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An Anatomy of a Grad Attack: Good Health and Well-Being

SDG 3 – Good Health and Well-Being

3.1.1 – Number or proportion of health facilities damaged or destroyed by explosive weapons

Case Study

The Vostochny district holds three outpatient clinics for primary medical care, as well as one specialist children’s clinic. Outpatient clinic No. 5 – located at the north of the district – was partly damaged by the attack, but no other medical facilities in the area were hit. All of Mariupol’s hospitals are located closer to the centre of the city and were not affected by rockets. The nearest hospital is roughly 4km east of where the attack occurred.

Global

There are currently several organisations which monitor attacks on healthcare facilities, resources and professionals throughout the world. These include the Safeguarding Health in Conflict Coalition (SHCC) and the World Health Organization’s Surveillance System for Attacks on Healthcare (SSA). However, published datasets compiled by these organisations do not currently disaggregate depending on weapon type, although they do provide information on whether attacks were carried out by ground-launched or air-launched explosive weapons.

Therefore damage to health facilities caused by Grad attacks must be observed on a case-by-case basis. In Ukraine, damage to hospitals from Grad rockets is well recorded, especially in areas close to the contact line; whilst in Libya, GICHD recorded damage to the Zintan Public Hospital when it was partly hit by a barrage of Grad rockets in April 2011. More recently HRW have reported Azerbaijani forces targeting public and military hospitals with LAR-160s (an Israeli-made 122mm MLRS highly similar to a BM-21 Grad).

3.1.2 – Number of health workers killed or injured by explosive weapons, disaggregated by gender

Case Study

“She went to do her job and the rocket killed her” – Lyobov Nikolaevna, retired doctor. 

Among those killed by the attack was Galina Vladimirovna Anikeenko, a 49-year-old nurse who lived and worked in the Vostochny district. She was walking to the house of a patient to give an injection when a rocket landed close to her on Poljetajeva Lane. Elsewhere, medical personnel were not listed amongst the dead or injured. 

Global

Since the WHO SSA began recording attacks on health personnel in January 2018, it has cited 52 incidents involving ‘heavy weapons’ which impacted on health workers in Syria, and 29 in Libya. However, as these incidents are not disaggregated for weapon type, conclusions cannot be easily drawn regarding the specific harm inflicted by Grad launchers. 

Clear examples of health workers killed or injured by Grad attacks are difficult to find. This is partly due to the fact Grads are often used alongside other explosive weapon types. AOAV found that during sustained attacks on Homs, Syria on 8th February 2012, several medical staff were severely injured and a Red Cross worker lost both legs in a single explosion. Although the use of Grads was clearly reported in the barrage, so too was mortar fire as well as artillery and tank shelling. 

Clearer cases highlighting direct impacts to health workers come from Tripoli in 2020. Amongst the 44 explosive incidents involving Grad MLRSs, AOAV recorded a Grad attack on a field hospital in southern Tripoli which injured five paramedics in April 2020. Only a fortnight before, at least six hospital employees had also been injured when the Libyan National Army (LNA) hit the Al-Khadra hospital in Tripoli with rockets fired from a Grad system.

3.1.3 – Shortages in essential medical supplies

Case Study

No shortages in medical supplies were recorded as a result of the attack. The intense fighting in 2014 had not disrupted medical supply lines to the city, and due to increased insecurity in the region, most local hospitals were well stocked with emergency materials given their proximity to the conflict. 

Global

The links between Grad attacks and shortages in medical supplies requires further investigation. WHO’s SSA has recorded incidents involving ‘heavy weapons’ impacting on medical supplies in two of the four countries where AOAV have recorded Grad attacks (Syria and Libya). However, this data is not disaggregated for weapon types and cannot be used for weapon-specific analysis. 

3.1.4 – Number or proportion of ambulances destroyed (locally)

Case Study

No ambulances were damaged or destroyed in the attack. 

Global

The International Commission of Inquiry on Libya found an example of three Grad rockets landing within a hospital compound in Zintan, Libya in April 2011, during an attack by pro-Gaddafi forces. Although there were no reports of the rockets damaging hospital buildings, several ambulances parked outside were damaged by the attack. The extent of the damage was not mentioned. 

Elsewhere, cases of Grad attacks damaging ambulances are difficult to find. WHO SSA records incidents that impact on health transport; however, as mentioned previously, weapon type is not mentioned.

3.2.1 – Number or proportion of health facilities with service disruptions

Case Study

‘When I arrived at 9:30 I could not go to the emergency room because there were 5 or 6 ambulances outside. I entered from a different entrance and the corridor was covered in blood, I’ve only seen this in movies’ – Tatiana Grigorievna Ovchinnikova, Medical Director of Hospital No. 4, Mariupol.

As no hospitals were damaged in the attack, service disruption was non-existent. Although the outpatient clinic No. 5 was partly damaged in the attack, there was no evidence to suggest that this affected its delivery of normal services. 

The large and sudden influx of patients, whilst shocking for medical staff, did not overwhelm facilities or bring about disruptions to normal hospital services. Victims were initially brought to Hospital No. 4 – the closest facility to the Vostochny district – but a well organised triage process meant that individuals with less serious injuries were quickly moved to other hospitals in the city. 

