The Lancet
One year after the invasion of Ukraine, the toll is heartbreaking: hundreds of thousands of dead and wounded, millions of displaced people and refugees, massive destruction of civilian infrastructure. The Russian army has also attacked health resorts and health workers (1).
The Russian invasion of Ukraine, which began a year ago on February 24, has caused enormous suffering and devastation. As of February 6, the Office of the United Nations High Commissioner for Human Rights recorded 7,155 civilian casualties and 11,662 wounded in Ukraine, although the actual figures are likely to be higher. 200,000 soldiers on both sides were killed or wounded. At least 6 million Ukrainians are internally displaced and over 8 million Ukrainian refugees are hosted across Europe. Acts of murder, torture, rape and deportation have been described as crimes against humanity by US Vice President Kamala Harris. Russia has bombed homes and civilian infrastructure, such as power plants. As is increasingly evident, a key feature of Russia’s strategy is the attempt to destroy the health care system, seriously undermining the Ukrainian people’s right to health.
A new report jointly published by EyeWitness to Atrocities, Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights e Ukrainian Healthcare Center documents the scale of attacks on Ukraine’s health care centers and personnel by Russian forces. In the first 2 weeks of the invasion, four to five hospitals and clinics were attacked every day. As of December 31, 2022, there had been 707 documented assaults, including damage to 218 hospitals and clinics (nearly 9% of hospitals in the country), 181 assaults on other healthcare facilities (such as pharmacies, blood transfusion centers, dental clinics and research institutions), 65 attacks on ambulances and 86 attacks on medical personnel (resulting in 62 deaths and 52 injuries, although this is probably an undercount). People’s stories are heartbreaking. Severodonetsk hospital in Luhansk was hit ten times between March and May 2022. Eyewitnesses say that drones were used before the attacks and the fact that many hospitals were repeatedly targeted is evidence that these attacks were deliberate . In regions under Russian control, many doctors have been threatened, detained, held hostage and forced to cooperate. Doctors detained in Russian-run prisons in Donetsk have revealed instances of torture and inhumane treatment.
Despite the efforts of Ukrainians, with cooperation with WHO and other non-governmental organizations, several areas of the country have experienced a decline in the quality of health care and service delivery due to the war. Many facilities have no running water or electricity. In eastern Ukraine, hospitals can provide only a small fraction of essential care, forcing patients to travel great distances or seek no assistance at all. The Ukrainian Ministry of Health has reported a sharp decline in routine immunizations since the start of the invasion. Childhood immunization coverage in 2022 has been estimated at 60%, raising the risk of spreading polio, measles, diphtheria and other diseases. While the supply chain of essential medicines is maintained and services are available in areas under the control of the Ukrainian government, very little is known about other regions that are under Russian control, particularly in terms of access to antiretroviral therapy and other services for HIV. Chronic illnesses have become more difficult to manage, with many displaced people reporting that they have stopped taking anti-hypertensive and cardiovascular medications. The conflict has also damaged mental health, causing psychological trauma among both civilians and soldiers.
At the international level, attempts are being made to bring Russia into the dock for the crimes committed. The United Nations International Court of Justice has ordered an end to the conflict and the United Nations General Assembly has demanded that war damages be paid to Ukraine. According to Ukraine’s Ministry of Health, 1,035 medical facilities have been damaged in the past 11 months and another 171 flattened, with the EyeWitness report saying $15.1 billion will be needed to restore essential health facilities and services. Russia’s civilian and military leadership, including Vladimir Putin, are being investigated for war crimes and crimes against humanity by the International Criminal Court, as well as a parallel special tribunal backed by the European Parliament and the German and British governments. However, jurisdiction issues will complicate matters, and even if found guilty, it’s hard to imagine the circumstances under which Putin and others could be arrested. Meanwhile, the war continues with no end in sight. Although the future is uncertain, emergency humanitarian response must now be directed towards longer-term planning, as argued by Paul Spiegel and colleagues in a commentary in this issue (2). It is not enough to end the conflict and bring justice to Ukraine. Progress must be made to safeguard health in that region, not only during today’s atrocities but also after the end of the war, for the new Ukraine, and for Europe as a whole.
- Russia’s invasion of Ukraina: an attack on health, Editorial, Lancet 2023, February 25; 401: 617. The translation is ours as well as the subtitles and bolds.
2. Spiegel PB et Al, The war in Ukraine 1 year on: the need to strategise for the long-term health of Ukrainians, Lancet, Published: February 21, 2023DOI:https://doi.org/10.1016/S0140-6736(23)00383-5