Operating under Fire:The Effects of Explosive Weapons on
Health Care in the East of Ukraine
Harvard Law School International Human Rights Clinic and PAX

www.paxforpeace.nl

Operatingunder FireThe Effects of Explosive Weapons
on Health Care in the East of Ukraine

Cover Illustration
Empty beds and stretchers line a hallway in Avdiivka City Hospital, where damage
from the use of explosive weapons has hindered the provision of health care.
© Anton Skyba for International Human Rights Clinic at Harvard Law School
and PAX / September 2016.
About the Harvard Law School International Human Rights Clinic
The International Human Rights Clinic (IHRC) at Harvard Law School seeks to protect
and promote human rights and international humanitarian law through documentation;legal, factual, and strategic analysis; litigation before national, regional, and international
bodies; treaty negotiations; and policy and advocacy initiatives.
hrp.law.harvard.edu/

Harvard Law School International Human Rights Clinic and PAX

About PAX
PAX means peace. PAX works with committed citizens and partners to protect civilians
in conflict, to end armed violence, and to build peace. PAX operates independently ofpolitical interests.
www.paxforpeace.nl
Satelite Images
All satellite images © Google.
Design and Maps
Tutaev Design
Copyright © 2017 President and Fellows of Harvard College and PAX. All rights reserved.

May 2017

Contents

Table of AcronymsiSummary and Recommendations
Armed Conflict and Health Care in Ukraine
Effects of Explosive Weapons on Health Care
Recommendations

1
2
3
5

Methodology

7

PART I: BACKGROUND

9

1. Explosive Weapons in Populated Areas
Explosive Weapons
Civilian Harm from the Use of Explosive Weapons in Populated Areas
Repercussions of Explosive Weapons on Health Care
International Concern and Response

11
11
13
14
15

2. International Law

17

International Humanitarian Law
International Human Rights Law: The Right to Health1820

3. Explosive Weapons and the Armed Conflict in Ukraine

21

History of the Armed Conflict in Ukraine
Explosive Weapons Used in Ukraine
Civilian Harm from Explosive Weapons in Ukraine
Multi-Barrel Rocket Launchers Used in the Ukraine Conflict

21
23
24
25

4. Health Care System in Ukraine

27

Organizational StructureStandard of Care
Impact of the Armed Conflict

28
28
29

PART II: FINDINGS

31

5. Direct Harm to the Health Care System
Damage to Medical Facilities and Ambulances
Harm to Medical Personnel and Patients

33
33
40

6. Indirect Harm to the Health Care System
Damage to Infrastructure
Travel Risks for Medical Personnel

41
41
48

7. Consequences for Patient Care
Quality of Health Care
Availability of Health Care
Accessibility of Health Care

55
55
60
62

Acknowledgments

67

Table ofAcronyms

AOAVAction on Armed Violence

ARES

Armament Research Services

CESCR

Committee on Economic, Social and Cultural Rights

CIMIC

Civil-Military Cooperation

EKG

Electrocardiograph

EU

European Union

GICHD

Geneva International Centre for Humanitarian Demining

HE/FRAG

High explosive/fragmentation

ICESCRInternational Covenant on Economic, Social and Cultural Rights

ICRC

International Committee of the Red Cross

IED

Improvised explosive device

IHL

International humanitarian law

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i

IHRC

International Human Rights Clinic

INEW

International Network on Explosive Weapons

MBRL

Multi-barrel rocket launcher

MLRS

Multiple launch rocket system

MSF

Médecins Sans Frontières

NGO

Nongovernmental organization

OCHA

Office for the Coordination of Humanitarian Affairs

OSCE

Organization for Security and Co-operation in Europe

SMM

Special Monitoring Mission

UDHR

Universal Declaration of Human Rights

UN

United Nations

UNICEFUN Children’s Fund

UNIDIRUN Institute for Disarmament Research

WHO

World Health Organization

ii

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Donbass Region
Slovyansk

Summary andRecommendations

GOVERNMENTCONTROLLED
AREAS

Kramatorsk

Bakhmut

contact line

Luhansk
People’sRepublic

Mayorsk

Avdiivka

NON-GOVERNMENTCONTROLLED
AREAS

Galytsinivka Karlivka
Krasnohorivka
Kurakhove
MaryinkaStarohnativka
Kamyanka

MariupolDonetskDonetsk
People’sRepublic

S

RussiaGranitne

Kiev

Ukraineince the armed conflict in the east of Ukraine began in 2014, the use of explosive
weapons in populated areas has adversely affected the region’s health care system.
Shelling, by which this report means use of ground-launched explosive weapons,has directly damaged hospitals, destroyed ambulances, and killed or injured healthworkers and patients. Shelling has also inflicted harm indirectly by shutting down infrastructure
and creating travel risks. As a result, the quality, availability, and accessibility of health care—three elements of the right to health—have declined. This situation has exacerbated the conflict-related difficulties faced by civilians in the east of Ukraine. It also exemplifies one of themany humanitarian problems associated with using explosive weapons in populated areas.
Explosive weapons encompass a range of air-dropped and ground-launched weapons, including aircraft bombs, artillery projectiles, rockets, and missiles. Some types have wide area effects
due to their broad radius of destruction, inaccurate delivery system, and/or delivery in salvos ofmultiple munitions. When explosive weapons with wide area effects are used in populated areas,
they almost always cause humanitarian harm. They kill or injure civilians immediately throughblast and fragmentation. They cause buildings to collapse and debris to fly, which can lead tomore civilian casualties. In addition, explosive weapons have reverberating effects; for example,
by damaging infrastructure, they can interfere with the operations of hospitals and schools aswell as compel local people to flee.
Concern about the use of explosive weapons, especially with wide area effects, in populatedareas has grown over the past decade. States, the United Nations (UN) secretary-general, UNbodies, the International Committee of the Red Cross (ICRC), and nongovernmental organizations

North
iv

Map depicts communities referenced in this report. It shows contact line asindicated in International Committee of Red Cross, “#New Normal,” April 2017,https://www.icrc.org/en/document/newnormal-eastern-ukraine.

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20 km
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1

(NGOs) have all condemned the humanitarian harm caused by the practice. A proposal to develop an international political commitment on the topic has gained momentum with a series ofmeetings organized by Austria. In documenting the harm that shelling has caused to Ukraine’s
health care system, this report aims not only to shed light on the serious and ongoing sufferingexperienced by the civilians of one country but also to underscore the need to adopt such an
overarching political commitment and end the use of explosive weapons with wide area effects
in populated areas.
This report is the result of a collaboration between Harvard Law School’s International Human
Rights Clinic (IHRC) and PAX, a Dutch peace organization that is a co-founder of the International
Network on Explosive Weapons (INEW). Part I of the report provides background on explosive
weapons and the situation in Ukraine. Chapters 1 and 2 examine the humanitarian concerns
raised by explosive weapons and the applicability of international humanitarian and human rights
law. Chapter 3 provides an overview of the armed conflict in the east of Ukraine and the role
played by explosive weapons. Chapter 4 provides an assessment of the Ukrainian health caresystem. Part II presents the findings of the report, which are based primarily on field researchdone in September 2016. Chapters 5 and 6 detail the direct and indirect harm that the use of
explosive weapons in populated areas has inflicted on the region’s health care system. Chapter
7 analyzes how this harm has adversely affected patient care.

Armed Conflict and Health Care in Ukraine
The armed conflict in the east of Ukraine emerged from a series of protests, collectively known
as the Euromaidan, about Ukraine’s relations with the European Union (EU) and, by extension,
with Russia. The civil unrest, which began in Kiev, spread east and escalated into armed conflictin 2014. Anti-maidan, pro-Russian armed groups seized territory and declared the Donetsk andLuhansk areas to be independent People’s Republics, although they were not recognized assuch by any UN member state. Ukraine responded with military force.
Over the past three years, all parties to the conflict have inflicted significant humanitarian harmthrough their widespread use in populated areas of explosive weapons, especially those withwide area effects. According to figures from Action on Armed Violence (AOAV), a UK-based
NGO, the use of explosive weapons in populated areas caused more than 2,300 civilian casualties in Ukraine from 2014 to 2016. In 2015, a peace deal known as Minsk II established a bufferzone, requiring the withdrawal of certain explosive weapons. Minsk II has been only partiallysuccessful, however, and fighting has continued along the contact line.
Ukraine’s health care system, which already fell below the standards of other parts of Europe,
has suffered as a result of the conflict. For example, the contact line has made it difficult forcivilians on the government controlled side to access the region’s specialized hospitals locatedin or near Donetsk in the non-government controlled areas. Military checkpoints have prevented
medical personnel from reaching their patients and patients from reaching nearby hospitals andclinics. Ambulances have reportedly come under small arms fire. Most relevant for this report,shelling has interfered with the provision of health care in a number of ways.

2

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Empty benches stand outside a wing of Avdiivka City Hospital that was abandoned after two direct hits by explosive weapons.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Effects of Explosive Weapons on Health Care
The use of explosive weapons in populated areas has directly harmed the health care system inthe east of Ukraine. When explosive weapons have hit hospitals or exploded nearby, they havecaused structural damage, shattered windows, and endangered personnel and patients. On
June 3, 2015, for example, shelling in Krasnohorivka struck an ambulance substation, setting
fire to the ambulance garage and adjacent neurology department. Staff members had to carry
the patients, many of whom were immobilized, across the hospital grounds to the basement ofanother building as shells fell around them. Although no one died in this attack, the substation
had yet to be repaired when IHRC-PAX researchers visited in September 2016.
Shelling has inflicted harm indirectly as well as directly, meaning that the health care system has
felt the reverberating effects of the use of explosive weapons in populated areas. In all of thecities and towns IHRC-PAX researchers visited, shelling had damaged infrastructure, causingwidespread and long-term interruptions to utilities essential to the provision of health care.
Explosive weapons have caused power outages by cutting electric wires and knocking out
transformers. They have interfered with water supplies by breaking water mains leading tohospitals. Explosive weapons have left medical facilities without heat because they severed hot
water pipes and above-ground gas lines. They have also cut communications with hospitals andambulance services by cutting phone lines and damaging cell phone towers. Ongoing shellinghas delayed restoration of services by making it too dangerous for workers to complete repairs.
In addition, new spikes in shelling, such as in Avdiivka in February 2017, have shut down services
previously repaired.

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Effects of Explosive Weapons on Health Care System and People It Serves

Travel Risks

Infrastructure Damage

Indirect Harm

Direct Harm

Consequences
Explosive weapons shattered windows at Maryinka District Central Hospital in Krasnohorivka. While some windows had been replaced
by September 2016, others consisted of broken glass and torn plastic sheeting.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Shelling has also caused indirect harm by making travel dangerous for medical personnel. While
many health workers have risked their lives to reach the hospitals and clinics where they care forpatients, shelling has at times made their journeys impossible. Some medical personnel haveeven felt compelled to leave the region altogether in order to protect themselves and their families. During periods of heavy shelling, the use of explosive weapons has prevented ambulance
personnel from leaving their stations and providing emergency services to residents in need.
The direct and indirect harm caused by the use of explosive weapons in populated areas has
had serious consequences for patient care. Quality has declined because hospitals have had torestrict their operations to confined spaces and treat patients in frigid temperatures. In addition,
medical personnel have had to improvise in their treatment, doing surgery by candlelight, sterilizing equipment off site, and bringing their own water to work in buckets or bottles. The use of
explosive weapons has also reduced the availability of health care. Many facilities have had tocut back on their services, send patients to distant hospitals for care, and rely on outside assistance from the military. Finally, shelling has created problems of accessibility. Civilians have often
found it too dangerous to travel to hospitals or clinics, except in emergencies, and they have had
trouble obtaining medications because security risks contributed to the closure of pharmacies
in the region.

4

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Immediate
Death and Injury

Decline in Quality,
Accessibility, and Availability

The web of direct and indirect harm caused by using explosive weapons in populated areas can kill and injure civilians immediately andcause a decline in the quality, accessibility, and availability of heath care.

Recommendations
To minimize the effects of fighting on the region’s civilian population, parties to the armed conflictin the east of Ukraine should immediately:! Cease the use of explosive weapons with wide area effects in populated areas, and! Take precautions to avoid harming medical facilities, transport, and personnel as well		
as the infrastructure essential for proper health care.
To prevent future harm from the use of explosive weapons in any part of the world, states should:! Cease the use of explosive weapons with wide area effects in populated areas, and! Develop and sign on to a political commitment that seeks to minimize the harm		 caused by the use of explosive weapons in populated areas.

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5

Methodology

I

HRC-PAX researchers conducted field research in Kiev and along the contact line in
the east of Ukraine in September 2016. They interviewed 55 people, including local
residents; doctors, nurses, ambulance personnel, and government health officials;
representatives of UN agencies; members of local NGOs; and military personnel
providing supplementary health care to civilians. Researchers also visited hospitals, clinics,
ambulance stations, and other medical posts to see damage first hand. They updated andsupplemented this information with desk research on explosive weapons, the armed conflictin Ukraine, and the country’s health care system.
This report focuses on the adverse effects of the use of explosive weapons in populated areas
on the Ukrainian health care system and the civilian population it serves. It does not seek to
identify the party responsible for any particular attack or the specific type of explosive weapon
used. In addition, the report does not address intentional attacks on hospitals, which would
amount to war crimes under international humanitarian law unless the facilities were used toharm the enemy. Although it is not always possible to determine the intent behind a particular
attack, researchers sought to document damage caused by the wide area effects of explosive
weapons rather than that caused by direct targeting of medical facilities, transport, or personnel.

6

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7

The IHRC-PAX team traveled to nine communities in government controlled areas just west of
the contact line. They applied for but did not receive permission to travel to non-government
controlled areas, but research suggests the effects of the shelling were similar on both sides ofthe line.1

PART I:BACKGROUND

1

8

See, for example, “Ukraine Conflict: Battle Rages in Donetsk and Luhansk,” BBC News, January 19, 2015,
http://www.bbc.com/news/world-europe-30878406 (accessed April 26, 2017); “Shelling Damages Hospital in Donetsk,”
video, BBC News, January 19, 2015, http://www.bbc.com/news/av/world-europe-33585489/shelling-damages-hospital-in-donetsk (accessed April 26, 2017); Organization for Security and Co-operation in Europe (OSCE), “Latest fromOSCE Special Monitoring Mission (SMM) to Ukraine, Based on Information Received as of 19:30, 8 June 2016,” OSCE
daily report, http://us6.campaign-archive2.com/?u=b11aceda364f8f9afa6cadbbb&id=65d997fda1&e=9f45643c49(accessed April 26, 2017).
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IHRC / PAX ! Operating under Fire9

1. Explosive
Weapons inPopulated
AreasT

he use of explosive weapons in populated areas has become a defining and devastating feature of contemporary armed conflicts. In places such as Iraq, South Sudan,
Syria, Yemen, and Ukraine, civilians have borne the brunt of the harm it has inflicted.
Explosive weapons come in a variety of forms. When used in cities, towns, andvillages, they cause civilian casualties and have ripple effects on daily lives, livelihoods, andthe provision of services. They have severe consequences for health care systems, which are
generally centered where civilians concentrate. The international community has recognized thehumanitarian problems created by explosive weapons and taken the first steps toward creatinga political commitment designed to minimize the harm caused by the use of explosive weapons
in populated areas.

Explosive Weapons
Explosive weapons operate through the detonation of a high explosive substance that createsblast and fragmentation effects. They can be air dropped or ground launched and encompass
a range of weapons, such as tank rounds, artillery projectiles, mortar bombs, rockets, missiles,
and aircraft bombs. They can be factory-made munitions as well as improvised explosive
devices (IEDs).22

10

IHRC / PAX ! Operating under FireInternational Committee of the Red Cross (ICRC), “Explosive Weapons in Populated Areas: Factsheet,” June 14, 2016,
https://www.icrc.org/en/document/explosive-weapons-populated-areas-factsheet (accessed March 2, 2017), p. 1.
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11

The humanitarian impact of explosive weapons is especially great when they have a wide area
effect and are used in populated areas. Wide area effects can come from:! The large destruction radius of an individual munition used,! The inaccuracy of a delivery system,! The delivery of multiple munitions over a wide area, or! A combination of the above.3
When used in places where civilians are concentrated, explosive weapons with wide area
effects will often fail to distinguish between civilians and combatants, civilian objects andmilitary objectives, and thus have an impact that extends beyond the military target.4

Wide Area Effects of Explosive Weapons

Civilian Harm from the Use of Explosive Weapons in Populated
Areas
The vast majority of people affected by the use of explosive weapons in populated areas arecivilians. They are killed or injured by either the weapons’ primary effects, i.e., blast and fragmentation, or secondary effects, such as collapsing buildings and flying debris. Since 2011, Action
on Armed Violence, a UK-based NGO, has done an annual global survey of casualties from
explosive weapons based on English-language media reports in which at least one casualty
was recorded. AOAV’s data does not reflect every casualty but is intended to be an indicatorof the scale and patterns of civilian harm.5 AOAV found that in 2016 more than 32,088 civilians
were reportedly killed or injured by explosive weapons around the world. When explosive
weapons were used in populated areas, civilians represented 92 percent of the casualties.6

1. Combined blast and fragmentation radii ofa single explosive weapon are centered where
the weapon actually detonates.

2. Blast and fragmentation radii are greater
for a weapon with larger explosive content.
1.

2.

