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AOAV: all our reportsHealth and explosive violenceReverberating effects

Blast injury: the reverberating health consequences from the use of explosive weapons – Infrastructure and personnel

This article is part of AOAV’s examination of the health impacts from explosive violence. The full report, Blast injury: the reverberating health from the use of explosive weapons, can be found here. The summary and key findings can be found here.

  • Between 2011 and 2019, AOAV recorded 3,447 civilian casualties from the use of explosive weapons in 221 attacks on hospitals. Such attacks were recorded in 23 countries from Afghanistan to Ukraine to Peru. 
  • In 2018 alone, the Safeguarding Health in Conflict Coalition documented that there had been a total of 973 attacks on healthcare professionals.
  • Of 600 primary health care facilities in Luhansk and Donetsk oblasts, over 35% of them have sustained damage.
  • In Ukraine, the most significant decreases in the number of full-time doctor positions between 2012 and 2016 were observed in territories that witnessed the fiercest fighting, namely: Avdiivka (a 23% decrease); Mariinka (15%); and Yasynuvata (14%). 
  • Physicians for Human Rights estimate that, by March 2020, at least 923 medical professionals had been killed in the conflict in Syria.

Increasingly, hospitals and other medical infrastructure have become the target of air and ground campaigns across conflict zones. Between 2011 and 2019, AOAV recorded 3,447 civilian casualties from the use of explosive weapons in 221 attacks on hospitals. Such attacks were recorded in 23 countries from Afghanistan to Ukraine to Peru. Further casualties have been recorded in attacks that hit both hospitals and other surrounding infrastructure such as homes or markets. Health personnel have also been killed or injured in explosive incidents, targeted and random, outside of medical facilities.

So problematic is this that, in June 2019, medics in Syria’s Idlib region stopped sharing the coordinates of health facilities to the UN to prevent targeting, as the health facilities whose location had previously been shared with the UN had come under attack. The targeting of operational hospitals is a breach of International Humanitarian Law. 

Such targeting is not without precedent. In the Sri Lankan civil war, a conflict that lasted from July 1983 through to May 2009, hospitals in rebel areas also stopped providing coordinates after being targeted. Despite such efforts, by the last few months of the conflict it was reported that shelling between the government forces and the Tamil Tigers had destroyed the last functioning hospital in the North. 

In recent years, the targeting of hospitals has reportedly become ‘the new normal’. This is devastating to civilian populations, both physically and psychologically, preventing access to treatment for thousands. When the MSF hospital in Saada, Yemen, was hit in an airstrike in October 2015, it was reported that up to 200,000 people lost access to medical care.

Personnel are also frequently targeted. In 2018, the Safeguarding Health in Conflict Coalition documented 973 attacks on healthcare professionals and facilities in 23 countries experiencing conflict. 272 attacks included the use of explosive weapons: 27% with surface-launched explosives; 55% with aerial bombs; 10% with IEDs. 

Infrastructure damage and the loss of personnel have devastated the healthcare systems in both Syria and Ukraine. 

Infrastructure 

Ukraine 

AOAV has recorded nine incidents of explosive violence on hospitals which resulted in reported deaths and injuries; 39 civilian casualties were reported. This is just as reported on English language media – more hospitals were damaged or destroyed. Of 600 primary health care facilities in Luhansk and Donetsk oblasts, 35% of them sustained damage. More are in disrepair due to a lack of maintenance and upkeep.

Of the damaged hospitals and clinics in the region, most are located near the contact line, with the majority lying near Donetsk.[i] Most of the damage occurred in 2014 and early 2015. There were 107 incidents of shelling on hospitals in Donbas: 73% occurred in the 12 months between April 2014 and March 2015. The World Health Organisation (WHO) reported that 150 of the 342 healthcare facilities in the conflict zone had been shelled by December 2016.

When AOAV visited Sloviansk, the bombed-out psychiatric hospital was a stark reminder of the conflict’s toll. Dr Yuriy Smal, the head-doctor of this facility for 30 years, once ran a centre with 450 beds, 48 doctors and 180 nurses – some 480 staff in total. It was the biggest psychiatric hospital in the region. Today, he has taken over a smaller building in the nearby city of Semenivka.  And while he retained his staffing levels, the number of his patients has dropped – today he only has space for 275 beds.  Some of the damaged buildings have been renovated, but three had to be demolished and the remainder are still under repair.  

Dr Yuriy Smal is the head of a major psychiatric centre that was bombed in the war .

Admittedly, some hospitals have been quickly rebuilt, and offer better facilities than before. Funding from regional and central government, as well as donations from the Swiss, Norwegians, French and Germans, has transformed the main hospital in Popasna. It is able to now cater to a population of over 77,000, comprised of locals and IDPs. Without such funding the hospital would have been dragged into despair, and the population left without quality care. 

Syria 

AOAV has recorded 1,388 civilian casualties from 92 incidents of explosive violence on hospitals in Syria, not including incidents that hit multiple locations.  

In 2018 alone, Syrian health workers, facilities and transport faced 257 attacks (data is available for 253 of these cases). Of this number, 208 attacks utilized explosive weapons, including 132 aerial bombs, 46 surface-launched explosives and in several cases hand grenades and landmines.

It is not only stationary healthcare facilities that have been the direct targets of violent attacks. Ambulances have been repeatedly bombed, shot at, stolen, looted and obstructed as part of the war strategy, with 204 individual attacks involving 243 ambulances occurring in Syria between 2016 and 2017.  

