(Berlin) – Insurgent forces in eastern Ukraine have threatened medical staff, stolen and destroyed medical equipment and hospital furniture, and compromised the ability of civilian patients to receive treatment, Human Rights Watch said today. Insurgent forces have also expropriated ambulances and used them to transport active fighters.

Such acts are strictly prohibited under the laws of war, which afford special protections to medical units and personnel as well as to the wounded and sick, Human Rights Watch said.

“Pro-Russian insurgents’ attacks on medical units and personnel are putting sick and vulnerable people and those who care for them at risk,” said Yulia Gorbunova, Europe and Central Asia researcher at Human Rights Watch. “This appalling disregard of people who are sick or wounded can be deadly and needs to stop immediately.”

Human Rights Watch has also documented attacks on hospitals by explosive weapons that killed at least two medical staff. While the circumstances suggest Ukrainian armed forces launched some of these attacks, further investigation is needed to determine responsibility.

Medical units are civilian objects with special protections under the laws of war. They include hospitals, clinics, medical centers and similar facilities, and ambulances and other medical transportation, whether military or civilian. Parties to a conflict must ensure that medical personnel are not endangered or harmed, and hospitals and ambulances are not attacked, damaged, or misused.

Through on-the-ground investigations in eastern Ukraine, Human Rights Watch found that insurgent armed fighters unlawfully expropriated and used ambulances to transport combatants, threatened medical staff, and damaged and stole medical equipment. Human Rights Watch also found that to secure treatment for their wounded, insurgents occupied hospital wards and buildings, compromising the safety of patients and staff and the treatment of civilian patients.

Human Rights Watch documented how insurgent forces unlawfully seized at least four ambulances in Sloviansk and used them to transport able-bodied armed fighters in Donetsk. A Human Rights Watch researcher witnessed ambulances in Donetsk transporting able-bodied armed fighters through the city.

Armed insurgents dressed in combat uniform also drove ambulances transporting wounded fighters. Human Rights Watch was unable to determine whether the drivers were exclusively assigned to medical duties, which would afford them special protection.

Human Rights Watch found, through its own observations and interviews with medical staff, that in four hospitals a significant number of armed, able-bodied insurgent fighters were on the hospital premises. While their presence was ostensibly for the hospitals’ or patients’ protection, the security needs did not appear to justify the presence of large numbers of fighters. Most of them appeared to serve no security function and they were not stationed at the gates or the perimeter of the hospital as could be expected if their function was to guard the hospital.

Instead of protecting the hospitals, the presence of a significant number of armed insurgent forces on hospital premises put the hospital at risk of becoming a military target, Human Rights Watch said. Under international law, parties to the conflict are obliged – to the extent possible – to avoid placing military targets such as troops within or near populated areas.

Insurgents seized wards to treat wounded insurgent fighters in at least two hospitals: the Kalinin Hospital in Donetsk and the Lenin City Hospital in Sloviansk. In the Lenin City Hospital and in the Semyonovka psychiatric hospital, insurgents also stole or destroyed surgical equipment, furniture, and, in the Lenin City Hospital, patient files. While the laws of war do not explicitly prohibit requisition of civilian hospitals for treatment of wounded fighters, such requisition should not be detrimental to patients. In all cases, the wards were in regular use by the hospitals, and the seizure inevitably had a negative effect on the treatment of civilian patients, Human Rights Watch said.

Explosive weapons such as artillery shells and unguided rockets have struck at least five hospitals in eastern Ukraine since June 2014, killing at least two medical staff, Human Rights Watch found. The circumstances of the attacks, most of which took place in insurgent-controlled areas under attack from government forces, suggest that government forces were responsible, but further investigation is needed to determine whether such attacks amounted to violations of humanitarian law. Ukrainian authorities should promptly and thoroughly investigate the attacks on hospitals, and hold accountable those responsible for any violations of the laws of war, Human Rights Watch said.

Human Rights Watch also called on Ukraine’s international supporters to urge Ukraine to strictly adhere to international humanitarian law in the conflict in eastern Ukraine.