3.
3. Inaccuracy of delivery means those blast andfragmentation effects will occur somewhere within alarger area. Where within the wider area the actual
effects will occur cannot be precisely controlled.
Repeated firings will land in slightly different locations.

4. Where multiple warheads are used, even weapons
with smaller individual blast and fragementation radii4.

can create effects over a wide area.

Source: Article 36 and PAX, Areas of Harm: Understanding Explosive Weapons with Wide Area Effects, October 2016,
http://www.inew.org/site/wp-content/uploads/2016/10/PAX-A36-Areas-of-Harm.pdf
A woman in the frontline village of Starohnativka shows a photograph of her home, which was partially destroyed by explosive weapons.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

3
4

12

Ibid.
For studies on the wide area impact of explosive weapons, see Article 36 and PAX, Areas of Harm: Understanding
Explosive Weapons with Wide Area Effects, October 2016, http://www.inew.org/site/wp-content/uploads/2016/10/
PAX-A36-Areas-of-Harm.pdf (accessed April 27, 2017); Armament Research Services (ARES) for the ICRC, Explosive
Weapons in Populated Areas: Technical Considerations Relevant to their Use and Effects, June 3, 2016,
https://www.icrc.org/en/document/explosive-weapons-populated-areas-use-effects (accessed April 27, 2017); Action
on Armed Violence (AOAV), Wide Area Impact: Investigating the Wide-Area Effect of Explosive Weapons, February 2016,
http://www.inew.org/site/wp-content/uploads/2016/03/Wide-Area-Impact-explosive-weapons-in-populated-areas.pdf(accessed April 21, 2017).
IHRC / PAX ! Operating under FireThe use of explosive weapons has significant tertiary or reverberating effects that extend beyond
the killing and injuring of individuals on impact. Demolition of homes causes residents to flee.
Destruction of hospitals and schools leads to a decline in health care and education. People
may lose their livelihoods when factories, offices, or other workplaces are hit. By damaging infrastructure, such as roads, electricity grids, water supply systems, heating, and communications

5

6

For the details of AOAV’s methodology, see AOAV, “Methodology,” https://aoav.org.uk/explosiveviolence/methodology/(accessed March 5, 2017).
Email from AOAV, to PAX, March 27, 2017.
IHRC / PAX ! Operating under Fire13

networks, explosive weapons can interfere with services essential to civilians’ daily lives. Theinterplay of these effects can exacerbate the harm they cause. For example, the loss of electricity
not only affects residential activities but can also undermine the operations of hospitals, schools,
and industrial facilities.7

Consequences for Health Care of Using Explosive Weapons in Populated Areas

Direct Harm

Affected
Object orService

Repercussions of Explosive Weapons on Health Care
Concern about the effects of armed conflict on health care has grown in recent years. Bodies
such as the World Health Organization (WHO) and the Safeguarding Health in Conflict Coalition,a group of international NGOs, have documented attacks on medical facilities and personnel
around the world. According to a WHO publication, “Over the two-year period from January 2014
to December 2015, there were 594 reported attacks on health care that resulted in 959 deaths
and 1561 injuries in 19 countries with emergencies. . . . Sixty-two per cent of the attacks werereported to have intentionally targeted health care.”8

Consequences
for Care

While in some cases health care is intentionally targeted in violation of international law, in others
cases, it is a victim of collateral damage. According to the same WHO publication, in 2014 and2015 at least 20 percent of attacks on health care objects (notably facilities, personnel, and transport) were unintentional, and intentionality was undetermined for another 19 percent.9 The use of
explosive weapons in populated areas was likely responsible for the majority of harm to healthcare objects that were not directly targeted. Because medical facilities are generally situated near
the people they serve, they are particularly vulnerable to the shelling of cities, towns, and villages.
Explosive weapons can affect health care in a number of ways. In addition to killing and injuring
medical personnel and patients, they may damage or destroy hospitals and clinics, leading to adecrease in or cessation of medical services. Shelled roads and travel risks can interfere with thetransport of patients, whether by ambulance or personal vehicle, and block the delivery of supplies and humanitarian aid. Medical personnel may be unable to reach their workplace or forced
to flee the region. Explosive weapons can also shut down utilities, such as electricity, water, andgas, which are necessary for the provision of proper care. Together these effects can lead to a
decline in the quality, availability, and accessibility of health care and harm the civilians who depend on it.

7

8

9

14

For an extensive list of reports on the humanitarian impact of explosive weapons in populated areas as documented
by NGOs and other actors, such as the UN Office for the Coordination of Humanitarian Affairs (OCHA), see International
Network on Explosive Weapons (INEW), “Learn More,” www.inew.org/learn-more-about-inew (accessed April 21, 2017).
World Health Organization (WHO), Attacks on Health Care: Report on Attacks on Health Care in Emergencies, 2016,
http://who.int/hac/techguidance/attacksreport.pdf?ua=1 (accessed March 2, 2017), p. ii.
Ibid., p. 7.
IHRC / PAX ! Operating under Fire

Indirect Harm

Declinein Accessibility

Declinein Availability

Declinein Quality

Affected
Civilian

The use of explosive weapons in populated areas can directly harm hospitals, ambulances, and health workers and cause indirect harmby damaging infrastructure and creating travel risks. This harm can have significant consequences for the level of health care and thepatients who need it.

International Concern and Response
The civilian harm caused by the use of explosive weapons in populated areas has generated
increasing concern in recent years. As of May 2017, more than 75 countries from all regions of
the world had recognized in official statements the humanitarian problems caused by explosive
weapons.10 The UN secretary-general has repeatedly drawn attention to the weapons’ adverse
impacts since 2009.11 In 2016, for example, the secretary-general urged states to “raise awareness of the widespread and predictable pattern of harm that results from the use of explosive
weapons with wide-area effects in populated areas” and called on parties to any armed conflictto “refrain from using explosive weapons with wide-area effects in populated areas.”12 Several
other UN bodies and representatives, such as the UN Children’s Fund (UNICEF), the UN emergency relief coordinator, the special representative of the UN secretary-general on children and

10
11

12

INEW, “Acknowledging the Harm,” www.inew.org/acknowledgements (accessed March 2, 2017).
UN Security Council, “Report of the Secretary-General on the Protection of Civilians in Armed Conflict,” S/2009/277,
May 29, 2009, http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2009/277 (accessed March 2, 2017), para. 36.
UN Security Council, “Report of the Secretary-General on the Protection of Civilians in Armed Conflict,” S/2016/447,
May 13, 2016, http://reliefweb.int/sites/reliefweb.int/files/resources/130516%20SG%20report%20on%20PoC%20-%20
advance%20copy.pdf (accessed March 2, 2017), paras. 67-68.
IHRC / PAX ! Operating under Fire15

armed conflict, and the UN Office for the Coordination of Humanitarian Affairs (OCHA) havehighlighted the issue and echoed the secretary-general’s call to avoid using explosive weapons
with wide area effects in populated areas.13
The International Committee of the Red Cross and civil society have also vocally criticized theuse of explosive weapons in populated areas. In a 2016 statement to the UN Security Council,
for example, the ICRC said, “Especially in urban environments these weapons are prone to indiscriminate effects, with often devastating consequences for civilians.”14 The ICRC concluded that“the use of explosive weapons with a wide impact area should be avoided in densely populatedareas.”15 The International Network on Explosive Weapons, a worldwide coalition of NGOs, has
actively campaigned for an end to the use of explosive weapons with wide area effects in populated areas, and its member organizations have bolstered its case by documenting the humanitarian harm the weapons have caused around the world.16
The mounting opposition to the use of explosive weapons, especially with wide area effects, in
populated areas, has led to a push to develop an international political commitment on the topic.
Since 2013, meetings convened by Norway, Chatham House, OCHA, and the ICRC have examined the problems of explosive weapons and ways to address them.17 In September 2015, Austria
hosted a group of governments, UN agencies, and civil society organizations to discuss the proposal to adopt a political commitment designed to minimize the humanitarian impacts of the useof explosive weapons in populated areas. Reaching Critical Will, a member of INEW, reported,“At the end of the meeting, many of the participating governments indicated support for developing a political commitment on this issue. . . . The outcome is a great step toward reducing humansuffering.”18 The UN secretary-general has expressed support for such work, urging states to“collect and share practice and policy on minimizing such harm and engage constructively in theongoing process to develop a political declaration addressing the issue.”19 Austria organized afollow-up meeting in October 2016 and further meetings are expected.

13

14

15
16

17

18

19

16

UN Children’s Fund (UNICEF) United Kingdom, Keeping Children Safe in Emergencies, November 2, 2015,
https://www.unicef.org.uk/publications/keeping-children-safe-in-emergencies/ (accessed March 2, 2017), p. 14;
Under-Secretary-General and Emergency Relief Coordinator Valerie Amos, “Security Council Briefing on Protection of
Civilians,” February 12, 2014, https://docs.unocha.org/sites/dms/Documents/USG%20Valerie%20Amos%20Security%20
Council%20Remarks%20on%20POC%2012Feb2014.pdf (accessed March 2, 2017); UN General Assembly, “Report of
the Special Representative of the Secretary-General for Children and Armed Conflict,” A/68/267, August 5, 2013,
http://www.un.org/en/ga/search/view_doc.asp?symbol=a/68/267 (accessed March 2, 2017), paras. 12, 14, and 19;
OCHA, “Protecting Civilians from the Use of Explosive Weapons in Populated Areas,” August 11, 2016,
https://docs.unocha.org/sites/dms/Documents/EWIPA%20Fact%20Sheet%20-%20Latest.pdf (accessed March 2, 2017).
ICRC, “Protection of Civilians: ICRC Statement to the UN Security Council,” January 19, 2016,
https://www.icrc.org/en/document/icrc-vice-president-speech-protection-civilians-un-security-council-debate(accessed March 2, 2017). See also ICRC, “International Humanitarian Law and the Challenges of Contemporary
Armed Conflicts,” report for the 31st International Conference of the Red Cross and Red Crescent, October 2011,https://www.icrc.org/eng/assets/files/red-cross-crescent-movement/31st-international-conference/31-int-conference-ihlchallenges-report-11-5-1-2-en.pdf (accessed March 2, 2017), pp. 40-42.
ICRC, “Protection of Civilians: ICRC Statement to the UN Security Council,” January 19, 2016.
For a list of some of INEW members’ publications, see INEW, “Learn More,”
http://www.inew.org/learn-more-about-inew#inew-member-material (accessed March 2, 2017).
Reaching Critical Will, “Ending the Use of Explosive Weapons in Populated Areas,” http://www.reachingcriticalwill.org/
news/latest-news/10180-ending-the-use-of-explosive-weapons-in-populated-areas (accessed March 2, 2017).
Reaching Critical Will, “States Move to Stop Bombing and Bombardment in Towns and Cities,”
http://www.reachingcriticalwill.org/news/latest-news/10182-states-move-to-stop-bombing-and-bombardment-in-townsand-cities (accessed March 2, 2017).
UN Security Council, “Report of the Secretary-General on the Protection of Civilians in Armed Conflict,” S/2016/447,
May 13, 2016, para. 68.
IHRC / PAX ! Operating under Fire

2. InternationalLawW

hen used in populated areas, explosive weapons, especially with wide area
effects, pose threats to civilians that raise concerns under several provisions ofinternational law. International humanitarian law, also known as the laws of war,prohibits attacks that fail to distinguish between civilians and combatants andrequires states to take precautions to protect civilians during attacks. International human rights
law establishes a right to health, which entitles people to “timely and appropriate” health care.20
Although this report does not seek to identify specific violations of international law, it documents
harm to the health care system that generally runs counter to these legal frameworks. The harm
reinforces the need for a political commitment to create a clear standard against the use of explosive weapons with wide area effects in populated areas.

20

Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 14, The Right to the Highest
Attainable Standard of Health (Art. 12), U.N. Doc. E/C.12/2000/4 (2000), para. 11.

IHRC / PAX ! Operating under Fire

17

International Humanitarian Law
Distinction
International humanitarian law places limits on the means and methods of warfare,21 and one ofits cornerstones is the principle of distinction. This principle requires parties to an armed conflictto distinguish at all times between civilians and combatants as well as between civilian objects
and military objectives.22 While civilian objects can lose their protected status if used to “make aneffective contribution to military action,” when in doubt, an object is presumed to have a civilian
purpose.23 According to the ICRC, the principle of distinction is customary international humanitarian law applicable in international and non-international armed conflicts.24
Indiscriminate attacks, which are unlawful, breach this principle. They include attacks that are:! Not directed at a specific military objective,! Employ a method or means of combat which cannot be directed at a specific military		objective, or! Employ a method or means of combat the effects of which cannot be limited as required		by international humanitarian law.25
The second and third types of indiscriminate attacks are most relevant to this report. The useof explosive weapons with wide area effects is problematic because such weapons generally
cannot be directed at a specific target and have effects that cannot be sufficiently limited. As
a result, their use in populated areas frequently inflicts harm on civilians and civilian objects.
In 2011, the ICRC stated, “The use of explosive weapons in densely populated areas exposes
the civilian population and infrastructure to heightened—and even extreme—risks of incidental
or indiscriminate death, injury or destruction,” and recommended it be avoided if the weapons
had a “wide impact area.”26 Certain explosive weapons, notably cluster munitions and antipersonnel landmines, have been banned under all circumstances because they were considered
indiscriminate especially when used in populated areas.27
International humanitarian law expressly prohibits two specific types of indiscriminate attacks.
First, it prohibits “attacks by bombardment by any methods or means which treats as a single
military objective a number of clearly separated and distinct objectives located in a . . .

21

22

23
24
25
26

27

18

See, for example, Protocol Additional to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victimsof International Armed Conflicts (Protocol I), adopted June 8, 1977, 1125 U.N.T.S. 3, entered into force December 7, 1978, art.
35(1) (“In any armed conflict, the right of the Parties to the conflict to choose methods or means of warfare is not unlimited.”).
ICRC, Customary International Humanitarian Law (IHL) Database, Rules 1 and 7,
https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul (accessed March 2, 2017). Many of the provisions that the
ICRC considers customary rules also appear in Protocol I to the Geneva Conventions, although that treaty applies only
to international armed conflicts. For the principle of distinction, see also Protocol I, art. 48.
ICRC, Customary IHL Database, Rules 8 and 10. See also Protocol I, art. 52.
ICRC, Customary IHL Database, Rules 1 and 7.
Ibid., Rule 12. See also Protocol I, art. 51(4).
ICRC, “International Humanitarian Law and the Challenges of Contemporary Armed Conflicts,” pp. 41-42. Citing Protocol I’s
negotiating history, the ICRC noted, “The prohibition of indiscriminate attacks was specifically ‘intended to take account of
the fact that means or methods of combat which can be used perfectly legitimately in some situations could, in othercircumstances, have effects that would be contrary to some limitations contained in the [First Additional] Protocol,
in which event their use in those circumstances would involve an indiscriminate attack.’” Ibid., p. 41.
Convention on Cluster Munitions, adopted May 30, 2008, CCM/77, entered into force August 1, 2010; Convention
on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction(Mine Ban Treaty), adopted September 18, 1997, 2056 UNTS 241, 36 ILM 1507, entered into force March 1, 1999.
IHRC / PAX ! Operating under Fire

concentration of civilians or civilian objects.”28 The use of explosive weapons with wide area
effects in a populated area often falls into this category because the weapons blanket an arearather than strike a single military target.
Second, international humanitarian law prohibits attacks that violate the principle of proportionality. In other words, an attack is unlawful if it “may be expected to cause incidental loss of civilian life, injury to civilians, damage to civilian objects, or a combination thereof, which would be
excessive in relation to the concrete and direct military advantage anticipated.”29 Although theproportionality of particular attacks is determined on a case-by-case basis, significant civilian
harm is foreseeable whenever explosive weapons, especially those with wide area effects, areused in populated areas. A proportionality analysis should account for this expected harm, including both direct and reverberating effects.30
Precautions in Attacks
International humanitarian law also requires parties to an international or non-international armed
conflict to take precautions to avoid harm to civilians. The ICRC’s Customary International
Humanitarian Law Database states, “In the conduct of military operations, constant care shallbe taken to spare the civilian population, civilians and civilian objects.”31 In particular, parties to aconflict should take “all feasible precautions . . . to avoid, and in any event to minimize, incidental
loss of civilian life, injury to civilians and damage to civilian objects.”32 Using explosive weapons
with wide area effects in populated areas generally runs counter to the requirement to take steps
to minimize civilian harm.
Protection of Medical Objects and PersonnelInternational humanitarian law includes many customary provisions related to health care. Article
18 of the Fourth Geneva Convention states, “Civilian hospitals . . . may in no circumstances be
the object of attack, but shall at all times be respected and protected by the Parties to the conflict.”33 Hospitals only lose that protection if they are no longer used for “humanitarian duties”
and parties use them to commit “acts harmful to the enemy.”34 Other provisions of international
humanitarian law establish protections for medical units and transport.35 Although these rules
focus on preventing intentional attacks on medical objects and personnel, they illustrate that international humanitarian law highly values the provision of medical care and considers it worthyof protection. As this report will show, the use of explosive weapons in populated areas endangers the health care system, even when that is not the underlying intent.

