Vol. 1, Issue 1, 2023
Impact of Explosive Weapons Use on the Provision of Healthcare in 2022
A review of data from the Safeguarding Health in Conflict Coalition
Tim Bishop, Conflict and Hunger & Press Lead, and Christina Wille, Director, Insecurity Insight
The Safeguarding Health in Conflict Coalition reported at least 634 attacks on healthcare in which explosive weapons were used in 2022. This data, collected by Insecurity Insight, shows the widespread disruption of the provision of healthcare across the globe as a result of the use of explosive weapons in populated areas, the full scope of which will extend long beyond the time and location in which they were recorded. Ongoing data collection on civilian harm from the use of explosive weapons remains critically important to supporting efforts to address and mitigate this harm.
“It was the sound of a whistle and an explosion. [...] It was the sound of broken glass, dust rising. But it was for a few seconds. Everything fell and everyone began to realise what had happened.” – Dr. Alla Barsehian, Ukrainian Healthcare Centre[i]
Ukrainian healthcare workers recalled a Russian cruise missile attack on the Bashtanka Multiprofile Hospital in southern Ukraine on an April afternoon in 2022 that completely destroyed about 30-40 percent of the hospital’s premises, including the infectious diseases department and the outpatient polyclinic. At least 330 of its windows were shattered, and multiple doors were blown off their hinges by the explosion’s blast.[ii] Meanwhile, Russian armed forces continued bombing Bashtanka city with Grad rockets, air-dropped bombs and Tochka-U missiles, wounding civilians in need of medical care from the city’s hospital.
This incident is just one of at least 634 attacks on healthcare in which explosive weapons were used in 2022 recorded by Insecurity Insight for the Safeguarding Health in Conflict Coalition (SHCC).[iii] In a June 2023 report published by the SHCC, ‘Ignoring Red Lines: Violence Against Health Care in Conflict 2022’, explosive weapons use accounted for a high proportion of all documented 1,989 incidents of violence against or obstruction of healthcare in conflicts across the world.[iv] This is no surprise – explosive weapons used in populated areas have devastating consequences for civilians across the world, including the damage and destruction of critical civilian infrastructure that affects access to essential services such as healthcare.
This article reports on the impact of explosive weapons on the provision of healthcare in 2022 as captured in data collected by Insecurity Insight and presented by the SHCC. This data shows the widespread disruption of the provision of healthcare across the globe as a result of the use of explosive weapons in populated areas, which demonstrates a pattern of civilian harm that both includes and stems from the damage and destruction of health infrastructure and the killing and injuring of health workers.
Widespread Disruption of the Provision of Healthcare
Hospitals, mobile clinics, pharmacies, ambulances, patients and health workers were directly impacted by the use of explosive weapons in 17 countries and territories in 2022. Nearly four-fifths of all 634 reported incidents of attacks on healthcare with explosive weapons occurred in Ukraine. Incidents also occurred frequently in Myanmar, where Insecurity Insight recorded 54 attacks, and in Syria and Yemen, where ten attacks were recorded in each country.
All of these events impacted the provision of healthcare in different and complex ways, beyond the damage and destruction to hospitals and clinics. For example:
- Airstrikes in Yemen damaged at least one medicines warehouse, making access to life-saving medicines more challenging for Yemeni civilians.
- At least one health worker travelling to assist injured civilians was killed by air-launched bombing in Syria.
- Ambulances were damaged by directly-emplaced explosives, such as landmines, on at least ten occasions in Myanmar.
The use of different types of explosive weapons, which range from small weapons, such as hand-grenades, to significantly larger aircraft bombs and ground-launched rockets and missiles, also had varied effects on the provision of healthcare.
Ground-launched explosive weapons
Ground-launched explosive weapons, such as artillery shells and ground-launched missiles and mortars, were reportedly used in 365 incidents that affected healthcare in 2022, and accounted for over half of all recorded attacks on healthcare with explosive weapons. Over 90 percent of these attacks were attributed to Russian armed forces in Ukraine, primarily in the eastern half of the country.
