Reports that Russian forces have put 61 hospitals in Ukraine out of operation, as well as targeting civilians have caused international anger and accusations of war crimes. Meanwhile, two doctors examine in MedPage Today whether the invasion – occurring during a global pandemic – constitutes biological warfare.
Dr Gavin Harris and Dr Joel Zivot of Emory University School of Medicine in the United States recall an ancient act of biological warfare in Crimea in southern Ukraine when the bodies of Mongol soldiers killed by bubonic plague were catapulted into Theodosia in a – successful – effort to decimate its people. From there, the Black Death spread across Europe.
61 hospitals out of action – Health minister
On Tuesday, Ukrainian Health Minister Viktor Lyashko announced on television that 61 hospitals are not operational because of attacks by Russian forces, Reuters reported.
“Terrorists from the aggressor country have put 61 hospitals out of action,” he said on television, adding that the authorities were unable to deliver critical medical supplies to front-line communities because of a lack of humanitarian corridors. Russia denies attacking civilian targets.
According to Interfax – Ukraine News Agency, the number of hospitals known to have been harmed has risen rapidly. Liashko said that as a result of shelling, hospital windows were broken, and walls and medical equipment were damaged. In one hospital, a new emergency department was destroyed, Interfax reported.
Liashko stressed that such actions violate all international conventions, and that he has been constantly informing responsible international structures, including the World Health Organisation (WHO), about such cases.
And late on Wednesday, Ukraine said that a Russian air strike had badly damaged a children’s hospital in the besieged Ukranian port city of Mariupoly, burying patients under rubble and injuring 17 people, including women in labour. The UN Human Rights Monitoring Mission in Ukraine was verifying the number of casualties, a UN spokesperson said.
The bombing, which Ukrainian President Volodymyr Zelensky called an “atrocity”, took place despite an agreed ceasefire to enable thousands of civilians trapped in the city to escape. A Kremlin spokesperson asked by Reuters for comment, said: “Russian forces do not fire on civilian targets.”
On Tuesday the United Nations human rights office reported that a total of 1,335 civilian casualties in Ukraine, including 474 killed and 861 injured, have been verified since Russia's invasion began on 24 February.
However, it said in a statement that the civilian toll was incomplete pending corroboration of reports. “This concerns, for example, the towns of Volnovakha, Mariupol, Izium where there are allegations of hundreds of civilian casualties.”
Ukraine's Ambassador to the UN in Geneva, Yevheniia Filipenko, told the UN Human Rights Council on Tuesday: “Not a day has passed without news of dozens of civilian casualties that resulted from indiscriminate bombing and shelling of residential areas of major Ukrainian cities.”
Attacks on hospitals and ambulances ‘increasing rapidly – WHO
On Tuesday WHO warned that Ukraine's health system is under “severe pressure”, Euronews reported. The head of WHO Europe office Dr Hans Kluge said the number of attacks on hospitals and ambulances in Ukraine have increased rapidly in recent days. WHO has confirmed 16 separate attacks on Ukrainian healthcare facilities since 24 February.
The attacks have led to at least nine deaths and 16 injuries. “It should go without saying that health workers, hospitals and other medical facilities should never be targeted, even during crises and conflicts,” Kluge stated.
He said the number of deaths due to COVID would “sadly increase” due to oxygen shortages and broken supply lines. WHO has been working to provide Kyiv with oxygen, insulin, personal protective equipment, surgical items and blood products, he told the briefing.
Kluge stressed the importance of establishing ‘safe’ corridors for humanitarian aid to reach those in need during the war. “A second priority is to ensure that neighbouring countries have the infrastructure and expertise in place to meet the urgent health needs of those arriving,” he added. An estimated two million refugees have fled Ukraine since Russia’s invasion.
According to the Jerusalem Post, the Ukrainian Foreign Ministry claimed on Tuesday that Russia allegedly shelled the civilian evacuation corridor from Zaporizhzhia to Mariupol, breaking a ceasefire.
“There has been confusion and disputed claims about what humanitarian corridors and ceasefires were active on Tuesday, the fourth day in a row that humanitarian corridors had been attempted. Fighting continued even as both sides attempted to come to a consensus on limited ceasefires and humanitarian corridors to allow civilians to flee the battlefront,” the Jerusalem Post reported.
The newspaper cited a Ukrainian military claim on Tuesday that Russian forces had allegedly “lost 1,000 military personnel in a day, reaching a total of 12,000 killed in action since the fighting began 13 days ago”.
However, according to The Washington Post, Lieutenant General Scott D Berrier, director of the Defence Intelligence Agency, told United States General Assembly lawmakers that the best estimate is between 2,000 and 4,000 Russian fatalities – though he did not have much confidence in that figure.
Does Russia's invasion of Ukraine constitute biological warfare?
