Press release available in English and Arabic

Executive Summary

Attacking health care facilities has been a deliberate tactic in the Syrian conflict, which is now 12 years old. Even as international recognition of the systematic nature of these attacks has grown in response to widespread documentation of assaults, impunity for perpetrators continues.

All parties to the conflict have perpetrated numerous acts of violence in violation of international humanitarian law (IHL). In the face of substantial evidence, however, member states of the United Nations have taken limited action to hold those responsible to account, or to protect health workers and the provision of vital health care services.

Today, international headlines rarely feature the Syrian conflict. Yet, the war in Syria is far from over. Indeed, since the 2020 ceasefire, three aerial bombardments have been carried out on health care facilities.^[1]

The long-term and cumulative impacts of the conflict have generated a health care crisis for the 4.6 million civilians in northwest Syria.^[2] Almost half of this population is female. Understanding how these attacks reduce availability and access to care for women and girls, including sexual and reproductive health (SRH) services, is vital to protect the human right to health, and to promote advocacy efforts in Syria and beyond.

Based on primary data collected in northwest Syria, this report shines a light on the daily experiences of health care staff who provide SRH services, and, in turn, the patients who try to access these services. Providing health care is ever more tenuous there: during the month of November 2022, almost a million medical procedures took place with supplies and equipment that entered Syria as part of the cross-border operation implemented through the use of the Bab al-Hawa crossing.^[3] While the impact of the violence in Syria on health care has been widely documented, the existing literature on the impact of violence on the provision of SRH care is scant. This report contributes to a greater understanding of this underexamined crisis.

The impact of violence across northwest Syria, combined with reduced donor funding and economic collapse, has meant inadequate and uneven provision of health care for Syrians, particularly women and girls. In response to the violence, providers have been forced to leave or relocate beyond the line of fighting, leaving many unable to reach the care they need. This not only impacts civilian access to services, but also increases demand on the service providers in safer areas, undermining the quality of care. The devastating earthquakes which struck southeast Türkiye and northwest Syria in early February 2023 further limit the already precarious access to health care detailed in this report.

“When health facilities were targeted, we saw pregnant women [only] during labor, instead of four or six times throughout their pregnancy. Some presented with ill-managed anemia. When we asked them why they didn’t come for medical care earlier, they said, ‘Who would dare visit the hospital when it’s being targeted? We would be crazy to stay in the hospital.’”

Female health care provider, Idlib

In order to assess the impact of violence on SRH, researchers spoke with more than 260 mostly female respondents, who shared their experience accessing or providing SRH services. Qualitative interviews with reproductive health care workers and extensive focus group discussions with displaced and resident women in Idlib and Aleppo demonstrate that continued violence poses increasing and complex barriers to health care. Syrian women in the northwest reported that fear or experience of bombings, kidnapping, or exploitation all undermine their ability to access health clinics, leaving them without care or reliant on informal health service provision. Attacks on health care facilities are frequent enough that a high number of pregnant women in northwest Syria prefer to undergo a cesarean section instead of a vaginal birth, partly to reduce the time spent inside a health care facility. They also avoid prenatal care visits.

Pregnant women reported they must travel long distances to seek medical care, putting themselves at risk. Providers and patients described deaths because of delays in care provision. Not all consequences were as visible: women also explained how the lack of access to SRH services negatively impacts both their mental health and that of their families.

As economic crisis, inflation, and the impact of the earthquakes continue to grip Syria, the cost of medicine, transportation, and private health care undermines people’s ability to access the often lifesaving care they require. Stigma, cultural expectations, and lack of awareness of their rights and of service availability make access even more difficult. The services that are the most stigmatized, including for sexually transmitted infections and HIV/AIDS care, are also the least accessible, according to those interviewed.

Many of the trends identified in this report can also be mapped to wider challenges that communities experiencing conflict face in meeting their health needs. Civilians and communities currently facing similar systematic violence against health care, such as in Myanmar, Ukraine, and Yemen, likely face similar barriers.

The findings of this research are intended to raise awareness of the ongoing plight of Syrians and to contribute to policy change. While health actors, including humanitarian organizations, have worked to fill the gaps in health care provision, the current approach to the crisis in Syria is inadequate. Urgent changes are needed to protect the right to health for populations in northwest Syria and ensure access for those who require medical care.

The devastating earthquakes that hit Syria and Türkiye on February 6, 2023 and the continuing damage caused by aftershocks further compound the already precarious access to health care detailed in this report. Challenges related to displacement, destruction of roads, lack of fuel, and limited health services provision will likely impact 148,000 pregnant women, 37,000 of whom are due to give birth in the three months following the earthquakes, with 5,550 women who may experience complications requiring emergency obstetric care, including C-section, according to the United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA).[4]

This report reflects the SRH concerns of those living and working in northwest Syria. It establishes a record upon which policymakers, donors, and health actors, including humanitarian organizations, may rely in addressing the crisis of SRH in northwest Syria. It provides core recommendations for the United Nations Security Council, United Nations member states, donors, health actors, and the coordination architecture.^[5] Respondents emphasized that accountability, improved access to health care, greater awareness, and sufficient resources should be prioritized by policymakers and practitioners.

Introduction

Attacks on health care facilities in northwest Syria (NWS) during the conflict have reduced both the facilities and the health care workers serving the country’s largest internally displaced population. More than two-thirds of the population in NWS is displaced, and the more than 1,400 camps for internally displaced people (IDPs) are a visible reminder of the human cost of 12 years of intense conflict. Civilians in NWS are routinely subjected to shelling, airstrikes, and clashes, and 90 percent of the population lives below the poverty line.^[6]

The impact of violence on health is clear. In rural Idlib, a displaced woman explained that “When they continue for a long time, bombing and bad security conditions cause many health problems. People who live in remote places, such as in tents in the mountains, on the outskirts, or in the countryside are unable to secure their basic needs.” ^[7]

The devastating earthquakes that hit Syria and Türkiye on February 6, 2023 have gravely worsened the humanitarian crisis in northwest Syria. In opposition-controlled areas, more than three million people were affected by the earthquakes, which, as of February 28, 2023, have caused more than 4,500 deaths and 8,700 injuries, mostly concentrated in Afrin, Harim, and Jisr-Ash-Shugur districts.[8] This has increased the need for health services, putting more pressure on medical staff, medical facilities, and health resources at a time when the entire region has been struggling with limited humanitarian access. Before the earthquakes, 30 people a day crossed the border into Türkiye to seek medical care for health issues that are unmanageable in northwest Syria, such as cancer treatment and intensive care for preterm babies. The earthquakes have made this movement largely impossible. A rapid protection assessment conducted by the protection cluster in the affected areas confirms what we know from other crises: women and girls are being disproportionally affected by the surge in needs and safety concerns in the aftermath of the earthquake, which compounds their inability to access SRH services – services that are already limited due to the impact of violence.[9]

2.3 million women and girls in NWS do not have easy access to necessary medical care, including sexual and reproductive health.

Health care in NWS depends almost entirely on cross-border provision of aid through the Bab al-Hawa border crossing with Türkiye. The current mandate for cross-border aid will expire in July 2023, unless the United Nations Security Council chooses to reauthorize it – which makes access to health care even more precarious.^[10] In response to the earthquakes, two additional border crossings – Bab al-Salam and al-Raee – were opened for a period of three months.

Against this backdrop, a less visible, but no less severe, crisis of sexual and reproductive health and rights is occurring. Among other basic human rights, sexual and reproductive health (SRH) is fundamental to the right to health.^[11] All parties to the conflict are obligated to uphold the right to health, including sexual and reproductive health and rights (SRHR), and to adhere to international humanitarian law, which also protects these rights. Conflict-affected women have additional, specific sexual and reproductive health needs.^[12]

This report documents the impact on women and girls of targeted violence on the availability of and access to SRH care, including basic and specialized services.^[13] The report findings include:

• SRH services are insufficient due to limited staff, facilities, equipment, supplies, and medication across NWS.
• SRH care provision is limited, among other things, by the fact that many health care facilities have been built in, or relocated to, geographic areas far from the front lines, limiting access to SRH services for communities close to conflict zones. Because of the large population and demand in safer areas, these facilities experience significant overcrowding.
• In areas where SRH services are largely unavailable, respondents reported harmful coping practices, including postponing essential SRH visits and forgoing medication.
• When required SRH services are not available or practically inaccessible, there are far-reaching, negative consequences for women’s health, including for both their psychosocial well-being and that of their children.
• The most marginalized people, including women residing in camps, those with a disability, those with limited income, and those married at a young age, are most adversely impacted by the paucity of SRH care.

Because of the current status of the conflict, health care services in NWS are largely provided by humanitarian organizations. The crisis of SRH in NWS is further impacted by funding gaps, shifts in donor priorities to other crises, the deteriorating economic situation in Syria , and the toll of the devastating earthquake which struck southeast Türkiye and northwest Syria in early February 2023. In June 2021, in the wake of the COVID-19 pandemic, the United Nations Office for the Coordination of Humanitarian Affairs reported a 60 percent funding gap in NWS and a 96.4 percent gap in health sector funding.^[14] In 2022, the funding gap for the health sector in NWS increased from 46 percent in June^[15] to 71.6 percent in October.^[16] In addition to economic factors, social and cultural norms often impact SRH behaviors. In NWS, respondents reported practices that have had multiple negative effects on women’s sexual and reproductive rights and health, including the need to be accompanied by a male family member or an older female family member in order to access care, and the need for this family member to consent to treatment.^[17]

This report reflects the SRH concerns of those living and working in NWS. It establishes a record upon which policymakers, donors, and health actors, including humanitarian organizations, may rely in addressing the underexamined crisis of sexual and reproductive health and rights in NWS. 

Terms and Definitions

This report employs a number of terms, concepts, and phrases, listed below in alphabetical order.

Abortion:  The original research on which this report is based was conducted in Syrian colloquial Arabic. Respondents (interviewed individually or in focus group discussions) used some sexual and reproductive health (SRH) terms in non-medical ways, reflecting their beliefs and practices. For example, many respondents referred to any pregnancy loss in Arabic, whether intentional or unintentional, as an “abortion.” Abortions can be spontaneous, induced, missed, complete, or incomplete. They can be safe or unsafe, depending on who performs them and where they are performed. For clarity, this report uses the terms “spontaneous abortion” or “induced abortion.” Spontaneous abortion is the loss of a fetus in early pregnancy, without interference. Respondents referred to “miscarriage” or a “natural abortion” to indicate spontaneous abortion. The report employs “induced abortion” for an intentional attempt to terminate a pregnancy. Induced abortion is restricted by the Syrian Penal Code and is limited to situations in which a medical specialist orders the procedure to prevent the mother’s death.^[18] 

Awareness:  Many focus group respondents indicated the need for increased SRH awareness programming. In this context, the term “awareness” includes knowledge on the availability and functioning of SRH services as well as an understanding of the relevance of such services to their lives.^[19]

Front line: This report uses the noun “front line” and the adjective “frontline” to describe areas where civilian infrastructure is targeted in violation of the 2020 ceasefire agreement. It uses “non-frontline” for areas that have experienced less violence and are closer to the Syrian-Turkish border.

Post-abortion care: A lifesaving, legal intervention, “post-abortion care” refers to therapeutic medical treatment after a pregnancy has been terminated or a spontaneous abortion has occurred. This type of care includes the treatment of any complications, if needed, information sharing, and post-abortion contraception.

Public hospital: In NWS, a hospital that does not take fees and is supported by humanitarian funding.

Sexual and reproductive health care: This report adopts the World Health Organization’s (WHO) SRH service categories, which include maternal and newborn care, contraception and family planning, clinical and psychosocial services for survivors of gender-based violence, HIV prevention and treatment, eliminating unsafe abortion, combatting sexually transmitted infections, and promoting sexual health. While not all of these categories of SRH service are currently available in Syria, they are all key to achieving SRH rights.

SRH care is provided through the “constellation of methods, techniques, and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems,” including sexual health, for women and other vulnerable groups.^[20]

Violence against health care: This report adopts the WHO’s definition of violence against health care as any act of physical or verbal violence, threat of violence, or other psychological violence or obstruction that interferes with the availability, access to, and delivery of curative and/or preventive health services.^[21]

Methodology

This report examines the impact of attacks on health care on sexual and reproductive health (SRH) services in northwest Syria (NWS) from 2017 to 2022.This five-year time interval covers multiple events which the research team believes are likely to have impacted SRH service availability and accessibility in NWS. Major events include: the forced displacement of the population of eastern Aleppo city in 2017 following a major military offensive in late 2016; the military offensive that targeted Idlib between October 2019 and April 2020, which resulted in the biggest internally displaced person (IDP) crisis of the Syrian conflict; the COVID-19 pandemic in 2020; and a cholera outbreak in 2022.

Importantly, the research team collected and analyzed the data prior to the devastating earthquakes that hit Syria and Türkiye on February 6, 2023. Therefore, these findings do not reflect the health care situation in northwest Syria after the disaster, which has only been exacerbated due to increased injuries, lack of capacity to address emergency and chronic health care needs, mass displacement, further damage to the health infrastructure and to transport, and the population´s ongoing inability to cover health-related expenses.

Using qualitative data collection and analysis, this research focuses on the availability of and access to SRH services in parts of Idlib and Aleppo governorates not controlled by the government of Syria or the Syrian Democratic Forces.^[22] Researchers focused on differences in SRH availability and access in urban, rural, and camp settings, as well as frontline versus non-frontline areas.

Physicians for Human Rights (PHR), the International Rescue Committee (IRC), Syria Relief and Development (SRD), and the Syrian American Medical Society (SAMS) jointly conducted this original research between September and November 2022 with Shafak supporting primary data collection. The Independent Doctors Association (IDA), Relief Experts Association (UDER), Syrian Expatriate Medical Association (SEMA), and Union of Medical Care and Relief Organizations (UOSSM) all contributed data to the study.

IRC and Shafak carried out 36 individual community-based interviews (CBIs) and led 26 focus group discussions (FGDs) comprising a total of 240 women in sub-districts throughout Idlib and Aleppo governorates in NWS.^[23] All interviews were conducted in Syrian Arabic by data collectors trained by the organizations and recorded at the discretion of the respondent.^[24] This information was supplemented by key informant interviews (KIIs) led by PHR with health experts based both inside and outside of NWS. The KIIs with health care experts, including providers and health sector planners, provided an overview of the status of SRH services in NWS.

The CBIs were conducted with an equal number of male and female professional staff with SRH expertise, including physicians, nurses, midwives, pharmacists, nutrition workers, community health workers, and health administrators. The sample included urban and rural areas (including IDP camp settings) across NWS. Approximately a third of the sample represents frontline areas (Ariha and al-Atareb sub-districts), with a female population of almost 150,000.^[25] A total of 26 FGDs of no more than 10 people each were conducted with 240 total respondents between the ages of 18 and 50, including displaced and resident women. The FGDs included a mix of pregnant, breastfeeding, and married women, some with children, as well as service providers working at the sub-district level. All respondents provided verbal or written informed consent. The study protocol was reviewed and approved by the IRC Institutional Review Board (IRB) and PHR’s Ethics Review Board (ERB).

Limitations

Historically, little to no data on SRH care in NWS has been gathered or reported. As a result, it is not possible to compare pre-conflict statistics related to SRH, such as maternal and newborn mortality rates, contraceptive access, the average number of antenatal visits, and other SRH services, with those provided during the conflict. Similarly, very little data has been systematically collected on the barriers to accessing SRH care.

Collecting data in conflict settings is challenging, and SRH is a particularly sensitive and stigmatized topic. Strongly held individual and societal beliefs about gender, sexuality, culture, traditions, and health care may have impacted participant willingness to speak openly about SRH issues, especially when the discussions were recorded. To mitigate these challenges, data collectors attempted to interview both males and females and include a variety of perspectives, particularly from female beneficiaries of SRH services in NWS. Female data collectors interviewed female participants in 16 of the 18 CBIs conducted with female respondents, and in all 26 FGDs. 

Background: Factors Impacting Health Care in NWS

More than a decade of conflict in Syria has degraded the health care system in northwest Syria (NWS) in complicated ways. Attacks have caused humanitarian NGO-funded hospitals and clinics to relocate to safer areas, and sustained fighting has shifted the population within NWS, which includes the territories of Idlib governorate and northern Aleppo governorate, bordering Türkiye.

“The ongoing war made it necessary for donors, NGOs, and medical staff to operate in safer areas. [These areas have] a high population density, and are away from front lines, continuous hostilities, and bombardment. The international border regions are less likely to be targeted.”

Health facilities, staff, and patients have been subjected to high levels of targeted violence in NWS. Since 2017, Physicians for Human Rights has documented 144 attacks on health care facilities throughout Syria. From 2017 to 2021, the Syrian American Medical Society reported damage from explosions to 368 health care facilities.^[26] Attacks have resulted not only in extensive damage to health infrastructure but have also led to high levels of casualties, displacement, and overall attrition among specialized health staff.^[27] In combination with the loss of medical equipment and medicine, this has further aggravated a severe health crisis among NWS’s population.

Ongoing significant violence in NWS has not only lowered the number of functioning facilities, it has also increased the internally displaced population. Of the 4.6 million people in NWS,^[28] 63 percent (2.9 million) are internally displaced persons (IDPs), of whom almost 80 percent are women and children.^[29] IDP access to health facilities is particularly challenging: although 40 percent of the population in NWS live in camps, only 18 percent of all health facilities are in camp settings.^[30]

“If my patient wants to go to the nearest hospital, it will cost her 50 Turkish lira ($2.65) [paying for rides in] passing cars and around 200 Turkish lira [$10.60] in a private vehicle.”

Finally, widespread poverty in NWS, exacerbated by years of conflict, has impacted the population’s access to health care because many are unable to afford the cost of transportation to health facilities. NWS is home to more than a quarter of the Syrians in need of humanitarian assistance (4.1 million out of 15.3 million nationwide).^[31]Economic deterioration has had the greatest impact on IDPs, vulnerable residents, including the disabled, and the more than 16,000 Syrians who have returned to their areas in NWS after being displaced.^[32]An example of the severe economic pressure on civilians is the price of food, which has increased by 85 percent compared to food prices in August 2021.^[33]

The NWS Health System: Beyond the Numbers

Health care facilities in NWS provide sexual and reproductive health (SRH) care but have struggled to meet the significant and growing needs of the population. Although SRH care is provided in private and public facilities, the majority of the population can only afford public facilities. The high demand on the free (or public) system results in patient overcrowding. Although NWS technically meets the minimum World Health Organization requirement for health facilities per population, in reality, these facilities are concentrated in areas considered safer from attack. This uneven geographic distribution of health facilities creates an access barrier, especially for some of the most vulnerable.

“[There is] fear of bombing, kidnapping, or harassment. Not all health centers are close to my residence, so I must rent a car to get to the hospital, and then I may be subjected to financial exploitation by the driver…. As a woman, I avoid going to [medical] centers alone.”

A health care expert involved in planning health programs confirmed that donors and non-governmental organizations have been forced to operate in the area closer to the international border with Türkiye, explaining, “The ongoing war made it necessary for donors, NGOs, and medical staff to operate in safer areas. [These areas have] a high population density, and are away from front lines, continuous hostilities, and bombardment. The international border regions are less likely to be targeted.”^[34] This northern region has seen a huge population increase, and health workers there reported significant overcrowding of medical facilities, and a lack of specialized health care workers, such as those who provide SRH care.^[35]

Families experiencing extreme poverty may be forced to live in areas close to the front line, where housing is less expensive. Women in frontline areas such as Ariha and Jisr as-Shughur reported that long distances and unsafe roads pose a practical barrier to accessing medical care. Transportation costs are prohibitively expensive for people living close to the front line, as well as those in rural and isolated areas. A health care provider in urban Idlib explained that, with a median estimated daily wage for unskilled labor of around one U.S. dollar, patients cannot always afford transportation to access health care. “If my patient wants to go to the nearest hospital, it will cost her 50 Turkish lira ($2.65) [paying for rides in] passing cars and around 200 Turkish lira [$10.60] in a private vehicle.”

A displaced woman in urban Aleppo explained the impact of violence on her health choices, noting that getting care is difficult: “[There is] fear of bombing, kidnapping, or harassment. Not all health centers are close to my residence, so I must rent a car to get to the hospital, and then I may be subjected to financial exploitation by the driver…. As a woman, I avoid going to [medical] centers alone.”^[36]

NWS SRH Services Landscape

The humanitarian sector in NWS represented by local and international non-governmental organizations has stepped in to bridge the gap in health services following the withdrawal of the Syrian government from territories that were captured by opposition forces beginning in 2012. Humanitarian agencies have offered services that evolved over time based on the needs, priorities, and available resources.^[37] Individual SRH services differ in terms of availability and geographic distribution within and between regions across the northwest, and in some places are simply unavailable.

Humanitarian health care workers in Syria adopted the Minimum Initial Service Package (MISP), a set of guidelines for SRH service delivery in crisis settings.^[38] The MISP aims to facilitate the coordination of SRH services, prevent and manage the consequences of sexual violence, reduce HIV transmission, minimize maternal and neonatal morbidity and mortality, and plan for comprehensive SRH services in the post-crisis phase.^[39]

Findings

The research yielded several key findings, all of which merit further study. A variety of themes emerged from the significant portion of the data that involved the impact of violence on maternal and newborn care, including availability, supply relative to the population’s need, and the role of violence in shaping birth preferences. Other topics, such as family planning, gender-based violence (GBV) – including early marriage – abortions and post-abortion care, sexually transmitted infections (STIs), and the impact on mental health of poor access to sexual and reproductive health (SRH) care were mentioned in less detail but provide a window into the health care struggles of women in northwest Syria (NWS).

The Impact of Violence on Maternal and Newborn Child Health

Violence has limited the availability of certain services in frontline areas, and driven population shifts that result in high demand on existing facilities. The World Health Organization (WHO) initiative “Health Resources and Services Availability Monitoring System” reported 367 functioning medical facilities in NWS in September 2022.^[40] A separate monitoring initiative led by the United Nations Population Fund, and run by the SRH Technical Working Group (health cluster) and the GBV Sub-cluster (protection cluster), reported in 2022 that only seven percent (50) of these facilities offer the packages of maternity care known as either comprehensive emergency obstetric and newborn care, or basic emergency obstetric and newborn care services.^[41] The same assessment found that outpatient reproductive health services are offered in fewer than 40 percent (142) of the facilities. Nevertheless, the SRH Technical Working Group estimates that between January 2021 and September 2022, SRH service providers offered more than 3.9 million reproductive health consultations and performed 220,000 deliveries.^[42]

Availability and Need

The SRH Technical Working Group partners provide essential SRH care through the Minimum Initial Service Package at three levels of health care facilities: two levels of primary health centers (PHCs), including facilities that offer basic emergency obstetric care and those that offer comprehensive emergency obstetric care. PHCs include mobile clinics and health points. PHCs distribute male condoms and provide clean delivery kits,^[43] treatment for sexually transmitted infections (STIs), and oral and injectable contraception. In addition, there are 14 health facilities in NWS providing basic emergency obstetric and neonatal newborn care, which can provide emergency medical care to women experiencing pregnancy or childbirth complications.^[44] The 36 highest-level facilities in NWS have comprehensive emergency obstetric and neonatal care, with the capacity to perform cesarean section deliveries, provide blood transfusions, and administer post-rape treatment.^[45]

Health care workers confirmed that public facilities provide free delivery care for pregnant women, including after childbirth, in addition to newborn care.^[46] However, the large population utilizing public hospitals in areas farther from the front line results in overcrowding, which has caused significant gaps in maternal and newborn services.^[47] Rural and frontline areas, on the other hand, have less availability of maternal and newborn care than in urban facilities. A doctor in rural Aleppo explained that although the health centers near his village are supposed to provide obstetric care, they are not equipped to do so.^[48]

Areas on the front line, such as Ariha sub-district, illustrate the mismatch between the available resources and the need. Between July and September 2022, only six facilities in Ariha provided family planning counseling and family planning kits to a population of more than 180,000. In contrast, 209 facilities in non-frontline areas of the NWS provided family planning kits and counseling to 4.4 million people. This translates to 4.8 facilities per 100,000 population in non-frontline areas compared with 3.3 facilities per 100,000 in Ariha, a 31 percent greater workload on such frontline area facilities. Unable to cover the population’s needs, these facilities are easily overwhelmed, which forces patients to travel to non-frontline areas, further burdening the system in these localities. 

The number of skilled providers operating within facilities also greatly impacts access to SRH care. For example, only two facilities in Ariha provide skilled care to assist with childbirth,^[49] while the service is available in 48 facilities in safer areas. A health center director in urban Ariha noted,

“After the last bombing campaign, almost all the [health care-providing] organizations withdrew their projects; the health centers and hospitals did not remain. Some have returned recently, but they are insufficient and do not meet the need.”^[50]

The violence has also impacted the number of SRH care providers in Ariha: since 2017, the number of midwives there decreased from 33 to 19 (42 percent decrease), and the number of gynecologists decreased from 9 to only 4 (56 percent decrease). ^[51] 

Attacks Impact Childbirth in NWS

Health facilities, staff, and patients have been subjected to high levels of targeted violence in NWS. Since 2017, Physicians for Human Rights has documented that 55 percent of attacks occurred in NWS, targeting 60 facilities.^[52] Almost 90 percent of the attacks were conducted by aircraft or land-to-land missiles.^[53] Three attacks were perpetrated in 2021 and targeted facilities in NWS, of which two provide SRH services. The attack on al-Atareb hospital on March 21, 2021 resulted in a 78 percent reduction in the number of reproductive and neonatal care consultations in the facility.^[54] The attack on the al-Shifa Hospital on June 12, 2021 destroyed the labor and delivery unit and killed 13 people, four of whom were hospital and ambulance staff.^[55]

“After the last bombing campaign, almost all the [health care-providing] organizations withdrew their projects; the health centers and hospitals did not remain. Some have returned recently, but they are insufficient and do not meet the need.”

Health center director in urban Ariha

Health workers reported how violent attacks on health care have impacted maternal and newborn care. During shelling, mothers may give birth while traveling on roads in areas of active fighting.^[56] A female health care administrator in a rural internally displaced persons (IDP) camp explained that after the al-Shifa Hospital health center was bombed, people were forced to travel far away to Afrin Hospital and “many women gave birth in the car on the way because of the distance.”^[57] Displaced women in focus groups recounted how pregnant women were forced to give birth at home or on the road during heavy shelling, and that women who miscarried couldn’t access the health center for care.^[58]

One displaced woman shared the tragic consequences of violence on her family:

“My relative gave birth at night, and the child needed an incubator. Because of the shelling of the village of al-Atareb, she could not reach the hospital, and the child suffered from hypoxia and was transferred to Türkiye, where he died.”^[59]

Violence Increases the Preference for Cesarean Sections

Violence has changed childbirth practices in NWS. Seeking to minimize their time in health facilities due to the risks of attacks, more women have opted for cesarean sections over natural births.  In 2000, the cesarean rate was 14.8 percent.^[60] A study from 2004 showed that the facility-based cesarean section rates were 12.7 per cent in government hospitals.^[61] After the beginning of the Syrian conflict in 2011, the rate increased. A study published in 2021 showed a peak in caesarean sections to 33.2 percent in March 2020 after the military campaign on NWS, following a drop in SRH service provision that correlated with the attacks.^[62] The SRH working group, using data from a total of 356 SRH-providing facilities between January 2021 and September 2022, found that the average cesarean section rate remained significantly higher than pre-conflict rates at 23 percent.^[63]

A health care provider who worked in directly targeted health facilities explained that vaginal delivery can require many hours, whereas a cesarean section takes only a few minutes and requires only six to seven hours for recovery. He explained that while not ideal, cesareans provide an element of certainty in a context in which patients feel “as if they were going to a front line when visiting a hospital, given how frequent attacks on health care were.” He added that he and his colleagues would avoid keeping the mother overnight if the recovery rooms were not underground, to avoid exposing her to bombings. While scheduling cesareans protected the staff and patients from facility attacks during unpredictably lengthy vaginal births, the health care provider observed that this approach often “negatively impacted the physical and psychological patient outcomes,” since the longer recovery period required post-cesarean may increase post-partum infection rates and increase pain.^[64]

While scheduling a cesarean has come to be considered safer, during a direct attack on a hospital, nobody is protected. A woman described giving birth during a bombing:

“I was in the operating room. I could hear the sound of planes flying over the hospital, and I was very stressed and crying. I was not fully anesthetized. The doctor had to give me general anesthesia after he had originally started epidural anesthesia so that he could complete the surgery. I was giving birth and heard the planes over the hospital. I was afraid for my family and husband who were in the hospital. As soon as I left the operating room, before I even woke up, they took me home, without examining me or my child. This created a bad psychological condition for me, with constant crying, which led to my loss of milk.”^[65]

The Impact of Violence on Other Specialized SRH Services

The impact of violence on access to maternal and newborn health was one of the most documented within this study. However, the provision and ability to access all types of SRH services have been affected by 12 years of conflict.  The analysis below discusses some of the main barriers women face when accessing specialized SRH services such as family planning, GBV services, post-abortion care, and STI services – including HIV/AIDS support – and the impact this lack of SRH care has had on women’s mental health. Ultimately, it highlights the role of violence against health care in aggravating the lack of SRH services and the ability to utilize them.

Family Planning

Focus group respondents indicated that family planning was among the most straightforward services to access. However, health care workers and administrators expressed concern that their patient population lacked sufficient awareness about family planning services, noting cultural and social norms that value fertility and having many children might form a barrier to women availing themselves of such services. 

Contraceptive kits and services are available free of charge in NWS’s public facilities, but respondents reported that these cannot meet the high level of need evidenced by patient overcrowding.^[66]The lack of accessible public health facilities for IDPs can force them to forgo family planning or to purchase contraception through the private system. Women in al-Jama’a IDP camp in Idlib requested more family planning clinics.^[67] Because transportation is costly and dangerous during attacks, a health manager in rural Idlib described the “need to provide mobile teams and awareness sessions on family planning, which positively affects the community.”^[68]

Gender-based Violence (GBV)

While GBV is a sensitive topic, both health care workers and women indicated that it must be addressed. In a focus group discussion in an informally organized IDP camp in Aleppo, al-Zeitoun, women reported the need for “increasing awareness regarding family planning and GBV … especially in camp settings and among IDPs.” They added that the camp needed to prevent GBV, since women “may be exposed to marital beatings that prevent them from reaching care.”^[69] In urban Idlib, a nurse explained the need to “intensify sessions to raise awareness of GBV and introduce GBV services,”^[70] and a health manager suggested provision of in-home awareness sessions to individuals or groups of women.^[71]

Early marriage is a form of GBV of concern throughout NWS. In fact, high rates of suicide among adolescent girls in NWS have been linked to early marriage.^[72] A nurse in rural Aleppo noted the need for early marriage awareness campaigns for all segments of society, observing, “It may lead to violence, and the girl may be forced to do anything. If she gets married at a young age, and cannot live with her husband, she may be afraid to return to her family. She may do something to herself.”^[73]

Access to Post-Abortion Care

Displaced women were concerned about the dangers of not receiving post-abortion care (PAC).  Post-abortion risks include bleeding, severe infections, and complications that may lead to death or the inability to conceive again.^[74]  Unfortunately, PAC availability is uneven, and there are an insufficient number of PAC-providing health care centers in rural and frontline areas of NWS for the population.^[75] Access for patients in rural and remote areas is limited by inconsistent and expensive transportation options. In practice, respondents said, husbands or heads-of-household needed to consent in order for women to seek PAC, as well as provide the transportation support to reach PAC services.^[76]

In urban Aleppo, a respondent in a focus group described her ever-present fear of attacks when accessing post-abortion care. Describing her spontaneous abortion, she said, “There were planes in the sky of the village [aerial attacks], and my husband was not present, and I needed transportation. I was afraid to go by car with strangers alone. I experienced heavy bleeding, severe anemia, and I passed out.”^[77]

Sexually Transmitted Infections and HIV/AIDs

Respondents among both patients and health care workers reported deep stigma based on social and cultural norms around accessing health care for STIs and HIV/AIDS. Provider consultations and treatment for STIs in NWS are available in facilities offering other health services, in order to avoid stigma and protect patient privacy. Nonetheless, more programming is needed.^[78] A nurse in urban Idlib reported the need for “programs addressing the urgent human right to HIV care specific to women, children, and vulnerable groups in the context of prevention, care, and access to treatment.^[79]

Across NWS, more STI education was requested. In urban Idlib, both male and female health care workers described the need for broad community education.^[80] In rural Aleppo, a health director noted that women and girls must understand the health impacts of STIs;^[81] this was echoed by a nurse who stated they must understand “the need to treat [STIs] as soon as possible so they do not worsen.”^[82]

 A nutrition worker shared her impression that, with regard to people seeking STI treatment, “Society does not understand, and takes an inferior, negative, and stigmatized view.”^[83] Some health professional respondents appeared reluctant to acknowledge that STIs and HIV/AIDS exist in NWS, reflecting potential widespread bias among providers.^[84]

Lack of Access to SRH Services Impacts Mental Health

Focus group discussions with displaced and resident women demonstrated how the lack of access to SRH care and ongoing violence result in mental health issues in NWS. A female midwife in urban Idlib expressed her concern that support for postpartum depression must be made available.^[85] In rural Idlib, a focus group participant suggested there should be “mobile teams to provide access to those who cannot leave the house.”^[86] Women in focus groups prioritized increased access and community capacity building.

Both health care providers and community member respondents were not always aware of existing efforts and available services, indicating that more resources are needed to educate the community about the availability of mental health and psychosocial support efforts.

 

Legal and Policy Analysis 

All parties to the conflict in northwest Syria (NWS) are obligated to protect the right to health, including the right to sexual and reproductive health (SRH), for civilian populations in areas they control.^[87] Donors have an ethical obligation to support humanitarians in promoting the right to health by providing assistance without discriminatory effect. This includes the duty to provide care to the most vulnerable, including women and the disabled.

International Humanitarian Law (IHL)

Any attack that deliberately targets health care facilities, or that does not take appropriate measures to avoid the destruction of health care facilities, is illegal. IHL requires special protections for medical personnel and facilities to ensure the functioning of health care throughout a conflict.^[88] It also prohibits the targeting of civilians^[89] and protects the care of the wounded and the sick.^[90] Finally, IHL requires all parties to a conflict to respect the protection, health, and assistance needs of women affected by armed conflict.^[91] Pregnant and breastfeeding women should receive special care with regard to the provision of assistance, including food, clothing, medical assistance, evacuation, and transportation.^[92]

Civilians in conflict areas have the right to receive humanitarian aid, including medical and other supplies essential to survival.^[93] IHL allocates primary responsibility for meeting civilian needs to the state or party that controls the territory in which the civilians are located.^[94] A non-state armed group that is organized and exercises administrative control over territory, as is the case in NWS, has the same duties as a state party to the conflict.^[95] Multiple United Nations Security Council resolutions have stated that organized armed groups exercising effective control over territory and carrying out administrative and public functions are responsible for protecting the rights of civilians in the territories they control.^[96]

International Human Rights Law 

Although Syria is party to numerous treaties that are relevant to SRH, three treaties are of particular relevance to SRH rights.^[97]

The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) requires states to address the specific health needs of women, including those living in poverty, rural settings, and in situations of humanitarian emergency. CEDAW further requires parties to provide access to educational material “to ensure the health and well-being of families, including information and advice on family planning.”^[98] CEDAW also requires that states take measures to eliminate discrimination against women “in the field of health care in order to ensure … access to health care services, including those related to family planning” and requires them to ensure “appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.”^[99] The Convention further provides that women have the right to decide the number and spacing of their children and “to have access to the information, education, and means to enable them to exercise these rights.”^[100]

In regard to SRH, the United Nations (UN) CEDAW Committee, which monitors implementation of the Convention and provides authoritative interpretations as to state party obligations, recommends that parties

“Ensure that … health care includes access to sexual and reproductive health and rights information; psychosocial support; family planning services, including emergency contraception; maternal health services, including antenatal care, skilled delivery services, prevention of vertical transmission and emergency obstetric care; safe abortion services; post-abortion care; prevention and treatment of HIV/AIDS and other sexually transmitted infections, including post-exposure prophylaxis; and care to treat injuries such as fistula arising from sexual violence, complications of delivery, or other reproductive health complications, among others.”^[101]

The CEDAW Committee notes the link between conflict and gender-based violence, since conflict exacerbates existing gender inequalities, “placing women at a heightened risk of various forms of gender-based violence by both State and non-State actors.”^[102]

The International Covenant on Civil and Political Rights (ICCPR)^[103] provides for SRH-related rights, including the right to privacy and freedom from torture, cruel, and inhuman or degrading treatment, as well as the right to life (Article 6). The Human Rights Committee, which monitors the ICCPR, has determined that protecting the right to life includes the following obligation:

“State parties must provide safe, legal and effective access to abortion where the life and health of the pregnant woman or girl is at risk, or where carrying a pregnancy to term would cause the pregnant woman or girl substantial pain or suffering, most notably where the pregnancy is the result of rape or incest or where the pregnancy is not viable.”^[104]

The International Covenant on Economic, Social and Cultural Rights (ICESCR) also provides for the right to health.^[105] In interpreting the Covenant, the UN Committee on Economic, Social and Cultural Rights (CESCR) has determined that sexual and reproductive health rights are integral to the right to health and are “indispensable to [women’s] autonomy and their right to make meaningful decisions about their lives and health.”^[106]

The obligations set out in these treaties must be respected, notwithstanding the emergency conditions prevailing in NWS. The CEDAW Committee has stated that states should “adopt strategies and take measures addressed to the particular needs of women in … states of emergency.”^[107]

The Committee on Economic, Social and Cultural Rights has clarified that this means that health facilities, goods, and services must be “accessible to everyone without discrimination.”^[108] Importantly, the ICESCR has recognized that international cooperation and assistance are key for realization of the right to SRH. The Committee’s General Comment 22 explicitly states that SRH is a crucial part of the human right to health and places an obligation on states to seek international assistance in situations where it cannot provide for these rights, recognizing the role UN entities play in realizing this right.^[109]

All parties to the conflict in northwest Syria are obligated to protect the right to health, including the right to SRH, for civilian populations in areas they control.^[110]

Donors have an ethical obligation to support humanitarians in promoting the right to health by providing assistance without discriminatory effect. This includes the duty to provide care to the most vulnerable, including women and the disabled.

Conclusion

For 12 years, mass atrocities have devastated Syria’s population and attacks on civilian infrastructure have choked its health care system. Continued attacks on health care compound the already challenging context within which many health care providers are operating. Violence has severely impacted the availability of and access to sexual and reproductive health (SRH) services, which should be addressed at the community, donor, and service provision levels.

In addition to the direct physical harms to SRH care providers and patients, the indirect impacts of violence on SRH services, though under-studied, are clear. These include SRH-related mental health issues and the increase of negative social practices such as early marriage, which the Committee on the Elimination of All Forms of Discrimination Against Women has declared a form of gender-based violence.^[111] This means that women and girls disproportionately feel the effects of attacks on health care. When coupled with a shrinking space for humanitarian response and the failure to secure a long-term political solution to the conflict in Syria, the crisis of SRH is likely to worsen, disproportionately impacting women and girls.

The findings of this study amplify the voices of affected women and health care workers regarding SRH needs on the ground. They demonstrate how the damage and destruction of health facilities in northwest Syria (NWS) during the conflict have, over time, resulted in a dire shortage of health facilities and workers to meet the needs of the population. Within this context, SRH services have become increasingly insufficient, particularly affecting the most marginalized, including women in camps, those with disabilities, those with limited income sources, and adolescent girls married at a young age. Further, inflation and extreme poverty have limited the means of many women, preventing them from accessing the full range of services, even when available. The demonstrated shift of donor funding to facilities in non-frontline areas rather than frontline areas has meant that many displaced women and those living in remote areas can’t avail themselves of these services. Finally, social and cultural norms pose additional barriers for women seeking SRH services; these have produced a culture of fear and hesitation among many women and adolescent girls. Meeting their need for care requires as an urgent matter better transportation to services, more information, the tools and knowledge to support their communities, and better overall coverage of SRH services delivery.

These issues are not new, but their documentation and tracking are crucial to measuring the depth of violations of human rights in Syria in how Syrian women and girls are physically and psychologically affected. The research presented in this study is further evidence of the humanitarian community’s imperative to achieve a more coordinated and holistic approach in NWS to health, based on community needs.

As Syria enters its thirteenth year of conflict, it is vital now, more than ever, that the international community reaffirm the importance of adherence to international humanitarian law and redouble diplomatic efforts for accountability. The responsibility to change both the access to and the provision of SRH services lies not only with parties to the conflict, but also with the aid and development sector, and with the international community. There is a need to push for accountability in parallel with a serious commitment to addressing violations of international law by parties to the conflict. There should be a commitment from donors to not only increase overall humanitarian assistance, but also to increase funding for essential SRH services.

Recommendations

Considering the impact of ongoing violence on the provision of health care in northwest Syria and the effects it has had on the ongoing sexual and reproductive health crisis, compounded by the devastating February 2023 earthquakes in Syria and Türkiye, more must be done to support both health care facilities and providers.

We call on the concerned parties to take the following actions in their response to the earthquakes:

To Donors and Health Actors:

• Ensure that humanitarian aid enters northwest Syria at scale and speed through all viable routes without restrictions;
• Provide immediate and flexible funding to support emergency response efforts to the current crisis;
• Reduce current barriers to accessing SRH services, primarily the lack of transport, income, and information, specifically targeting those most marginalized;
• Ensure that lifesaving SRH services are integrated into the emergency health response;
• Ensure that members of the affected population have access to fact-based information about current SRH service availability;
• Continue systematic data collection and analysis to enable prioritization based on needs, such as to women, girls, and other vulnerable populations; and
• Build the local capacity of the health system in northwest Syria to provide SRH services that are only available in Türkiye but inaccessible due to the interruption of cross-border referral services.

To All Parties to the Conflict:

• Ensure immediate, unhindered humanitarian assistance to all communities affected by the earthquakes in northwest Syria; and
• End all attacks on civilians and other violations of international humanitarian law, and protect and respect the right of the wounded and sick to seek health care.

To Active Governing Entities in Northwest Syria:

• Ensure that humanitarian assistance is available and accessible to all affected communities in northwest Syria and is distributed based on need; and
• Ensure that the most vulnerable populations – such as women, girls, and people with disabilities – among those affected by the earthquake have access to emergency SRH services.

To the United Nations (UN) Security Council and UN Member States:

• Ensure that life-saving humanitarian aid is able to enter Syria at scale and speed through all viable routes without restrictions.

There are concrete steps that parties to the conflict, the international community, humanitarian organizations, and donors must take to support the availability of and access to sexual and reproductive health care in northwest Syria. The international aid community, including donor governments and non-governmental organizations (NGOs), must work to ensure more services are provided, while addressing the barriers to access noted throughout this report.

We call on the concerned parties to take the following actions:

To All Parties to the Conflict:

• Cease all attacks on health care and ensure the protection of health care workers as obligated by international humanitarian law. 

To Health Actors:

• Provide additional financial and technical support for sustainable strategies to increase access to SRH services, such as support to existing health networks and the use of mobile health facilities;
• Build health work force capacity, prioritizing the work of female health care providers in order to overcome potential cultural barriers to accessing SHR services, and support to local medical schools;
• Ensure meaningful access is available to a full package of SRH services, prioritizing such interventions to marginalized groups and ensuring there is fair geographic distribution and equity in service provision within communities, both displaced and host;
• Comply with minimum standards for coordination of humanitarian health system rehabilitation to avoid inequitable access to SRH care;
• Support health facilities, health workers, and social workers in addressing misinformation and awareness-building initiatives for women, men, girls, and boys to better understand what SRH services are available and how to access them;
• Adopt a holistic approach to SRH service provision, which includes awareness-raising campaigns around SRH rights and de-stigmatization at the community level, and that focuses on both health-seeking behavior and perceived health priorities;
• Ensure that SRH service provision is integrated into wider health strategic planning;
• Integrate mental health and psychosocial support activities into SRH service provision and adopt a cross-cutting approach; and
• In hard-to-reach areas, strengthen community networks through structured psychosocial support programs.

To Active Governing Entities in Northwest Syria:

• Ensure that humanitarian health sector services are available for all populations, equitably distributed geographically, accessible, and at a level commensurate with community need;
• Promote coordination within the health governance sector by engaging with local actors, including NGOs, United Nations (UN) agencies, and donors;
• Empower community-led initiatives to increase the number of ground-up approaches to health care system development to reflect patient populations’ needs and desires; and
• Prioritize accessibility and availability of health care for the physically disabled and for women.

To Donors:

• Increase support to the health sector of the Syria Humanitarian Response Plan through increased, flexible, multi-year funding that covers population needs in both the short- and long-term;
• Sustain and increase SRH and mental health and psychosocial support funding, with a focus on sustainable service provision strategies;
• Ensure the adequate funding of SRH services, particularly emphasizing that they reach the most vulnerable populations (i.e., those closest to the front lines, displaced people, adolescents, and those with disabilities);
• Ensure resource allocation and planning is informed by evidence and guided by the voices of those most affected: women, girls, and health staff; and
• Plan specific investments in programs that repair, restore, and fortify damaged or destroyed health facilities, in addition to other civilian infrastructure impacted by such attacks.

