donetska oblast, where almost 8 out of 10 points of health care service provision, sites where medical assistance is available, were either damaged or destroyed.
In 10 oblasts, 48 hospitals were hit multiple times, underscoring the possibility that they were deliberately targeted. For instance, the Severodonetsk City Multi-Profile Hospital in Luhanska oblast was hit 10 times between March and May 2022.
Many hospitals bore internationally recognized symbols of their status as medical centres, which were clearly visible from the air, such as the Bashtanka Multi-Profile Hospital, which was heavily damaged in an April attack, even though it was marked with a Red Cross painted on white canvas that had been placed on the roof.
According to Dr Alla Barsehian, the Bashtanka director, drones flew over the facility first.
“They saw very well, they knew that this was a medical institution,” Dr Barsehian said.
“We hoped this would somehow save us, but it turns out nothing is sacred in this war.”
Similarly, the Ukrainian ambulance fleet has also been devastated by the conflict, with a doctor from Trostianets City Hospital, who spoke to UHC on the condition of anonymity, stating that their ambulances sustained severe damage because of shelling in March 2022, and the remaining ambulance was destroyed by a mine.
“A sanitary medical aid car stored near the hospital was also shelled towards the end of the occupation,” the doctor said.
“The only remaining ambulance was taken by Russian forces, leaving medical personnel unable to provide care outside of the hospital. As a result, pregnant women had to be transported to the hospital in wheelchairs with flags marked with crosses because there were no ambulances left.”
Russian forces have also reportedly engaged in the theft and destruction of vital Ukranian medical equipment, which are also protected under international humanitarian law and in late October 2022, Ukraine’s President Volodymyr Zelensky stated that “Russian forces in the occupied Ukrainian region of Kherson are engaged in mass theft of medical equipment and ambulances in a bid to make the area uninhabitable.”
Most verified cases of looting have been uncovered in recently liberated Ukrainian territories. For example, on 4 April 2022, Dr Rudenko evacuated the Balakliia Clinical Multi-Profile Intensive Care Hospital (Kharkivska oblast) hospital, only to return five months later after the liberation of Balakliia by Ukrainian forces.
Much like reports of widespread looting in other hospitals that were allegedly occupied by Russian forces in the Kharkivska oblast, the “occupiers completely plundered” the Balakliia Clinical Multi-Profile Intensive Care Hospital, and “what they could not steal was broken and mutilated.”
“Almost everything was stolen. They took away everything that could be taken away,” Dr. Rudenko said.
“They could not move the CT scanner, so they looted the electronics from it… We had two surgical stands.… We hid them in the basement, but they found them and stole them. All the tools were stolen.
“The diagnostic department: there is nothing at all, everything was stolen; they lived there. That is, all ultrasound machines, cardiographs, encephalographs; nothing. They took it out.… We also had a generator for 100 kilowatts: disappeared. Out of 15 [ambulance] cars, 14 disappeared with them. Telephones, 37 washing machines, microwave ovens…”
Dr Rudenko also told UHC that hospital property, such as beds, was found across the town or in nearby villages while other property, not belonging to the hospital, was found on the premises.
The report pointed out that the scale of these attacks underscores the broader destabilizing effects they have had on Ukraine’s population, from reduced access to critical medications, to severely restricted access to health care, and vastly diminished vaccine rates.
Damaged or destroyed health care infrastructure have left entire communities in Ukraine without access to essential services and a survey by the International Organization for Migration found that, as of the beginning of December 2022, one in three Ukrainians lacked access to medical services.
Russia’s invasion has also caused a substantial increase in psychological harm and distress for all segments of Ukraine’s population. Mental health disorders such as depression, alcohol use disorder, and suicide, were already the second leading cause of disability in the country, affecting up to 30% of the population.
Now, almost 10 million people (not including veterans) could be potentially at risk of mental disorders such as acute stress, anxiety, depression, substance use, or PTSD.
“Based on the evidence presented here, there is a reasonable basis to believe that attacks on Ukraine’s health care system constitute war crimes and comprise a course of conduct that could potentially constitute crimes against humanity as well,” the report said.
“At a minimum, this evidence warrants immediate investigation by prosecutorial authorities. The Russian Federation’s continued aggression – leading to both targeted and indiscriminate attacks on Ukraine’s health care facilities, amongst other civilian infrastructure – constitutes a gross violation of international law.”
Keep an eye out for the upcoming April edition of Medical Forum which explains how doctors around the world are rallying to help displaced Ukrainians.