 Nurses tend to a child in a room protected by sandbags at Zaporizhzhia Regional Clinical Children's Hospital in Ukraine on March 22. (Emre Caylak/AFP/Getty Images) | As the conflict in Ukraine ticks on, hospitals and health care continue to be in the firing line — with potentially devastating consequences. The World Health Organization has verified 64 attacks on health-care facilities, personnel and patients since Russia invaded a month ago, with 15 deaths and 37 injuries as a result. "We are in the process of verifying further attacks," WHO Director General Tedros Adhanom Ghebreyesus told a news conference Wednesday. "Attacks on health must stop. Health systems, facilities and health workers should never be a target." What we are seeing could be just the tip of the iceberg. Outside of direct attacks on health care, the war is likely to have huge knock-on effects. Roughly a quarter of Ukraine's population has already been forced from their homes, living in uncertain conditions. Medical supplies, such as lifesaving drugs like insulin, are in short supply in many parts of the country. But direct attacks can be catastrophic, too. Ukrainian Health Minister Viktor Liashko told local media Tuesday that 10 hospitals had been destroyed in Russian attacks. The Washington Post could not confirm that number, but earlier this month our visual forensics team was able to find evidence that at least nine health-care facilities had been hit by Russian attacks. Ukraine's former deputy health minister, Pavlo Kovtoniuk, shared a photograph Wednesday that he said showed a young girl who had been injured in southern Ukraine before being evacuated to a children's hospital in Zaporizhzhia. The window by her bed was boarded up, covered by sandbags. "Zaporizhzhia Children's Hospital has not been shelled. Yet." Kovtoniuk wrote on Twitter. Violent disruptions to health care during wartime carry ominous consequences. I asked Judyth Twigg, a professor at Virginia Commonwealth University who tracks public health in Ukraine and Russia, what worried her most about the situation. She said the most immediate risk was posed to those living in places under occupation or assault from Russian forces. "In those areas, health facilities — hospitals, ambulances, health workers themselves — are being destroyed at the very locations where the need is most acute. Most physicians and other health workers are women, and while many are courageously staying put, most with children have left, risking critical shortages of medically trained personnel," Twigg responded. Longer-term, the concerns multiply. "There's going to be tremendous need for expanded capacity to diagnose and treat long-term anxiety, depression, post-traumatic stress disorder, and other conditions. We should also be paying attention to treatment and management of chronic, noncommunicable disease, which is the primary part of Ukraine's existing health burden," Twigg added. Shortages of supplies of medicines like insulin and treatments for high blood pressure — as well as limited access to treatment by professionals — could hurt people already sick in a country where a significant portion of the population already lives with chronic health problems. "Without that ongoing care, and under the stress of wartime conditions, those patients are at highly increased risk of death, even in the short term," Twigg said. As WHO officials noted Wednesday, the world remains in a pandemic even as it is distracted by the conflict. War or no war, the coronavirus remains a worrying threat for Ukrainian people. Only around a third of the population is fully vaccinated, while some of the countries accepting Ukrainian refugees, like Romania and Moldova, have similar or even lower vaccination rates. Other infectious diseases pose other risks. Health experts have raised warnings about the coronavirus, but also a resurgence in cases of tuberculosis and polio, which was detected in the country shortly before fighting broke out in early 2022. Measles could also pose a risk; there were cases of cholera in Mariupol as recently as 2011. On Wednesday, Tedros said the disruption caused to Ukraine's health system posed an "extreme risk to people with cardiovascular disease, cancer, diabetes, HIV and TB, which are among the country's leading causes of mortality." "As we've seen in wars over the years, viruses and bacteria are happy to exploit those situations where human beings are put under pressure," Máire Connolly, a global health professor at the National University of Ireland Galway, told my colleagues earlier this month. The question isn't just how much damage is done to Ukraine's health-care system, but how long the disruption lasts. If Ukraine's war ends tomorrow, there's a good chance of a return to normalcy. But if it drags on for months — or perhaps longer — all bets are off. Deliberate attacks on health-care facilities constitute a war crime. The Geneva Conventions say that civilian hospitals should be protected during the war, assuming they are not used in a manner to commit attacks against an enemy. Medical workers are assumed to be neutral in a conflict and should be allowed to continue their work. But attacks still happen. Physicians for Human Rights, a U.S.-based nonprofit organization, has accused the Syrian government of using attacks on medical care as a weapon of war, with "hundreds of attacks on hospitals and medical facilities since 2011, and nearly 900 medical personnel who have been killed." Conflicts in Yemen, El Salvador and Chile have seen similar deliberate attacks, according to the humanitarian group. WHO leader Tedros has recently called on governments to do more to support areas where war and conflict have cut off people from medical care, including Afghanistan and Ethiopia's Tigray region, where he himself is from. But Russia, a key ally of government forces in the Syrian war, appears to be shifting to tactics that only increase the risk to health care in Ukraine. Having failed to win a divisive victory on the battlefield, it has resorted to siege techniques — surrounding cities like Mariupol and bombarding them with often imprecise artillery and bombing. Such tactics are fundamentally likely to devastate health care, with unpredictable results. "You have to place yourself in the situation many civilians find themselves in Mariupol," Mike Ryan, executive director of WHO's health emergencies program, said Wednesday. "It doesn't matter if the hospital is open or closed. You are in a basement, you cannot move, you are stuck. That in and of itself is an attack on health care." | 
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