To the United Nations Security Council and UN Member States:             

• Call on all parties to the conflict to uphold their obligations under international humanitarian law and ensure the protection of health care from attack;
• Elevate humanitarian diplomacy and center Syria-focused strategies and policies around the protection and expansion of humanitarian access to ensure aid delivery is needs-based, independent, and depoliticized by all parties to the conflict;
• Reauthorize UN Security Council Resolution 2672, before the July 2023 deadline, to maintain UN-led cross-border access into northwest Syria through the Bab al-Hawa border crossing for a minimum of 12 months; 
• Break the cycle of impunity by ensuring that perpetrators of attacks against health care and other violations inside Syria are held to account; and
• Work to strengthen implementation of UN Security Council Resolution 2286 to protect health facilities and personnel from attack and hold perpetrators accountable.

To the Wider Whole of Syria Humanitarian Coordination System:

• Demand protection of health care workers and facilities;
• Enforce standards for SRH service delivery, including the Minimum Initial Service Package;
• Track the rebuilding and rehabilitation of facilities that provide SRH services;
• Support comprehensive monitoring and analysis of attacks against health care and its impacts;
• Deliver SRH-related medication and supplies to northwest Syria to address inequitable distribution; and
• Monitor SRH needs and the provision of SRH services and share regular analysis to inform priorities for programming, advocacy, and funding activities. 

    

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Acknowledgments

Principal Contributors

Physicians for Human Rights (PHR)

Houssam al-Nahhas, MD, MPH, Middle East and North Africa researcher

Adrienne L. Fricke, JD, MA, PHR expert consultant

Diana Rayes, MHS, PhD student, Department of International Health, Johns Hopkins Bloomberg School of Public Health

International Rescue Committee (IRC)

Ihlas Altinci, MD, Emergency Response Team health coordinator

Jennifer Higgins, MA, Syria policy, advocacy, and communications coordinator

Leonie Tax, LLM, MSc, health and protection data specialist

Syria Relief & Development (SRD)

Abdulselam Daif, MD, MSc ENT surgery, MSc, Epi., senior strategic advisor

Okba Doghim, MD, MSc student, programs director, Sexual and Reproductive Health Technical Working Group co-lead

 Amany Qaddour, MHSA, regional director; DrPH candidate and associate, Johns Hopkins Bloomberg School of Public Health; Visiting scholar, Brown University Center for Human Rights & Humanitarian Studies

Syrian American Medical Society (SAMS)

Ahmad Albik, MD, MEAL (monitoring, evaluation, accountability, and learning), and information manager

Mohamed Hamze, DDS, CES, DU, MSc, Health Research Department manager

The contributing agencies of this report would like to thank the following individuals and partners who provided guidance and support during the research project.

PHR leadership and staff contributed to the writing and editing of this report, including Erika Dailey, MPhil, director of advocacy and policy; Christian De Vos, MSc, JD, PhD, director of research and investigations; Michele Heisler, MD, MPA, medical director; Thomas McHale, SM, deputy director of the Program on Sexual Violence in Conflict Zones; Karen Naimer, JD, LLM, MA, director of programs; Catherine Pilishvili, MA, international advocacy officer; Payal Shah, JD, director of the Program on Sexual Violence in Conflict Zones; Kevin Short, deputy director, media and communications; Gerson Smoger, JD, PhD, interim executive director; and Middle East and North Africa interns Samia Daghestani and Justin Liu.

IRC leadership and staff contributed to the data collection, analysis, writing, and editing of this report, including Bushra Acam, MSc, northwest Syria (NWS) health information management officer; Mohammad AlJasem, MD, NWS health coordinator; Moder Almohamad, MSc, NWS senior protection manager; Nur Barakat, NWS senior health officer; Sanni Bundgaard, MSc, technical advisor SRH (sexual and reproductive health) & WPE (women’s protection and empowerment) integration; Haya Qdeimati, MEAL expert and researcherconsultant, Marcus Skinner, MSc, humanitarian and conflict policy lead, and all IRC northwest Syria technical teams.

SRD leadership and staff contributed to data collection, technical review, writing, editing and outreach related to this report, including Boraq Albsha, media manager; Hassan Al Qasem, MEAL coordinator; Sosan Azmeh, marketing & advocacy manager; Ahmad Odaimi, MD, MSc, SRD country director (interim), and all SRD northwest Syria technical teams.

SAMS leadership and staff contributed to the writing and editing of the report, including Evan Barrett, SAMS Head Quarter advocacy manager, and Dima Marrawi, Türkiye office advocacy manager.

The contributing agencies would like to thank Anas Barbour, MA, Shafak senior health and nutrition program manager, Mahmoud Sabsoub, Shafak health project manager, and all Shafak data collection teams; the Independent Doctors Association (IDA); the Relief Experts Association (UDER); the Syrian Expatriate Medical Association (SEMA); and the Union of Medical Care and Relief Organizations (UOSSM) for their data contributions to the study. The team would also like to thank the more than 260 respondents who shared their experiences as part of this survey.

The report benefited from review by Adam Richards, MD, PhD, MPH, PHR board member and associate professor of global health and medicine at The George Washington University, Milken Institute School of Public Health and School of Medicine and Health Sciences. It was reviewed, edited, and prepared for publication by Claudia Rader, MS, PHR senior communications consultant, with assistance from Samantha Peck, PHR program and executive associate.

The contributing agencies are grateful to Ali Barazi and his associates for Arabic translation services and to Elif Kaya for the Turkish translation. The contributing agencies are especially thankful for the health care and humanitarian aid workers and health experts inside Syria and beyond who are working tirelessly to provide sexual and reproductive health services in northwest Syria.

This document covers humanitarian aid activities implemented with the financial assistance of the European Union. The views expressed herein should not be taken, in any way, to reflect the official opinion of the European Union, and the European Commission is not responsible for any use that may be made of the information it contains. 

Annexes

Annex I – Methods
Annex II – Survey Tools
Annex III – Availability of Selected Reproductive Health Services in Northwest Syria

Endnotes

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[1] Physicians for Human Rights, “Illegal Attacks on Health Care in Syria,” Feb. 2022, https://syriamap.phr.org/#/en.

[2] United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), “North-west Syria Situation Report,” Jan. 24, 2023, https://reports.unocha.org/en/country/syria/.

[3] UNOCHA, “Syrian Arab Republic: Cross-Border Humanitarian Reach and Activities from Türkiye (November 2022),” Jan. 16, 2023, https://reliefweb.int/report/syrian-arab-republic/syrian-arab-republic-cross-border-humanitarian-reach-and-activities-turkiye-november-2022.

[4] UNOCHA, “Flash Appeal: Syrian Arab Republic (February – May 2023,” Feb. 14, 2023, https://reliefweb.int/report/syrian-arab-republic/flash-appeal-syrian-arab-republic-earthquake-february-may-2023.

[5] For a history of the development of the global humanitarian coordination structure, referred to as “humanitarian architecture,” see ICVA, The IASC and the global humanitarian coordination architecture: How can NGOs engage?, May 15, 2017, https://www.icvanetwork.org/uploads/2021/07/Topic_1_humanitarian_coordination.pdf; to understand how the UN cluster system works within the humanitarian coordination architecture, see UNOCHA, “Who does what?,” Jan. 14, 2019, https://www.humanitarianresponse.info/en/coordination/clusters/who-does-what.

[6] Euro-Mediterranean Human Rights Monitor, “Syria: Unprecedented rise in poverty rate, significant shortfall in humanitarian aid funding” Oct. 17, 2022, https://euromedmonitor.org/en/article/5382/Syria:-Unprecedented-rise-in-poverty-rate,-significant-shortfall-in-humanitarian-aid-funding.

[7] FGD #22, Rural, Armanaz, Idlib.

[8] UNOCHA, “Earthquakes: North-west Syria: Flash Update No. 14 (as of 28 February 2023),” Feb. 28, 2023, https://reliefweb.int/report/syrian-arab-republic/earthquakes-north-west-syria-flash-update-no-14-28-february-2023.

[9] Protection Sector, “Rapid Protection Assessment Findings: Syria Earthquake, February 2023 Protection Sector Report,” Feb. 21, 2023, https://reliefweb.int/report/syrian-arab-republic/rapid-protection-assessment-findings-syria-earthquake-february-2023-protection-sector-report.

[10] Physicians for Human Rights, ““A Nightmare Every Six Months”: UN Security Council Extension of Cross-Border Aid Keeps Millions of Syrians in Dangerous Limbo,” Jan. 10, 2023, https://phr.org/news/a-nightmare-every-six-months-un-security-council-extension-of-cross-border-aid-keeps-millions-of-syrians-in-dangerous-limbo/.

[11] SRH is related to multiple human rights the government of Syria is obligated to uphold, including the rights to life, health, non-discrimination and equality, privacy, freedom from torture and ill treatment, benefits of scientific progress, and determination of the number and spacing of one’s children. See the “Legal and Policy Analysis” section of this report for more information.

[12] Women and girls in conflict settings have increased SRH needs resulting from their increased vulnerability, including a higher risk of infectious diseases and experiencing gender-based violence. Mariella Munyuzangabo et al., “Delivery of sexual and reproductive health interventions in conflict settings: a systematic review,” BMJ Global Health, vol. 5, Suppl. 1, (Jul. 21, 2020): https://gh.bmj.com/content/bmjgh/5/Suppl_1/e002206.full.pdf. Although the SRH needs of men and boys in NWS merits study, this report focuses on the needs of women and girls, who are disproportionately impacted because of the social and economic situation in NWS.

[13] Many important issues related to SRH are implicated by, but lie outside the scope of, this study, including a full evaluation of the impact of violence on decision-making, autonomy, and health outcomes for SRH.

[14] UNOCHA, “Northwest Syria Funding Gap Analysis,” Jul.–Sep. 2021, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/20210701_funding_gap_analysis_all_clusters_final.pdf.

[15] UNOCHA, “Northwest Syria Funding Gap Analysis,” Jul.–Sep. 2022, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/nws_funding_gap_analysis_july_to_sep_2022_final_14072022.pdf.

[16] UNOCHA, “Northwest Syria Funding Gap Analysis,” Oct.–Dec. 2022, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/nws_funding_gap_analysis_oct_to_dec_2022.pdf.

[17] As noted in endnote 10, while a deep analysis of such social and cultural practices lies outside the scope of this report, the topic merits further study.

[18] Paragraph 39 (f) of United Nations Convention on the Elimination of All Forms of Discrimination against Women, “Concluding observations on the second periodic report of the Syrian Arab Republic,” Jul. 24, 2014, https://digitallibrary.un.org/record/778824; for the prohibition on abortion, see articles 524-529, 532, and 544 of The Syrian Penal Code 148 of 1949 (amended by Legislative Decree 1 of 2011) which apply to those who seek, cause, or perform an induced abortion, available at http://www.parliament.gov.sy/arabic/. Respondents also noted the limited conditions under which abortions may be performed to save the life of the mother. See, e.g., CBI #6, Female, Urban Aleppo, Medical.

[19]A practical example of this definition of awareness can be seen in the publication International Rescue Committee, Access to sexual and reproductive health services during the COVID-19 pandemic: A mixed methods assessment, May 2022, https://www.rescue.org/sites/default/files/document/6817/srh-bangladesh.pdf.

[20] Although the Cairo International Conference on Population and Development of 1994 (ICPD, paragraph 7.2), first provided a global policy framework for reproductive rights, the right to sexual and reproductive health was incorporated in the Nairobi Statement (ICPD+25). For a detailed discussion of the components of SRH rights, see Ann M. Starrs et al., “Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission,” The Lancet, vol. 391, no. 10140, (Jun. 30, 2018): 2642–2692, https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2930293-9.

[21] World Health Organization, “Attacks on health care initiative: Documenting the problem,” Jul. 22, 2020, https://www.who.int/news-room/questions-and-answers/item/attacks-on-healthcare-initiative-documenting-the-problem.

[22] The Syrian Democratic Forces (SDF) is a multi-ethnic alliance of Kurdish and Arab militias. It is led by the Syrian Kurdish People’s Protection Units (YPG) and is heavily dominated by Kurdish fighters. See Al Jazeera English, “Who are the Syrian Democratic Forces?,” Oct. 15, 2019, https://www.aljazeera.com/news/2019/10/15/who-are-the-syrian-democratic-forces/.

[23] For more information, see Annex I (Methods).

[24] IRC led one-day training sessions for data collectors to establish research ethics and principles and familiarize the staff with the questionnaire, data collection protocol, and data management/protection considerations. In addition, the training explained SRH concepts and sensitivities. Two data collectors were present in each interview: one data collector asked questions and the other transcribed the interview if participants did not consent to recording.

[25] Humanitarian Needs Assessment Programme (HNAP) Population Baseline Data NWS, Nov. 2022, on file with authors.

[26] Note that a different methodology was employed to produce this number. See page 16: “There is reason to believe that violations against international law were … committed, and … investigators [should] explore further whether crimes against humanity or war crimes have taken place” of Syrian American Medical Society (SAMS), “Report limitations,” A Heavy Price to Pay: Attacks on Health Care Systems in Syria 2015-2021, May 2022, https://www.sams-usa.net/wp-content/uploads/2022/05/202205-SAMS-A-heavy-price-to-pay_Final_Version_En-1.pdf.

[27] SAMS, “Impact of attacks,” A Heavy Price.

[28] UNOCHA, “North-west Syria Situation Report,” Key Figures, as of Jan. 31, 2023, https://reliefweb.int/report/syrian-arab-republic/northwest-syria-factsheet-21-september-2022.

[29] Ibid.

[30]  World Health Organization, “Health Resources and Services Availability Monitoring System HeRAMS – Third Quarter, 2022 Report – Türkiye Health Cluster for Northwest of Syria, Jul – Sep 2022,” Jan. 10, 2023, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/herams_q3_2022_final.pdf.

[31] UNOCHA, “Humanitarian Needs Overview: Syrian Arab Republic,” Dec. 2022, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/hno_2023-rev-1.12_1.pdf.

[32] UNOCHA, “Northwest Syria Factsheet: As of 21 September 2022,” Sep. 22, 2022, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/northwest_syria_key_figures_factsheet_20220921.pdf.

[33] World Food Programme, “Syria Country Office Market Price Watch Bulletin,” Aug. 2022, https://docs.wfp.org/api/documents/WFP-0000142857/download/.

[34] KII #40, Male.

[35] CBI #26, Male, Rural Aleppo, Medical.

[36] FGD #21, Urban, Atareb, Aleppo.

^[37] For more information, see Annex III (Availability of Selected Reproductive Health Services in Northwest Syria).

[38] For a description of the MISP, see Inter-Agency Working Group on Reproductive Health in Crises, “Quick Reference for the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health (SRH),” May 16, 2022, https://iawg.net/resources/misp-reference.

[39] For a history and analysis of the MISP and its effectiveness, see Monica Adhiambo Onyango, Bretta Lynne Hixson, and Siobhan McNally, “Minimum Initial Service Package (MISP) for reproductive health during emergencies: Time for a new paradigm?,” Global Public Health, vol. 8, no. 3, (Feb. 11, 2013): 342–356, https://pubmed.ncbi.nlm.nih.gov/23394618/. Note that while the MISP does not address all aspects of SRH care as defined by the WHO, it aims to provide SRH in crisis settings and as such can be the basis for future expanded care. In NWS, a comprehensive SRH plan is being developed that is hoped will provide expanded services beyond the MISP. Telephone communication, Co-lead of the SRH TWG, Gaziantep, Türkiye, Jan. 26, 2023.

[40] World Health Organization, “Health Resources and Services Availability Monitoring System HeRAMS – Third Quarter, 2022 Report – Türkiye Health Cluster for Northwest of Syria, Jul – Sep 2022,” Jan. 10, 2023, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/herams_q3_2022_final.pdf.

[41] Okba Doghim, “GBV Integration into Health Facilities in NW Syria Base-line assessment report,” Jul. 19, 2022, on file with authors.

[42] Note that since not all humanitarian partners report to the SRH system, this number is a conservative estimate of the actual workload during this time period. It does, however, provide a sense of how active SRH care providers are in NWS. UNFPA team and SRH Working Group for Türkiye cross-border, “SRH Working Group Activities,” Jul. 2022,  https://app.powerbi.com/view?r=eyJrIjoiM2IyZTdhYjAtMjllOC00MmZhLWJjMWYtMTVjMjcwZTQxNDU2IiwidCI6IjZjOTBmNzA3LTUxYzgtNGY1ZC04MGRiLTBlNTA5ZWYxZGE2MCIsImMiOjl9.

[43] PATH recommends four items in clean delivery kits (CDKs): 1) soap for cleaning the attendant’s hands and the mother’s perineum, 2) a clean plastic sheet for use as a delivery surface, 3) a clean string for tying the umbilical cord, and 4) a clean razor blade for cutting the cord. Most CDKs supplement this with pictorial instructions for use. While more items can be included, nonessential components can make costs prohibitive for some areas. PATH, “Clean-Delivery Kits: Guidelines for Their Use in Programmatic Settings,” Jan. 2006, https://media.path.org/documents/RH_dk_fs.pdf.

[44] Examples of basic emergency obstetric and newborn care (BEmONC) include administering intravenous fluid, antibiotics, or anticonvulsants; using a vacuum extractor or forceps to assist vaginal birth; manually removing the placenta; and removing the products of conception following a miscarriage or abortion. United Nations Population Fund, “Setting standards for emergency obstetric and newborn care,” Oct. 2014, https://www.unfpa.org/resources/setting-standards-emergency-obstetric-and-newborn-care.

[45] To see how comprehensive and basic emergency obstetric and newborn care differ, see Table 1 of Gizachew Tadele Tiruneh et al., “The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia,” BMC Pregnancy and Childbirth, vol. 18, no. 123, (May 2, 2018), https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1751-z.

[46] CBI #3, Male, Urban Idlib, Non-medical.

[47] CBI #11, Male, Urban Idlib, Medical.

[48] CBI #2, Male, Rural Aleppo, Medical.

[49] Note that skilled childbirth assistance is a single service, unlike the basic emergency obstetric care and comprehensive emergency obstetric care packages provided by the MISP. WHO, “HeRAMS Third Quarter, 2022.”

[50] CBI #1, Male, Urban Idlib, Non-medical.

[51] World Health Organization, “[HeRAMS] Health Resources Availability Mapping System, Report: 2^nd Quarter 2017 – Turkey Hub Health Cluster for Syria,” Jul. 30, 2017, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/herams_2stquarter_2017_final_0.pdf.

[52] Note that other organizations using different methodologies have also documented attacks in NWS. SAMS has recorded 422 since 2017. SAMS, A Heavy Price.

[53] Multiple sources indicate that over 90% of attacks involve air assaults or missiles. See PHR Database of Attacks on Health Care (last updated 2020), on file with authors. For a similar estimate (93%) generated using a different methodology, see SAMS, A Heavy Price.

[54] Physicians for Human Rights, “No Place Is Safe for Health Care – The Attack on Syria’s al-Atareb Hospital,” Jul. 14, 2021, https://syriamap.phr.org/#/en/case-studies/9.

[55] SAMS, “Two staff killed, eleven injured in an attack on al-Shifaa Hospital in Afrin,” Jun. 12, 2021, https://www.sams-usa.net/press_release/two-staff-killed-eleven-injured-in-an-attack-on-al-shifaa-hospital-in-afrin/.

[56] CBI #24, Female, Rural Aleppo, Medical.

[57] CBI #30, Female, Rural Aleppo, Non-medical.

[58] FGD #25, Rural, Dana, Idlib.

[59] FGD #21, Urban, Atareb, Aleppo.

[60] Rozzet Jurdi and Marwan Khawaja, “Caesarean section rates in the Arab region: a cross-national study,” Health Policy and Planning, vol. 19, no. 2, (Mar. 1, 2004): 101–110, https://academic.oup.com/heapol/article/19/2/101/643460.

[61] Hyam Bashour and Asmaa Abdulsalam, “Syrian Women’s Preferences for Birth Attendant and Birth Place,” Birth, vol. 32, no. 1, (Mar. 2005): 20–26, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1457105/pdf/nihms9784.pdf.

[62] Note that this publication used facility-based data which can be used as an indicator of the percentage of cesareans. Sara Basha et al., “Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria,” BMJ Global Health, vol. 7, no. 8, (Aug. 30, 2022), https://gh.bmj.com/content/bmjgh/7/8/e008001.full.pdf.

[63] UNFPA and SRH Working Group, “SRH Working Group Activities.”

[64] KII #23, Male.

[65] FGD #17, Rural, Armanaz, Idlib.

[66] CBI #15, Female, Urban Idlib, Medical.

[67] FGD #12, al-Jam’a camp in Idlib.

[68] CBI #23, Male, Rural Idlib, Non-Medical.

[69] FGD #8, Al-Zeitoun Camp in Azaz,Aleppo.

[70] CBI #19, Female, Urban Idlib, Medical.

[71] CBI #27, Female, Urban Idlib, Non-medical.

[72] See Evita Mouawad Jourdi and Vanessa Kyrillos, “Main Findings,” Reaching the Final Straw, Dec. 7, 2022, https://www.wvi.org/sites/default/files/2022-12/W378-0159-002.pdf; see also Lara Bellone d’Altavilla and Samer Daboul, “Warnings of worrying rise in northwest Syria suicide rate among women,” Nov. 29, 2021, https://www.thenewhumanitarian.org/news-feature/2021/11/29/warning-rise-northwest-Syria-suicide-rate-women.

[73] CBI #24, Female, Rural Aleppo, Medical.

[74] FGD #3 Rural, Afrin, Aleppo; FGD #2, Wadi Al-Hamam Camp in Afrin, Aleppo.

[75] CBI #21, Male, Rural Aleppo, Non-medical.

[76] CBI #29, Female, Rural Aleppo, Non-medical.

[77] FGD #20, Urban, Atareb, Aleppo.

[78] CBI #17, Male, Urban Aleppo, Medical.

[79] CBI #32, Male, Rural Idlib, Medical.

[80] CBI #11, Male, Urban Idlib, Medical; CBI #8, Female, Urban Idlib, Medical.

[81] CBI #10, Female, Rural Aleppo, Non-medical.

[82] CBI #24, Female, Rural Aleppo, Medical.

[83] CBI #8, Female, Urban Idlib, Medical.

[84] CBI #1, Male, Urban Idlib, Non-Medical; CBI #2, Male, Rural Idlib, Medical; CBI #4, Male, Rural Aleppo, Non-medical.

[85] CBI #15, Female, Urban Idlib, Medical.

[86] FGD #25, Rural, Dana, Idlib.

[87] For a detailed overview of international legal approaches to SRH rights, see Rebecca Brown and Christina Zampas, “Accountability for Sexual and Reproductive Health and Rights in Humanitarian Settings: Examining the Role and Relationship of Diverse Branches of International Law,” Jun. 7, 2021, https://reproductiverights.org/wp-content/uploads/2021/06/SRHR-humanitarian-settings-6-2021.pdf.

[88] See, e.g., William H. Boothby and Michael N. Schmitt, The Law of Targeting (Oxford: Oxford University Press, 2013), 233.

[89] Jean-Marie Henckaerts and Louise Doswald-Beck, “Rule 22: Principle of Precautions against the Effects of Attacks,” Customary International Humanitarian Law – Volume I: Rules, 2005, https://www.icrc.org/en/doc/assets/files/other/customary-international-humanitarian-law-i-icrc-eng.pdf.

[90] International Committee of the Red Cross, “IHL Treaties – Geneva Convention (I) on Wounded and Sick in Armed Forces in the Field, 1949 – Article 3,” https://ihl-databases.icrc.org/en/ihl-treaties/gci-1949/article-3.

[91] Jean-Marie Henckaerts and Louise Doswald-Beck, “Rule 134: Women,” Customary International Humanitarian Law – Volume I: Rules, 2005, https://www.icrc.org/en/doc/assets/files/other/customary-international-humanitarian-law-i-icrc-eng.pdf.

[92] See Fourth Geneva Convention, Articles 16–18, 21–23, 38, 50, 89, 91 and 127 (ibid., §§ 76–80); Additional Protocol I, Article 70(1) (adopted by consensus) (ibid., § 81) and Article 76(2) (adopted by consensus) (ibid., § 82).

[93] Dapo Akande and Emanuela-Chiara Gillard, “Arbitrary Withholding of Consent to Humanitarian Relief Operations in Armed Conflict,” International Law Studies, vol. 92, (2016): 483–511. https://digital-commons.usnwc.edu/cgi/viewcontent.cgi?article=1696&context=ils.

[94] See principles 3 and 25 of UNOCHA, “Guiding Principles on Internal Displacement,” 1998, https://www.unhcr.org/43ce1cff2.pdf.

[95] Matthias Vanhullebusch, “Do Non-State Armed Groups Have a Legal Right to Consent to Offers of International Humanitarian Relief?,” Journal of Conflict & Security Law, vol. 25, no. 2, (Jul. 2020): 317–341, https://academic.oup.com/jcsl/article/25/2/317/5857287.

[96] United Nations Security Council (UNSC), “Resolution 1574 (2004),” Nov. 19, 2004, http://unscr.com/files/2004/01574.pdf; UNSC, “Resolution 1376 (2001),” Nov. 9, 2001, http://unscr.com/files/2001/01376.pdf; UNSC, “Resolution 1417 (2002),” Jun. 14, 2002, http://unscr.com/files/2002/01417.pdf.

^[97] Other relevant treaties include the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child, and the Convention Against Torture.

[98] Syria acceded to the CEDAW on Mar 28, 2003. It submitted its initial report to the CEDAW Committee in 2005. See United Nations Committee on the Elimination of All Forms of Discrimination against Women (UN CEDAW), “Consideration of reports submitted by States Parties under article 18 of the Convention on the Elimination of All Forms of Discrimination against Women: Initial Report of States Parties, Syria,” Aug. 25, 2005, https://www.refworld.org/country,,CEDAW,,SYR,,4537782e0,0.html.

[99] See Article 12 of Office of the United Nations High Commissioner for Human Rights (OHCHR), “Convention on the Elimination of All Forms of Discrimination against Women,” Dec. 18, 1979, https://www.ohchr.org/sites/default/files/Documents/ProfessionalInterest/cedaw.pdf.

[100] See Article 16 (e) of UN OHCHR, “CEDAW.”

[101] UN CEDAW, “General recommendation No. 30 on women in conflict prevention, conflict and post-conflict situations,” Nov. 1, 2013, https://www.refworld.org/docid/5268d2064.html.

[102] Ibid.

[103] UN OHCHR, “International Covenant on Civil and Political Rights,” Dec. 16, 1966, https://www.ohchr.org/sites/default/files/ccpr.pdf.

[104] United Nations Human Rights Committee (UN HRC), “General Comment no. 36: Article 6: right to life, Sep. 3, 2019, https://www.refworld.org/docid/5e5e75e04.html.

[105] See Article 12 of UN OHCHR, “International Covenant on Economic, Social and Cultural Rights.” Dec. 16, 1966, https://www.ohchr.org/en/instruments-mechanisms/instruments/international-covenant-economic-social-and-cultural-rights.

[106] United Nations Committee on Economic, Social and Cultural Rights (UN CESCR), “General comment No. 22 (2016) on the right to sexual and reproductive health (article 12 of the International Covenant on Economic, Social and Cultural Rights),” May 2, 2016, http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1a0Szab0oXTdImnsJZZVQfQejF41Tob4CvIjeTiAP6sGFQktiae1vlbbOAekmaOwDOWsUe7N8TLm%2BP3HJPzxjHySkUoHMavD%2Fpyfcp3Ylzg.

[107] UN CEDAW, “General Recommendation No. 28 on the Core Obligations of States Parties under Article 2 of the Convention on the Elimination of All Forms of Discrimination against Women,” Dec. 16, 2010, https://www.refworld.org/docid/4d467ea72.html.

[108] UN CESCR, “CESCR General Comment No. 14: The Right to the Highest Attainable

Standard of Health (Art. 12),” Aug. 11, 2000, https://www.refworld.org/docid/4538838d0.html.

[109] UN CESCR, “General comment No. 22.”

[110] Brown and Zampas, Accountability for Sexual and Reproductive Health and Rights in Humanitarian Settings.

[111] UN CEDAW, “Harmful Practices as Gender-based Violence against Women and Girls – CEDAW Convention, General Recommendations (Nos 12, 14, 19, 31 and 35) and Practice of the Committee with Recommendations and Guidance to State Parties to the Convention.” Sep. 2022, https://www.ohchr.org/en/documents/tools-and-resources/harmful-practices-gender-based-violence-against-women-and-girls-cedaw.

The Russian Federation’s 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. This map documents these assaults which have a devastating impact on Ukraine’s health care system. 

This map is a joint undertaking among eyeWitness to Atrocities (eyeWitness), Insecurity Insight, Media Initiative for Human Rights (MIHR), Physicians for Human Rights (PHR), and the Ukrainian Healthcare Center (UHC). Together, our coalition of organizations has been monitoring and documenting attacks against Ukraine’s health care system and its infrastructure since the onset of Russia’s full-scale invasion of Ukraine in February 2022. 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.

Press release available in English and Ukrainian.

Executive Summary

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.

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 immediate 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.”

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 out of 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.

“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.

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]

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 Ukrainians 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 of all parties to an armed conflict, all parties to the conflict must ensure compliance with international humanitarian law principles.

To other engaged actors, the report makes the topline recommendations below (full recommendations can be found starting on p. 82).

Selected 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. 

Introduction

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, while violence against the Ukrainian health care system has featured prominently in its conduct. One notorious incident came only two weeks after the full-scale invasion began, when Russia’s air force bombed the Women’s and Children’s Health Territorial Medical Association, 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.

Critically, February 2022 was not the first Russian attack on Ukraine’s sovereignty, nor was it the first time it targeted the country’s health care system. Indeed, the current aggression stretches back to at least 2014, when, following the Revolution of Dignity that ousted Ukraine’s former president, Viktor Yanukovych, Russia moved to annex Crimea from Ukraine, and both supported and directed pro-Russian separatists in a long-running conflict in the country’s eastern, Donbas region.[4] As a 2019 study concluded, “healthcare infrastructure in the Donbas region has experienced significant degradation, with one-third or more of the large care facilities damaged as the result of combat operations.”[5]

Protecting health care is a shared responsibility of all parties to an armed conflict. International humanitarian law (IHL), which is the body of law that applies to armed conflicts, sets out detailed rules that seek to protect health care from conflict-related violence, principally by limiting the means and method of warfare. Health care facilities, providers, and ambulances are further afforded special protection under IHL so as to mitigate the impact of conflict on their work and ensure the delivery of care to the sick and injured. Beyond protection, however, there is a pressing need to ensure accountability when IHL rules and principles are violated.

This report documents the damage and destruction done to Ukraine’s health care system – including attacks on health care facilities and violence against health care workers – during the first year of Russia’s full-scale invasion. Drawing on detailed case studies and a joint dataset of 707 reported attacks, it shows how Russia appears to be violating IHL by deliberately and indiscriminately targeting Ukraine’s health care system as part of a broader attack on Ukraine’s civilian population and infrastructure. The database and case studies below show that, rather than Ukraine’s health care system being protected from the effects of Russia’s war of aggression, the system has been devastated by it. 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.  

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.

Building on the dataset and case studies, the legal analysis in the report’s final section offers a roadmap for investigators and prosecutors to build cases that focus on attacks on Ukraine’s health care system, in order to promote accountability for these crimes.[6] It shows that 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 immediate 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.”[7] Similarly, a recent report by the United Nations (UN) Human Rights Monitoring Mission in Ukraine notes that, “The extent of damage to educational and medical facilities directly impacts the enjoyment of the rights to health and education. Children, women in need of perinatal care and persons with vulnerabilities who require stable access to healthcare are particularly affected.”[8]

This report proceeds in three parts. The first outlines overall numbers of documented attacks on health care facilities and health care workers from February 24, 2022 to December 31, 2022, based on a dataset and interactive map that has been collectively developed from open-source and confidential information over the course of the year.[9] The early impact of these devastating, crushing attacks on Ukraine’s health care system, and their historical roots in other conflicts in which Russian forces have been engaged –Chechnya, Georgia, Syria – is also examined. The second part offers 10 detailed case studies that illustrate the kinds of attacks that have been perpetrated on hospitals, health care workers, and medical transport in Ukraine since February 2022. The final section outlines the legal framework for understanding how these attacks may constitute war crimes and crimes against humanity under international law, and then provides a broad overview of specific crimes that may have been committed, all of which require further investigation as part of a comprehensive, multifaceted approach to accountability. This includes: (1) enforcement through international criminal law as set forth in the Rome Statute of the International Criminal Court (ICC) (which has jurisdiction over international crimes committed in Ukraine); (2) a consideration of available charges under Ukrainian criminal law; and (3) the availability of prosecutions in third countries under the principle of universal jurisdiction. All three are critical, complementary avenues for criminal accountability. 

The principle of equal application under IHL dictates that the law applies to all parties in an armed conflict; it binds both Ukraine and Russia. This report, however, focuses on the conduct of Russian forces over the course of 2022, because the scale and weight of available evidence point towards attacks perpetrated against Ukraine’s health care system in the course of Russia’s aggression. The authors are aware of reports of Ukraine allegedly not abiding by certain IHL obligations as well, for instance by failing to move civilians away from areas of fighting – including in the vicinity of hospitals – and a non-specific claim that hospitals were used as military outposts.[10] Investigation of violations of a duty to remove civilians from areas of fighting is beyond the scope of this report. Another claim is that Ukraine fired from health care facilities or otherwise used them for military purposes. Despite efforts, the authors have not seen or been able to obtain evidence of a hospital attack or misuse of hospitals for military purposes by Ukrainian forces.[11] If or when evidence points to unlawful conduct on the part of Ukrainian forces in relation to health facilities (or other protected sites), these incidents should similarly be investigated by relevant domestic or international authorities. Under IHL, if a health facility is being intentionally misused to gain a military advantage, the facility would lose its protection; however, as discussed further below, the attacker still has a duty to warn and to minimize harm to civilians.

The report does not identify individual suspected perpetrators among Russian forces.  To do so would require the gathering of additional testimony, documentation, and other evidence, which will be incumbent upon the ICC and competent national authorities.   A full investigation of this kind should expose the criminal accountability not just of perpetrators directly responsible for carrying out the criminal acts outlined in the report, but of those ultimately, as well as indirectly, responsible for designing, developing, pursuing, and instructing others to destroy and weaken Ukraine’s health care system.

Methodology

This report used a mixed-methods approach to document and legally analyze case studies of attacks on Ukraine’s health care system as well as the devastating impact these attacks have had on the right to health. It documents visible destruction to the health care system combined with witness testimonies and other reported descriptions of how the damage occurred in areas of Ukraine, where such information is available. Drawing on an incident dataset of attacks collectively developed by the authoring organizations and supplemented by the case studies, the report then analyzes these attacks for potential violations of international criminal law and Ukrainian criminal law. The events and data herein focus on the period from February 24, 2022, when Russia’s full-scale invasion of Ukraine began, to the end of December 2022.

The report draws on a range of sources: audiovisual 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 United Nations 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 non-governmental organizations.

Partner Organizations

This research is a joint undertaking among organizations based both inside and outside Ukraine, each of which shares an interest in ensuring the protection of health care in conflict and in ensuring compliance with international humanitarian law (IHL). Each brings a unique background to the collaboration:

eyeWitness to Atrocities, initiated by the International Bar Association in 2015, seeks to bring the perpetrators of atrocities to justice by providing legal and technical expertise in building photo and video dossiers that can be authenticated for use in criminal investigations or trials.

Insecurity Insight is a humanitarian to humanitarian (H2H) organisation that aims to elevate the voices of those affected by insecurity and to raise awareness of the impact of violence. Insecurity Insight has been monitoring violence against health care since 2008 and generates data for the Safeguarding Health in Conflict Coalition (SHCC) on attacks on health care. Its innovative data collection and analysis methods have generated insights relevant for aid workers, aid agencies, and those concerned with the protection of health workers, educators, internally displaced persons, and refugees.

Media Initiative for Human Rights (MIHR) advocates for Ukraine’s integration into the free world. Its main areas of activity are the investigation of war crimes committed in connection with the Russian aggression in Ukraine and advocacy to support compliance with and observance of human rights and freedoms.

Physicians for Human Rights (PHR) is a human rights organization that documents and seeks accountability for violations of human rights and other international crimes. It has a particular focus on protecting health facilities, workers, and volunteers providing medical assistance and care during conflict.

Ukrainian Healthcare Center (UHC) is a think tank based in Kyiv, Ukraine, providing consultancy, analytics, and educational services. Its core competencies include health system policy and governance, health economics and financing, and health system transformation. UHC began documenting attacks on health care in February 2022, after the large-scale Russian invasion began.

As organizations with presence in Ukraine, both UHC and MIHR served as the initial point of contact with Ukrainian health care professionals. As explained below, UHC’s monitoring of attacks on health facilities and existing contacts with many hospital staff and directors enabled the sharing of sensitive information and, in several cases, access to the health facility to undertake further interviews and analysis. Similarly, MIHR researchers were able to speak with medical personnel who were originally trapped in occupied territories of Ukraine but later managed to escape. These individuals trusted MIHR to share their experience through semi-structured interviews, which are described further in the report’s case studies.

Site Visits and Interviews

Between April and November 2022, UHC and MIHR researchers gathered first-hand accounts of attacks on health care in Ukraine, visiting areas that were accessible at the time of research. These included areas that were either initially the site of heavy fighting as part of the Russian offensive or were occupied by Russian forces but later liberated. UHC’s research teams visited hospital sites in four different regions of Ukraine now under the control of the Ukrainian government – Makariv (Kyivska oblast, May 23, 2022), Chernihiv (Chernihivska oblast, July 14-15, 2022), Trostianets (Sumska oblast, August 11, 2022), and Izium and Balakliia (Kharkivska oblast, November 18, 2022) – to inspect attack sites, assess damage, take photographs, and conduct semi-structured interviews with hospital staff who were present at the time of the attack.[12] During these months, MIHR researchers also interviewed several Ukrainian doctors and medics about their experiences providing health care during bombardment by Russian forces or under occupation. Three of these interviews – with health care professionals who managed to escape or were later freed from captivity – are recounted in detail.  

This report’s methodology was approved by PHR’s Ethics Review Board (ERB) in order to ensure compliance with U.S. requirements for human subject research.[13] Accordingly, for all interviews, the research teams obtained informed oral consent from each subject after the subject received a detailed explanation of the five partner organizations, the purpose of the investigation, and the potential benefits and risks of participation. All interviews were conducted using a range of security precautions and protections. First, participants could stop the interview at any time or refuse to answer any questions. Audio recordings of interviews were only made with the explicit permission of the interviewee. Second, all images obtained by UHC or through the eyeWitness app – which has been used in Ukraine since 2017 to capture photos, video, and sound and to record metadata – are stored on secure systems owned by each respective organization. All interview files are stored on a secure, password protected file-sharing system to which only the partner organizations have access. Finally, while all health personnel interviewed for the report were spoken with after they had managed to escape occupied territories, the identities of several have been withheld upon their request to ensure their safety and anonymity. Subjects are only described in a manner that does not identify them or provide any identifying characteristics unless they specified that they wished to be identified. Interviews were conducted in Ukrainian and translated into English.

Dataset

To understand the scale and extent of attacks on health care, the report draws, in part, on an incident dataset that research partners developed over the course of 2022. The dataset brings together 707 individual incidents from a range of sources, including open-source research, the eyeWitness app, witness and victim accounts, site visits undertaken by UHC, and networks from organizations working on the ground. It has been compiled using an incident-based approach to evidence collection, where individual incidents are collected, verified, and combined to allow for an analysis of patterns of violence over time and in different locations.

The dataset follows Insecurity Insight’s standard data structure as developed for the Safeguarding Health in Conflict Coalition, of which it, PHR, and UHC are members.  Insecurity Insight has been monitoring violence against health care since 2008 and generates data for the Safeguarding Health in Conflict Coalition on attacks on health care in all active conflicts. In March and May 2022, Insecurity Insight provided regular, near-time updates on reported incidents of attacks on health care in Ukraine.[14] In its monitoring of attacks, Insecurity Insight used established online data search methods, including both algorithms and manual searches; it then combined this information with confidential event contributions from long-term partner organizations to compile its dataset of attacks on health care in Ukraine.^[15] This data can be visually explored in online interactive maps and downloaded from the Humanitarian Data Exchange.^[16]

UHC’s data collection began as an effort to verify attacks reported by the World Health Organization (WHO) and the Ukrainian Health Ministry in March 2022. For each event, UHC followed a two-level verification protocol that was adapted from the Berkeley Protocol on Digital Open Source Investigations.[17] It included conducting open-source research of news reporting about an attack (including social media posts), consulting photographic or video evidence of damaged or destroyed hospitals, reviewing satellite imagery, and/or speaking with witnesses to an incident. This included, in some cases, interviewing representatives from the affected hospitals by phone or in person to confirm the attack and the level of damage the facility sustained.[18]

For this report, the research teams undertook a cross-checked merger of UHC and Insecurity Insight’s previously independent datasets, reconciling any identical attacks, to create a unified online documentation of attacks on Ukraine’s health care system, including health care facilities and personnel.[19] All incidents were then reviewed and verified based on a range of criteria within the limits of research partners’ technical and resource capacity.[20] The merged dataset follows the WHO’s definition of attacks on health care: “any act of verbal or physical violence, obstruction, or threat of violence that interferes with the availability of, access to, and delivery of curative and/or preventive health services.” [21]

Map

Accompanying the release of this report is the launch (in English and Ukrainian) of an online, interactive map – located at www.attacksonhealthukraine.org – of documented attacks on health care perpetrated in Ukraine since the onset of the February 24 invasion. Whereas this report reflects data current as of December 31, 2022, the map and dataset will be continuously updated into the future. The map complements the report, however, as it provides a visual depiction of the scale and widespread nature of the attacks on Ukraine’s health care system described herein; it also highlights apparent patterns in the types of attacks and where they were committed relative to the broader history of Russia’s invasion. All of the case studies detailed herein are included on the map, as are the overall numbers of attacks discussed in the following section. The map also includes additional information on other conflict-related incidents that affected Ukraine’s health care system (e.g., the death of health care personnel by attacks perpetrated outside the course of their professional duties), but which are not further discussed here.

The images for the accompanying map were captured by or shared with UHC (with the informed consent of the individual who took the picture) or provided using the eyeWitness to Atrocities app, which has been actively used in Ukraine since 2017. To date, users of the app have captured and uploaded to the eyeWitness server more than 30,000 photos, videos, and audio recordings from across Ukraine. The app enables users to capture material and uses the device sensors to record metadata (such as GPS, nearby cell towers, and/or nearby Wi-Fi networks) that helps to authenticate the date, time, and location of the images and sound.[22] All users of the eyeWitness app have granted consent for the use of photographs contained in this report and the accompanying map.

Limitations

The report focuses on traceable evidence connecting attacks on Ukraine’s health care infrastructure to Russian forces. The numbers shown on the map and presented in the dataset provide a minimum estimate of the conflict damage to the health care system in Ukraine in 2022; however, they are likely an undercount. Like any other incident data collection, this dataset suffers from selective reporting, insofar as it depends on those who first reported an attack. Events may be captured or ignored for a range of reasons, including lack of access, lack of knowledge, disruption of Internet connection, or simple errors of omission. Specifically, incidents that occurred in territories directly or previously occupied by Russia are infrequently or rarely reported, resulting in an underrepresentation of the scale of violence in some of the Russian-occupied areas of Donetska and Luhanska oblasts and other, adjacent territories. There is also a possibility of bias in the reports as a result of mistaken perceptions and/or partiality toward Ukraine that could lead to exaggeration or inferences that might not be warranted by the evidence. It is possible that information about Ukrainian attacks on health facilities will come to light in the future, but no such information was available during the period of data collection.

The dataset therefore likely covers incidents in certain locations – and certain types of incidents – more systematically than others.  The authors have relied on multiple sources whenever possible to address this potential bias. However, the authors were not able to obtain some underlying incident data that has been collected by others. The WHO has released the total number of attacks on health care in Ukraine it has collected and published information on aggregated number of attacks by oblast, but it does not publicly share information about particular incidents beyond the date, victims, and whether explosive weapons were used.[23] Without this information, it was not possible to determine whether the WHO had evidence of attacks beyond those in the database, nor to learn the nature and location of incidents it found.^[24]

In addition to these monitoring limitations, situational constraints also posed limits to the ability to conduct physical documentation of attacks on the ground. For this reason, while research teams were able to speak with health personnel who had escaped occupied territories or travel to some regions that had been previously occupied by Russian forces later in 2022 to provide corroboration or confirmation of incidents, they were unable to access regions that remain occupied or where active conflict is ongoing.

Overview and Impact of Attacks on Ukraine’s Health Care System

From February 24 to December 31, 2022, partner organizations documented a total of 707 attacks on Ukraine’s health care system. These include:

• 292 attacks on health facilities (hospitals and clinics), which damaged 186 facilities and destroyed 32. Of the 218 facilities that were damaged or destroyed, 48 were affected by attacks more than once. Assaults were particularly intense in February and March; in the first two weeks of the full-scale invasion, an average of four to five hospitals and clinics were attacked daily.
• There were 65 documented attacks on ambulances, in which 40 ambulances were damaged.
• There were 181 documented attacks on other health infrastructure (e.g., pharmacies, blood centers, dental clinics, research centers, etc.).^[25]  
• 86 attacks on health care workers, which killed 62 and injured 52. Many attacks impacted more than one health care worker.