28

29
30

31
32
33

34
35

ICRC, Customary IHL Database, Rule 13. See also Protocol I, art. 51(5)(a). Protocol III to the Convention on Conventional
Weapons has defined “concentration of civilians” broadly to mean “any concentration of civilians, be it permanent or temporary,such as in inhabited parts of cities, or inhabited towns or villages, or as in camps or columns of refugees or evacuees, orgroups of nomads.” Protocol on Prohibitions or Restrictions on the Use of Incendiary Weapons (Protocol III) to the Convention on Conventional Weapons, adopted October 10, 1980, 1342 U.N.T.S. 137, entered into force December 2, 1983, art. 1(2).
ICRC, Customary IHL Database, Rule 14. See also Protocol I, art. 51(5)(b).
ICRC, “Q&A on the Issue of Explosive Weapons in Populated Areas,” International Review of the Red Cross (2016), pp. 7-8(“While acknowledging that it is both impractical and impossible for commanders to consider all possible effects of an attack,the ICRC considers that those reverberating effects which are foreseeable in the circumstances must be taken into account.”).
ICRC, Customary IHL Database, Rule 15. See also Protocol I, art. 57(1).
ICRC, Customary IHL Database, Rule 15. See also Protocol I, art. 57(1).
Geneva Convention (IV) Relative to the Protection of Civilian Persons in Time of War (Fourth Geneva Convention), adopted
August 12, 1949, 75 U.N.T.S. 287, entered into force October 21, 1950, art. 18. See also ICRC, Customary IHL Database,Rule 35.
Fourth Geneva Convention, art. 19.
See, for example, ibid., arts. 20-22. See also ICRC, Customary IHL Database, Rules 25, 26, 28, and 29.
IHRC / PAX ! Operating under Fire

19

International Human Rights Law: The Right to HealthInternational human rights law considers health to be a “fundamental human right indispensible
for the exercise of other rights.”36 It appears in a number of instruments, including the Universal
Declaration of Human Rights (UDHR) and the International Covenant on Economic, Social andCultural Rights (ICESCR).37 According to the Committee on Economic, Social and Cultural Rights(CESCR), the treaty body that interprets the ICESCR, the right to health encompasses both “theunderlying determinants of health” and “timely and appropriate health care.”38 The latter is particularly relevant to this report’s discussion of the effects of explosive weapons on Ukraine’s healthcare system.
In its General Comment No. 14, the CESCR lays out four elements of the right to health, which
can be used as a framework to judge the standard of health care after the use of explosive
weapons in populated areas. The elements are:Quality: Under this element, “health facilities, goods and services must . . . be scientifically andmedically appropriate and of good quality. This requires, inter alia, skilled medical personnel,
scientifically approved and unexpired drugs and hospital equipment, safe and potable water,
and adequate sanitation.”39
Availability: To meet the standards of this element, “[f]unctioning public health and health-carefacilities, goods, and services, as well as programmes, have to be available in sufficient quantity.”
Availability requires “safe and potable drinking water. . . , hospitals, clinics and other healthrelated buildings, trained medical and professional personnel . . . , and essential drugs.”40
Accessibility: This element has several dimensions, but the one most applicable to this report isphysical accessibility, which requires that “health facilities, goods and services . . . be within safe
physical reach for all sections of the population.”41
Acceptability: This element mandates that “health facilities, goods and services . . . be respectfulof medical ethics and culturally appropriate.”42 It is less relevant to the discussion of the effects
of explosive weapons.
Chapter 7 will employ these elements (except for acceptability) to evaluate how the use of
explosive weapons in populated areas has affected health care in the east of Ukraine.

36
37

38
39
40
41
42

20

CESCR, General Comment No. 14, para. 1.
Universal Declaration of Human Rights (UDHR), adopted December 10, 1948, G.A. Res. 217A(III), U.N. Doc.
A/810 at 71 (1948), art. 25(1); International Covenant on Economic, Social and Cultural Rights (ICESCR),
adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49,
U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 12.
CESCR, General Comment No. 14, para. 11.
Ibid., para. 12(d).
Ibid., para. 12(a).
Ibid., para. 12(b).
Ibid., para. 12(c).
IHRC / PAX ! Operating under Fire

3. Explosive
Weapons and theArmed Conflictin UkraineFor more than three years, armed conflict has divided Ukraine and caused significant
harm to the civilians living along the so-called contact line that separates government
and non-government controlled areas. Parties to the conflict have used an array of explosive weapons, many of which are notorious for their wide area effects, and they havelaunched the weapons into cities, towns, and villages on both sides of the line. This practice has
killed or injured thousands of civilians in Ukraine and highlights why bringing an end to the use of
explosive weapons with wide area effects in populated areas is a humanitarian imperative.

History of the Armed Conflict in Ukraine
The armed conflict in the east of Ukraine emerged from civil unrest about the country’s relations
with the EU and by extension with Russia, 22 years after Ukraine gained independence fromthe Soviet Union. Protests erupted in Kiev in November 2013 after the Ukrainian government
announced it would suspend the Ukraine-European Union Association Agreement and seek closer
economic ties with Russia.43 In the months that followed, demonstrations, collectively known
as the Euromaidan, took place throughout the country. On February 20, 2014, clashes between

43David Stern, “Ukraine Suspends Preparations for EU Trade Agreement,” BBC News, November 21, 2013,
http://www.bbc.com/news/world-europe-25032275 (accessed March 14, 2017); “Huge Ukraine Rally over EU Agreement
Delay,” BBC News, November 24, 2013, http://www.bbc.com/news/world-europe-25078952 (accessed March 3, 2017);“Ukraine Crisis: Timeline,” BBC News, November 13, 2014, http://www.bbc.com/news/world-middle-east-26248275(accessed March 14, 2017).
IHRC / PAX ! Operating under Fire21

protestors and police in Kiev left dozens of people dead and hundreds more wounded.44 Soon
after, an agreement to settle the political crisis was reached between President Viktor Yanukovych
and the main opposition leaders. The next day, President Yanukovych fled the country. The protestors took control of presidential administration buildings and the Parliament voted to remove
the president from power and establish a new government.45

2017, with OCHA reporting 38 civilian casualties, including 7 deaths, from January 29 toFebruary 2 alone.52

Anti-maidan and pro-Russian elements responded to these developments with their own protests
and government-building takeovers in the east and south of Ukraine, especially in Crimea and the
Donbass, which encompasses the Donetsk and Luhansk regions. Russian President Vladimir
Putin signed a bill to annex Crimea in March 2014, and political turmoil in the Donbass soon
escalated into armed conflict. In April, armed groups seized parts of the Donbass, eliciting a
military response from Ukraine. On May 11, 2014, after controversial referendums, separatists
declared Donetsk and Luhansk to be independent “People’s Republics,” although they were
not recognized as such by any UN member state.46

All parties to the conflict in Ukraine have used explosive weapons in populated areas. Human
Rights Watch documented the use of cluster munitions by Ukrainian and Russia-backed rebel
forces at multiple points in the conflict.53 Cluster munitions, which have a wide area effect because
they disperse dozens or hundreds of submunitions over an area the size of a football field, arebanned by the 2008 Convention on Cluster Munitions, to which neither Ukraine nor Russia areparty.54 The Minsk II agreement required the withdrawal of several types of explosive weapons.
It mandated that parties pull out “all heavy weapons to equal distance with the aim of creation of
a security zone [a] minimum 50 kilometres apart for artillery of 100mm calibre or more, and a security zone of 70km for [multi-barrel rocket launchers] and 140 kilometres for [multi-barrel rocket
launchers] Tornado-S, Uragan, Smerch, and tactical missile systems Tochka U.”55 The explosive
weapons specifically named by Minsk II all have wide area effects and have been used frequently
along the front line in the east of Ukraine. In demanding the removal of these explosive weapons,
Minsk II seemed to acknowledge the immense humanitarian impact of their use in populated areas.

Under international pressure, Ukraine, Russia, and the Donetsk and Luhansk People’s Republics
signed the Minsk Protocol and a follow-up memorandum in September 2014. One of the provisions of the memorandum dictated that parties should pull heavy weapons at least 15 kilometers
back from the contact line, thus creating a 30-kilometer buffer zone.47 The agreements werelargely unsuccessful, however. Ongoing hostilities necessitated the signing of a second deal,
known as Minsk II, on February 12, 2015. It laid out 15 military and political measures designed
to bring peace to the region, including an immediate ceasefire and withdrawal of certain heavy
weapons.48

Explosive Weapons Used in Ukraine

Despite some progress toward a cessation of hostilities, conflict in the region has continued.
The Special Monitoring Mission (SMM) of the Organization for Security and Co-operation in
Europe (OSCE)—formally mandated to observe and report on the situation in Ukraine in an
impartial and objective way—has reported numerous breaches of Minsk II.49 Those breaches
have involved several spikes in violence. For example, in June 2015, a major battle, which will
be discussed later in this report, took place in Krasnohorivka and Maryinka. In June-July 2016,
the armed conflict caused 142 civilian casualties, including 20 deaths, according to a UN report;shelling accounted for more than half of those casualties.50 Parties agreed to a ceasefire tomark the start of the school year in early September 2016, and it coincided with the IHRC-PAX
research mission.51 Fighting along the contact line intensified again in January and February

44

45
46
47

48

49

50

51

22

See, for example, Ian Traynor, “Ukraine’s Bloodiest Day: Dozens Dead as Kiev Protesters Regain Territory from Police,”
The Guardian, November 13, 2014, https://www.theguardian.com/world/2014/feb/20/ukraine-dead-protesters-police(accessed March 14, 2017); “Ukraine Crisis: Timeline,” BBC News, November 13, 2014.
“Ukraine Crisis: Timeline,” BBC News, November 13, 2014.
Ibid.
“Memorandum on Stabilizing Ceasefire Another Important Step towards De-escalation, OSCE Chairperson-in-Office
Says,” OSCE press release, September 20, 2016, http://www.osce.org/cio/123808 (accessed March 2, 2017). For
memorandum in Russian, see http://www.osce.org/ru/home/123807?download=true (accessed April 27, 2017).
“Minsk Agreement on Ukraine Crisis: Text in Full,” The Telegraph, February 12, 2015, http://www.telegraph.co.uk/news/
worldnews/europe/ukraine/11408266/Minsk-agreement-on-Ukraine-crisis-text-in-full.html (accessed March 7, 2017).
See generally OSCE Special Monitoring Mission (SMM) to Ukraine, “Daily and Spot Reports from the Special Monitoring
Mission to Ukraine,” http://www.osce.org/ukraine-smm/reports (accessed April 21, 2017).
“UN Warns of Escalating Tension in Eastern Ukraine as Casualties Hit Highest since Last August,” UN News Centre,
August 3, 2016, http://www.un.org/apps/news/story.asp?NewsID=54615#.WL9vY4WADpK (accessed March 14, 2017).
“Ukraine Crisis: New Ceasefire ‘Holding with Eastern Rebels,’” BBC News, September 1, 2016,
http://www.bbc.com/news/world-europe-37243434 (accessed March 14, 2017).
IHRC / PAX ! Operating under FireAn explosive weapon penetrated the road in front of this home in a neighborhood of Krasnohorivka.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

52

53

54
55

OCHA, “Ukraine Update No. 1; Deterioration of the Humanitarian Situation in the East,” February 6 2017,https://www.humanitarianresponse.info/system/files/documents/files/ukraine_update_deterioration_of_the_humanitarian_situation_in_the_east_6_feb_2017.pdf (accessed March 2, 2017).
“Ukraine: More Civilians Killed in Cluster Munitions Attacks,” Human Rights Watch news release, March 19, 2015,
https://www.hrw.org/news/2015/03/19/ukraine-more-civilians-killed-cluster-munition-attacks (accessed April 4, 2017).
Convention on Cluster Munitions, art. 1.
“Minsk Agreement on Ukraine Crisis: Text in Full,” The Telegraph, February 12, 2015.
IHRC / PAX ! Operating under Fire

23

Civilian Harm from Explosive Weapons in Ukraine
Explosive weapons have been a major source of civilian casualties during the armed conflict in the
Donbass. According to AOAV data, from 2014 to 2016, they caused about 2,357 civilian casualties,
which represented 66 percent of all casualties from the use of explosive weapons in Ukraine.56
Eighty-nine percent of the total civilian casualties, i.e., 2,096 casualties, were attributable to theuse of explosive weapons in populated areas in particular.57 Ukraine ranked seventh on AOAV’slist of countries with the most civilian deaths and injuries from explosive weapons in both 2014
and 2015, and twentieth in 2016.58 AOAV noted, however, that the drop in 2016 was partly due tothe decrease in reporting that year because the conflict in Syria overshadowed that in Ukraine.59

attacks, other organizations recorded continued use of the weapons system in 2016 and 2017.62
According to AOAV data, from 2014 to 2016, additional civilian casualties were caused by aerial
weapons, IEDs, mines, car bombs, and attacks involving a combination of delivery methods.63

Multi-Barrel Rocket Launchers Used in the Ukraine Conflict
In Ukraine multi-barrel rocket launchers, which are designed to attack an area rather than
individual target objects, have been especially devastating when used in populated areas.64
They have generally had a higher casualty rate per attack, and the Minsk II agreement specifically required that they be withdrawn to create a security zone. Using a cluster munition warhead on a multi-barrel rocket launcher contravenes the international norm set by the 2008
Convention on Cluster Munitions.65 Regardless of their warhead, multi-barrel rocket launcherspresent serious humanitarian problems when used against towns and cities because of theindiscriminate wide area effect resulting from the large number of munitions they deliver
simultaneously. The information below highlights three multi-barrel rocket launchers usedwidely in Ukraine.

Ukraine deaths and injuries in populated areasfrom explosive violence (2014-2016)
2500
2000
1500

Grad
The BM-21 Grad, meaning “hail” in Russian, can launch up to 40 122mm rockets within 20
seconds.66 Grad rockets can contain different types of warheads, but most commonly deliver
a high explosive/fragmentation (HE/FRAG) warhead. While the original types of rockets firedby the Grad had a maximum firing range of 20 kilometers, more recent versions have a rangeof up to 40 kilometers.67 One rocket has a lethal area68 of between 700 and 850 square meters.69 All rockets in a single salvo land within a rectangular shape of around 54,000 square
meters.70 Both Ukrainian government forces and armed rebel groups have used Grads in the
Donbass.71

1000
500
0

Populated area
Civilians

Not reported as populated
Armed Actors

Courtesy of AOAV, aoav.org.uk.

