Uliana Poltavets serves as the Ukraine Emergency Response Coordinator for Physicians for Human Rights (PHR). In a recent survey conducted between July 21 and September 18, 2024, PHR examined the impact of targeted attacks on Ukraine’s healthcare and energy infrastructure. The study, which surveyed 2,261 healthcare workers, uncovered alarming consequences: 92 percent reported power outages, leading to critical disruptions in surgeries, life support systems, and water supplies—resulting in deaths and permanent health complications.

Despite efforts to adapt through backup systems, significant gaps remain. The toll on frontline medical workers is staggering, with 83 percent experiencing severe stress and burnout. The report calls for urgent action, highlighting the need for increased resources, mental health support, and legal accountability for these attacks as war crimes. Its recommendations include continued financial and political support for Ukraine, reinforced international norms against targeting civilian infrastructure, and legal action against those responsible.

Scott Douglas Jacobsen: What methodology was used in the survey of 2,261 Ukrainian healthcare workers?

Uliana Poltavets: We distributed an online survey to healthcare workers across Ukraine. 2,261 respondents to that survey were included in our analysis (5.6 percent were excluded due to incomplete data). The online survey is available in Ukrainian and English.

The survey gathered a wide range of data on the frequency and timing of attacks on health care and energy systems, power outages, and the impact of attacks and power cuts on health services, facility operations, and patient outcomes.
Healthcare worker respondents represented diverse demographics, including physicians (37.3 percent), nurses (10.2 percent), administrative staff (44.4 percent), and other healthcare professionals (8.2 percent), from all 24 oblasts (provinces) of Ukraine and Kyiv, with females constituting a majority (71.7 percent). Demographic data was compared to the National Health Service of Ukraine and Medical Statistics of Ukraine data and is generally consistent with these distributions.

The survey’s voluntary nature and absence of probability sampling mean that the findings cannot be generalized to Ukraine’s healthcare system. Under-reporting and potential double counting of incidents may affect accuracy, though flagged cases of medical complications or deaths help mitigate this risk. Self-reported data may include recall bias and inconsistencies due to the challenging conflict conditions. Given the difficulties in reporting faced by clinicians, particularly in Russian-occupied regions of Ukraine, figures may undercount the true tolls of attacks on civilians and civilian infrastructure.

Jacobsen: The report highlights that 92 percent of healthcare workers experienced power outages. These were targeted attacks on energy infrastructure. How do these impact patient care?

Poltavets: Electricity is the lifeblood of the health sector, powering lifesaving devices and enabling essential medical services. It supports diagnostics, emergency response, vaccinations, medication distribution, and the daily functionality of health facilities. As our report title references, health care in Ukraine was forced to proceed “in the dark” due to Russian attacks.

As recognized by many accountability mechanisms and international organizations, such as the United Nations Human Rights Monitoring Mission in Ukraine (UN HRMMU) and the United Nations Independent International Commission of Inquiry on Ukraine, energy attacks have devastating impacts on the health sector in Ukraine. The damage to power facilities and resulting blackouts have limited hospitals’ capacity to provide essential services, interrupted medical procedures, and compromised patient care.

Among notable examples of impacts on patient care are interrupted or delayed surgeries, forcing surgeons to operate in darkness illuminated only by flashlights; failures in life support systems; medication and biological samples storage issues; discontinued flow of water to hospitals; diagnostic and treatment equipment becoming unusable; impeded maternal care service delivery; and other impacts on health care provision.

Jacobsen: Permanent health harms and deaths were reported because of these energy attacks. What are concrete examples of this?

Poltavets: Our survey identified 20 reports of deaths and 36 reports of permanent health harms, though these figures likely undercount the full extent of harms given the challenges in reporting. Most often, Ukrainian healthcare workers reported cases of organ damage and deaths due to inadequate oxygenation (when patients who are unable to breathe on their own lose access to their mechanical breathing support). Out of 36 reported cases of permanent harm, 11 were linked to inadequate oxygenation, and among 20 reported deaths, seven were attributed to the same cause.