The 707 total also includes a range of additional incidents which meet 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 formal care structures in order to protect them.

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. Attacks continued throughout the year, with an average of 47 attacks documented each month between April and 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.

Attacks on Hospitals

With 218 hospitals reported damaged or destroyed, one out of 10 of Ukraine’s hospitals have been directly damaged from attacks.[26] As the map below clearly shows, the destruction is most marked in the east of the country. In some cities and towns, nearly all the health facilities were affected in some way. According to the Ukrainian Healthcare Center (UHC), in Mariupol and the southern part of Donetska oblast, almost 8 out of 10 points of health care service provision – sites where medical assistance is provided – were either damaged or destroyed. The oblasts that experienced the most attacks on hospitals were Kharkivska, Donetska, Luhanska, Khersonska, and Kyivska.

Multiple Attacks on the Same Hospitals

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 Multiprofile Hospital in Luhanska oblast appears to have been hit 10 times between March and May 2022; a hospital in Kharkiv was hit five times, another, in Kharkivska oblast, was hit four times. 

Attacks on Health Care Workers

In 2022, the course of the Russian invasion killed at least 62 health workers in Ukraine and injured least 52. While this is likely an undercount, it is an important indication of the scale of the impact on the health system. Moreover, at least eight health workers were injured from the conflict violence outside of work, highlighting the broader impact of the war on the Ukrainian health care system, even when not the result of direct attacks on health.

The conflict has also diminished Ukraine’s health care workforce. Mass displacement of specialist care professionals has resulted in severely understaffed facilities and a risk of burnout for the remaining staff. Communities have resorted to online consultations with doctors who fled to the western part of Ukraine or abroad.[27] Notwithstanding valiant efforts by the WHO, NGOs, Ukraine’s Ministry of Health (MoH), facility managers, and health care staff to maintain quality health care and service delivery, in some places it has suffered. A lack of running water and electricity in some facilities caused by conflict damage has compounded this problem.

Indirect Attacks on Ukraine’s Health Care System

Other attacks on Ukraine’s health system which are beyond the scope of this dataset include:

• Infrastructure damage has led to direct losses of raw materials for medicines, along with losses in manufacturing, storage, and distribution capacities, and delays in manufacturing and distribution.
• A large number of attacks on Ukraine’s energy infrastructure have affected the ability of health facilities – ranging from hospitals to retail pharmacies – to remain operational.

Estimated Damage and Loss

All of these attacks have caused widespread and costly damage. As of August 2022, according to the World Bank, the Ukrainian government, and the European Commission, the direct damage to Ukraine’s health sector was estimated at US$1.4 billion. [28] This represents the monetary estimate of the cost of destroyed and damaged health infrastructure included in the inventory of damage that Ukraine’s MoH compiles.  It is likely that the actual level of damage is higher, however, given incomplete reports about damaged facilities located in territories temporarily not under Ukrainian government control and other private sector facilities. In addition:

• The estimated further losses from attacks on health are upwards of US$6 billion, which includes the removal of debris and demolition from destroyed health facilities, loss of income of private providers, losses from the financing of facilities that have not been fully operational during the war, and additional losses incurred by the population’s waning health. 

• According to WHO, the European Union Delegation to Ukraine, the U.S. Agency for International Development (USAID) Mission in Ukraine, and the World Bank, the overall needs of Ukraine’s health sector are estimated to be US$15.1 billion (equivalent to almost three times the annual public spending on health) in order to cover accumulated infrastructure damage as well as the need to rapidly scale up critical health services.[29] This amount includes the cost of building new infrastructure using a “building back better” approach and the immediate recovery of facilities that were partially damaged. It also includes a significant expansion of rehabilitation and mental health services in Ukraine, which, as discussed below, will need to be scaled up to address the impacts of the war.

Explosive Weapons

Explosive weapons were reported in 89 percent of all incidents of damaged and destroyed health infrastructure (414 of 464).[30] The majority of health care objects appear to have been damaged through ground-launched explosives (including sea-launched missiles and mortars), such as shelling by conventional artillery, Multiple Launch Rocket Systems or mortars, rather than missiles, piloted-aircraft drop bombs, or those launched/dropped from drones. In total, 257 events causing damage to health infrastructure were attributed to ground-launched explosives in 14 oblasts. As a result, 120 hospitals and clinics were damaged and 25 were destroyed.

Ground-launched attacks on hospitals occurred in situations where tanks and other vehicle systems were used to shoot at health facilities from a relatively short distance. In these instances, the soldiers firing these weapon systems would have clearly seen the building they were targeting. If hospitals and other health facilities were clearly marked, they would have been aware that they were targeting a hospital. While it cannot be excluded that some health infrastructure, in particular warehouses or administrative buildings, may not have been clearly identifiable as such (and that Ukrainian forces may have been inside or nearby some health facilities that came under attack), the extent of damage they sustained through short distance ground-launched weapons systems strongly suggests that these attacks were intentional.

Air, sea, and ground-launched long-distance missiles and rockets have damaged health care infrastructure across a wide expanse of Ukrainian territory. These weapon systems have often been fired over several hundred kilometers. Both the weapon systems and the long distance over which they were fired makes it highly unlikely that the weapon systems were capable of accurately targeting and of avoiding wide-area effects around any potentially intended target. Such weaponry thus caused widespread indiscriminate effects in densely populated areas and among vital civilian infrastructure. Indeed, many incidents of reported damage to health facilities were due to the wide area effects of the explosive weapons, rather than from direct hits. To that end, the extent to which long-range ground missiles have been fired at cities and towns suggests that the Russian command pursued a military strategy of targeting civilians and civilian infrastructure, including health care. Indeed, Russian President Vladimir Putin explicitly admitted that Russia was targeting civilian infrastructure in a December 8, 2022 speech.[31]

In addition to ground-launched explosives, the dataset includes 35 incidents (out of the total of 464) where Russian airstrikes apparently used piloted airplanes in attacks that damaged or destroyed health infrastructure in 10 oblasts. Piloted air strikes were common during the initial weeks of the full-scale invasion in March, during which time 21 of these 34 recorded piloted air strikes took place. Air strikes continued to occur around contested cities, such as on December 21, 2022, in the Zaporizka oblast.

Air dropped bombs were recorded from Chernihivska, Donetska, Kharkivska, Kyivska, Luhanska, Mykolaivska, Sumska, Vinnytska, Zaporizka, and Zhytomyrska oblasts. In some instances, more than one hospital was hit during a single attack (see map above).

When aircraft pilots carry out air strikes, they would normally be able to identify larger and clearly marked hospitals, allowing them to distinguish between military and civilian health infrastructure if using so-called “precision guided” weapons. However, the majority of piloted Russian airstrikes have used so-called “dumb” or “iron” bombs that are released by the pilot after reference to a visual cue on the ground seen through a sight mounted in the cockpit. These bombs cannot be controlled once released and do not allow for variations or errors in altitude, airspeed, atmospheric pressure, temperature, precipitation, humidity, or wind – all of which can affect the trajectory of a bomb once released.[32]

While genuine mistakes cannot be excluded and some health facilities may not have been easily identifiable – and  pilots will have been under high levels of stress, potentially causing them to target incorrectly – the extent to which Ukraine’s health facilities were damaged through air-dropped bombs suggests that pilots had likely been instructed to hit civilian infrastructure without regard for the fact that there may have been protected facilities in the areas being targeted.

Patterns of Attacks in Previous Conflicts

The patterns of Russia’s attacks on health care facilities in Ukraine are consistent with historical patterns as well. For instance, Physicians for Human Rights (PHR) documented how the Russian military attacked health facilities and workers in Chechnya as part of a relentless crackdown on the civilian population over the course of 2000 during the longstanding conflict there.[33] Similar reports later surfaced during the Russian-Georgian war in 2008, where medical facilities and personnel also came under attack. In a 2008 statement, the Georgian Medical Association reported that Russian armed forces had attacked an emergency hospital in Gori, severely injuring a doctor who was providing medical assistance at the time. Levan Labauri, the association’s then-secretary general, said that doctors had been “working under the permanent air attacks of Russian jets, even in the capital city Tbilisi. Some of our physicians [have been] killed and severely injured and hospitals destroyed. It is a really catastrophic situation.”[34]

In Syria, PHR has extensively documented at least 601 attacks on 400 health care facilities since the Syrian conflict began in March 2011.[35] In total, Syria and its Russian allies, who entered the conflict in 2015, have carried out 90 percent of all attacks on health targets (542 attacks), including the killing of 831 health workers.[36]Notably, the rate of attacks on hospitals increased by 62 percent between 2015 and 2016, following Russia’s entry into the conflict, compared to the period between 2012 and 2014. Indeed, in 2015 and 2016, PHR recorded the highest number of annual attacks on health care attributed to the Syrian government and Russia.[37]

The apparent existence of Russia’s policy to attack the Ukrainian health care system as a means of attacking the civilian population cannot be viewed in isolation from its pre-2022 conduct – even in Ukraine. From 2014, Ukrainian citizens living in Crimea without residency permits or Russian passports lost access to public health care,[38] and, since the onset of the full-scale invasion, the Crimean local population is reportedly being denied access to hospitals, which are reserved for wounded Russian soldiers.[39] Similarly, between 2014 and 2017, damage to health care facilities in the Donbas region has been described as “devastating beyond what was generally known.”[40] Researchers, for instance, determined that “over one-third (102) of the hospitals and clinics were damaged or destroyed [during that period], with over three-quarters of those attacks occurring during the period of heaviest fighting” between mid-2014 and early 2015.[41] The widespread use of largely indiscriminate weaponry was likewise noted as a contributor to the scale of damage during this period. A 2017 report of the Safeguarding Health in Conflict Coalition further found “that checkpoints and roadblocks, or conflict lines, impede[d] access to health care for one-third of households in conflict-affected areas in the east of [Ukraine], with dire implications for the 50 percent of families in the region that have members suffering from chronic diseases.”[42]

Impacts of Attacks on the Health of Ukraine’s Civilian Population

The health care facilities and infrastructure detailed above are all critical to ensuring the sustainable functioning of a complex health system. Beyond the direct damage and destruction perpetrated on the health care system, however, there is the broader impact that these attacks have on the right to health. Indeed, notwithstanding the resilience of Ukraine’s entire health care sector and the significant international support that has been provided, the scale of these attacks underscores the broader destabilizing effects they have on the country’s population, from reduced access to critical medications to severely restricted access to health care and vastly diminished vaccine rates. Some of these early indications since the onset of the February 24 invasion are highlighted below:

Diminished Access to Care. Damaged or destroyed health care infrastructure have left entire communities in Ukraine without access to essential services.

• In Mariupol, about 80 percent of health care infrastructure has been destroyed. In small and medium size communities – Izium (Kharkivska oblast), Balakliia (Kharkivska oblast), Makariv (Kyivska oblast) – hospitals are able to provide only a small segment of essential care, forcing patients to travel long distances to get it or to refuse to seek care at all. These communities are discussed further in the case studies below.

• An International Organization for Migration survey found that, as of the beginning of December 2022, one in every three Ukrainians was experiencing the lack of medical services. Most of the affected populations are concentrated in the southern part of the country. 

Moreover, residents from areas not under Ukrainian government control or regions still experiencing active hostilities were significantly less likely (38 percent) to seek health care for a chronic disease than residents of Ukraine’s other regions (53–56 percent). In addition, there have been numerous reports from temporarily occupied areas about hospitals being used to treat Russian soldiers, while Ukraine’s civilian population is denied care.[43] 

Reduced Vaccination Rates. Ukraine’s MoH reported a dramatic drop in routine vaccination rates since the onset of the full-scale Russian invasion, as health facilities struggle to meet pre-2022 rates. Lower vaccination rates create the risk of potential outbreaks of polio, measles, diphtheria, and other vaccine-controlled diseases.

• The Public Health Center (PHC) of the MoH reports that at the midyear, of all children under one year of age, only 29.7 percent received shots against tuberculosis; 23.1 percent against viral hepatitis B; 33.9 percent against diphtheria, tetanus, and pertussis; and 33.3 percent received polio vaccination doses. The PHC predicted that Ukraine would reach only about 60 percent coverage by the end of 2022, which is far less than what is needed for effective population protection.[44] 

• Ukraine experienced a polio outbreak in the fall of 2021: 22 cases of polio were registered and a national polio control plan was enforced in February 2022 with the aim to boost vaccination in regions at risk. However, the Russian full-scale invasion halted the campaign and now, the possible repercussions of the continued outbreak are unclear.[45]

• The overall COVID-19 vaccine coverage has remained almost unchanged compared to the pre-war level of about 37 percent of the fully vaccinated population. Over the course of 10 months (from February 22, 2022 to January 9, 2023), only 522,339 first doses of COVID-19 were administered in Ukraine: this comprises about one percent of the population. Only 0.5 percent of Ukraine’s general population has received the second dose of the vaccine (237,551 doses administered). In total, since February 24, 2022, approximately five percent of Ukraine’s population has received a booster shot.[46]

Diminished Ability to Manage Chronic Disease. According to the International Organization for Migration, internally displaced persons in Ukraine most often reported they had stopped taking medication for high blood pressure and cardiovascular diseases. The WHO has reported that the types of medicines most frequently cited by respondents as difficult to obtain were medication for high blood pressure and for heart conditions (49 percent each).

Based on UHC’s independent analysis of Ukrainian government-funded prescriptions in 2022, there was a significant drop in the intake of the top three government-reimbursed medications in the first quarter of 2022. The top cardiovascular conditions’ drug (Bisoprolol) intake dropped by 34 percent compared to the similar period the previous year, the main type 2 diabetes medication (Metformin) dropped 27 percent, and the main asthma drug (Salbutamol) fell by 57 percent.

Growing Financial Barriers. Ukraine’s dramatic gross domestic product decline (about 30 percent in 2022) and high inflation suggest a looming health-related financial burden and threaten to impoverish a significant share of Ukraine’s population.

• Out-of-pocket health spending is high in Ukraine (about 51 percent of total health spending in 2019), meaning that there is a high risk of reduced affordability of health care, especially for essential medicines. 

• According to a WHO survey, the main barrier (53 percent) to accessing health services reported by respondents’ households was the cost of medicines/treatments.[47]

• As of early December 2022, almost one-fifth of Ukraine’s population (17 percent) reported insufficient access to health care services and medication. The most common barrier for both was lack of funds to buy medicines or cover services needed.[48]

Worsening Mental Health. Russia’s invasion has caused a substantial increase in psychological harm and distress for all segments of Ukraine’s population. Mental health disorders, including a high prevalence of depression, alcohol use disorder, and suicide, were already the second leading cause of disability in the country, affecting up to 30 percent of the population.[49] 

• Now, almost 10 million people could be potentially at risk of mental disorders such as acute stress, anxiety, depression, substance use, or post-traumatic stress disorder.[50]

• Notably, this figure excludes Ukraine’s growing veteran population: as of May 2022, the future number of veterans was estimated at five million, a more than five-fold increase from pre-war levels.[51] Veterans experience mental health disorders, post-traumatic stress, and other metal health issues at vastly disproportionate rates compared to the civilian population. 

Case Studies of Attacks on Ukrainian Health Care

The 10 case studies below detail alleged attacks by Russian forces on Ukraine’s health care facilities, infrastructure, and workers in the conduct of the full-scale invasion of Ukraine. Several of these attacks were perpetrated in February and March 2022, as Russian forces encircled or occupied cities like Izium, Chernihiv, Trostianets, and Mariupol as part of the first phase of its full-scale invasion.

1.     Attacks on Health Care Facilities

Siege warfare, bombardment, and the use of indiscriminate weapons have characterized Russian offensives in Ukraine, particularly urban areas with high civilian populations. Attacks on hospitals have appeared, in many cases, to be the result of widespread attacks on civilian areas, in which health care facilities – like other civilian objects, such as schools, residential dwellings, and places of worship – were part of a broader disregard for certain core international humanitarian law (IHL) principles relating to civilian protection: distinction, the prohibition on indiscriminate attacks, proportionality, and precaution. In addition, evidence suggests that some attacks are also part of a deliberate effort to attack health care facilities, meaning that the intention of Russian forces has been to target these facilities.

Case Study #1

Izium Central City Hospital (Kharkivska oblast)

Izium is a town of about 50,000 inhabitants split into two by the Siverskyi Donets River and connected by three bridges. The town center is located on the southern bank, hosting essential infrastructure such as administrative buildings and educational and medical facilities. On the northern bank are blocks of private residential buildings. The town’s location is strategic:[52] it stands on the M03/E40 highway connecting Kharkiv and the Sloviansk-Kramatorsk agglomeration (the administrative center of the Ukraine-controlled portion of the Donetska oblast) and on the P-79 road to Kupiansk in the north (another important transport hub) and Dnipropetrovska oblast in the southwest.

Following the capture of Kupiansk (on February 27, 2022) and Balakliia (on March 2, 2022; see Case Study #7) by Russian forces, Izium experienced heavy bombardments and was cut off from electricity, water, and mobile communications.[53] On April 1, 2022, Russian forces managed to occupy the town.[54] Izium remained under occupation until its liberation by Ukrainian forces on September 10, 2022.[55] Atrocities committed during the occupation have since come to light, including extensive destruction of civilian infrastructure and mass killings.[56]

The Izium Central City Hospital, located south of the river in the town’s city center, is a public, nonprofit hospital founded in 1822. Situated on the highway connecting Kyiv-Kharkiv-Dovzhanskyi, it had been designated as a roadside hospital to provide emergency care.[57] Prior to February 24, 2022, the hospital provided inpatient care in surgical, internal medicine, trauma, pediatric, infectious, and gynecological departments.[58] The hospital contained 220 beds, with the outpatient department additionally able to treat over 450 patients per shift.[59] In 2021, a CT scanner was installed, allowing tests to be conducted every day, at all hours.[60] 

The Izium Central City Hospital was damaged on several occasions and struck directly at least once in March 2022. On the night of March 2 to March 3, an airstrike attributed to Russian forces by the Izium District Prosecutor[61] hit a high-rise building and a private house,[62] killing at least eight people, including two children,[63] and inflicting severe damage to the city center where the hospital is located.[64] The police department of the National Security Service of Ukraine – which is located less than 250 meters away from the Izium Central City Hospital – was reportedly the target of the strike.[65]

Dr. Bohdan Berezhnyi, a surgeon and medical director of the Izium Central City Hospital who lived at the hospital from February 25 until March 12, 2022, told UHC:

“[There was a] roaring sound and [distant] explosions…. Everyone asked me what to do, whether to go to the basement…. I opened the window, the entire sky was roaring, something flew away … and then I saw a bright explosion, a fireball in front of me. I crouched behind the windowsill, and the door behind me had been blown away.”[66]

On March 6, 2022, Ukraine’s Ministry of Defense reported that two of Russia’s battalion tactical groups failed to seize the town of Izium, instead firing on the city center with artillery systems and carrying out air raids.[67] Russian forces failed at another reported attempt to seize Izium on March 7 and continued to shell the civilian homes and infrastructure.[68] Dr. Berezhnyi also recalled that “[s]ometime on the 6^th or 7^th, the ‘Grads’ … flew over us. Of course, we immediately hid in the basement. On the 7^th, aviation also was flying during the day, and it did also so very low, it was foggy.”[69] That day, Volodymyr Matsokin, deputy mayor of Izium, reported the “most extensive destruction since the Second World War.… Schools and hospitals were damaged.”[70]

As Russian forces retreated on or around March 7,[71] Ukrainian forces preventively blew up all bridges connecting the north of Izium, occupied by Russian forces, and the south of the town, “controlled by the Armed Forces of Ukraine and the Territorial Defense Forces of Izium.”[72] The bridges would have been considered strategically important both for Russian and Ukrainian forces: they were a key crossing for Russian forces to move to the southern bank and occupy the city center of Izium, and were also important for Ukrainian defensive efforts, particularly to move forces, equipment, and ammunitions.[73]

According to Dr. Berezhnyi, on March 7, 2022, the only time Ukrainian forces came to the hospital was after blowing up the bridges: “We gave them tea and coffee, they stayed with us for two hours, and then they left. That’s all. After this, the connection with the military was that they brought their wounded from time to time.”[74] He added, however, that Ukrainian forces were based in a building nearby – perhaps the city council (located about 500 meters away from the hospital) – and that a Ukrainian armed personnel carrier often transited on a road nearby after the bridges were blown up.[75]

On March 8, 2022, the deputy mayor of Izium and the media reported on a strike that directly hit the hospital.[76] According to local authorities, the hospital was hit by Russian shells.[77] Part of the main building was destroyed, including the intensive care unit, the entrance to the emergency department, and the operating block,[78] and the heat, water, and electricity supplies were cut off as a result.[79] Volodymyr Matsokin described patients climbing out “from under the rubble as they could.”[80]

Dr. Berezhnyi recounted:

“[On] maybe the 7^th or 8^th [of March], there was an incoming at this annex.… It hit the corner in the operating room and broke the wall; we understood we needed to evacuate everything, evacuate the equipment into the basement, [we] brought what we could to the basement, and discharged patients.… And then, on [March] 8^th or 9^th … it came at the main building; it had been blown apart by the explosion… It hit in the night on the fourth floor, and everyone in the basement … we got scared because the elevator collapsed from the fourth floor right into the basement…. So, in general, we lost the operating room and the intensive care. And we understood that in case something happens, we can do nothing.… We understood it will flood with patients, wounded … and what [can we do]?[81]

In the days that followed, town residents were evacuated en masse through “green corridors” under shelling.[82] Dr. Berezhnyi managed to leave the town on the evening of March 12, 2022.[83]

Satellite imagery dated March 12[84] and March 24[85] depict severe damage to the hospital’s main entrance as well as the destruction of most infrastructure around the hospital, including the Lyceum #4 building about 200 meters away, a large crater in a sport field 170 meters away, and a destroyed bridge less than 300 meters away from the hospital. The hospital also showed signs of other types of damage, including limited traces of shrapnel damage on the hospital façade.[86] According to a weapons analyst, the extent of the damage makes it likely that large conventional artillery rounds or unguided aerial bombs damaged the hospital and that the traces on the hospital façade were caused by debris projected by the initial blast.[87]

On January 31, 2023, Human Rights Watch released a report calling for Ukraine to “investigate its military’s apparent use of thousands of rocket-fired antipersonnel landmines in and around the eastern city of Izium” during the occupation of the town by Russian forces.[88] Some of the reported incidents concern the Izium Central City Hospital, which had reportedly become a military base for Russian forces while also continuing to function as a health care facility.[89] Indeed, the hospital remained (and continues to be) operational even as it came under attack; however, it can only work at 10 percent of its capacity due to the extensive damage it suffered.[90] At the time of the Ukrainian Healthcare Center’s (UHC) visit to the hospital site in November 2022, the non-acute services and trauma department had been relocated to the first floor of the hospital. However, the intensive care unit and operating block could not be similarly relocated. Both remain out of commission due to the extent of the building’s destruction and the loss of medical equipment. 

Case Study #2

Makariv Multiprofile Intensive Care Hospital, Makariv Primary Care Clinic, Adonis Medical Center (Kyivska oblast)

Makariv is a town located 30 kilometers west of Kyiv, with a population of almost 15,000.^[91] The location of the town is strategic: it sits in proximity to a significant junction on the E40 highway, which connects Kyiv with the western part of Ukraine, making it a crucial gateway for Russian forces to surround and seize the capital. On February 28, 2022, Russian troops advanced on Makariv from the north, armed with tanks and armored personnel carriers,[92] with the aim of cutting off the E40 highway. Members of Ukraine’s Territorial Defense Forces (UTDF) managed to repel the offensive. However, the town remained under shelling, resulting in severe damage to civilian infrastructure^[93] and the death of many civilians.^[94] While the town was never occupied, Russian troops held the northeastern outskirts until April 1, 2022. It continues to be a contested frontline vulnerable to Russian aerial attack. 

The Multiprofile Intensive Care Hospital and the Primary Care Clinic are located on the same campus in the northwestern part of Makariv. The Multiprofile Intensive Care Hospital consists of several buildings, including the main hospital building, the administrative building, the emergency care station, and several minor buildings and provides inpatient care in six departments (surgical, internal medicine, neurology, infectious diseases, pediatrics, and anesthesiology) with intensive care beds. Before the full-scale invasion, the hospital had more than 400 employees, including 78 doctors, and 170 available beds.^[95] The Primary Care Clinic was a brand-new, well-equipped facility which began operating in December 2020 as the first clinic dedicated to primary care in Makariv.^[96] The clinic offered primary care services for around 16,000 people, including 4,000 children, as well as COVID-19 vaccination.[97]

Dr. Serhiy Solomenko was the director of the Primary Care Clinic and worked as an anesthesiologist at the Multiprofile Intensive Care Hospital until March 7, 2022, when the UTDF evacuated all remaining patients and doctors from the facility.[98] With the advance of Russian forces, the evacuation of the clinic had gradually begun on February 25 with the UTDF’s help through corridors established by the Kyivska Oblast Military Administration.[99]

According to Dr. Solomenko, “Before the evacuation, everything was done to the maximum so that our Territorial Defense and the Armed Forces of Ukraine were not on the hospital’s territory, in order not to give the aggressor a reason to shell.”[100] After the March 7 evacuation, however, Ukraine’s armed forces reportedly established a base at the hospital,[101] where there was a large basement, a generator, and a nearby water tower.[102] Dr. Solomenko added that they [the UTDF and Armed Forces of Ukraine] would hide in the hospital rather than the clinic, as they knew the clinic was not safe: “it was made of wood … there was no basement.”[103]

Between February 26 and his evacuation on March 7, Dr. Solomenko witnessed several attacks that damaged both the hospital and the clinic. At the time, he reported that Russian forces had placed their vehicles and other equipment “at a distance of 100-300 meters from the hospital territory … they fired from tanks, grads, mortars.”[104] He recalled:

“The first shelling was on February 26, when a machine gun was fired at the [Multiprofile Intensive Care] hospital. Then, there was a mine explosion which shattered almost 50 windows of the hospital.… The [Primary Care] clinic was damaged by bullets when the fighting was going on, and for example, when there was active mortar shelling on the territory of the [Intensive Care] hospital, the clinic’s facade and roof were damaged.… The town’s water tower was also damaged.[105]”

During a site visit in May 2022, UHC detected “four funnels from mortar strikes near the [Primary Care Clinic] located along one line at a distance of approximately 10 [meters] from one another” and two other holes in the rubble of the facility, suggesting that “the mortar fire was corrected stepwise until the target was finally hit.”[106] They also analyzed the traces of explosion left on the ground to determine the direction from which the mortar had been fired.[107] Their findings as to the probable firing location coincide with statements made by Makariv residents as to the position of Russian forces at the time.[108]

Following the March 7, 2022 evacuation, more attacks ensued. On March 22, 2022, all of the Multiprofile Intensive Care Hospital’s ambulances were destroyed in reported shelling.[109] On March 28, according to a member of the UTDF who spoke with Dr. Solomenko, the hospital was shelled again and a projectile flew from a multiple launch rocket system, causing the Primary Care Clinic to catch fire.[110] The entire facility, equipment, vaccines, and documents burned down;[111] they no longer exist.[112] Despite the absence of clear imagery of munitions fragments, a weapons analyst assessed that the type and extent of the destruction suffered by the clinic are consistent with that of a BM-21 Grad MLRS.[113]

The Multiprofile Intensive Care Hospital partly reopened on April 5, 2022, providing care to around 200 patients daily while the reconstruction work is ongoing. In May 2022, a fundraising campaign was announced to restore the facility.[114] In July 2022, a mobile hospital was opened in the hospital’s territory.[115] By September 2022, most of the windows that had been broken were replaced, and the roof and facade were repaired.[116] As of January 2023, the hospital operates at 50 percent of its prewar capacity, with only 50 beds available for inpatient treatment.[117]

The Adonis Medical Center was located near the Makariv town center, surrounded by residential buildings, shops, and the city council building. The area was strategically important due to its proximity to the bridge over the Zdvyzh River, crucial to control access for refugees, reinforcements, and supplies, as well as to prevent Russian forces’ advancement from the north. Opened in January 2019, the Adonis Medical Center was a multidisciplinary private hospital providing a wide range of services, including pediatrics, surgery, neurology, physiotherapy, dental care, and orthodontics.^[118] The hospital halted its functions on February 25, 2022 as a result of the Russian invasion.

While the exact date of the attack on the Adonis Center is unknown, CNN published an article on March 12, 2022 reporting a series of “apparent Russian airstrikes” that devastated several buildings in the area.^[119] Based on its geolocation and verification of the authenticity of photos posted on social media, CNN concluded that many of the buildings, including the Adonis Medical Center, “sustained damage on their northern facades, evidence that points to military strikes that hit them being Russian.”^[120] The facility was entirely destroyed and all its equipment was lost. There is no information as to whether or when it will be restored.

Disruptions to Community Health Care

The scale of damage to the health care system in the Makariv municipality – with three health facilities and 30 pharmacies damaged or destroyed to different extents^[121] – has led to severe disruption of health services and infrastructure in the area, further limiting the right to adequate health care. The town also suffered repeated disruptions to the supply of electricity, water, and gas; access to the Internet and mobile communications were also precarious.

Case Study #3

Chernihiv Regional Children’s Hospital (Chernihivska oblast)

Chernihiv, a city of 280,000 inhabitants in the north of Ukraine, is historically known as a fortress city. In February 2022, it literally became one as it was set upon and encircled by Russian forces. As Russia’s offensive moved southward towards Kyiv, its armed forces initially attempted to enter Chernihiv on February 24 but were forced to retreat after facing fierce battles at the outskirts of the city.[122] Failing to take the city itself, Russian forces began subjecting it to continuous fire, terrorizing its population[123] and destroying civilian infrastructure. By the middle of March, Chernihiv had “been under effective blockade for more than two weeks, with most buildings left without electricity, heat, or water.… All the while, the Russian military pummeled Chernihiv with bombing raids and missile fire, turning a locked-in city into an urban death trap.”[124] In February and March 2022, numerous health care facilities were hit during attacks on the city and its surrounding areas,[125] including hospitals in the city center and two primary health care facilities in the nearby village of Kyinka.[126]

The Regional Children’s Hospital, located in the city center of Chernihiv and surrounded by residential buildings, provided care to children from both the city and the broader oblast of Chernihivska. Approximately 700 medical personnel worked there prior to the February 2022 Russian invasion, with the capacity to treat nearly 500 children at any given time.[127] The hospital offered a wide range of pediatric services, including intensive care for newborns and premature babies, infectious diseases, neonatal pathology, and surgery. It also exclusively provided around-the-clock comprehensive inpatient and consultative care for children with disabilities with the most complex pathologies, all of which require intensive therapy.[128]

Following the 2022 invasion, the hospital started treating both adults and children.[129] It also became a de facto shelter for many civilians who sought safety from explosions in their neighborhoods.[130] The Chernihiv Regional Tuberculosis Clinic was also transferred there because the hospital had an infectious disease ward.[131]

Over the course of Chernihiv’s encirclement, there was a steep increase in patients brought to the Regional Children’s Hospital for care; the largest influx took place on March 3. That day, heavy unguided aerial bombs with explosive warheads – likely FAB-250 or FAB-500 bombs dropped from a Su-34 or a Su-35 Russian fighter aircraft[132] – destroyed apartment buildings on Chornovola and Bohuna streets, inflicted heavy damage on the Regional Cardiac Center, and blew out the frames of the Regional Children’s Hospital located nearby.[133] Following the influx of patients, personnel of the Regional Children Hospital were forced to use medical triage: There were “37 injured adults [rushed to the hospital] within an hour.… There was medical sorting: the 200s [military term for the deceased] there, the children here, those who could be saved were saved.”[134] Among the injured brought immediately after the March 3 strike were children with fragments and metal shards in their faces.[135] One boy and an adult died at the hospital that day.[136]

After the March 3, 2022 strike, Dr. Mykola Liutkevych, the head of the Regional Children’s Hospital trauma department, who was on duty at the time, and his colleagues created a group in a messenger app to engage and organize doctors at the Regional Children’s Hospital.[137] When Dr. Liutkevych received a phone call about a boy with multiple fractures who was undergoing surgery in another hospital across town, he knew he had to go, even under shelling. But with no normal heating or electricity, the boy’s injuries were too severe. He died two days later.[138]

Two weeks later, attacks damaged two hospitals in Chernihiv.[139] On March 16 or March 17, 2022, City Hospital #2, located in a medical complex in the northeastern part of Chernihiv, was struck.[140] In the morning of March 17, civilian areas in the city center of Chernihiv, where the Regional Children’s Hospital and City Hospital #1 are located, were shelled.[141]

The Regional Children’s Hospital suffered significant damage: 238 windows from the first to the fifth floors, doors, and the roof were damaged,[142] while the hospital’s oxygen station posed a high risk of explosion.[143] The attack also killed at least 14 people and injured at least 26 others.[144] Wounded civilians were brought to the hospital from the surrounding area: at least three heavily injured children were admitted immediately after the shelling; shrapnel was removed from several patients’ bodies, including children.[145]

According to Dr. Liutkevych, the attack came without a prior air raid alarm.[146] In an interview with UHC, he also stated that the hospital’s management ensured that military vehicles were not parked in the surrounding area at any time; they knew they could be attacked if there were weapons around.[147] At some point, the hospital was guarded “because we were scared that Russian sabotage and reconnaissance groups might come in at night as patients, say they’re sick, take hostages and attack from within.”[148] An investigation conducted by Human Rights Watch (HRW) also found “no indications that Ukrainian forces were in the vicinity at the time” and “no obituaries … of Ukrainian armed force members who died there that day.”[149]   

The attack that damaged the Regional Children’s Hospital was likely launched from a BM-27 Uragan multiple launch rocket system (MLRS) – a system whose accuracy is significantly limited compared to modern guided systems – with warheads carrying cluster munitions.[150] A HRW on-site investigation into the attack revealed at least five splatter patterns consistent with the detonation of cluster munition shelling near the hospital.[151] Munition fragments and debris of cluster munition rockets were found along both sides of the hospital, on its premises, and in its rooms, as well as in the surrounding area.[152] During a site visit in July 2022, UHC captured photographs of the hospital’s façade, revealing traces of cluster munition shelling. An emergency responder also confirmed that his team found four unexploded 9N210 submunitions from a BM-27 Uragan, including one in the grounds of the hospital, as well as the empty cargo section of the MLRS only 20 meters away from the hospital’s main building.[153]

According to Andriy Prosnyak, chief investigator of the Security Service of Ukraine, “by the direction of the shelling, it is theoretically possible to determine where it came from.”[154] This, in turn, could help identify those responsible for launching the attack. During a site visit in July 2022, UHC calculated, based on the traces of explosion on the ground, that the attack that damaged the Regional Children Hospital had been launched from the south, directed approximately 45-49 degrees northeast, along the line between Shevchenka and Novoselivka and in the direction of Terekhivka.[155] The range of the BM-27 Uragan from which the attack was likely launched – up to 34 kilometers[156] – along with Russian forces’ close to full encirclement of Chernihiv at the time, including from the south,[157] suggest that the launch took place from areas they controlled.

March 2022: Ukraine’s Hospitals in the Dark

At the Regional Children’s Hospital, there was not enough food, medicine, and water, and there was only one power generator. Doctors had to manually resuscitate six premature babies who would usually require special life support equipment. At times, there were only two surgeons performing surgeries, and surgical supplies were particularly scarce after the bridge to Chernihiv was blown up at the end March.^[158] 

Case Study #4

Bashtanka Multiprofile Hospital (Mykolaivska oblast)

In late February 2022, Russian armed forces advanced into the Mykolaivska oblast, occupying towns and cities. By mid-March, the frontlines reached the city of Bashtanka, located roughly 30 kilometers from the Bashtanka Multiprofile Hospital, with Russian forces occupying several towns in the city’s vicinity. Ukrainian forces defended the city, with reports of a Russian convoy being ambushed and destroyed on or around March 1, 2022.[159] Throughout March and April, 2022, Russian forces repeatedly bombed the city with Grad rocket launchers, warplanes, and Tochka-U missiles.[160]

The Bashtanka Multiprofile Hospital is a public nonprofit hospital, renovated in 2004 to expand its overall capacity and improve services,[161] that, before the full-scale Russian invasion, provided care to more than 144,000 patients.[162] The hospital offered a wide range of services, including a childbirth department, ambulatory outpatient polyclinic, inpatient care, same-day surgery, and an infectious disease department.[163] Alongside two other hospital campuses owned by the two other major hospitals in the city, the Bashtanka Multiprofile Hospital is located on the northwestern edge of the city, in a remote area just off the H11 main road that connects the cities of Kryvyi Rih and Mykolaiv, the oblast’s administrative center. The hospital’s buildings are the highest in the area; as such, they could provide a vantage point to overlook Russian forces’ advance from the south.[164]

According to local officials, there was no military presence “anywhere near the hospital”[165] except for the treatment of wounded members of the armed forces.[166] 

On April 19, around 5:20 p.m., the Bashtanka Multiprofile Hospital was struck by a missile.[167] A weapons analyst’s review of a video released by Sky News showing the missile remains at the hospital reveals what appears to be a Russian cruise missile, likely a 3M-54 Kalibr.[168] The missile was possibly launched from the Black Sea, which would likely make it an anti-ship Kalibr missile used against a land target.[169] When used against land targets, sea-launched precision-guided missiles may struggle to reach the intended target and, instead, strike the highest buildings in the area.[170] However, these types of precision-guided weapons are very expensive, fairly scarce, and require a high level of clearance.[171] According to a weapons analyst, they are commonly used to strike previously identified, high-priority targets.[172] Based on its relatively isolated but strategic location, due both to its proximity to the H11 road and the vantage point provided by its tall buildings, it is possible that the Bashtanka Multiprofile Hospital was the intended target of the attack.

Although the staff received no warning of the impending attack, there were fortunately no casualties among the patients and medical personnel because the missile hit the hospital’s outpatient polyclinic[173] and primary care center after reception hours.[174] Still, at the time of the strike, doctors were in the midst of performing surgery in another department and three women were in labor in the maternity ward.[175] Moreover, as a result of the missile attack, the institution’s security personnel were injured.[176]

The facility, like other hospitals in the region, had been marked with a Red Cross painted on a white canvas placed on the roof.[177] According to Dr. Alla Barsehian, the hospital director, drones flew over the facility, “They saw very well, they knew that this was a medical institution.”[178] In her words, “We hoped this would somehow save us. But it turns out there is nothing sacred in this war.”[179] In an interview with UHC, Dr. Barsehian clarified that she was not at the hospital when the missile struck, but returned immediately when she heard the explosion. Her colleagues who were at the hospital told her that:

“It was the sound of a whistle and an explosion. […] It was the sound of broken glass, dust rising. But it was for a few seconds. Everything fell and everyone began to realize what had happened. Literally seconds.”[180]

Following the strike, the hospital’s evacuation team, which also included three military doctors who lived in the premises, immediately moved 60 staff and 90 patients, including children, to the attached bomb shelter in preparation for a second potential attack.[181] The evacuation team contacted a nearby medical facility and transported patients there within an hour.[182] Hospital guards conducted patrols of the property together with a unit of the Ukrainian Territorial Defense and moved all remaining medical materials from the hospital warehouses to safer locations.[183]

The missile attack reportedly destroyed around 30-40 percent of the hospital’s premises,[184] completely decimating the outpatient polyclinic and adjacent infectious disease department, as well as the dialysis department, two gas boilers, and a range of medical equipment.[185] Shelling also destroyed two on-site drug depots, rendering the facility without medicine until materials could be supplied from another location.[186] Hospital staff counted at least 330 shattered windows, while several doors were blown off their hinges.[187] The overall damage caused by the strike is estimated at more than one million euros.[188] The hospital’s main building retained its structural integrity, however, despite heavy damage. [189] 

Efforts were also made to quickly restore operations, with repairs starting on April 20, 2022 and the hospital opening to the public on the following day.[190] In the words of the hospital director, “We understood that it is necessary to restore the work of the facility as soon as possible. Therefore, a decision was made: we moved medical inpatients, quickly restored the polyclinic department.”[191]

After a gradual reconstruction process, the hospital is once again fully operational, with some remaining disruptions, particularly for the childbirth services.[192] Staff noted that the demand for services in the neurology, infectious disease, and ambulatory departments have greatly increased in order to treat the wounded and accommodate the influx of patients from newly liberated areas.[193]

Case Study #5

Trostianets City Hospital (Sumska oblast)

Trostianets, a town of nearly 20,000 inhabitants close to the Russian border, was occupied by Russian forces from February 24 to March 26, 2022.[194] After the first few days of the occupation, Russian forces cut the cellular network and electricity, isolating residents from the outside world.[195] During the occupation, residents alleged brutal, inhumane treatment by Russian forces, low food supplies, and limited access to heat.[196] Fighting in Trostianets was heavy, with city Mayor Yuriy Bova stating that “traces of bullets and shrapnel remained on almost every building.”[197]

The Trostianets City Hospital is located in a forested area in the city’s outskirts; it is a “standalone complex of buildings accompanied by several residential houses.”[198] The hospital was marked with a large hospital sign and a white flag bearing a red cross.[199]

Prior to being attacked, the hospital had been operational throughout the occupation, providing care to everyone, including Russian soldiers.[200] Speaking to UHC in August 2022 on the condition of anonymity, a doctor who worked at the Trostianets City Hospital stated that the polyclinic closed on February 25, 2022, but that the hospital continued to accept patients in the emergency and surgical departments, with general practitioners, surgeons, gynecologists, anesthesiologists, and pediatricians providing care.[201]

The doctor reported that, until March 18, there were no military forces or equipment nearby. On March 18, however, several Ukrainian soldiers were spotted near the hospital: according to the doctor, a witness stated that they were in the forested area close to the hospital, while another stated that they were providing humanitarian aid at the hospital.[202] On the same day, a Russian officer visited the doctor at his house, possibly looking for Ukrainian partisans.[203] Later that day, around 5:00 pm, a tank drove down the street and shot two blank projectiles at the hospital’s building.[204]

A day later, a Russian officer[205] came armed to the hospital, searched it, and after first talking to the staff, shot randomly on the first floor.[206] The officer said he had mined the territory of the hospital and warned the doctor not to walk there.[207] Russian soldiers then set up two roadblocks, behind and in front of the hospital.[208]

In the following days, the doctor witnessed what he called “mutual altercations” between Russian forces and Ukrainian partisans across the street from the hospital.[209] Dr. Tetiana Sydorenko, the head of the hospital’s maternity ward, also reported incessant attacks on the facility: “It’s hard to explain, the explosions. It was in your head. It was above your head. It was exploding inside of you. It was hell.”[210] According to Dr. Anna Shevtsova, the hospital’s medical director, the hospital then came under persistent, repeated assault, with attacks also reported on March 20, 23, 24, and 25.[211]

The worst strike reportedly occurred on March 23, when at least one Russian tank[212] fired directly at the hospital[213] and hit the second and fifth floors of the inpatient building.[214] The infectious diseases department, located in a separate building, was also apparently hit in the attack by an object described by the doctor who spoke to UHC as a “mine.”[215] A tank was reportedly “blown up as it bombarded [the] hospital” and was left behind at the site of the attack, with “its gun still pointing directly at the hospital.”[216] Ukrainian investigators later identified the commander alleged to have given the order to fire at the hospital, reportedly with a T-80 tank.[217] They also identified two other Russian servicemen – a T-72 tank commander and his assistant – alleged to have encircled the hospital and fired a 125-mm high-explosive fragmentation shell with a tank on an unspecified date in March.[218]

The doctor who spoke to UHC described the difficult conditions he and his team had to work under: there was no power for more than a week, no heating, and almost no water.[219] Under shelling, the medical personnel was forced to get a generator at a gas station.[220] The doctor managed to escape from Trostianets with his family on March 24, just two days before the town was liberated.[221]

As a result of the repeated attacks, the hospital’s operating room was burned, the gynecology, maternity, and surgical wards were damaged, the roof of the infectious disease department was fully destroyed, and exterior walls of the hospital were marred by shelling impact.[222] Evidence gathered by UHC after the shelling also shows a destroyed ambulance, damage caused by multiple shells, and destroyed oxygen tanks.[223] A video of the aftermath of the shelling posted by the Head of the Sumska Oblast Military Administration additionally depicts what appears to be a severely damaged pharmacy.[224]

The severity of the damage sustained by Trostianets City Hospital means that it was no longer functional in the aftermath of the occupation, with patients in need of medical care being treated at facilities located 45-50 kilometers away.[225] Yuri Bova, the mayor of Trostianets, stated:

“We used to have almost 400 staffers there before the war, but only 20 people are left. We can’t actually provide care with that small a staff, so doctors from other cities have to travel to help us, which firstly isn’t safe enough and secondly doesn’t solve the need for daily service. We believe our staff will feel safe enough to return once we have repaired the windows, restored heating, and provided treatment for the most urgent cases.”[226]

The cost of rebuilding the facility is estimated at approximately 116 million Ukrainian hryvnias (nearly US$4 million).[227] Nevertheless, while the hospital is still in need of repair, patient care has resumed.[228] International aid has helped to set up a field hospital where surgeries can resume, and donated medical equipment, medicines, and five ambulances to replace those that were destroyed.[229] A temporary “mobile hospital” serves the local community until Trostianets City Hospital is fully repaired, a project that will take years.[230]

2.     Attacks on Ambulances 

Ambulances have a critical role to play in armed conflict by evacuating the wounded, providing life-sustaining treatment, and transporting patients to seek necessary medical care. These vehicles are protected under international humanitarian law: the Geneva Conventions explicitly provide that “[c]onvoys of vehicles or hospital trains on land or specially provided vessels on sea, conveying wounded and sick civilians, the infirm and maternity cases, shall be respected and protected in the same manner as … hospitals”[231] and Additional Protocol I provides that “[m]edical vehicles shall be respected and protected in the same way as mobile medical units.”[232] 

Alongside attacks on hospitals, attacks on ambulances have become another distinctive feature of the war in Ukraine. Since February 2022, documented attacks on ambulances have ranged upwards of 66. Some of the attacks happened at the premises of hospitals, while others occurred as ambulances were on call. Illustrative, non-exhaustive examples of attacks include:

• February 26, Khersonska oblast: On a highway in the Khersonska oblast, Russian forces reportedly shot at an ambulance carrying a wounded Ukrainian soldier from Tyahynka of Beryslav district to a hospital in Kherson, killing the driver and the patient and injuring a paramedic.[233] The ambulance caught fire.[234]

• February 27, Poltavaska oblast: Ihor Lidovy, the head of the Serhiivska community, reported that an ambulance was shot by a “sabotage and reconnaissance group of the enemy” while responding to an emergency call between the city of Hadiach and the village of Serhiivska.[235] At that time, in the north, near the city of Hadiach, Russian forces were advancing on the oblast.[236] The ambulance was riddled with 17 bullet holes and both the driver and a nurse were wounded.[237]

• March 4, Sumska oblast: Russian forces reportedly shot at an ambulance with small arms on the Sumy-Kyiv highway.[238] There were no casualties,[239] but Dmytro Zhyvytskyi, head of the Sumy Regional State Administration, reported that “shelling of civilian vehicles and civilians in the region continues.”[240]

• March 12, Sumska oblast: Yuriy Bova, the mayor of Trostianets, reported that Russians soldiers destroyed the Trostianets emergency ambulance station, stole three ambulances, and seized emergency medical supplies as people were leaving the city through the designated “green corridor” (a ceasefire on specific routes to evacuate civilians).[241] A week before, Russian forces had reportedly captured the city’s ambulance station, threatening to shoot medics attempting to leave the premises except for pediatric emergencies.[242]

• December 13, Kharkivska Oblast: The Office of the Prosecutor General of Ukraine reported that, around 4:30 a.m., the Russian military launched a S-300 type of missile on Kupiansk.[243] The blast wave broke the glass of an ambulance en route to Kupiansk and a paramedic was injured.[244]

There are other examples of incidents that resulted in the damage or destruction of ambulances, for which the alleged perpetrators were not named:

• March 12, Kharkivska oblast: The Kharkiv Center for Emergency Medical Aid and Disaster Medicine reported that their ambulance brigade came under fire after responding to a call in one of the Kharkiv neighborhoods.[245] The vehicle was hit by debris and the paramedic was wounded.[246]

• On or after March 23, Chernihivska oblast: In an interview with UHC, Dr. Mykola Liutkevych, the head of the Regional Children’s Hospital trauma department in Chernihiv, reported that after the siege of the city began and the main bridge was destroyed,[247] an ambulance was shelled, apparently with mortars, as it attempted to cross the river via a pedestrian bridge to retrieve a power generator.[248]

• October 3, Kharkivska oblast: An ambulance was blown up by a mine on its way to Balakliia.[249] A paramedic was injured, the driver died at the scene, and the ambulance burned down.[250]

Similarly, all of the Trostianets City Hospital’s ambulances sustained severe damage as a result of shelling in March 2022. A doctor who worked there and spoke to UHC on the condition of anonymity said that their ambulance was destroyed by a mine.[251] A sanitary medical aid car stored near the hospital was also shelled towards the end of the occupation.[252] The only remaining ambulance was taken by Russian forces, leaving medical personnel unable to provide care outside of the hospital.[253] 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.[254]

Case Study #6

Ambulance Attack in Lyman (Donetska oblast)

Situated in Donetska oblast, near the Russian border, Lyman is an important town on the frontline of the war. Between the start of the hostilities in the region in 2014 and the full-scale Russian invasion of Ukraine in 2022, Lyman’s ambulance station was largely unaffected.[255] In February 2022, however, almost all doctors fled Lyman for safer territory. Only four doctors and medical personnel remained.

