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Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System [1]

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Date: 2023-02

Press release available in English and Ukrainian.

On February 24, 2022, the Russian Federation began its full-scale invasion of Ukraine. This act of aggression against a sovereign nation is a gross violation of international law, one that has been widely condemned by the international community. In the year that has followed, 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. One notorious incident came only two weeks after the full- scale invasion began, when Russia’s air force bombed a maternity and children’s hospital in the city of Mariupol. The photograph of a heavily pregnant woman being carried from the hospital on a stretcher, who later died, together with her baby, became an early, stark example of the brutal, indiscriminate way in which Russia has waged its illegal war.

This report – a joint undertaking among eyeWitness to Atrocities (eyeWitness), Insecurity Insight, the Media Initiative for Human Rights (MIHR), Physicians for Human Rights (PHR), and the Ukrainian Healthcare Center (UHC) – documents the staggering toll that Russia’s aggression has had on Ukraine’s health care system since February 2022. Using 10 case studies and a joint dataset of attacks, this report shows how Russia appears to be violating international humanitarian law by deliberately and indiscriminately targeting Ukraine’s health care system as part of a broader attack on its civilian population and infrastructure. As the report details, the apparent targeting of the health care system is carried out through a variety of means, including: (1) attacks on health care facilities, (2) attacks on ambulances, (3) destruction of critical health infrastructure and theft of supplies, and (4) assaults, torture, and ill-treatment of health workers, including doctors, nurses, and paramedics.

For 35 days, Ukraine’s health care infrastructure was damaged every single day. In the first two weeks of the invasion, an average of four to five hospitals and clinics were attacked daily.

A destroyed ambulance in Trostianets, Sumska oblast, which was occupied by Russian forces at the start of the war. Photo captured on March 28, 2022 by Oleg Pereverzev/Global Images Ukraine via Getty Images.

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. When committed as part of a state policy on a widespread or systematic basis, such attacks are also crimes against humanity. Based on the evidence gathered in this report, 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. This evidence urgently warrants further investigation by prosecutorial authorities.

The broader impact of these attacks – in terms of the ability of the Ukrainian government to ensure the human right to access adequate health care – is equally devastating. While it is too soon to know the full extent of this war’s damage on Ukraine, a recent health needs assessment conducted by the World Health Organization (WHO) notes that “spiraling costs, logistical hurdles and damaged infrastructure are making access to essential services all the more challenging for growing numbers of civilians.”

“They saw very well, they knew that this was a medical institution. We hoped this would somehow save us. But it turns out nothing is sacred in this war.” Dr. Alla Barsehian, director of Bashtanka Multiprofile Hospital, which was heavily damaged in an attack.

This report breaks new ground by providing the most comprehensive documentation to date of attacks on Ukraine’s health care system as well as their devastating impact on the right to health. The report draws on a dataset of attacks – collectively developed from open-source and confidential information over the course of 2022 – supplemented by detailed case studies based on visits to hospitals in four different regions of Ukraine to inspect attack sites, assess damage, take photographs, and conduct semi- structured interviews with hospital staff who were present at the time of the attacks.

The findings are stark. During just the first weeks of the Russian full-scale invasion, there were constant, daily attacks on Ukraine’s health care system. For 35 days, Ukraine’s health care system was damaged every single day. Assaults were particularly intense in February and March; during the first two weeks of the invasion, an average of four to five hospitals and clinics were attacked daily.

Attacks continued throughout the year, with 235 attacks on health care overall in March and an average of 47 attacks each month from April through December 2022. Over the entire period studied in this report (February 24-December 31, 2022), there was an average of more than two attacks on health care each day.

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.

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 centers, dental clinics, research centers, 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.

One in 10 of Ukraine’s hospitals have been directly damaged from attacks, with the heaviest destruction in the eastern oblasts of Kharkivska, Donetska, and Luhanska, and also in Khersonska and Kyivska.

In some cities and towns, nearly all the health facilities were harmed in some way. In Mariupol, in the southern part of Donetska oblast, almost 8 out of 10 points of health care service provision, sites where medical assistance is available, were either damaged or destroyed.