Russia’s invasion of Ukraine in the midst of a pandemic surely begs this discussion, said Dr Gavin Harris and Dr Joel Zivot in MedPage Today on 7 March 2022. They wrote:
War can be the cause of, and the perpetuation of, a public health emergency. The current Russian-Ukrainian conflict is no exception, and warrants a discussion of whether invading a country in the midst of a global pandemic constitutes an act of biological warfare.
A look back in history can help explore this question. In 1346, in the port city of Kaffa (now modern-day Theodosia) on the Crimean Peninsula of the Black Sea, the consequences of a different war were unfolding.
In that time, Italian notary Gabriele de' Mussi wrote: “One infected man could carry the poison to others and infect people and places with the disease by look alone. No one knew, or could discover, a means of defence…the scale of the mortality and the form which it took persuaded those who lived…that the last judgement had come.”
According to Harris and Zivot in MedPage Today, de' Mussi was describing the horrors of Yersinia pestis, in what came to be called bubonic plague or the Black Death.
Kaffa came under attack by a Mongol army controlled by Kipchak khan Janiberg, a descendant of Genghis Khan. Janibeg laid siege to the city but the war dragged on for years, until, as de' Mussi later wrote: “…the whole army was affected by a disease which overran…and killed thousands every day…all medical advice and attention was useless."
First intentional act of biological warfare
Janibeg eventually called off the siege, but not before ordering that the bodies of soldiers felled by the plague be launched via catapult into the city in the hopes of decimating the population. This has been seen as the first intentional act of biological warfare in recorded history and contributed to the explosion of a devastating pandemic.
It has been postulated that Italians fleeing the carnage on ships brought the plague to their home ports (among other routes of transmission). Within a year, the plague had gained a firm grip on Europe. Within five years it has been estimated that as much as 40% of the global population was killed, corresponding to 200 million people.
Flash forward to modern day: The COVID-19 pandemic
Today, the article in MedPage Today continues, there is a new war during a global pandemic in the same region where the Black Death exploded. As expected, the risk of greater spread of COVID-19 and threats to an already strained healthcare system are significant.
According to the Russian Ministry of Defence, as of December 2021 military vaccination against COVID-19 was broadcast as upwards of 95%, with 25% receiving boosters. Despite this, the Russian army is not invincible, especially in the face of Omicron, and cases have reportedly been spreading throughout units.
Reports (unconfirmed) have estimated the Russian military has been losing almost 300 troops daily to injury or death. With images of soldiers being left on the battlefield and military units refusing to fight and surrendering, one has to wonder whether COVID-19 is a factor.
Potentially infected Russian troops create a health hazard as they increasingly mix with the Ukrainian population, engaging in warfare in close quarters and being taken as prisoners by the Ukrainian army (or vice versa).
The Ukrainian population has a low rate of people fully vaccinated against COVID-19 at only 35%, and just over 36% having received at least one dose. With such low vaccination rates, COVID-19 can continue to spread.
MedPage Today goes on to describe how COVID may easily spread under various conditions of war and with the flight of up to two million Ukrainians into neighbouring European countries. Further, healthcare workers in Ukraine must not only contend with traditional battlefield casualties, but also the consequences of additional COVID-19 infections.
This becomes exceptionally challenging given that the oxygen supply to Ukrainian hospitals is already at the point of exhaustion. Moreover, electrical shortages from the invasion pose immense risk to hospital systems and supplies including ventilators, dialysis machines and lights. Other critical supplies are increasingly unavailable.
Médecins Sans Frontières suspended normal operations in the country in the last week of February, and staffing shortages are already apparent.
According to MedPage Today, the world is receiving reports of hospitals and healthcare workers deliberately being targeted by the Russian military, using internationally banned weapons, such as cluster munitions. As of 7 March, the WHO confirmed at least 14 attacks on healthcare facilities – killing nine people and injuring 16 – and classified two more as possible.
We posit that launching this invasion in the midst of the COVID-19 pandemic constitutes a form of a biological warfare, intentional or not, wrote Harris and Zivot in MedPage Today.
Biological warfare occurs when a state uses a disease-causing agent in waging war. While the 1972 Biological Weapons Convention specifically bans microbial or other biologic agents for use other than peaceful or protective purposes as well as the production of weapons or equipment designed to deliver these agents during conflict, the Soviet Union, parent of the current Russian government, has a long history of treaty non-compliance.
While exacerbating the spread of COVID-19 may not have been Russia's primary goal when invading Ukraine, it is an obvious side effect that Russian leaders had to be aware of when they made the decision to invade.
Dr Gavin Harris is an assistant professor of infectious diseases and critical care at the Emory University School of Medicine in Atlanta. Dr Joel Zivot is an associate professor of anesthesiology and critical care at Emory University School of Medicine.
MedPage Today story – Does Russia's Invasion of Ukraine Constitute Biological Warfare? (Open access)