On April 18, 2022, Serhii Haidai, the head of the Luhanska Oblast Military-Civilian Administration, reported that the Russian military had entered the city of Kreminna (Luhanska oblast) and that the Ukrainian army had left.[256] On the same day, around 12:00 p.m., an ambulance operator called the Lyman station and reported a call from an injured man close to the village of Torske (Donetska oblast) on the highway connecting the village to Kreminna.[257] The man was reportedly injured when his car was “shelled from large-caliber machine guns mounted on the turrets of tanks, as well as from assault rifles” as he and his family rushed to escape the Russian forces advance into Kreminna; his wife, mother-in-law, and dog all died in the attack.[258] According to an investigation conducted by the Media Initiative for Human Rights (MIHR), the man’s car was almost certainly fired at by Russian forces.[259]

A paramedic and a doctor, along with the ambulance’s driver, went to the man’s aid. The paramedic on duty at the time spoke with MIHR on the condition of anonymity:

“We passed through four [Ukrainian] checkpoints, they let us through, said it was safe, said ‘Please, go ahead.’ When we had passed all the checkpoints, about two kilometers, according to the driver, from the last checkpoint near the village of Torske, we came under fire.”[260]

The paramedic recalled:

“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, we stopped. We fell into a ditch. When everything was calm, the shooting stopped, we took the things that could be carried on our shoulders and carefully walked in the opposite direction. Making a call was very scary because we didn’t know what they could do to us.”[261]

According to the paramedic, the target of the shots was the ambulance. “When we were going in the direction of Kreminna, they were shooting from the right side. You could tell by the holes, because the car was shot from the right side, and the bullets remained on the left side of the [ambulance]. That is, the left side was not shot, there were no holes.”[262] The MIHR investigation makes no conclusion about the perpetrator of the attack on the ambulance. However, on the morning of April 18, 2022, a witness who fled from Kreminna to Torske through a road passing by Dibrova saw the bodies of Ukrainian soldiers and a convoy of vehicles with Russian flags, which began to shoot at his car.[263]

When the shooting stopped, the ambulance team fled in the direction of Torske on foot. The paramedic and the driver were picked up by Ukrainian soldiers in a car and taken from the village of Torske to the village of Zarichne and back to the Lyman ambulance station.[264] In Zarichne, they had to wait in the basement of the school because of the shelling of the villages of Torske and Zarichne. In the paramedic’s words, “The stress level was 100 percent.… I did not believe that I would return alive from the shelling.… Even now, I feel anxious.”[265]

As the ambulance team fled towards Torske, they lost sight of the doctor. He “had heart problems … the doctor must have stopped to rest and that’s how we lost him,” the paramedic said.[266] A Ukrainian soldier went back to get the doctor, but the paramedic does not know what happened to either of them.[267] A video was later released on a pro-separatist Telegram channel in which the doctor explained that he ended up in the occupied territories following the ambulance team’s escape from the scene of the attack.[268]  

Following the attack, the paramedic and another colleague continued to work at the Lyman ambulance station on an outpatient basis; they no longer left for calls.[269] On April 23, 2022, the station stopped functioning entirely because the other colleague no longer came, and the paramedic could not work alone every day.[270] On April 30, 2022, the paramedic left Lyman and went to live in Odesa for a month, before moving to Cherkasy to work as a nurse until November 2022. Since then, the paramedic has returned to work at a different ambulance station in the Donetska oblast, ready to go on calls again if it is safe to do so.[271]  

3.     Theft and Destruction of Medical Equipment

Russian forces have also reportedly engaged in the theft and destruction of vital Ukranian medical equipment. Medical equipment and supplies are protected under international humanitarian law.[272]

Most verified cases of looting have been uncovered in recently liberated Ukrainian territories. 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.”[273] The scale of these acts began to come into focus when the right bank of the Kherson region was liberated on November 11, 2022. 

Instances of medical equipment theft reported in open sources include:

• The hospital director of the Adonis Medical Center in Bucha (Kyivska oblast) reported that, in March 2022, medical equipment was stolen; some of it was taken along with the electrical sockets.[274]

• Russian forces reportedly took valuable medical equipment away, including computers, patient monitors, a mobile X-ray machine, a generator, equipment from the intensive care unit, and almost 100 oxygen concentrators used to treat COVID-19 patients, as well as blankets and pillows from the Izium Central City Hospital.[275]
  
• On April 29, 2022, the Mariupol City Council reported that around 60 ventilators had been stolen from city hospitals and transported to Russia.[276]
  
• On May 1, 2022, Ukraine’s military intelligence service reported that all equipment provided under programs from international donors and the Ukrainian government since 2014 had been taken away from the infectious diseases department of the Starobilsk Multiprofile Hospital (Luhanska oblast).[277]

• In mid-May 2022, Serhiy Haidai, head of the Luhanska Oblast Military Administration, reported that Russian forces had begun dismantling medical equipment from a hospital in Kreminna (Luhanska oblast) and transporting it to occupied Luhansk or Russia.[278]
  

Multiple cases of looting of medical equipment, medicines, furniture, and cars and of damaging facility premises were also reported by the hospital personnel of the Kyiv Regional Mental Health Center in Vorzel (Kyivska oblast).[279]

Case Study #7

Balakliia Clinical Multiprofile Intensive Care Hospital (Kharkivska oblast)

Balakliia is a town of 27,000 located in the east of Ukraine. It was occupied by Russian forces in early March 2022[280] and remained under occupation until September 8, 2022.[281] The Balakliia Clinical Multiprofile Intensive Care Hospital was not occupied until early April 2022. Located in an isolated forest area on the outskirts of the town, the hospital was initially situated beyond the control of Russian military checkpoints.

The Balakliia Clinical Multiprofile Intensive Care Hospital is a public non-profit hospital that served more than 80,000 residents of the Balakliia and neighboring districts.[282] The facility was equipped with modern, high-tech equipment[283] and provided inpatient care in infectious, therapeutic, neurology, maternity, and pediatric departments with more than 350 inpatient beds.[284] Around 14,000 patients were treated annually in inpatient departments.[285]

Until early April 2022, the hospital was fully operational, despite the occupation of the nearby town by Russian forces; it provided care to patients and sheltered civilians from nearby areas.[286] On April 2, 2022, the hospital was hit, reportedly by a tank.[287] According to Dr. Maryna Rudenko, the hospital’s director, “all the windowpanes were immediately smashed, there were shards in all the offices” and one patient was injured by shards.[288]

Dr. Rudenko lived inside the facility until she evacuated on April 4, 2022. In an interview with UHC, she recounted the events that unfolded between the day it was hit and April 4, 2022, when Russian forces reportedly seized the hospital:

“On April 2, they set up a tank somewhere behind the forest and shot the hospital, just like that, from the tank – six shells – five of them hit our buildings. .… They interrupted our heat supply and water system, and we realized on the 3rd of April that the hospital could not work here. On [that day], we discharged as many patients as possible and everyone else who was [sheltering] in the basement.

“The FSB [Russia’s Federal Security Services] came to us on April 3 in the evening. They gathered all the medical staff … and said, ‘Don’t even think about going anywhere, you have to live here, you have to work here. We need to establish communication with the local population, so we will not let the doctors leave the city. You will not leave here. You were shelled by Ukraine, don’t even doubt it.’

“The Russians came on the night between the 3rd and the 4th of April with assault rifles. They threatened us, shot in the air and all over the building in the darkness.… They hit our acute care department chief on the head with a rifle butt .… They [ordered] our male doctors to lay on the floor faces down and started to shoot at the floor.… The bullets rebounded and could hit anyone.… Then, they let us out and left. But they had put the ultimatum: until morning, none of us could stay here [in the hospital].”[289]

On April 4, 2022, Dr. Rudenko evacuated the 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,[290] the “occupiers completely plundered” the Balakliia Clinical Multiprofile Intensive Care Hospital, and “what they could not steal was broken and mutilated.”[291] In an interview with UHC, Dr. Rudenko described:

“Almost everything was stolen. They took away everything that could be taken away. They couldn’t 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…”[292]

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.[293]

Upon her return, Dr. Rudenko also found evidence that Russian forces had established their base in the hospital and left hastily, leaving behind cans of food, scores of ammunition in the basement, and grenades attached to stretchers.[294] The hospital was more damaged than when she evacuated in April 2022, with the children’s department blown out, the roof seriously damaged, and the ceiling of the second floor collapsed. “It could have happened during the liberation, or maybe at another time,” she says.[295]

During a site visit in November 2022, UHC found broken walls, windows, and traces of fire in the conjunction corridor connecting the two hospital buildings.

Even as the town was liberated, the hospital could not reopen immediately, as sappers worked to demine the facility.[296] Due to the extensive damage suffered and the looting of equipment, the hospital referred patients to its polyclinic department located in the city center.[297] On January 3, 2023, the hospital finally reopened.[298]

4.     Attacks on Health Care Workers

Health systems depend on their health work force. Violence against health personnel reduces the number of health workers and affects the quality of care that surviving doctors and nurses are able to provide. Death and injuries of colleagues not only reduce the workforce but add strain on those who stay. Witnessing the violent death of a colleague also frequently traumatizes health care staff, making it harder for them to care for others.

As in many conflicts, health care workers in Ukraine are on the front lines, providing lifesaving care to civilian communities, while facing attacks themselves. The narratives of three doctors below highlight the harrowing situation many Ukrainian health care professionals faced while also striving to provide care in the face of unsanitary, inhumane conditions.

Case Study #8

Providing Health Care under Occupation: Kherson Regional Clinical Hospital (Khersonska oblast)

The occupation of Khersonska oblast began on February 24, 2022[299] and extended into the health care system that summer. On the condition of anonymity, a doctor at Kherson Regional Clinical Hospital,[300] located in one of the residential areas of the city of Kherson, spoke to MIHR researchers on several occasions.[301] The doctor provided the following testimony about what he personally witnessed and what medical colleagues communicated to him after he escaped Kherson on July 7, 2022. The doctor had been one of the last specialists in his field who remained in the city, until he fled disguised as a student. His testimonies have been translated, edited, and condensed for clarity.

At the beginning of the spring of 2022, the occupation authorities banned the import of medicines into Kherson; this spurred an “underground” trade in medicines throughout the city. From the start of the occupation, Russian “entrepreneurs” appropriated Ukrainian pharmacies and started selling Russian medicines. They were of much lower quality than Ukrainian and European ones.

Until the beginning of the summer, Russians were present in hospitals [of the Khersonska oblast], but they did not try to influence the work of the hospital. As long as there was a Ukrainian cellphone connection on the territory of the city, doctors could write electronic prescriptions for patients in the oblast. Despite the shelling, volunteers delivered medical supplies to the sick. However, every month it became more and more difficult to work.

In the summer of 2022, hospital management was summoned to talks with the occupation administration. Ukrainian doctors were offered to cooperate with the administration at special meetings held in the occupied Department of Health Protection of the Kherson State Regional Government.[302] I was forced to attend these meetings twice.

At the first meeting in June 2022, the new occupation authorities demanded access to the electronic database of patients, “e-Health,” from Ukrainian doctors; they asked which of my patients receive insulin and how much it costs. The database stores confidential information, accessible only to the doctor. In addition to home addresses and phone numbers, it stores passport data and contact information. Special population groups are also indicated, including veterans of [Ukraine’s] Anti-Terrorist Operation [which ended in 2018].[303] I was worried, because the week before, I had received a patient from the occupied city of Mykolaiv oblast; he was a former member of the Anti-Terrorist Operation suffering from diabetes. The Russians found out about his illness, arrested him, and waited for him to die slowly without insulin. The man somehow managed to escape. I gave him the contacts of acquaintances who sheltered him.

At the second meeting, Russian forces announced the mandatory “retraining” of Ukrainian doctors and an obligation to work according to the laws of the Russian Federation.[304] They emphasized that doctors should register as Russian specialists and therefore suggested that they go to Russia to take courses and requalify as doctors. This meeting was guarded by two people armed with machine guns who did not have any distinguishing markings but wore flags of the Russian Federation on their chevrons. 

On July 1, 2022, representatives of the Federal Security Service of Russia came to the Regional Clinic Hospital; they detained the director of medical affairs and the head of the hospital’s personnel department. In order to contain the doctors’ discontent, the Federal Security Service took some of the Ukrainian doctors away for “a conversation” or summoned them to the occupied Department of Health [to limit the spread of rebellion].

It was dangerous for Ukrainian doctors to work under occupation, especially in small settlements, as they could become victims of kidnappings. First, there are fewer witnesses to kidnappings in towns and villages; second, it is easier to pressure and force cooperation. The reason for the abduction could be the refusal to take Russian salaries or social assistance, or the compulsion to travel for retraining, which had been announced in June 2022. Many Kherson doctors left, but specialists who could provide emergency care remained in the city. Several private clinics also operate in Kherson, but due to the lack of specialists in narrow fields and the lack of specific equipment, their treatment options were limited.

Shortly after [I left on July 7, 2022], Russian forces drew up lists of people who were not allowed to leave, including Kherson’s health sector management. The new management of the hospital[305] told the nurses and orderlies to help them in everyday life, including by cleaning after them and washing their clothes. Doctors were forced to switch to a Russian cellphone connection.

Case Study #9

Providing Health Care under Bombardment: Mariupol Regional Intensive Care Hospital (Donetska oblast)

Dr. Oksana Kyrsanova, an anesthesiologist at the Regional Intensive Care Hospital in the city of Mariupol, spoke to MIHR researchers[306] about the occupation of the hospital by Russian forces on March 12, 2022, how doctors provided care during its occupation, and the conditions under which staff worked.[307] As a multidisciplinary medical and preventive institution, the Intensive Care Hospital was designed to provide inpatient and outpatient polyclinic care to Tsentralny, Mariupol’s largest district.

Dr. Kyrsanova personally witnessed these events or heard them from colleagues contemporaneously as she worked at the hospital from February 24 until March 15, 2022, when she escaped. She had worked part-time at the hospital since 2020. Her main place of work was the Maternity City Hospital on the left bank of the Kalmius River; however, at the end of February 2022, with Russia’s offensive already underway, she could no longer access the hospital and switched to working full time at the Regional Intensive Care Hospital. Dr. Kyrsanova’s testimony has been translated, edited, and condensed for clarity.

On February 24, 2022, around 11:00 a.m., a lot of patients started coming in, many wounded, mostly Ukrainian military personnel. The wounded were admitted almost in a coma with a lot of blood loss, in a state of shock. The doctors could not even collect medical history, find out surnames and ages. In order to keep documentation, a description of the wounded person was made on an A3 sheet, and then, if they learned the last name, they added it. On the first day, the department received 16 wounded at once, among them were two to three civilians, one of them was a young girl with very serious injuries. All operating rooms were functional. There were more doctors than usual, considering the circumstances, but still not enough. Later, the wounded soldiers were taken to the military hospital. Special aviation transported all military personnel who were stabilized to the hospital in Dnipro. The civilian population was treated at the Regional Hospital.

The hospital had a generator powering the first two floors. On the first floor, there was a reception room; on the second floor, there was an operating unit. In the first days, medics covered the generator with sandbags so that it would not be damaged, because it powered ventilators. Medics also cooked food and made hot tea from the generator to feed the patients.

On February 28, 2022, a missile hit the hospital yard.[308] It was the intensive care unit that was affected. All the windows were smashed there. The hospital lost its electricity first, then its water supply and Internet connection. Next, the mobile connection disappeared, and the hospital was cut off from the outside world. After some time, the gas went out in Mariupol, and people started cooking outside.

After February 28, very busy days began. There were many surgeries. The wounded came with various injuries: explosive, shrapnel, bullet injuries; there were children, adults, and then pregnant women. It was very difficult because there was not enough medicine. Patients needed special nutrition, antibacterial therapy, and special antibiotics that doctors could not provide. Instruments were sterilized, but it was relative sterility.

There were no windows [left] in the hospital, and the temperature was below zero outside. It was necessary to create a thermal regime so that there would be no hypothermia after operations on patients. There were also pregnant women in the hospital, so the doctors brought them a heater. The doctors stayed with the pregnant women so that the surgeons could attend the births. Every day at five or six in the morning there were air raids, air strikes, and everyone woke up from this.

Starting from March 8, 2022, doctors remained at the hospital permanently. There were a lot of sick people, civilians, and especially children in critical condition. On March 9, 2022, around 4:00 p.m., there was an airstrike on the Women’s and Children’s Health Territorial Medical Association in Mariupol. It was destroyed, and pregnant women were brought to the Regional Hospital for intensive treatment [about 3.5 kms away]. They brought six women. One pregnant woman was brought in in a very serious condition. She had a completely shattered pelvis and a torn hip. Surgeons urgently performed a caesarean section, but the child was dead. The woman had injuries incompatible with life. It was not possible to resuscitate her; she died.[309] Another pregnant woman was admitted to the operating room. Half of her foot was amputated.

By March 10 or 11, 2022, another missile had hit the hospital.[310] There was a big hole in the wall. It was between the sixth and seventh floors. The impact caused one floor to fall on top of the other. Neurosurgery was on the sixth floor and there were patients who were crushed by the slab. Doctors tried to pull them out, but it was very difficult because the ceiling had fallen.

On March 12, 2022, Russian military occupied the hospital. Their target was the hospital itself, because they could shoot from it and knew that [the Ukrainian military] would not fire back. The hospital became a human shield.

On the day of capture, I remember doctors were in the operating room, performing a caesarean section. Colleagues entered and said not to leave the room, because there were Russian soldiers in the corridor. The military did not have any chevrons or insignia, only white bandages and green uniforms. From their pronunciation it was possible to understand that they were soldiers from the “Donetsk People’s Republic,” Russians and Chechens. The most important one was from Ossetia.

The Russian military went around all the floors, making doctors and medical personnel face the wall. The men were stripped to the waist while Russians searched them for military symbols, gunpowder stains on their fingers, and imprints from the use of weapons on their shoulders. The military broke down all the doors of rooms and warehouses that were not used by doctors to check that no one was hiding there. They made our hospital their headquarters. They had a rotation, first there were some, then others came. They occupied the entire building, completely surrounded and controlled the hospital, all entrances, exits, and stairs. They were on the roof of our hospital. We had a very big building, and they had a view of everything.

And indeed, we saw it all, they [Russian forces] set up their equipment and shot from the hospital buildings. Military equipment was placed around the perimeter of the hospital. Armored personnel carriers stood on all sides of the hospital. There were snipers on the roof and top floors. There were probably four soldiers on each floor. There were a lot downstairs, probably 10 [soldiers] and three armored personnel carriers. The soldiers would rotate; the armored personnel carriers hid, for example, between two houses right in front of the windows.

The military emphasized that those who tried to leave the hospital could be shot. Doctors, medical personnel, and those who were in the hospital became hostages of the Russian military. Doctors were threatened with deportation to Russia.

The Russian military began to bring people from nearby residential buildings to the hospital. In the 17th and 23rd districts of the city, all residential buildings were completely destroyed. Soldiers approached the residents and said that it was dangerous in the city and offered to take them to a bomb shelter in the hospital. Every day, they brought 200 people to the hospital. Five floors out of eight were filled even before the hospital was taken over. All other floors and corridors were filled with civilians – children, elderly people, animals. There was no water, so it quickly became completely unsanitary … and there was no food at all. There was broken glass in the corridors, there was dried blood on the floor, scattered clothes, broken stretchers, everything was dirty. Civilians sat in such conditions. There was a terrible smell. Medicines and other materials were [also] running out. It was impossible to transport the sick to the hospital. Cars got shot from the roof of the hospital in front of the doctors … so the wounded were carried on blankets, in [people’s] arms … The dead bodies were first taken to the morgue located in the basement. Then they were taken to the mass grave.

We understood that staying in the hospital was dangerous. On March 15, 2022, when water was brought to the hospital and people began to line up, we changed into civilian clothes and went out into the yard. The military’s attention was focused on the water distribution point, so I was able to leave the hospital along with at least five other people. I ran 20 kilometers to the highway under constant shelling and explosions. On the road, I was offered a seat in a car by residents who were evacuating from Mariupol. After passing 20 Russian checkpoints, I entered the territory controlled by Ukraine.

Case Study #10

Providing Health Care in Captivity: Garrison Hospital No. 555 (Donetska oblast)

In an interview with MIHR researchers, Dr. Y,[311] a military doctor from Dnipro, recounted his living and working conditions in Mariupol. He also spoke about his captivity at several correctional colonies (Russian-operated prisons), where he provided medical care to wounded prisoners following his capture by Russian forces.[312]

In late March 2022, Dr. Y agreed to go to Mariupol to provide medical assistance, including providing support to Garrison Hospital No. 555.[313] The hospital – located in Mariupol’s Kalmius district, near the Ilyich Metallurgical Plant (Plant) – was immediately on the front line after the full-scale Russian invasion began and remained operational while most other medical facilities in Mariupol stopped functioning throughout the siege of the city. As such, wounded people were brought in from all over the city.[314]

Due to heavy bombardment, Hospital No. 555 was already non-functional by the time of Dr. Y’s arrival. Its operations had been relocated to the Plant, which is where medical personnel, including Dr. Y, sought shelter. While sheltering, the doctor treated wounded Ukrainian soldiers from the 36th Marine Brigade (under whose command he was) and other divisions, as well as civilians. On April 12, 2022, Russian forces captured all those who were sheltering at the Plant. Dr. Y was initially taken to the village of Sartana, a filtration point for correctional colonies,[315] and later transferred to the Olenivka Correctional Colony No. 120 in Volnovakha. Having survived an attack on the Olenivka Correctional Colony No. 120 on the night between July 28 and 29, 2022,[316] the doctor was eventually transferred to the Kalinin Correctional Colony No. 27 in Horlivka in late September 2022. On November 3, 2022, he was released as part of an exchange of prisoners. Dr. Y’s testimony has been translated, edited, and condensed for clarity.

Ilyich Metallurgical Plant

There were at least 300 wounded at the Plant, though the highest figure I heard was 980. These numbers were recorded by a doctor who is still in captivity. Doctors worked every day, at all hours. The large basement was completely filled with wounded civilians and soldiers. One child was present at the Plant, a 10-year-old boy who had a shrapnel injury to his face. He was with a woman; I don’t know who she was – whether she was his mother or a neighbor. There was no time to ask people who they were. The main thing for me was that he was alive and healthy. We crossed paths with them once more during the period in captivity while in Sartana, but I do not know their fate.

During the entire period of stay at the Plant, in addition to providing support to the units, medics dealt with logistics, fed, transported, and generally took care of the wounded. We could not simply surrender, as we were a support unit, working for the brigade, and could thus not operate separately from the main military unit. If there were no medicines available, the commander would go outside to get it. We don’t know how he did it, but we always had everything we needed. We worked as part of the medical and nursing team at the Plant until April 12, 2022. On that day, we surrendered to the Russian military by order of the commander of the 36th Brigade.

Sartana

In Sartana, we were received by people without identification marks or chevrons, it was not clear who they were. We could only understand they were not “our people” by listening to their accents. We would immediately hear if someone was from the “Donetsk People’s Republic” and “Luhansk People’s Republic.”

During the first night in captivity, we were not sorted, we were all taken in a row to the barracks. Later, women were separated, they were taken somewhere [else]. All our things were taken away from us, including medicines and things to keep warm. One of our doctors had to hand his sleeping bag: he threw it on the ground, together with his badge. The guards witnessed the scene, called him up, and after asking who he was, they separated the medics, who were ordered to treat the prisoners.

There were many wounded, and something had to be done with them. A separate barrack was set aside for captured medics to treat the less severe injuries. We were reminded that we should be grateful to be alive, that we were not killed. In essence, it was “be happy we did not kill you.”

We treated the wounded and did everything we could as we used to do in Mariupol, but the working conditions were much worse. They did not give us anything except one bag filled with individual bandage packages and some medicines. It was some of the medicines that they took from us when we were taken prisoner. The way we were forced to treat people is not medical care. There was no access to adequate facilities and supplies to provide appropriate care. What kind of medical care is this? We need to treat people in a hospital, not just keep them in a barrack and be happy to have a bag of first-aid kit bandages.

There was not enough drinking water for the number of people in the barracks and we were given some kind of bread and one can of food to share with several people. There were so many wounded prisoners to be cared for that we prioritized resting rather than eating or drinking. Whenever possible, we leaned against each other on the concrete floor to sleep.

We were in Sartana for three or four days. The medics and the wounded were the last ones to leave. Only the persons with the most serious injuries were sent to hospital; there were 28 of them. The rest all went with us to Olenivka.

Olenivka Correctional Colony No. 120

Upon arriving at the colony, we underwent an “admission” procedure. As soon as we got off the bus, the jailers identified and continued to beat us: while we were saying our names, then again along a corridor they formed, and finally after they forced us to squat down. There was constant physical violence. They could have let this bus in without this “ritual,” everyone knew the bus was carrying wounded people and doctors. But the wounded were not spared. There was a guy with a crutch; they took the crutch from him and beat him with it, even as he fell to the ground. A wounded prisoner of war, who survived two airstrikes and had facial burns, was beaten to death. The head of the colony approached, and this is how I understood that there was some kind of ban on such a severe beating. I was in line after him; if it was not for his death, I would have been beaten just as hard.

The medics and the wounded were all placed in the same barrack and were forced to sleep on the floor. Several wounded had broken and torn limbs, some were paralyzed, they were in pain, but they were forced to live in such conditions. Initially, all the wounded – including those who were unable to walk due to their injuries – were forced to line up and walk 50 meters to the canteen. Food was eventually allowed to be brought to the barracks for the wounded, but this was subject to sudden change, depending on guards’ shifts. Physical force at that point was only used in the disciplinary isolation ward as a punishment for violating rules. But we were under constant moral pressure. We were forced to sing both the [Russian national] anthem and other songs.

“Admission” procedure at the Olenivka Correctional Colony No.120 – a MIHR investigation[317]

Detainees stayed in transit camps for up to a week before being transferred to Olenivka Correctional Colony No. 120. “We stood on our knees. Some people were beaten very hard. When we looked around, we realized that it was a former [temporary detention facility]. There were about 30-40 people in the cell,” a detainee who was released told MIHR regarding conditions in one of the transit camps. 

Upon transfer to Olenivka, detainees were forced to sit for hours in “slav squat,” a position requiring them to lock their hands behind their neck and squat, heels to the ground. Those who moved were beaten with clubs and rubber batons or kicked. Detained soldiers were also stripped naked.

Before being transferred to barracks, where detainees were forced to work, most were sent to a “punitive segregation unit” comprised of 15-square-meter cells in which up to 55 people were kept at the same time. There, meals consisted of a loaf of bread for eight prisoners per day and 200 ml of water per person per day.

There were 2,000 people in the colony, but not enough medicine to treat all the injured. From April to October 2022, no official medicines were delivered from Russia or the Red Cross in the colony. Everything the medics managed to obtain in this period was thanks to the diplomacy of one captured doctor. These medicines were the same [ones] that were confiscated upon the medics’ arrival into the colony. It was only in October 2022 that Russians brought medicines to the colony for the first time. They were not interested in providing medical care but only in avoiding deaths.

All assistance was based on human relations with the administration. When there were strokes, heart attacks, the senior medic could turn to the colony management and ask to send the patient to the hospital. But, if the chief was not in the mood, then the wounded prisoners would die. There were also women in captivity, one of them was pregnant. A senior medic contacted her. When the story of the pregnant woman became public, she was provided with vitamins, but was not released from captivity. She was later transferred to the hospital [in Sartana].

On the night of July 28-29, 2022, we heard cries in the colony. One of the leaders of the colony came and informed us that help was needed quickly. At the time when we got there, the entire road was covered with bodies. We were told that 47 persons died on the spot as a result of the explosion, and 116 were wounded. Representatives of the administration did not organize the evacuation, they watched us rescue the wounded all night. All they did to help was to provide some torn rags to be used as bandage material. Those who were less severely wounded were left at the colony, in a disciplinary isolation ward, with 20 injured people stuffed into four-bed wards. Five of them died during the night. Four had a combat craniocerebral injury, one had bleeding that could not be stopped. In general, the majority were craniocerebral injuries. If these people had been evacuated earlier, they might have survived.

Legal Framework and Analysis

This section explains the relevant rules and principles of international humanitarian law (IHL) that govern the conduct of parties in armed conflict, and the protected status of health facilities. The section then analyzes how the attacks detailed in the case studies above could give rise to criminal liability at both the international level under the Rome Statute of the International Criminal Court (ICC) and the domestic level under the Criminal Code of Ukraine (CCU) of 2001^[318] and through the exercise of universal jurisdiction in other countries.^[319] A special tribunal for aggression – another avenue relevant to Russia’s full-scale invasion of Ukraine – is currently being envisaged, but it is not examined here.^[320]

International Humanitarian Law

IHL is the body of laws that applies to armed conflicts.[321] As parties to an international armed conflict,[322] Russia and Ukraine are equally bound to comply.[323] This body of law is enshrined in the four Geneva Conventions of 1949 and their Additional Protocol I of 1977, [324] and in the Hague Conventions of 1899 and 1907.[325] Collectively, these instruments seek to protect those who do not or are no longer participating in the hostilities and to restrict the means (i.e. weapons) and method (i.e. tactics) of warfare. Many of the rules contained in these instruments also have the status of customary international law, consisting in a general practice accepted as law by states.

At the heart of the IHL framework lie several interrelated principles and legal obligations, which together lay the basis for the protection of civilians generally and special protections for health care. In a comprehensive report covering the initial five weeks of the full-scale Russian invasion of Ukraine (First Report), the Organization for Security and Co-operation in Europe (OSCE) Moscow Mechanism[326] found “clear patterns of IHL violations by the Russian forces in their conduct of hostilities.” In particular, the Mechanism noted that “[i]f they had respected their IHL obligations in terms of distinction, proportionality and precautions in attack and concerning specially protected objects such as hospitals, the number of civilians killed or injured would have remained much lower.”[327] These obligations are detailed in turn below:

Distinction. Under the principle of distinction, parties to a conflict must always distinguish between civilians and civilian objects on the one hand[328] and combatants and military objects on the other.[329] The principle of distinction means that operations may be directed only against combatants and military objects, an obligation that translates into a prohibition of attacks against civilians and civilian objects,^[330] unless the protections have been suspended due to the civilian directly participating in hostilities[331] or the civilian object is being used for military purposes.[332] In other words, “what counts for IHL is not what was destroyed or who was killed or injured but what and who was targeted.”[333] In its First Report, and with reference to the conduct of Russian forces, the OSCE Moscow Mechanism found that “it is highly implausible that so many civilian buildings, in particular, those situated far away from actual fighting between ground forces, had thus turned into military objectives or that so many of them were destroyed by mistake while a military objective was targeted.”[334]

Proportionality. Even where the principle of distinction is respected – and combatants or military objectives are targeted – an attack violates the principle of proportionality if the expected incidental death of, or injury to, civilians or the expected damage to civilian objects is excessive in relation to the anticipated military advantage.^[335] Prior to targeting a military object, if damage to civilian objects or civilian death or injury is anticipated, an assessment must be undertaken in which the anticipated military advantage to be gained is weighed against the “collateral” damage to protected civilians or civilian objects that is anticipated. Thus, under IHL, not every attack that results in civilian death or injury, or the destruction of a civilian object, is prohibited. In its First Report, the OSCE Moscow Mechanism found it “highly implausible … that in each case in which civilians were killed, the military advantage sought was so important that it justified the impact on civilians which had to be expected in an urban area.”[336] The Mechanism further concluded that even where military objectives were targeted, Russia should not only have taken into account the incidental effects on civilians or civilian objects near the target, “but also reverberating effects” such as “interruptions of electricity, gas, heating and water supplies … including their impact on the health system.”[337]

Precaution. Parties to a conflict must also respect the principle of precaution and take constant care “to spare the civilian population, civilians and civilian objects” in order to minimize any incidental loss of civilian life, injury to civilians, and damage to civilian objects.^[338] In particular, they must: (1) verify that the objectives to be attacked are neither civilians nor civilian objects and are not subject to special protection;^[339] (2) give advance warning of attacks which may affect the civilian population, if possible;^[340] (3) cancel or suspend an attack if it becomes apparent that the principles of distinction or proportionality may be violated;^[341] and (4) chose means and methods of warfare to at least minimize incidental death of, or injury to, civilians and damage to civilian objects.^[342] In its First Report, the OSCE Moscow Mechanism found it “particularly implausible” that Russia respected the principle of precaution or that it was not feasible “to choose weapons, ammunitions, tactics and timings other than those which it actually used” in densely populated areas.[343] The Mechanism further concluded that it is “highly implausible that the undisputed use of cluster munitions, munitions with a large blast radius, such as large bombs or missiles, unguided missiles, artillery and mortars, multiple launch rocket systems (MLRS) and dumb bombs released by aircraft … in densely populated areas, was in each case the only feasible choice for the Russian commander.”[344]

Medical Personnel, Units, and Vehicles. In addition to the general rule prohibiting attacks on civilians and civilian objects, IHL affords specific, enhanced protection to medical personnel,^[345] medical units,^[346] and medical vehicles.^[347] This is due to “their primary importance during armed conflicts, both to maintain public health and to care for the wounded and sick caused by the armed conflict” and applies regardless of whether they are military or civilian.[348] They shall be respected and protected at all times by the parties to an armed conflict.[349]

Similarly, IHL and human rights law, along with medical ethics, frame the rights and responsibilities of health care professionals, which includes the principle of medical impartiality. Medical impartiality requires that medical personnel not be punished for acting in accordance with their ethics and to ensure the protection of medical personnel, patients, facilities, and transport from attack or interference.[350] For those delivering assistance to affected populations, the humanitarian principles of impartiality, neutrality, and independence are essential to facilitate access to those in need of aid, including support for the health system.

The prohibition on directing attacks is not absolute: medical personnel, units, and vehicles lose their protection where they are used, outside their humanitarian function, to commit acts harmful to the enemy.[351] Acts not considered “harmful to the enemy,” which therefore do not lead to a loss of protection include, for example: when a hospital is guarded by an escort made up of soldiers or uniformed police force[352] or when members of the armed forces are in the hospital or unit for medical reasons.[353] By contrast, hospitals and other medical units lose their protection when they are, for example, used as a shelter for able-bodied combatants, as an arms or ammunition dump, or as a military observation post.[354] In such case, the hospital becomes a legitimate military objective, but only “after a warning has been given setting, whenever appropriate, a reasonable time-limit, and after such warning has remained unheeded.”[355] However, even in the case of loss of special protection, the general protection afforded to civilians and civilian objects applies and a “proportionality evaluation has to be made between the military advantage of stopping the acts harmful for the attacker and the expected death and injury of the medical personnel and current and future patients.”[356]

In its First Report, the OSCE Moscow Mechanism found that the large number of affected health care facilities in Ukraine  between February 24 and March 22, 2022 cannot be explained even “assuming that some attacks were directed against facilities engaged in acts harmful to the enemy or were incidentally harmed by attacks against legitimate targets.”[357] Additionally, even in the one instance in which Russia claimed to have issued the necessary warning, the Mechanism found that it had done so “without a time-limit and without any indication what had to be done to preserve the special protection.”[358] The Mechanism thus concluded that the special protection afforded to health care facilities had never been lost, rendering any of the intentional attacks directed against the structures war crimes.[359]

Certain violations of IHL may constitute war crimes and, if widespread or systematic, and committed pursuant to or in furtherance of a state or organizational policy, may also constitute crimes against humanity. Indeed:

The Geneva Conventions and Additional Protocol I establish that certain violations of IHL are to be considered “grave breaches”, and they must be prosecuted by High Contracting Parties, including on the basis of the principle of universal jurisdiction. Individual criminal responsibility for other serious violations of IHL is established by customary international law and by international criminal law treaties [such as the Rome Statute of the International Criminal Court]. Such serious violations of IHL, together with grave breaches, constitute war crimes.… Certain acts violating IHL, including war crimes, such as murder, extermination, or deportation may also constitute crimes against humanity, if they are committed “as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack”.[360]

Avenues for Accountability

Ukrainian courts have primary jurisdiction to adjudicate crimes committed within the country. However, in relation to international crimes, both the ICC and third countries can serve – with some limitations discussed below – as important additional avenues for accountability.

War crimes can be prosecuted under the Criminal Code of Ukraine (CCU), at the International Criminal Court (ICC), and by third countries pursuant to universal jurisdiction. Crimes against humanity can be prosecuted by third countries under both the principle of universal jurisdiction and at the ICC under the Rome Statute. The latter provides the most commonly accepted definition of crimes against humanity,[361] defining them as certain acts of violence – including what the Statute calls “other inhumane acts” – that are carried out as part of a widespread or systematic attack against a civilian population.[362] This definition is largely accepted by third countries exercising the principle of universal jurisdiction.[363] While the notion of crimes against humanity is currently absent from Ukrainian law, proposed amendments to Ukraine’s Criminal Code replicate the Rome Statute definition of the crime verbatim.[364]  

Neither Ukraine nor Russia are state parties to the ICC. On January 20, 2000, the Ukrainian Parliament signed the Rome Statute but never ratified it.[365] However, in 2014 and 2015, Ukraine lodged two declarations pursuant to Article 12(3) of the Rome Statute, effectively accepting the ICC’s jurisdiction over alleged crimes committed on its territory. The first declaration granted the ICC jurisdiction over crimes allegedly committed from November 21, 2013 to February 22, 2014 in relation to the Maidan protests.[366] Accordingly, in April 2014, former ICC prosecutor Fatou Bensouda opened a preliminary examination of the situation in Ukraine limited to these events.[367] The second declaration covered crimes allegedly committed in Ukraine from February 20, 2014 onwards,[368] which prompted the ICC to extend its preliminary examination to include alleged crimes committed there.[369]

In December 2020, the Office of the Prosecutor concluded its preliminary examination and determined that there was reasonable basis to seek the opening of an investigation into the “Situation in Ukraine.”[370] In the meantime, Ukraine’s parliament also amended Article 124 of the Constitution to recognize the jurisdiction of the ICC, thus removing all legal obstacles to ratification of the Rome Statute.[371]

On March 2, 2022, following Russia’s full-scale invasion of Ukraine, ICC Prosecutor Karim A.A. Khan, KC opened an investigation into the “Situation in Ukraine” on the basis of an unprecedented joint referral by 43 state parties.[372] As such, even without Ukraine or Russia being state parties to the Rome Statute, and in absence of a referral from the United Nations Security Council, the ICC has jurisdiction to investigate and prosecute those who commit Rome Statute crimes in Ukraine, such as war crimes and crimes against humanity, including those at the highest level of the Russian military and its political apparatus. Importantly, the ICC is also mandated to investigate crimes committed by all parties to the conflict.

However, there are crimes particularly relevant to attacks on health care in Ukraine that the ICC cannot prosecute, such as the prohibition on the use of certain weapons which, despite being listed as a war crime under the Rome Statute, is not currently in force for lack of an annex listing the prohibited weapons,[373] or certain attacks against humanitarian corridors.[374] Nevertheless, certain countries that have adopted a wider definition of war crimes and who are able – under universal jurisdiction statutes – to prosecute such crimes may still be an available forum to do so. In addition, as a matter of policy, the ICC Prosecutor focuses its resources on “the investigation and prosecution of a limited number of mid- and high-level perpetrators,” while not precluding the prosecution of lower-level perpetrators “where their conduct has been particularly grave or notorious.”[375]

Gaps in the prosecution of certain crimes or certain perpetrators at the domestic and international levels can be filled by third countries exercising universal jurisdiction, which allows them to prosecute serious crimes under international law, like war crimes or crimes against humanity, regardless of where they were committed or of the nationality of the perpetrators and the victims. These countries incorporate the crimes listed in the international conventions they ratified, such as the Geneva Conventions, the Convention against Torture, and the Rome Statute. Since the beginning of the full-scale Russian invasion, several third countries have opened investigations into crimes allegedly committed in Ukraine.

This section analyzes attacks on health care in Ukraine in light of relevant war crimes under Article 8(2)(a) and (b) and crimes against humanity under Article 7 of the Rome Statute. As noted, analysis under the Rome Statute is relevant for both the ICC and other, domestic jurisdictions that may have implemented it into their penal code or, indeed, have criminalized provisions that the ICC cannot yet prosecute (e.g., the use of certain prohibited weapons). The analysis relies on the “reasonable basis” standard that the ICC Prosecutor must satisfy when seeking the opening of an investigation.[376] Under this standard, the information gathered is “not expected to be ‘comprehensive’ or ‘conclusive’”; rather, a “sensible or reasonable justification [must] exist for the belief that a crime falling with the jurisdiction of the Court ‘has been or is being committed.’”[377] However, the report does not identify individual suspected perpetrators responsible for the attacks outlined in the case studies above, but rather recommends the Office of the Prosecutor at the ICC to investigate cases of attacks on health care.

