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The invasion of Ukraine by the Russian Federation has been characterised by attacks on healthcare facilities, and the staff and patients within them. From 24 February to 2 June 2022, the World Health Organisation has reported 269 attacks on health services in Ukraine. Such attacks are not unique to this conflict, yet their occurrence within the context of an international ‘state on state’ armed conflict signals a derogation of the Geneva Convention and its Additional Protocols. There is mounting evidence that Russian forces may have engaged in other violations of international humanitarian law (IHL); showing a clear disregard for the inherent protections within IHL. Together with recent historical parallels visible in the conflict in Syria, this represents a stark and concerning modern trend. While there have been no openly publicised attacks against units of the Ukrainian Military Medical Service, the distinction between military and civilian medical facilities is academic in this context. Western military leaders should now be asking what protection the Red Cross will afford to our wounded and their healthcare providers in any future conflict, and what mitigating strategies are urgently needed to reduce the risk from attack.
International Humanitarian Law (IHL)
International Humanitarian Law is a set of rules that seek to limit the effects of armed conflict. IHL has been agreed through treaties; the most notable being the Geneva Conventions. It has evolved to include ‘Customary IHL’ that comes from a ‘general practice accepted as law’. Customary IHL acts to strengthen the protections that the formal treaties offer. The 1949 Geneva Conventions state that military medical units and civilian hospitals shall be protected, respected and not be the object of attack. The 1977 Additional Protocol affords this same protection to civilian medical units. Under Article 18 of the Conventions, civilian hospitals “may in no circumstances be the object of attack, but shall at all times be respected and protected”. Article 16 appositely notes that “expectant mothers, shall be the object of particular protection and respect”.
Expanded in the aftermath of World War Two, the conventions set out the basic rights of civilians and military personnel, and established protection for the wounded and sick. They were ratified by what was then the Soviet Union in 1954. A breach of the Geneva Conventions can be investigated by the International Criminal Court in the Hague. Medical personnel still retain the right to self-defence and to defend their patients. However, that protection is lost if medical personnel step outside their humanitarian function and engage in acts that are harmful to the enemy. The use of medical facilities or medical transport for non-medical means also leads to a loss of protection.
Attacks on Healthcare
The World Health Organisation (WHO) defines an attack on healthcare as “any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access, and delivery of curative and/or preventive health services during emergencies”. The nature of these incidents is varied; attacks with violence, with heavy or individual weapons; abduction, psychological intimidation, or assault of healthcare personnel or patients; militarisation, or removal of healthcare assets; and obstruction to, or criminalisation of healthcare.
An on-line portal has been established as a mechanism for collecting primary source data of attacks on healthcare and has verified the attacks within Ukraine since the start of the war. The WHO has expressed that the rate of these attacks represent ‘a paradigm shift in the strategy and tactics of war’ – and while these attacks are recognised as likely breaches of international law, it may prove difficult to bring those responsible to justice. The consequences of a belief of impunity could place healthcare in even greater danger. However, the indicators of this ‘paradigm shift’ were previously becoming evident in the contemporary conflict in Syria.
From Syria to Ukraine
Doctors working in rebel-held northern Syria have learned not to share the locations of medical facilities with the United Nations after doing so failed to stop them being targeted by airstrikes. At least 70 attacks have taken place against hospitals, health facilities and health workers in Syria’s northwest in recent years. In 2016, in a speech to the United Nations Security Council, the President of Médecins Sans Frontières directly urged world leaders to stop the bombing of hospitals in the city of Aleppo. In 2019 the New York Times collated video footage, radio logs and geolocation data to show that Russian Air Force bombers had deliberately ‘worked’ hospitals in Syria, particularly the Nabad al Hayat Surgical Hospital near the town of Haas in Idlib Province.
In Ukraine, over 270 WHO-verified attacks against medical capabilities in the first 100 days of conflict confirm a strategic and tactical intent. It is immoral to regard such damage to medical facilities at scale as simply ‘collateral’; and it is inconceivable to believe it is simply incompetence. This would indicate gross professional incompetence within a peer adversary. More likely, therefore, it is a deliberate choice to strain the medical logistical chain in managing the injured, undermining military and civilian morale, and directly influencing a political will to surrender.
