Hospitals and healthcare workers must be protected from the waging of warBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o764 (Published 22 March 2022) Cite this as: BMJ 2022;376:o764
An injured pregnant woman was carried out of a maternity hospital in Mariupol, Ukraine on a stretcher after Russian forces bombed the hospital on 9 March 2022. Surrounded by scorched buildings and rubble, photographs of her reverberated around the world via social media. Several days later, the Ukrainian government confirmed that the unnamed woman and her baby had died.1
The two were among the growing number of patients who have been killed by attacks on Ukrainian healthcare facilities since the Russian invasion began on 24 February 2022.2 As of 12 March 2022, the monitoring group Insecurity Insight has documented 47 reported attacks on healthcare facilities in Ukraine. In 29 of these reported attacks, health facilities were damaged or destroyed, 24 health workers were injured, and eight health workers were killed.3 The World Health Organisation’s Surveillance System for Attacks on Health Care has verified 52 attacks on healthcare since the conflict began. Both are likely conservative figures.4
According to news reports, one of the clinicians killed was Leila Ahmed, who died under Russian mortar fire on Kharkiv regional hospital on 3 March. It is a cruel irony that Ahmed, a Syrian gynaecologist, had fled with her husband from Deir Ez-zor, a Syrian province also ravaged by Syrian and Russian air strikes, only to die in a Russian attack on her hospital in Ukraine.3
International humanitarian and human rights law protect medical spaces and health workers from interference and attack during armed conflicts. The four Geneva Conventions of 1949 have been ratified by 196 countries, including Russia and Ukraine, both of which also ratified Additional Protocol I.5 These require that all parties to a conflict protect and ensure the functionality of medical facilities, transport, and personnel; protect and ensure unbiased treatment for both wounded civilians and combatants; and that medical personnel provide impartial care to both civilians and wounded combatants, in line with medical ethics.
There are only limited exceptions to these regulations, for instance where a medical facility is being used to commit acts in furtherance of the conflict and unrelated to its humanitarian function, provided that the “collateral damage” of any such attack is proportional to the anticipated military advantage. But any lawful targeting is the exception to an overriding norm: hospitals and healthcare workers must be protected from the waging of war.
Attacks on health facilities and personnel during conflict are, unfortunately, not unique to Russia’s invasion of Ukraine. Such attacks have been documented throughout the world in conflict-affected places such as Afghanistan, Iraq, Myanmar, Palestine, Somalia, Sudan, Syria, and Yemen. More than 4,000 attacks or threats to healthcare were perpetrated globally from 2016 to 2020, according to the Safeguarding Health in Conflict Coalition.6 Their toll on local populations can be devastating in the short and the long term and can cripple entire health systems. These include an inability to manage conflict related injuries, a reduced capacity to care for people with chronic conditions, and failure to safeguard public health and manage communicable disease outbreaks.
In Syria, Russia has actively supported Syrian government actions to “weaponize” deliberate attacks on healthcare that deprive people of the care they need by killing, imprisoning, and torturing thousands of health workers and attacking and destroying hundreds of hospitals and other healthcare facilities.7 Since the conflict in Syria began 11 years ago this month, Physicians for Human Rights (PHR) has corroborated 601 attacks on 400 health facilities and the killing of 942 medical workers, with more than 90 percent of these attacks perpetrated by the Syrian government, Russia, and other allies.
Russia has suffered no consequences or accountability for these crimes—nor for attacks that destroyed or severely damaged hospitals in Chechnya's capital, Grozny, during Russia’s invasion in 1994-95 and again during its 1999-2000 campaign that destroyed much of the city.
Russia is now applying these same tactics to Ukraine. Unless the architects of this war and other perpetrators are held accountable, violations like these will continue and likely worsen.
While securing a ceasefire and access for humanitarian assistance to Ukraine is a clear priority, it is also urgent that independent health and human rights organizations such as Physicians for Human Rights (PHR) rigorously investigate and document evidence that can be used by international justice mechanisms to hold perpetrators accountable and push back against lies and propaganda spread by Russian officials.
The International Criminal Court’s prosecutor has already found there is sufficient evidence to launch an investigation in Ukraine for potential war crimes and crimes against humanity, while the United Nations has also established a Commission of Inquiry to investigate violations of human rights and international humanitarian law “stemming from the Russian aggression in Ukraine.”8
The world must insist on the enforcement of UN Security Council Resolution 2286's safeguards to protect healthcare in conflict and ensure that evidence of war crimes and other human rights violations is meticulously gathered, preserved, and documented. As Peter Maurer, president of the International Committee for the Red Cross has noted: “After outrage must come action, not complacency.”9 The haunting image of a pregnant woman in Mariupol reminds us.
Competing interests: none declared
Provenance and peer review: commissioned, not peer reviewed