In the Makariv municipality – where three health facilities and 30 pharmacies have been damaged or destroyed – the scale of the attacks has led to the severe disruption of health services and infrastructure in the area.

In 10 oblasts, 48 hospitals were hit multiple times, underscoring not only the indiscriminate nature of attacks but also the possibility that they were deliberately targeted. For instance, the Severodonetsk City Multiprofile Hospital in Luhanska oblast was hit 10 times between March and May 2022. One hospital in Kharkivska oblast was hit five times, and another was hit four times.

Many hospitals bore internationally recognized symbols of their status as medical centers, which were clearly visible from the air. Bashtanka Multiprofile Hospital, which was heavily damaged in an April attack, was marked with a Red Cross painted on a white canvas placed on the roof.[1] According to Dr. Alla Barsehian, the Bashtanka Multiprofile Hospital director, drones flew over the facility and “they saw very well, they knew that this was a medical institution.”[2] “We hoped this would somehow save us. But it turns out nothing is sacred in this war.”[3]

“At first, I didn’t understand what was happening, it felt like stones were being thrown on metal, that was the sound. When the car caught fire, we realized that we were being fired at.” A paramedic whose ambulance was attacked in Donetska oblast in April 2022

The scale of these attacks underscores the broader destabilizing effects they have on Ukraine’s population, from reduced access to critical medications to severely restricted access to health care and vastly diminished vaccine rates. An International Organization for Migration survey found that, as of the beginning of December 2022, one in every three Ukrainian was experiencing the lack of medical services.

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. Russia must cease these attacks and end its aggression. Accountability for war crimes and crimes against humanity, as well as for the crime of aggression, will be critical; however, Russia is also obligated to make reparations for its breaches of international law, including compensating the Ukrainian state and individual Ukrainians – and other killed or injured nationals – for devastating loss of life and injury, extensive destruction, and the enormous costs of reconstruction. Because protecting health care is a shared responsibility, all parties to the conflict must ensure compliance with international humanitarian law principles.

A room in a damaged hospital building. Photo captured December 15, 2022. Sergey Bobok/AFP/Getty Images

To other engaged actors, the report makes the following recommendations:

To the International Criminal Court’s Office of the Prosecutor, the Prosecutor General of Ukraine, the Independent International Commission of Inquiry on Ukraine, and other National Prosecutors:

Prioritize investigation of attacks on health care facilities and health care workers and commit resources to prosecuting cases specifically focused on these violations as war crimes and crimes against humanity.

To the Diplomatic Community, including Member States of the European Union, the United Nations (UN) Security Council, and the Organization for Security and Co-operation in Europe:

Publicly condemn attacks on health care personnel and facilities in Ukraine, and urge compliance with the Geneva Conventions, Additional Protocol I, and UN Security Council Resolution 2286, including rules on medical impartiality.

Continue to exert all available political, economic, and diplomatic pressure on the Russian Federation to immediately cease both indiscriminate and targeted attacks on civilians and civilian infrastructure, including on health care workers, facilities, and vehicles, as well as to withdraw from Ukrainian territory.

To the Government of Ukraine:

Ratify the Rome Statute of the International Criminal Court and adopt domestic implementing legislation that sufficiently captures the substantive crimes and modes of liability provided for under the Rome Statute.

To the UN Human Rights Council and its Member States:

Renew the mandate of the UN Independent International Commission of Inquiry on Ukraine on an open-ended basis and ensure robust funding and support for its continued functioning.

Convene a thematic debate to address widespread and systematic attacks on Ukraine’s health care system and the need to ensure criminal accountability.

Endnotes

[1] “Ukraine War: Hospital destroyed by Russian missile in southern Ukraine,” Sky News, April 22, 2022, https://www.youtube.com/watch?v=ff1eF2JSfnE.

[2] Interview with Dr. Alla Barsihian, UHC, December 17, 2022 (on-file).

[3] “Ukraine War: Hospital destroyed by Russian missile in southern Ukraine,” Sky News, April 22, 2022, https://www.youtube.com/watch?v=ff1eF2JSfnE.

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[1] Url: https://phr.org/our-work/resources/russias-assault-on-ukraines-health-care-system/

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