On 8 March 2022 an attack on the newly refurbished central hospital in Izyum, south of Kharkiv, was typical. “After the first bombing, the windows of the hospital blew out,” the deputy mayor Volodymyr Matsokin told the BBC. A second attack destroyed the hospital’s operating rooms, he added. That day hospital staff were treating children, pregnant women and three newborn babies as well as soldiers and civilians injured in fighting in the region, according to the Ukrainian authorities. They were sheltering in the basement at the time of the attack. “The government had invested millions to provide good facilities with modern equipment,” said Mr Matsokin; “Patients had to climb out of the rubble on their own to escape.”
Of the attacks on healthcare facilities investigated by the WHO, most have resulted in damage to hospitals, medical transport and supply stores. However, WHO has also recorded the probable abduction or detention of healthcare staff and patients.
Attacks on Healthcare in the Military Context
Experience from contemporary conflicts may be used to predict how military health may be targeted in future conflict. Most likely would be indirect attacks using artillery and precision missiles against deployed military medical facilities or military medical transport. Air strikes (including the use of UAVs and drones) using both conventional and unconventional (chemical, simple radiation contamination/dispersal) weapons are also another option, based on both capability and observed intent to use. It is also worth considering the wider definition of attacks on healthcare and assessing how they might impact operations. Under IHL, captured medical personnel do not become prisoners of war, but rather are classed as ‘retained persons’ with rights and responsibilities that vary from those of other captured persons.
The criminalisation of healthcare may see captured medical staff denied their status as retained personnel; something that has already been observed in Syria. Medical staff are subject to criminal proceedings for treating individuals deemed to be enemies. After capture, staff may be intimidated or prohibited from conducting their medical duties based on clinical need, or may be denied the facilities to provide medical care to other prisoners entirely. Intimidation may also be used to deter the non-combatant population and enemy prisoners from accepting medical treatment that they require. This obstruction will see those affected by conflict unable to adequately access available medical care now and in future wars.
If there truly is no longer any innate protection afforded by being in plain sight and showing a Red Cross emblem (or equivalent Red Crescent or Red Crystal), is it time for a real-world reset in how permanent civilian medical facilities with a war role are constructed, and how temporary military facilities (whether Role 1 primary care; or Role 2 and Role 3 secondary care) operate when they are deployed in the field?
Trân Châu Hospital Cave in Vietnam, built from 1963-65 with the help of the Chinese, was a concrete bombproof cave laid out over three stories; the bottom two stories acted as a military hospital, and the tiny third floor acted as a safe house for Viet Cong leaders. The shelter was equipped with access to fresh water and ventilation shafts. Hospital Cave was abandoned in 1975 at the end of the war. It had included an operating theatre, several recovery rooms, and a huge natural cavern that was used as a group (cinema) room for the recovering soldiers. The conflation of its use for medical reasons and to protect senior leaders would have removed its protection under the Geneva Conventions. A similar concept was observed within the German Underground Hospital on Jersey, constructed during World War 2 and ‘The Cave’ in Syria.
The Israeli Field Hospital in Western Ukraine has shared its location with the Russian and Ukrainian Forces. In other theatres, this is not so. According to Michiel Hofman from Médecins Sans Frontières, the targeting of hospitals and humanitarian workers in war is becoming a “new normal”. Speaking in 2016, Hofman accused permanent members of the UN security council of being complicit in the killing of medics. He offered a grim analysis, saying instead of rebel groups it was conventional armies that were repeatedly violating the laws of war. Hofman chided the permanent members of the Security Council, saying such a situation had not occurred since the Korean war in the 1950s.
An anti-terrorism law passed in 2012 by the Syrian parliament declared illegal any medical facility operating in opposition-held areas without government approval, effectively making them legitimate targets for Assad’s air force. Since then, clinics in the rebel-controlled parts of the country have gone underground, sometimes literally in caves and basements, and they refuse to share their GPS coordinates for fear of being targeted.
