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May 26, 2022
The World Watched Russia Bomb Ukraine’s Hospitals. What Happens Next?
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The World Watched Russia Bomb Ukraine’s Hospitals. What Happens Next?

Ukrainian emergency workers carry an injured pregnant woman from a maternity hospital damaged by shelling in Mariupol, Ukraine. The baby was born dead and the mother later died.

Associated Press/Evgeniy Maloletka

Global human rights experts are cautiously optimistic that social media, smartphones and near real-time monitoring of attacks could usher in a new era of accountability for war crimes.

There are rules when it comes to war. Russia just isn’t following them.

Video and photographs from the besieged port city of Mariupol in southeast Ukraine have seared images into the global consciousness of pregnant women evacuating a bombed hospital – one woman being carried through the rubble on a stretcher, her pelvis bloodied; another woman walking down the stairs of the destroyed building in polka dot pajamas with cuts and bruises on her face.

Attacks on healthcare facilities, medical transport and patients are recognized as violations of international humanitarian law that has been codified in treaties and reaffirmed in U.N. resolutions that Russia itself has signed. The U.N. has so far recorded 847 civilian deaths and 1,399 injuries since the war began on February 24, though the actual numbers are expected to be significantly higher. The World Health Organization has confirmed 46 attacks on hospitals and medical transport units, while the Ukrainian Ministry of Health puts the number above 60. These attacks, among other actions, led President Joe Biden to call Russia’s president Vladimir Putin a “war criminal” last week, while the Russian government has falsely claimed the maternity hospital was taken over by military radicals.

As the war of words plays out between governments, people on the ground in Ukraine have been documenting the atrocities in real-time, which are now shared and amplified worldwide through the press, online messaging apps and social media platforms. This proliferation of information aided by technology has global human rights experts cautiously optimistic that Russia’s war in Ukraine could finally be a tipping point for holding those who commit war crimes, specifically attacks on patients and hospitals, accountable for their actions.

Russia and Putin have a running track record of bombing hospitals, including in Chechnya in the 1990s, Syria in the 2010s and now Ukraine in the 2020s. “There’s an opportunity for global leadership to say we ignored, downplayed and did not follow through on commitments with respect to the security of hospitals in conflict, and now we’re going to be serious about taking some action,” says Leonard Rubenstein, a human rights lawyer and professor of practice at the Johns Hopkins Bloomberg School of Public Health. “I can’t say that I’m confident it will happen, but unlike other circumstances, like Syria, these attacks have really seized the world’s attention.”

Mariana Vishegirskaya walks down stairs in of a maternity hospital damaged by shelling in Mariupol. She survived the shelling and later delivered a baby girl in another hospital.

Associated Press/Evgeniy Maloletka

There’s precedent for communications technology to advance the cause of preventing war crimes. It was thanks to the invention of the telegraph and dispatches from the Crimean War in the 1850s by The Times of London’s William Howard Russell that the public began to wake up to the terrible conditions for wounded soldiers on the battlefields and lack of proper medical care. A few years later, Swiss businessman Henry Dunant would witness the battle of Solferino in northern Italy and try to aid the wounded and dying. He was instrumental in the creation of the International Committee of the Red Cross and cementing the idea of medical neutrality and caring for sick and wounded soldiers through the First Geneva Convention in 1864. “The pressure to have better health, protection, medical facilities and care for those wounded in combat came from outside the armed forces,” says Eric Stover, faculty director of the Human Rights Center at the University of California Berkeley School of Law.

Eighty-five years later, following the destruction caused by World War II, the Fourth Geneva Convention dealt specifically with the protection of civilians, specifying that hospitals have a protected status and cannot be attacked during war. The one exception was if the hospital engaged in “acts harmful to the enemy,” in which case, it would lose its protected status.

Fast-forward to the present war in Ukraine and this is very likely the motivation behind a disinformation campaign being spread by Russian embassies on social media, including Twitter, Facebook and Telegram, which falsely claimed the maternity hospital in Mariupol was empty and being used as a military outpost and calling pregnant women in the photographs “crisis actors.” The Russian government has already been laying the groundwork for why it believes the hospital lost its protected status, even as two adults and a child died and 17 people were injured. Facebook and Twitter took down some of the posts last week.

One of the reasons Russia is likely emboldened to violate these agreed upon humanitarian protocols is that there has never been a specific international criminal prosecution for attacks on hospitals, “which weakens the law and impugns all these perpetrators,” says Rohini Haar, an emergency room physician and faculty member at the University of California Berkeley School of Public Health. A case in point is how quickly Russia escalated airstrikes on hospitals in Ukraine within the first few weeks, whereas, in Syria, Russia didn’t start conducting airstrikes on hospitals until several years into the war, she says.

The way we have near real-time reporting on attacks on health – I’m hoping that that will translate into faster mitigation or accountability.