While other presumptively civilian structures become military objectives if they are being used for a military purpose, hospitals only lose their protection from attack if they are being used, outside their humanitarian function, to commit “acts harmful to the enemy.” The presence of armed guards or of small arms belonging to wounded fighters does not constitute “acts harmful to the enemy.” Even if military forces misuse a hospital to store weapons or shelter able-bodied combatants, the attacking force must issue a warning that sets a reasonable time limit and may attack only after such a warning has gone unheeded.

The leadership of the armed groups connected to the self-declared Donetsk People’s Republic and Luhansk People’s Republic should hold accountable those among their ranks responsible for abuses against medical staff, facilities, and patients, Human Rights Watch said.

In its July 15 report, the Office of the UN High Commissioner for Human Rights described the insurgent armed groups’ leadership as including “many … nationals of the Russian Federation” and under whose central command “previously rag-tag of armed groups with different loyalties and agendas were now organized.”

With its influence over rebel forces in Ukraine, Russia should insist that they adhere to norms of international humanitarian law, including the special protections afforded to medical units and personnel as well as to the wounded and sick, Human Rights Watch said.

The Office of the UN High Commissioner for Human Rights estimated that hundreds of civilians had been killed and more than a thousand wounded in the conflict in eastern Ukraine between mid-April and July 26.

“Civilians are already bearing the brunt of the conflict in eastern Ukraine,” Gorbunova said. “Interfering with the medical assistance they need is simply unconscionable.”

Insurgents’ Unlawful Expropriation and Use of Ambulances

A driver at the ambulance station in Sloviansk told Human Rights Watch that insurgent forces had tried to seize the station’s ambulances several times when they controlled Sloviansk, from April 2014 to early July:

They came at least a couple of times, shooting in the air, threatening, and demanding that we give them ambulances, but at those points all the ambulances were out driving, so they were unsuccessful.

Another employee of the ambulance service said that on at least one occasion, in May, the insurgents wanted the ambulances to transport bodies of insurgents killed in fighting.

When the Ukrainian armed forces drove the insurgents out of Sloviansk on July 4 and 5, the insurgents seized four ambulances and used them to retreat from the city. “It probably made it easier for them to run away from the Ukrainian forces,” one driver told Human Rights Watch.

Independent journalists and observers told Human Rights Watch that they saw armed insurgents driving ambulances on numerous occasions in Donetsk. Human Rights Watch researchers saw armed insurgents driving ambulances twice in one day.

On July 21, a Human Rights Watch researcher, standing at an intersection close to the train station, witnessed a convoy of several military vehicles moving from an area of active fighting in the northern part of Donetsk. Among the vehicles was an ambulance with its side door open, revealing several armed insurgent fighters inside, none of whom appeared to be injured. The same day, a Human Rights Watch researcher witnessed an ambulance arriving at the Kalinin hospital in Donetsk. The driver was dressed partly in camouflage uniform and carried an automatic weapon. The ambulance carried what appeared to be an injured fighter.

Carrying firearms for self-defense does not constitute an act “harmful to the enemy,” but medical personnel, even if they are members of a fighting unit, should be exclusively assigned to medical duties. Human Rights Watch was not able to verify whether the ambulance driver arriving at the Kalinin hospital was exclusively assigned to medical duties.

Insurgents’ Presence at and Occupation of Hospitals

Insurgent forces also partially or fully occupied buildings of at least three hospitals – in Sloviansk, Semyonovka, and Donetsk. Wounded fighters in a non-international armed conflict are entitled to care and can be treated in civilian hospitals without compromising the protection afforded to the hospital. Likewise armed opposition groups may use civilian hospitals for treatment of wounded fighters, insofar as it is not detrimental to the treatment of other patients.

Human Rights Watch witnessed first-hand the presence of numerous armed insurgent fighters on hospital premises during visits to hospitals in areas controlled by insurgent forces. Several armed insurgent fighters were standing outside the central city hospital in Snezhnoe when Human Rights Watch visited on July 18. Human Rights Watch also observed numerous armed insurgents on the premises of the Kalinin hospital in Donetsk during two visits. It was not evident that the fighters were there to provide security for the hospitals.

