Workers attach a banner with a photo of a pregnant woman being carried on a stretcher after the bombing of a maternity ward in Mariupol during Russia’s war in Ukraine that is displayed as part of an exhibition at the railway station in Vilnius, Lithuania on March 25, 2022, where transit trains from Moscow to Kaliningrad make a stopover. PETRAS MALUKAS/AFP VIA GETTY IMAGES

Article initially published in Foreign Policy on April 11, 2022 and written by Annie Sparrow.

The Kremlin is reviving the brutal methods it used in Syria, and the World Health Organization is refusing to name the crime and its perpetrator.

War is synonymous with suffering, but for civilians, the severity of the consequences depends on how a war is waged.

One war crime stands out for its singular capacity to amplify the suffering of civilians, multiply the effect of mass atrocities, and drive forced displacement: Russia’s deliberate assault on health care. Because of its cruelty and devastating effect, this strategy deserves special attention and should be prioritized for prosecution.

On March 9, the Russian assault on a Mariupol maternity hospital in Ukraine sparked international condemnation. The Russian foreign minister confirmed that the attack was intentional but justified it by the specious claim, backed by fake images, that the hospital was a military base. For one critically injured mother-to-be, the attack destroyed the chance of an emergency cesarean section that could have saved her baby’s life. Without the surgery that she herself needed, she also died in physical and emotional pain.

Attacks on hospitals began on the first day of the invasion, and at the time of writing, these attacks included 41 hospitals and clinics, four maternity hospitals, one blood bank, eight children’s hospitals, three cancer centers, four psychiatric facilities and rehabilitation homes, seven ambulances, and several teams of first responders. At least 10 medical workers have been killed.

Russian President Vladimir Putin has a long history of bombing health facilities with surgical precision. In Syria, Russian forces systematically attacked hospitals and humanitarian convoys. They even bombed a vital vaccine storage facility containing more than 150,000 vaccines during a polio outbreak, depriving children of protection at a time of critical need.

Similarly, in 1996 during the First Chechen War, Russian forces attacked 24 hospitals and occupied a clearly marked, purpose-built International Committee of the Red Cross (ICRC) hospital, where they executed six ICRC staff. In the Second Chechen War, Russian forces decimated hospitals and punished doctors who treated people considered to be enemy combatants.

This history leaves little doubt that the attacks in Ukraine are a deliberate strategy aimed at denying civilians access to health care at the moment they need it most. That both deprives patients of lifesaving treatment and deters patients from seeking care at other health care facilities. This is the weaponization of health care.

The purpose of international humanitarian law is to minimize suffering in times of war. Following World War II, civilian immunity was broadly established in the 1949 Geneva Conventions and specifically in the 1977 Additional Protocols.

Yet access to health care is considered so vital for relief of suffering that attacks on hospitals have been banned since 1863, after Henry Dunant, a Swiss banker, traveled to the front lines of Italy’s war for independence to seek French Emperor Napoleon III’s help with a business problem. Instead, he was confronted by the visceral suffering created by the 1859 Battle of Solferino, where tens of thousands of wounded soldiers were left to die in misery.

Dunant’s business trip became a humanitarian mission. Back in Geneva, his front-line report, A Memory of Solferino, drove the creation of the ICRC and the first Geneva Convention. The treaty explicitly established legal immunity of medical personnel, ambulances, and health facilities. Medical neutrality provides the humanitarian space required for access to treat the sick and wounded.

Still, unscrupulous warring parties sometimes violate this fundamental ban and even have used the ICRC as a target. This makes sense in terms of narrow military logic. In 1863, very few wounded soldiers returned to the battlefield. For one, most people, not just soldiers, died of infectious diseases, which doctors didn’t understand and didn’t know how to treat. Without anesthesia or infection control, surgery was a treatment of last resort.

