World leaders gathered at the United Nations in New York a decade ago to commit to ending attacks on healthcare during war. The unanimous adoption of U.N. Security Council Resolution 2286 on May 3, 2016, reaffirmed that parties to conflict must protect healthcare and that states must prevent attacks, investigate them, and hold perpetrators to account.
But in the 10 years since, a staggering 18,000 attacks on healthcare have been documented, with violent attacks surging to all-time highs in recent years. From Ukraine to Ethiopia to Gaza, hospitals are bombed, ambulances are shelled, and doctors are killed for performing their solemn duties.
Yet the international response and accountability for these attacks have been muted at best. The failure to prevent and ensure justice for these violations reflects in part the overwhelming number and severity of these violent conflicts, but also the relative invisibility of the full breadth and scope of harm that results for patients, healthcare systems, and civilian life. Though available information about the immediate impacts of such attacks has grown, methods for documenting the longer-term and reverberating harm remain underdeveloped.
Longer-Term Impacts Fall to the Attention Economy
Discussions about attacks on health usually focus on observed structural damage and human casualties rather than on an accurate longer-term assessment of foreseeable civilian harm that is likely to result. While immediate damage and casualties are, of course, essential considerations, such analysis is incomplete. It may even risk leaving the impression that far more sweeping attacks are allowed than international law would possibly permit.
In contemporary conflicts, some of the gravest harms to health do not end with the strike itself, though attention to that is crucial. Rather, harms unfold over time, through interrupted care and referrals, medical supply shortages, delayed diagnostics, lost preventive care, untreated long-term and chronic diseases, and psychological trauma. Conditions that could be easily treated and cured in a normal setting escalate with alarming rates once healthcare facilities are incapacitated by attacks. And the long-term consequences on people’s health and well-being are profound: individuals with otherwise treatable cancer die, women with untreated urinary tract infections may become infertile, and malnutrition hampers children’s growth and development. Equally harmful is the gradual erosion of trust in the idea that healthcare is an available and safe choice, as the options to seek care are limited and risky.
From Ukraine to Gaza to Syria, the organizations where we work — Insecurity Insight, Medecins du Monde (Doctors of the World), Truth Hounds, and Physicians for Human Rights, respectively — and other partners have documented how attacks on health have impeded care and caused death and suffering. These are part of the largely unmeasured impacts that reverberate widely: harms that spread across health systems, communities, and generations. In protracted conflicts, these impacts are devastating and often foreseeable.
Failing to capture reverberating impacts undercounts the human cost of war, obscures long-term humanitarian needs, distorts legal analysis that informs targeting decisions, and impedes accountability. There is a risk of missing the predictable ways in which modern warfare destroys civilian life and the conditions necessary for achieving the right to health and a dignified living.
Proportionality and Precaution
International humanitarian law affords special protection to medical personnel, medical units, and transports, which are not allowed to be directly targeted. Only in narrow circumstances can that protection be lost, and even then, the principles of proportionality and precaution still apply. These require, respectively, that commanders refrain from launching an attack expected to cause civilian harm that is excessive in relation to the concrete and direct military advantage anticipated, and take all feasible precautions to spare civilians the effects of attack. When assessing the lawfulness of a strike, key questions therefore include: Was the site being used for a military purpose? What weapons were used? Was the facility clearly identified? Was an effective warning issued where required? And, crucially, what harm to civilians was reasonably foreseeable?”
There is some consensus that precaution entails consideration of harm to patients, staff, and hospital functioning. With respect to proportionality, many states only account for direct effects of attack — for example, kinetic damage from a strike, or a power outage to a hospital as a result of an attack on energy infrastructure.
But, properly construed, proportionality analysis should include consideration of the reverberating effects of an attack, in particular consequences to the health of a population following attacks on hospitals, energy systems, water infrastructure, transport, as well as restrictions of movement and access for humanitarian and medical teams. Consideration of reverberating effects is not a novel add-on to the law; rather, it is necessary to give the standard its intended effect by incorporating the actual scope of foreseeable civilian harm.
Particularly in the context of extended campaigns, it is reasonably foreseeable that attacks on energy and health infrastructure will cause both acute and lasting harm to the civilian population. To this point, consideration of reverberating effects may gain weight over time, as available knowledge grows. In Gaza and Ukraine, for instance, extensive and public reporting by humanitarian actors, health professionals, and investigative bodies makes patterns of harm clear and knowable to commanders planning attack.
A proportionality analysis that ignores those patterns risks being used as a shield for destructive conduct rather than a constraint on it. Commanders may claim that strikes are proportional, even though they cause massive harm that is apparent and foreseeable but a further link down the causal chain from the attack.
Documenting Reverberating Harm
Research often shows associations rather than clear causal links between immediate attacks and the long-term impacts, and tracking may fail to capture effects that unfold over months or years or lose track of chains of causation amid the broader impact of conflict. Systematic documentation needs to be comprehensive, interdisciplinary, and inclusive of indicators beyond the immediate harm. Case studies such as the following are therefore essential to make sense of overlapping and cumulative effects.
In Syria, for example, Physicians for Human Rights documented how attacks on health reshaped reproductive decision-making. Women avoided prenatal visits out of fear of experiencing a bombing incident, kidnapping, or exploitation. Some chose cesarean sections over vaginal birth because it reduced the time they would have to spend inside facilities they no longer believed to be safe. For instance, Physicians for Human Rights showed that, in the months following a March 2021 attack on al-Atareb Hospital in Aleppo governate, reproductive and neonatal care consultations dropped 78 percent. What begins as the destruction of a single facility or targeting of an ambulance can translate into delayed care for acute needs, riskier clinical choices, increased adverse maternal and neonatal health outcomes, and deep psychological harm.