Under the Rome Statute, a single attack may amount to a war crime.^[378] However, the Rome Statute also adds that the ICC has jurisdiction over war crimes “in particular when committed as part of a plan or policy or as part of a large-scale commission of such crimes.”[379] While this sentence should not be interpreted as limiting the jurisdiction of the ICC,[380] it gives the ICC “a particular guideline”[381] over war crime prosecutions. By contrast, to establish the existence of an attack as a crime against humanity, the Rome Statute requires a “course of conduct” involving the multiple commission of acts against a civilian population, “pursuant to or in furtherance of a state or organizational policy.”^[382] Establishing the existence of a policy is therefore, at a minimum, relevant for assessing evidence of war crimes, but required for the prosecution of crimes against humanity before the ICC.[383]

A policy does not need to be clear from the outset but may crystalize over time “such that definition of the overall policy is possible only in retrospect, once the acts have been committed and in light of the overall operation or course of conduct pursued.”^[384] Even if a policy is not explicitly defined, it can still be “surmised from the occurrence of a series of events.”[385]

ICC jurisprudence has adopted the factors set out by the International Criminal Tribunal for the former Yugoslavia (ICTY) to assess the existence of a policy.^[386] These include, among others: (1) the “general historical circumstances and the overall political background against which the criminal acts are set”; (2) the “mobilization of armed forces”; (3) the “scale of the acts of violence perpetrated,” including “the destruction of non-military property”; and (4) the existence of “temporally and geographically repeated and coordinated military offensives.”^[387] In most cases, a policy implies a regular pattern and can be inferred from “repeated actions according to the same sequence, or the existence of preparations or collective mobilization orchestrated and coordinated” by a state.^[388]

War Crimes under the Rome Statute

A threshold question for war crimes analysis is whether an armed conflict exists.[389] The Rome Statute gives the ICC jurisdiction over alleged war crimes committed in international armed conflicts,[390] which the Russia-Ukraine war undoubtedly is, as well as non-international armed conflicts. Under this framework, war crimes require two contextual elements: (1) that the conduct “took place in the context of and was associated with” an international conflict and (2) that the perpetrator was aware of factual circumstances that established the existence of an armed conflict. In most cases, this can be shown by the perpetrator’s awareness of the link between their conduct and the conflict.[391]

Many of the incidents described in the case studies above may, in themselves, constitute war crimes. Their combination, along with all other reported incidents in the dataset, appears to indicate the existence of a plan or policy to attack Ukraine’s health care system or, at a minimum, the large-scale commission of these attacks. As noted, these are not a strict requirement for the exercise of the ICC’s jurisdiction over war crimes,[392] but serve as a “particular guideline for the Court.”[393] While all incidents demand further investigation by the ICC Prosecutor, key elements of these crimes and their application to the alleged role of the Russian forces in attacks on Ukraine’s health care system are described below:

Attacking Protected Objects (Article 8(2)(b)(ix)): The special protection afforded to protected objects is rooted in the IHL principle of distinction and the general prohibition against attacking civilian objects.[394] Under the Rome Statute, protected objects include hospitals and places where the sick and wounded are collected. ICC jurisprudence makes it clear that protected objects “deserve special protection because of the role [they] play in the daily life and welfare of the civilian population.”[395] This protection must be respected “[e]specially in times of armed conflict and during ongoing hostilities, when as a result of the fighting more persons become injured or wounded… Attacking such structures disrupts the ability of medical personnel to care for the sick and wounded.”[396]

To fall within the meaning of Article 8(2)(b)(ix) of the Rome Statute, the perpetrator must not only have intended to launch an attack, but also have been aware of the target’s protected status – for example, if it was known to be a medical facility or was indicated by the emblems of the Geneva Conventions or other distinctive signs[397] – andintended  it to be the object of the attack.[398] These requirements mean that hospitals, as protected objects, must be the primary object of the attack.[399] The attack itself, however, does not require a particular result; in other words, it does not matter if a hospital did not suffer damage as a result of the attack.[400]

Hospitals are protected objects unless and for so long as they are military objectives, i.e., used to commit acts harmful to the enemy outside their humanitarian function.[401] For instance, the presence of armed forces in a hospital for medical reasons is not an act harmful to the enemy and does not deprive a hospital of its protected status.[402] Further, even if a hospital might become a military objective, its special protection against attacks ceases only after a warning has been given and such warning is ignored.[403]

There is a reasonable basis to believe that Russian forces intentionally attacked hospitals, as protected objects, on several occasions following the onset of the invasion. By targeting functioning hospitals, Russian forces not only severely endangered the welfare and lives of patients receiving care as well as medical personnel, but also further disrupted future medical care for those in need.  

The April 19, 2022 strike on the Bashtanka Multiprofile Hospital is illustrative (case study #4). There are reasonable indications that Russian forces were aware that it was a medical facility: according to the hospital director, drones flew over the hospital and “saw very well” the Red Cross painted on a white canvas placed on the roof of the facility.[404] A cursory online search also reveals the hospital’s geo-coordinates and its location on the edge of the city alongside two other hospital campuses. The hospital had retained its status as a protected object: Ukrainian forces were not stationed there, there does not appear to have been prior or contemporaneous reports of military activities in or around the hospital, and the hospital’s staff was in the midst of providing care to patients at the time of the attack. Its relatively isolated position on the edge of the city,

its potential strategic importance to observe the advance of Russian troops towards the city of Mykolaiv, and the use of a precision-guided missile – which the Russian media claimed in 2017 had an accuracy of within 30 meters[405] and whose launch requires high-level clearance due to its high cost and low availability[406] – are indications that Russian forces may have intended to strike the hospital. The attack resulted in the destruction of 30-40 percent of the hospital’s premises.  

Other examples include the series of attacks directly aimed at the Trostianets City Hospital between March 18 and March 25, 2022 (case study #5). Like the Bashtanka Multiprofile Hospital, the Trostianets City Hospital was marked with the emblem of the Red Cross. At the time of the attacks, Ukrainian forces were fighting to liberate the city of Trostianets from Russian occupation.[407] While Ukrainian forces may have been in the vicinity of the hospital or on the grounds of the hospital on one occasion and fighting ensued between Ukrainian and Russian forces across the street, the hospital’s location near legitimate military targets alone did not deprive it of its protected status. In fact, the hospital continued to operate exclusively as a medical facility, albeit at reduced capacity, by providing care to incoming patients. Despite its protected status, Russian forces allegedly set up two military posts behind and in front of the hospital, mined the area around it, and used tanks to repeatedly shell the hospital.[408] On March 19, 2022, an armed Russian soldier also reportedly entered the building and fired inside the premises. The series of attacks resulted in the destruction of the Trostianets City Hospital’s gynecology, maternity, and surgical wards, infectious diseases department, and overall structure.

Other incidents falling into this category of war crimes possibly include attacks on three health care facilities which, while located near the fighting line, do not appear to have become legitimate military objectives. These are:

• The February 26, 2022 attack by machine gun on the Makariv Multiprofile Intensive Care Hospital (case study #2);
• The attack on the Makariv Primary Care Clinic, if it was prior to the March 7 evacuation, reportedly carried out by successive, adjusted mortar strikes until the facility was hit (case study #2); and
• The April 2, 2022 shelling of the Balakliia Clinical Multiprofile Intensive Care Hospital prior to its seizure by Russian forces a day later (case study #7).

Excessive incidental death, injury, or damage (Article 8(2)(b)(iv)): This provision reflects, as the International Committee of the Red Cross has noted, the IHL prohibition on indiscriminate attacks.[409] It criminalizes attacks launched against a military target[410] that would result in death, injury, or damage that is clearly excessive in relation to the “concrete and overall military advantage anticipated.”[411] This assessment must be made before launching the attack.[412] Crucially, however, the attack itself does not require a particular result: as one commentator notes, “the crime would be committed even if, for example, an attack was launched against a military objective, but due to the failure of the weapon system, the expected excessive incidental damage did not occur.”[413]

There is a reasonable basis to believe that Russian forces engaged in attacks that may have resulted in excessive damage to civilian areas, including health care facilities. In the examples below, the assessment of whether the damage was excessive in relation to the military advantage gained in the attacks – and therefore whether the attacks fall under Article 8(2)(b)(iv) – would presuppose knowledge of what advantage Russian forces where seeking; a task that lies with investigators. At a minimum, there is a reasonable basis to believe an investigation into these incidents is warranted.

One such example can be found in the attacks that resulted in the damage of the Izium Central City Hospital,[414] including at least one attack that struck the facility directly, reportedly launched with the use of wide-area effect weapons such as large conventional artillery rounds or unguided air bombs (case study #1). The hospital had not lost its special protection: the fact that the hospital cared for wounded soldiers[415] or that Ukrainian soldiers had possibly established a base in a building nearby did not make it a military objective. Nor does it seem that any of the attacks were specifically directed at the facility. Rather, it appears that the hospital was hit in attempts to strike Ukrainian forces possibly positioned in the area or in wider operations targeting the whole city center of Izium. Even if Russian forces targeted legitimate military objectives near the hospital, the type of weapons employed – which were specifically designed to be inaccurate so that a barrage of rockets covers a wide area – resulted in the severe damage of parts of the hospital, including the complete destruction of the intensive care unit and operating block, and most buildings located within 500 meters.

Russian forces appear to have engaged in similar tactics in civilian areas of Chernihiv, including where hospitals are concentrated. The Chernihiv Regional Children’s Hospital was struck in one such attack (case study #3). On March 17, 2022, a BM-27 Uragan MLRS with warheads containing cluster munitions was reportedly launched from Russian-controlled areas towards the city center of Chernihiv. The hospital had not become a military objective: at the time of the attack, civilians were sheltering inside the facility while patients were receiving medical care. The fact that the hospital was at some point guarded did not make it a military objective.[416] Even if there had been military targets in the area, Russian forces not only used a type of weapon incapable of destroying only these objectives, but also appear to have failed to assess whether launching the attack in a densely populated area would result in excessive casualties or damage in relation to the military advantage anticipated. As established, the number of casualties – with at least 14 killed and 26 injured – and the damage caused to the hospital were significant.

Similarly, on or around March 12, 2022, the Adonis Medical Center in Makariv was struck in a series of airstrikes reportedly launched by Russian forces that caused significant damage to several other civilian objects – including apartment buildings and schools – in the city center of Makariv (case study #2). While the city was under heavy fighting between Ukrainian and Russian forces at the time, the widespread destruction of the area suggests the Russian forces’ disregard for the incidental damage caused to civilian objects around.

Attacking Objects Using the Emblems of the Geneva Conventions (Article 8(2)(b)(xxiv)): Recognized emblems of the Geneva Conventions are those of the Red Cross, the Red Crescent, the Red Lion and the Sun, the Red Crystal and any “other method of identification indicating protection under the Geneva Conventions” such as light signals, radio signals, or electronic identification. This provision expands on the war crime of attacking protected objects criminalized under Article 8(2)(b)(ix) of the Rome Statute in that it also covers, among others, attacks on medical units or transports. Identical to the war crime of attacking protected objects, the war crime of attacking objects using the emblems of the Geneva Conventions does not require that the object was destroyed or damaged as a result of the attack.[417]

The attacks on the Bashtanka Multiprofile Hospital and the Trostianets City Hospital (cases study #4 and #5, respectively), both of which were reportedly marked with a Red Cross, and the March 12 destruction, reportedly by Russian forces, of an ambulance station in Trostianets (see “Attacks on Ambulances”) may fall under this category of war crimes.

There is also a reasonable basis to believe that ambulances using distinctive signals identifying them as medical transport have been routinely and intentionally struck by Russian forces. For example, on April 18, the ambulance in Lyman was shot several times, causing it to fall into a ditch, while responding to an emergency call (case study #6). The dozen bullets shot towards the moving vehicle suggests that the attack was deliberate. The paramedic who was in the ambulance at the time also had the impression that the “target of the shots was the ambulance.” There are other examples of apparent intentional attacks on ambulances marked with emblems of the Geneva Conventions, several of which led to the injury or death of medical personnel and patients:

• On February 26, 2022, Russian forces reportedly shot at an ambulance transporting a wounded soldier in Khersonska oblast;
• On February 27, 2022, a presumed Russian group shot at an ambulance 17 times in Poltavska oblast; and
• On March 4, 2022, Russian forces reportedly shot at an ambulance with small arms in Sumska oblast.

Pillaging (Article 8(2)(b)(xvi)): The Rome Statute prohibits “all forms of appropriation, public or private, including organized and systematic appropriation, as well as acts of appropriation committed by combatants in their own interest.”[418] As such, the provision requires the perpetrator to appropriate certain property[419] without the consent of the owner,[420] for private or personal use.[421] By contrast, seizing the enemy’s property (Article 8(2)(b)(xiii)) only covers property protected from seizure under IHL.[422] Aside from the nature of the property, the perpetrator’s intent to obtain the property for private or personal use is the main distinctive element between pillage and seizure of the enemy’s property, where such requirement does not need to be met.[423] Under both provisions, however, appropriations of property justified by military necessity do not constitute war crimes.[424]

There is a reasonable basis to believe that, on several occasions, Russian forces and individuals appropriated medical supplies, equipment, and transport belonging to Ukraine, that were protected from seizure under IHL. In the examples below, the assessment of whether such appropriations were justified based on military necessity and whether they intended to appropriate them for private or personal use may only be conducted based on additional investigations into each separate incident. For example, from March 2022, Russian “entrepreneurs” allegedly seized several Ukrainian pharmacies to sell Russian medicine in the Khersonska oblast (case study #8). Between April and September 2022, Russian forces reportedly stole most of the equipment they could carry from the Balakliia Clinical Multiprofile Intensive Care Hospital (case study #7), where they had established a base, including ultrasound machines, cardiographs, encephalography machines, the CT scanner’s electronics, and surgical stands. Similarly, following the series of attacks on Trostianets City Hospital between March 18 and March 25, 2022, Russian forces allegedly stole the only undamaged ambulance left, leaving medical personnel unable to provide care outside of the hospital (see “Attacks on Ambulances”).

The case studies in this report highlight a number of other war crimes likely committed by Russian forces in Ukraine:[425]

Using Protected Persons as Shields (Article 8(2)(b)(xxiii): The prohibition against moving or otherwise taking advantage of the location of civilians, prisoners of war, or medical personnel with the specific intent to protect military objectives, or to aid or prevent a military operation, is rooted in the IHL principle of distinction. The provision is violated regardless of whether the human shields were actually attacked or harmed: indeed, the prohibition is designed to protect civilians and other protected persons from being exposed to the risk of harm, and not only to the harm itself.[426] For example, there is a reasonable basis to believe that Russian forces and allies seized the Regional Intensive Care Hospital in Mariupol and effectively compelled medical personnel to remain in the premises (case study #9). Whether this was in an effort to shield their forces from attacks depends on further investigations by relevant authorities. The following facts are relevant to this assessment: following missile strikes on the hospital between February 28 and March 12, 2022, Russian forces and allies reportedly began occupying the hospital: they placed armed personnel carriers around the premises, stationed soldiers on each floor and snipers on the roof, threatened to shoot anyone attempting to venture outside, and brought in up to 200 civilians, including children and the elderly, per day.

Unlawful Confinement (Article 8(2)(a)(vii)-2): While the movement of protected persons during armed conflicts may be restricted, or even temporarily suppressed, the justification for their confinement must be limited to valid needs and follow procedural requirements, such as an opportunity to contest their confinement.[427] In addition to the unlawful confinement of medical personnel at the Mariupol Regional Intensive Care Hospital (case study #9), several other incidents discussed above provide a reasonable basis to believe that Russian forces unlawfully confined medical personnel and other protected persons elsewhere in the oblast. For instance, Dr. Y and his colleagues were captured on April 12, 2022 and successively transferred to several correctional colonies controlled by Russian forces (case study #10). There, the medics were held in poor conditions, given insufficient supplies to treat the wounded, and witnessed prisoners being beaten or left to die.

Torture (Article 8(2)(a)(ii)-1)) and Inhuman Treatment (Article 8(2)(a)(ii)-2)): Torture is the intentional infliction of severe pain or suffering, whether physical or mental, upon a protected person for the purpose of, among others, obtaining information, punishment, intimidation, or coercion.[428] Inhuman treatment does not require such purpose.[429] Between August and October 2022, the United Nations Human Rights Monitoring Mission in Ukraine “documented widespread practices of torture and ill-treatment in places of internment in the Russian Federation and in Ukrainian territory it occupies.”[430] This is consistent with doctors held in captivity at the Russian-controlled correctional colonies of Olenivka and Horlivka (Donetska oblast) (case study #10). There, doctors, like other prisoners, underwent the so-called “admission procedure” and were beaten by guards, but also witnessed guards denying care to injured prisoners and intentionally inflicting pain and suffering on the detainees. Witnessing this treatment likely caused severe mental suffering, which was worsened by doctors’ inability to provide proper medical care to wounded prisoners, due to the unavailability of adequate medicines and facilities. Further, the conditions in which they were held – including overcrowding, lack of beds, and inadequate access to food and water – fell short of the minimum standard of humane detention, which may, at the very least, qualify as inhuman treatment.[431]

Wilful killing (Article 8(2)(a)(i)): Wilful killing occurs when the conduct of the perpetrator was the substantial cause for the death[432] of a protected person.[433] A striking example can be found in the reported shooting by Russian troops ofan ambulance that was transporting a wounded soldier to a hospital in Kherson. As a result, the ambulance caught fire, causing the death of both the driver and the patient, as well as the injury of a paramedic (p. X). Another example includes the treatment of prisoners in the Russian-controlled correctional colonies of Olenivka and Horlivka (Donetsk oblast), where medical personnel witnessed many people dying as a result of insufficient medical supplies, lack of sanitary conditions, refusal to evacuate patients to the hospital, and extreme beatings (case study #10). According to one of the medics who was held captive, wounded prisoners would be left to die “if the chief was not in the mood” to evacuate them. On another occasion, a wounded man was beaten to death at Olenivka.

Crimes Against Humanity under the Rome Statute

Between February 24 and December 31, 2022, partner organizations have documented 292 incidents that resulted in damage or destruction of hospitals and clinics, 65 incidents that resulted in the damage or destruction of ambulances, and 86 incidents, including detention and inhumane treatment, as well as injury and death, that affected health care workers.[434] The case studies above provide detailed information into some of these incidents. While each incident requires further investigation by relevant authorities, the volume of information appears sufficient to, at a minimum, warrant an investigation into whether attacks on Ukraine’s health care system are constitutive of crimes against humanity.

Crimes against humanity are specific acts, such as murder, imprisonment, torture, and, importantly, other inhumane acts, listed in Article 7(1) of the Rome Statute, “committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack.” For a specific act to fall under the definition of crimes against humanity, the ICC identifies “chapeau elements,” namely: (1) that an attack is directed against a civilian population; (2) that the attack is widespread or systematic; (3) that there is a link between the individual act and the attack; and (4) that the perpetrator knew their act to be part of the attack.[435]

As noted, the existence of a state or organizational policy is a pre-requisite to establish the existence of an attack as a crime against humanity.^[436] Taking into account relevant factors set out by the ICTY^[437] – and adopted by the ICC,^[438] – some elements that need to be considered include:

The general historical circumstances and political background: Russia’s “thorough aspiration to dominate Ukraine politically, militarily, and economically” predates the 2022 invasion of Ukraine.[439] It stretches back to at least 2014, when Russian President Vladimir Putin moved to illegally occupy Crimea and supported pro-Russia separatists in the Donbas region[440] – which he continues to date. On February 21, 2022, only days before launching the full-scale invasion of Ukraine, President Putin made a speech denying the existence of Ukrainian statehood.[441] On September 30, 2022, he moved to illegally annex Donetska, Khersonska, Luhanska, and Zaporizka oblasts[442] and, in December 2022, the State Duma (the lower house of the Federal Assembly of Russia) adopted Bill no. 246425-8 in the first reading – a bill which proposes to remove criminal liability for crimes committed in the four oblasts before their annexation provided they were “aimed at protecting the interests of the Russian Federation” or the territories.[443] It is against this background that attacks on health care have been taking place throughout the conflict in Ukraine.

The mobilization of Russia’s armed forces: The movement of Russian armed forces was reported on or near the Ukrainian border as early as mid-October 2021.[444] On February 24, 2022,President Putin launched a coordinated, full-scale land, sea, and air invasion of Ukraine through three entry points: the north from Belarus, the south through Russian-occupied Crimea, and the east through Russia.[445] Up to 200,000 Russian troops are estimated to have been deployed in the first few days of the invasion.[446] Six months later, President Putin signed a decree increasing the size of Russia’s armed forces[447] and, shortly after, declared the partial mobilization of military reservists.[448] In December 2022, a second wave of mobilization was reported.[449]

The scale of the acts of violence: The case studies, together with the dataset, reveal the frequency and intensity with which Ukraine’s health care system has been disrupted through attacks that resulted in the damage, destruction, and looting of health care facilities and transport, as well as attacks on health care workers. As noted by the OSCE Moscow Mechanism in its Second Report covering the period between April 1 and June 25, 2022 “[t]he war has increased the demand for healthcare services while reducing the system’s ability to provide them, particularly in areas of active conflict.… These attacks against health facilities, transportation, personnel, patients, supplies, and warehouses, put healthcare workers in danger, deny patients access to desperately needed care, and damage the health system. The number is increasing.”[450] While requiring further investigation by relevant authorities to ascertain the circumstances in which attacks have occurred, including the perpetrators, this suggests that attacks on civilians and civilian objects generally, and on Ukraine’s health care system specifically, were pursued pursuant to a policy, rather than as a mere accumulation of spontaneous or isolated acts. 

The repeated and coordinated military offensives: Russian forces reportedly played an active role in each of the attacks detailed in the case studies above. Military offensives on Ukraine’s health care system seem to have largely followed Russia’s invasion pattern, for example: the first attacks on ambulances in Khersonska oblast and on health care facilities in the city of Chernihiv reported in February 2022; targeted attacks on a hospital in the outskirts of Trostianets in March 2022 as Russian troops occupied the town; the capture and mistreatment of health care workers in Mariupol in March 2022 as the city was under siege; the carpet bombing of Izium resulting in severe damage to a hospital prior to the town’s occupation from April to September 2022; and the attack on an ambulance in Lyman as Russian troops entered the nearby town of Kreminna in April 2022.

The attack against the civilian population, including through the health care system, appears to have been both widespread and systematic.[451] The term “widespread” refers to the large-scale nature of the attack in that it “should be massive, frequent, carried out collectively with considerable seriousness and directed against a multiplicity of victims.”[452] The assessment is “neither exclusively quantitative nor geographical, but must be carried out on the basis of the individual facts,” meaning “a widespread attack may be the cumulative effect of a series of inhumane acts or the singular effect of an inhumane act of extraordinary magnitude.”[453] The term “systematic” refers to “the organised nature of the acts of violence and the improbability of their random occurrence.”[454] Much like the existence of a policy, the systematic nature of an attack is assessed through “patterns of crimes, in the sense of non-accidental repetition of similar criminal conduct on a regular basis.”[455]

An analysis of the “widespread” or “systematic” nature of the attack would therefore necessarily rely on much of the same factors reviewed above. The number of attacks against Ukraine’s health care system – including facilities, vehicles, and personnel – throughout several oblasts that span a broad expanse of Ukraine’s territory and the multiplicity of victims among both health care professionals and patients, as well as the associated consequences of the disruption of future care on the general population, suggest that the attack on the civilian population may be widespread in nature. It is also possibly systematic as the acts of violence appear to be neither spontaneous nor isolated. They share a number of similarities consistent with a “course of conduct”: they followed similar temporal and geographical patterns as Russia’s full-scale invasion unfolded, attacks detailed in the case studies involved the presence of mobilized Russian forces, and almost consistently resulted in severe damage to health care facilities, destruction or loss of medical equipment and vehicles, and violence against medical personnel and patients alike, including serious injury and loss of life.[456]

On the basis of the above, the information provided appears sufficient to warrant an investigation into whether Russia’s armed forces have, at a minimum, engaged in the crime against humanity of “other inhumane acts” (Article 7(1)(k)). Other inhumane acts are “serious violations of international customary law and the basic rights pertaining to human beings, drawn from the norms of international human rights law,” that cause great suffering, or serious injury to body or mental or physical health to the victims.[457]

International courts and tribunals have, in the past, made findings on crimes against humanity involving, among others, the perpetrators’ deliberate deprivation of medical care to civilians under their control.[458] These acts likely apply directly in the context of, for example, the treatment of patients and health care professionals in the Russian-controlled correctional colonies of Olenivka and Horlivka, where prisoners were routinely denied proper medical care by guards (case study #10).[459] The overall disruption and destruction of Ukraine’s health care system, as demonstrated by the case studies and the dataset, could similarly constitute a deliberate deprivation of medical care. As noted by the OSCE Moscow Mechanism, “by causing a high level of destruction and by interfering with the provision of vital services (education, healthcare), the conflict started by the unlawful attack by Russia has made it very difficult for Ukraine to effectively respect, protect and fulfil the human rights of its inhabitants.”[460] A full investigation into the context and circumstances of attacks on Ukraine’s health care system may uncover what appears to be a more generalized deprivation of access to health – of the right to health – as a method of war, carried out as a part of a deliberate effort to cause civilian mental and physical suffering.

Ukrainian Criminal Law

As noted, Ukrainian courts will serve as the primary seat to adjudicate crimes occurring on Ukrainian territory. As of January 2023, the office of the prosecutor general (OPG) of Ukraine has already registered more than 63,000 instances of alleged war crimes since the beginning of the full-scale invasion of Ukraine.[461] Relying on the standard prosecutors must satisfy when opening an investigation – circumstances “likely to indicate” that a criminal offence has been committed[462] – this section analyzes attacks on health care in Ukraine in light of relevant provisions of the CCU.[463]

Despite its broad title, the current wording of Section XX of the CCU (“criminal offenses against peace, security of mankind and international order”)[464] makes no reference to crimes against humanity and lacks specificity in its approach to the criminalization of IHL violations.[465] In order to bring Ukraine in conformity with the international legal framework on war crimes and crimes against humanity, two draft laws have been submitted to the Verkhovna Rada (Ukraine’s parliament) to date: Bill no. 2689[466] and Bill no. 7290.[467] The former includes provisions on war crimes and crimes against humanity, including on command responsibility, consistent with the Rome Statute.[468] It was adopted by the Verkhovna Rada in May 2021, but was not signed into law by the president.[469] On April 15, 2022, the cabinet of ministers registered another draft law for consideration – Bill no. 7290.[470] While this draft law has been criticized for restricting the application of command responsibility and lacking a provision instituting universal jurisdiction in Ukraine,[471] the list of criminalized acts – war crimes and crimes against humanity – is the same as that of Bill no. 2689 and would therefore constitute a step forward in the prosecution of these crimes under the CCU. 

As such, Section XX of the CCU, in its current version, is the governing law in the context of domestic prosecutions of alleged war crimes, including attacks against Ukraine’s health care system by Russia’s armed forces.[472] These include, chiefly:

Violations of the Laws and Customs of War (Article 438 CCU): Article 438 of the CCU lists several relevant, conflict-related crimes; some of which are currently being investigated or have already been adjudicated since the beginning of the full-scale invasion.[473] For instance, three Russian service members – two tank commanders and one assistant – were charged in absentia for their alleged role in firing at the Trostianets City Hospital with T-80 and T-72 tanks in March 2022.[474] Article 438 CCU includes a non-exhaustive list of conduct that gives rise to criminal liability, including the “use of means of warfare prohibited by international law” and “any other violations of rules of the warfare” recognized by international treaties ratified by Ukraine. An analysis of the provision by Global Rights Compliance[475] reveals that:

While Article 438 generally criminalizes the use of means of warfare through reference to any prohibition contained in international law (thereby encompassing both international treaties and customary international law), it takes a narrower approach to the other violations of the “laws and customs of war,” in other words, violations of methods of warfare. In the case of violations of methods of warfare, only those contained in international treaties ratified by Ukraine are included, and not those that are recognized by customary international law.

A literal reading of Article 438 suggests that it is not intended to incorporate all crimes or violations of the methods of warfare that are part of customary IHL, instead limiting itself to those enumerated in the treaties ratified by Ukraine, such as the Geneva Conventions and Additional Protocols, as well as other violations enforced by other treaties ratified by Ukraine.[476]

Nonetheless, the case studies above point to the likely commission of the following crimes enumerated in the Geneva Conventions and Additional Protocol I, allowing the application of Article 438 of the CCU:

• Indiscriminate attacks resulting in loss of life or injury to civilians or damage to civilian objects;[477]
• Disproportionate attacks;[478]
• Making medical objects or personnel the objects of attack;[479]
• Pillage and extensive destruction or appropriation of property;[480]
• Using human shields;[481]
• Unlawful confinement;[482]
• Willful killing;[483] and
• Torture or inhuman treatment.[484]

These IHL violations overlap, in broad terms, with war crimes under the Rome Statute examined above.[485] As such, the case studies and their analysis under the Rome Statute discussed above fall under the respective categories of IHL violations, as transposed into Ukrainian criminal law by Article 438 CCU.

Ordinary crimes under Ukrainian law: There are no legal barriers to prosecuting the alleged crimes outlined in the report as ordinary crimes under Ukrainian law, such as crimes against property,[486] crimes against the life and health of persons,[487] and crimes against the liberty, honor, and dignity of persons.[488] However, prosecutions under Article 438 of the CCU should be prioritized – whenever possible – to appropriately capture the specific and international character of the offences. Given the international character of the armed conflict, the categories of ordinary crimes listed above fall under the scope of Article 438 CCU when committed within context of the armed conflict and should thus be prosecuted accordingly.

Universal jurisdiction allows third countries to prosecute serious crimes under international law – such as war crimes and crimes against humanity – regardless of where they were committed or of the nationality of the perpetrators and the victims.[489] It was first codified in the Geneva Conventions,[490] expanded in Additional Protocol I,[491] and further reinforced in other international conventions.[492] An increasing number of countries worldwide and member states of the ICC recognize the principle of universal jurisdiction[493] in an effort to manifest solidarity with the victims and survivors of such crimes.[494]

These countries have adopted domestic legislation to incorporate the crimes listed in the international conventions they ratified, such as the Geneva Conventions,[495] the Convention against Torture,[496] and the Rome Statute.[497]

As of October 2022, at least 12 third countries had opened investigations into alleged war crimes and crimes against humanity committed in Ukraine since the beginning of the full-scale invasion.[498] Considering the thousands of instances of war crimes registered by the OPG since the beginning of the full-scale invasion, the gaps in Ukrainian law concerning crimes against humanity, the absence of certain war crimes contained in the Geneva Conventions from the Rome Statute, and the finite resources Ukrainian courts and the ICC have, the exercise of universal jurisdiction can be a powerful tool to ensure that serious crimes committed in Ukraine do not remain unpunished.

In the context of Ukraine, most of the obstacles that usually present a challenge in the exercise of universal jurisdiction – such as access to the victims, witnesses, and crime sites or the lack of political will to pursue cases against citizens of foreign countries – are easily surmountable.[499]

Conclusion and Recommendations

The case studies and dataset highlighted in this report describe the staggering toll that Russia’s war of aggression has had on Ukraine’s health care system. From repeated attacks on health care facilities and ambulances, theft and destruction of critical infrastructure and supplies, and evidence of assaults and ill-treatment of Ukrainian health workers, the devastation wrought since Russia’s full-scale invasion is clear. The true scale and impact that it is having on access to health care – and on the right to health of Ukraine’s people – will not be known for years to come. 

Protecting health care, including access to and delivery of health care services, is a shared responsibility of all parties to an armed conflict. This duty extends to Russia and Ukraine equally under international humanitarian law (IHL).

Beyond protection, however, there is a pressing need to ensure accountability. For too long, violations of IHL with respect to health care have been ignored by the international community.[500] It was not until 2016, following building momentum, that the United Nations Security Council finally achieved a political breakthrough: it adopted Resolution 2286, which condemns attacks against health and commits to their prevention and to holding perpetrators to account domestically and internationally. Despite this, hospital attacks and other crimes against health care have only rarely been prosecuted.[501]

This report is a call to investigators and prosecutors – in Ukraine, at the International Criminal Court, and in third states that may also have jurisdiction – to prioritize prosecution for such attacks and affirm that the laws protecting medical facilities and personnel be respected and enforced.

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. 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. It must cease these attacks and end its aggression. 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 resulting from its attacks on the health care system.

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 as both war crimes and crimes against humanity.
• Build cases specifically focused on crimes concerning attacks on Ukraine’s health care facilities and health care personnel, ensuring adequate resource allocation and training to do so effectively.
• Ensure continued strong cooperation and coordination among prosecutorial offices and bodies at the national and international level, in order to maximize information sharing and efficiency.

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.
• Call for the immediate release of detained health care professionals and the humane treatment of all detainees in compliance with international humanitarian law.
• Convene an Arria-Formula Meeting of the UN Security Council to address widespread and systematic attacks on Ukraine’s health care system and reinforce the need to ensure criminal accountability.
• Commit adequate and long-term funding and other resources to justice and accountability mechanisms working to document international crimes and other gross human rights violations in Ukraine, including violations of the right to receive and access health care.
• Support and cooperate with international and Ukrainian non-governmental organizations (NGOs) to assist in gathering, coordinating, and disseminating data on attacks on health care.

To the Government of Ukraine:

• Ratify the Rome Statute of the International Criminal Court.
• Adopt domestic implementing legislation that sufficiently captures the substantive crimes and modes of liability provided for under the Rome Statute, including crimes against humanity and command responsibility, as well as other relevant offenses under international humanitarian law.

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.
• Consider expanding the mandate of the inaugural Special Rapporteur on the “Situation of Human Rights in the Russian Federation” to encompass violations related to the 2022 full-scale invasion, including the rights of Ukrainian civilians currently being held on Russian territory.

To the UN Secretary-General:

• Promote further coordination and cooperation among the Secretary-General’s Office and with other relevant UN agencies, investigative mechanisms, and non-governmental organizations (NGOs) to share their methods, data, reporting capacities, and roles on attacks on health care.
• Appoint a Special Representative on Violence Against Health Care to address attacks on Ukraine’s health care system and in other conflicts.

To the World Health Organization (WHO) and its Member States:

• Proactively work with NGOs and UN agencies to expand data collection and, where appropriate, public disclosure in Ukraine and elsewhere.
• Adopt a resolution by the World Health Assembly to address ongoing concerns in structure, oversight, and operation of the Surveillance System for Attacks on Health Care, including a review of WHO’s Framework of Engagement with Non-State Actors that would allow for mutual data sharing with UN agencies and NGOs, in both Ukraine and other countries.
• Acting under Article 7 of the WHO Constitution, suspend voting rights of the Russian Federation and remove representatives of the Russian Federation from executive positions.

Acknowledgements

This report is a joint product of eyeWitness to Atrocities (eyeWitness), Insecurity Insight, the Media Initiative for Human Rights (MIHR), Physicians for Human Rights (PHR), and the Ukrainian Healthcare Center (UHC).

The report was researched and written by Christian De Vos, MSc, JD, PhD, PHR director of research and investigations; Anna Gallina, LLM, advanced LLM, eyeWitness associate legal advisor; Pavlo Kovtoniuk, MPh, UHC co-founder; the MIHR team; Uliana Poltavets, MSc, PHR Ukraine emergency response coordinator; Julianne Romy, MA, MA, LLM, eyeWitness legal advisor; Diana Rusnak, MPh, UHC research analyst; and Christina Wille, MPhil, Insecurity Insight director. Will Jaffe, PHR research fellow, also contributed to the drafting of the report.

The report was reviewed by eyeWitness staff members Wendy Betts, MA, JD, director, and Alla Malomuzh, LLM, PhD, legal specialist (Ukraine); the MIHR team; and PHR staff members Erika Dailey, MPhil, director of advocacy and policy; Michele Heisler, MD, MPA, medical director; Karen Naimer, MA, JD, LLM, director of programs; Catherine Pilishvili, international advocacy officer; Kevin Short, deputy director, media and communications; and Gerson Smoger, JD, PhD, interim executive director.

Interviewing, data collection, and verification was carried out by UHC staff members Tetiana Korchak, LLM, lawyer; Mariia Kravchenko, head of communication projects; Volodymyr Lotushko, MSc, MD, research analyst; Mariia Lypovchenko, project manager; and Olena Sinitsyna, MPh, consultant. Interviews were also conducted by the MIHR team.

Insecurity Insight’s team of 10 people delivered the large-scale exercise in open-source monitoring and data processing required for this study. Insecurity Insight jointly developed the interactive map with DrivenData and was responsible for data analysis and editorial comments on the report. The report was further supported by data from the International NGO Safety Organisations’ (INSO) Conflict and Humanitarian Data Centre (CHDC).

The report received external review from Leonard S. Rubenstein, JD, LLM, professor of the practice at Johns Hopkins Bloomberg School of Public Health and chair of the Safeguarding Health in Conflict Coalition, who provided invaluable advice and support. In addition, we gratefully acknowledge the assistance of the following staff members of Global Rights Compliance, all of whom are also members of the mobile justice team supporting the Office of the Prosecutor General of Ukraine: Julian Elderfield, LLM, international legal advisor; Wayne Jordash, QC, managing partner; and Anna Mykytenko, LLM, senior legal adviser. Our organizations also acknowledge the assistance of a weapons analyst with years of experience working in support of international criminal investigations and as NATO weapons inspector, with whom we consulted. The expert’s comments provided invaluable detail to the report’s case studies and are referenced accordingly in the report.

The report was reviewed, edited, and prepared for publication by PHR’s senior publications consultant, with assistance from Samantha Peck, PHR program and executive associate.

PHR research and investigations interns Erica Berry and Kseniia Michkodan also supported the project.

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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 Barsehian, 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.

[4] For an in-depth analysis of Russia’s involvement in Crimea and Donbas between December 2013 and February 13, 2022, see Global Rights Compliance, “International Law and Defining Russia’s Involvement in Crimea and Donbas,” February 13, 2022, https://globalrightscompliance.com/wp-content/uploads/2022/05/International-Law-and-Russia-Involvement-in-Crimea-and-Donbas-1.pdf. See also Marieke de Hoon, “Dutch Court, in Life Sentences: Russia Had ‘Overall Control of Forces in Eastern Ukraine Downing of Flight MH17,” JustSecurity.org, December 19, 2002, https://www.justsecurity.org/84456/dutch-court-in-life-sentences-russia-had-overall-control-of-forces-in-eastern-ukraine-downing-of-flight-mh17/; Ukraine and the Netherlands v. Russia, No. 8019/16, 43800/14, 28525/20, ECHR (Grand Chamber), January 25, 2023 (finding that Russia exercised “effective control” on account of its military presence in eastern Ukraine and the decisive degree of influence it enjoyed over these areas as a result of its military, political and economic support to the “DPR” and the “LPR”).

[5] See Cynthia J. Buckley, Ralph S. Clem, and Erik Herron, “Attacks on Healthcare Infrastructure in the Donbas: Implications for Ukrainian State Legitimacy,” PONARS Eurasia (January 11, 2019), https://www.ponarseurasia.org/attacks-on-healthcare-infrastructure-in-the-donbas-implications-for-ukrainian-state-legitimacy/.  

[6] Because Insecurity Insight does not a have a specific mandate for or expertise in criminal accountability, it did not contribute to – and does not take a view on – the portion of the report that legally analyzes alleged IHL violations under international criminal law and Ukrainian domestic law.

[7] World Health Organization, “Accessing health care in Ukraine after 8 months of war: The health system remains resilient, but key health services and medicine are increasingly unaffordable,” October 24, 2022, https://www.who.int/europe/news/item/24-10-2022-accessing-health-care-in-ukraine-after-8-months-of-war–the-health-system-remains-resilient–but-key-health-services-and-medicine-are-increasingly-unaffordable.

[8] United Nations Human Rights – Office of the High Commissioner, “Update on the Human Rights Situation in Ukraine”, August 1 – October 31, 2022, p. 2, https://www.ohchr.org/en/documents/country-reports/hrmmu-update-human-rights-situation-ukraine-1-august-31-october-2022.

[9] As detailed further below, this map includes incidents between February 24 and December 31, 2022; however, it will also serve as an ongoing record of documented attacks, beyond the time period this report covers. See www.attacksonhealthukraine.org.

[10] See, e.g., “Ukraine: Ukrainian fighting tactics endanger civilians,” Amnesty International, August 4, 2022, https://www.amnesty.org/en/latest/news/2022/08/ukraine-ukrainian-fighting-tactics-endanger-civilians/; Human Rights Watch, “Russian, Ukrainian Bases Endangering Civilians: Basing Forces in Populated Areas Creates Unnecessary Risk,” Human Rights Watch, July 21, 2022, https://www.hrw.org/news/2022/07/21/russian-ukrainian-bases-endangering-civilians; “Ukraine: Banned Landmines Harm Civilians” Human Rights Watch, January 31, 2023, https://www.hrw.org/news/2023/01/31/ukraine-banned-landmines-harm-civilians. For a helpful corrective to Amnesty’s claims, see Michael N. Schmitt, “Ukraine Symposium – Amnesty International’s Allegations of Ukrainian IHL Violations,” August 8, 2022, https://lieber.westpoint.edu/amnesty-allegations-ukrainian-ihl-violations/.

[11] In Case Study #2 detailed herein (Makariv Multiprofile Intensive Care Hospital and Makariv Primary Care Clinic), there is evidence that Ukraine’s armed forces reportedly established a base at the hospital as of March 7, 2022, thus depriving it of its protected status under IHL; however, this was after all remaining patients and doctors had been evacuated from the facility.

[12] A note on spelling: in accordance with the 10th United Nations Conference on the Standardization of Geographical Names this report uses the “Romanization system” as the international system for the transliteration of Ukrainian geographical names. See, e.g., https://mfa.gov.ua/storage/app/sites/1/e-conf101-84-roman-system-ukraine-eng.pdf.

[13] PHR’s Ethics Review Board provided guidance and approved this study based on regulations outlined in Title 45 CFR Part 46, which are used by academic Institutional Review Boards in the United States. All of PHR’s research and investigations involving human subjects are conducted in accordance with the Declaration of Helsinki 2000, a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data.

[14] See “Timeline of Attacks on Health Care in Ukraine,”  https://insecurityinsight.org/country-pages/ukraine.

[15] For more information on the Insecurity Insight’s SIND database used for the Safeguarding Health in Conflict Coalition see SHCC methodology, https://shcc.pub/2021Methodology.

[16] See The Humanitarian Data Exchange, “Ukraine: Attacks on Aid Operations, Education, Health and Conflict-related Sexual Violence (CRSV),” https://data.humdata.org/dataset/ukraine-data-on-attacks-on-aid-operations-education-health-and-protection.

[17] See https://humanrights.berkeley.edu/berkeley-protocol-digital-open-source-investigations. If UHC obtained only one type of evidence to confirm an incident, it was coded as a first level verification; if UHC obtained two or more types of evidence, an incident received a higher, second level verification.

[18] Sources’ reliability was based on four principal criteria: their credibility, based on the online presence and posting history of sources; independence and impartiality; specificity, i.e., the extent to which a source can reveal more details of the occurrence; and attenuation. For the latter, reports and text drafted contemporaneously with the events that they reference tend to be viewed as more reliable than those produced after the events have occurred.

[19] The data is stored in a secure online database that follows Insecurity Insight’s standard event-based coding and data protection procedures.

[20] Digital forensic examination was excluded from the verification protocol as that is not within any of the research partners’ capacities.

[21] See https://www.who.int/activities/stopping-attacks-on-health-care. Examples of types of attacks on health can include: violence with individual weapons or heavy weapons, psychological violence/threat of violence/intimidation, obstruction to delivery of care, assault without weapons, sexual assault, denial of access to services, armed or violent search of health resources, removal of health care assets, setting fire to health resources, and militarization of health care facilities. Notably, incidents were only included that could be considered directly relevant to the Russia-Ukraine War because the violence was perpetrated by conflict actors; violence by private individuals (e.g., patients) is not included. The database also does not include counts of the reported deaths of patients as the impact of attacks on patients is much wider in ways that are not possible to capture through incident-based monitoring. For more information on methodologies to document the impact of attacks on health care for patients, see https://riah.manchester.ac.uk/.

[22] The app is designed so that neither the footage nor its associated metadata can be tampered with by the user or third parties. In conjunction with transmission protocols, eyeWitness’ server creates a chain of custody with embedded information for the footage from the point of capture to its receipt by the server. eyeWitness seeks consent before sharing footage captured by non-anonymous users with third parties. Users provided consent to share the photos they captured with the app and uploaded to eyeWitness’ server for the purpose of this report and associated map. For more information about the App and resources, see eyeWitness to Atrocities, “Resources,” accessed February 3, 2023, https://www.eyewitness.global/resources.     

[23] See Rohini Haar and Susannah Sirkin, “Strengthening Data to Protect Healthcare in Conflict Zones,” International Peace Institute, November 2022, https://www.ipinst.org/2022/11/strengthening-data-to-protect-healthcare-in-conflict-zones.