Global

When Grad rockets damage hospitals, it typically brings about some disruption to their services. Grads were used alongside artillery and mortars during intense fighting in Benghazi, Libya on 2nd June 2014. As a result, several wards of the Ibn Sina Clinic – including intensive care, maternity and physiotherapy – were damaged by shrapnel, and the work of the clinic was suspended for two days at a critical juncture.

More recently, grad rockets hit the Weryemma polyclinic in Tajura Municipality, Tripoli on 29th April 2020, causing it to close due to the damages sustained. The facility was the only reproductive and maternal health clinic serving a population of 48,000 in this municipality of Tripoli.

3.2.2 – Health worker density and distribution per 10,000 population, compared with pre-conflict

Case Study

Official reports highlight that in 2014, 17 doctors and 28 nurses served the Vostochny district. In 2021, the figure was 16 doctors and 25 nurses. Given the high levels of displacement from Vostochny in the same time frame, there is little evidence to suggest the Grad attack in January 2015 had a significant impact on health worker density.

Interviews with the Medical Director of Hospital No. 4 revealed that neither individual attacks, nor conflict more widely had made a significant impact on the numbers of available staff in the city’s hospitals. She highlighted a constant lack of trained nurses and certain specialists, but this had been a problem prior to hostilities.

As in-depth interviews by International Alert and the Mariupol Youth Union in 2017 reflect, the outflow of specialists in the city was not typically a major concern amongst citizens. However, psychological problems in the city became the most dominant issue raised in the majority of cases. This reflects the fact that although the Grad attack, and conflict more widely, did not cause a significant exodus of medical specialists, there was not the necessary influx of professionals to combat the growth in psychological issues brought about by conflict and trauma. 

Image: ‘Ranking of issues based on in-depth interviews’, taken from interviews in Mariupol in 2017.

Global

There is currently insufficient information available to present causal links between Grad attacks and changes in health worker density and distribution. All the cases of Grad use, as recorded by AOAV, occurred within an environment of conflict, where other weapon types were regularly used. Attributing any national or regional changes in health worker density directly to Grad attacks would ignore a myriad of other factors. 

3.2.3 – Difference in proportion of births attended by skilled health personnel, compared with pre-conflict

Case Study

There is no evidence to suggest that the attack on Vostochny caused any change in access to skilled health personnel during childbirth. The city is served by a specialist children’s and maternal health hospital, located more than 10km east of where the attack took place. Access to this facility was not disrupted. 

Global

Whilst national data is available on the proportion of births attended by skilled health personnel in some countries, there is insufficient information to draw linkages between the use of Grads and this indicator.  The destruction of the Weryemma polyclinic in Tripoli by Grad rockets in April 2020, would have undoubtedly impacted local access to skilled health personnel as it was the only maternal health clinic in the region. However, exact figures are not currently available.

3.2.4 – Difference in proportion of the population with access to affordable medicines and vaccines, compared with pre-conflict

Case Study

Tatiana Grigorievna Ovchinnikova, Medical Director of Hospital No. 4, Mariupol, told AOAV that she had noticed no changes in access to medicines or vaccines for those in Mariupol, or Vostochny, as a result of the Grad attack or conflict in the area more broadly.

Global

In the two countries worst affected by Grad attacks in the past decade – Ukraine and Libya – WHO has highlighted a growing problem with the supply and coverage of vaccines and medicines. However, in both cases, there is scarce evidence to suggest how Grad attacks may have contributed to these concerns. 

3.3

1 – Difference in maternal, neonatal and under-five mortality, compared with pre-attack

2 – Difference in mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease, compared with pre-attack

3 – Difference in reported cases of and number of deaths from preventable diseases such as cholera, measles or polio or changes in the life expectancy of HIV-positive patients, compared with pre-attack

Case Study

The Medical Director of Hospital No. 4 told AOAV that she had witnessed no discernible changes in maternal or neonatal care, nor in the levels and survival rates of the diseases mentioned above. She did, however, highlight a spike – localised to the Vostochny district – in those suffering from post-traumatic stress disorder (PTSD) in the months following the events of the 24th January. 

As no hospital facilities were damaged in the attack and Mariupol remained relatively well connected to the rest of the country, it is not surprising that third-level health impacts are less apparent. However, in other areas of eastern Ukraine, there has been a more noticeable impact on healthcare systems. WHO has highlighted that in rural areas, closest to the contact line, 30% of people have no access to essential health care, whilst every second HIV case is not detected. AOAV has also recorded a fall in the provision of doctors, specialists and beds in the Donetsk region since conflict began and significant spikes in diabetes in areas close to the contact line. 

These concerns are more likely attributable to a complex web of factors brought about by conflict, and further information is required to highlight the direct role Grad MLRSs have played long-term health impacts in the region.

Global 

Undoubtedly Grads have the potential to badly damage health facilities, kill health workers, and interrupt services key to health systems – such as water and electricity. Nevertheless, to attribute long-term health consequences to a single weapon ignores other significant factors. 

If a Grad rocket hits a hospital, killing a specialist and badly damaging a cancer ward, can we attribute a rise in cancer mortality rates solely to this weapon? Or is it in fact the result of development and security concerns brought about by conflict, where a single incident can tip extreme fragility into disaster? 

It is worth noting that an event of explosive violence in a resilient, economically-advanced country – not blighted by conflict – would not cause drastic changes to the above indicators. Therefore, it is important to be wary in drawing direct, causal links, when the reality is far more complex.

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