In Gaza, evidence presented by Medecins du Monde, alongside research by Physicians for Human Rights and the University of Chicago Global Human Rights Clinic, shows how attacks on hospitals, health centers and ambulances, restrictions on availability of medical supplies, malnutrition linked to restrictions on basic food supplies, and the systematic bombing of basic infrastructure combine to produce severe and foreseeable harm for pregnant, postpartum, and lactating women, as well as for newborns. Women and girls face significant obstacles to access antenatal care, emergency obstetric services, family planning, menstrual hygiene supplies, and abortion care. Medecins du Monde reported sharp increases in genital infections linked to displacement and lack of access to healthcare, a high prevalence of anemia and infection among pregnant women, and long-term risks that extend from hemorrhage and sepsis during delivery to developmental harm for infants and intergenerational deprivation. This situation was highlighted by one of Medecins du Monde’s doctors, who said “the war is not only destroying infrastructure and lives. It is destroying the future, womb by womb.”
A neonatologist working in Gaza told Physicians for Human Rights about premature babies born amid malnutrition, stress, and attacks. They recounted: “We had a baby that had suffered a brain injury from a lack of oxygen during delivery. That baby did not get the treatment that baby needed or standard of care because they didn’t have the right equipment to take care of that baby. And also because Al-Shifa [hospital], [which] would’ve been where the baby would’ve been transferred to, was destroyed.”
In Ukraine, where attacks on health were on the rise in 2025, Russia’s systematic bombardments of energy infrastructure have also devastated healthcare by targeting the systems that make the provision of care possible. Among healthcare workers surveyed by Physicians for Human Rights and Truth Hounds, 92 percent reported power outages at the facilities where they work, as a result of attacks on energy infrastructure, and 66 percent said those outages affected medical procedures. Reported consequences included disruptions to water supply, heating, ventilation, communications, elevators, diagnostic equipment, storage of medicines and biological samples, planned procedures, surgeries, as well as permanent health harms and deaths.
Repeated attacks on energy predictably echo through every part of the health system. Many healthcare facilities that were never physically attacked still suffer the consequences. A missed ultrasound or brain scan due to a power cut today can mean delayed diagnosis and care tomorrow.
Harm in Ukraine, as we have seen in other conflicts, also extends beyond clinical settings. Much of it develops in private homes or otherwise occurs in places that usually aren’t covered in traditional documentation methodologies. Interruptions to at-home medical devices, treatment routines, heating, and other essential services increase risks for older people, people with disabilities, and those living with chronic illnesses. The loss of regular capacity to sustain care and chronic treatments, combined with isolation and limited mobility due to non-functioning elevators or transportation disruptions, also contribute to mental health harms.
Healthcare facilities and patients at home rely on power generators or other workarounds. But these adaptations carry their own costs. They are expensive, divert resources, degrade quality of care, and become harder to sustain over time. The fact that a system continues functioning under attack should not be mistaken for evidence that the harm is limited, as these impacts unfold over time, chipping away at the system’s ability to sustain itself. Healthcare services may continue to be delivered by humanitarian and health actors in makeshift, tents facilities. However, the dedication of healthcare staff cannot compensate for the lack of drugs, equipment, and for the collective trauma both staff and patients often share.
Finally, as documented by Insecurity Insight, the high numbers of attacks in which medical personnel are killed, detained or kidnapped – more than 1,200 cases in 2024 worldwide — imply that the capacity to provide care will be reduced often for years to come. Training and certification for provision of medical care demand a lasting systemic effort to ensure the right professionals will be allocated in the right places, to deliver care as needed. The death of doctors, nurses, midwives, and many other health professionals resounds far beyond the immediate casualty documented after an attack, and leaves behind a gap in health systems that will take years, if not decades, to recover from.
Tracking and Preventing Reverberating Harms
What should be done so that these harms do not continue to fall through the cracks?
First, documentation practices must improve. Investigators, monitors, and authorities responsible for ensuring accountability should systematically collect evidence not only of the immediate incident but also of foreseeable downstream health effects: treatment interruption, referral failure, maternal and neonatal outcomes, disease burden, disability-related harms, mental health impacts, displacement-related barriers to care. This requires combining legal, medical, and public-health approaches that focus on survivors rather than treating attacks on health as a narrow infrastructure issue.
Second, military doctrine and operational guidance should expressly incorporate reverberating impacts into precaution and proportionality assessments. That means reviewing rules of engagement, tactical directives, standard operating procedures, and training materials to ensure that protected medical personnel, facilities, and transports are not attacked, and that foreseeable indirect consequences for civilian health are part of operational planning.
Third, accountability mechanisms should assess incidents in their full context. A more robust application of proportionality could become one of the most important tools for evaluating the lawfulness of strikes in contemporary warfare. It requires asking what a reasonable commander could and should have anticipated, especially after repeated warnings and accumulated evidence.
When violence affects complex and interconnected civilian systems, the full measure of civilian harm lies in what comes after the blast. The debate over reverberating impact goes to the heart of whether the protection of health in war will be treated as a meaningful legal obligation.
Next week, U.N. member states will convene in New York in an “Arria-formula” meeting — an informal Security Council format intended to increase the involvement of civil society and non-governmental organizations on issues — to discuss attacks on healthcare and the implementation of Resolution 2286, 10 years after its adoption. The meeting offers a timely opportunity to translate longstanding commitments into more practical steps on prevention, documentation, and accountability. Whether states seize that opportunity will help shape the legacy of Resolution 2286.
