As Russia’s full-scale invasion of Ukraine enters its third summer, the scale of attacks on the country’s critical civilian infrastructure – and the attacks’ long-term impact on the health of Ukrainians – have come into sharper focus. Russian forces have directly attacked not only hospitals and other critical healthcare facilities, but also Ukrainian power plants and the electric grid. The latter attacks left 12 million people with no or limited access to energy in the winter of 2022-2023, and nearly 2 million without power in the most recent attacks of March 2024. They have also  systematically undermined civilians’ access to essential services and disrupted their ability to meet basic needs.

Attacking Ukraine’s critical civilian infrastructure has been a hallmark of Russia’s war strategy since February 2022. Last year, Ukraine’s Prosecutor General Andriy Kostin condemned the use of “hundreds of missiles and Iranian-manufactured kamikaze drones to strike power plants and substations, resulting in the deprivation of electricity, heat and hot water for hundreds of thousands of people amid harsh Ukrainian winter conditions.”

Importantly, in March, the International Criminal Court (ICC) issued two new arrest warrants against Russian commanders for alleged war crimes and crimes against humanity during the campaign of attacks on Ukraine’s energy infrastructure, noting that the “alleged strikes were directed against civilian objects” and that “the expected incidental civilian harm and damage would have been clearly excessive to the anticipated military advantage.”

Services that are crucial to the survival of Ukraine’s civilian population – like healthcare – are affected by these attacks, adding to the severe and cumulative harm done by Russian efforts to degrade energy infrastructure. The energy and healthcare systems are interdependent. As two International Committee of the Red Cross legal advisers put it, “the disruption of one can have domino effects on others and result in multiple services being disrupted or even collapsing.”

In the context of energy, two different types of Russian attacks have impacted Ukraine’s healthcare infrastructure: those on Ukraine’s electric grid that have negatively impacted health services and strikes on hospitals that directly led to loss of power. Both kinds of attacks have disrupted healthcare services for Ukrainian communities and destabilized the broader health system. Given the historic lack of criminal accountability for attacks on healthcare workers and facilities, any investigation into the assault on Ukraine’s electric grid must ensure close attention to its impact on health.

Critically, Russia’s assault on Ukraine’s healthcare system is also unfolding against a larger backdrop of rising attacks on health globally – from Syria to Sudan, and Myanmar to Gaza. The growing erosion of the legal rules prohibiting attacks on healthcare has become increasingly evident. Data indicate that such attacks surged by 45 percent between 2021 and 2022. The Safeguarding Health in Conflict Coalition (SHCC), a group of international NGOs that works to protect health workers, services, and infrastructure, reported more than 1,900 incidents of violence against healthcare in 2022 alone – driven largely by in the conflicts in Ukraine and Myanmar.The SHCC’s just released 2023 report, “Critical Condition: Violence Against Health Care in Conflict,” recorded a further 25 percent increase in reported attacks on health, the highest ever since the Coalition began reporting.

More recently, in the Occupied Palestinian Territories, the World Health Organization has recorded over 800 attacks on healthcare since Israel began its assault on the Gaza Strip following the terrorist attacks of October 7, 2023. These rising numbers should galvanize the medical, humanitarian, and legal communities to protect healthcare workers and patients, emphasizing the importance of prevention, accountability, and adherence to international law to prevent further atrocities during conflicts.

Russia’s Assault on Ukraine’s Energy Grid

According to the Energy Damage Assessment by the World Bank and the United Nations Development Program, attacks on Ukraine’s energy grid have resulted in reduction of power generating capacity by 51 percent, damaging or destroying 41 out of 94 (about 45 percent) high-voltage transforming substations, which serve as crucial intermediaries in the power grid that help manage and distribute electricity. Many of these stations have also faced repeat attacks.

Throughout the 2022-2023 heating period (October to April), Russia launched more than 1,200 missile and drone strikes, damaging 43 percent of Ukraine’s trunk power grid network (designed to transmit electricity from power stations to local networks). As of June 2023, the cost of the direct damage to Ukraine’s energy infrastructure, which offers insight into the scope of the damage thus far, has been estimated to be at least $11.5 billion, including $8.8 billion in the energy sector and $2.7 billion in utilities infrastructure (damages to heat supply facilities, water supply and sewage, and municipal waste management facilities).

Nuclear stations have also been a target: the International Atomic Energy Agency has repeatedly condemned Russian forces’ illegal occupation of Ukraine’s Zaporizhzhia Nuclear Power Plant, Europe’s largest nuclear facility, while three other stations have also been affected by attacks. The calculated destruction of key energy facilities, including the Kakhovka Dam in June 2023, have further inflicted severe damage on not only Ukraine’s energy infrastructure and the environment, but triggered a humanitarian crisis as well.