In such instances, health workers resort to manual ventilation, which, if prolonged or improperly performed, can cause serious complications or fatalities. Additional harms included delays in critical surgeries, interruptions in dialysis, and failures of life-saving equipment, resulting in deaths and severe health consequences. This aligns with global findings that power outages, even in non-conflict settings, can lead to increased morbidity and mortality, particularly among patients relying on electricity-dependent medical devices.

Jacobsen: These attacks disrupt critical services like surgeries, life support systems, and water supply. How have healthcare facilities adapted to these challenges?

Poltavets: Healthcare facilities in Ukraine have implemented various measures to adapt to power outages caused by attacks on energy infrastructure. The Ministry of Health, with the help of international partners, has provided backup generators and is working to supply hospitals with alternative energy sources, such as solar panels. However, these measures are not always sufficient. Surveyed healthcare workers reported delays in activating backup systems—sometimes lasting hours or even days—which can severely disrupt critical hospital functions. While helpful, generators offer limited capacity and cannot fully replace grid power, leading to gaps in service and risks to sensitive medical equipment. Health workers emphasize the need for additional resources such as solar panels, hybrid energy systems, and reliable Internet access to improve resilience.

Jacobsen: Stress and burnout increased among 83 percent of healthcare workers surveyed. What measures can be taken to support these frontline workers’ mental health and resilience?

Poltavets: Ukrainian healthcare workers face immense stress and burnout, exacerbated by working in disaster conditions for nearly three years, grappling with power outages, trauma, and the unrelenting toll of patient care coming under attack. Measures to support their mental health and resilience should include access to counseling, mental health services, and peer support programs, as well as training on preparedness for response to attacks. Addressing systemic challenges, such as providing reliable power sources and reducing administrative burdens caused by delayed data systems, can also alleviate stress. Additionally, the government and international community must ensure that the burden of response does not fall solely on staff by equipping facilities with the necessary resources and creating robust mental health support systems.

Jacobsen: Given the minimum of 1,539 verified attacks on healthcare workers and infrastructure since February 2022, how are perpetrators held accountable under international law?

Poltavets: To date, the perpetrators of these attacks on healthcare in Ukraine have not been held to account under international law – this must remain an urgent priority for Ukrainian and international prosecutors. And it is important to note that these are not just separate incidents but a clear pattern of violations. We have analyzed these patterns, and we have a reasonable basis to believe that Russian attacks on health in Ukraine constitute war crimes and potential crimes against humanity.

We see numerous possibilities for addressing crimes, such as attacking health care. There are opportunities for investigations and arriving at justice at both the international and domestic levels—through the International Criminal Court, national prosecutions, the UN mechanisms, and compensation and restitution mechanisms. There is also the possibility of individual sanctions against perpetrators of attacks.

For years, health care has been a target of many conflicts worldwide, but these cases are hardly ever prosecuted as the international crimes that they are, if at all. The ICC charge put forward in 2024 against Russian commanders for alleged war crimes and crimes against humanity during the campaign of attacks on Ukraine’s energy infrastructure suggests “alleged strikes were directed against civilian objects” and “the expected incidental civilian harm and damage would have been excessive to the anticipated military advantage.” But more needs to be done. For example, the ICC case represents an opportunity to ensure accountability for the harm to the health sector resulting from attacks on energy infrastructure.

Jacobsen: What are the key recommendations from the report to support Ukraine’s healthcare system?

Poltavets: The global community must ignite efforts to hold Russia accountable for international law violations resulting from these attacks. Increasing financial and political support for Ukrainian health care facilities, condemning attacks on health and energy infrastructure as well weapons sellers to the Russian Federation for violating United Nations Security Council resolutions, and advocating for the protection and safe release of health care workers in conflict zones should be priorities. Strengthening international norms against such attacks, enhancing data collection, and supporting accountability mechanisms to investigate and prosecute violations as war crimes and crimes against humanity are critical.

Jacobsen: Thank you for the opportunity and your time, Uliana.