Attacks on hospitals and other health facilities have been a prominent – and horrifying – feature of the war in Ukraine. A maternity and children’s hospital was bombed in Mariupol in a widely publicized attack, and Ukraine accused Russia of attacking a psychiatric hospital in Kharkiv, to name just two examples.

The country’s health minister said that Russian forces have shelled 135 hospitals and damaged 43 ambulances, and the WHO has confirmed 49 attacks on hospitals and nine on medical transport units.

“The number is astonishing in such a short period of time,” said Leonard Rubenstein, a professor and director of the Program on Human Rights and Health in Conflict Johns Hopkins University’s Bloomberg School of Public Health.

He compared the situation in Ukraine to the more than ten years of war in Syria – in which health facilities have been heavily targeted and in which Russia is likewise significantly involved. Even compared to Syria, “where the attacks were horrific and sustained over many, many years…this concentration is astonishing.”

The war in Ukraine is likely to hurt the health of those affected for a long time to come, and it’s likely that the destruction of hospitals and other health facilities will have grave consequences, Rubenstein said.

The attacks in context

Only a small percentage of the country’s roughly 2,500 hospitals have been attacked, but health economist and former Ukrainian Deputy Minister of Health Pavlo Kovtuniuk, who is working with a team evaluating damage to Ukraine’s health facilities, said that’s not the right way to consider the matter: “We should look at where they are destroyed…there are cities where all the health infrastructure is destroyed.”

Because these attacks frequently come in areas occupied or under siege by Russian forces, “facilities are being destroyed exactly in the areas where needs are becoming most acute,” said Judy Twigg, a professor of political science at Virginia Commonwealth University and an expert on Russia’s and Ukraine’s health systems.

“With the number of hospitals hit, we know that their capacity in the short term to deal with the enormous demand on services, particularly with traumatic injuries, is going to be severely compromised,” Rubenstein said. “Most hospitals, most communities, are not used to dealing with…these traumatic injuries.”

Rubenstein also heads up the Safeguarding Health in Conflict Coalition and Is the author of “Perilous Medicine: The Struggle to Protect Health Care from the Violence of War.” He explained that conflict situations severely affect health systems and public health, in ways that aren’t necessarily intuitive.

Although the conflict in Ukraine – and Syria and Yemen before it – have drawn public attention to wartime attacks on health facilities, there isn’t enough information to know whether such attacks are on the rise.

“Nobody was tracking them like we are trying to track them now, so we don’t have a baseline,” Rubenstein said. “It had the problem of not being on the global health agenda, and it wasn’t particularly on the human rights agenda, except for a handful of organizations.

Dangerous consequences

But it’s clear that war increases the prevalence of infectious disease, both because people are in crowded conditions and because vaccine campaigns are often disrupted by the conflict. In Yemen, where the health and water infrastructure were damaged, which led to more than a million cases of cholera – “and the capacity to treat it was also diminished by attacks on hospitals,” Rubenstein said.

Because travel is dangerous, people often “take their chances without medical care, which leads to more suffering and more death.”

Women giving birth are often afraid to go to hospitals, and more likely to receive a Caesarean section if they do, Rubenstein said.

In addition, “the hospitals are stressed and the supplies diminished, so dialysis programs diminish. Trauma care often has to be prioritized to save people’s lives, so chronic disease care diminishes significantly.”

Trauma from the event leads to widespread mental health issues – and perhaps particularly for people like health care workers, a fact that Rubenstein said is not widely addressed.

Attacks on hospitals – and the harm it causes to civilians – most often goes unpunished. “There has been complete impunity,” said Rubenstein. “There’s been no accountability in Syria, there’s no amount of accountability in Yemen, so yes, they feel they can get away with it.”

And health care workers often flee the country along with other civilians during a war, further decimating the medical system where a conflict is taking place.

Health in transition

Before the conflict, Ukraine’s health system was in transition.

“Prior to 2015, Ukraine was the last of the countries that had been part of the Soviet Union to undergo any kind of reform,” Twigg said. “It was an inefficient, wasteful, corrupt dinosaur.”

But reforms beginning in 2015 addressed the issue of corruption in drug procurement and created a new national health service, in which state funding for health care went through an independent agency that published its records. Nearly every Ukrainian adult signed a contract with a primary health care doctor. The country focused its efforts on primary care, reducing reliance on what Twigg described as a bloated hospital system with the longest average lengths of hospital stay in the world.

The country maintained its share of health problems, however. Kovtuniuk described repeated recent outbreaks of polio and measles, due largely to extremely low vaccination rates. Tuberculosis, hepatitis C, and HIV/AIDS were all ongoing challenges.

In addition, rates of alcohol use and smoking were high, as was the prevalence of non-communicable diseases like diabetes and hypertension. Rates of mortality among middle-aged men were especially pronounced, according to Twigg.

The dozens of facilities shelled in the war present a significant problem for Ukraine’s health system, Twigg said. “I think what we can expect to see is a huge need for resources to be diverted, once the war is over, into reconstruction of destroyed or damaged facilities,” she said. “Even with an enormous amount of postwar investment…it’s going to take a lot of money.”

Regardless of outcome

Twigg is concerned that Ukrainians’ day-to-day health needs will be affected by the urgent requirement to rebuild health infrastructure and deal with the most pressing health issues. She’s also deeply concerned about the mental health of people affected by the conflict. And should the war continue, she feels Russian attacks on health facilities are sure to follow suit.

Should the worst-case scenario occur and Russia end up occupying most or all of Ukraine, Twigg said Ukrainians will continue to resist, most likely leading to ongoing war injuries. People who use intravenous drugs could be denied medications like methadone, which Twigg said are illegal in Russia.

Should Ukraine manage to repel the Russians, Twigg said it’s essential for humanitarian organizations to follow the country’s lead when it comes to rebuilding, and to “support according to their priorities and their needs.”

But even when the war comes to an end, Kovtuniuk said, normalcy won’t return. “They use civilians and their sufferings as part of the war,” he said. “The world will never be the same again.”