Operating under Fire: The Effects of Explosive Weapons on Health Care in the East of Ukraine

Aftermath of a missile strike in Kyiv, Ukraine (March 2022) Aftermath of a missile strike in Kyiv, Ukraine (March 2022) © Алесь Усцінаў on Pexels

This article is a brief summary of a 2017 report on the effects of explosive weapons on eastern Ukraine's health system in the Donbass War

The work presents a detailed overview of the situation that arose in hospitals and health facilities in Eastern Ukraine due to the massive explosive weapons, used in populated areas by both Ukrainian and separatist government forces of the Donetsk and Luhansk People's Republics.

The methodology of the report is mainly based on interviews and analyses carried out on the field, specifying that deliberate attacks against hospitals, which constitute a war crime, are not considered. Rather, the main objective is to inform about the catastrophic effects, direct and indirect, that explosive weapons can cause  when used against sensitive civilian targets such as healthcare system personnel and facilities.

The first part focuses on the description of some essential notions: the basics of the functioning of explosive weapons (missiles, artillery shells and bombs that can be launched from land, air, or water) and their effects on densely populated areas. Next, the main rules of International Humanitarian Law concerning this context, the precautions to be followed, as well as the concept of the right to health as set by the Human Rights Law.

A brief presentation of the historical origins of the conflict in Donbass and the use of explosive weapons follows. With reference to the latter aspect, the report emphasizes how, according to Action on Armed Violence (AOAV), between 2014 and 2016 there were 2,357 civilian victims, which, at the time, constituted 66% of all losses due to explosive weapons in the conflict. Of these, about 89% are attributable to the use of those weapons in densely populated areas. Also, according to AOAV, 90% of these casualties are attributable to the massive use of ground-launched ammunition, such as artillery, mortars, and missile launchers, especially those with multiple capabilities such as the BM-21 "Grad" or the BM-30 "Smerch”, both of Soviet-Russian manufacture. During the same period, fewer casualties are attributable to other types of explosive weapons, such as car bombs, landmines, and improvised explosive devices (IEDs). 

The first part ends with an examination of the Ukrainian health system, focusing on the Donbass region, the center of the conflict. The basic assumption  is that the Ukrainian healthcare system is extensive but profoundly qualitatively inadequate compared to the European efficiency standards. Quoting World Bank and the Ukrainian Ministry of Health, the report attributes these shortcomings, among other things, to high costs for patients, economic constraints on public spending, insufficient equipment, and high corruption rates. The outbreak of the conflict in the east of the country has slowed the insufficient efforts of the public administration to reform the health system, and military operations have caused various direct and indirect damage to the hospital service.

The second part, focuses on analyzing the nature and consequences of these damages on the Ukrainian national health system, shedding light on some of the most relevant bombing cases and attacks at the time of the drafting of the report. Mentioning the incidents occurred in Krasnohorivka and Avdiivka, two villages both located in the Donetsk Oblast, The report examines cases when indirect effects were most severe. In both cases, massive shelling has involved local hospitals, causing various direct damages such as destroyed windows, entire sections unusable, and damaged ambulances. Such military operations have forced doctors and nurses to relocate most departments to smaller structures and sections, considerably limiting the quality and effectiveness of care and services. In addition to causing casualties and damaging hospital buildings, the use of explosive weapons has also created distress for both patients and healthcare personnel. The members of the latter category have suffered considerable psychological damage due to the desperate working conditions, the lack of adequate tools, and the general situation that sees their safety and that of their patients constantly in danger.

Indirect damage to infrastructure often leads to power outages in hospitals, which make operations drastically more difficult. In addition, the lack of electricity makes the supply of water more complicated, which is essential for maintaining adequate hygiene in health facilities. Other significant infrastructural damages concern the functioning capacity of heat pumps and communication lines with the outside, such as telephone lines, radio, and internet.

Among the indirect damages, the report also examines those that entail difficulties for healthcare personnel in being able to move freely to carry both emergency relief and routine services. In fact, conditions in the field were often so dangerous not to let doctors reach areas where medical assistance was required According to local sources, villages within 10 kilometers of the “line of contact” between the two sides were unable to obtain the necessary medical assistance.

The last section of the second part illustrates  the consequences of the use of explosive weapons on  patient’s care. To do this, the report bases the analysis of  the non-compliance of three out of the  four elements making up the  framework of the right to health according to the general comment number 14 of the Committee on Economic, Social and Cultural Rights (CESCR). These three elements are the quality of health care, which in such situations tends to decrease due to the lack of adequate facilities and qualified personnel, as well as due to the use of improvised treatments. For example, explosions near a clinic in the village of Granitne, in 2015, resulted in the destruction of most of the windows of the structure and the interruption of the supply of gas, electricity, and water which made the fulfillment of operations virtually impossible. This is followed by the availability of basic care and assistance, conditions that inevitably fail due to the often complete lack of both specific health services and external aid unable to carry out operations in war zones. For example, as of  September 2016, in the central hospital of Maryinka (which used to house around 350 beds) only the general clinic and the neurology and therapy departments remained operational.

Finally, the accessibility for the individual patient to obtain routine and emergency medical services not related to injuries or trauma reported in the context of the war, as well as to obtain essential drugs and medicines to deal with specific treatments, as reported by the Deputy Director of Health of the Donetsk Oblast.

The recommendations that the International Human Rights Clinic and PAX propose, in the introduction of the report, are both of a resolutive and a preventive nature. The resolutive recommendation relies on taking precautions in order to prevent medical facilities and their assets from being involved in war actions and that basic health is guaranteed. The preventive one, in the longer term, calls on the parties involved in the conflict to adopt and respect precise guidelines that minimize the use of explosive weapons in densely populated areas.


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