In at least 187 incidents in Ukraine, hospitals were damaged or destroyed, often to a large extent, as documented above with regards to the Bashtanka Multiprofile Hospital. In addition to the damage and destruction of hospitals, ambulances, clinics and mobile health centres were damaged or destroyed by ground-launched explosive weapons in 63 incidents in Ukraine.
Some hospitals were directly hit by ground-launched explosive weapons, and others were damaged by the wide area effects of the weapon’s blast and fragmentation. The ground-launched Iskander-M missile, for example, which was often used by Russian armed forces at the start of the conflict, has a blast radius of 25,000 square metres.[v]
Devastation of the Ukrainian Healthcare System by Explosive Weapons
Over four-fifths of all incidents recorded by Insecurity Insight in 2022 in which explosive weapons were used in attacks on healthcare were reported in Ukraine in the context of the full-scale invasion by Russian armed forces.
During the first two weeks of the invasion, at least seven attacks on health facilities were reported every day, and rates of attacks on healthcare remained high throughout the year.[vi]The high number and frequency of attacks by armed forces destroyed Ukraine’s health infrastructure and reduced the number of active healthcare personnel by at least 14 percent. Further, it disrupted the medical supply chain and health facilities’ ability to maintain data registration and reporting.
This had a profound impact on civilian health outcomes and forced health workers to change how routine care is provided. For example, the number of strokes and myocardial infarctions increased significantly - even considering gaps in surveillance data in the regions at the fighting frontline - indicating a critically higher burden of these conditions.[vii]
A least 29 health workers, most of whom worked in Ukraine’s national healthcare system, were also killed in Ukraine. Often, health workers were struck by shelling or rocket fire while travelling to work and, in several instances, by mortars or shelling while working as military medics in battlefield contexts. In at least four cases, health workers were killed during attacks on health facilities. For example, in September 2022, a psychiatric hospital was shelled by Russian armed forces in Strelechya village, Kharkiv oblast, leading to the deaths of four health workers who had been helping evacuate the hospital due to heavy fighting in the surrounding areas.[viii]
In Myanmar, Myanmar’s armed forces damaged and destroyed hospitals with the use of artillery and shelling on at least seven occasions. Ground-launched explosive weapons also damaged or destroyed ambulances, hospitals, health centres and clinics in Afghanistan, Armenia, Kyrgyzstan, Libya, Mali, Somalia, Syria and Yemen.
Air-Launched Explosive Weapons
At least 97 incidents in which air-launched explosive weapons, such as airstrikes and air-dropped bombs, were used against health facilities were recorded by Insecurity Insight in 2022. Nearly 60 percent of these incidents were attributed to Russian armed forces in Ukraine. The devastation from these air-launched explosive weapons was often large-scale. For example, the wards, showers, toilets and dental office of the Khukhra Primary care clinic in Sumy oblast were completely destroyed when it was struck by a 500 kg Russian air-dropped bomb in March 2022.[ix] The wide area effects of the bombs also affected the health system. A hospital in Poltava oblast, though not attacked directly, was forced to use a generator to continue operating in November after Russian forces attacked nearby critical infrastructure with air-launched explosive weapons, disrupting the supply of water and causing power outages.[x]
In Myanmar, at least 20 airstrikes against health facilities were recorded by Insecurity Insight in 2022. More than half of these attacks damaged or destroyed hospitals, clinics and health centres. Six health workers were also killed in four separate incidents. In one of these incidents, the People’s Defense Forces used drones to drop an improvised explosive device (IED) on a health centre in Sagaing, later claiming the attack had targeted SAC military personnel believed to be occupying the centre.[xi]
Affects on health infrastructure as a result of airstrikes were also recorded in Ethiopia, Mali, Syria and Yemen. In Yemen, the Saudi-led coalition damaged or destroyed health infrastructure with air-dropped explosive weapons on at least six occasions. In Syria, plane and drone-launched bombing by the armed forces of Türkiye damaged or destroyed two health centres, including one used for COVID-19 vaccinations, a hospital under construction and a clinic. A health worker was also killed by an air-dropped bomb by the armed forces of Türkiye.[xii]
Directly-emplaced explosive weapons
Directly-emplaced explosive weapons, such as anti-personnel mines and IEDs, were reportedly employed in at least 58 incidents affecting healthcare in 2022. Twenty-three of these incidents occurred in Myanmar, half of which resulted in the damage or destruction of ambulances that drove over and detonated mines or IEDs. In several other instances, health workers were injured when mines and IEDs detonated as they were walking to work or to visit patients. The placement of directly-emplaced explosive weapons in locations such as roads can also have a significant on the transportation of patients who need access to healthcare.[xiii]
Outside of Myanmar, incidents in which directly-emplaced explosive weapons affected the provision of healthcare occurred most frequently in Ukraine, Afghanistan, Burkina Faso, Colombia, Iraq, Mali, Pakistan, Somalia, Syria and Yemen.