AOAV found that ground-launched explosive weapons were the most significant cause of civilian
casualties in Ukraine from 2014 to 2016. These weapons were responsible for 2,127, or 90 percent,of the civilian casualties from explosive weapons that AOAV recorded in Ukraine in that period.
Artillery shells, mortar bombs, and rockets were responsible for the majority of those casualties.60
Multi-barrel rocket launchers, which fire rockets in salvos, were particularly deadly, causing an
average of 14 civilian deaths per attack in 2014-2015, while overall, explosive weapons caused
an average of 9 civilian casualties per attack in 2014 and 6 in 2015.61 Although in 2016 AOAV
did not specify whether any casualties were specifically caused by multi-barrel rocket launcher

62

63
64

65

56
57
58

59
60

61

24

AOAV, “Explosive Weapons in Ukraine,” data provided to PAX and IHRC, March 2017.
Ibid.
AOAV, Explosive States: Monitoring Explosive Violence in 2014, May 2015,
https://aoav.org.uk/wp-content/uploads/2015/06/AOAV-Explosive-States-monitoring-explosive-violence-in-2014.pdf(accessed March 7, 2017), p. 11; AOAV, Unacceptable Harm: Monitoring Explosive Violence in 2015, April 2016,
https://aoav.org.uk/wp-content/uploads/2016/05/AOAV-Explosive-Monitor-2015.pdf (accessed March 7, 2017), p. 12;
email from AOAV, to PAX, March 27, 2017.
AOAV, “Explosive Weapons in Ukraine,” data provided to PAX and IHRC, March 2017.
Ibid. In 2014, missiles killed or injured 300 civilians in three incidents, but almost all of these occurred in the shooting
down of Malaysia Airlines Flight MH17 in July 2014. Ibid.
AOAV, Wide Area Impact: Investigating the Wide-Area Effect of Explosive Weapons, p. 20.
IHRC / PAX ! Operating under Fire

66

67

68

69
70

71

See, for example, OSCE, “Latest from OSCE Special Monitoring Mission (SMM) to Ukraine, Based on Information
Received as of 19:30hrs, 8 January 2016,” OSCE daily report, January 8, 2016, http://www.osce.org/ukraine-smm/215211(accessed April 26, 2017); OSCE, “Latest from OSCE Special Monitoring Mission (SMM) to Ukraine, Based on Information
Received as of 19:30hrs, 8 April 2016,” OSCE daily report, April 9, 2016, www.osce.org/ukraine-smm/232316 (accessed
April 26, 2017); OSCE, “Latest from OSCE Special Monitoring Mission (SMM) to Ukraine, Based on Information Received
as of 19:30hrs, 28 July 2016,” OSCE daily report, July 29, 2016, http://www.osce.org/ukraine-smm/257106 (accessed April
26, 2017); Ukraine Crisis Media Center, “SMM OSCE: Third Highest Use of Grad MLRS [Multiple Launch Rocket Systems]
since January 2016 Recorded Last Week,” March 10, 2017, http://uacrisis.org/53573-osce-51 (accessed April 26, 2017).
AOAV, “Explosive Weapons in Ukraine,” data provided to PAX and IHRC, March 2017.
“Multi-barrel rocket launcher” and “multiple launch rocket system” are often used interchangeably, but this report will
use the former because it is a more generic term that encompasses the latter.
Ukraine is not party to the Convention on Cluster Munitions. For an up-to-date list of states party to the convention,
see www.stopclustermunitions.org.
AOAV, “Investigation: Syria’s Dirty Dozen,” September 23, 2013, http://aoav.org.uk/2013/syrias-dirty-dozen-grad/(accessed April 21, 2017).
Geneva International Centre for Humanitarian Demining (GICHD), “122 mm BM-21 Multi Barrel Rocket Launcher (MBRL),”
2017, http://characterisationexplosiveweapons.org/studies/annex-a-122-mm-mbrl/ (accessed March 20, 2017).
“Lethal area” refers here to the area in which a weapon’s effect will incapacitate unprotected adult persons—in otherwords, the area in which all people present will be killed. See ARES, Explosive Weapons in Populated Areas: Technical
Considerations Relevant to their Use and Effects, p. 48.
Ibid., p. 57, Table 2.10: Estimated Lethality of Common Artillery Rockets.
“Ukraine: Unguided Rockets Killing Civilians,” Human Rights Watch news release, July 24, 2014,
https://www.hrw.org/news/2014/07/24/ukraine-unguided-rockets-killing-civilians (accessed April 21, 2017).
Ibid.
IHRC / PAX ! Operating under Fire25

Uragan
The BM-27 Uragan, meaning “hurricane” in Russian, can launch up to 16 220mm rockets
within 20 seconds.72 Each rocket has a lethal area of between 1,700 and 1,950 square meters.73 Rockets for the BM-27 Uragan can be equipped with HE/FRAG warheads, cluster
munitions, enhanced blast warheads, or high explosive or scatterable landmines (PTM-1G,
PTM-3, or PFM-1). A full salvo of 16 rockets can engage targets within a range of 35 kilometers. When launched from its maximum range, a full salvo covers an area of 43,000 square
meters.74 In Ukraine, Uragan rockets have been used with an HE/FRAG warhead variant,scatterable anti-tank mine variant,75 enhanced blast variant,76 and cluster munition variant.77
Both Ukrainian government forces78 and the groups opposing them79 have used Uragans.
SmerchThe BM-30 Smerch or Tornado-M, meaning “whirlwind” in Russian, can launch up to 12300mm rockets in 38 seconds.80 Each rocket has a lethal area of between 2,400 and 2,600
square meters.81 Various warheads have been developed for the Smerch multi-barrel rocket
launcher, including cluster munition, anti-tank mine, HE/FRAG, and fuel-air explosive or enhanced blast variants. The fire range of the Smerch HE/FRAG variant is up to 90 kilometers,
while the cluster munition variant has a maximum range of 50 kilometers.82 In Ukraine bothsides to the conflict used the BM-30 Smerch with cluster munition and HE/FRAG variants.83

4. Health Care
System in
Ukraine

T

72
73

74
75

76

77

78
79

80
81

82
83

26

Military Today, “BM-27 Uragan,” 2017, http://www.military-today.com/artillery/bm27_uragan.htm (accessed April 21, 2017).
ARES, Explosive Weapons in Populated Areas: Technical Considerations Relevant to Their Use and Effects, p. 57,
Table 2.10: Estimated Lethality of Common Artillery Rockets.
Military Today, “BM-27 Uragan.”
Human Rights Watch, “Landmines in Ukraine: Technical Briefing Note,” April 2015, https://www.hrw.org/sites/default/files/
supporting_resources/lm_landmines_in_ukraine-technical_briefing_note_6april2015_final.pdf (accessed April 21, 2017).
N. R. Jenzen-Jones, ARES, “Soviet & Russian ‘Flame Weapons’: Incendiary, Thermobaric, and FAE Systems in Ukraine,”
http://armamentresearch.com/soviet-russian-flame-weapons-incendiary-thermobaric-and-fae-systems-in-ukraine/(accessed March 27, 2017).
“Ukraine: Widespread Use of Cluster Munitions,” Human Rights Watch news release, October 20, 2014,
https://www.hrw.org/news/2014/10/20/ukraine-widespread-use-cluster-munitions (accessed April 21, 2017).
Ibid.
OSCE, “Spot Report by the OSCE Special Monitoring Mission to Ukraine (SMM), 24 January 2015: Shelling Incident on
Olimpiiska Street in Mariupol,” January 24, 2015, http://www.osce.org/ukraine-smm/136061 (accessed March 20, 2017).
Military Today, “BM-30 Smerch,” http://www.military-today.com/artillery/smerch.htm (accessed March 20, 2017).
ARES, Explosive Weapons in Populated Areas: Technical Considerations Relevant to Their Use and Effects, p. 57,
Table 2.10: Estimated Lethality of Common Artillery Rockets.
Military Today, “BM-30 Smerch.”“Ukraine: More Civilians Killed in Cluster Munition Attacks,” Human Rights Watch news release, March 19, 2015.
IHRC / PAX ! Operating under Firehe armed conflict in the east of Ukraine has had significant ramifications for the region’s
health care system. While the country is known for having a broad-reaching and multitiered medical structure, the standard of care has been low for Europe, even without
the fighting.84 In the long run, this situation could make it more difficult for the system
to recover from the conflict and the use of explosive weapons in particular. Systems that havebeen well managed and resourced prior to damage usually recover more quickly than those thathave been neglected.85 In the short term, medical personnel have had to overcome several conflict-related impediments to providing services. As will be detailed in Chapters 5-7, the use of
explosive weapons in populated areas has had many adverse humanitarian impacts, but delays
to reforms, obstacles to access, and heightened security risks have caused additional problems.

84

85

Valery Lekhan et al., Ukraine: Health System Review 2015, 2015,
http://www.euro.who.int/__data/assets/pdf_file/0018/280701/UkraineHiT.pdf (accessed March 4, 2017), p. 21;
Health Strategic Advisory Group, National Health Reform Strategy for Ukraine 2015-2020, 2015,
http://healthsag.org.ua/wp-content/uploads/2015/03/Strategiya_Engl_for_inet.pdf (accessed March 2, 2017), p. 8.
Christina Wille and John Borrie, UN Institute for Disarmament Research (UNIDIR), Understanding the Reverberating
Effects of Explosive Weapons: A Way Forward, 2016,
http://www.unidir.org/files/publications/pdfs/reverberating-effects-research-agenda-en-653.pdf (accessed March 2,2017), p. 5.
IHRC / PAX ! Operating under Fire

27

Organizational Structure
Health care facilities in the east of Ukraine range from nurse’s stations in small villages toadvanced specialty departments at regional hospitals. According to Volodymyr Kolesnyk,
the Ministry of Health’s deputy director for Donetsk Oblast, Ukraine’s health care system canbe divided into four tiers:! Primary care: family medicine services,! Secondary care: district and municipal medical facilities,! Tertiary care: regional hospitals and specialized care units, and! Research laboratories.86
Emergency services, including ambulance substations, are another important component. This
report focuses on primary and secondary health care and emergency services. In September
2016, the region’s tertiary facilities were located in non-government controlled areas inaccessible
to IHRC-PAX researchers.87
Due to the legacy of the Soviet era, Ukraine’s health care system formally falls under the jurisdiction of the national Ministry of Health. In practice, however, much of the control has been
decentralized. A 2015 study described the structure as “a complex multi-layered, sometimes
parallel, system in which responsibilities in the health care sector are fragmented among central
government . . . as well as 27 regional administrations and numerous administrative bodies atmunicipal, district and community levels.”88 Control over primary and secondary services, which
encompasses the majority of health care, has been delegated to local (i.e., municipal and district)authorities. Tertiary and emergency services fall under the responsibility of the Ministry of Health’s
regional administrators, who are “financially and managerially independent.”89 The private healthcare sector, other than pharmacies, is quite small.90

Standard of Care
Despite having “an extensive health care infrastructure,”91 Ukraine’s standard of health carehas fallen far short of European standards, even setting aside the impact of the armed conflict.
A 2014 publication, co-published by the Ministry of Health, found that “Ukraine presents one of
the worst health profiles in the European region.”92 That document expressed concern about highout-of-pocket spending by patients, budgetary constraints, inefficient system design, decline inmedical personnel, poor equipment, and corruption.93 In 2015, the World Bank reported that the

86

87
88
89
90
91
92
93

28

Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk,
September 19, 2016.
Ibid.
Lekhan et al., Ukraine: Health System Review 2015, p. xix.
Ibid., pp. 18-21, 109.
Ibid., p 15; Health Strategic Advisory Group, National Health Reform Strategy for Ukraine 2015-2020, pp. 12-13.
Lekhan et al., Ukraine: Health System Review 2015, p. 21.
Health Strategic Advisory Group, National Health Reform Strategy for Ukraine 2015-2020, p. 8.
Ibid., pp. 11-14.
IHRC / PAX ! Operating under Fire

country’s “health outcomes remain very poor.”94 It found that the system has suffered from “inefficient allocation and use of resources, decades of neglected investments and rampant corruption
in the sector.”95
In November 2014, an advisory group that included the minister of health released a National
Health Reform Strategy for 2015-2020. The minister wrote that the strategy sought to “revitalize
and speed up the process of reforms in Health sector” and aimed to create a more “peoplecentered, outcomes oriented, and implementation focused” health care system.96 The strategy’s
components included reducing what it described as the “exorbitant” number of beds.97 As of
2015, Ukraine had approximately 40 percent more hospitals and hospital beds than the EU
average,98 and the number of beds determined the number of staff members per hospital.99 Whilethe extent of the policy’s implementation is unclear, IHRC-PAX researchers did hear reports that
downsizing had begun and that the government was not always replacing facilities damaged by
the conflict or staff members displaced by it.100 The IHRC-PAX report takes no position on thegovernment’s restructuring of the health care system; instead, it distinguishes the effects of thepolicy from those of the armed conflict. This report focuses on the humanitarian consequencesof the reduction of staff and services attributable to the use of explosive weapons in populatedareas.

Impact of the Armed Conflict
As detailed in the rest of this report, explosive weapons have caused significant damage to thehealth care system in the east of Ukraine. They have not been the exclusive source of harm, however. Changed priorities, a new boundary line, and other security risks have also played a role.
While the loss of staff and departments may have ironically expedited the government’s efforts
to downsize, the armed conflict has generally slowed efforts to reform the health care system.
According to a study published by the World Health Organization in 2015, “conflict and politicalinstability have proved the greatest barrier to reform implementation. . . . [G]overnments havenecessarily concentrated on more pressing humanitarian concerns.”101

Qimiao Fan, “Ukraine’s Health System: Time for Change,” World Bank, April 6, 2015,
http://www.worldbank.org/en/news/opinion/2015/04/06/ukraines-health-system-time-for-change(accessed March 2, 2017).
95
Ibid.
96
Health Strategic Advisory Group, National Health Reform Strategy for Ukraine 2015-2020, p. 18.
97
Ibid., p. 12. The strategy aimed to “[e]liminate duplication and reduce the need for available beds as per the existingnorms.” Ibid., p. 37.
98
Fan, “Ukraine’s Health System: Time for Change,” World Bank.
99
Lekhan et al., Ukraine: Health System Review 2015, p. 23.
100
See, for example, interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member(name withheld), Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016; interview with Dr. Natalia
Dolzhenko, head of therapy department, and nurse in therapy department (name withheld), Maryinka District Central
Hospital, Krasnohorivka, September 20, 2016; interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast,
Ministry of Health, Kramatorsk, September 19, 2016; interview with Dr. Viktoria Nikolova, head of family services andtherapy department, Avdiivka City Hospital, Avdiivka, September 21, 2016.
101
Lekhan et al., Ukraine: Health System Review 2015, p. xxi.
94

IHRC / PAX ! Operating under Fire

29

The contact line that splits the Donbass has had significant impacts on health care for residents.
As of March 2017, the line cut through both the Donetsk and Luhansk oblasts and created an
artificial divide in the region’s health care services. Most of the specialized, tertiary health care islocated in the city of Donetsk, part of the non-government controlled area of the self-proclaimed
Donetsk People’s Republic. Ministry of Health official Volodymyr Kolesnyk told IHRC-PAX researchers in September 2016 that “90 percent of the best equipment” was on that side of the line.102
As a result, to access the care they needed, some residents in government controlled areas have
had to make a lengthy and dangerous trip through the checkpoints to Donetsk city or had totravel to other regions of Ukraine.103 Either approach has been expensive because residents have
had to pay for transport and accommodation.104 People who lack the time, freedom, or money
to travel have often had to forgo specialist health care.
Military activities and security threats, beyond the use of explosive weapons in populated areas,
have also interfered with the provision of health care. Ambulances have reportedly come undersmall arms fire, which has in some cases killed or injured ambulance personnel and patients.105
Checkpoints have prevented medical personnel from accessing patients and patients fromaccessing nearby hospitals and clinics.106 Travel has also been blocked by conflict-related
destruction: for example, retreating forces blew up a bridge that prevented doctors and paramedics based in Galytsinivka from reaching patients.107

PART II:
FINDINGSInterview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk, September
19, 2016.
103
Interview with Marina Papuna, activist; Elena Horhulu, grandmother; and Maria Bero, mother, Starohnativka, September
22, 2016 (statements of all three) (Papuna, whose husband has had to travel to Donetsk city for treatment, said that since
the armed conflict began, what used to be a 45-minute trip has taken six to seven hours due to the checkpoint delays).
104
Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk, September 19,
2016.
105
Ibid. (reporting that sniper fire injured ambulance staff members and a patient in 2015); interview with Dr. Victor Zinchenko,
ambulance general assistance doctor, and staff member (name withheld), Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko) (reporting that two members of their substation and a patientdied when an ambulance was shot at while at a checkpoint); interview with Dr. Lyudmila Tkachenko, head of clinic andgeneral practitioner of family medicine, Galytsinivka Ambulatory Clinic, and paramedic (name withheld), Galytsinivka
ambulance substation, Galytsinivka, September 21, 2016 (statement of paramedic) (recalling, “We received warning
shots at the checkpost . . . over our heads to say we were standing there too long. No one was hurt, but it was scary.”).
106
Interview with Dr. Lyudmila Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka Ambulatory
Clinic, and paramedic (name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21, 2016(statement of Dr. Tkachenko) (saying that “the checkpost was not a check but a block post. I couldn’t get in village
and villagers couldn’t get out.”).
107
Ibid. (statements of both).
10230

IHRC / PAX ! Operating under Fire

IHRC / PAX ! Operating under Fire31

Krasnohorivka Medical Facility

5. Direct Harmto the HealthCare System

Maryinka District Central Hospital

Krasnohorivka ambulance substation headquarters
therapy departmentneurology department

destroyed ambulance garage

HT

he use of explosive weapons in populated areas has directly harmed the health caresystem in the east of Ukraine. Some explosive weapons have hit medical facilities,
damaging structures and destroying ambulances parked on site. Other explosive
weapons have detonated nearby, and their blast and fragmentation have shatteredwindows and caused additional damage to buildings. Shelling has also endangered and sometimes killed or injured health workers and patients.