[24] Notably, previous work has shown that there was “minimal overlap” between Insecurity Insight’s database and the WHO’s, suggesting “significant underreporting of attacks on health care.” For similar reasons, the number of reported incidents in Ukraine is likely an undercount as well. See Vanessa Parada, Larissa Fast, Carolyn Briody, Christia Wille and Rudi Coninx, “Underestimating attacks: Comparing two sources of publicly available data about attacks on health care in 2017,” Conflict and Health 17 (2023), https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-023-00498-w.      

[25] WHO definition of “health care infrastructure”: “Any infrastructure necessary to provide health care, including but not limited to laboratories, pharmacies, medical warehouses, ambulances, ambulance stations and/or garages, administrative buildings used to administer health care and to provide medical education, or any other health care facility not named here.”

[26]  Across all of Ukraine there are approximately 2,500 hospitals (https://reliefweb.int/report/ukraine/attacks-ukraine-s-hospitals-will-cause-long-term-harm-health ), of which some 300 are in zones of active fighting while some 1,000 are in areas that have seen changes in territorial control. (WHO Ukraine crisis strategic response plan for June December, July 2022)  With 218 hospitals reported damaged or destroyed, nearly nine percent of the country’s hospitals have been directly affected by conflict damage.

[27] “Area-based assessment in conflict-affected area of Ukraine – Briefing note: Basic service provision for women and children in Kharkiv city, Ukraine (November 2022),” Reach, November 2022, https://reliefweb.int/report/ukraine/area-based-assessment-conflict-affected-area-ukraine-briefing-note-basic-service-provision-women-and-children-kharkiv-city-ukraine-november-2022.

[28] “War in Ukraine: situation report from WHO Ukraine country office. Issue No. 31, 9 October 2022,” WHO Ukraine country office, No. 31, October 9, 2022, https://reliefweb.int/report/ukraine/war-ukraine-situation-report-who-ukraine-country-office-issue-no-31-9-october-2022.

[29] “Priorities for health system recovery in Ukraine – joint discussion paper,” Ukraine, WHO Health Emergencies Programme, December 28, 2022, https://www.who.int/europe/publications/m/item/priorities-for-health-system-recovery-in-ukraine-joint-discussion-paper.

[30] This does not mean that explosive weapons were only used in 89 percent of cases, but rather that those who provided the event description mentioned a specific weapon category. The absence of information on specific weapons system is likely more due to lack of knowledge and awareness by the event describer than whether a weapons system was actually engaged. 

[31] “Putin Admits Attacks on Ukraine Infrastructure, Asking, ‘Who Started It?,’” Washington Post, December 8, 2022, https://www.washingtonpost.com/world/2022/12/08/russia-attacks-ukraine-infrastructure-putin/.

[32] Correspondence with weapons analyst (on file).

[33] See “Endless Brutality: War Crimes in Chechnya,” Physicians for Human Rights, May 2001, https://phr.org/wp-content/uploads/2001/05/chechnya-endless-brutality-report2001.pdf.

[34] Peter Moszynski, “Health facilities in Georgia have been attacked,” BMJ, August 19, 2008 (Vol. 337),  https://www.bmj.com/content/337/bmj.a1357.

[35] “Medical Personnel Are Targeted in Syria,” Physicians for Human Rights (accessed January 6, 2023), https://phr.org/our-work/resources/medical-personnel-are-targeted-in-syria/.

[36] Dr. Houssam al-Nahhas, “As Putin bombs hospitals in Ukraine, I hear echoes from Syria,” The New Humanitarian, April 13, 2022, https://www.thenewhumanitarian.org/opinion/first-person/2022/04/13/putin-bombs-hospitals-ukraine-i-hear-echoes-syria; see also Annie Sparrow, “Russia is waging war on Ukrainian healthcare,” Financial Times, July 5, 2022, https://www.ft.com/content/87c0e3c4-8e4b-4c85-b5b3-ef5c180369e3.

[37] “Anatomy of a Crisis: A Map of Attacks on Health Care in Syria,” Physicians for Human Rights, December 2017, https://s3.amazonaws.com/PHR_syria_map/findings.pdf.

[38] Organization for Security and Co-operation in Europe, “Report of the Human Rights Assessment Mission on Crimea (6-18 July 2015),” September 17, 2015, paras. 43, 204-13, https://www.osce.org/files/f/documents/0/2/180596.pdf.

[39] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 72, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[40] Cynthia J. Buckley, Ralph S. Clem and Erik Herron, “Attacks on Healthcare Infrastructure in the Donbas: Implications for Ukrainian State Legitimacy,” PONARS Eurasia (January 11, 2019), https://www.ponarseurasia.org/attacks-on-healthcare-infrastructure-in-the-donbas-implications-for-ukrainian-state-legitimacy/. 

[41] Cynthia J. Buckley, Ralph S. Clem and Erik Herron, “Attacks on Healthcare Infrastructure in the Donbas: Implications for Ukrainian State Legitimacy,” PONARS Eurasia (January 11, 2019), https://www.ponarseurasia.org/attacks-on-healthcare-infrastructure-in-the-donbas-implications-for-ukrainian-state-legitimacy/. 

[42] “Impunity Must End: Attacks on Health in 23 Countries in Conflict in 2016,” Safeguarding Health in Conflict Coalition, 2017, p. 11,  https://www.safeguardinghealth.org/sites/shcc/files/SHCC2017final.pdf.

[43]  Events 35991, 35723, 35826. According to reports from Ukrainian military intelligence,patients from the regional tuberculosis hospital in Vovchansk (Kharkivska oblast) have been turned out and buildings have instead been filled with wounded Russian soldiers, with the medical personnel forced to care for them (https://t.me/DIUkraine/433). Ukrainian medical personnel from the Central District Hospital in Polohy (Zaporizka oblast) have been prevented from treating civilians while Russian forces instead use the hospital premises as a warehouse for ammunition (https://t.me/DIUkraine/433). According to the Luhansk Regional Military Administration, at least three hospitals in Luhanska oblast are being used to treat Russian soldiers (https://t.me/luhanskaVTSA/7961). Media reports suggest the civilian population in Mariupol is being denied care. https://suspilne.media/355930-v-mariupoli-zrosla-zahvoruvanist-likarni-perepovneni-andrusenko/.

[44] Public Health Center of the Ministry of Health of Ukraine, https://apps.who.int/iris/bitstream/handle/10665/365564/WHO-EURO-2023-6904-46670-67870-eng.pdf?sequence=1&isAllowed=y.

[45] See “Catch-up polio immunization campaign to begin in Ukraine,” WHO Europe, January 27, 2002, https://www.who.int/europe/news/item/27-01-2022-catch-up-polio-immunization-campaign-to-begin-in-ukraine. 

[46] Analysis conducted by UHC (on-file). 

[47] “Health needs assessment of the adult population in Ukraine: Survey report,” World Health Organization – European region, September 2022, p. 20,  https://apps.who.int/iris/bitstream/handle/10665/365564/WHO-EURO-2023-6904-46670-67870-eng.pdf?sequence=1&isAllowed=y.

[48] “Ukraine Internal Displacement Report—General Population Survey Round 11,” International Organization for Migration (25 November-5 December 2022), p. 11, https://dtm.iom.int/reports/ukraine-internal-displacement-report-general-population-survey-round-11-25-november-5.

[49] Oleksii Sukhovii, Olga Khan, Olena Doroshenko, and Vrishali Shekhar, “The Cost of Mental Health in Ukraine: The Review of Privately and Publicly Procured Medicines and Dietary Supplements (2015-2019),” World Bank (2022), https://openknowledge.worldbank.org/handle/10986/38122.

[50] “Ukraine’s mental health crisis could impact generations to come. Here’s how the country is responding,” World Economic Forum, October 9, 2022, https://www.weforum.org/agenda/2022/10/ukraine-mental-health-crisis-world-mental-health-day/.

[51] Yurii Korogodskyi, “The number of veterans may increase to 5 million people,” May 8, 2022, https://lb.ua/society/2022/05/08/516086_kilkist_veteraniv_mozhe.html.

[52] See for instance Lorenzo Tondo, “‘Very similar’: fears gateway city to Donbas will become another Bucha,” The Guardian, April 18, 2022, https://www.theguardian.com/world/2022/apr/18/bucha-izyum-fears-gateway-city-donbas-russia-ukraine; Thomas Gibbons-Neff and Marc Santora, “Ukrainian Offensive Seen as Reshaping the War’s Contours,” The New York Times, September 10, 2022, https://www.nytimes.com/2022/09/10/world/europe/ukraine-offensive-izium-donbas.html.

[53] Pavlo Bakhura, “No safe way out of Izyum: ‘I Can’t Imagine How it Will End’,” The Guardian, April 4, 2022, https://www.theguardian.com/world/2022/apr/04/izyum-ukraine-shelling-russian-soldiers; Maksym Strelnyk, Facebook, March 8, 2022, https://www.facebook.com/max.strel.9/posts/1712768382263714. 

[54] Pavlo Bakhura, “No safe way out of Izyum: ‘I can’t imagine how it will end’,” The Guardian, April 4, 2022.

[55] Thomas Gibbons-Neff and Marc Santora, “Ukrainian Offensive Seen as Reshaping the War’s Contours,” The New York Times, September 10, 2022, https://www.nytimes.com/2022/09/10/world/europe/ukraine-offensive-izium-donbas.html; “Izium and Balakliia after liberation from Russian occupation – in pictures,” The Guardian, September 21, 2022, https://www.theguardian.com/world/gallery/2022/sep/21/ukraine-izium-and-balakliia-after-liberation-from-russian-occupation-in-pictures.

[56] Dan Bilefsky and Edward Wong, “Izium Discoveries Renew Focus on Holding Russia Accountable for Civilian Toll,” New York Times, September 17, 2022, https://www.nytimes.com/2022/09/17/world/europe/izium-graves-russia-war-crimes.html. See also Pavlo Bakhura, “No safe way out of Izyum: ‘I can’t imagine how it will end’,” The Guardian, April 4, 2022, https://www.theguardian.com/world/2022/apr/04/izyum-ukraine-shelling-russian-soldiers.

[57] Sasha Solovei, “History of the Pishchanska Bohomatir Izium Central City Hospital,” Izium Informatsiinyi, December 27, 2022, https://city-izyum.pp.ua/history-of-the-izyum-central-city-hos/.

[58] Sasha Solovei, “History of the Pishchanska Bohomatir Izium Central City Hospital,” Izium Informatsiinyi, December 27, 2022, https://city-izyum.pp.ua/history-of-the-izyum-central-city-hos/.

[59] Sasha Solovei, “History of the Pishchanska Bohomatir Izium Central City Hospital,” Izium Informatsiinyi, December 27, 2022, https://city-izyum.pp.ua/history-of-the-izyum-central-city-hos/.

[60] “The Emergency Department is Being Renovated at the Izium Central City Hospital,” Kharkiv Region Military Administration, February 11, 2021, https://kharkivoda.gov.ua/news/107072; “New CT scanner delivered to Izyum Central City Hospital,” Izium Informatsiiny, April 4, 2021, https://city-izyum.pp.ua/a-new-computed-tomograph-was-brought-to-the-izyum-central-city-hospital101/.

[61] Office of the Prosecutor General, Telegram, March 3, 2022, https://t.me/pgo_gov_ua/3025.

[62] Suspilne Kharkiv, Telegram, March 2, 2022, https://t.me/suspilnekharkiv/8594; Suspilne Kharkiv, Telegram, March 2, 2022, https://t.me/suspilnekharkiv/8597; Verkhovna Rada of Ukraine – Ukrainian Parliament, Twitter, March 3, 2022, https://twitter.com/ua_parliament/status/1499184974213357571?lang=en.

[63] “Number of Victims from Airstrike in Izyum Increases: Serious Damage in the City,” Pravda,March 3, 2022, https://www.pravda.com.ua/eng/news/2022/03/3/7327625/. 

[64] Suspilne News, Twitter, March 3, 2022, https://twitter.com/suspilne_news/status/1499279121410662406.

[65] “Number of Victims from Airstrike in Izyum Increases: Serious Damage in the City,” Pravda,March 3, 2022, https://www.pravda.com.ua/eng/news/2022/03/3/7327625/; “Russia Launches an Airstrike on Izium at Night, Children among the Dead,” Rubryka, March 3, 2022, https://rubryka.com/en/2022/03/03/rosiya-vnochi-nanesla-aviaudar-po-izyumu-sered-zagyblyh-dity/. The police department caught fire, a school was damaged, and the city council’s windows were shattered. See Office of the Prosecutor General, Telegram, March 3, 2022, https://t.me/pgo_gov_ua/3025; Suspilne Kharkiv, Telegram, March 3, 2022, https://t.me/suspilnekharkiv/8608; Suspilne News, “Aerial Bombardment of Izyum in the Kharkiv Region: The Prosecutor’s Office has Started Criminal Proceedings, March 4, 2022, https://suspilne.media/213576-izum-m/. 

[66] Interview with Dr. Bohdan Berezhnyi, UHC, November 18, 2022 (on-file).

[67] Suspilne Kharkiv, Telegram, March 6, 2022, https://t.me/suspilnekharkiv/8860. Lester W Grau and Charles K Bartles, “Getting to Know the Russian Battalion Tactical Group,” RUSI,April 14, 2022, https://rusi.org/explore-our-research/publications/commentary/getting-know-russian-battalion-tactical-group: A battalion tactical group is a “semi-permanent task force … capable of conducting deep raids, envelopment and flanking manoeuvres.” According to Nicolas J. Fiore, a captain in the US Army, “[w]hen possible, the BTG commander will employ his strike assets to cause casualties to pressure his opponent to negotiate a settlement … To preserve combat power, BTGs employ a force of local paramilitary units as proxy forces to secure terrain and guard the BTG from direct and indirect attack.” CPT Nicolas J. Fiore, “Defeating the Russian Battalion Tactical Group,” U.S. Army Fort Benning and the Maneuver Center of Excellence,2017, https://www.benning.army.mil/armor/earmor/content/issues/2017/spring/2Fiore17.pdf.

[68] Suspilne Kharkiv, Telegram, March 7, 2022, https://t.me/suspilnekharkiv/9019.

[69] Interview with Dr. Bohdan Berezhnyi, UHC, November 18, 2022 (on-file).

[70] Suspilne Kharkiv, Telegram, March 7, 2022, https://t.me/suspilnekharkiv/8944.

[71] Suspilne Kharkiv, Telegram, March 8, 2022, https://t.me/suspilnekharkiv/9030.

[72] Suspilne Kharkiv, Telegram, March 8, 2022, https://t.me/suspilnekharkiv/9077; Maksym Strelnyk, Facebook, March 8, 2022, https://www.facebook.com/max.strel.9/posts/1712768382263714. 

[73] Information provided by weapons analyst (on-file).

[74] Interview with Dr. Bohdan Berezhnyi, UHC, November 18, 2022 (on-file).

[75] Interview with Dr. Bohdan Berezhnyi, UHC, November 18, 2022 (on-file).

[76] Volodymyr Matsokin, Facebook, March 8, 2022, https://www.facebook.com/volodymyr.matsokin/posts/7675042065901336. See also Suspilne Kharkiv, Telegram, March 8, https://t.me/suspilnekharkiv/9057; Russian Troops Destroy Central Hospital in Izyum, Kharkiv Oblast,” Kyiv Independent, March 8, 2022; https://kyivindependent.com/uncategorized/russian-troops-destroy-central-hospital-in-izyum-kharkiv-oblast.

[77] See Jim Reed, “Ukraine War: WHO says Attacks on Health Facilities are Rising Daily,” BBC News, March 26, 2022, https://www.bbc.co.uk/news/health-60866669.

[78] Interview with Dr. Berezhnyi, UHC, November 18, 2022 (on-file).

[79] Suspilne Kharkiv, Telegram, March 8, 2022, https://t.me/suspilnekharkiv/9076.

[80] Volodymyr Matsokin, Facebook, March 8, 2022, https://www.facebook.com/volodymyr.matsokin/posts/7675042065901336.

[81] Interview with Dr. Berezhnyi, UHC, November 18, 2022 (on-file). The dates mentioned by Dr. Berezhnyi in his interview with UHC do not always appear to be fully accurate. They were compared with other evidence collected by UHC during their site visit and open-source information.

[82] See e.g. Suspilne Kharkiv, Telegram, March 9, 2022, https://t.me/suspilnekharkiv/9135; Suspilne Kharkiv, Telegram, March 10, 2022, https://t.me/suspilnekharkiv/9216; Suspilne Kharkiv, Telegram, March 11, 2022, https://t.me/suspilnekharkiv/9259.

[83] Interview with Dr. Berezhnyi, UHC, November 18, 2022 (on-file).

[84] “Ukraine: Beleaguered town of Izium at breaking point after constant attack from Russian forces – new testimony,” Amnesty International, March 16, 2022, https://www.amnesty.org/en/latest/news/2022/03/ukraine-beleaguered-town-of-izium-at-breaking-point-after-constant-attack-from-russian-forces-new-testimony/.

[85] Centre for Information resilience, Twitter, March 25, 2022, https://twitter.com/Cen4infoRes/status/1507382359867465731/photo/1.

[86] Information provided by weapons analyst (on-file).

[87] Information provided by weapons analyst (on-file).

[88] “Ukraine: Banned Landmines Harm Civilians” Human Rights Watch, January 31, 2023, https://www.hrw.org/news/2023/01/31/ukraine-banned-landmines-harm-civilians. See also Truth Hounds, “On the use of anti-personnel mines,” February 2, 2023, https://truth-hounds.org/en/shchodo-vykorystanna-protypikhotnykh-min/.

[89] “Ukraine: Banned Landmines Harm Civilians” Human Rights Watch, January 31, 2023, https://www.hrw.org/news/2023/01/31/ukraine-banned-landmines-harm-civilians.

[90] Oleg Synyehubov, Facebook, December 15, 2022, https://www.facebook.com/synegubov.official/posts/pfbid0323NXrmX45AfY6rkCdWeT7nA6JRnGgQ5TgaexR8QHJhF95hbA8mG5gvcbo23FFpZ7l.

^[91] Head of the Makariv City Council Vadym Tokar, “Let’s Rebuild Together!,” accessed January 25, 2023, https://new.makariv-rada.gov.ua/help/. From 15,000 residents living in the town, less than 1,000 left during the active phase of the Russian offensive. See “In Makariv near Kyiv, the occupiers shot 132 people – the village head,” New Voice of Ukraine, April 8, 2022, https://nv.ua/ukr/kyiv/makariv-rosiyski-okupanti-vbili-132-miscevih-zhitelya-novini-kiyeva-50232318.html.

[92] See Frederick W. Kagan et al., “Russian Offensive Campaign Assessment, March 1,” Institute for the Study of War,March 1, 2022, https://www.understandingwar.org/backgrounder/russian-offensive-campaign-assessment-march-1: “Social media users report Russian tanks present in Makariv, a town on that ring road approximately 30 miles west of the center of Kyiv. The presence of Russian mechanized forces at Makariv suggests that the Russians intend to conduct a relatively deep envelopment of Kyiv, possibly following roads south as far as Fastiv before turning east, although they could choose avenues of approach to the capital further east.” See also Igor Girkin, March 1, 2022, Twitter, https://twitter.com/GirkinGirkin/status/1498664725978173446 (showing tanks reportedly driving through Makariv on February 28, 2022).

^[93] Police of the Kyiv Region, Facebook, March 12, 2022, https://www.facebook.com/pol.kyivregion/posts/333708318793491.

^[94]  “Air strike in Makariv, Kyiv region: 13 people were killed,” Radio Svoboda, March 7, 2022,  https://www.radiosvoboda.org/a/news-aviaudar-makariv/31741485.html. Reports by local authorities also emerged suggesting that at least 132 civilians were shot by Russian troops. Evgenia Lutsenko, “132 shot dead civilians were found in Makarov, Kyiv region, the village head,” Hromadske, April 8, 2022, https://hromadske.ua/posts/u-makarovi-na-kiyivshini-znajshli-132-rozstrilyanih-civilnih-selishnij-golova.

^[95] “Communal Non-Profit Enterprise ‘Makariv Multiprofile Intensive Care Hospital’ of the Makariv Settlement Council,” Makariv Settlement Council, accessed January 6, 2023, https://makariv-crl.itmed.org/.

^[96] Serhiy Solomenko, “How the Makariv Dispensary, Destroyed by the Russians, gets a New Life,” UkrInform, October 7, 2022, https://www.ukrinform.ua/rubric-regions/3588113-ak-zrujnovana-rosianami-makarivska-ambulatoria-otrimue-nove-zitta.html.

[97] Serhiy Solomenko, “How the Makariv Dispensary, Destroyed by the Russians, gets a New Life,” UkrInform, October 7, 2022, https://www.ukrinform.ua/rubric-regions/3588113-ak-zrujnovana-rosianami-makarivska-ambulatoria-otrimue-nove-zitta.html.

[98] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[99] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[100] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[101] Sarah Rainsford, “When an Ambulance Drove Out… the Russians Shot Right at It,” BBC, May 5, 2022,  https://www.bbc.co.uk/news/live/world-europe-61330132. Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file). Note that the special protection afforded to hospitals and other medical units ceases when they are, for example, used as a shelter for able-bodied combatants, as an arms or ammunition dump, or as a military observation post. See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, para. 551, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined. In such case, the hospital becomes a legitimate military objective. However, Additional Protocol I, Art. 13 makes it clear that the loss of protection is not instantaneous; it may only cease “after a warning has been given setting, whenever appropriate, a reasonable time-limit, and after such warning has remained unheeded.”

[102] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[103] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[104] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[105] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[106] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, p. 29, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[107] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, p. 30, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[108] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, p. 30, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[109] Makariv Multiprofile Intensive Care Hospital, Facebook, March 22, 2022, https://www.facebook.com/hospital.makariv.adm/posts/496469798729539.

[110] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file). Note that Dr. Solomenko had been evacuated at the time of the March 28, 2022 strike, and reported the incident based on a discussion he had with a member of Ukraine’s Territorial Defense Forces who witnessed the attack.

[111] The estimated cost of the Primary Care Clinic’s loss of equipment is around 2.5 million Ukrainian hryvnias (approximately 68,000 US dollars). Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[112] See Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, Facebook, May 15, 2022, https://www.facebook.com/watch/?v=559894918897841.

[113] Information provided by weapons analyst (on-file). The BM-21 Grad is a multi-launch rocket system designed to be inaccurate, firing a salvo of up to 40 rockets in less than 20 seconds to saturate an area and damage as many targets as possible. The BM-21 Grad is deployed at the lowest tactical levels of the Russian military. Orders to fire are normally given by officers at the level of Major and likely at the level of Captain. Information provided by weapons analyst (on-file). See also Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/. 

[114] “KSE Foundation will restore a local hospital in Makariv (Kyiv region),” Kyiv School of Economics, May 30, 2022, https://kse.ua/about-the-school/news/kse-foundation-will-restore-a-local-hospital-in-makariv-kyiv-region/.

[115] Head of the Kyiv Regional Military Oleksyi Kuleba, Telegram, July 10, 2022, https://t.me/OleksiyKuleba/1953.

[116] Makariv Multiprofile Intensive Care Hospital, Facebook, September 29, 2022,  https://www.facebook.com/hospital.makariv.adm/posts/pfbid02fNfLkEV1qBu6FNLbFaxaDMkBsGDa7ZhAWgLfnqxu5arSLECq8T5B915YwaQAZfFhl.

[117] Interview with a representative of the Makariv Multiprofile Intensive Care Hospital [anonymous], UHC, January 26, 2023, (on-file).

^[118] “Summary,” Treatment and diagnostic center Adonis-Makariv, accessed January 6, 2023, https://adonismakariv.business.site/. The construction cost was almost 13 million UAH. The clinic was built according to high energy-effective and eco-friendly standards. Most of its walls were constructed from wood, which is one of the reasons that a massive fire broke out after the clinic was struck.

^[119] Paul P. Murphy, “Significant Destruction Seen in Makariv, a Ukrainian Village 30 Miles West of Kyiv,” CNN, March 12, 2022, https://edition.cnn.com/europe/live-news/ukraine-russia-putin-news-03-12-22/h_2ee0ca37b6577f631528c18edcf80e6d.

^[120] Paul P. Murphy, “Significant Destruction Seen in Makariv, a Ukrainian Village 30 Miles West of Kyiv,” CNN, March 12, 2022, https://edition.cnn.com/europe/live-news/ukraine-russia-putin-news-03-12-22/h_2ee0ca37b6577f631528c18edcf80e6d.

[121] Interview with Dr. Serhiy Solomenko, UHC, December 13, 2022 (on-file).

[122] Denys Shaposhnikov, “How did the first battles around Chernihiv take place and what significance did the city have for the Russians?,” Suspilne, December 5, 2022, https://suspilne.media/327410-ak-vidbuvalis-persi-boi-navkolo-cernigova-ta-ake-znacenna-malo-misto-dla-rosian/.

[123] Ashleigh Stewart, “The Siege of Chernihiv: Residents Recount Five Weeks of Horror under Russian Terror,” Global News, May 4, 2022, https://globalnews.ca/news/8808055/chernihiv-ukraine-war-aftermath/; General Staff of the Armed Forces of Ukraine, Facebook, March 18, 2022, https://www.facebook.com/GeneralStaff.ua/posts/275463534766732: “In the Chernihiv region, [R]ussian occupiers are intimidating locals to quell civilian resistance.”

[124] Joshua Yaffa, “The Siege of Chernihiv,” The New Yorker, April 15, 2022, https://www.newyorker.com/news/dispatch/the-siege-of-chernihiv.

[125] “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv. 

[126] Notes of site visit, UHC, July 14-15, 2022 (on-file); Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, p. 46, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[127] Oleksandra Balandyukh, “God, Don’t Let Anyone Experience This,” Zaxid, May 10, 2022, https://zaxid.net/ne_day_bozhe_nikomu_take_perezhiti_n1542483. See also “Operational information on the occupancy of beds in health care institutions of the Chernihiv oblast designated for hospitalization of patients with a confirmed case of COVID-19” (updated February 8, 2022), Chernihiv Oblast State Administration, accessed January 6, 2023, https://ssd.cg.gov.ua/index.php?id=31676&tp=1.  

[128] “Comfortable Beds for Patients. Chernihiv Regional Children’s Hospital Received Help from Benefactors,” Chernihiv City, January 14, 2022, https://chernihiv.city/articles/189182/zruchni-lizhka-dlya-paciyentiv-chernigivska-oblasna-dityacha-likarnya-otrimala-dopomogu-vid-blagodijnikiv.

[129] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[130] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file). According to Dr. Liutkevych, there were 200 people sheltering in the hospital.

[131] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[132] “Ukraine: Russian Air-Dropped Bombs Hit Residential Area,” Human Rights Watch, March 10, 2022, https://www.hrw.org/news/2022/03/10/ukraine-russian-air-dropped-bombs-hit-residential-area; Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/.

[133] Notes of site visit, UHC, July 14-15, 2022 (on-file); Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, pp. 31-32, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[134] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[135] Human Rights Watch, “Ukraine: Russian Air-Dropped Bombs Hit Residential Area,” March 10, 2022, https://www.hrw.org/news/2022/03/10/ukraine-russian-air-dropped-bombs-hit-residential-area.

[136] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[137] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[138] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[139] “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv.

[140] Reports differ as to the date of the strike on City Hospital #2. See e.g. Ari Daniel, “Doctors in Chernihiv Bear Witness to their Hospital’s Fate after Russian Shelling,” NPR, April 7, 2022, https://www.npr.org/sections/goatsandsoda/2022/04/07/1091333939/doctors-in-chernihiv-bear-witness-to-their-hospitals-fate-after-russian-shelling (reporting that the strike occurred on March 16, 2022);“Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv (reporting that the strike occurred on March 17, 2022).

[141] According to eyewitnesses, explosions occurred sometime between 9:00 and 11:00 am on March 17, 2022. See Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, pp. 44-45, https://uhc.org.ua/en/2022/09/15/report-by-uhc/. This information was also confirmed by Truth Hounds, a Ukrainian organization that documents war crimes and crimes against humanity in the war contexts since 2014, following a confidential investigation into the attack, including through interviews with eyewitnesses.

[142] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file); “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv.

[143] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[144] These figures are confirmed by Truth Hounds, a Ukrainian organization that documents war crimes and crimes against humanity in the war contexts since 2014, following a confidential investigation into the attack, including through interviews with eyewitnesses. See also “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch, June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv; also “End Cluster Munition Attacks in Ukraine,” Human Rights Watch, May 11, 2022, https://www.hrw.org/report/2022/05/11/intense-and-lasting-harm/cluster-munition-attacks-ukraine. A doctor who spoke with Human Rights Watch said that there were at least 20 patients inside the hospital at the time of the attack. See “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv. Most patients had remained in the hospital’s shelter after the previous air raid siren. However, some people, largely from neighboring areas who were sheltering in the hospital, were outside seeking warmth from the sun. Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[145] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[146] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[147] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file): “[T]here was no military equipment anywhere. There’s a morgue not far from us. The military brought and took their dead from there. We told them that [we have] children [here], urging them to leave, and they said “yes, no problem”, but they didn’t stay, of course, they didn’t stay, nothing like this happened.

[148] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file). Note that the special protection afforded to hospitals and other medical units does not cease when it is guarded by pickets, sentries, or an escort made up of soldiers or civilian uniformed police force. The mere presence of guards shelters them from attacks as they have no offensive role to play and are only there to protect the sick and wounded. See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 565-68, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

[149] “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch,June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv. 

[150] Like the BM-21 Grad, the BM-27 Uragan is designed to be inaccurate. The BM-27 Uragan was designed to fire a heavier warhead than the older and smaller BM-21 Grad. The BM-27 Uragan can fire 16 220 mm rockets within a range of up to 35 kilometers. Six different warheads are available for its rockets including high explosive, incendiary, chemical, a variety of ‘cargo’ modules that carry anti-material cluster munitions as well as more conventional scatterable anti-personnel and anti-armor mines. Each cargo module can carry about 30 munitions. The BM-27 Uragan is normally deployed at the level of rocket artillery regiments. Orders to fire are generally only given by relatively senior commanders of Colonel level and above. Information provided by weapons analyst (on-file). See also Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/: BM-27 Uragan can launch 16 220 mm rockets, which have a range of 34 kilometers.

[151] “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch, June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv.

[152] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[153] “Ukraine: Russian Strikes Killed Scored of Civilians in Chernihiv,” Human Rights Watch, June 10, 2022, https://www.hrw.org/news/2022/06/10/ukraine-russian-strikes-killed-scores-civilians-chernihiv. See also “End Cluster Munition Attacks in Ukraine,” Human Rights Watch, May 11, 2022, https://www.hrw.org/report/2022/05/11/intense-and-lasting-harm/cluster-munition-attacks-ukraine: “Clearance teams destroyed the remnants of an Uragan cluster munition rocket and four unexploded 9N210 submunitions remaining from the attack.”

[154] Victoria Zhuhan and Clair Pres, “‘Everything around began to explode.’ The BBC’s investigation into the cluster bombardment in Chernihiv,” BBC, June 27, 2022, https://www.bbc.com/ukrainian/features-61908780.

[155] Notes of site visit, UHC, July 14-15, 2022 (on-file).

[156] See Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/: BM-27 Uragan can launch 16 220 mm rockets, which have a range of 34 kilometers.

[157] Suspilne, Facebook, July 6, 2022, https://www.facebook.com/suspilne.chernihiv/photos/pcb.5020472224742229/5020470618075723 (map as of March 6-22) See also Hugo Bachega and Orysia Khimiak, “In Chernihiv, Civilians are Trapped as Hospitals and Schools Attacked,” BBC, March 28, 2022, https://www.bbc.co.uk/news/world-europe-60860197 (map as of March 26).

[158] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[159] Ukraine Weapons Tracker, Twitter, March 1, 2022, https://twitter.com/UAWeapons/status/1498757834087051270.

[160] Daniel McLaughlin, “’We hit them with everything we had’: Ukrainian town fights off the Russians,” The Irish Times, April 29, 2022, https://www.irishtimes.com/news/world/europe/we-hit-them-with-everything-we-had-ukrainian-town-fights-off-the-russians-1.4865429; “Russia Ukraine War Day 7 | Russian troops attack Bashtanka in Ukraine,” CNN News18, March 2, 2022, https://www.msn.com/en-in/video/news/russia-ukraine-war-day-7-russian-troops-attack-bashtanka-in-ukraine-cnn-news18-latest-news/vi-AAUuPoY; Interview with Dr. Alla Barsehian, UHC, December 17, 2022 (on-file). Tochka-U are ground-based ballistic missile system that can be fitted with conventional, chemical, nuclear or cluster munitions. “Tochka-U missiles, which are out of production, are not used as frequently due to their shorter range (120km), but they have had deadly consequences for parts of Ukraine neighbouring Russian-occupied regions. Able to stray 150m off target, these indiscriminate missiles also pose a real threat to civilians when fired at populated areas.” In this sense, see Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/. 

[161] “KNP Bashtanka Multiprofile Hospital,” Bashtanka City Council, Mykolaiv oblast, accessed January 6, 2023, https://xn--80aaab1cr7azc.xn--k1ajr.xn--j1amh/vid-istorii-do-sohodennia/.

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

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

[164] Information provided by weapons analyst (on-file).

[165] Daniel McLaughlin, “‘We hit them with everything we had’: Ukrainian town fights off the Russians,” The Irish Times, April 29, 2022, https://www.irishtimes.com/news/world/europe/we-hit-them-with-everything-we-had-ukrainian-town-fights-off-the-russians-1.4865429.

[166] Interview with Dr. Alla Barsehian, UHC, December 17, 2022 (on-file). The doctor explains that at the beginning of March, the hospital served as a “first-line” hospital due to its proximity to the frontline, but as the fighting progressed they became a “second-line” hospital. Ibid. Note that the special protection afforded to hospitals and other medical units does not cease when members of the armed forces are in the hospital or unit for medical reasons. See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 571-74, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

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

[168] Information provided by weapons analyst (on-file). The identification of the type of missile is based on the munition remains shown in the following video: “Ukraine War: Hospital destroyed by Russian missile in southern Ukraine,” Sky News, April 22, 2022, https://www.youtube.com/watch?v=ff1eF2JSfnE. According to Action On Armed Violence, an organization conducting research and advocacy on the incidence and impact of global armed violence, “[t]he Kalibr missile is Russia’s most advance cruise missile, and has ship-launched, submarine-launched, and air-launched versions.” Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/.

[169] Information provided by weapons analyst (on-file).

[170] Information provided by weapons analyst (on-file).

[171] Information provided by weapons analyst (on-file).

[172] Information provided by weaponsanalyst (on-file); Joely Thomas and Chiara Torelli, “Russia’s Dirty Dozen: An Examination of Russian Explosive Weapons Used in Ukraine,” Action On Armed Violence, January 18, 2023, https://aoav.org.uk/2023/russias-dirty-dozen/. 

[173] A polyclinic is a clinic or health care facility that provides both general and specialist examinations and treatments for a wide variety of diseases and injuries to outpatients.

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

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

[176] Anastasiya Zubova, “Healthcare Under Fire: Russian Troops Destroy Medical Facilities in the Mykolaiv Region,” Bihus, July 11, 2022, https://bihus.info/healthcare_under_fire_russian_troops_destroy/.

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

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

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

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

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

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

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

[184] Anastsasiya Zubova, “Healthcare Under Fire: Russian Troops Destroy Medical Facilities in the Mykolaiv Region,” Bihus, July 11, 2022, https://bihus.info/healthcare_under_fire_russian_troops_destroy/.

[185] Interview with Dr. Alla Barsehian, UHC, December 17, 2022 (on-file). See also TPYXA, Twitter, April 20, 2022, https://twitter.com/TpyxaNews/status/1516659728146857986?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1516659728146857986%7Ctwgr%5E840bccaf8182ea9931c9ebc8e09337d10045f9ec%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Feyesonrussia.org%2Fevent%2Fevent_3199_1650409200000 (video verified by Bellingcat and reviewed by Center for Information Resilience, see https://eyesonrussia.org/).

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

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

[188] Daniel McLaughlin, “‘We hit them with everything we had’: Ukrainian town fights off the Russians,” The Irish Times, April 29, 2022, https://www.irishtimes.com/news/world/europe/we-hit-them-with-everything-we-had-ukrainian-town-fights-off-the-russians-1.4865429.

[189] Daniel McLaughlin, “‘We hit them with everything we had’: Ukrainian town fights off the Russians,” The Irish Times, April 29, 2022, https://www.irishtimes.com/news/world/europe/we-hit-them-with-everything-we-had-ukrainian-town-fights-off-the-russians-1.4865429.

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

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

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

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

[194] Thomas Gibbons-Neff, Natalia Yermak, “This is True Barbarity: Life under Russian Occupation,” New York Times, April 3, 2022, https://www.nytimes.com/2022/04/03/world/europe/ukraine-war-russia-trostyanets.html.

[195] Christopher Reuter, “A Visit to Trostyanets After the End of the Occupation,” Der Spiegel, March 30, 2022, https://www.spiegel.de/international/europe/liberated-from-the-russians-a-visit-to-trostyanets-after-the-end-of-the-occupation-a-c088be53-5f6c-4059-8d46-68803276e473.

[196] Thomas Gibbons-Neff, Natalia Yermak, “This is True Barbarity: Life under Russian Occupation,” New York Times, April 3, 2022, https://www.nytimes.com/2022/04/03/world/europe/ukraine-war-russia-trostyanets.html. One resident, Dr. Volkova, reported that, “They would not give us any green corridors, they searched the apartments, took away the phones, abducted people — they took them away, mostly young men, and we still don’t know where these people are.” Ibid.

[197] Dmytro Synyak, “‘The Russians Turned the Whole City into an Entire Wound…’ Interview with the Mayor of Trostyanets,” Decentralization, June 27, 2022, https://decentralization.gov.ua/en/news/14726.

[198] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, p. 25, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[199] “Russian Occupation Leaves Scars on Trostyanets,” Deutsche Welle,  July 2, 2022, https://www.dw.com/en/russian-occupation-leaves-scars-on-trostyanet/video-62136969; Notes of site visit, UHC, August 11, 2022 (on-file).

[200] Thomas Gibbons-Neff, Natalia Yermak, “This is True Barbarity: Life under Russian Occupation,” New York Times, April 3, 2022, https://www.nytimes.com/2022/04/03/world/europe/ukraine-war-russia-trostyanets.html.

[201] Notes of site visit, UHC, August 11, 2022 (on-file).

[202] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[203] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[204] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file); Notes of site visit, UHC, August 11, 2022 (on-file). See also Dmytro Zhyvytskyi, Telegram, March 19, 2022, https://t.me/Zhyvytskyy/1260.

[205] The doctor identified the Russian officer by name. Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[206] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[207] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[208] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[209] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[210] Franco Ordoñez, Olena Lysenko, “Ukrainian Doctors Describe Delivering Babies as Russia Shelled the Hospital,” NPR, April 26, 2022, https://www.knkx.org/2022-04-26/ukrainian-doctors-describe-delivering-babies-as-russia-shelled-the-hospital.

[211] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, pp. 25-27, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[212] Both T-72 and T-80 tanks were reportedly used to hit the Trostianets City Hospital, possibly at different dates. See Office of the Prosecutor General of Ukraine, “Another Russian serviceman who ordered to shell the Trostianetska hospital from a tank has been identified,” August 17, 2022, https://www.gp.gov.ua/ua/posts/vstanovleno-shhe-odnogo-viiskovosluzbovcya-rf-yakii-viddav-nakaz-obstrilyuvati-z-tanka-trostyanecku-likarnyu (identifying a T-80 tank); State Bureau of Investigation of Ukraine, “The SBI Identified Russian Service Members who, with Tanks, were Firing at a Hospital in Trostyanets,” May 5, 2022, https://dbr.gov.ua/en/news/dbr-vstanovilo-vijskovosluzhbovciv-rf-yaki-z-tankiv-rozstrilyuvali-likarnyu-v-trostyanci (identifying a T-72 tank). The T-80 tank is a cheaper and more reliable version of the T-72 tank; both of which have been reportedly used to equip Russian elite units in the 2022 conflict in Ukraine. The T-80 uses the same 125 mm 2A46 smoothbore gun as the T-72, which can fire regular high explosive (4,000-meter range) and armor piercing shells (3,000-meter range) as well as the 9M119 ‘Svir’ anti-tank guided missile (5,000-meter range). The T-80 and T-72 tanks use similar sighting systems from the 1970s and are, therefore not as accurate as those of modern NATO armored vehicles. Information provided by weapons analyst (on-file).

[213] “Russian Occupation Leaves Scars on Trostyanets,” Deutsche Welle,  July 2, 2022, https://www.dw.com/en/russian-occupation-leaves-scars-on-trostyanet/video-62136969; “Locals look to rebuild their lives in liberated Trostianets,” The Irish Times, March 31, 2022, https://www.irishtimes.com/news/world/europe/locals-look-to-rebuild-their-lives-in-liberated-trostianets-1.4841334; Dzerkalo Tyzhnia, Telegram, August 17, 2022, https://t.me/znua_live/51689. According to the town head of Trostianets Yuri Bova “[o]n the 23rd of March, there were two tanks. They drove out to the street and began to fire directly at the hospital.” “Having Seen the Conditions in the Trostianets Hospital, the Invaders Began to Shoot at It with a Tank,” Television Service of News, April 17, 2022, https://tsn.ua/en/ato/having-seen-the-conditions-in-the-trostianets-hospital-the-invaders-began-to-shoot-at-it-with-a-tank-2039266.html. The State Bureau of Investigations mentions several tanks surrounding the hospital and opening fire. See State Bureau of Investigations, Telegram, 20 May, 2022, https://t.me/DBRgovua/2508. There is also unsourced footage of a tank firing directly at a building that matches the features of the hospital: Pavlo Kovtoniuk, Twitter, April 2, 2022, https://twitter.com/pavlokovtonyuk/status/1510163664061480968.

[214] Notes of site visit, UHC, August 11, 2022 (on-file).

[215] Notes of site visit, UHC, August 11, 2022 (on-file).

[216] “Ukraine war: Medic’s shock over Russian tank hospital hit,” BBC, May 18, 2022, https://www.bbc.co.uk/news/uk-england-leicestershire-61485495. See also Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[217] Office of the Prosecutor General of Ukraine, “Another Russian serviceman who ordered to shell the Trostianetska hospital from a tank has been identified,” August 17, 2022, https://www.gp.gov.ua/ua/posts/vstanovleno-shhe-odnogo-viiskovosluzbovcya-rf-yakii-viddav-nakaz-obstrilyuvati-z-tanka-trostyanecku-likarnyu.

[218] State Bureau of Investigation of Ukraine, “The SBI Identified Russian Service Members who, with Tanks, were Firing at a Hospital in Trostianets,” May 5, 2022, https://dbr.gov.ua/en/news/dbr-vstanovilo-vijskovosluzhbovciv-rf-yaki-z-tankiv-rozstrilyuvali-likarnyu-v-trostyanci; State Bureau of Investigation of Ukraine, “The SBI Put on the Wanted List the Russian Tankers who Shot the Local Hospital during the Occupation of Trostianets. The Repaired Tank ‘Takes Revenge’ on Former Owners for their Crimes,” October 24, 2022, https://dbr.gov.ua/en/news/dbr-ogolosilo-v-rozshuk-rosijskih-tankistiv-yaki-pid-chas-okupacii-trostyancya-rozstrilyali-miscevu-likarnyu.-vidremontovanij-tank-mstit-kolishnim-gospodaryam-za-zlochini.

[219] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[220] Notes of site visit, UHC, August 11, 2022 (on-file).

[221] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[222] Notes of site visit, UHC, August 11, 2022 (on-file).

[223] Notes of site visit, UHC, August 11, 2022 (on-file).

[224] Dmytro Zhyvytskyi Telegram, March 28, 2022, https://t.me/Zhyvytskyy/1443.

[225] India Today, Facebook, April 21, 2022, https://www.facebook.com/IndiaToday/videos/inside-a-hospital-in-trostyanets-sumy-region-of-ukraine/543236797447222/.

[226] Taras Kaidan et al., “A Ukrainian Mayor Looks at Life After Liberation,” Bloomberg, April 12, 2022, https://www.bloomberg.com/news/features/2022-04-12/ukraine-town-mayor-confronts-ruins-rebuilding-after-liberation.

[227] “Trostyanets Town Hospital,” United 24, accessed January 6, 2023, https://u24.gov.ua/needs/trostyanets_town_hospital.

[228] “The destroyed Trostyanets Hospital Resumes its Activities,” AAM, June 9, 2022, https://aam.com.ua/en/2022/06/09/the-destroyed-trostyanets-hospital-resumes-its-activities/.

[229] “The destroyed Trostyanets Hospital Resumes its Activities,” AAM, June 9, 2022, https://aam.com.ua/en/2022/06/09/the-destroyed-trostyanets-hospital-resumes-its-activities/; National Agency ZDOROVI, Instagram, April 28, 2022, https://www.instagram.com/p/Cc40DBmJjuL/.

[230] Alina Moh, “A German-Designed Mobile Hospital will be Built in Trostianets,” Pragmatika, September 26, 2022,https://pragmatika.media/en/news/u-trostjanci-sporudjat-mobilnu-likarnju-za-nimeckoju-rozrobkoju/.

[231] Geneva Convention IV, Art. 21.

[232] Additional Protocol I, Art. 21.