The full scope of harm to civilians from the use of explosive weapons in attacks on healthcare reported here will extend long beyond the time and location in which they were recorded. After being struck by Russian air-launched explosive weapons in March 2022, the Izium Central City Hospital in Ukraine was still functioning at only 10 percent of its capacity in December of that year due to the extensive damage caused to it.[xiv] Physical restrictions to accessing healthcare due to the attacks will remain in place, civilians will feel less confident that they can visit hospitals, clinics and health centres in safety, and unexploded ordnance from explosive weapons which initially failed to detonate will exacerbate these challenges. The traumatisation of health workers who endured attacks will also persist. This is all likely to undermine civilians’ physical and mental health for years to come.
Ongoing data collection on civilian harm from the use of explosive weapons remains critically important to supporting efforts to address and mitigate this harm, including through implementation of the commitments of the Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences arising from the use of Explosive Weapons in Populated Areas.[xv] This will be a key area of work for all stakeholders to this process to avoid the use of explosive weapons in populated areas.
[i] Interview with Dr. Alla Barsehian, Ukrainian Healthcare Centre, quoted in Insecurity Insight, et. al. (2022). ‘Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System’, p. 32.
[ii] Insecurity Insight, et. al. (2022). ‘Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System’, pp. 31-32.
[iii] Attacks on healthcare are defined generally by Insecurity Insight according to the World Health’s Organisation’s definition, which includes “any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access and delivery of curative and/or preventive health services during emergencies.” For an expanded definition, see World Health Organisation (2020). ‘Attacks on health care initiative: Documenting the problem’.
[iv] Safeguarding Health in Conflict Coalition (2023). ‘Ignoring Red Lines: Violence Against Health Care in Conict 2022’.
[v] Action on Armed Violence (2023). ‘Russia’s Dirty Dozen: an examination of Russian explosive weapons used in Ukraine,’ 18 January 2023.
[vi] The figure of an average of more than seven attacks on healthcare using explosive weapons per day in Ukraine was calculated based on the period from 24 February 2022 - 9 March 2022.
[vii] Ukrainian Healthcare Center, et. al. (2023). ‘Healthcare at War: the Impact of Russia’s full-scale invasion on the Healthcare in Ukraine’. April 2023.
[viii] Insecurity Insight (2023). Explosive Weapons Incidents Affecting Health Care 2022 Dataset, SiND ID: 34682.
[ix] Ibid., SiND ID: 34758.
[x] Ibid., SiND ID: 35482.
[xi] Ibid., SiND ID: 35144.
[xii] Ibid., SiND ID: 36043.
[xiii] International Committee of the Red Cross (2022). ‘Explosive Weapons with Wide Area Effects: A Deadly Choice in Populated Areas’. January 2022, p. 124.
[xiv] Insecurity Insight, et. al. (2022). ‘Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System’, p. 23.
[xv] Ireland Department of Foreign Affairs (2022). Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences Arising from the Use of Explosive Weapons in Populated Areas.