During a 12-hour period beginning on 5 May 2019, four hospitals in areas of Syria held by opponents of President Bashar al-Assad were attacked by Russian aircraft. First to be struck was Nabad al-Hayat Surgical Hospital, a major trauma centre in southern Idlib province. It had already been attacked three times since opening in 2013 and for that reason had recently been relocated to an underground complex on agricultural land. But the Russian pilots knew how to find it.
In fact it wasn’t hard for them to find it. The hospital, along with the other three later attacked, had put its location on a “deconfliction” list, held by the United Nations. The intention of this list was to advise the Russians what not to attack to help them follow the dictates of international law (see Article 18 of the Geneva Convention). Instead the Russians used the information to pass on to the pilots so that they could hit the hospitals with greater accuracy. In a transmission obtained by New York Times a pilot could be heard receiving the hospital’s exact coordinates before bombing it.
As it happened the staff at Nabad al-Hayat had been warned of a possible strike and so had evacuated the hospital three days earlier. Journalists were waiting to record the attack, which they did. As the pilot confirmed the release of his weapons, saying, “Worked it”, the journalists filmed three precision bombs penetrating the roof of the hospital, “blowing it out from the inside in geysers of dirt and concrete”. The next strike was on Kafr Nabl Surgical Hospital, three miles away, which had also moved underground after being hit repeatedly earlier in the war. This hospital was occupied when it was hit four times, leaving one man dead and medical staff and patients having to find their way out through dust. Later Russian pilots bombed Kafr Zita Cave Hospital and Al-Amal Orthopaedic Hospital.
These were not isolated incidents. The Syrian regime began attacking hospitals and clinics early in the civil war, which started in 2011. More than 300 had been hit by the time of the start of the Russian intervention in September 2015. From this point to 2019 another 266 attacks were recorded, by which time the rebels were being pushed back. The group Physicians for Human Rights (PHR), which monitors these attacks has corroborated 604 attacks on 400 separate facilities and documented the killing of 949 medical personnel from March 2011 through February 2024. (Some of these were committed by opposition forces and also the Islamic State.)
This record is important to keep in mind when assessing Russian denials that as part of a set of missile strikes across Ukraine, they deliberately attacked Okhmatdyt Children’s Hospital in Kyiv on 8 July. The centre treats children with serious conditions, including cancer and kidney disease. It was occupied by around 670 child patients and some 1,000 staff at the time of the attack. One doctor and another adult were killed. At least ten more people were injured, including seven children. It was only because staff had moved children to a bunker when the air raid sirens went off that the casualties were not far worse. The damage from the attack forced the evacuation of very ill young patients onto the streets.
As the children’s hospital was hit, debris from another Russian missile crashed into the Isida maternity hospital in Kyiv and a private clinic close by, killing nine more people, including two children. In all, the bombardment killed at least 38 people, including 27 in Kyiv. It would also have been worse if 30 of the 38 missiles launched by Russia had not been shot down by Ukrainian air defences.
As with the attacks in Syria, this attack was also not an isolated incident and reflected a pattern evident since the start of the war. As early as March 2022 Mariupol maternal hospital was destroyed. The next month a Russian missile hit the only hospital in Bashtanka, a district centre in southern Ukraine.
“The explosion destroyed an outpatient clinic and some critical equipment, while the blast wave ripped through the rest of the hospital buildings, shattering windows and knocking out doors.”
According to the World Health Organisation, already this year, before the Kyiv hospital attack, there had been 18 deaths and 81 injuries from more than 175 attacks on the health care infrastructure in Ukraine. They have also recorded 44 attacks on medical vehicles. Last year they recorded 22 deaths and 117 injuries from 350 such attacks, and 45 more specifically on medical vehicles like ambulances.
According to a group of NGOs, including PHR, this understates the scale of attacks. They have counted, since the full-scale invasion of 24 February 2022, 1,442 attacks on Ukraine’s health care system, leading to 742 hospitals and clinics being damaged or destroyed, and 210 health workers killed. So regular have been the attacks that many hospitals have taken precautions to limit the effects of direct hits, from sandbags round the walls to boarding up windows. They dare not assume that a hospital is a place of safety.
The Russian excuses following the attack on the Okhmatdyt Hospital followed a familiar pattern. On social media and even official pronouncements can be found claims to the effect that:
(1) It didn’t really happen, so was essentially staged;
(2) Even if did happen, it wasn’t as bad as presented;
(3) It might have happened and been bad, but it was Ukraine’s fault because the damage was caused by an air defence missile;
(4) Even if it was a Russian missile that was because somewhere in the hospital there was a legitimate military target;
(5) Even if it was a Russian missile and there was no military target the Ukrainians deserve whatever they get because they are terrible people and should be punished for seeking independence from Russia.
The preferred official Russian government explanation was that this was a Ukrainian air defence missile. The foreign ministry spokesperson Maria Zakharova (who justified the Mariupol attack on the basis that the Ukrainians had “equipped combat positions” inside it) used this line. She accused Ukraine of using the strike to “further escalate” the war. Picking up on this theme, Putin’s shameless spokesman, Dmitri Peskov described it as a “PR operation in blood”.
There have been instances in the past where debris from air defence missiles has caused damage. If that had happened in this case it would still not excuse Russia because air defences are only activated because of incoming missile strikes against populated areas. This explanation, however, was a clear fabrication. Supposed evidence of shrapnel from an air defence missile came from old photos. At the site wreckage was found from a Russian Kh-101 cruise missile. There is also a video which shows the Kh-101 about to hit its target. The UN Human Rights monitoring Agency in Ukraine (HRMMU) concluded that the damage was caused by a direct hit.