[233] Irina Venediktova, Facebook, February 26, 2022, https://www.facebook.com/irina.venediktova.31/posts/pfbid021AtYKbsbMAMBscx6fHmt2dm8sb42K3wBCMu6cTcoAS2fswEaJkJLW96WoxNo3BbBl; “Near Kherson, Russian Troops Overturned an Ambulance Carrying a Wounded Man,” UkrInform, February 26, 2022,https://www.ukrinform.ua/rubric-regions/3413928-pid-hersonom-rosijski-vijska-pidbili-svidku-aka-vezla-poranenih.html; “Civilian Toll Rises as Russians Enter Kherson,” Institute for War & Peace Reporting, March 1, 2022, https://iwpr.net/global-voices/civilian-toll-rises-russians-enter-kherson.

[234] Euromaidan Press, Twitter, February 26, 2022, https://twitter.com/EuromaidanPress/status/1497635178805698562?s=20&t=anX5wqUizRB5PIw4WCkYwQ.

[235] Victoria Bondarenko, “Shelling of an ‘Ambulance’ in Poltava Region: How it all Happened,” Suspilne, February 27, 2022,https://suspilne.media/211692-obstril-svidkoi-na-poltavsini-ak-use-stalosa/.

[236] Ihor Izotov, “‘Hadyatsky Safari’: Memories of Locals who Stopped the Russian Military in the North of Poltava Oblast,” Suspilne, July 11, 2022,https://suspilne.media/258713-gadacke-safari-spogadi-miscevih-aki-zupinali-rosijskih-vijskovih-na-pivnoci-poltavsini/.

[237] Victoria Bondarenko, “Shelling of an ‘Ambulance’ in Poltava Region: How it all Happened,” Suspilne, February 27, 2022,https://suspilne.media/211692-obstril-svidkoi-na-poltavsini-ak-use-stalosa/.

[238] Konstantin Shirokun, “Russian soldiers fired at the door to help on the way from Sumy to Kiev,” RBC-Ukraine, March 4, 2022, https://www.rbc.ua/ukr/news/rossiyskie-voennye-obstrelyali-skoruyu-pomoshch-1646384952.html; Insecurity Insight, “Violence Against or Obstruction of Health Care in Ukraine,” March 3-12, 2022, https://insecurityinsight.org/wp-content/uploads/2022/03/Violence-Against-or-Obstruction-of-Health-Care-in-Ukraine-03-12-March-2022.pdf.

[239] Konstantin Shirokun, “Russian soldiers fired at the door to help on the way from Sumy to Kiev,” RBC-Ukraine, March 4, 2022, https://www.rbc.ua/ukr/news/rossiyskie-voennye-obstrelyali-skoruyu-pomoshch-1646384952.html.

[240] Dmytro Zhyvytskyi, Facebook, March 4, 2022, https://www.facebook.com/Zhyvytskyy/posts/pfbid02iSLcjjvXB8hYh3o7cCsPbccq3rkNEXmCxNSQNjW4sHd8xGuy3tMY7qfq9xgPNRNsl.

[241] Yuriy Bova, Facebook, March 12, 2022, https://www.facebook.com/yura.bova.trostyanets/posts/pfbid0h5boWYaUmi3r32wwpJeEu7Bu63P94W8jzRuYo6MsEL5u1qUCo7357sQyVha84154l. See also Dmytro Zhyvytskyi, Telegram, March 13, 2022, https://t.me/Zhyvytskyy/1099. In an interview with UHC, a doctor confirmed this information: “In the first days of the occupation, there was an unreasonable instruction to accompany the green corridor column with an ambulance. Other ambulances (two or three) were stolen by Russians.” Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[242] Dmytro Zhyvytskyi, Telegram, March 4, 2022, https://t.me/Zhyvytskyy/768.

[243] Office of the Prosecutor General of Ukraine, Telegram, December 13, 2022, https://t.me/pgo_gov_ua/8099. See also Head of the Kharkiv Oblast Military Administration Oleg Synyehubov, Telegram, December 13, 2022, http://t.me/synegubov/5032. S-300 missiles are designed as anti-aircraft or anti-missile missiles. They are guided to their target by a separate ground-based radar array. However, when used against ground targets, S-300 missiles are not particularly accurate. Information provided by weapons analyst (on-file). See also “Factbox: What is the S-300 missile that is reported to have hit Poland?,” Reuters, November 16, 2022, https://www.reuters.com/world/europe/what-is-s-300-missile-that-is-reported-have-hit-poland-2022-11-16/: “The S-300 is a family of surface-to-air missiles, originally developed by the Soviet Union. S-300 missiles are intended to shoot down aircraft, drones and incoming cruise and ballistic missiles. Full S-300 launchers include detection radars that track incoming targets. Missiles are equipped with guidance systems to automatically latch on to targets.”

[244] Office of the Prosecutor General of Ukraine, Telegram, December 13, 2022, https://t.me/pgo_gov_ua/8099.

[245] Center for Emergency Medical Aid and Disaster Medicine, Facebook, March 12, 2022, https://www.facebook.com/ekstrena.dopomoga.kh/posts/493387372385092. See also Anna Tsyomyk, “An Ambulance in Kharkiv Came under Fire: a Paramedic was Injured,” Suspilne, March 12, 2022, https://suspilne.media/216646-svidka-u-harkovi-potrapila-pid-obstril-feldserka-svidkoi-otrimala-poranenna/.

[246] Center for Emergency Medical Aid and Disaster Medicine, Facebook, March 12, 2022, https://www.facebook.com/ekstrena.dopomoga.kh/posts/493387372385092.

[247] Chernihiv’s main bridge was reportedly blown up by Russian forces on March 23, 2022. See “Live Updates: Governor: Russians Destroyed Chernihiv Bridge,” The Independent,March 23, 2022, https://www.independent.co.uk/news/ukraine-ap-lviv-dmitry-peskov-kyiv-b2041939.html.

[248] Interview with Dr. Mykola Liutkevych, UHC, July 15, 2022 (on-file).

[249] Natalia Popova, Telegram, October 2, 2022, https://t.me/krotkh/1005.

[250] Center for Emergency Medical Aid and Disaster Medicine, Facebook, October 2, 2022, https://www.facebook.com/ekstrena.dopomoga.kh/posts/pfbid0276KRpmW8sN1FMjVDavhSG3K6BAANrp1Nds6fp7qYWA3NJACPYPv4St5Vbh18Sh9Jl; Natalia Popova, Telegram, October 2, 2022, https://t.me/krotkh/1005; Head of the Kharkiv Oblast Military Administration Oleg Synyehubov, Telegram, October 3, 2022, https://t.me/synegubov/4392.

[251] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[252] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[253] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, pp. 25-27, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[254] Interview with a doctor at the Trostianets City Hospital [anonymous], UHC, August 11, 2022 (on-file).

[255] Ambulance stations in Ukraine house medical vehicles but also serve broader purposes for the community, including hosting trainings and/or storing medications. During the height of the COVID-19 pandemic, some stations served as vaccination centers.

[256] “The Russians Captured Kreminna and Killed Several Civilians, Evacuation in Impossible, Fighting Continues, Gayday,” Espreso TV, April 18, 2022, https://espreso.tv/rosiyski-viyska-zayshli-u-kreminnu-trivayut-vulichni-boi-evakuatsiya-nemozhliva-ova.

[257] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[258] Stanislav Miroshnychenko and Olha Reshetylova, “Road of Death: The Shooting of Civilians on Kreminna-Lyman Road,” Media Initiative for Human Rights, October 28, 2022, https://mipl.org.ua/en/the-road-of-death-the-shooting-of-civilians-on-the-kreminna-lyman-road/.

[259] MIHR’s investigation, based on field and remote research, including interviews and an analysis of photographs, video recordings, satellite imagery, and open-source information, provides an in-depth analysis of the Lyman attack, which appeared to be part of a broader attack on civilians who were fleeing the shelling by Russian forces of Kreminna along the Torske-Kreminna highway. See Stanislav Miroshnychenko and Olha Reshetylova, “Road of Death: The Shooting of Civilians on Kreminna-Lyman Road,” Media Initiative for Human Rights, October 28, 2022, https://mipl.org.ua/en/the-road-of-death-the-shooting-of-civilians-on-the-kreminna-lyman-road/.

[260] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[261] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[262] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[263] Stanislav Miroshnychenko and Olha Reshetylova, “Road of Death: The Shooting of Civilians on Kreminna-Lyman Road,”  Media Initiative for Human Rights, October 28, 2022, https://mipl.org.ua/en/the-road-of-death-the-shooting-of-civilians-on-the-kreminna-lyman-road/.

[264] Stanislav Miroshnychenko and Olha Reshetylova, “Road of Death: The Shooting of Civilians on Kreminna-Lyman Road,”  Media Initiative for Human Rights, October 28, 2022, https://mipl.org.ua/en/the-road-of-death-the-shooting-of-civilians-on-the-kreminna-lyman-road/.

[265] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[266] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[267] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[268] See Stanislav Miroshnychenko and Olha Reshetylova, “Road of Death: The Shooting of Civilians on Kreminna-Lyman Road,”  Media Initiative for Human Rights, October 28, 2022, https://mipl.org.ua/en/the-road-of-death-the-shooting-of-civilians-on-the-kreminna-lyman-road/.

[269] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[270] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[271] Interview with paramedic [anonymous], MIHR, November 22, 2022 (on-file).

[272] Geneva Convention IV, Art. 55; Additional Protocol I, Art. 14.

[273] “Russians engaging in mass theft of medical equipment, says Zelenskiy,” Reuters, October 28, 2022, https://www.reuters.com/world/europe/russians-engaging-mass-theft-medical-equipment-says-zelenskiy-2022-10-28/.

[274]Information provided by the head of the medical department of Kyiv Regional Military Administration, UHC, May 3, 2022 (on-file).

[275] Anna Mamonova et al., “The Hardest Thing is When they Bring Friends, and they are in Agony, and you are Powerless,” Babel, November 10, 2022,https://babel.ua/texts/86822-nayvazhche-koli-privozyat-znayomih-a-voni-v-agoniji-i-ti-bezsiliy-likar-z-izyumu-p-yat-misyaciv-okupaciji-zhiv-u-pidvali-likarni-i-operuvav-bez-anesteziji-poranenih-ta-katovanih-os-yogo-istoriya.

[276] Mariupol City Council, Telegram, April 29, 2022, https://t.me/mariupolrada/9447.

[277] Department of Intelligence of the Ministry of Defense of Ukraine, Telegram, May 1, 2022, https://t.me/DIUkraine/433.

[278] Luhansk Military Administration, Telegram, May 10, 2022, https://t.me/luhanskaVTSA/2478.

[279] Ukrainian Healthcare Center, “Massive. Brutal. Deliberate. Attacks on Hospitals in the Russia-Ukraine War during the First Phase of the Invasion,” September 2022, pp. 41-43, https://uhc.org.ua/en/2022/09/15/report-by-uhc/.

[280] Tatyana Fedorkova, “Russian troops have captured Balaklia and are blocking Kharkiv from the north — General Staff,” Suspilne, March 4, 2022, https://suspilne.media/213600-vijska-rf-zahopili-balakliu-i-blokuut-harkiv-z-pivnoci-genstab/.

[281] Oleg Kononenko, “The Ukrainian flag is already flying over Balaklia – video,” New Voice of Ukraine, September 8, 2022, https://nv.ua/ukr/ukraine/events/zvilnennya-balakliji-u-misti-vivisili-ukrajinskiy-prapor-video-novini-ukrajini-50268723.html.

[282] Mykola Melnyk, “An Updated Intensive Care Unit will be Opened in the Balakli District,” Slobidsky Krai, June 14, 2018, https://www.slk.kh.ua/news/oblast-online/u-balaklijskomu-rajoni-vidkriyetsya-onovlene-reanimacijne-viddilennya.html.

[283] “‘Balakliya Clinical Multidisciplinary Intensive Care Hospital’ Received Medical and Laboratory Equipment in November,” Healthy Future, December 1, 2022, https://healthyfuture.com.ua/en/projects/ourprojects/balakleya-medical-and-lab-equipment.html.

[284] Mykola Melnyk, “An Updated Intensive Care Unit will be Opened in the Balakli District,” Slobidsky Krai, June 14, 2018, https://www.slk.kh.ua/news/oblast-online/u-balaklijskomu-rajoni-vidkriyetsya-onovlene-reanimacijne-viddilennya.html.

[285] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[286] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[287] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file); Oleg Synyehubov, head of the Kharkiv Regional State administration, Telegram, April 2, 2022, https://t.me/synegubov/2789; “Russian Military Shells Occupied Balakliya Again, 3 People Killed – Prosecutor’s Office,” Interfax Ukraine, April 7, 2022, https://interfax.com.ua/news/general/821912.html.

[288] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[289] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[290] “Russians Loot Hospitals in Kharkiv Oblast – Loss of Equipment are at 95%,” Pravda,September 20, 2022, https://www.pravda.com.ua/eng/news/2022/09/20/7368361/.

[291] “‘Balakliya Clinical Multidisciplinary Intensive Care Hospital’ Received Medical and Laboratory Equipment in November,” Healthy Future, December 1, 2022, https://healthyfuture.com.ua/en/projects/ourprojects/balakleya-medical-and-lab-equipment.html.

[292] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[293] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[294] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[295] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[296] “UNICEF Provides Medical Supplies to Hospital in Balakliya,” UNICEF,January 10, 2023, https://www.unicef.org/ukraine/en/stories/medical-supplies-to-hospital-in-balakliya.

[297] Interview with Dr. Maryna Rudenko, UHC, November 18, 2022 (on-file).

[298] “In Balakliia, the Multiprofile Hospital Destroyed by the Occupiers Resumed Work,” Kharkiv Regional Military Administration, January 3, 2023, https://kharkivoda.gov.ua/news/119057; “UNICEF Provides Medical Supplies to Hospital in Balakliya,” UNICEF,January 10, 2023, https://www.unicef.org/ukraine/en/stories/medical-supplies-to-hospital-in-balakliya.

[299] “Part of Kherson Region Territory Occupied by Aggressor – Regional Administration,” Interfax Ukraine, February 24, 2022, https://en.interfax.com.ua/news/general/801461.html. On September 30, 2022, the Kherson oblast was illegally annexed by Russia. See Pjotr Sauer and Luke Harding, “Putin Annexes Four Regions of Ukraine in Major Escalation of Russia’s War,” The Guardian, September 30, 2022, https://www.theguardian.com/world/2022/sep/30/putin-russia-war-annexes-ukraine-regions.

[300] The hospital has 19 inpatient departments, 11 of which are surgical departments. The hospital has 565 beds, where more than 23,000 patients are treated annually. More than 15,000 surgeries are performed annually. See “Kherson Regional Clinical Hospital,” accessed January 6, 2023, https://www.oblhospital.com.ua.

[301] Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous], MIHR, October 23, 2022 (on-file); Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous], MIHR, October 28, 2022 (on-file) For additional reporting, see Anastasia Pantelieieva, “Medicine in the Occupation: A Curator from Tuva, Russian doctors and Detention for Refusing to Cooperate,” Media Initiative for Human Rights (November 10, 2022), https://mipl.org.ua/en/medicine-under-occupation-overseer-from-tuva-russian-doctors-and-detention-for-refusing-to-cooperate/.

[302] Upon occupying the building, Russian authorities renamed it as the “Ministry of Health Protection of Kherson Region.”

[303]  “2014 – the start of the Anti-terrorist operation in the east of Ukraine was officially announced,” Ukraine’s Institute of Memory, April 14, 2021, https://uinp.gov.ua/istorychnyy-kalendar/kviten/14/2014-oficiyno-ogolosheno-pro-pochatok-antyterorystychnoyi-operaciyi-na-shodi-ukrayiny. On April 14, 2014, an anti-terrorist operation was launched to liberate the territories of the Donetsk and Luhansk regions of Ukraine captured by Russian-controlled militants. The operation ended on April 30, 2018. The launch of the operation was preceded by the annexation of Crimea and the escalation of tension in the south and east of Ukraine, which were accompanied by the seizure of the premises of the Security Service of Ukraine, police and administrative buildings, and the declaration of the so-called “People’s Republics.” After April 2018, the Operation of the United Forces was launched under the leadership of the Armed Forces of Ukraine.

[304] “The Occupation Authorities of the Kherson Region Force Doctors to Cooperate,” Suspilne, June 20, 2022,https://suspilne.media/252113-okupacijna-vlada-hersonsini-primusue-medikiv-do-spivpraci/.

[305] Names of alleged collaborators are not made public in this report but, to the extent the authoring organizations are aware of them, will be made available to interested prosecutors and accountability mechanisms upon request.

[306] Interview with Dr. Oksana Kyrsanova, MIHR, March 19, 2022 (on-file); Interview with Dr. Oksana Kyrsanova, MIHR, December 2, 2022 (on-file).

[307] In 2014, after the occupation of Donetsk, the Donetsk Regional Hospital was relocated to Mariupol and became part of Mariupol City Hospital No. 2. On December 22, 2016, the hospital was renamed the Mariupol Regional Intensive Care Hospital. In 2021, 14,732 surgeries were performed at the hospital, and 74,197 patients received treatment. See “Regional Hospital for Intensive Care,” accessed January 6, 2023, http://mariupol.medkontrol.pro/oblastnaya-bolnica-intensivnogo-lecheniya-g-mariupolya; Donetsk State Administration, “Order of the Head of the Regional State Administration No. 1163 dated 22.12.2016 “On acceptance into joint ownership of the territorial communities of villages, towns, and cities under the management of the regional council, of the integral property complex of the communal institution ‘Mariupol City Hospital No. 2,’” December 22, 2016, https://web.archive.org/web/20170118053235/http://dn.gov.ua/rozporyadzhennya-golovy-oda-vid-22-12-2016-1163-pro-pryjnyattya-do-spilnoyi-vlasnosti-terytorialnyh-gromad-sil-selyshh-mist-shho-znahodytsya-v-upravlinni-oblasnoyi-rady-tsilisnogo-majnovogo-kompleksu/.

[308] See “They Spent Three Weeks in the Hell of Mariupol: The Doctor who Managed to Get Out Talked about his Experience,” Bug, March 31, 2022,http://bug.org.ua/interview/try-tyzhni-proviv-u-pekli-mariupolya-likar-yakomu-vdalosya-vybratysya-rozpoviv-pro-perezhyte-650256/.

[309] Matt Murray, “Ukraine War: Refugee tells of wife’s death after maternity hospital bombing,” BBC, November 11, 2022, https://www.bbc.com/news/uk-wales-63588749.

[310] Dr. Kyrsanova did not remember the exact date, but said that the missile hit the hospital before March 12, 2022. Interview with Dr. Oksana Kyrsanova, MIHR, December 2, 2022 (on-file). Other witnesses reported bombings in the area on March 10 and 11, 2022. See “‘They Drove a Tank and Two Armored Personnel Carriers and Started Shooting Houses Around…’ How the Russians Captured the Hospital in Mariupol, and What Happened There After That,” 0629.com.ua Mariupol City Website, March 31, 2022, https://www.0629.com.ua/news/3362062/voni-prignali-tank-i-dva-btra-i-pocali-rozstriluvati-budinki-navkolo-ak-rosiani-zahopili-likarnu-v-mariupoli-i-so-tam-vidbuvalos-pisla-cogo; “Armoury, Prison, Graveyard: Mariupol Intensive Care Hospital under Russian Occupation,” International Partnership for Human Rights, Truth Hounds, Global Diligence, November 2022, https://www.iphronline.org/wp-content/uploads/2022/11/Mariupol-report_for_distribution_final_1.pdf.

[311] The doctor only agreed to be identified with the initial of his first name, to focus the interview on the living and working conditions of health workers and other prisoners generally, rather than his own personal experience only.

[312] Interview with Dr. Y, MIHR, November 24, 2022 (on file).

[313] Garrison Hospital No. 555 in Mariupol had been established in July 2020.

[314] For additional reporting, see Media Initiative for Human Rights, “Medic from Mariupol: ‘Doctors operated in bulletproof vests and helmets, did not take them off for several days,’” July 12, 2022, https://mipl.org.ua/medyk-iz-mariupolya-likari-operuvaly-v-bronezhyletah-i-kaskah-ne-znimaly-yih-po-kilka-dib/.

[315] On “filtration camps” and the crime of forcible transfer, see Human Rights Watch, “‘We Had No Choice’: ‘Filtration’ and the Crime of Forcibly Transferring Ukrainian Civilians to Russia,” September 2022, https://www.hrw.org/report/2022/09/01/we-had-no-choice/filtration-and-crime-forcibly-transferring-ukrainian-civilians#4455.

[316] On the night of July 28-29, a large explosion in one of the barracks killed 53 Ukrainian prisoners of war and injured at least 75 others. Following requests from both Ukraine and Russia, the United Nations appointed a fact-finding mission to investigate the incident on August 3, 2022. See “Members of Fact-Finding Mission regarding Incident at Olenivka, Ukraine, on 29 July 2022,” United Nations Secretary-General Press Statement, August 22, 2022, https://www.un.org/sg/en/content/sg/personnel-appointments/2022-08-22/members-of-fact-finding%C2%A0mission-regarding-incident-olenivka-ukraine-29-july-2022%C2%A0.https://www.un.org/sg/en/content/sg/personnel-appointments/2022-08-22/members-of-fact-finding%C2%A0mission-regarding-incident-olenivka-ukraine-29-july-2022%C2%A0. The fact-finding mission was disbanded in January 2023 because the “UN mission cannot deploy to the site.” “Russia-Ukraine War Live,” The Guardian, January 5, 2023, https://www.theguardian.com/world/live/2023/jan/05/russia-ukraine-war-live-no-rational-reason-west-hasnt-sent-tanks-says-zelenskiy-as-allies-offer-armoured-vehicles-instead?page=with:block-63b72a3a8f084f5e7540c7f6#block-63b72a3a8f084f5e7540c7f6.

[317] See Tetyana Katrychenko et al., “Crimes in Olenivka: Chronology, Testimonies and Names of Those Involved,” Media Initiative for Human Rights, December 1, 2022, https://mipl.org.ua/en/crimes-in-olenivka-chronology-testimonies-and-names-of-those-involved/.

[318] The current Criminal Code of Ukraine was adopted on April 5, 2001 and came into force on September 1, 2001, with subsequent amendments since. It replaced the 1960 Criminal Code of the Ukrainian SSR. See http://www.encyclopediaofukraine.com/display.asp?linkpath=pages%5CC%5CR%5CCriminalCodeofUkraine.htm.

[319] See “What is Universal Jurisdiction,” TRIAL International, accessed January 6, 2023, https://trialinternational.org/topics-post/universal-jurisdiction/.

[320] See “Statement Calling for the Creation of a Special Tribunal for the Punishment of the Crime of Aggression against Ukraine,” March 2022, https://gordonandsarahbrown.com/wp-content/uploads/2022/03/Combined-Statement-and-Declaration.pdf; “Law Not War: A Special Tribunal for the Crime of Aggression,” UN Web TV,  October 25, 2022, https://media.un.org/en/asset/k1q/k1qyewjw26. For an analysis of the proposed tribunal, see Olivier Corten, Vaios Koutroulis, “Tribunal for the Crime of Aggression against Ukraine – a Legal Assessment,” European Parliament, December 2022, https://www.europarl.europa.eu/RegData/etudes/IDAN/2022/702574/EXPO_IDA(2022)702574_EN.pdf.

[321] ICRC, “What is International Humanitarian Law?,” July 2004, https://www.icrc.org/en/doc/assets/files/other/what_is_ihl.pdf.

[322] An international armed conflict exists where the resort to armed force involves at least two States. See Geneva Conventions I, II, III, IV, Art. 2.

[323] Russia’s war on Ukraine is distinct from its status as the aggressor state (what is known as jus ad bellum, the law that regulates the conditions for initiating war or the use of armed force). Regardless of which party initiated a conflict, IHL also regulates the conduct of both parties in the conduct of the conflict itself (jus in bello).

[324] The four Geneva Conventions of 1949 have been ratified by 196 countries, including Russia and Ukraine, both of which also ratified Additional Protocol I of 1977.

[325] The Hague Convention of 1899 and The Hague Convention IV of 1907 and annexed regulations on the Laws and Customs of War on Land have been ratified by Russia and Ukraine. The two versions differ only slightly from each other. See ICRC, “Convention (IV) respecting the Laws and Customs of War on Land and its Annex,” access February 6, 2023, https://ihl-databases.icrc.org/en/ihl-treaties/hague-conv-iv-1907?activeTab=default.

[326] The Moscow Mechanism of the human dimension of the Organization for Security and Co-operation (OSCE) in Europe allows OSCE participating States to request investigations. The Moscow Mechanism was invoked by Ukraine and supported by 45 States on March 3, 2022. Its mandate is to establish the facts and circumstances concerning contraventions of OSCE commitments, violations and abuses of international human rights law and international humanitarian law, and establish the facts and circumstances of possible war crimes and crimes against humanity cases in the context of Russia’s full-scale invasion of Ukraine.

[327] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. i, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[328] Additional Protocol I, Art. 50 provides by reference that civilians are those who do not belong to the armed forces. In case of doubt, the person shall be considered civilian.

[329] Additional Protocol I, Art. 52 defines civilian objects as “objects which are not military objectives” and defines military objectives as “objects which by their nature, location, purpose or use make an effective contribution to military action and whose total or partial destruction, capture or neutralization, in the circumstances ruling at the time, offers a definite military advantage.” It further provides that in case of doubt, the object shall be considered civilian.

[330] International Committee of the Red Cross (ICRC), “Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts,” June 8, 1977, 1125 UNTS 3 (Additional Protocol I), Art. 48; ICRC, Customary International Humanitarian Law, Rules 1, 7, accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v1. Russia’s and Ukraine’s military manuals specifically provide for the principle of distinction. See ICRC, “Practice relating to Rule 7 (Russian Federation),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule7?country=ru; see ICRC, “Practice relating to Rule 7 (Ukraine),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule7?country=ua.

[331] Additional Protocol I, Art. 51(3); ICRC, Customary International Humanitarian Law, Rule 6.

[332] Cf Additional Protocol I, Art. 52(1), (2); ICRC, Customary International Humanitarian Law, Rule 10.

[333] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 27, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[334] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 27, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[335] Additional Protocol I, Art. 51(5)(b); ICRC, Customary International Humanitarian Law, Rule 14. See also ICRC, “Practice relating to Rule 14 (Russian Federation),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule14?country=ru; ICRC, “Practice relating to Rule 14 (Ukraine),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule14?country=ua.

[336] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 29, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[337] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 29, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[338] Additional Protocol I, Art. 57(1); ICRC, Customary International Humanitarian Law, Rule 15. See also ICRC, “Practice relating to Rule 15 (Russian Federation),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule15?country=ru; ICRC, “Practice relating to Rule 15 (Ukraine),” accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v2/rule15?country=ua.

[339] Additional Protocol I, Art. 57(2)(a)(i); ICRC, Customary International Humanitarian Law, Rule 16.

[340] Additional Protocol I, Art. 57(2)(c); ICRC, Customary International Humanitarian Law, Rule 20.

[341] Additional Protocol I, Art. 57(2)(b); ICRC, Customary International Humanitarian Law, Rule 19.

[342] Additional Protocol I, Art. 57(2)(a)(ii); ICRC, Customary International Humanitarian Law, Rule 18.

[343] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 30, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[344] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, pp. 30-31, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[345] Additional Protocol I, Arts. 8(c), 15; ICRC, Customary International Humanitarian Law, Rule 25. Medical personnel is defined as persons assigned, by a Party to the conflict, exclusively to the medical purposes or to the administration of medical units or to the operation or administration of medical transports, either permanently or temporarily.

[346] Additional Protocol I, Arts. 8(e), 12; ICRC, Customary International Humanitarian Law, Rule 28. Medical units are defined as establishments and other units, whether military or civilian, organized for medical purposes, be they fixed or mobile, permanent or temporary, including, for example, hospitals and other similar units, blood transfusion centers, medical depots and the medical and pharmaceutical stores of such units.

[347] Additional Protocol I, Arts. 8(f)-(j), 21; ICRC, Customary International Humanitarian Law, Rule 29. Medical vehicles are defined as means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to medical transportation under the control of a competent authority of a party to the conflict, including means of transportation by land, water or air, such as ambulances, hospital ships and medical aircraft.

[348] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 36, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[349] See Geneva Convention IV, Arts. 18, 20; Additional protocol I, Arts. 12, 15, 21.

[350] “A Physician’s Ethical Responsibility to Provide Care During Times of War is Identical to That During Times of Peace,” Physicians for Human Rights, https://phr.org/issues/health-under-attack/medical-impartiality/.

[351] Additional Protocol I, Arts. 12, 13.

[352] See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 565-68, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined: The special protection afforded to hospitals and other medical units does not cease when it is guarded by pickets, sentries, or an escort made up of soldiers or civilian uniformed police force. The mere presence of guards shelters them from attacks as they have no offensive role to play and are only there to protect the sick and wounded.

[353] See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 571-74, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

[354] See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, para. 551, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

[355] Additional protocol, Art. 13.

[356] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 36, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[357] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 37, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[358] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 37, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[359] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 37, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[360] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, pp. 8-9, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[361] Unlike war crimes, there is no comprehensive, universal treaty on crimes against humanity. Since its first authoritative articulation in the Charter of the Nuremberg International Military Tribunal, the concept of crimes against humanity has extensively developed outside treaty law and is rather a product of customary international law. See David Luban, “A Theory of Crimes against Humanity,” Georgetown University Law Center (2004), https://scholarship.law.georgetown.edu/facpub/146/. In 2019, the International Law Commission—a body of experts established by the United Nations General Assembly to develop international law and its codification—completed a set of proposed articles for a Convention on Crimes against Humanity. The project is currently under discussion. See Priya Pillai, “Draft Convention on Crimes against Humanity: A Window of Opportunity,” Opinio Juris, November 22, 2022, http://opiniojuris.org/2022/11/22/draft-convention-on-crimes-against-humanity-a-window-of-opportunity/.

[362] See Roger O’Keefe, International Criminal Law (Oxford University Press, 2017), pp. 137-145.

[363] See for instance Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in Germany”, Briefing Paper, March 2019, https://www.justiceinitiative.org/uploads/0b3c66af-68e0-4fd3-a8e0-d938a6e2b43b/universal-jurisdiction-law-and-practice-germany.pdf, 5-6 in relation to Section 7 VStGB; Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in Sweden”, Briefing Paper, April 2020, https://www.justiceinitiative.org/uploads/550b6548-a951-425f-84b3-d75e5d78688c/universal-jurisdiction-law-and-practice-sweden.pdf, 7, in relation to Section 2 of the UCA; Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in France”, Briefing Paper, February 2019, https://www.justiceinitiative.org/uploads/b264bc4f-053f-4e52-9bb8-fccc0a52816a/universal-jurisdiction-law-and-practice-france.pdf, 6 in relation to Article 212 of the French Criminal Code (FCC).

[364] See Rome Statute, Art. 7; Parliament of Ukraine, “Draft Law on Amendments to Certain Legislative Acts of Ukraine on the Implementation of International Criminal and Humanitarian Law,” accessed January 8, 2023, http://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=67804; The Law of Ukraine “About Making Changes to Criminal Code of Ukraine and Code of Criminal Procedure of Ukraine,” April 14, 2022, https://itd.rada.gov.ua/billInfo/Bills/pubFile/1271913.

[365] A 2001 decision by the Constitutional Court of Ukraine found the Rome Statute to overall be in compliance with the Constitution of Ukraine, with the exception of provisions on complementarity. See Case N 1-35/2001, N 3-v/2001, Constitutional Court of Ukraine, July 11, 2001, https://zakon.rada.gov.ua/laws/show/v003v710-01#Text.

[366] See Embassy of Ukraine, No. 61219/35-673-384, April 9, 2014, https://www.icc-cpi.int/sites/default/files/itemsDocuments/997/declarationRecognitionJuristiction09-04-2014.pdf.

[367] ICC-OTP, The Prosecutor of the International Criminal Court, Fatou Bensouda, opens a preliminary examination in Ukraine, April 25, 2014, https://www.icc-cpi.int/news/prosecutor-international-criminal-court-fatou-bensouda-opens-preliminary-examination-ukraine.

[368] See Minister for Foreign Affairs of Ukraine, No. 145-VIII, September 8, 2015, https://www.icc-cpi.int/sites/default/files/iccdocs/other/Ukraine_Art_12-3_declaration_08092015.pdf#search=ukraine.

[369] ICC-OTP, ICC Prosecutor extends preliminary examination of the situation in Ukraine following second article 12(3) declaration, September 29, 2015, https://www.icc-cpi.int/news/icc-prosecutor-extends-preliminary-examination-situation-ukraine-following-second-article-123.

[370] ICC-OTP, “Report on Preliminary Examination Activities (2020),” December 2020, paras. 267-90, https://www.icc-cpi.int/sites/default/files/itemsDocuments/2020-PE/2020-pe-report-eng.pdf.

[371] See Parliament of Ukraine, “On Amendments to the Constitution of Ukraine (Regarding Justice), June 2, 2016, https://zakon.rada.gov.ua/laws/show/1401-19#Text. The amendment entered into force on September 30, 2016.

[372] ICC, “Situation in Ukraine (ICC-01/22), https://www.icc-cpi.int/ukraine. ICC, “Statement of ICC Prosecutor, Karim A.A. Khan QC, on the Situation in Ukraine: receipt of referral from 39 States Parties and the opening of an investigation,” March 2, 2022, https://www.icc-cpi.int/news/statement-icc-prosecutor-karim-aa-khan-qc-situation-ukraine-receipt-referrals-39-states. 

[373] Rome Statute, Art. 8(2)(b)(xx), providing for the war crime of employing weapons, projectiles or materials or methods of warfare listed in the Annex to the Statute. The annex was never drafted. In the absence of such an Annex, the Elements of Crimes of the Rome Statute provide: “Elements will have to be drafted once weapons, projectiles or material or methods of warfare have been included in an annex to the Statute.” See also Knut Dörmann, “War Crimes under the Rome Statute of the International Criminal Court, with a Special Focus on the Negotiations on the Elements of Crimes” (Max Planck Yearbook of United Nations Law, Volume 7, 2003, 341-407), pp. 346-45, https://www.mpil.de/files/pdf3/mpunyb_doermann_7.pdf.  

[374] Melanie O’Brien, “Russian Violations of IHL: The ICC is Not the Complete Answer,” Opinio Juris, March 18, 2022, https://opiniojuris.org/2022/03/18/russian-violations-of-ihl-the-icc-is-not-the-complete-answer: “There is a provision (Article 8(2)(b)(iii)) prohibiting attacks on against personnel and material (etc) involved in humanitarian assistance, however this only applies to those involved in a humanitarian assistance mission in accordance with the Charter of the United Nations, thus only providing protection to UN mandated missions and inapplicable to the Ukrainian conflict. The attack on humanitarian corridors could be prosecuted under the Rome Statute offence of directing attacks against the civilian population (Article 8(2)(b)(i)), but again, this would not fully capture the conduct in question, which is violating the sanctity of a specially created non-military zone.”

[375] Office of the Prosecutor of the International Criminal Court, “Policy Paper on Case Selection and Prioritisation,” September 15, 2016, p. 14, https://www.icc-cpi.int/sites/default/files/itemsDocuments/20160915_OTP-Policy_Case-Selection_Eng.pdf.

[376] Rome Statute, Arts. 15(4) and 53(1).

[377] ICC, Situation in the Republic of Cote d’Ivoire (ICC-02/11), Corrigendum to “Decision Pursuant to Article 15 of the Rome Statute on the Authorisation of an Investigation into the Situation in the Republic of Côte d’Ivoire,” November 15, 2011, paras. 23-25, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2011_18794.PDF.

[378] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Mbarushimana, Decision on the Confirmation of Charges (ICC-01/04-01/10), December 16, 2011, para. 94, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2011_22538.PDF.

[379] Rome Statue, Art. 8(1).

[380] ICC, Situation in the Central African Republic, Prosecutor v. Bemba Gombo (ICC-01/05-01/08), Decision Pursuant to Article 61(7)(a) and (b) of the Rome Statute on the Charges of the Prosecutor Against Jean-Pierre Bemba Gombo, June 15, 2009, para. 211, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2009_04528.PDF; ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Mbarushimana, Decision on the Confirmation of Charges (ICC-01/04-01/10), December 16, 2011, para. 94, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2011_22538.PDF.  See also John J. Paust, “The International Criminal Court Does Not Have Complete Jurisdiction over Customary Crimes against Humanity and War Crimes,” 43 J. Marshall L. Rev. (2010) 603-713, p. 701, https://repository.law.uic.edu/cgi/viewcontent.cgi?article=1090&context=lawreview (“Under customary international law, war crimes do not have to be committed as part of a plan or policy or large-scale set of crimes and it would be illogical and not policy-serving to impose a limitation by interpreting the phrase “in particular” differently than its ordinary meaning.”).

[381] ICC, Situation in the Central African Republic, Prosecutor v. Bemba Gombo (ICC-01/05-01/08), Decision Pursuant to Article 61(7)(a) and (b) of the Rome Statute on the Charges of the Prosecutor Against Jean-Pierre Bemba Gombo, June 15, 2009, para. 211, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2009_04528.PDF.

[382] Rome Statute, Art. 7(2)(a). 

[383] While the existence of a policy is relevant to both war crimes and CAH, in the case of crimes against humanity it is a “chapeau element,” meaning the existence of a policy must be established as a predicate to criminal liability. For war crimes, however, the existence of a plan or policy is not a jurisdictional requirement but serves as a guideline for the Court.

[384] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, para. 1110, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF.

[385] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 87, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF (quoting ICTY, Prosecutor v. Blaškić (Case No. IT-95-14-T), Judgement, March 3, 2000, para. 205, https://www.icty.org/x/cases/blaskic/tjug/en/bla-tj000303e.pdf).

[386] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 87, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[387] ICTY, Prosecutor v. Blaškić (Case No. IT-95-14-T), Judgement, March 3, 2000, para. 205, https://www.icty.org/x/cases/blaskic/tjug/en/bla-tj000303e.pdf.

[388] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, para. 1109, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF.

[389] Relying on ICTY jurisprudence, the ICC considers that “an armed conflict exists whenever there is a resort to armed force between States or protracted violence between governmental authorities and organized armed groups or between such groups within a State.” ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Lubanga Dyilo (ICC-01/04-01/06), Judgment pursuant to Article 74 of the Statute, March 14, 2012, para. 533, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2012_03942.PDF.

[390] An international armed conflict is one that “takes place between two or more States.” ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Lubanga Dyilo (ICC-01/04-01/06), Judgment pursuant to Article 74 of the Statute, March 14, 2012, para. 541, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2012_03942.PDF. International armed conflicts also include military occupation, i.e. when it is actually placed under the authority of the hostile army, and this authority can be exercised. Elements of Crimes, fn. 34; ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Lubanga Dyilo (ICC-01/04-01/06), Decision on the Confirmation of Charges, January 29, 2007, para. 212, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2007_02360.PDF.

[391] Knut Dörmann, “War Crimes under the Rome Statute of the International Criminal Court, with a Special Focus on the Negotiations on the Elements of Crimes” (Max Planck Yearbook of United Nations Law, Volume 7, 2003, 341-407), pp. 362-63, https://www.mpil.de/files/pdf3/mpunyb_doermann_7.pdf.

[392] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Mbarushimana, Decision on the Confirmation of Charges (ICC-01/04-01/10), December 16, 2011, para. 94, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2011_22538.PDF.

[393] ICC, Situation in the Central African Republic, Prosecutor v. Bemba Gombo (ICC-01/05-01/08), Decision Pursuant to Article 61(7)(a) and (b) of the Rome Statute on the Charges of the Prosecutor Against Jean-Pierre Bemba Gombo, June 15, 2009, para. 211, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2009_04528.PDF.

[394] See ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Sentencing Judgment, November 7, 2019, para. 138, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_06674.PDF. Attacks against protected objects are considered by ICC jurisprudence as more grave than attacks against objects that are protected as regular civilian objects. ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Sentencing Judgment, November 7, 2019, para. 138, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_06674.PDF.

[395] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Sentencing Judgment, November 7, 2019, para. 138, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_06674.PDF.

[396] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Sentencing Judgment, November 7, 2019, para. 138, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_06674.PDF.

[397] See e.g. ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Judgment, July 8, 2019, para. 1147, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF (considering that the perpetrators referred to a health center as a dispensary sufficient to establish their awareness of its protected status).

[398] Intent can be inferred from various factors such as, for example, the means and methods used during the attack and the discriminatory nature of the attack. Elements of Crimes, General Introduction, para. 3. Cf ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, paras 807, 878 (in relation to intentional attacks against civilians), https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF.

[399] However, the protected object does not need to be the sole target of the attack: the crime would likely also be committed when the perpetrator launches the attack with two distinct specific aims – to target a military objective and simultaneously to target a protected object in the vicinity. Cf  ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga and Ngudjolo Chui (ICC-01/04-01/07), Decision on the Confirmation of Charges, September 30, 2008, paras 272-74 (in the context of showing attacks against the civilian population or individual civilians), https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2008_05172.PDF. 

[400] Knut Dörmann, “War Crimes under the Rome Statute of the International Criminal Court, with a Special Focus on the Negotiations on the Elements of Crimes” (Max Planck Yearbook of United Nations Law, Volume 7, 2003, 341-407), pp. 380-81, https://www.mpil.de/files/pdf3/mpunyb_doermann_7.pdf.

[401] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Judgment, July 8, 2019, para. 1147, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF.

[402] Other acts that are not considered harmful to the enemy include: equipment of unit’s personnel with light individual weapons for personal defense or for that of the wounded and sick in their charge; guarding of the unit by a picket, by sentries or by an escort; presence in the units of small arms and ammunition taken from the wounded and sick, and not yet handed to the proper service. See Protocol Additional I, Art. 13(1).

[403] Cf ICTY, Prosecutor v. Prlić, Case No. IT-04-74-T, Judgement (TC), 29 May 2013, para 125, https://www.icty.org/x/cases/prlic/tjug/en/130529-1.pdf.

[404] “Interview with Dr. Alla Barsehian, UHC, December 17, 2022 (on-file).

[405] Igor Rozin, “Russia’s Most Devastating Sear, Ground, and Air Missiles,” Russia Beyond, November 7, 2017, https://www.rbth.com/science-and-tech/326642-russias-most-devastating-sea-ground.

[406] Information provided by weapons analyst (on-file).

[407] The occupation of Trostianets reportedly lasted from February 24 to March 26, 2022.

[408] Two tank commanders and one assistant were identified by Ukrainian prosecutors for their alleged role in the attack(s). See See Office of the Prosecutor General of Ukraine, “Another Russian serviceman who ordered to shell the Trostianetska hospital from a tank has been identified,” August 17, 2022, https://www.gp.gov.ua/ua/posts/vstanovleno-shhe-odnogo-viiskovosluzbovcya-rf-yakii-viddav-nakaz-obstrilyuvati-z-tanka-trostyanecku-likarnyu; State Bureau of Investigation of Ukraine, “The SBI Identified Russian Service Members who, with Tanks, were Firing at a Hospital in Trostyanets,” May 5, 2022, https://dbr.gov.ua/en/news/dbr-vstanovilo-vijskovosluzhbovciv-rf-yaki-z-tankiv-rozstrilyuvali-likarnyu-v-trostyanci.

[409] See ICRC, War Crimes under the Rome Statute of the International Criminal Court and their source in International Humanitarian Law – Comparative Table, October 31, 2012, https://www.icrc.org/en/document/war-crimes-under-rome-statute-international-criminal-court-and-their-source-international. See also Harmen van der Wilt, “Towards a Better Understanding of the Concept of ‘Indiscriminate Attack’ – How International Criminal Law Can be of Assistance,” Yearbook of International Humanitarian Law, 22 (2019), 29-42, https://pure.uva.nl/ws/files/59114194/Wilt2021_Chapter_TowardsABetterUnderstandingOfT.pdf.

[410] See Harmen van der Wilt, “Towards a Better Understanding of the Concept of ‘Indiscriminate Attack’ – How International Criminal Law Can be of Assistance,” Yearbook of International Humanitarian Law, 22 (2019) 29-42, p. 38, https://pure.uva.nl/ws/files/59114194/Wilt2021_Chapter_TowardsABetterUnderstandingOfT.pdf.

[411] Rome Statute, Art. 8(2)(b)(iv). According to the Elements of Crimes, the expression “concrete and direct overall military advantage” refers to a military advantage that is foreseeable by the perpetrator at the relevant time. Such advantage may or may not be temporally or geographically related to the object of the attack. In other words, the crime admits the possibility of lawful collateral damage provided it does not violate the law applicable in armed conflict, in line with the principle of proportionality. See Rome Statute, Elements of Crimes, fn. 36. In some instances, the use of indiscriminate weapons may reveal that the attack was directed at a protected object, especially where the damage caused is so great that it appears that the perpetrator meant to target it.

[412] Rome Statute, Elements of Crimes, fn. 37.

[413] Knut Dörmann, “War Crimes under the Rome Statute of the International Criminal Court, with a Special Focus on the Negotiations on the Elements of Crimes” (Max Planck Yearbook of United Nations Law, Volume 7, 2003, 341-407), p. 384, https://www.mpil.de/files/pdf3/mpunyb_doermann_7.pdf. 