Damage to Medical Facilities and Ambulances
Krasnohorivka
The impact of shelling on Maryinka District Central Hospital, located in Krasnohorivka, offers astriking example of the harm explosive weapons have inflicted on medical facilities in the region.
This hospital, which serves patients from Krasnohorivka and Maryinka, reportedly housed at leasta dozen departments and about 350 beds before the armed conflict. As of September 2016, only
two departments, a general clinic, and 70 beds remained.108 Shelling has also adversely affected
the Krasnohorivka ambulance substation, which is located on the hospital grounds. As of September 2016, two ambulances continued to operate and were responsible for emergency calls

108

North
32

IHRC / PAX ! Operating under Fire

20 m

Interview with hospital official (name withheld), Maryinka District Central Hospital, Krasnohorivka, September 20, 2016;
interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016.
IHRC / PAX ! Operating under Fire33

within a 30-kilometer radius.109 Victor Zinchenko, a doctor at the substation, reported that a
recent decline in staff numbers had forced the substation to cut a typical ambulance team fromfour people to two. While the downsizing discussed in Chapter 4 contributed to the problem,
Dr. Zinchenko estimated that about 30 percent of the attrition was due to the armed conflict.110

Explosive weapons struck the medical facility on June 3, 2015, causing significant damage. The
shelling in the area reportedly lasted from about 7 to 9 a.m.118 Zinchenko, the doctor at the ambulance substation, said that he had just ended his shift when the shelling began. He and anotherstaff member took cover in the hallway of the substation’s main building, leaving doors open on
both sides to keep shockwaves from blowing the doors off their frames. The blast from a direct
hit on the ambulance garage across the parking lot threw them against the wall, and fragments
left pockmarks in the plaster just above their heads. Dr. Zinchenko remembered the staff trying
to seek cover in the hospital’s basement: “We [were] all running there. It’s very scary when everything is gone. You’re outside with no protection.” The strike and fire it caused destroyed the
garage, which had at least nine ambulance bays. Fire also burned one ambulance, and fragments
damaged other ambulances.119

The painted word “shelter” marks the way to a protected section of Maryinka District Central Hospital in Krasnohorivka. Medical
personnel and patients usually took cover in the hospital’s basement during the worst of the shelling.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

The hospital was caught in a crossfire of nearly constant shelling for two years beginning in 2014.
When asked how many attacks they had witnessed, a doctor and nurse from the therapy department, both of whom worked at the hospital throughout the conflict, would not even venture aguess.111 Department head Dr. Natalia Dolzhenko said, “No one counted them. If it happened,it happened.”112 The therapy department nurse described one attack in which shells exploded
near the hospital, and fragments landed on patients’ beds; fortunately the beds were unoccupied
at the time.113 The two women showed IHRC-PAX researchers pieces of the weapons that they
kept in the staff room, and Dr. Dolzhenko noted that “everyone collects the shrapnel as souvenirs.”114 The continuous shelling broke almost every window in the hospital at some point.115 Dr.
Dolzhenko recalled, “All the time you are feeling afraid for yourself and your patients when bullets
and shelling are whistling all around.”116 In cases of heavy shelling, staff members and patientswould seek shelter in the basement of the hospital.117
Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko).
110
Ibid. (statement of Dr. Zinchenko).
111
Interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016.
112
Ibid. (statement of Dr. Dolzhenko).
113
Ibid. (statement of nurse in therapy department).
114
Ibid. (statement of Dr. Dolzhenko).
115
Ibid. (statement of Dr. Dolzhenko).
116
Ibid. (statement of Dr. Dolzhenko).
117
Ibid. (statement of Dr. Dolzhenko).
109

34

IHRC / PAX ! Operating under FireIn June 2015, explosive weapons destroyed the ambulance garage of the Krasnohorivka ambulance substation and left a burned
ambulance in the far right bay. Fire also damaged the adjacent neurology building of Maryinka District Central Hospital (left).
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

The neurology department, which shares a wall with the ambulance garage, also felt the impactof the attack. The fire in the ambulance garage spread to the roof of the neurology building, forcing hospital personnel to evacuate a dozen patients across a lawn to another hospital building.
Staff members had to carry many of the patients, particularly those who had suffered strokes orwere immobilized due to back pain. Dr. Valentina Ksenofontova, the head of the neurology department, witnessed the attack and helped move the patients. The shelling, which she describedas “massive,” continued throughout the evacuation and made the process terrifying and perilous.120 Remembering that day, Dr. Ksenofontova said, “As a shell falls down, people start to cry
and you need to find a way to reassure them.” She added, “To carry patients was also quite
dangerous. . . . You know shells are falling but you don’t know where.”121

Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko).
119
Ibid. (statement of Dr. Zinchenko).
120
Interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016.
121
Ibid.
118

IHRC / PAX ! Operating under Fire35

the hospital was forced to shut it down and relocate all of its services to the smaller structure,previously a maternity ward.125 As of September 2016, the main building remained closed, andthe hospital reportedly had only five departments and 150 beds.126 Volodymyr Kolesnyk, deputy
director of the Ministry of Health for Donetsk Oblast, estimated that the Avdiivka hospital was
operating at around 30 percent of its original capacity at that time.127
Explosive weapons hit the five-story main building on September 3, 2014.128 Neurology nurse
Lyudmila Buravleva said she and other staff members cleaned up after the attack, collecting
bricks and other pieces of debris, and carrying them out of the room on their shoulders in thedark because there was no electricity.129
In January 2015, the main building was hit again.130 At that point, the hospital decided to move
all medical personnel and services to the smaller building, and abandoned the main building
almost completely.131 The latter had sustained serious damage. For example, despite efforts to
fix the roof, water flowed down to the third floor during heavy rains, a problem that continued
in September 2016.132 The attack also made it clear that people could not evacuate the mainbuilding quickly enough.133

Dr. Valentina Ksenofontova, head of the neurology department at Maryinka District Central Hospital in Krasnohorivka, helped carryimmobilized patients to safety when the facility was shelled in June 2015.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

The fire brigade arrived at the hospital about 30 minutes after receiving a call from the ambulance
staff.122 Firefighters battled the flames as the shelling continued, but they ran out of water. Eventually water from the hospital well saved the neurology building from burning to the ground, although
it continued to smoke and occasionally reignite for about 12 hours.123
By September 2016, the hospital had repaired the neurology department, but not the ambulance
garage. IHRC-PAX researchers found that all that remained of the garage roof were twisted partsof the metal frame and collapsed sheets of corrugated steel. The burned-out ambulance, which
was beyond repair, was still parked in its bay. A large pile of rubble spilled out of one end of the
garage.
Avdiivka
In 2014 and 2015, explosive weapons caused significant direct damage to Avdiivka City Hospital.
The facility serves the city of Avdiivka and local villages in the area.124 Before the conflict, the hospital operated out of two buildings. After explosive weapons twice hit the larger, main building,Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko).
123
Interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016.
124
Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
122

36

IHRC / PAX ! Operating under Fire

Explosive weapons that detonated on the grounds next to the hospital caused further harm.
Blast and fragmentation shattered almost every window in the main building and some in thesmall one. The Avdiivka Coke Plant, a major coke producer owned by Metinvest, repaired thehospital’s windows on numerous occasions and replaced a total of 112 windows throughout theconflict.134 According to a doctor and plant engineer, in one case, only two weeks to a monthafter installation of new windows, nearby explosions of shells broke 12 of them again.135 When
IHRC-PAX researchers visited the hospital in September 2016, they observed plywood and torn
plastic sheeting covering dozens of windows. At the end of January 2017, two artillery shells
exploded on the hospital grounds shattering additional windows, according to a photojournalist
who visited the site immediately after the attack.136

Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk, September 19,
2016; interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
126
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
127
Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk, September 19,
2016.
128
“Eastern Ukraine: Both Sides Responsible for Indiscriminate Attacks,” Amnesty International press release, November 6,
2014, https://www.amnesty.org/en/latest/news/2014/11/eastern-ukraine-both-sides-responsible-indiscriminate-attacks/(accessed March 3, 2017).
129
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
130
Ibid.; interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
131
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
132
Ibid.
133
Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
134
Ibid.
135
Ibid.; interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
136
Email from Anton Skyba, eyewitness and photojournalist, to PAX, March 30, 2017.
125

IHRC / PAX ! Operating under Fire

37

Avdiivka City Hospital

Explosive weapons shattered dozens of windows in the main building of Avdiivka City Hospital. In 2015, the hospital abandoned thebuilding and moved all of its operations to a second, smaller building, where they remained in September 2016.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

operational hospital building

Other Damaged Facilities
The use of explosive weapons in populated areas has directly damaged health care facilities inseveral other communities in the east of Ukraine. The Center for Primary Medical Help in Maryinka
experienced repeated shelling beginning in mid-2014. Dr. Olga Tokmakova, who worked at thecenter throughout the conflict, said, “It was a permanent process of receiving bullets and shells.”137
Explosive weapons blew out windows and doors and knocked pieces of ceiling to the floor.138 On
January 26, 2015, the hospital sustained significant damage from heavy shelling and staff members were temporarily relocated, according to Médecins Sans Frontières (MSF).139 In September
2016, IHRC-PAX researchers found some evidence of damage from fragmentation, but the hospital had largely been repaired and was operating again, at least in part.

closed pharmacy

abandoned main hospital building
Avdiivka Coke Plant

Smaller medical facilities also felt the impact of the use of explosive weapons in populated areas.
Dr. Lyudmila Tkachenko, head of the Galytsinivka Ambulatory Clinic, said that in 2014 shelling
seriously damaged a paramedic office in Karlivka, a nearby village.140 The paramedic who ran it
escaped injury because she was on maternity leave at the time. As of September 2016, the officeInterview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center for Primary
Medical Help, Maryinka, September 20, 2016.
138
Ibid.
139
Médecins Sans Frontières, “Ukraine: MSF Calls for Safety of Civilians and Respect for Medical Facilities,” February 3,
2015, http://www.msf.ie/article/ukraine-msf-calls-safety-civilians-and-respect-medical-facilities (accessed March 3, 2017).
140
Interview with Dr. Lyudmila Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka
Ambulatory Clinic, and paramedic (name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21,
2016 (statement of Dr. Tkachenko).
137

H

North
38

IHRC / PAX ! Operating under Fire

50 m

IHRC / PAX ! Operating under Fire39

had not been repaired or reopened, and the Karlivka paramedic was forced to work out of the
Galytsinivka ambulance substation.141 In Mayorsk, a village located in the gray zone—i.e., thebuffer zone between government and non-government controlled areas—residents reported thatfragments from an explosive weapon struck their local nursing point early in the armed conflict,causing superficial damage.142

Harm to Medical Personnel and Patients
Besides damaging buildings, the use of explosive weapons in populated areas in the east of
Ukraine has also put health care workers and their patients at risk and caused some casualties.
For example, Amnesty International reported that 66-year-old Taisiya Yurchenko, a patient in thetrauma department of Avdiivka City Hospital, died from fragmentation wounds sustained in the
September 3, 2014 strike.143 The same attack injured a 65-year-old nurse, Vera Ivanovna, who
was moving patients to the basement to protect them from the shelling. She told IHRC-PAX researchers that as she carried a patient out of Room 5, she heard an explosion in Room 1. Thenshe felt a hot sensation in her legs and stomach and saw that she had suffered several injuries
and lost part of her finger. Doctors immediately operated on the nurse, by candlelight because
the power was out, but they had to leave at least one piece of shrapnel in her stomach. The nurse
showed researchers shrapnel scars on both legs and her left arm. She said she underwent rehabilitation for four months and then took a month’s leave before returning to work at the hospital.144
Slovyansk Central Hospital lost at least one staff member to explosive weapons. Shelling
occurred near the facility in mid-2014, according to Vladimir Stepanov, the hospital’s seniordoctor.145 An explosive weapon that detonated approximately 100 meters from the hospitalinjured a female surgery nurse. She ultimately died from her fragmentation wounds.146
There have likely been additional casualties among medical personnel and patients in parts ofthe east of Ukraine that IHRC-PAX researchers did not visit. Hospitals have taken great care toprotect human life, however, and may thereby have reduced the total number of deaths and injuries. As will be discussed in Chapter 7, personnel and patients have frequently taken shelter inwindowless parts of hospitals, and hospitals have sometimes sent patients home where it wassafer. Casualties among staff members and patients may also have been limited because many
people have fled the region and those who remained have often found it too dangerous to travel
to hospitals for work or treatment.

Ibid. (statement of paramedic).
Interview with shopkeepers #1 and #2 (names withheld) and Elena Shtoda, head of Free Mayorsk, Mayorsk,
September 24, 2016.
143“Eastern Ukraine: Both Sides Responsible for Indiscriminate Attacks,” Amnesty International press release,
November 6, 2014. See also interview with Dr. Viktoria Nikolova, head of family services and therapy department,
Avdiivka City Hospital, Avdiivka, September 21, 2016.
144
Interview with Vera Ivanovna, nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016; see also “Eastern Ukraine:
Both Sides Responsible for Indiscriminate Attacks,” Amnesty International press release, November 6, 2014.
145
Interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
146
Ibid.
141
142

40

IHRC / PAX ! Operating under Fire

6. Indirect Harmto the HealthCare SystemIn addition to affecting the health care system in the east of Ukraine directly, the use of
explosive weapons in populated areas has inflicted harm indirectly by damaging infrastructure and creating travel risks for medical personnel. In other words, the health caresystem has felt the reverberating effects of explosive weapons that have damaged othersites and services. Shelling has caused widespread and long-term interruptions to the provisionof utilities essential to health care, including electricity, water, heat, and communication, and has
made restoring these services a slow and dangerous process. In addition, the use of explosive
weapons has in some cases prevented health professionals from reaching their places of workand ambulances from responding to emergency calls.

Damage to Infrastructure
Power Outages
Explosive weapons have significantly disrupted the delivery of electricity, a utility critical to theoperation of medical facilities. Electricity powers key equipment, such as refrigerators that preserve vaccines and other medicines; electrocardiograph (EKG) machines, which monitor heart
rates; and ultraviolet lamps used, for example, to treat skin conditions.147 Electricity runs elevators

147

See, for example, interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic,
Granitne, September 23, 2016.
IHRC / PAX ! Operating under Fire41

that transport patients from floor to floor. It provides light that illuminates operating rooms andallows hospitals to provide care at night. Electricity is also needed to sterilize surgical and other
instruments.148

The power outages that have affected hospitals in the east of Ukraine have generally been wide
reaching and long lasting. Avdiivka City Hospital lost its power in 2015 as part of an outage that
Aleksandr Pasternak, chief engineer at the Avdiivka Coke Plant, estimated affected between three
to four thousand people in the city.151 The hospital went without power for about six months,
according to Dr. Viktoria Nikolova, a senior doctor and department head.152 On January 30, 2017,
renewed shelling cut a key power line between the Avdiivka Coke Plant and Avdiivka, leaving thecity of 16,000 without electricity for about a week.153 Even after power was restored on February
5, OCHA reported, the city was running “mainly on three high-power generators to ensure minimum services.”154 In addition, OCHA warned that “the ongoing hostilities still pose a risk of new
or repeated damage to the infrastructure.”155 The city, and thus its hospital, remain vulnerable tofuture use of explosive weapons.
Other cities and towns have also felt the impacts of severe power outages. The head doctor at
Slovyansk Central Hospital said that when shells knocked out electricity lines across the city, thedamage was “massive” and caused “hospitals and the whole city to have the same problem.”156
His hospital had no electricity for at least several weeks.157 A resident of Granitne reported that
her village on the front line lost power for 280 days during the first year of the armed conflict.158
Compromised Water Supply
The use of explosive weapons in populated areas has also damaged hospitals’ water mains.
Water is crucial to maintaining hygiene at medical facilities. Health workers use water to wash
patients and to clean hospital buildings and equipment.159 In addition, patients need potablewater to drink. Consumption of non-potable water can exacerbate patients’ health problems
and increase the influx of patients if other individuals are exposed to disease.