In 40% of such attacks, ambulances have been rendered entirely inoperative. One of the tactics used to achieve such outcomes has become known as ‘double-tap attacks’, whereby one attack is followed by another in the same area. The most common form of attacks on ambulances in 2017 were air-to-surface missiles (making up 53% of ambulance attacks) and shelling (making up 31% of ambulance attacks). The use of cluster bombs, barrel bombs and IEDs have also been routinely used, accounting for 13% of ambulance attacks in 2016. Attacks on ambulances increasingly impeded the healthcare system, significantly restricting the ability to safely evacuate the wounded and provide medical aid.  

At points in the conflict, as mentioned, some actors and organisations in Syria stopped providing the coordinates of the healthcare centres under their control, as it was felt that such coordinate sharing led to hospitals being targeted. MSF stopped providing the coordinates of their healthcare centres in rebel-held areas by early 2016. Such seemingly targeted attacks on healthcare have continued throughout the conflict. Hospitals in Idlib decided not to share coordinates in 2019.   

Despite these efforts, by February 2020, Physicians for Human Rights had recorded 595 attacks on at least 350 separate medical facilities. In total, it was reported in 2020 that “only 64% of hospitals and 52% of primary healthcare centers across Syria were fully functional at the end of last year”. 

Personnel 

Ukraine 

In Ukraine, it is thought that over 1,500 healthcare professionals have left the conflict-affected areas since 2014. In Donetsk, some estimates suggest that as many as 40% of doctors left

The low numbers of psychologists and other mental health workers and the escalating scale of need has also meant that many have experienced professional burnout. One psychologist reported losing their health and even their ability to walk for two years. Many now only want to work for a decent salary with suitable, fixed working hours – in other words, outside the afflicted areas or even overseas.  

A report undertaken by the Deputy Chief of Healthcare Statistics in Donbas found that the number of full-time staff positions of doctors in the Donetsk region between 2012 and 2016 decreased by 7.2%. The most significant decreases were observed in territories that witnessed the fiercest fighting, namely: Avdiivka (23% decrease); Mariinka (15%); and Yasynuvata (14%). 

The number of doctors per 10,000 in the Donetsk region fell by 8.8. There was also a decline in doctors with specialisms, especially amongst paediatric surgeons. Furthermore, as of 2016, there were no pulmonologists, urologists, or neurosurgeons with a paediatric specialism across the entire region at all, with but a few specialists in paediatric haematology and gastroenterology. 

The report also found that the provision of beds also decreased by 14%. At the same time, many specialist wards were closed down. The most significant decrease in the provision of beds was that of specialist beds for children. These reductions, in both medical specialism and beds available, may have fuelled the rise in the region’s hospital mortality rates, which increased 10.5% between 2012 and 2016.  

Syria 

Physicians for Human Rights estimated that at least 923 medical professionals had been killed in the conflict by March 2020. Of the health workers killed, it is estimated that shelling and bombing accounted for 55% of deaths. 88 individual health workers were killed in Syria in 2018 alone, with a further 75 injured. 73 of these deaths were caused by explosive weapons, 45 of which were aerial bombs. Up to 70% of healthcare workers are said to have fled the country. 

Refugee camp in Arsal, Lebanon

There are also indirect impacts from the use of explosive weapons on health personnel. For example, in Lebanon, the surge in demand for services from the millions of Syrians who sought refuge in Lebanon was not met with increased human resources in Lebanese health centres. According to interviews with health professionals in Lebanon and international organisations, Lebanese healthcare professionals reported being overwhelmed and experiencing reduced satisfaction with their occupations, with significant rises in stress.[ii] This contributed to issues with staff retention and recruitment. Such impacts on staff influence the level and quality of patient care, for both Syrians and Lebanese.  

A key complaint among refugees interviewed by AOAV in Lebanon was that they felt like they were discriminated against when trying to access healthcare, while others reported mistreatment at hospitals. One refugee told AOAV that during their experience of accessing healthcare treatment in Lebanon, they were ‘made to feel worthless’. Of the refugees surveyed by AOAV in Lebanon, 81% were unsatisfied with the healthcare they received. The reduced health professional to patient ratio would undoubtedly result in such consequences, causing frustration for both patients and professionals.

A veterinary surgeon in a camp in Lebanon’s Arsal region explained that many come to him for advice as they cannot afford to seek healthcare. As Syrian health professionals are not allowed to work in healthcare in Lebanon for the most part, many provide informal care. Dr Gladys Honein, Assistant Professor at AUB- Hariri School of Nursing, highlighted that while this filled a gap in healthcare provision, the Syrians providing such care, did so at considerable risk to themselves, given that it was illegal. Though such care enables many of those who cannot access healthcare formally to not go entirely without, far more must be done to ensure adequate care provisions for all. Currently in Lebanon, many refugees rely almost entirely on local NGOs to ensure access to healthcare.

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AOAV’s research in post-conflict areas found that while damage to health infrastructure was often repaired within a matter of years, the loss of health personnel can persist for decades; with many professionals remaining in the countries or areas where they had sought refuge during the conflict.  In addition, impacted countries all too often fail to retain promising young health professionals in post-conflict environments, and training for such individuals is often sparse. Given this, it likely that the damage to infrastructure and the loss of personnel will continue to impact the healthcare provided to civilians in eastern Ukraine and Syria for many years to come.


[i] Buckley, C. et al. 2019. ‘An assessment of attributing public healthcare infrastructure damage in the Donbas five years after Euromaidan: implications for Ukrainian state legitimacy’, Eurasian Geography and Economics, DOI: 10.1080/15387216.2019.1581634.

[ii] Interview with Dr Nada Awada, Senior Medical Advisor at IMC, January 28th 2020, and also reported in an interview with Gladys Honein, Assistant Professor at AUB, Hariri School of Nursing, January 28th 2020.