[414] On the night of March 2 to March 3, March 6, March 7, and March 8, 2022.

[415] See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 571-74, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

[416] See ICRC, Commentary of 1987 on Additional Protocol I, Art. 13, paras 565-68, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined.

[417] Knut Dörmann, “War Crimes under the Rome Statute of the International Criminal Court, with a Special Focus on the Negotiations on the Elements of Crimes” (Max Planck Yearbook of United Nations Law, Volume 7, 2003, 341-407), pp. 380-81, https://www.mpil.de/files/pdf3/mpunyb_doermann_7.pdf.

[418] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, para. 905, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF; ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Judgment, July 8, 2019, para. 1028, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF; ICC, Situation in Uganda, Prosecutor v. Ongwen (ICC-02/04-01/15), Trial Judgment, February 4, 2021, para. 2763, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2021_01026.PDF.

[419] The “war crime of pillaging under Article 8(2)(b)(xvi) of the Statute requires that the property subject to the offence belongs to an ‘enemy’ or ‘hostile’ party to the conflict.” ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga and Ngudjolo Chui (ICC-01/04-01/07), Decision on the Confirmation of Charges, September 30, 2008, para. 329, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2008_05172.PDF.

[420] “In the absence of the owner, or in coercive circumstances, the perpetrator’s knowledge of non-consent of the owner may be inferred.” See ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Judgment, July 8, 2019, para. 1028-29, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF.

[421] Appropriations justified by military necessity do not constitute the crime of pillaging, as any military necessity would require its use to be directed to further the war effort and thus use for military purposes. See Elements of Crimes, fn. 47; ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), Judgment, July 8, 2019, para. 1030, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF.

[422] In this regard, see Geneva Convention IV, Arts. 18, 21, 57.

[423] See Commentary on the Law of the International Criminal Court, Article 8(2)(b)(xvi), updated June 30, 2016, accessed January 6, 2023, https://cilrap-lexsitus.org/clicc/8-2-b-xvi/8-2-b-xvi.

[424] This exception must be interpreted narrowly. Only measures which are indispensable for securing the ends of the war and are lawful according to the modern law and usages of war are considered military necessity. ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, para. 894, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF.

[425] The crimes listed below are a non-exhaustive list of possible applicable Rome Statute provisions.

[426] Cf ICTY, Prosecutor v. Blaškić (Case No. IT-95-14-A), Judgement, July 29, 2004, para. 654, https://www.icty.org/x/cases/blaskic/acjug/en/bla-aj040729e.pdf.

[427] ICRC, Customary International Humanitarian Law, Rule 99, accessed January 16, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v1.

[428] The definition of torture as a war crime, which requires that the victims be “protected persons” (as doctors and medics are), differs slightly from the definition of torture as a crime against humanity, which requires the victims to be in the custody of, or under the control of the perpetrator. See Rome Statute, Elements of Crimes, fn. 35. Further, unlike the definition of torture under the United Nations Convention against Torture, the Rome Statute does not require the perpetrator to hold the status of a public official or to have acted in an official capacity. Cf UN Convention against Torture, Art. 1.

[429] Rome Statute, Elements of Crimes, Art. 8(2)(a)(ii)-2.

[430] United Nations Human Rights Monitoring Mission in Ukraine, “Update on the Human Rights Situation in Ukraine (1 August – 31 October 2022), December 2, 2022, p. 4, https://www.ohchr.org/sites/default/files/documents/countries/ua/2022-12-02/HRMMU_Update_2022-12-02_EN.pdf.

[431] In this sense see “Armoury, Prison, Graveyard: Mariupol Regional Intensive Care Hospital under Russian occupation”, International Partnership for Human Rights, Truth Hounds, Global Diligence, November 2022, https://www.iphronline.org/wp-content/uploads/2022/11/Mariupol-report_for_distribution_final_1.pdf,  pp. 28 – 31.

[432] Under the Elements of Crimes, the term “killed” is interchangeable with the term “caused death.” 

[433] Protected persons include, among others: the wounded and sick, civilians in the power of the occupying party that are not nationals of the occupying power, and medical personnel. “Glossary: Protected Persons,” ICRC, accessed January 12, 2023, https://casebook.icrc.org/glossary/protected-persons. To be wounded or sick under IHL, two cumulative criteria have to be fulfilled: (1) a person must require medical care; and (2) he or she must refrain from any act of hostility. Additional Protocol I, Art. 8(a).

[434] See infra, “Overview and Impact of Attacks on Ukraine’s Health Care System.”

[435] Rome Statute, Arts. 7(1), 7(2)(a).

[436] Rome Statute, Art. 7(2)(a). 

[437] ICTY, Prosecutor v. Blaškić (Case No. IT-95-14-T), Judgement, March 3, 2000, para. 205, https://www.icty.org/x/cases/blaskic/tjug/en/bla-tj000303e.pdf.

[438] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 87, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF

[439] Jeffrey Mankoff, “Russia’s War in Ukraine – Identity, History, and Conflict,” Center for Strategic & International Studies, April 2022, https://www.csis.org/analysis/russias-war-ukraine-identity-history-and-conflict

[440] For an in-depth analysis of Russia’s involvement in Crimea and Donbas between December 2013 and February 13, 2022, see Global Rights Compliance, “International Law and Defining Russia’s Involvement in Crimea and Donbas,” February 13, 2022, https://globalrightscompliance.com/wp-content/uploads/2022/05/International-Law-and-Russia-Involvement-in-Crimea-and-Donbas-1.pdf.  See also Ukraine and the Netherlands v. Russia, No. 8019/16, 43800/14, 28525/20, ECHR (Grand Chamber), January 25, 2023 (finding that Russia exercised “effective control” on account of its military presence in eastern Ukraine and the decisive degree of influence it enjoyed over these areas as a result of its military, political and economic support to the “DPR” and the “LPR”).

[441] “Extracts from Putin’s Speech on Ukraine,” Reuters, February 21, 2022, https://www.reuters.com/world/europe/extracts-putins-speech-ukraine-2022-02-21/.

[442] Pjotr Sauer and Luke Harding, “Putin Annexes Four Regions of Ukraine in Major Escalation of Russia’s War,” The Guardian, September 30, 2022, https://www.theguardian.com/world/2022/sep/30/putin-russia-war-annexes-ukraine-regions.

[443] On December 13, 2022, the bill was considered by the State Duma and adopted in the first reading, with its submission for amendments due December 17, 2022. The draft law neither defines the concept of “interests of the Russian Federation” or territories, nor specifies the crimes to which it applies. At the time of publication of this report, amendments to the bill have not been published on the website of the State Duma. See Parliament of Russia, “Bill No. 246425-8 ‘On the Application of the Provisions of the Criminal Code of the Russian Federation and the Code of Criminal Procedure of the Russian Federation in the Territories of the Donetsk People’s Republic, the Lugansk People’s Republic, the Zaporozhskayaa oblast, the Khersonskaya oblast,” accessed January 16, 2023, https://sozd.duma.gov.ru/bill/246425-8. Bill No. 246425-8 and Explanatory Notes to Bill No. 246425-8  are on-file.

[444] “Russia’s War in Ukraine: Military and Intelligence Aspects,” Congressional Research Service, September 14, 2022, https://crsreports.congress.gov/product/pdf/R/R47068.

[445] Pablo Gutierrez et al., “Buildup, Bombing, Resistance: Mapping Russia’s Invasion of Ukraine,” The Guardian,March 17, 2022, https://www.theguardian.com/world/ng-interactive/2022/mar/17/russia-invasion-of-ukraine-maps-mapping-buildup-bombing; Andrew Roth et al., “Russia’s war in Ukraine: complete guide in maps, video and pictures,” The Guardian,May 15, 2022, https://www.theguardian.com/world/2022/mar/17/russias-war-in-ukraine-complete-guide-in-maps-video-and-pictures.

[446]  “How Many Troops has Russia Sent into Invasion of Ukraine?,” AS English, February 26, 2022, https://en.as.com/en/2022/02/24/latest_news/1645729870_894320.html.

[447] Pjotr Sauer, “Vladimir Putin Signs Decree to Increase Size of Russian Armed Forces,” The Guardian, August 25, 2022, https://www.theguardian.com/world/2022/aug/25/vladimir-putin-signs-decree-increase-size-russian-armed-forces-ukraine.

[448] Office of the President of Russia, “Decree ‘On the announcement of partial mobilization in the Russian Federation,’” September 21, 2022, http://kremlin.ru/events/president/news/69391.

[449] Kateryna Stepanenko et al., “Russian Offensive Campaign Assessment, December 22,” December 22, 2022, https://www.criticalthreats.org/analysis/russian-offensive-campaign-assessment-december-22.

[450] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine (1 April – 25 June 2022),” July 11, 2022, p. 42,  https://www.osce.org/files/f/documents/3/e/522616.pdf.

[451] These terms are disjunctive, not cumulative. See ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 94, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[452] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 95, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[453] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 95, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[454] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 96, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[455] ICC, Situation in Kenya (ICC-01/09), Decision Pursuant to Article 15 of the Rome Statute on the Authorization of an Investigation into the Situation in the Republic of Kenya, March 31, 2010, para. 96, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2010_02409.PDF.

[456] See further, “Evidence of Widespread and Systematic Bombardment of Ukrainian Healthcare Facilities,” Yale School of Public Health – Humanitarian Research Lab, May 17, 2022, https://search.issuelab.org/resource/evidence-of-widespread-and-systematic-bombardment-of-ukrainian-healthcare-facilities.html: “Based on a review of nearly 300 facilities across five cities and regions, the HRL has concluded that Russia-aligned forces have engaged in widespread and systematic bombardment of Ukrainian healthcare facilities.”.

[457] ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga and Ngudjolo Chui (ICC-01/04-01/07), Decision on the Confirmation of Charges, September 30, 2008, para. 448, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2008_05172.PDF. 

[458] Sunčana Roksandić Vidlička, “Systemic Deprivation of Access to Essential Medicine and Medical Care – a Crime against Humanity?” (Koninklijke Brill NV, Leiden, 2021), pp. 159-61, https://doi.org/10.1163/9789004364424_008, noting that courts and tribunals have relied on the underlying offenses of persecution, enslavement, and other inhumane acts in relation to large-scale violations of economic, social, and cultural rights, including deprivation of medical care.

[459] Note that the case studies discussed above may give rise to other crimes against humanity qualifications, such as murder, imprisonment, and torture. See Rome Statute, Art. 7(1)(a), (e), (f), respectively.

[460] Organization for Security and Co-operation in Europe, “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” April 22, 2022, p. 87, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[461] Office of the Prosecutor General of Ukraine, “Statistics,” accessed January 23, 2023, https://www.gp.gov.ua/.

[462] Code of Criminal Procedure of Ukraine, Art. 214(1), https://zakon.rada.gov.ua/laws/show/4651-17#Text.

[463] For a comprehensive analysis of the application of IHL rules under Ukrainian law more generally, see Global Rights Compliance, “The Domestic Implementation of International Humanitarian Law in Ukraine (updated),” February 2021, https://www.asser.nl/media/794633/2021-the-domestic-implementation-of-ihl-in-ukraine-updated.pdf.

[464] Criminal Code of Ukraine, Law No. 2341-III of April 5, 2001, revised on December 29, 2022, https://zakon.rada.gov.ua/laws/show/2341-14?lang=en#Text.

[465] See Global Rights Compliance, “The Domestic Implementation of International Humanitarian Law in Ukraine (updated),” February 2021, https://www.asser.nl/media/794633/2021-the-domestic-implementation-of-ihl-in-ukraine-updated.pdf.

[466] See Parliament of Ukraine, “Draft Law on Amendments to Certain Legislative Acts of Ukraine on the Implementation of International Criminal and Humanitarian Law,” accessed January 8, 2023, http://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=67804. For a comparative table of the amendments to the CCU proposed in Bill No. 2689, see: Parliamentarian for Global Action, “Bill No. 2689: Comparative Table to the Draft Law of Ukraine “On Amendments to Certain Legislative Acts on the Enforcement of International Criminal and Humanitarian Law,” accessed January 8, 2023, https://www.pgaction.org/pdf/2021/en-bill-2689-10-03-2021.pdf.

[467] The Law of Ukraine “About Making Changes to Criminal Code of Ukraine and Code of Criminal Procedure of Ukraine,” April 14, 2022, https://itd.rada.gov.ua/billInfo/Bills/pubFile/1271913.

[468] Parliamentarians for Global Action, “Parliament of Ukraine Adopts Bill to Implement International Criminal and Humanitarian Law,” May 20, 2021, https://www.pgaction.org/news/ukraine-bill-2689.html: “In the merits, Bill 2689 enshrines principles of international criminal law, including command responsibility; equips Ukraine with universal jurisdiction to effectively combat impunity even for acts without a link with Ukraine; includes provisions on crimes against humanity, otherwise missing in the legislation previously in force; and defines war crimes in conformity with the requirements of International Law.” See also Maria Zheltukha, “Conflict-Related Sexual Violence in Ukraine: Legislative Regulation,” Analytical Center JurFem, July 25, 2022, https://jurfem.com.ua/en/conflict-related-sexual-violence-in-ukraine-legislative-regulation/.

[469] See Center for Civil Liberties, “Euromaidan SOS: a New Government Bill No. 7290 Artificially Reduces Opportunities to Prosecute Russian Military Commanders and Civilian Superiors Liable for War Crimes,” April 20, 2022, https://ccl.org.ua/en/claims/euromaidan-sos-a-new-government-bill-%E2%84%96-7290-artificially-reduces-opportunities-to-prosecute-russian-military-commanders-and-civilian-superiors-liable-for-war-crimes/.

[470] See Parliament of Ukraine, “Draft Law on Amendments to the Criminal Code of Ukraine and the Criminal Procedure Code of Ukraine,” accessed January 8, 2023, http://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=74105.

[471] Zmina, “Human Rights Defenders Recommend the Ukrainian Authorities to Finilize [sic] the Draft Law No 7290,” April 22, 2022, https://zmina.ua/en/statements-en/human-rights-defenders-recommend-the-ukrainian-authorities-to-finilize-the-draft-law-no-7290/. See also Center for Civil Liberties, “Euromaidan SOS: a New Government Bill No. 7290 Artificially Reduces Opportunities to Prosecute Russian Military Commanders and Civilian Superiors Liable for War Crimes,” April 20, 2022, https://ccl.org.ua/en/claims/euromaidan-sos-a-new-government-bill-%E2%84%96-7290-artificially-reduces-opportunities-to-prosecute-russian-military-commanders-and-civilian-superiors-liable-for-war-crimes/; Office of the High Commissioner for Human Rights, “Situation of Human Rights in Ukraine in the Context of the Armed Attack by the Russian Federation,” June 29, 2022, paras. 130-31, https://www.ohchr.org/sites/default/files/documents/countries/ua/2022-06-29/2022-06-UkraineArmedAttack-EN.pdf; T.M.C. Asser Institute and Global Rights Compliance, “MATRA-Ukraine: The Halfway Mark,” September 22, 2022, https://www.asser.nl/matra-ukraine/news-and-events/matra-ukraine-the-halfway-mark/. On command responsibility specifically, the text of Bill No. 7290 proposes to only criminalize “the omission of a commander, person acting as a commander or other superiors to terminate a war crime, crime of aggression, crime against humanity or genocide by a subordinate.” T.M.C. Asser Institute and Global Rights Compliance, “MATRA-Ukraine: The Halfway Mark,” September 22, 2022, https://www.asser.nl/matra-ukraine/news-and-events/matra-ukraine-the-halfway-mark/.

[472] Note that this section only analyzes provisions that are directly relevant to attacks against Ukraine’s health care system. For a comparative table identifying the relevant provisions of the CCU that are most relevant to a consideration of the propriety of pursuing war crimes or the lesser corresponding domestic crime, see Global Rights Compliance, “The Domestic Implementation of International Humanitarian Law in Ukraine (updated),” February 2021, Annex VIII, https://www.asser.nl/media/794633/2021-the-domestic-implementation-of-ihl-in-ukraine-updated.pdf.

[473] For an analysis of prosecution and adjudication of war crimes since the beginning of Russia’s invasion of Ukraine under Article 438 of the CCU, see e.g. Iryna Marchuk, “Domestic Accountability Efforts in Response to the Russia-Ukraine War,” Journal of International Criminal Justice, Volume 20, Issue 4, September 2022, https://doi.org/10.1093/jicj/mqac051. See also Ukrainian Legal Advisory Group, “‘The First Trial against the Russian Soldier’ as an Indicator of the State Justice System of Ukraine,” May 25, 2022, https://zmina.info/en/articles-en/the-first-trial-against-the-russian-soldier-as-an-indicator-of-the-state-justice-system-of-ukraine/.

[474] See State Bureau of Investigation of Ukraine, “The SBI Identified Russian Service Members who, with Tanks, were Firing at a Hospital in Trostyanets,” May 5, 2022, https://dbr.gov.ua/en/news/dbr-vstanovilo-vijskovosluzhbovciv-rf-yaki-z-tankiv-rozstrilyuvali-likarnyu-v-trostyanci; Office of the Prosecutor General of Ukraine, “Another Russian Serviceman who Ordered to Shell the Trostianetska Hospital from a Tank has been Identified,” August 17, 2022, https://www.gp.gov.ua/ua/posts/vstanovleno-shhe-odnogo-viiskovosluzbovcya-rf-yakii-viddav-nakaz-obstrilyuvati-z-tanka-trostyanecku-likarnyu; State Bureau of Investigation of Ukraine, “The SBI Put on the Wanted List the Russian Tankers who Shot the Local Hospital during the Occupation of Trostianets. The Repaired Tank ‘Takes Revenge’ on Former Owners for their Crimes,” October 24, 2022, https://dbr.gov.ua/en/news/dbr-ogolosilo-v-rozshuk-rosijskih-tankistiv-yaki-pid-chas-okupacii-trostyancya-rozstrilyali-miscevu-likarnyu.-vidremontovanij-tank-mstit-kolishnim-gospodaryam-za-zlochini.

[475] Global Rights Compliance a Foundation made up of lawyers and development experts, specialized in on-the-ground international humanitarian law and issues in conflict-affected and high-risk areas around the world, working to identify, prevent and mitigate adverse human rights impacts. See: https://globalrightscompliance.com/.

[476] Global Rights Compliance, “The Domestic Implementation of International Humanitarian Law in Ukraine (updated),” February 2021, p. 63, https://www.asser.nl/media/794633/2021-the-domestic-implementation-of-ihl-in-ukraine-updated.pdf.

[477] Additional Protocol I, Art. 51(4).

[478] Additional Protocol I, Art. 51(5)(b).

[479]  Additional Protocol I, Arts. 12, 15, 21.

[480] Geneva Convention IV, Arts. 33, 147.

[481] Additional Protocol I, Art. 51(7).

[482] Geneva Convention IV, Art. 147.

[483] Additional Protocol I, Art. 75(2)(a).

[484] Additional Protocol I, Art. 75(2).

[485] ICRC, “War Crimes under the Rome Statute of the International Criminal Court and their source in International Humanitarian Law – Comparative Table,” October 31, 2012, https://www.icrc.org/en/document/war-crimes-under-rome-statute-international-criminal-court-and-their-source-international.

[486] Criminal Code of Ukraine, Arts. 185, 186.

[487] Criminal Code of Ukraine, Arts. 115, 127.

[488] Criminal Code of Ukraine, Art. 146.

[489] “What is Universal Jurisdiction,” TRIAL International, accessed January 6, 2023, https://trialinternational.org/topics-post/universal-jurisdiction/. It must be noted, however, that the exercise of universal jurisdiction varies around the world and depends on the country’s legislation. For example, several states have incorporated crimes contained in the Rome Statute in their national legislation and vested their courts with exercising the principle of universal jurisdiction. However, the definitions of the crimes may differ across different jurisdictions. For example, some countries may distinguish between war crimes committed in international armed conflicts and those committed in non-international armed conflicts, while others do not. Similarly, the requirements to exercise universal jurisdiction may also vary in different countries. For example, certain states condition the exercise of universal jurisdiction to the presence or residence of the alleged perpetrator on their territory or to the principle of double criminality, while others do not.

[490] Geneva Convention I, Art. 49; Geneva Convention II, Art. 50; Geneva Convention III, Art. 129; Geneva Convention IV, Art. 146.

[491] See Additional Protocol I, Art. 85(1).

[492] Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 1465 UNTS 85, adopted on December 10, 1984, entered into force on June 26, 1987; International Convention for the Protection of All Persons from Enforced Disappearance, 2716 UNTS 3, adopted on December 20, 2006, entered into force on December 23, 2010.

[493] Elise Baker and Gissou Nia, “Attacks on Hospitals from Syria to Ukraine: Improving Prevention and Accountability Mechanisms,” Atlantic Council Issue Brief, 4, June 2022, https://www.atlanticcouncil.org/wp-content/uploads/2022/06/Attacks-on-Hospitals-from-Syria-to-Ukraine-Improving-Prevention-and-Accountability-Mechanisms.pdf. See also Anya Neistat, “Victims of war crimes in Ukraine have an unprecedented chance to seek justice”, The Guardian, July 24, 2022, https://www.theguardian.com/commentisfree/2022/jul/24/war-crimes-ukraine-investigations-justice, noting that cases can be brought under the universal jurisdiction principle in more than 150 countries.

^[494] Mark Kersten, “Universal Jurisdiction in Ukraine: States should commit to using their own courts to address Russian atrocities”, Justice in Conflict, October 17, 2022, https://justiceinconflict.org/2022/10/17/universal-jurisdiction-in-ukraine-states-should-commit-to-using-their-own-courts-to-address-russian-atrocities/.

[495] See e.g. Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in the Netherlands,” Briefing Paper, April 2019, https://www.justiceinitiative.org/uploads/e91b3105-914b-415d-9067-54543fac7e36/universal-jurisdiction-law-and-practice-netherlands.pdf.

[496] See e.g. Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in the Netherlands,” Briefing Paper, April 2019, https://www.justiceinitiative.org/uploads/e91b3105-914b-415d-9067-54543fac7e36/universal-jurisdiction-law-and-practice-netherlands.pdf; Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in France,” Briefing Paper, February 2019, https://www.justiceinitiative.org/uploads/b264bc4f-053f-4e52-9bb8-fccc0a52816a/universal-jurisdiction-law-and-practice-france.pdf.

[497] See Parliamentarians for Global Action, “Implementation,” accessed January 27, 2023, https://www.pgaction.org/ilhr/rome-statute/implementation.html: Note that the definitions do not need to be verbatim but can also go beyond what the Rome Statute provides “to reflect more protective definitions that may exist under general international law or applicable treaties.” See e.g. Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in Germany,” Briefing Paper, March 2019, https://www.justiceinitiative.org/uploads/0b3c66af-68e0-4fd3-a8e0-d938a6e2b43b/universal-jurisdiction-law-and-practice-germany.pdf; Open Society Justice Initiative and TRIAL International, “Universal Jurisdiction Law and Practice in Sweden,” Briefing Paper, April 2020, https://www.justiceinitiative.org/uploads/550b6548-a951-425f-84b3-d75e5d78688c/universal-jurisdiction-law-and-practice-sweden.pdf.

[498] Mark Kersten, “Universal Jurisdiction in Ukraine: States should commit to using their own courts to address Russian atrocities”, Justice in Conflict, October 17, 2022, https://justiceinconflict.org/2022/10/17/universal-jurisdiction-in-ukraine-states-should-commit-to-using-their-own-courts-to-address-russian-atrocities/. These countries are Germany, Spain, Sweden, France, Lithuania, Canada, Poland, Estonia, Latvia, Slovakia, the United States, and the United Kingdom.

[499] Anya Neistat, “Victims of war crimes in Ukraine have an unprecedented chance to seek justice”, The Guardian, July 24, 2022, https://www.theguardian.com/commentisfree/2022/jul/24/war-crimes-ukraine-investigations-justice.

[500] See Leonard Rubenstein, Perilous Medicine – The Struggle to Protect Health Care from the Violence of War, Columbia University Press, 2021, p. 284.

[501] Lara Hakki, Eric Stover, and Rohini J. Haar, “Breaking the silence: Advocacy and accountability for attacks on hospitals in armed conflict,” International Review of the Red Cross (2021).

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An estimated one in three women worldwide have been subjected to physical and/or sexual violence in their lifetime, a traumatizing experience with short- and long-term adverse health consequences that impact individuals and communities. For people who survive sexual violence in the context of war or conflict, the barriers to accessing high-quality services, support, and accountability can be particularly steep.  

Through the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights (PHR) works to confront these challenges and empower multisectoral professionals to offer survivor-centered services and document forensic evidence of injuries sustained to strengthen accountability and access to justice. PHR has a well-established track record of evidence-based interventions that achieve impact for survivors and support for the professionals who provide care and services. Working at the global level as well as in Kenya, the Democratic Republic of the Congo (DRC), Central African Republic (CAR), Iraq, Myanmar/Bangladesh, and Ethiopia, we center survivors and our partners in our conversations and efforts to understand how to drive progress at a systemic level, primarily through capacity building, multisectoral networks, and research. As we mark the International Day for the Elimination of Violence Against Women on November 25, we continue to challenge ourselves to understand what works and what doesn’t, using the following rigorous, scientific, and trauma-informed approaches.  

This International Day for the Elimination of Violence Against Women, PHR will continue fighting for justice for survivors of conflict-related sexual violence, and empowering the clinicians that support them.

Here are five ways that evidence makes change possible for survivors of conflict-related sexual violence: 

1. Multisectoral Trainings and Partnerships with Clinicians and the Legal Sector 

At the heart of PHR’s work to pursue access to justice for survivors of conflict-related sexual violence are the multisectoral networks and partnerships built among healthcare professionals, police officers, forensic analysts, lawyers, and judges. Health professionals are often essential first responders for sexual violence survivors. However, professionals in conflict regions require support to strengthen their capacity to properly collect and document forensic medical evidence, which is a key first step needed to engage with multisectoral partners, including legal services and law enforcement, and to seek accountability for crimes of sexual violence. 

PHR prioritizes trauma-informed, survivor-centered, multisectoral trainings and partnerships, particularly to enhance medical-legal processes for survivors, that have proven effective. A recent article about our work in Kenya found that scaling medical–legal training and strengthening multisectoral networks in areas with high rates of sexual and gender-based violence (SGBV) are promising strategies for increasing collaboration, enhancing the quality of services, and improving justice processes for survivors. These approaches have promoted prosecutions and appeared to have encouraged other survivors to come forward.  

Another recent article about our work in DRC, published in the journal Violence and Victims, found that participants completing PHR’s multisectoral training had improved knowledge and attitudes of health, law enforcement, and legal professionals and, overall, viewed PHR’s training as beneficial. This study suggests that PHR’s training is effective in under-resourced, conflict-affected regions. PHR started developing these trainings in 2011, and we have been consistently refining our approaches ever since to ensure alignment with best practices and in collaboration with our partners and colleagues living and working in the communities where the trainings are taking place. 

2. Innovative Technologies Co-Designed with Colleagues in Kenya and the DRC 

To support the reliable and secure documentation of forensic evidence needed to support sexual violence cases, PHR designed and developed MediCapt, an award-winning mobile application to document forensic evidence of sexual violence. MediCapt provides a digital platform to facilitate the comprehensive collection of evidence, including forensic photography of injuries sustained by survivors. MediCapt also allows forensic evidence to be securely stored in the cloud and safely shared with law enforcement and justice sector officials to inform investigations and prosecutions. To date, MediCapt has been successfully piloted in DRC at HEAL Africa Hospital in Goma, in Kenya at Naivasha Sub-County Hospital in Naivasha, at Nakuru County Referral and Teaching Hospital in Nakuru, and at the Mukuru Health Centre in the Embakasi South Sub-County in Nairobi. MediCapt standardizes and improves the quality of information collected compared to the paper-based form. A report we published in collaboration with the first end-users, who self-describe as the “pioneers,” addresses the effectiveness of MediCapt from their unique perspective. Further information about the extensive process we undertook to collaboratively design and develop the app can be found here and here. 

3. Survivor-Centered Litigation to Hold Perpetrators Accountable 

These multisectoral partnerships are helping to achieve justice for survivors of sexual violence. One notable example of our work in this area has been in the South Kivu village of Kavumu in the DRC. Over a three-year period, beginning in 2013, more than 42 young girls in DRC, some as young as 18 months, were kidnapped from their homes, raped, and then left in the fields surrounding Kavumu, a small town in South Kivu. To pursue justice for the girls and their families, PHR worked with multisectoral professionals to gather forensic evidence from the survivors, coordinate the investigation, and provide technical assistance to medical, law enforcement, and legal professionals. This work was critical for achieving a landmark conviction in December 2017 of 11 militia members, including a sitting member of parliament, for crimes against humanity for rape and murder. The judgment was upheld on appeal in July 2018. In Kenya, in Constitutional Petition No. 122 of 2013, a group of eight survivor-petitioners and four civil society organizations, including PHR, sought to hold the Kenyan government accountable for sexual violence in the post-election period. In December 2020, the High Court of Nairobi issued a landmark judgment holding the Government of Kenya accountable for failing to investigate and prosecute the cases of survivors who reported to the police or who were violated by government security forces. However, the court failed to acknowledge the government’s responsibility in those cases where survivors were not able to report their cases. To that end, PHR and our co-petitioners filed a partial appeal in January 2022 at the Court of Appeal at Nairobi. While this litigation has wound its way through the Kenyan legal system for nearly a decade, repeatedly subjected to unacceptable delays, PHR and our partners remain committed to seeing justice delivered for the courageous survivors of post-election sexual violence in Kenya. 

4. Research to Document and Corroborate Reports of Conflict-Related Sexual Violence 

PHR also conducts research to document and corroborate reports of conflict-related sexual violence (CRSV). Most recently, our work addressing CRSV has focused on Rohingya refugees from Myanmar who fled to Bangladesh. We have documented patterns of injuries and physical and psychological conditions experienced by the Rohingya related to sexual violence, and examined how the COVID-19 pandemic affected SGBV and the provision of services for Rohingya refugees. Our work has corroborated previous reports that the Rohingya experienced CRSV by the Myanmar military and security forces and documented barriers to providing comprehensive SGBV care services to Rohingya survivors in Bangladesh. This important evidence has been shared with various international fact-finding and accountability processes, supporting the pursuit of justice for the Rohingya. 

5. New Projects to Understand and Communicate Experiences of Survivors 

PHR is also conducting innovative research to better understand the experiences of survivors of sexual violence in Kenya as they access mental health services. These experiences are important as they convey advocacy needs and priorities related to mental health and survivor-centered care, from the perspective of survivors themselves. For this project, PHR will use a visual research strategy consisting of an approach called “Photovoice” to collect data and make a gallery of photos and captions from survivors to advocate for them and influence change. We are also doing this research to understand the impacts of our work and to create stronger strategies that reflect survivors’ experiences and perspectives. Our advocacy in Kenya also helped bring about the Mental Health Amendment Act, which prioritizes ensuring that all people with mental health needs receive the best care they can attain, including survivors of sexual violence.  

This International Day for the Elimination of Violence Against Women, PHR will continue comprehensively fighting for justice for survivors of conflict-related sexual violence and empowering the clinicians and professionals that support them. Through evidence and advocacy, change is possible for survivors of conflict-related sexual violence. 

Photo: A physician at HEAL Africa Hospital in Goma, DRC uses PHR’s MediCapt app

Last week, I was part of the delegation of Physicians for Human Rights (PHR) to the 51^st session of the United Nations Human Rights Council in Geneva. Christian DeVos, PHR’s director of research and investigations, and I were joined by our Ukrainian partner Pavlo Kovtoniuk, co-founder of the Ukrainian Healthcare Center, as we took part in the second of four weeks of this session of the HRC. 

Our team was there to deliver strong statements to world leaders to stop illegal attacks on health care in places such as Myanmar, Syria, and Ukraine, and demand accountability for human rights abuses. We provided recommendations based on years of PHR’s expert research and investigations. We met with special rapporteurs, diplomats, commissioners of inquiry, and civil society partners.   

Myanmar 

In Myanmar, health care personnel navigate a chaotic and crooked political environment, all while struggling to get their hands on the few supplies they can to meet the demands of a population that simply can’t be met, no matter how hard they try.  

Interactive dialogues on both the oral progress report of the Special Rapporteur on human rights in Myanmar and on the report on Myanmar by the Office of the High Commissioner for Human Rights were held during the Human Rights Council. PHR contributed written statements, highlighting the arrest, torture, and murder of health care personnel by military forces in Myanmar since the coup d’état in February 2021. PHR called for justice and accountability efforts to prevent and punish both these crimes and human rights abuses, including sexual violence, against the Rohingya and other ethnic minority groups by the Tatmadaw. 

Our team was there to deliver strong statements to world leaders to stop illegal attacks on health care in places such as Myanmar, Syria, and Ukraine, and demand accountability for human rights abuses.

Syria 

After more than a decade, millions of Syrians in the northwest continue to race against a ticking clock, wondering if in six months’ time their last lifeline at the Bab al-Hawa border crossing will be shut for good. Families of the disappeared desperately seek answers to their loved ones’ whereabouts. Health care workers in Syria risk death daily to provide even the most rudimentary care. 

At the Human Rights Council, interactive dialogues addressing enforced or involuntary disappearances and arbitrary detention were held, as well as a session with the Commission of Inquiry on the Syrian Arab Republic. During the latter, PHR called for Member States to push publicly for actionable items contained in UN Security Council resolution 2286, to hold perpetrators of attacks on health care accountable. PHR also encouraged States to extend cross-border authorization for humanitarian aid at Bab al-Hawa for at least 12 months, calling last summer’s Security Council decision to renew for six months a disgraceful compromise. 

Ukraine 

Ukrainians continue to suffer at the hands of the Russian army as it decimates the country’s health care facilities and personnel in the ongoing illegal invasion. During the Human Rights Council, PHR attended the interactive dialogue with the Commission of Inquiry on Ukraine, during which Member States and various NGOs highlighted the egregious atrocities committed by Russian troops against Ukrainians since the start of the illegal invasion of Ukraine in February 2022. During the Item 3 General Debate, PHR demanded accountability for attacks on health care in Ukraine and encouraged Member States to push publicly for actionable items contained in resolution 2286.  

For me, the daily sessions at the HRC elicited a rollercoaster of emotions. It was quite daunting, sitting in a room filled with representatives from 47 countries, each with their own agendas, but also the ability to affect real change. Some States were known perpetrators of the very crimes PHR has spent years documenting. There were encouraging moments as I looked around at the numerous bustling NGO participants, all actively involved on the ground in dire humanitarian crises in the world. There were also moments when hope went out the door, as representatives hurled accusations at one another and avoided discussing the issues at hand.  

During these long hours of debate and discussions, I couldn’t help but think of the courageous individuals in Syria, Myanmar, and Ukraine, including health care personnel, doing everything in their power to help those around them in the midst of these deadly conflicts. And here we were, in the Palais des Nations, delivering our messages and calling, again, for concrete action, together with hundreds of colleagues.   

It was hard not to ask myself what more we could be doing. What was the point of all this conversation, if it didn’t actually get us anywhere? 

During a break, I grabbed a coffee and took my work to the back patio of the palais. One of the deputy permanent observers had the same idea and joined me for a chat. We got to talking about her 12 years’ work in Geneva, for the same mission, with the same discussions and interventions taking place session after session at the UN. The exhaustion was written clearly on her face. 

I asked her when she thought she might throw in the towel. 

She smiled. “The day I stop caring.”  

That’s how it is in this space, be it in New York or Geneva. No matter how seemingly futile and impossible, you try to reach as many people as you can to make even the smallest difference. If you’re lucky, maybe things don’t get worse, or maybe a resolution passes that addresses just one of your asks. But you keep going because for those who are living through conflict, even the little victories count. 

The efforts made all around by vocal UN Member States and numerous activists in these arenas prove to me that there really is a chance these situations we’re fighting for will eventually change for the better. We’re all doing what we can, fighting the same fights, for the same end goal. In those moments of hopelessness, when I ask why and for what, I’m reminded of these people and efforts. And like the DPO I had the pleasure to meet with, I know that we won’t stop, because we care too much.  

And so, we keep going. 

Originally published by STAT, September 27, 2022.

The California State Legislature has sent a bill to Gov. Gavin Newsom that strengthens discipline for doctors who knowingly spread Covid-19 misinformation. Legislation like this is sorely needed across the country.

More than two years into the pandemic, Covid-19 misinformation still runs rampant. Some comes from doctors spreading lies about unproven — and actually harmful — “treatments” for Covid-19 and promoting anti-vaccine conspiracy theories. Physicians account for three of the 12 individuals thought to be responsible for up to 73% of anti-vaccine content on Facebook. These physicians have been highly influential in their claims that, for example, masks suppress the immune system and that, after getting the vaccine, “becoming sterile [is] almost a certainty.” These lies have real and potentially deadly consequences.

An effective response to misinformation and its effects requires a multilayered approach, including one that holds rogue physicians accountable for their pronouncements, helping to preserve integrity within the medical profession.

As a primary care physician, I see the effects of Covid-19 misinformation every day. Some of my patients continue to decline getting vaccinated against SARS-CoV-2, the virus that causes Covid-19, based on false theories about immunizations causing death or decreased fertility. A few have become severely ill from the virus just weeks after saying “no” to vaccination during their visit to my office.

They are not alone. Polls have shown that 78% of U.S. adults believe common false statements about Covid-19. Multiple reports document cases of individuals who have been harmed or died after trying harmful Covid “treatments” like drinking methanol and taking ivermectin. Nationwide, misinformation is responsible for up to 30% of people’s decisions to not get vaccinated and has contributed to the more than 300,000 Covid-19 deaths that could have been prevented by vaccines.

I find it shocking that some of the doctors peddling medical misinformation are still practicing medicine without accountability. These professionals, who swore an oath to protect the health of their patients, have been undermining trust and contributing to poor health outcomes.

The scientific and medical communities have taken modest steps to rein in this type of behavior. Last year, the Federation of State Medical Boards released a statement describing its intention to discipline and potentially revoke the licenses of physicians who participate in the dissemination of mis- or disinformation. Since then, at least 10 states have disciplined doctors accordingly, including revoking licenses for supporting anti-masking, spreading vaccine misinformation, and issuing inappropriate exemption letters.

Multiple physicians’ professional organizations and several nonprofit organizations have stepped up their support of the Federation of State Medical Boards’ efforts, including the health worker-run organization No License for Disinformation, which advocates on this issue.

Despite these efforts, the preponderance of misinformation, including that spread by physicians, remains a potent and very real threat to all Americans. Firstly, the disciplinary action being pursued by medical boards has been limited. Thus far, reported fines have been relatively low (one Houston doctor was fined $500 — a drop in the bucket compared to an average yearly salary of $200,000), and even physicians who lose their licenses may choose to continue promoting misinformation using their MD titles.

Furthermore, legislation in some states adds to the problem: The efforts of some state medical boards have been stymied by legislation that allows for off-label prescribing of medications like ivermectin, which is proven to be ineffective at treating Covid-19 and can be harmful. Other legislation under discussion would prohibit medical boards from disciplining physicians for Covid-19 “free speech.” So far, these types of laws have been passed in North Dakota, Tennessee, and Missouri, with additional legislation in process in more than half of U.S. states.

The political motives behind these efforts have dangerous implications: lawmakers with no medical knowledge or training are trying to dictate public health decisions and dominate the discourse. The country’s policy response to national health emergencies should be informed by experts who have knowledge and training in safeguarding health and human well-being and by the patients and communities most affected by those emergencies, not self-appointed experts committed to promulgating their own anti-science agendas.

Mistrust in medicine is a complicated topic. Even if all Covid-19 misinformation were eliminated tomorrow, there would still be issues with trusting medical professionals, given the sordid and ongoing history of racism, ableism, and other forms of discrimination within health care. Promoting truthful, helpful information requires multifaceted processes of truth-seeking, reconciliation, and accountability not only to prevent harm but to work to heal communities. Stopping the spread of ongoing Covid-19 misinformation is just one — though critical — piece of the puzzle.

As the U.S. takes further steps towards accountability, the core principles of health care ethics — autonomy (affirming that patients have the right to make their own decisions), beneficence (acting for the benefit of others), nonmaleficence (doing no harm), and justice — must all be in effect. Rooting out misinformation and fighting back against anti-science laws that embolden misinformation remain vital first steps toward ensuring physicians are held accountable to their professional ethics as well as to the patients and the communities they serve.

The California bill is a good first step on a long road to accountability and to reducing the toll of Covid-19.

Covid-19 medical misinformation must be tackled like any other type of professional negligence. Physicians must be required to tell the truth and be held accountable for not doing so. Safeguards like these improve public trust, help physicians like me to do our jobs, and help communities across the country access reliable information to combat the pandemic.

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Juliana E. Morris is a primary care physician in Chelsea, Mass., an instructor in medicine at Harvard Medical School, and a member of the Physicians for Human Rights Asylum Network.

As Russian artillery shells fall indiscriminately in Ukraine, efforts are under way by the international community to document the resulting human rights violations, including a range of attacks that likely constitute war crimes and crimes against humanity. These efforts may indeed be the most robust in recent history. But as the International Criminal Court (ICC) commemorates its 20^th anniversary on July 17, international criminal justice’s uneasy relationship with the ICC looms large.

Often criticized for having done too little too late to secure justice for victims of crimes against humanity, war crimes, and genocide, the ICC, the world’s only permanent criminal court, reifies the good, the bad, and the unintended consequences of the Court’s best intentions.

The ICC at age 20 is a story about complementarity in action and the courageous witnesses, investigators, prosecutors, and judges working at national level.

While the ICC was created in 2002 to be a major venue for investigating and prosecuting war crimes, crimes against humanity and genocide, many factors have made the Court less likely to be able to respond to atrocities. However, the domestication of the Rome Statute by many States has enabled some groundbreaking developments for international justice to be implemented at the national level.

The ICC at age 20 is a story about complementarity in action and the courageous witnesses, investigators, prosecutors, and judges working at national level.

Despite its mixed record, the ICC has both benefited from and catalyzed one of the most promising developments since the signing of the Rome Statute, the ICC’s foundational covenant: the symbiosis between the law, on the one hand, and medicine and public health, on the other. This partnership has spawned both good healthcare practices and powerful forms of justice for human rights victims.

Achieving meaningful accountability for grave crimes is painstaking work. Securing indictments and convictions of war criminals requires vast amounts of fact-based evidence. Here at Physicians for Human Rights (PHR), an international non-governmental organization working at the intersection of medicine, science and human rights, we have both witnessed and facilitated the growing role of science in criminal justice.  

Achieving meaningful accountability for grave crimes is painstaking work. Securing indictments and convictions of war criminals requires vast amounts of fact-based evidence.

The pioneering work of the International Criminal Tribunal for the former Yugoslavia and the International Criminal Tribunal for Rwanda in the 1990s saw early advances in accountability. PHR’s forensic teams have also advanced criminal justice by exhuming mass graves in the former Yugoslavia and providing expert testimony before the International Criminal Tribunal for the former Yugoslavia and the International Criminal Tribunal for Rwanda.

Similarly, a measure of domestic accountability was achieved in the shadow of the ICC’s broader engagement in the Democratic Republic of the Congo (DRC). PHR partner Nobel Prize-winner Dr. Denis Mukwege, a Congolese gynecologist and first-hand witness to mass rape in eastern Congo, used systematic forensic documentation to establish the use of rape as a weapon of war, opening the door to accountability for thousands of survivors.

For example, following the abduction and rape of more than 42 children in 2013 – one as young as 18 months old –  a Congolese court convicted 11 militia members of crimes against humanity by rape and murder and sentenced them to life in prison. This marked a watershed moment for justice in the DRC. The so-called Kavumu case blended forensic medicine and criminal justice in a way that is emblematic of the mutual advances these two fields have made in recent years and their increasing interdependence in achieving justice.

Given the widespread nature of conflict-related rape worldwide, true justice for survivors must first and foremost be secured at the local and national levels, following the principle of complementarity with the ICC. To that end, PHR has trained hundreds of health professionals to document conflict-related rape and other atrocity crimes, including through the global adoption of the Istanbul Protocol, UN-backed international guidelines for documentation of torture and its consequences.

A revised version of the Protocol, supported by PHR and integrating some twenty years of advances in the field, launched in June. Over the previous six years, PHR had led a comprehensive, global effort to update the Istanbul Protocol with advances in anti-torture jurisprudence, investigation and documentation practices, and additional implementation guidance to States and civil society based on experience in more than 40 countries over the previous 20 years.

Over time, PHR has increasingly come to understand the Rome Statute not only as a legal text, but as a touchstone in a much broader system of international justice (the “Rome Statute system,” as it is often referred to), in which domestic courts, prosecutors, investigators, civil society, and, critically, medical professionals all have vital roles to play.

Justice for grave crimes has advanced substantially, in practice and symbolically, since the ICC’s establishment twenty years ago. Recent experience shows that the future of those advances will be in the hands of health professionals as well as lawyers, researchers, and advocates.

Moreover, the struggle to infuse human rights principles into criminal proceedings will – and must – be led by communities closest to the violations, at community and national level. That struggle is likely to be the essence of medico-legal efforts to advance international criminal justice in the next twenty years.