Attacks on Energy Infrastructure as Attacks on Health

These attacks have also severely damaged Ukraine’s healthcare system. As one World Health Organization official noted, intensified attacks on Ukraine’s energy infrastructure “mean hundreds of hospitals and health-care facilities are no longer fully operational – lacking fuel, water and electricity to meet basic needs,” in turn, this has “knock-on effects on the health system and on people’s health.” The interconnectedness of essential services – water, heating, sanitation, waste disposal, and the distribution of medication and medical supplies – means that the disruption of even a few of these services can have crippling effects.

Physicians for Human Rights (PHR), together with Ukrainian and international partners, has been monitoring attacks on Ukraine’s healthcare facilities, workers, and medical infrastructure since February 2022. Our monitoring has recorded more than 1,400 such attacks to date, and our report “Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System” – published in February 2023 together with the nonprofit organizations eyeWitness to Atrocities, Insecurity Insight, the Media Initiative for Human Rights, and the Ukrainian Healthcare Center – established a reasonable basis to believe that attacks on Ukraine’s healthcare system, both deliberate and indiscriminate, likely constitute war crimes and, potentially, crimes against humanity. A more recent report from late 2023 highlights the impact on healthcare in Russian-occupied territories, where Ukrainian civilians’ right to health has been further compromised by imperiling access to essential medical services, detaining healthcare workers, requiring Ukrainians to change their nationality to Russian as a precondition for gaining access to healthcare (a practice known as ”passportization”), and unlawfully repurposing health facilities for nonmedical purposes.

Currently, our data indicate that there have been at least 71 attacks[1] that disrupted the functioning of hospital utilities.[2] Forty-two percent of these disruptions reportedly happened as a result of attacks on Ukraine’s critical and energy infrastructure, with the majority occurring in the coldest months (October-April) of the 2022-2023 heating season.

Timeline of attacks with reported impact on health facilities' utilies, Feb. 24, 2022 - Feb. 21, 2024

Source: Attacks on Health Care in Ukraine, as of Feb. 21, 2024.

Surgeries in the Dark, Wards with Freezing Temperatures

In principle, infrastructure that forms part of an energy system enabling the delivery of essential services – such as water, sanitation, and medicine – is protected under international humanitarian law (IHL). It benefits from a presumption of civilian status. Whether a particular part of Ukraine’s energy infrastructure would arguably qualify as a military objective under IHL is a factual question; however, there must be a “proximate nexus” between the infrastructure and the fighting itself and a concrete advantage to the objective sought. Any military advantage that could be gained through attacking a facility that provides power supply must also be held to the principle of proportionality and precaution, in order to mitigate harm to the civilian population. In case of doubt as to whether an infrastructure object which is normally used for civilian purposes could effectively contribute to military action, there is a presumption in favor of its civilian status.

Importantly, IHL also prohibits attacks on energy infrastructure solely for degrading economic capacity, influencing negotiations, intimidating leaders, or spreading terror among the civilian population, recognizing that these objectives exceed legitimate bounds in warfare. Hospitals and other health facilities as well as medical personnel must be respected and protected at all times and shall not be the object of attack.

Map of attacks with reported impact on health facilities’ energy and water supplies, Feb. 24, 2022 Feb. 21, 2024

Map of attacks with reported impact on health facilities' energy and water supplies, Feb. 24, 2022 – Feb. 21, 2024

Sources: Attacks on Health Care in Ukraine, as of Feb. 21, 2024; Territorial control in Ukraine and directions of Russian attacks, Russian-occupied territories marked in red, from DeepState Map, as of Nov. 20, 2023.

Our dataset of 71 incidents suggests that hospitals far from active battle reported disruptions of power that impacted their provision of health services. In one incident (see Event ID 36011) a hospital in Chortkiv, a city about 400 miles from the nearest front line, was forced to run a generator in order to continue operating after an energy attack cut its power. In another attack (see Event ID 34328) on a health facility, a medical center in the Kyiv region was damaged by Russian forces, leaving it with no electricity, heating, or water supply.

Hospitals have had to turn to power generators due to electricity deprivation; in some cases, doctors were forced to perform surgeries in the dark and patients had to stay in wards with no heating. Chain reactions also follow. Continuous blackouts, for instance, place the cold-chain supply for medications, which ensure temperature control while in transit or storage, under constant risk of disruption, potentially undermining the delivery of vaccines and life-saving medications to patients. Electronic medical record-keeping, now standard practice across Ukraine, is likewise at risk of disruption by blackouts caused from energy attacks. Blackouts have forced patients to postpone planned surgeries and procedures.

Attacks on energy infrastructure disproportionately affect vulnerable populations, including pregnant women and children, who face unique challenges in accessing essential healthcare services during times of conflict. One woman from Kyiv described her experience navigating constant blackouts during rocket attacks to theNew York Times, highlighting the increased difficulty and risks she faced while pregnant:

When I was about seven months pregnant, my belly was large and round. Getting down to the bomb shelter as often as three times a day became more complicated, and blackouts after rockets attacks were harder. If I was home alone, I had to navigate the darkness and the snow piled up around our house to turn on the generator.