Shelling has severed power lines and poles throughout the region, depriving hospitals of electricity needed for essential operations.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

All of the hospitals visited by IHRC-PAX researchers experienced power outages due to the shelling. In several towns and cities, including Avdiivka, Galytsinivka, and Slovyansk, fragments from
explosive weapons reportedly cut wires that carried electricity to health care facilities as well as
homes and businesses.149 In at least three communities—Granitne, Krasnohorivka, and Maryinka—local interviewees said explosive weapons also hit transformers, which are necessary for thetransmission and distribution of electricity.150

The effects of the damage to water mains has extended across the region and in some caseslasted for years. The loss of one pipe can disrupt the water supply to thousands of people, explained Yanna Thay, humanitarian affairs officer at OCHA in Kramatorsk.160 Medical professionals
in the cities and towns visited by IHRC-PAX researchers described long periods of time in which
their hospitals’ water supplies were cut off or limited. For example, in September 2016, Dr. Natalia
Dolzhenko, head of the therapy department, estimated that Maryinka District Central Hospital had
operated without municipal water for about two years. She said, “We are receiving only promises

Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
153
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017,
http://reliefweb.int/report/ukraine/ukraine-update-no-1-deterioration-humanitarian-situation-east-6-february-2017(accessed March 7, 2017), p. 1 (noting, “The use of heavy artillery, including multi-rocket launchers (MLRS ‘GRAD’),was widely reported.”); OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 2,
February 13, 2017, http://reliefweb.int/sites/reliefweb.int/files/resources/ukraine_update_issue_2_10_feb_final_0.pdf(accessed March 7, 2017), p. 1.
154
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017, pp. 1-2.
155
Ibid., p. 1.
156
Interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
157
Ibid.
158
Interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016.
159
Interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016 (washing patients); interview with Dr. Viktoria Nikolova, head of family services andtherapy department, Avdiivka City Hospital, Avdiivka, September 21, 2016 (cleaning).
160
Interview with Yanna Thay, humanitarian affairs officer, OCHA, Kramatorsk, September 19, 2016.
151
152

Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
149
See, for example, interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka,
September 21, 2016; interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September
21, 2016; interview with Dr. Lyudmila Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka
Ambulatory Clinic, and paramedic (name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21,
2016; interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
See also interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016; interview with hospital official(name withheld), Maryinka District Central Hospital, Krasnohorivka, September 20, 2016; interview with Dr. Olga
Tokmakova, deputy head of medical services for civilians and gynecologist, Center for Primary Medical Help, Maryinka,
September 20, 2016.
150
See, for example, interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016 (saying, “The transformer
was hit. The wires were cut.”); interview with Aleksandr Kisil, paramedic, entry control point near Maryinka, September 22,
2016 (saying that fragments hit electricity lines, transformers, and substations in Krasnohorivka and Maryinka).
148

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the pipe will be repaired.”161 At that time, the facility was relying on well water, which staff members
carried to the hospital each day. Two doctors predicted that even if the well were connected tothe hospital water system, the water would freeze and burst the pipes during the winter because
the hospital lacked heat.162 Other affected medical facilities included the Center for Primary Medical Help in Maryinka163 and Slovyansk Central Hospital.164
In some cases, disruption of the water supply has recurred after repairs. In Avdiivka, Aleksandr
Usor of the city’s utility service company and Dr. Nikolova of Avdiivka City Hospital recalled water
restrictions in 2015 that lasted six months.165 As a result of renewed shelling in January 2017,
Avdiivka experienced another severe water shortage. The loss of electricity on January 30 shut
down the Donetsk Filtration Station, which usually provides water to about 400,000 people in thecity and neighboring towns on both sides of the contact line.166 The ICRC reported that despite
efforts to repair it, the station had yet to be restarted by March 4.167 The following day, the OSCE
stated that the station had been shelled, further delaying the restoration of water services.168
The use of explosive weapons in populated areas has not only decreased the quantity of available water, but also compromised its quality. Bacteria growing within pipes broken by shelling
has at times contaminated the water.169 According to Yanna Thay of OCHA, the quality of water
can be adversely affected even when pipes were not completely destroyed.170
Loss of Heat
Explosive weapons have also severed hot water tubes and above-ground gas lines that provide
heat to medical facilities. Hospitals require heat to keep patients comfortable, which promotes
healing, and to prevent the development of illness related to cold weather, such as bronchitis
and pneumonia.171 Heat is also necessary to make working conditions tolerable for staff, especially when windows are broken and the average winter temperature in the east of Ukraine is-6 degrees Celsius (21 degrees Fahrenheit).172

Interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016 (statement of Dr. Dolzhenko).
162
Ibid. (statement of Dr. Dolzhenko); interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka
District Central Hospital, Krasnohorivka, September 20, 2016.
163
Interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center for Primary
Medical Help, Maryinka, September 20, 2016.
164
Interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
165
Interview with Aleksandr Usor, head of brigade, Utility Service Company, and Vladimir Yuhimishin, resident, Avdiivka,
September 21, 2016 (statement of Aleksandr Usor); interview with Dr. Viktoria Nikolova, head of family services andtherapy department, Avdiivka City Hospital, Avdiivka, September 21, 2016. See also interview with Lyudmila Buravleva,
neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
166
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017, p. 1,
167
ICRC Ukraine twitter feed, March 4, 2017, https://twitter.com/ICRC_ua (accessed March 7, 2017).
168
OSCE SMM Ukraine twitter feed, March 5, 2017, https://twitter.com/OSCE_SMM (accessed March 7, 2017).
169
Interview with Yanna Thay, humanitarian affairs officer, OCHA, Kramatorsk, September 19, 2016 (explaining that even
if a pipe is not completely destroyed, water quality declines when bacteria can penetrate it); interview with Fatima
Yandieva, education specialist, UNICEF, Kramatorsk, September 19, 2016.
170
Interview with Yanna Thay, humanitarian affairs officer, OCHA, Kramatorsk, September 19, 2016.
171
Interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne,
September 23, 2016.
172
Climates to Travel, “Climate—Ukraine,” undated, http://www.climatestotravel.com/climate/ukraine(accessed March 3, 2017).
161

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Aleksandr Pasternak, chief engineer at the Avdiivka Coke Plant, described how explosive weapons damaged tubes that carried heatedwater from the plant to Avdiivka, forcing the hospital to treat patients in frigid conditions.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

IHRC-PAX researchers documented the loss of heat in medical facilities in a number of communities, including Avdiivka, Granitne, Krasnohorivka, and Maryinka.173 Aleksandr Pasternak of the
Avdiivka Coke Plant explained that in late January 2015 an explosive weapon hit the connection
tube that carried heated water five kilometers from the plant to the city of Avdiivka, thereby disrupting the provision of heat to the city.174 Aleksandr Usor, the utility repair worker, who was overseeing repairs to the tube at the time of his September 2016 interview, estimated that the 2015
outage lasted about six months.175 Avdiivka experienced another citywide breakdown of its heating system after shelling on January 30, 2017, shut down its supply of electricity and water.176
In Mayorsk, a shopkeeper explained in early September 2016 that there had been no gas to fuelheat in the village since late 2014.177

Interview with Dr. Viktoria Nikolova, head doctor of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016; interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne
Ambulatory Clinic, Granitne, September 23, 2016; interview with hospital official (name withheld), Maryinka District
Central Hospital, Krasnohorivka, September 20, 2016; interview with Dr. Natalia Dolzhenko, head of therapy department,
and nurse in therapy department (name withheld), Maryinka District Central Hospital, Krasnohorivka, September 20,
2016; interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016; interview with Dr. Olga Tokmakova, deputy head doctor for medical services forcivilians and gynecologist, Center for Primary Medical Help, Maryinka, September 20, 2016.
174
Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
175
Interview with Aleksandr Usor, head of brigade, Utility Service Company, and Vladimir Yuhimishin, resident, Avdiivka,
September 21, 2016 (statement of Aleksandr Usor).
176
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017.
177
Interview with shopkeepers #1 and #2 (names withheld) and Elena Shtoda, head of Free Mayorsk, Mayorsk,
September 24, 2016 (statement of Elena Shtoda).
173

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Unreliable Communications
By severing phone lines and damaging cell phone towers, explosive weapons have cut communications with medical facilities and personnel as well as with ambulance services. Local people
need to be able to speak with health care providers, who can advise them on treatment over thephone, especially in cases of emergency. Residents also need to be able to communicate quickly
and clearly with ambulance dispatchers so that paramedics arrive as soon as possible and areprepared to provide proper care. Reliable networks are especially critical during armed conflict
when it can be dangerous for individuals to search for a cell phone signal outdoors.178
Shelling affected both landline and cell phone services in a number of locations visited by IHRCPAX researchers in September 2016, including Granitne, Krasnohorivka, Maryinka, Mayorsk,
Slovyansk, and Starohnativka.179 A resident of Granitne told researchers that the town telephonestation, located in the post office, was hit on one of the first days of shelling, cutting communications.180 Cell phones in that town and elsewhere were frequently an unreliable alternative, andsometimes did not function at all.181 The Granitne resident described her cell phone connection

as “jumping” and attributed this problem to the loss of electricity due to shelling.182 Dr. Elena
Baturina of the Starohnativka Ambulatory Office said shelling damaged the cell phone connection,
making it “very challenging to call an ambulance.”183
Compounded Harm
The damage caused by explosive weapons to one type of infrastructure has often adversely
affected another type, which has in turn harmed health care. For example, electricity outages,
like the one in Avdiivka in January 2017, have shut down pumping stations, interfering with the
supply of water to hospitals.184 Loss of power has prevented the use of electricity to back up
gas as a source of heat.185 It has also interfered with communications because both portablelandlines and cell phones require charging. The provision of water and gas have also been
linked: loss of heat can cause pipes to freeze, thereby affecting the water supply.186
Challenges of Repairs
The dangers posed by the use of explosive weapons in populated areas have frequently maderepairing infrastructure slow and difficult, and thus led to longer-term problems for medical
facilities.187 A shopkeeper in the frontline village of Granitne recalled that military clashes often
interrupted repairs.188 Col. Mykola Tsybulko and Col. Vadym Borysenko, of the Civil-Military
Cooperation system (CIMIC) of the Ukrainian Armed Forces, said that a ceasefire was a necessary precondition to conducting repairs.189 In some cases, repairs had to wait for the completionof the demining process because of the risks explosive remnants of war posed to workers.190“It’s a question about risk assessment and security issues,” said Pasternak, the Avdiivka Coke
Plant engineer. “You need a lot of time and resources arranging security. If someone is woundedor dies on reparation, then no one will do it.”191

Ibid.
Interview with Dr. Elena Baturina, Starohnativka Ambulatory Clinic, Starohnativka, September 22, 2016.
184
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017.
See also interview with Col. Mykola Tsybulko, chief, and Col. Vadym Borysenko, Civil-Military Cooperation (CIMIC),
Kramatorsk, September 19, 2016 (statement of Col. Tsybulko).
185
Interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center for Primary
Medical Help, Maryinka, September 20, 2016.
186
Interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016.
187
Interview with Yanna Thay, humanitarian affairs officer, OCHA, Kramatorsk, September 19, 2016; interview with hospital
official (name withheld), Maryinka District Central Hospital, Krasnohorivka, September 20, 2016; interview with Dr. Lyudmila
Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka Ambulatory Clinic, and paramedic(name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21, 2016 (statements of both); interview
with Fatima Yandieva, education specialist, UNICEF, Kramatorsk, September 19, 2016 (adding that the process of
repairing water pipes damaged by explosive weapons can also adversely affect medical facilities by necessitating a
shutdown of the whole water system).
188
Interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016.
189
Interview with Col. Mykola Tsybulko, chief, and Col. Vadym Borysenko, CIMIC, Kramatorsk, September 19, 2016(statements of both).
190
Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
The OSCE reported that mine clearance and a ceasefire were necessary to facilitate repairs on the Donetsk Filtration
Station, which provides water to Avdiivka and surrounding communities. OSCE, “Latest from the OSCE Special
Monitoring Mission to Ukraine (SMM), Based on Information Received as of 19:30, 3 March 2017,” OSCE daily report,
March 4, 2017, http://www.osce.org/ukraine-smm/302856 (accessed March 7, 2017).
191
Interview with Aleksandr Pasternak, chief engineer, Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016.
See also interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016
(saying that in some cases repairs were made quickly and services were restored straight away, but in others repairs
took a long time because the situation made it too dangerous for repair services to work).
182
183

Explosive weapons knocked out Granitne’s telephone station, located in the town post office, on one of the first days of the armed
conflict. The loss of the station made it more difficult for residents to communicate with the hospital or ambulance station.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of shopkeeper); interview with resident #1 (name withheld), Granitne, September 23, 2016.
179
Interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016; interview with Dr. Lyudmila Bagmut,
executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne, September 23, 2016; interview with Dr. Victor
Zinchenko, ambulance general assistance doctor, and staff member (name withheld), Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of staff member); interview with Aleksandr Kisil, paramedic, entry
control point near Maryinka, September 22, 2016; interview with shopkeepers #1 and #2 (names withheld) and Elena
Shtoda, head of Free Mayorsk, Mayorsk, September 24, 2016 (statement of Elena Shtoda); interview with Dr. Vladimir
Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016; interview with Dr. Elena Baturina,
Starohnativka Ambulatory Clinic, Starohnativka, September 22, 2016.
180
Interview with resident #1 (name withheld), Granitne, September 23, 2016.
181
Ibid.
178

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In some cases, the risks of explosive weapons use could not be overcome. Dr. Lyudmila Bagmut,
executive doctor and pediatrician at Granitne Ambulatory, regularly braved shelling as she bicycled 15 kilometers from Kamyanka to her clinic every day.194 On at least two occasions, however,shelling kept her away. In early 2015, on the same day her husband was evacuating their children,
shelling was particularly heavy. As she passed a checkpoint, “shelling came in, and I fell down inthe ditch. I started running down, but I had a feeling shells were following me and I was changing
my position. I left one ditch, and the shells fell down there. It was the most scary experience I
have passed through.” Dr. Bagmut said she prayed to God, “‘If you consider it is safe there, giveme the force to pass through. If you think it is not safe, give me more fear.’” She added, “Because
I was coming from uphill, I saw the village, and I saw blasts every second. I was thinking, ‘Will I
be useful if I die?’”195 Ultimately Dr. Bagmut determined the danger was too great and returned
home.196

Workmen repair heating pipes near Avdiivka City Hospital in September 2016. Shelling has often presented obstacles to repairingdamaged infrastructure in the east of Ukraine.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Travel Risks for Medical Personnel
Shelling has posed security concerns for medical personnel as well as repair workers. Many
health care professionals in the east of Ukraine have risked their lives in order to help the sickand wounded, but shelling has limited their best efforts in two ways. First, the threats posed byshelling have at times denied doctors, nurses, ambulance teams, and other medical personnel
access to their workplaces where they care for patients. Some staff members have even felt
compelled to flee the region in order to protect themselves and their families. Second, shelling
has often made it too dangerous for ambulance drivers and paramedics to respond to emergency calls, even if they can reach their stations for their shifts.
Obstacles to Reaching Medical Facilities
The use of explosive weapons in populated areas has made accessing medical facilities in theeast of Ukraine a life-threatening endeavor for many staff members. Dr. Andrey Markevich of theGranitne Ambulatory Clinic said that “the biggest security issue was to get to my job here.”192
Describing one of his drives from home to hospital, he said, “The village was in the crossfire.
There were military positions behind it on both sides. . . . [M]issed shells were falling down fromboth sides.”193

Dr. Lyudmila Bagmut, executive doctor and pediatrician at Granitne Ambulatory Clinic, braved heavy shelling to reach work every day
during the height of the armed conflict. On at least two occasions, shelling kept her from reaching the clinic.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne,
September 23, 2016.
195
Ibid.
196
Ibid.
194

192
193

48

Interview with Dr. Andrey Markevich, ambulatory doctor, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
Ibid.
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Granitne Ambulatory Clinic
Other doctors related similar experiences. Dr. Olga Tokmakova at the Center for Primary Medical
Help in Maryinka remembered particularly heavy shelling during an offensive operation in thearea on June 3, 2015, the same day as the attack on the Krasnohorivka ambulance substation
discussed in Chapter 5. Dr. Tokmakova could not safely reach the hospital from her home in
Krasnohorivka and instead sought shelter in her basement.197
The use of explosive weapons has made it especially difficult for medical personnel to travel
along the front line and in the gray zone. Volodymyr Kolesnyk, the deputy director of the Ministryof Health for Donetsk Oblast, explained: “The dangerous part is mostly along the contact line.
You can’t send civilian medics to a dangerous zone.”198 According to Dmitri Shybalov of the local
NGO Responsible Citizens, there has been “no medical care, no pharmacy, nurses, doctors,
nothing” for villages within 10 kilometers of the contact line.199 The medical staff that used to workand live in those villages has largely left, and security concerns have deterred others from taking
their place.200 A military paramedic who was working along the contact line for ASAP, a military
ambulance service that sometimes assists civilians, explained, “Personal safety is the biggest
instinct. Not a lot of doctors are willing to go here because every hour poses a threat to life.”201

Granitne Ambulatory Clinic

While many medical professionals have tried to continue their work in the east of Ukraine despite
the risks, shelling has motivated others to move away from the conflict zone. Dr. Viktoria Nikolova
reported that some of her colleagues at Avdiivka City Hospital went to safer parts of the country
during the height of hostilities. One doctor relocated to Kramatorsk after she was injured byshelling.202 Dr. Nikolova said, “People fled because they wanted to save themselves and theirfamilies.” After a direct hit on her hospital in late January 2015, the doctor left for four months:“I decided to save myself because I was living in the [hospital] building and watching shells fall
down.”203 The head doctor at Slovyansk Central Hospital said that the hospital lost almost 20
percent of its personnel because staff members fled the area due to the conflict.204
Some interviewees also attributed the departure of ambulance staff to the use of explosive
weapons. For example, while in September 2016 three paramedics worked in Granitne, reportedly only one had stayed on during the worst of the shelling from October 2014 to February 2015.
As a result, the ambulance station was unable to operate at full capacity during those months.205

Interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center forPrimary Medical Help, Maryinka, September 20, 2016.
198
Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk,
September 19, 2016.
199
Interview with Dmitri Shybalov, Responsible Citizens, Kramatorsk, September 18, 2016.
200
Interview with shopkeepers #1 and #2 (names withheld) and Elena Shtoda, head of Free Mayorsk, Mayorsk,
September 24, 2016 (statement of shopkeeper #1); interview with Dmitri Shybalov, Responsible Citizens,
Kramatorsk, September 18, 2016; interview with UNICEF officials (names withheld), Kiev, September 16, 2016.
201
Interview with military paramedic (name withheld), ASAP; Dr. Igor Maidenko, head of pediatrics department,
Dnipro Regional Child Hospital, and ASAP volunteer; and Aleksey Turchak, civilian paramedic and ASAP volunteer,
ASAP camp near contact line crossing point, September 24, 2016 (statement of military paramedic).
202
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
203
Ibid.
204
Interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
205
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of hairdresser).
197

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Center for Primary Medical Help in Maryinka
The decision of some staff to escape the shelling is understandable, and it highlights how theuse of explosive weapons in populated areas can adversely affect health services. Ministry of
Health official Volodymyr Kolesnyk explained: “When medical staff leave the territory, those thatlive there can’t get medical care.”206
Impediments to Ambulance Response
The use of explosive weapons in populated areas has also endangered on-duty ambulancedrivers and paramedics and interfered with their ability to reach civilians in need. In some cases,
shelling has slowed response times207; in other cases, it has prevented ambulances from leaving
their stations.208 These obstacles have interfered with both patient transport and crucial care bytrained first responders.
Shelling has frequently prevented ambulance travel at night. For example, in Galytsinivka, ambulance staff were urged not to “visit patients during the night because of security [concerns],” mostnotably shelling.209 In September 2016, residents of Granitne reported that ambulances had only

Center for Primary Medical Help

Dr. Victor Zinchenko of the Krasnohorivka ambulance substation stands in front of a damaged garage with scorched ambulance. He
explained that the use of explosive weapons has often made it too dangerous for ambulances to reach residents in need.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk, September 19, 2016.
Interview with Yanna Thay, humanitarian affairs officer, OCHA, Kramatorsk, September 19, 2016.
208
See, for example, interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist,
Center for Primary Medical Help, Maryinka, September 20, 2016; interview with Aleksandr Pasternak, chief engineer,
Avdiivka Coke Plant, Metinvest, Avdiivka, September 21, 2016; interview with Aleksandr Kisil, paramedic, entry control
point near Maryinka, September 22, 2016; interview with Marina Papuna, activist; Elena Horhulu, grandmother; andMaria Bero, mother, Starohnativka, September 22, 2016; interview with hairdresser, shopkeeper #2, and resident #2(names withheld), Granitne, September 23, 2016.
209
Interview with Dr. Lyudmila Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka Ambulatory
Clinic, and paramedic (name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21, 2016 (statementof paramedic).
206
207

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recently been allowed to drive at night.210 Because one ambulance served several villages in theGranitne area, the restrictions imposed because of the shelling exacerbated the problems of analready stretched system.211
In other cases, the severity of the shelling rather than the time of day has dictated safety precautions. In Krasnohorivka, management ordered the ambulance team not to leave the station if
shelling created an unwarranted risk.212 When asked how team members decided which circumstances were too risky, Dr. Victor Zinchenko explained that they simply used their ears to determine the proximity of the shelling. He said, “Everybody became a military expert” regarding thewhistling sounds of shells.213 Even when Dr. Zinchenko and his driver were able to respond tocalls, the trips took longer than usual, in large part because of the damage that explosive weapons had caused to the roads.214
Medical personnel and residents in other towns also reported that shelling had impeded the abilityof ambulances to reach people in need. Marina Papuna, who worked at a local aid organizationin Starohnativka, said, “We had situations where an ambulance couldn’t get to a location due toshelling.”215 In those cases, residents relied instead on a retired doctor who lived in town andcame to their homes.216 A resident of Avdiivka, who worked at the coke plant, said ambulancedrivers “didn’t want to drive through the city because of shelling,”217 and Dr. Olga Tokmakova
of the Center for Primary Medical Help in Maryinka, said there was “heavy shelling in the areas
where ambulance[s] operated.”218 One woman in Granitne said that during particularly heavy
shelling, ambulances could not reach those who called for help: “If you’re dying, nobody would
come.”219
Shelling has compelled residents to find alternative ways to access health care. As will be discussed further in the next chapter, the sick and injured have often been left with three options.
Some have tried to “evacuate themselves using regular transport.”220 Some have called onmilitary-run ambulance services for transport in areas inaccessible to civilian ambulances.221
Others have simply gone without professional care.222

Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statements of hairdresser and shopkeeper).
211
Ibid. (statement of hairdresser).
212
Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of staff member).
213
Ibid. (statement of Dr. Zinchenko).
214
Ibid. (statement of Dr. Zinchenko).
215
Interview with Marina Papuna, activist; Elena Horhulu, grandmother; and Maria Bero, mother, Starohnativka,
September 22, 2016 (statement of Marina Papuna).
216
Ibid.
217
Interview with resident (name withheld), Avdiivka, September 21, 2016.
218
Interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center forPrimary Medical Help, Maryinka, September 20, 2016.
219
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of hairdresser).
220
Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko).
221
Interview with Dmitri Shybalov, Responsible Citizens, Kramatorsk, September 18, 2016.
222
See, for example, interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City
Hospital, Avdiivka, September 21, 2016; interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016.
210

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IHRC / PAX ! Operating under Fire

7. Consequences
for Patient CareThe direct and indirect effects of explosive weapons on the health care system in theeast of Ukraine have had serious consequences for the care provided to patients.
Shelling has reduced the quality, availability, and accessibility of health care, three ofthe four essential elements of the right to health under international human rights law.223(For further discussion of the right to health, see Chapter 2.) The inadequacy of medical facilities
and use of makeshift methods of treatment exemplify the decline in quality. The loss of hospitals
and departments as well as reliance on outside help are signs of the decrease in availability.
The inability of patients to reach care without endangering themselves indicates a problem ofaccessibility. The situation, largely a result of the use of explosive weapons in populated areas,
has compromised the treatment of routine and emergency health problems and thus put thecivilian population at risk.

Quality of Health Care
Shelling has undermined the quality of hospitals and clinics and forced medical professionals
to improvise in their treatment. Dr. Lyudmila Bagmut, an executive doctor and pediatrician, said,“If it was peacetime, we would definitely be prohibited to work in these conditions.”224

223
224

The fourth element is acceptability. CESCR, General Comment No. 14, para. 12.
Interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne,
September 23, 2016.
IHRC / PAX ! Operating under Fire

55

Inadequate Facilities
The shelling’s direct and indirect impacts have compelled some medical centers, including Dr.
Bagmut’s clinic in Granitne, to care for their patients in confined spaces. After shelling began toblow out the Granitne Ambulatory Clinic’s windows, the staff “tried to work in halls because there
were no windows there [and] we tried to work far away from windows.”225 As the conflict continued, the staff had to move the operations of the entire facility into one small room with only three
beds and a desk. Although the room had a window, it was the only part of the clinic with a stovethat could provide heat. Shelling had knocked out gas lines, leaving the facility dangerously cold.
Showing the room to IHRC-PAX researchers, Dr. Bagmut explained that one bed was for testing
patients with the EKG machine, another was for infusions, and the third served as a waitingarea.226 Dr. Bagmut said working in a one-room clinic with all the equipment and patients crowded together “was a disaster.”227

lamented the fact that “there is no room, no space.”230 The space restrictions attributable tothe use of explosive weapons reportedly necessitated the closure of two departments and aloss of 70 patient beds.231
The Avdiivka hospital’s X-ray machines could not be removed from the damaged main building,however, because they were permanently installed there.232 As of September 2016, staff members still had to take patients outside to the otherwise abandoned building in order to perform
X-rays.233 Moving patients has been challenging and hazardous, particularly due to the bitterly
cold temperatures in winter.
Explosive weapons have further compromised the quality of health care by forcing doctors totreat patients in frigid temperatures. Dr. Bagmut of the Granitne clinic explained that in 2015
blown-out windows and a lack of electricity, gas, and water to provide heat left patients andmedical personnel “freezing” even though volunteers had delivered a wood stove.234 To minimize
the impact of the low temperatures, the “booking of patients was minute to minute. We didn’t
want them to wait and freeze.”235 At Avdiivka City Hospital, which had only one room with aheater, staff members attempted to warm patients with blankets,236 and visited patients at homewhen possible. Neurology nurse Lyudmila Buravleva said in September 2016, “Why keep themat a cold hospital?”237 As discussed in Chapter 6, an attack on January 30, 2017 left Avdiivka
without electricity, water, and heat. Although the specific effects on Avdiivka City Hospital were
not reported, OCHA wrote that “[w]ith temperature as low as -17C [1 degrees Fahrenheit] thesystems are barely managing to maintain acceptable temperature inside people’s houses aswell as local hospital, schools and other critical social infrastructure.”238
Medical personnel as well as patients suffered from the lack of heat because many had to spend
the night at their workplace. For example, at the Krasnohorivka ambulance substation, staff had
to work through temperatures that dropped to -2 degrees Celsius (28 degrees Fahrenheit) insidetheir building.239 When the use of explosive weapons cut off electricity and gas to the adjacentMaryinka District Central Hospital, staff members turned to heating pellets. They had to carry 40
kilograms packages of pellets upstairs to warm the upper floors. Dr. Natalia Dolzhenko, head of thehospital’s therapy department, described these pellets as “technology from a previous century.”240

Due to loss of heat, frequent power outages, and the risk of errant shells, Granitne Ambulatory Clinic limited its operations to this room,
which used a wood stove for warmth. One doctor referred to the conditions as “a disaster.”© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

As discussed in Chapter 5, in 2015 Avdiivka City Hospital was forced to relocate all staff, patients,and equipment from its larger, five-story building into a smaller, three-story one after shellingcaused structural damage and broke dozens of windows.228 Lyudmila Buravleva, a neurology
nurse who worked in the main building for 17 years, said the staff had “trouble fitting everything”
into the smaller building.229 In September 2016, the situation remained unchanged, and Buravleva

Ibid.
Ibid.
227
Ibid.
228
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
229
Ibid.
225
226

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Ibid.
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
232
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016;
interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
233
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016;
interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
234
Interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne,
September 23, 2016.
235
Ibid.
236
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital,
Avdiivka, September 21, 2016.
237
Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
238
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017, p. 1.
239
Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of staff member).
240
Interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016 (statement of Dr. Dolzhenko).
230
231

IHRC / PAX ! Operating under Fire57

machine home with anyone who had a generator in order to recharge it.246 Nevertheless, there
were obstacles to care that could not be overcome with improvisation.247 According to Dr. Bagmut,
the clinic had trouble dealing with illnesses, such as bronchitis and pneumonia, brought on by thecold. She explained that patients with such illnesses required breathing tubes, but the equipment
could not function without electricity.248
Personnel at some hospitals have had to provide their own water because the use of explosive
weapons has interrupted the regular supply. In September 2016, health workers at Maryinka
District Central Hospital carried water to the hospital from a well on site. Dr. Dolzhenko said,“All the staff carries canisters every day. They promised the well will be connected to the hospitalwater system. . . . We’re hearing only promises, but we need water.”249 Dr. Valentina Ksenofontova,
head of the neurology department, added, “We will continue our duty by bringing water by ourhands.”250 IHRC-PAX researchers observed large bottles of water lining the hallway of the hospitaland the adjacent Krasnohorivka ambulance substation.

The Krasnohorivka ambulance substation relied on this stove for heat in temperatures that dropped to -2 degrees Celsius.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Improvised Care
Shelling has also caused a decline in the quality of services because it has forced medical personnel to improvise in their care. At Avdiivka City Hospital, which lost electricity and water for atleast six months in 2015, doctors performed surgery by candlelight.241 As described in Chapter 5,surgeons operated on an injured nurse under such conditions.242 The hospital also had to send
equipment to a private clinic at the nearby Avdiivka Coke Plant to be sterilized because it could
not even boil water. The hospital relied on the plant’s ambulance to return the equipment aftersterilization, a process one doctor described as “crucial for survival.”243 The power outage that
affected the whole city of Avdiivka in early 2017 likely created similar problems for the hospital.244
The Granitne Ambulatory Clinic also improvised in the wake of power and water outages causedby shelling. For example, medical staff used a stove to sterilize equipment,245 and sent the EKG

Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
242
Interview with Vera Ivanovna, nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
243
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
244
For details of the power outage, see OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,”
Update No. 1, February 6, 2017, p. 1; OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,”
Update No. 2, February 13, 2017, p. 1.
245
Interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne Ambulatory Clinic, Granitne,
September 23, 2016.

In September 2016, Maryinka District Central Hospital in Krasnohorivka depended on water that staff members carried from a well inbottles and buckets. At that time, the hospital had been without running water for about two years.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

241

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IHRC / PAX ! Operating under Fire

Ibid.
Ibid.
248
Ibid.
249
Interview with Dr. Natalia Dolzhenko, head of therapy department, and nurse in therapy department (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016 (statement of Dr. Dolzhenko).
250
Interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016.
246
247

IHRC / PAX ! Operating under Fire

59

The situation was similar in Avdiivka. Lyudmila Buravleva, the neurology nurse at Avdiivka City
Hospital, explained in September 2016 that staff members had had to carry buckets of waterfrom a nearby well.251 Buravleva said, “We used every bucket and canister we had. Fire brigades
brought us water, but when they didn’t, we had to get it [ourselves].”252 When the attack on
January 30, 2017, knocked out Avdiivka’s electricity, it in turn shut down the Donetsk Filtration
Station, the area’s major supplier of water.253 Although it did not report on the effects on thehospital in particular, on March 2 the ICRC said that the “water supply situation [in Avdiivka] is
critical” and that the city had depleted key back-up reservoirs.254 According to the OSCE, thestation itself was shelled on March 5.255
Medical facilities have also turned to humanitarian aid organizations for help. UNICEF has supplied water and water tanks to medical facilities on both sides of the contact line256; IHRC-PAX
researchers saw one of its tanks inside Avdiivka City Hospital.

Availability of Health Care
Shelling has limited the availability of health care by compelling many facilities to reduce theiroperations. As a result, some residents have had to turn to ad hoc assistance from outside
sources, especially the military.
Loss of Services
Shelling has caused many medical facilities, including in Avdiivka, Granitne, Karlivka, Krasnohorivka, Mayorsk, and Slovyansk, to cut back their services.257 For example, the combinationof direct danger from shelling and lack of essential utilities forced Maryinka District Central
Hospital to shut down entire departments. One administrator recalled how, prior to the armed
conflict, “the hospital was a city” with 350 beds and at least a dozen departments.258 Due tothe shelling and its proximity to the front line, however, only the neurology and therapy departments and a general clinic remained operational as of September 2016.259 Some of the departments were moved to Kurakhove, while others were closed indefinitely.260 As of September 2016, patients were still being sent to other hospitals for treatment. Dr. Ksenofontova,

Interview with Lyudmila Buravleva, neurology nurse, Avdiivka City Hospital, Avdiivka, September 21, 2016.
Ibid.
253
OCHA, “Ukraine Update: Deterioration of the Humanitarian Situation in the East,” Update No. 1, February 6, 2017, p. 1.
254
ICRC Ukraine twitter feed, March 2 and March 4, 2017, https://twitter.com/ICRC_ua (accessed March 7, 2017).
255
OSCE SMM Ukraine twitter feed, March 5, 2017, https://twitter.com/OSCE_SMM (accessed March 7, 2017).
256
Interview with UNICEF officials (names withheld), Kiev, September 16, 2016; interview with Fatima Yandieva, education
specialist, UNICEF, Kramatorsk, September 19, 2016.
257
See, for example, interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City
Hospital, Avdiivka, September 21, 2016; interview with Dr. Lyudmila Bagmut, executive doctor and pediatrician, Granitne
Ambulatory Clinic, Granitne, September 23, 2016; interview with Dr. Lyudmila Tkachenko, head of clinic and generalpractitioner of family medicine, Galytsinivka Ambulatory Clinic, and paramedic (name withheld), Galytsinivka ambulance
substation, Galytsinivka, September 21, 2016 (statement of Dr. Tkachenko); interview with hospital official (name withheld),
Maryinka District Central Hospital, Krasnohorivka, September 20, 2016; interview with shopkeepers #1 and #2 (names
withheld) and Elena Shtoda, head of Free Mayorsk, Mayorsk, September 24, 2016 (statement of shopkeeper #1);
interview with Dr. Vladimir Stepanov, head doctor, Slovyansk Central Hospital, Slovyansk, September 18, 2016.
258
Interview with hospital official (name withheld), Maryinka District Central Hospital, Krasnohorivka, September 20, 2016
(saying the hospital could have “gotten the status of [an] intensive care hospital”).
259
Ibid.
260
Ibid.

