Russian attacks on medical facilities in Ukraine made 2022 the most violent year in a decade for hospitals and health workers operating in conflict zones, according to a new report by a coalition of humanitarian organisations. With 750 reported attacks in 2022, Russia set a 10-year record, according to the Safeguarding Health in Conflict Coalition, which includes Human Rights Watch and the Johns Hopkins Center for Humanitarian Health. More than half of the 1,989 attacks on health facilities and workers reported globally took place in Ukraine and Myanmar. Under international law, attacking or interfering with medical services during an armed conflict is a war crime. “The scale of destruction in Ukraine is mind-boggling. There is not a day without a facility being impacted,” said Christina Wille, one of the report’s authors. “I’ve been looking at data [like this] for years, and I can hardly believe my eyes.” Some of the attacks appeared to target medical facilities deliberately, Wille said, while others were due to “indiscriminate” use of explosives in civilian areas. Ukrainian healthcare workers were also the most affected by killings and kidnappings, although those in Myanmar were the most impacted by arrests. Russia’s behaviour in Ukraine was not unique, said Wille, but it was distinguished by its scale and intensity. “For example, we’ve also seen very violent moments in the occupied Palestinian territories in 2021,” she said. “But that was 11 days, not over a year.” “Contempt for law is contagious,” said Len Rubenstein, chair of the coalition and a professor at Johns Hopkins University. “When you see that someone can get away with attacking hospitals and healthcare, you’re encouraged to do it. “Russia faced no consequence for targeting hospitals in Syria, and now assaults on hundreds of Ukraine hospitals follow,” he said. As well as Ukraine, the report noted arrests and imprisonment of medical staff in retaliation for providing health services to dissidents. In Myanmar and Iran, 183 doctors were affected. “We have seen in Iran and Myanmar that when political demonstrations are violently crushed, medical staff providing healthcare to demonstrators are arrested,” Wille said. The global situation is not set to improve in 2023 as attacks in Ukraine are not subsiding and new conflicts appear. The war in Sudan started in April and has brought the country’s already struggling healthcare system to near collapse, with hospitals and clinics looted and bombed, and medics kidnapped. “I got rid of my medical ID when I was fleeing Khartoum,” said Mohamed Eisa, secretary general of the Sudanese American Physicians Association. “I was worried I might be kidnapped by the RSF [Rapid Support Forces], or even the army might take me hostage. They have been kidnapping doctors to treat their wounded.” “The effect of the conflict on Sudan’s healthcare system has been dire and extreme,” Eisa added. “60% of hospitals near the conflict area are not open at all. At least 19 healthcare workers have been killed. Physicians in Khartoum feel threatened.” Rubenstein said he hoped this year’s report would be a “turning point” that sparked greater political commitment and action. “Judicial mechanisms to hold perpetrators accountable exist,” he said. “Deliberate attacks against healthcare and indiscriminate attacks are war crimes.” However, there is little precedent for state actors facing legal consequences due to violating these laws, Rubenstein said. Only one case of an attack against a health facility has been successfully prosecuted under international law, when two former officers in the Serb armed forces were convicted in 2007 for their role in the Vukovar hospital massacre during the Croatian war of independence in 1991. “We hope our report will encourage the use of diplomatic leverage to exert pressure on perpetrators,” Rubenstein said. “In Ukraine, the international community got behind justice, so we think there will be interest in making sure that people finally pay the price for these kinds of crimes.”