Active – Protect
If hospitals are predictably vulnerable to attack, should they be protected to the same degree as a Military Force Headquarters? Do they require any additional point defence beyond what could be expected from a broader air defence umbrella? Options might include Phalanx/CIWS/Iron Dome/Patriot missile defence systems; or Trophy (Windbreaker) style active protection systems against ATGMs, RPGs and HEAT rounds and a Rheinmetall Skynex system to counter drone attack. Medical personnel are justified to defend themselves and their patients, including with long-barreled weapons. If there is any ethical justification to extend beyond a personal weapon it must be balanced with the ontological sense of being a healthcare worker—in other words, can a healthcare worker ‘square their conscience’ with bearing offensive arms? To some, this is contrary to one of the fundamental precept of medicine: primum non nocere—first, do no harm, but may illustrate and extend one of the perpetual dichotomies of military medicine: In care under fire, the first actions of the caregiver are; to return fire, to win the firefight, and only then, apply tourniquets and dressings.
Hide – Disguise
All medical telemetry, including anaesthetic monitoring equipment and surgical diathermy, emits RF energy. If the frequencies are similar to other military hardware they might simply be lost in the overall RF noise. Yet if such frequencies are distinct or unique, they might be a means to identify and deliberately target a medical treatment facility. Where similar, and where medical capabilities are being deliberately targeted, could the signals be disguised, Faraday caged or even manipulated to spoof the enemy’s SIGINT?
Hide – Mobile
With deep fires, cruise missiles and short-ranged ballistic missiles such as the Iskander, modern battlefields are non-linear. A whole country can and will be attacked, as has been observed in Lviv to the west of Ukraine. Cruise missiles such as the 3M-14K Kalibr have a range of 2,000-2,500km. Any static medical facility is therefore vulnerable to long range targeting. A continuously mobile resuscitation and operating theatre capability may offer advantage: As examples, Estonia and Jordan have exploited truck-mounted clinical complexes that include resuscitation, surgery, critical-care and laboratory services to create an agile and mobile capability.
Remote – Drones
Unmanned aerial vehicles can fly at 300km. Subject to air superiority; we might choose to site our hospital units and medical facilities (relatively) far-away from the battlefield and even in a neighbouring nation, using UAVs to transport casualties. As an illustration, Odessa (Ukraine) to Chisinau (Moldova) is 178km by road or 35 minutes by fast drone. Updated guidance systems mean that these aircraft can fly below radar and almost below line of sight at 15m altitudes, using guidance systems previously only seen on Tomahawk cruise missiles (GPS, INS, TERCOM, and DSMAC). As noted in a previous Wavell Room paper, the potential for use of drones within medical support is being explored within many military and civilian communities.
When en route to pick up a casualty, a drone can be regarded as ‘expendable’. On the return journey only the casualty is at human risk, but the alternative is an expensive and almost strategic risk that involves the aircrew and the medical treatment team. A MERT helicopter is a very large, and a very high-value target. The loss of perhaps even two such platforms might be campaign altering in the eyes of the public. A specific limitation to UAV transport without a treatment team is it represents CASEVAC (no intervention during flight) rather than MEDEVAC (dynamic intervention during flight).
Where the key outcome determinant is time to hospital and time to surgical intervention, the rationale for CASEVAC may prevail; but where continuous intervention is needed to assure outcome, MEDEVAC becomes essential. Remote, robotic-led interventions are being developed. A recent analysis of 1267 US combat casualties showed that only 47% would have needed any medical intervention in flight and thus ‘could have been transported safely by UAV’. The obvious solution therefore becomes intelligent hybrid use of the available transport systems. Drones offer the potential for applying greater precision while reducing the demand for the more sophisticated MEDEVAC platform and at less risk.
The Russian invasion of Ukraine is an inflection point in contemporary Euro-Atlantic security; it is also a specific challenge to the framework of ethical behaviour of states in abiding to the protection of medical services from deliberate harm. Medical services, both military and civilian, have historically relied on protection from a symbol (the Red Cross, or associated emblem) and a principle (the Geneva Convention and Additional Protocols). This has not been enough in Syria or Ukraine, where there are serial examples and a consistent trend of International Humanitarian Law being abused by state aggressors. How medical facilities and transport are better protected for the future, and how they operate differently to reduce their attrition, must be a planning and capability priority. Medical care contributes to the moral component and the will to fight. It is a key enabler to mission success.
Without evidence to the contrary, in any future peer-on-peer conflict where a military force does not have any degree of clear air-superiority, it is our opinion, with great regret, that the Red Crosses which we currently wear and display will provide nothing except a target for the enemy.