Russia is waging war on Ukrainian healthcare
The writer is a practising physician and associate professor at the Icahn School of Medicine at Mount Sinai, New York
5,493,437. That’s the number of Ukrainians who have fled the country since February 24, according to the United Nations. Eight million more have fled their homes but stayed inside Ukraine. Russia’s indiscriminate bombardment has been widely noted, but one particularly insidious aspect of Vladimir Putin’s strategy is the deliberate attack on healthcare institutions.
Attacks on healthcare flout the most fundamental prohibitions of international humanitarian law (IHL). Russia is deploying people’s dependence on healthcare against them. By concurrently attacking civilians and targeting hospitals, Russian forces simultaneously create an urgent medical need while denying people access to that care.
These attacks magnify the harm of mass casualties caused by air strikes and augment the suffering of chronic conditions. They are especially harmful to girls and women, leaving them unable to access emergency management of rape, treatment for sexually transmitted diseases, antenatal care or life-saving caesarean sections for complicated pregnancies.
Because everyone has the need for healthcare, the deliberate targeting of hospitals is a primary driver of displacement. Indeed, the systematic targeting of healthcare underscores that displacement is a primary objective rather than an unfortunate outcome. The Kremlin has used this strategy in Chechnya, Syria and now in Ukraine.
There is no doubt that attacks on healthcare are central to the Russian military’s way of waging war. On February 24, the first day of the invasion, Russian forces hit three hospitals. Since then, attacks have damaged more than six hundred others, according to Ukraine’s health ministry.
There is a cruel logic to Russia’s forced displacement of Ukrainians. Depopulated regions are easier for an invading military to control. Five million refugees from Ukraine are 5mn fewer people present to hold the country together. Eight million internally displaced people fighting for survival do not have time to struggle for democracy. Forced dispersion facilitates political dominance.
This sinister doctrine is surfacing in other armed conflicts such as in Ethiopia’s northernmost region of Tigray and in Myanmar. The increasing global popularity of such tactics strikes at the heart of IHL and the core of the Geneva Conventions.
The protection of healthcare forms the basis of IHL, established in the first Geneva Convention in 1864. At that time, medical care made little or no difference to the outcome of a war. There was no infection control or antibiotics. Surgery was a treatment of last resort. By the first world war, advances in clinical medicine enabled wounded soldiers to return to the battlefield, which provided one illegal incentive to attack those providing it. But still, after the second world war, attacks weren’t just banned but eventually redefined as war crimes.
Today, modern healthcare has become central to a full life for civilians. That heightened need increases the cruelty of deliberately depriving civilians of medical aid.
Once we understand that attacks on healthcare are a high-yield war crime, our aim must be to change the Kremlin’s cost-benefit analysis. Governments should single out this criminal strategy for denunciation. Urgent efforts should be made to convey to the Russian people, in Russian, the human costs of targeting hospitals.
The World Health Organization must identify attacks on healthcare in Ukraine as war crimes and describe the public health consequences. Beyond avoidable deaths, the combination of mass displacement and unsanitary conditions affect global health, providing ideal conditions for incubating Covid-19 variants or even the next pathogen with pandemic potential.
Prosecutors should prioritise these war crimes, and pay special attention to those who orchestrate such attacks. Under Putin, this strategy has become entrenched military doctrine, exemplified by his proven record in Syria, where attacks were proved beyond doubt. Ukraine presents the opportunity to prosecute Putin for these crimes, not just the foot soldiers.
We should ensure that Putin pays every possible reputational, diplomatic, and political price for these atrocities. Otherwise, this criminal doctrine will become normalised. The desperate exodus of Ukrainian civilians is likely to continue and be replicated elsewhere. And the global biosecurity repercussions affect everyone.