Between enemy lines: the destruction of health care in Ukraine

Since the escalation of the war in February 2022, MSF has expanded its humanitarian activities in Ukraine, with an emphasis on support for people living near the frontline, where the humanitarian and medical needs are most acute. This support has taken the form of surgical and emergency room care, evacuating patients to medical facilities further from the frontline, providing essential medicines and medical equipment, establishing mobile medical clinics, and providing physiotherapy and mental health care. 

Following the frontline’s shift toward the southeast, MSF teams assessed the medical and humanitarian needs of people in 161 towns and villages that had been caught between shifting frontlines in Donetsk and Kherson regions. The aim was to provide medical treatment for those still living in the contested territory; often the medical teams worked as close as 12 km from the frontline. What they witnessed was a pattern of devastation: homes, shops, playgrounds, schools, and hospitals reduced to rubble by incessant shelling and bombing.  

Drobysheve, a village in Donetsk region, was one such location. MSF medical teams could not find a single building left with the structural integrity to serve as a makeshift clinic; in the end they repurposed imported shipping containers as clinics. They followed this practice in 10 different villages in Kherson and Donetsk regions.  

As with Drobysheve, some of the villages in Kherson and Donetsk regions have undergone two or three changes of control between the two sides, involving heavy fighting. In the battle for villages like Drobysheve, it is very likely that the destruction arose from the use of heavy artillery by both sides, leaving little respite for those caught in the middle. 

In areas of Kherson region retaken by Ukrainian forces, according to Kherson Regional Authorities, 89 medical facilities have been damaged beyond functioning. Based on the towns and villages where these facilities were and taking into account the number of people who have been displaced, this leaves more than 163,000 people with no access to medical facilities. 

Attacks on health care infrastructure 

In early 2022, MSF medical workers were already seeing attacks on health care infrastructure using various weapons. On two separate occasions, MSF medical teams witnessed the apparent impact of cluster munitions on hospitals. On April 4, 2022, a team from MSF visited Mykolaiv town, in southeast Ukraine, to meet with city and regional health authorities. At around 3:30 pm, as the team entered the city’s oncology hospital, which has been treating wounded patients since the end of February 2022, the area around the hospital came under fire from Russian forces.

Following several explosions near them, the team emerged from their shelter and saw dead and wounded people in the street. Later that day, they witnessed an attack that hit the city’s pediatric hospital. There was no massive crater, as with so many other explosions; instead, there were numerous small holes in the building and ground surrounding the area—an impact consistent with the use of cluster munitions.

On the morning of June 15, 2022, another MSF team witnessed similar damage in Apostolove hospital directorate, in the south of Dnipro region. This was a functioning hospital which had come under fire during the night. Once again there were hundreds of holes in the hospital building and ground, and fragments of shrapnel in the clinic and surrounding area. As a result of this attack, medical activities were suspended by the director of the hospital and MSF medical teams for several days until the area had been decontaminated and confirmed safe, effectively denying patients access to medical care in case of emergency.   

Following the Ukrainian counter-offensive, MSF was able to reach numerous medical facilities located in former Russian-occupied areas in both Kherson and Donetsk regions. MSF medical teams discovered that the facilities had been looted, while medical vehicles including ambulances had been destroyed. Inside two of these facilities they saw weapons and explosives.  

While the widespread destruction of civilian infrastructure by shelling and airstrikes has been well-documented in this war, MSF also witnessed three separate instances of the presence of anti-personnel landmines inside functioning hospital compounds—on October 8, 11, and 15. These medical facilities were in areas previously under Russian occupation in Kherson, Donetsk, and Izyum regions. 

A further fatal illustration of the dangers faced by health care facilities and providers was exemplified by the shelling of Kherson city’s main square on December 16, 2022, where MSF had previously established a mobile medical clinic, but stopped activities because of the danger of shelling. After MSF’s withdrawal, the Ukrainian Red Cross resumed mobile medical clinics; when the site was hit, two people were killed. 

Health care under occupation 

Between November 15, 2022 and February 19, 2023, MSF’s medical teams provided around 11,000 consultations to people in towns and villages in formerly Russian-occupied areas of Donetsk and Kherson regions. These teams observed that people who had been unable to flee had few options for accessing health care. The majority (65 percent) of patients were older, less mobile or suffering from chronic diseases, including chronic hypertension, cardiovascular disease, and diabetes. Often these chronic diseases had gone untreated for several months, while food shortages had prevented them from controlling their diets, leading to problems with mobility, eyesight, and muscle function, and increasing their dependence on others.  

From November 2022 to January 2023, MSF conducted 48 interviews with patients and health practitioners, who described access to essential medicines and medical care being severely restricted during the Russian occupation. This corroborated reports from many more private consultations between MSF staff and patients. According to the patients and health practitioners, those medical facilities and pharmacies that were not destroyed were looted, while the supply of medicines was not assured by the occupying forces.