Semyonovka Psychiatric Hospital

The deputy chief of the in-patient psychiatric hospital in Semyonovka, a sprawling complex of 20 buildings about three kilometers from Sloviansk, told Human Rights Watch that in early May, armed insurgent fighters seized one of the hospital’s buildings, usually used by patients in their leisure time:

They came in without asking and set up shop here. The head of the hospital asked them to leave, because there were people in the hospital receiving treatment for serious psychiatric conditions. He said that they had no business bringing armed men and guns there. I heard the fighters threatening him in response: “Try and stop us and we will kill you and all your patients,” they said. After that, we no longer allowed patients outside.

The doctor said that the insurgents stole or destroyed much of the hospital’s property, including furniture, equipment, and a laboratory.

Throughout May there was heavy fighting between government and insurgent forces in the immediate area around the hospital, the doctor said (see below, Attacks on Hospitals). On May 26, medical staff evacuated the hospital’s patients and personnel to other facilities in Zhdanovka, Gorlovka, and Donetsk. The insurgents allowed staff to evacuate the patients, the doctor said.

Subsequent fighting completely destroyed the hospital complex. Human Rights Watch documented major destruction of all buildings in the hospital complex during a visit in July.

Lenin City Hospital, Sloviansk

Medical personnel at the Lenin City Hospital in Sloviansk told Human Rights Watch that armed insurgents arrived in mid-June and occupied one of the hospital’s two surgical wards, on the ground floor of a hospital building. The loss of one of the wards meant that doctors did not have the capacity to treat all of their civilian patients. The presence of the armed insurgents also contributed to increasing stress among the medical staff. Many did not show up for work, leaving the hospital understaffed to serve the patients.

Medical staff told Human Rights Watch that the insurgents used the ward to treat injured fighters, but the insurgents guarded the ward around the clock, preventing access for the hospital’s medical personnel. Two hospital nurses also said that the insurgents controlled the hospital’s bomb shelter and prevented medical personnel and patients from using it.

During a Human Rights Watch visit to the hospital in July, the hospital’s staff was trying to prepare the ward for use again. One of the nurses told Human Rights Watch that the insurgents had damaged the ward’s walls and floors and stolen all the surgical equipment, as well as some hospital furniture. Human Rights Watch observed that several doors in the ward had been removed and that all windows in the ward had been barricaded with sandbags.

Medical personnel also told Human Rights Watch that the insurgents stole the hospital’s paperwork, including all patient files, when they fled Sloviansk on July 5.

Kalinin Hospital, Donetsk

Human Rights Watch visited the Kalinin Hospital in Donetsk after insurgent forces took over two of the hospital’s buildings in mid-July. One of the hospital’s doctors told Human Rights Watch that between 30 and 40 armed insurgents took over the buildings:

The hospital administration told them that they didn’t want them here, but [the insurgents] didn’t listen. They behave fine and the hospital has made them leave their weapons in the ward where they are located, but we are concerned that there might eventually be fighting on the hospital premises.

The insurgents left one of the hospital buildings about a week after they had taken it over and after Human Rights Watch spoke to the doctor.

However, they continue to occupy another building, a rehabilitation center for radiation victims from the Chernobyl nuclear accident, the doctor said. This led to the closure of inpatient treatment for those patients. The doctor told Human Rights Watch:

They have set up a military hospital there with their own doctors. Seriously injured fighters first come to us and then we transfer them there. I don’t know what happens to the patients after this. I really don’t know what goes on there. I know they have a military hospital there, but maybe they use the building for other purposes as well. None of [our] medical staff go there at all.

Attacks on Hospitals

In at least five cases Human Rights Watch documented, explosive weapons struck hospitals, killing two medical workers. Although Human Rights Watch has not been able to establish with certainty who attacked the hospitals, four of the hospitals were in insurgent-controlled areas at the time of attack. In at least two of the hospitals, insurgents were on the hospital premises, suggesting that Ukrainian armed forces might have been responsible. The fifth hospital was in a government-controlled area. Further investigation of these cases is necessary to establish responsibility with certainty.

Lenin City Hospital, Sloviansk

On the afternoon of June 14, at least two shells struck the area of the Lenin City Hospital in Sloviansk, medical personnel told Human Rights Watch. Insurgent forces had established control over Sloviansk in April and had erected a checkpoint at the intersection of Taras Shevchenko and Uritskogo streets, approximately 800 meters from the hospital’s main entrance and almost adjacent to the hospital premises.