Children’s and maternity hospitals as well as their patients experience the immediate and reverberating effects of these attacks. In March 2022, when Chernihiv was under siege, Mykola Liutkevych, who was a doctor at Chernihiv Regional Children’s Hospital, explained that with no electricity, doctors had to manually resuscitate premature babies who would normally require special life support equipment. In one October 2022 incident(see Event ID 35271), a children’s hospital in Zaporizhzhya was forced to operate on emergency power due to a Russian attack on the city.

The Urgent Need for Accountability

Accountability for these attacks is a priority for the Ukrainian government and must be for other prosecutors as well. As PHR and partner organizations have noted, attacks on health as a violation of IHL have been ignored by the international community for far too long. It was not until 2016 that the United Nations Security Council achieved a political breakthrough and adopted Resolution 2286, which condemns attacks against health and commits to their prevention and to holding perpetrators to account domestically and internationally. Despite this victory, accountability for such crimes has been exceedingly rare. Indeed, despite over 20 years of investigations in 17 countries to date, the ICC has yet to issue an indictment for an attack on medical personnel or infrastructure.

It is unclear why attacks on health have been so curiously overlooked. To be sure, these are hard cases to investigate and prosecute – they are resource intensive and fact specific, often turning on disputed questions of whether a health facility might have lost its protected status or around debates over proportionality. But similar challenges are also present in other cases, and these are crimes that cannot be ignored, not only as violations of the laws of war but also because of their devasting impacts on public health. Attacks on healthcare violate a range of human rights, including the rights to life and health. Considering the disproportionate impact of such attacks on vulnerable communities, especially women and children, and people with disabilities, they also violate the right to equality. Now is the moment for prosecutors in Ukraine, at the ICC, and in third States that may also have jurisdiction to act and to affirm the norm that the laws protecting medical facilities and personnel be respected, protected, and enforced.

Investigations by independent organizations as well as the Ukrainian government have already identified suspects likely responsible for carrying out attacks on Ukraine’s electric infrastructure. At a leadership level, Sergei Kobylash, commander of Russia’s Long-Range Aviation of the Aerospace Force, and Viktor Sokolov, who led the Black Sea Fleet, were charged by the ICC Prosecutor in March of this year for their alleged responsibility in “missile strikes carried out by the forces under their command” from October 2022 until at least March 2023. The ICC Prosecutor has thus far pursued charges for war crimes and importantly, the crime against humanity of “inhumane acts.”

Russia’s actions also underscore the devastating legacy – and connections between – its full-scale war in Ukraine and attacks perpetrated on Syria’s healthcare system, where PHR has similarly documented widespread and systematic attacks since the conflict began. Of the 604 total attacks on health documented by PHR in Syria to date, 80 percent were perpetrated by the Syrian government and/or Russian armed forces since October 2015 (when Russia formally entered the conflict). Overall, the scale, frequency, and intensity ofsuch attacks peaked in the two years following Russian intervention. The ICC’s accused in Ukraine also have connections to Syria: Kobylash was promoted to the rank of lieutenant-general in 2017 for his service in Syria (where Long Range Aviation bombers carried out repeated attacks) while, in 2016, Sokolov led a detachmentof Russia’s Northern Fleet engaged in operations off the Syrian coast. As in Ukraine, PHR’s map of attacks demonstrates how attacks on health in Syria are consistent with direct targeting of health facilities in areas far from military objects or the frontline.

Targeting power plants, electric grids, and dams disrupts essential energy supplies, but also directly impacts critical healthcare services, depriving civilians’ access to life-saving medical treatment and exacerbating humanitarian crises. Not only do civilian objects like hospitals enjoy special protected status during armed conflicts, but the repercussions of interruptions in their services have profound impacts on the affected population for years.

Enough is enough. The ICC has the resources to investigate and prosecute these egregious violations, which have already caused so much death and destruction in Ukraine and beyond. The time for accountability is now.

[1] These were attacks critical/energy infrastructure with reported impact on a health facility; attacks causing damage to a health facility that disrupted its energy and/or water supplies; and incidents that had other reported impacts on health facilities’ energy and water supplies, or on such supplies within their vicinity. The incidents that had other reported impacts include incidents where an energy infrastructure object and a health facility were damaged in one attack, but it was not immediately possible to determine the connection and impact on the health facility, or where a health facility or its vicinity was impacted by an attack, but it was not (yet) clear whether the energy supply was interrupted.

[2] This information cited is based on reported incidents. The team has sought data from multiple sources, including audiovisual evidence, open-source research, and, where possible, interviews with Ukrainian healthcare workers. However, the ability to physically document and verify attacks on the ground remains complicated and impeded, constraining the scope of this analysis. To that end, the reported incidents are almost certainly an undercount.

IMAGE: Residents stand in line for drinking water during a power outage caused by a Russian missile strike on the city’s energy sector on March 22, 2024 in Kharkiv, Ukraine. (Photo by Oleksandra Novosel/Suspilne Ukraine/JSC “UA:PBC”/Global Images Ukraine via Getty Images)