As clinical care advanced, so did military rationale for attacking military hospitals: to deny care to enemy combatants. Early 20th-century advances in public health meant that by World War I, more soldiers died from combat than cholera, and during World War II, penicillin became widely available. By 1977, smallpox was eradicated, and the demise of infectious diseases seemed certain. Still, the Geneva Conventions’ Additional Protocols of 1977 spelled out special protections for health workers and institutions because they were so essential to human welfare during wartime.

By concurrently attacking civilians and targeting hospitals, Russian forces simultaneously create an urgent need for care and deprive people of that care at the moment they need it most. These attacks do not reflect ignorance or indifference of international humanitarian law; they consciously weaponize people’s need for health care with the specific aim of amplifying human suffering.

For the war-wounded, trauma easily turns into infection and amputation. Without birth control or Plan B, gang rapes at gunpoint can result in unwanted pregnancies, backstreet terminations, and even infanticide. The consequences transcend individuals in need of health care and affect public health more broadly. Forced displacements and unsanitary living conditions provide ideal conditions for incubating the next coronavirus variant of concern or even the next pathogen with pandemic potential.

A backdrop of fragile health systems, surging COVID-19 variants, and a population only 35.7 percent vaccinated against the disease and potentially immunocompromised by Chernobyl doesn’t augur well. HIV and tuberculosis both advance more quickly when medical care is disrupted. People with diabetes forced to ration their insulin go blind more quickly; they become more vulnerable to infection, and their kidneys fail faster.

Interrupting tuberculosis treatments breeds drug resistance. Babies born in bomb shelters no longer receive Bacille Calmette-Guérin, or BCG, (the anti-tuberculosis vaccination), and infants and young children aren’t protected against polio, measles, pertussis, or chicken pox. Teenagers miss HPV and meningitis vaccines, and older adults miss pneumonia and shingles jabs. Airborne droplets, like chemicals, are heavier than air and sink to basements, where crowded living facilitates the spread of diseases.

In Syria, this kind of deprivation was deliberate. There, the Russian-Syrian military alliance besieged politically unsympathetic areas and withheld humanitarian aid as well as vital medical equipment and medicines—including intravenous fluids, blood products, antibiotics, painkillers, hepatitis B vaccines for health care workers, vaccines for children, sterilizing equipment, and chlorine. These were deleted from the handful of humanitarian convoys allowed.

In 2019, the United Nations’ Office for the Coordination of Humanitarian Affairs (OCHA) gave coordinates of Syrian underground hospitals directly to Russian authorities, ostensibly to protect them. No one except the OCHA was surprised when at least four of these hospitals were bombed.

The U.S. government has been warning that the Kremlin might use biological weapons in Ukraine, but it is already waging indirect biological warfare by withholding clean water, medicine, and vaccines.

Given the ability of attacks on health care to greatly magnify the already considerable suffering of war as well as fuel outbreaks, one would think that the World Health Organization (WHO), the United Nations body responsible for global health and specifically mandated to monitor attacks, would be on top of it. Instead, it reported nothing until March 5. It reports that hospitals have been attacked but not where, how, or by whom, leaving the world no way to understand intent or consequences.

And although the WHO calls for accountability, it doesn’t call these attacks war crimes, only “violations of international humanitarian law.” That’s a problem because war crimes are serious violations of international humanitarian law, and systematic attacks on hospitals are war crimes. Nor does it name the perpetrators.

The WHO’s surveillance is a study in timidity. Now, when the world needs it most, the WHO’s approach is devoid of context, deprived of meaning, and dehumanizing. This is a derogation of the WHO’s status as the United Nations’ official statistical agency for health.

The international community needs a new approach to document these war crimes wherever and whenever they occur—one that is not scared to portray its human dimension, identify the attackers, and push vigorously and repeatedly for these crimes to stop while pressing for special prosecutorial attention because of the greater culpability—and cruel intent—that they represent.

All war is horrible, but a special place in hell should be reserved for leaders who deliberately compound the human suffering of war by attacking hospitals.

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