One shell struck the roof of a building housing the trauma and cardiology wards and one of the surgical wards. At the time of the strike, insurgent forces occupied the building’s surgical ward on the ground floor of the building that was hit. The strike shattered significant parts of the wooden roof and an attic, but did not damage the wards. The damage to the roof did not allow Human Rights Watch to establish the direction of the incoming shell, and Human Rights Watch did not find any remnants of the weapon that would have allowed further identification.

The second shell struck an intersection just outside the fence of the hospital premises, close to the insurgent checkpoint, severely injuring 36-year-old Tatyana Kubran, a surgical nurse who was leaving the hospital with her husband after her 24-hour shift. Medical staff told Human Rights Watch that Kubran, who had worked as a nurse at the hospital for many years, died later that day from her injuries. When Human Rights Watch visited the hospital in July, there were still visible shrapnel marks in the asphalt, on the hospital fence, and a nearby traffic sign at the intersection where Kubran was injured. Human Rights Watch also observed remnants of the insurgent checkpoint nearby.

Semyonovka Psychiatric Hospital

In the early morning on May 25, a shell hit the in-patient psychiatric hospital in Semyonovka, partially destroying a wall of one of the hospital’s buildings, the hospital’s deputy chief said. None of the patients or medical personnel were injured during the attack, she said, because they spent the night hiding in the basement.

The doctor said that in early May, the insurgents set up a checkpoint approximately one kilometer from the hospital. Between May 5 and May 26, when the hospital staff and patients were evacuated, the hospital was almost constantly surrounded by heavy fighting:

The fighting was right next to us, there were bullets flying into the hospital yard and ricocheting off the walls. And there were loud explosions; it was especially bad at night. There was only one time when we had a siren warning of the upcoming attack. All other times, there was no warning – we would just run every time we heard shooting or explosions. Altogether, we had to evacuate all our patients into the basement seven times at least. Sometimes patients had to stay in the basement for two nights in a row.

Krasny Liman Railway Hospital

On June 3, shells struck the Krasny Liman Railway Hospital, killing the hospital’s surgeon. Medical personnel at the hospital told Human Rights Watch that shelling began at about 3:30 p.m. without warning and that the attack lasted no longer than 10 minutes. The chief doctor of the hospital said that the hospital’s surgeon, Vasiliy Shistka, had just finished a planned operation when the shelling started. As he was walking out of the operating room, a shell fragment hit him on the head. He died two weeks later as a result of his injury. No other hospital personnel or patients were killed or wounded in the attack.

The attack also significantly damaged the hospital. In particular, the roof and infrastructure of the general therapy wing was seriously damaged, as were the walls and infrastructure of the surgery wing, the gynecology wing, and the hospital’s pharmacy. The explosions shattered the windows.

The hospital serves mainly railway workers and is located approximately 25 kilometers southeast of Sloviansk. At the time of the attack, Ukrainian government forces were engaged in military operations to re-establish control over Krasny Liman. The chief doctor told Human Rights Watch that on June 4, the morning after the attack, a group of Ukrainian servicemen approached the hospital in an armored carrier to carry out a search, as they believed insurgents were using the hospital for military purposes. They did not show any identification documents but demanded that he lead them through the hospital, the chief doctor said.

Having examined all the wards and hospital grounds in that manner, the military acknowledged there were no insurgents present. The doctor also alleged that the military commander showed him a map on which the hospital was marked as an insurgent hospital and explained that they believed that insurgents had been using the hospital for military purposes.

As of early July, the prosecutor’s office had started an investigation into the shelling of the hospital. Because there was strong evidence suggesting the targeted nature of this attack, on July 18, Human Rights Watch sent a letter to President Poroshenko urging him to ensure that the investigation into this attack is thorough and prompt.

In addition to the three cases detailed above, a doctor at the hospital in Gorlovka, a town just north of Donetsk, told Human Rights Watch by phone that what she presumed was a Grad rocket struck the hospital premises on July 27, shattering the hospital windows.

Medical personnel at the children’s hospital in Sloviansk told Human Rights Watch that a shell had struck the hospital on May 30. Human Rights Watch confirmed during a visit that the front wall of the hospital was partially destroyed. At the time of the attack, all patients had been evacuated. Human Rights Watch has no information that there were armed fighters present at the Gorlovka or Sloviansk children’s hospitals at the time of the attacks.