A doctor In the Kherson region said, “Only a few doctors and medical staff remained in the hospital when Russian troops entered our town. We had no surgeons at all. People with shrapnel injuries were brought to the hospital every day. We helped them."

Gradually, he said, they began to run out of medical supplies. "We did not have urethral catheters, which are needed for people with serious injuries who are being treated in intensive care and cannot get up. We had to soak these catheters in special solutions and then reuse them." They didn't have urine collection bags and used bottles instead.

The difficulties of obtaining medicines and accessing medical care is further corroborated by messages sent by mobile phone between MSF medical teams and Ukrainian doctors and nurses working in Russian-occupied areas of Kherson and Zaporizhzhia regions who made repeated requests to be supplied with essential medicines.   

From May to September 2022, MSF was able to fulfil a limited number of these requests with the support of Ukrainian volunteer organizations, who worked to move essential medicines and supplies from Ukrainian-held territory to areas under Russian military control. The only officially authorized crossing point at the frontline was in Vasylivka, a town in Zaporizhzhia region. However, from September 2022, the flow of supplies entering Russian-occupied areas from Ukraine was impeded, and MSF teams had no option but to stop sending medical supplies.

According to patients’ reports, some people survived for months without essential medicines in areas with fierce fighting; many were visibly weakened by their experiences, which frequently included seeing their villages turned into battlegrounds, relentless shelling and the disappearance and death of family members. 

Patients told MSF that their ability to obtain treatment from medical facilities was curtailed by a number of factors, including restrictions on their movements. In several instances, villagers were not allowed to leave their streets for months at a time, even to look for essential medicines. 

Because of the destruction of health care facilities, people needing emergency care had to travel much longer distances than before, through dangerous terrain, putting themselves at greater risk. A 65-year-old female patient from Borozenske village in Kherson region described how she had to accompany her husband through 12 checkpoints to an emergency medical consultation while the area was under Russian occupation.

Although it is difficult to discern a clear pattern, the interviews conducted with MSF patients indicate that the treatment of civilians and their access to health care under Russian occupation depended on the unpredictable behavior of individual Russian units. 

Numerous MSF patients described asking occupation authorities for assistance and for medicines, with varying results. Sometimes requests for assistance were flatly refused, even by military doctors; at other times, people were asked to write lists of the medicines required, although these never materialized.

Patients indicated that the behavior of Russian units varied widely, with some actively working to treat wounded civilians and ensure the provision of medicine, while others looted pharmacies and medical facilities.  

Furthermore, medical practitioners who previously lived in areas occupied by Russian forces described to MSF teams the treatment they received at the hands of soldiers, which included intimidation, detention, violence, and ill-treatment. One doctor working in a facility supported by MSF in the Mykolaiv region described how Russian soldiers came to his house to arrest him, interrogated him for two hours, told him they wanted hospital staff to collaborate with them. He was beaten and ordered to stop speaking Ukrainian. 

The doctor then had to follow a road full of landmines and was terrified that he would die in the car. He made it across the fields to the Ukrainian armed forces. He showed them the cuts and bruises caused by the handcuffs on his hands, and they helped him cross to controlled territory to reach his family.

Warring parties must respect international humanitarian law

The level of destruction in the war in Ukraine has been massive, crippling medical infrastructure in the process. This will have a long-term impact on people’s access to health care. In interviews conducted by MSF, patients who lived in territories occupied by Russia since the February 2022 invasion reported severe restrictions on their access to essential medicines and medical facilities, as well as the looting of hospitals and pharmacies. Their reports are consistent with the medical condition of many MSF patients, many of whom went without treatment for months.  

Warring parties must respect international humanitarian law and abide by their obligations to protect civilians and civilian infrastructure; hospitals and other health care facilities must never be targets. Warring parties must allow the unobstructed supply of lifesaving medicines and medical supplies and provide safe and unhindered access to independent humanitarian assistance for those in need.  

 MSF first worked in Ukraine in 1999. Since February 24, 2022, we have significantly scaled up and reoriented our activities to respond to the needs created by the war in Ukraine. Today MSF is working in Apostolove, Dnipro, Fastiv, Ivano-Frankivsk, Kharkiv, Konstiantynivka, Kropyvnytskyi, Kryyih Rih, Kyiv, Lviv, Lyman, Mykolaiv, Odessa, Pokrovsk, Sloviansk, Ternopil, Uzhhorod Zaporizhzhia and Zhytomyr. Our medical services include emergency surgery, tuberculosis treatment, care for survivors of sexual violence, physiotherapy and mental health care. We also run a fleet of ambulances and a specialist medical evacuation train; in 2022, 2,558 patients, including 700 with trauma injuries, were evacuated from near the frontline.