When it comes to individual liability for violations of international humanitarian law under war tribunals and the International Criminal Court, the process is slow, with many prosecutions taking place years or even decades after the crimes were committed. Plus, prosecutors have to make trade-offs with limited time and resources on which charges to pursue, often opting for genocide and crimes against humanity over other war crimes like attacks on hospitals. Since its founding in 2002, the court has only heard 30 cases, which have resulted in 10 convictions and 4 acquittals. Neither Russia, Ukraine nor the United States are party to the Rome Statute, which is the foundational basis of the court’s authority. This doesn’t preclude Russian nationals from being tried, but it means Russia would have to hand them over to the court (extremely unlikely) or they could be arrested in a country that recognizes the court’s authority.

Haar says what’s different this time around is just how fast the International Criminal Prosecutor Karim Kaan was on the ground in Ukraine, starting his investigation less than three weeks after the war began. “The speed with which we are aware of this violence and the way we can document and report is dramatically better now than it even was five years ago,” she says. “The way we have near real-time reporting on attacks on health – I’m hoping that that will translate into faster mitigation or accountability.”

Criminal prosecution is but one piece of the global accountability framework that is supposed to prevent these war crimes from happening in the first place. It relies on a combination of hard power tactics, like prosecution and sanctions, and soft power tactics, like naming and shaming by the U.N. or NGOs and the collection of independent information about the attacks. But the system can also be thwarted by individuals and governments who just don’t seem to care about the consequences.

“We need to find ways to enhance compliance and to enforce these global norms,” says Lawrence Gostin, a professor and faculty director of the O’Neill Institute for National & Global Health Law at Georgetown University. “Because what’s the point in trying to be a decent and humane world where you have bad actors like Putin intentionally bombing hospitals and medical facilities and humanitarian corridors?”

A medical worker holds a newborn girl, Alana, who was born in Mariupol, Ukraine. Her mother had to be evacuated from another maternity hospital and lost some of her toes after it was shelled.

ASSOCIATED PRESS/Evgeniy Maloletka

While international criminal justice may be slow and limited to individual perpetrators, Russia’s deliberate misinformation campaign shows it does care about the less tangible but still important court of public opinion, which is another way to force accountability for war crimes. This relies on the public, NGOs, the U.N. and other states effectively “naming and shaming” the perpetrators and also collecting information and evidence of what has occurred. And here, the speed of information gathering is making a big difference.

For the past 40 years, Stover of Cal-Berkeley’s Human Rights Center has worked on forensic investigations of war crimes from Argentina to Bosnia to Rwanda to Ukraine. When it comes to collecting evidence, there are three types: testimonial, documentary and physical. But digital technology – from satellite images to social media accounts to smartphone video – is playing an increasingly important role in piecing together what happened. “It’s not the sort of boots-on-the-ground investigations I’d been involved in, but it’s a tool,” says Stover. “What’s important in gathering this information, both for the press and for courts, is that you verify it, because there’s so much misinformation that’s sent.” That’s why he worked with the U.N. Commission on Human Rights to develop the Berkeley Protocol on Open Source Investigations, which walks through the steps to collect and verify online data. “We’re passing on the baton to the next generation.”

The World Health Organization has also stepped up in recent years when it comes to monitoring and confirming attacks on health systems, including posting an online dashboard that became operational in 2017. As of Sunday it reported 46 attacks on healthcare in Ukraine, including facilities, transport and warehouses, with 12 deaths and 34 injuries. “The best process is to raise awareness of these attacks in order to prevent them from ever taking place to begin with, because there are very few international legal mechanisms of restitution,” says Benjamin Mason Meier, a lawyer and professor of global health policy at the University of North Carolina at Chapel Hill.

But the WHO system has several shortcomings: It doesn’t list where the attack took place or the specifics of what happened. The other big issue is the WHO doesn’t name the perpetrators of the attacks. “If our goal is to shine a spotlight on a harm, it’s not enough simply to identify the harmed body,” says Meier. “We need to identify the perpetrator to engage with the perpetrator to prevent future attacks.”

With the attacks in Ukraine, it’s clear the aggressor is Russia, but the WHO and its Director-General Tedros Adhanom Ghebreyesus have so far refused to name names, which is largely seen as a political decision. “We need to make sure that WHO is not so obsequious to its powerful member states like Russia or China and that it will actually call nations out,” says Gostin of Georgetown. “There’s been a history of WHO not wanting to do that.”

The importance of stopping governments and other actors from attacking hospitals cannot be understated. Even as the photographs of the hospital bombings in Ukraine fade into memory, the fear of accessing hospital services, the lack of adequate care, the increase in severity of untreated diseases, and the eventual exodus of health workers will reverberate far beyond the war’s end. “There’s a crucial role to play for monitoring as a foundation for accountability,” says Meier. “If we don’t know what’s happening, or if we don’t believe the data, then we have no ability to condemn it.”

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