The Russian invasion of Ukraine has placed an extraordinary burden on civilians and civilian infrastructure. According to the UN High Commissioner for Human Rights, as of March 20, 2022, 902 civilians have been killed and another 1,459 have been wounded. This casualty rate is likely much higher and will certainly increase as the conflict continues.
Threats to Health Care in Ukraine
Hospitals and health care facilities are sustaining damage as part of Russia‘s bombing. Several apparently deliberate attacks on hospitals have occurred. These attacks, which are war crimes if intentional and without distinction, are a significant humanitarian concern especially in urban settings. At least 43 verified attacks against health care facilities have been documented by the World Health Organization (WHO). For example, on March 9 an attack on a maternity hospital in embattled Mariupol initially killed 3 patients and injured 17. A few days later an injured baby and mother succumbed to their injuries. The Central City Hospital in Vuhledar was targeted on February 24 by a ballistic missile armed with cluster munitions. Four persons were killed and 10, including 6 health care workers, were injured. Cluster munitions are inherently indiscriminate when used in dense urban settings. Their use – like the attacks on health care facilities – may be war crimes.
Attacks on civilian objects – such as shelters like the Mariupol theatre on March 16, which was marked “children” in Russian, and hospitals – are generally prohibited under the principle of distinction unless they house military objectives or functions. Medical Personnel, Medical Activities, Medical Units, Medical Transports; Humanitarian Relief Personnel and Objects, as well as Hospital Safety Zones are off limits from attack unless they breach their protected status under Customary International Humanitarian Law – commonly known as the Geneva Conventions.
The Syria Campaign: Russian Precedent for Breaching Protections on Hospitals
Russia denies deliberately targeting hospitals, medical activities, and civilian objects in Ukraine. Nevertheless, such activity has been a staple of Russian urban warfare from Grozny (Chechnya) to Syria. Russia has embraced attacks on hospitals as a means of demoralizing its opponents, destroying civilian morale and instilling terror. In the Syrian conflict bombing hospitals has been a mainstay of Russian warfighting with over 400 such attacks. These deliberate attacks on health care in Syria included strategic targeting of hospitals, attacks on health care using chemical agents, and repeated attacks on underground medical facilities.
Crafting a Humanitarian Response
The first step includes reinforcing the humanitarian norms against attacking hospitals, medical personnel, and health care activities contained in the Geneva Conventions, customary international law, and related practice. After all, the Fourth Geneva Convention specifically articulates their protected status “unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given.” Next, sufficient humanitarian medical capacity must be developed to evacuate persons from at-risk areas to safe, neutral zones where they can receive treatment. Beyond that, diplomatic measures must be employed to reinforce the customary humanitarian norms against attacking civilians in general, and hospitals and medical personnel and activities in specific. Clearly the humanitarian imperative seeks to end these attacks without escalating the conflict. Toward that end, I propose a humanitarian demonstration of resolve.
Humanitarian Demonstration of Resolve
A humanitarian demonstration of resolve is the civil analog to a military show of force. Except rather than surging highly visible military forces it would involve a concerted effort to surge medical capacity to support efforts for humanitarian medical relief of Ukraine. To achieve this capacity, I envision a large-scale exercise on the template of the Cold War Reforger Exercises (Return of Forces to Germany). These Reforger exercises ran from 1969 through 1993 and were designed to demonstrate the capacity to deploy a large-scale deployment and rapid reinforcement capability to demonstrate resolve to counter Soviet aggression. This humanitarian return to Europe would use medical capacity to bolster humanitarian relief to Ukrainian medical and health care operations. Specifically, this would involve a large-scale deployment of the National Disaster Medical System (NDMS) to our NATO allies including Germany, Poland, Romania, and Slovakia, and potentially other states such as Moldova.
NDMS was established in 1984 under the United States Public Health Service and its coordination was transferred to the Department of Homeland Security (DHS) under the Federal Emergency Management Agency (FEMA). NDMS is a coordinated partnership of the United States Department of Health and Human Services, DHS, Defense (DOD), and Veterans Affairs. While primarily designed to augment military casualty care and disaster response domestically in the United States, it has been deployed internationally following earthquakes in Iran in 2003 and Haiti in 2010. NDMS includes several specialty teams including Disaster Medical Assistance Teams (DMATs) able to handle a range of injuries, including burns, crush injuries, and pediatric patients; Trauma and Critical Care Teams (TCCTs), formerly known as the International Medical Surgical Response Team to provide fully capable field surgical care; Disaster Mortuary Operational Response Teams (DMORTs) able to process fatalities, including victims of Weapons of Mass Destruction (WMD) incidents; and Incident Management Teams (IMTs) to manage the disaster medical response.
This humanitarian/medical exercise could forward deploy these specialty medical assets to casualty collection points in the NATO nations surrounding the Ukrainian frontier to assist existing medical relief efforts, including WHO-qualified Emergency Medical Teams and other local and international humanitarian relief efforts such as those deployed by Médecins Sans Frontières (MSF or Doctors Without Borders) and the Red Cross. This Humanitarian Resolve exercise can be integrated with existing military medical operations by the United States and other NATO nations, can augment international relief operations, and can demonstrate resolve to support Ukraine and our NATO partners against the conflict disaster stemming from Russia’s Crime of Aggression in a non-military manner limiting escalatory potentials.