neurology department head, explained that her hospital has had to send stroke patients to
Kurakhove to receive proper treatment.261
Patients have often had to travel hours to receive care. Because of the loss of services at
Maryinka District Central Hospital, as of September 2016 ambulances from the neighboring
Krasnohorivka ambulance substation regularly transported patients to distant hospitals alongroads severely damaged by shelling. Dr. Victor Zinchenko said ambulances drove trauma andcardiology patients about two hours to Kurakhove and psychiatric patients five hours to Mariupol.262 Dr. Zinchenko recalled that a paramedic had to deliver twins in the field due to the extended time of travel.263 Delivering a baby in a vehicle without a well-equipped specialist can endanger
both the mother and child if complications occur. Long journeys have not only posed health risks
to the patients being transported but also interfered with the ambulance crews’ ability to respondto other people in need.264
Outside AssistanceAs the availability of regular medical services has declined, residents of communities along thecontact line, especially those living within the gray zone, have had to rely on aid from outside
sources, including units from the Civil-Military Cooperation system and ASAP.265 CIMIC consistsof Ukrainian military personnel whose duties include coordinating and supplying humanitarianand medical aid for civilians.266 CIMIC has provided transportation, medications, and emergency
services to civilians, including to residents of some gray zone villages where “access of medical
assistance is limited [due] to constant shelling.”267 ASAP units have both military and volunteer
civilian medical personnel who have provided care and transport for the Ukrainian military andfor civilians in the gray zone and along the contact line.268
While CIMIC and ASAP have helped the local population cope with the decrease in available
health care, their services have been offered on a more ad hoc basis. For example, ASAP’s
primary responsibility is to care for military personnel, so its staff members focus on urgent situations and may only provide medical aid to civilians when doing so does not conflict with theirmilitary duties.269 In addition, ASAP staff members, and especially its civilian volunteers, rotate
regularly. A military paramedic said ASAP has had a shortage of doctors and uses social media
to try to recruit volunteers for one week at a time.270 At the time of the IHRC-PAX visit, a civilian

251
252

60

IHRC / PAX ! Operating under FireInterview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016.
262
Interview with Dr. Victor Zinchenko, ambulance general assistance doctor, and staff member (name withheld),
Krasnohorivka ambulance substation, Krasnohorivka, September 19, 2016 (statement of Dr. Zinchenko).
263
Ibid. (statement of Dr. Zinchenko).
264
Ibid. (statement of Dr. Zinchenko).
265
Interview with Dmitri Shybalov, Responsible Citizens, Kramatorsk, September 18, 2016.
266
Interview with Col. Mykola Tsybulko, chief, and Col. Vadym Borysenko, CIMIC, Kramatorsk, September 19, 2016(statement of Col. Tsybulko).
267
Ibid. (statement of Col. Borysenko).
268
Interview with military paramedic (name withheld), ASAP; Dr. Igor Maidenko, head of pediatrics department, Dnipro
Regional Child Hospital, and ASAP volunteer; and Aleksey Turchak, civilian paramedic and ASAP volunteer, ASAP
camp near contact line crossing point, September 24, 2016 (statement of military paramedic); interview with Olga
Ivanenko, volunteer paramedic, ASAP, Avdiivka, September 21, 2016.
269
Interview with military paramedic (name withheld), ASAP; Dr. Igor Maidenko, head of pediatrics department, Dnipro
Regional Child Hospital, and ASAP volunteer; and Aleksey Turchak, civilian paramedic and ASAP volunteer, ASAP
camp near contact line crossing point, September 24, 2016 (statement of military paramedic).
270
Ibid. (statement of military paramedic).
261

IHRC / PAX ! Operating under Fire61

pediatrician from a regional children’s hospital was finishing his third short tour; he had volunteered to spend his vacation time with ASAP.271 The lack of continuity and change in specialization means that the health care that ASAP can provide varies depending on the expertise of the
medical professionals on call at the time.

Dr. Tokmakova explained, “We [have] had some days, physically, where you cannot leave yourplace. It’s too dangerous.”274
Because of the danger, many local people have chosen to forsake non-emergency health care.
In Avdiivka, which has weathered several periods of intense shelling, Dr. Viktoria Nikolova told
IHRC-PAX researchers that “people didn’t ask for help for light diseases, like flu or headache.
[They asked] only for heavy diseases.”275 Some residents have not even attempted to obtaintreatment for more significant ailments. A Granitne shopkeeper, whose husband did not seek
professional help for a heart problem after the armed conflict began, said, “During the war
everyone dealt with diseases on their own.”276

ASAP volunteers Dr. Igor Maidenko and paramedic Aleksey Turchak provided care to military personnel and, when time allowed,
civilians along the contact line in September 2016. ASAP’s services have helped fill a gap left by the decrease in availability health care.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Accessibility of Health Care
The use of explosive weapons has impeded access to both routine and emergency medical
services. Dr. Ksenofontova of Maryinka District Central Hospital described shelling as the “biggest problem” for access. “People are insecure about coming” to the hospital for treatment, shesaid.272 Explosive weapons have also contributed to the closure of pharmacies in communities
along the contact line.
Routine Care
The risks of traveling in a region experiencing heavy shelling have deterred residents from seeking professional health care. Dr. Olga Tokmakova reported that patients frequently faced difficulties
in getting to the Center for Primary Medical Help in Maryinka as a result of the shelling.273

Ibid. (statement of Dr. Maidenko).
Interview with Dr. Valentina Ksenofontova, head of neurology department, Maryinka District Central Hospital,
Krasnohorivka, September 20, 2016.
273
Interview with Dr. Olga Tokmakova, deputy head of medical services for civilians and gynecologist, Center forPrimary Medical Help, Maryinka, September 20, 2016.

The use of explosive weapons has hindered Maria Bero’s access to proper health care for her young daughter who has cerebral palsy.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Shelling presented obstacles to treatment for one young girl with cerebral palsy, whose story
exemplifies how inadequate access to medical care has in certain cases exacerbated serious,
pre-existing conditions. The use of explosive weapons prevented the girl, who lived near thecontact line in the village of Starohnativka, from reaching her cerebral palsy specialist and fromcontinuing her regular treatment of massages and physical therapy. The girl’s mother, Maria
Bero, and grandmother Elena Horhulu recalled that during the first six months of the armed
conflict, they tried to reach the girl’s doctor in Donetsk in the non-government controlled areas,
but shelling of both the contact line crossing point and local villages along the way forced them

271
272

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Ibid.
Interview with Dr. Viktoria Nikolova, head of family services and therapy department, Avdiivka City Hospital, Avdiivka,
September 21, 2016.
276
Interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016.
274
275

IHRC / PAX ! Operating under Fire63

to stay at home. Bero said, “We couldn’t find the proper moment to go. We couldn’t put the babyin the car and drive. It was unsafe.”277
In February 2015, the family evacuated the girl so that she could receive some medical care, but
it merely maintained her health and the lack of treatment by a specialist slowed the girl’s development. “Lots of progress has been lost,” Bero said. In particular, the girl, who was 6 years old in
September 2016, started learning to walk much later than many children with cerebral palsy. Her
mother said she also believed that the use of explosive weapons caused psychological stressthat exacerbated the girl’s medical problems. She suffered from sleep deprivation and panic,and “if someone shut the door loudly, she would cry and start to panic.”278
Emergency Care
Emergency situations have sometimes compelled residents to expose themselves to danger inorder to receive health care. A paramedic at the Galytsinivka ambulance substation said she andher colleagues have done phone consultations with patients when they could not reach villages
due to shelling or roadblocks. She added, however, that “some people tried to evacuate themselves because they knew we weren’t going out at night.”279
For example, when Valentina Kurkchi sustained serious injuries from explosive weapons thatlanded on Starohnativka in January 2015, her husband and a local doctor had to drive her 30
kilometers, through intense shelling, to the hospital.280 Kurkchi told IHRC-PAX researchers that
she remembered going out to close her barn on a quiet evening and then waking up, unable tomove and buried under rubble. While the bricks of her destroyed barn had protected her to adegree, weapons fragments penetrated her leg. No ambulances were available so her husband
sought help from Dr. Andrey Markevich, who worked at the Granitne Ambulatory Clinic but lived
in Starohnativka.281 Dr. Markevich recalled that the husband arrived “worried and terrified” ataround 10 p.m., and when they returned to the barn, they found Kurkchi bleeding but conscious.282
The doctor stopped the blood flow, used a stick to make a splint for her leg, and bandaged thewound.283 The two men then carried Kurkchi, who had lost consciousness, to the backseat of thefamily car and sped to the hospital in a neighboring district.284 Dr. Markevich could only provide alight painkiller,285 and he had to sit in the front seat and was therefore unable to treat the injured

Interview with Marina Papuna, activist; Elena Horhulu, grandmother; and Maria Bero, mother, Starohnativka,
September 22, 2016 (statement of Maria Bero).
278
Ibid. (statement of Maria Bero). Activist Marina Papuna, who lived in the same town, said that the use of explosive
weapons has interfered with the health care of her husband, a Chernobyl liquidator who was exposed to radiation
during cleanup of the nuclear disaster. Shelling prevented him from receiving his regular treatment until he relocated to
Donetsk, on the other side of the contact line from his wife. Papuna noted that she believed the psychological stresscaused by explosive weapons exacerbated his pre-existing psychological problems. Interview with Marina Papuna,activist; Elena Horhulu, grandmother; and Maria Bero, mother, Starohnativka, September 22, 2016 (statement ofMarina Papuna).
279
Interview with Dr. Lyudmila Tkachenko, head of clinic and general practitioner of family medicine, Galytsinivka
Ambulatory Clinic, and paramedic (name withheld), Galytsinivka ambulance substation, Galytsinivka, September 21,
2016 (statement of paramedic).
280
Interview with Dr. Andrey Markevich, ambulatory doctor, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
281
Interview with Valentina Kurkchi, resident, Starohnativka, September 22, 2016.
282
Interview with Dr. Andrey Markevich, ambulatory doctor, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
283
Ibid.
284
Interview with Valentina Kurkchi, resident, Starohnativka, September 22, 2016; interview with Dr. Andrey Markevich,ambulatory doctor, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
285
Interview with Dr. Andrey Markevich, ambulatory doctor, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
277

64

IHRC / PAX ! Operating under Fire

woman during the journey.286 Kurkchi said her husband later told her that “the main problem was
the rockets—they were falling the whole time we were driving.”287 While Kurkchi acknowledgedthat “it’s more important they saved my leg,” she has lost mobility and experienced ongoing pain.
In addition, she said, she could no longer crouch down or carry heavy objects, and she felt
“stressed” and “nervous” when she recalled what happened.288
In some cases, the people of the east of Ukraine have had to risk their lives just to communicate
with an ambulance station. Residents in Granitne said that after shelling destroyed the landline
network on one of the first days of the conflict, they had to rely on their cell phones for emergency calls.289 Cellular reception was only available at the top of the hills surrounding the town, but a
shopkeeper said, “It is dangerous to go up on the hills. You never know when shelling or shooting
will start.”290 Because of the uncertainty, another woman explained, residents stayed near theirhomes all day.291 Even if a person in need found a signal on the hilltop, the response could bedelayed because calls were routed to a dispatcher in distant Mariupol who then radioed a local
ambulance.292
Medications
Civilians in the region have had limited access to necessary prescriptions. Some pharmacies
along the contact line have closed, temporarily or indefinitely, at least in part because of thedangers of shelling. Volodymyr Kolesnyk, the Ministry of Health’s deputy director for the Donetsk
Oblast, said, “The medical supply chain has been broken because all pharmacies in the greyzone left due to security.”293 For example, a pharmacy near one of the crossing points along thecontact line reportedly closed for two weeks in February 2016 due to the heavy use of explosive
weapons. A woman working at the pharmacy said, “We were forced to close because of theshelling. Villagers couldn’t reach here . . . and the road was blocked.”294
Local people have improvised by turning to each other to obtain their medications. In September
2016, several residents of Granitne described how they depended on a bread deliveryman tobring medications from other areas of Ukraine.295 One woman explained that customers came toher shop to place orders, which she then relayed to a friend at a city hospital via the bread deliveryman.296 When the deliveryman stopped at her store, he brought the medicines the residents

Interview with Valentina Kurkchi, resident, Starohnativka, September 22, 2016.
Ibid.
288
Ibid.
289
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016;
interview with resident #1 (name withheld), Granitne, September 23, 2016.
290
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statements of hairdresser and shopkeeper). See also interview with Dr. Lyudmila Bagmut, executive doctor
and pediatrician, Granitne Ambulatory Clinic, Granitne, September 23, 2016.
291
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of hairdresser).
292
Ibid. (statement of shopkeeper).
293
Interview with Volodymyr Kolesnyk, deputy director for Donetsk Oblast, Ministry of Health, Kramatorsk,
September 19, 2016.
294
Interview with pharmacy staff member (name withheld), Logistical Center of Humanitarian Services, near contactline crossing point, September 24, 2016.
295
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of shopkeeper #2); interview with shopkeeper #1 (name withheld), Granitne, September 23, 2016.
296
Interview with hairdresser, shopkeeper #2, and resident #2 (names withheld), Granitne, September 23, 2016(statement of shopkeeper #2).
286
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requested as well as bread.297 During their interview with this woman, IHRC-PAX researchers
observed an elderly woman coming into the shop to pick up her medications.
Shelling compelled the people of Mayorsk, located in the gray zone, to adopt a similar approachto obtaining medicines. A shopkeeper explained that during the heavy period of shelling in 2014,
few people, and especially not elderly, immobilized residents, could enter or exit their village.298
Despite the risks, the shopkeeper would travel to Bakhmut (formerly Artemivsk), “take a huge listof medicines for grandmothers, buy them, and bring them back here.”299 She was still performing
this service in September 2016. “Everyone with transport takes a list and buys medicine” as longas there is no shelling, the shopkeeper said.300 The residents of Mayorsk have also relied on
ASAP, the military medical unit stationed nearby, for medical assistance. ASAP personnel have
distributed medicines and provided paramedic training, bandages, and other supplies to the
shopkeeper for the times when ASAP cannot come and assist.301 In the end, due to the harm
explosive weapons have inflicted on Ukraine’s health care system, civilians in this village—and
other communities along the contact line—have often had to treat themselves.

AcknowledgmentsT

he lead researchers and authors of this report were Bonnie Docherty, associate director
for armed conflict and civilian protection at Harvard Law School’s International Human
Rights Clinic (IHRC), and Roos Boer, program lead humanitarian disarmament at PAX.
Torry Castellano, Carolin Ott, and Loren Voss, students from IHRC, and Hugo vanHalder, project officer at PAX, also contributed significantly to the research and writing.
IHRC and PAX are grateful for the input and comments provided by Cinta Depondt, Steve Goose,Mark Hiznay, Diederik Lohman, Tanya Lokshina, Dinah Pokempner, and Frank Slijper. Katherine
Talbot, IHRC program associate, provided additional support.
IHRC and PAX wish to thank Anton Skyba for his invaluable assistance during their field mission
and for the photos he contributed to the report as well as Responsible Citizens for facilitating
certain site visits.
Finally, IHRC and PAX express their gratitude to the many individuals who shared their experiencesand expertise during interviews for this report.

The pharmacy at Avdiivka City Hospital was closed when damage from explosive weapons shut down the facility’s main building.
© Anton Skyba for International Human Rights Clinic at Harvard Law School and PAX / September 2016.

Ibid. (statement of shopkeeper #2).
Interview with shopkeepers #1 and #2 (names withheld) and Elena Shtoda, head of Free Mayorsk, Mayorsk,
September 24, 2016 (statement of shopkeeper #1).
299
Ibid. (statement of shopkeeper #1).
300
Ibid. (statement of shopkeeper #1).
301
Ibid. (statement of shopkeeper #1).
297
298

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Operating under Fire:The Effects of Explosive Weapons on Health Care in the East of Ukraine
May 2017
The armed conflict in the east of Ukraine has significantly affected the region’s health care systemand the people who depend on it. The use of explosive weapons in populated areas has caused
much of the harm. This report, based on field research along the contact line between government and non-government controlled areas, documents the humanitarian impact of this methodof warfare and calls on countries to commit to minimizing this impact in the future.
Explosive weapons encompass a range of munitions, including air-dropped bombs, artillery
projectiles, rockets, and missiles. When such weapons have wide area effects and are usedin cities and towns, they are likely to hit civilians and the infrastructure upon which their lives
depend.
Since 2014, the use of explosive weapons in Ukraine has directly damaged hospitals, destroyed
ambulances, and killed or injured health workers. It has also indirectly inflicted harm on the healthcare system by shutting down infrastructure—causing loss of electricity, water, heat, and communications—and creating travel risks for ambulances, medical personnel, and civilians in need.
The harm attributable to explosive weapons’ use in populated areas has had serious consequences for patient care. It has infringed on quality, accessibility, and availability, which arethree elements of the right to health.
Operating under Fire spotlights the conflict’s impact on Ukraine’s health care system and its
people. It also makes the case for an international political commitment to prevent the harmcaused by the use of explosive weapons in populated areas.

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