Perhaps, as has also happened before, the Russians were aiming for something else. But as we have seen it is not out of character for Russia to deliberately target hospitals. There is no reason to suppose that they were aiming for something else.
Before we try to work out why Russian forces might attack the Ukrainian health care system in such a way, we need to consider another campaign being waged, this time with more candour, against the Ukrainian people. This is attacks on energy supplies.
To do this we need to look at the way that Russia has picked its targets behind the front lines, which are struck with mixtures of drones, cruise and ballistic missiles. In the weeks after the full-scale invasion the focus was on Ukrainian communications systems and military supplies. The Russians left infrastructure alone, largely because the plan then was to use it once the country was occupied. Special forces were assigned to capture Ukraine’s power stations, airfields and water supplies. The idea that they might be destroyed came only after a full occupation of the country appeared to be beyond Russian capabilities.
Many of these strikes led to tragedies – targeting rail transport led on 8 April 2022 to the shelling of Kramatorsk station, packed with people trying to get away from the combat zone, resulting in the deaths of 57 civilians (including seven children). Later, on 27 June 2022, when the Kremenchuk energy complex, involved in petroleum refining, electricity generation and oil storage, was attacked, two Kh-22 missiles hit the Kremenchuk shopping mall, killing at least 20 people and injured up to 56.
In September, probably in response to Ukraine’s successful counter-offensive in the Kharkiv oblast, Russia attacked the city of Kharkiv’s electricity grid, leading to a blackout. Attacks of this sort became much more systematic from 10 October. This reflected a shift in strategy by General Surovikin, then in charge of the Russian operation. His plan was to stabilise the front lines, so that Russia could hold what it had already taken, and then make life as difficult as possible for the Ukrainian government by targeting electricity. This included attacking targets well away from the front (such as Lviv) to demonstrate that no part of Ukraine was safe.
The Russians knew where to aim for in Ukraine’s electricity network because it had been designed and built in Soviet times. They knew that the most vulnerable targets were the large transformers that must be in the open for cooling purposes. The most vital of these were those that took the high voltage electricity from Ukraine’s nuclear power stations, of which there are four, with 15 reactors providing more than half of Ukraine’s electricity. The biggest single blow to Ukraine’s energy sector came when the Russians occupied the Zaporizhzhia nuclear power plant and turned off its reactors.
Russia launched more than 1,350 rockets and drones at Ukraine’s energy infrastructure between early October and late January 2023. The most severe strikes came on 23 November 2022. Some 70 cruise missiles and “kamikaze” drones attacked the grid. Kyiv lost electricity and the consequential blackouts extended to neighbouring Moldova, connected to Ukraine’s grid. It was a struggle to restore power. By early December around 50 per cent of Ukraine’s energy infrastructure had been damaged, with some parts “totally destroyed”. The danger for Ukraine if its electric grid collapsed completely led to some apocalyptical visions, with everything shutting down, all supplies running low, famine and epidemics taking hold, nuclear reactors melting down. Without subscribing to the more extreme scenarios, the then commander-in-chief, General Valery Zaluzhny, worried about the effects on public morale and Ukraine’s ability to keep fighting.
Fortunately Ukraine found ways to deal with the challenge, keeping damaged systems operating, prioritising essential services, protecting key sites, and powering down the electricity system on warnings of an incoming attack. Air defences became tactically more adept and more and better systems arrived from abroad, pushing interception rates up from 20-30 per cent to 75 per cent. By the spring of 2023, with winter over, it appeared that Ukraine had won this battle. Russia turned its attention to striking Ukrainian logistics and equipment concentrations in preparation for the coming counter-offensive.
Although the second winter of the war was not as bad as the first, earlier this year the campaign resumed against Ukrainian electricity in earnest. This became part of Russia’s big push for a quick end to the war at a time when it seemed like Ukraine had been badly weakened. The previous year’s offensive had been a disappointment and now the army was undermanned and outgunned. Air defences had been depleted and replacements, in particular Patriot systems, had yet to be delivered. Kyiv appeared to have been abandoned by the US, or at least the US Congress.
In March 2024, a month before the supplemental bill was eventually passed in the House of Representatives, there were a series of targeted attacks on Ukraine’s energy infrastructure, with multiple sites hit. Putin boasted: “We can hit civilian infrastructure and all other facilities. We have our views on this, and our plans.” The ubiquitous Peskov justified the attacks because “Naturally, this [power grid] is associated with military infrastructure in specific cases.” The real target however was Ukraine’s civil society and economy. With so much power-plant capacity lost blackouts became – and remain – common in Ukrainian cities. As the Kharkiv area became the focus of much Russian military activity, the city’s energy supplies were especially targeted. For now repairs are improving the situation but as winter approaches we can assume that Russia will continue to target energy systems. Russian attacks are becoming more sophisticated, which is why enhancing Ukraine’s air defences is such a priority. This winter is going to be difficult.
There are two distinct but related explanations for these deliberate attacks on Ukrainian society. The first is that the aim is to make life intolerable for residents of towns and cities that are on or close to the front line so that they are obliged to flee, making it easier for Russian forces to occupy them. The second is that it is purely coercive, designed to make conditions unbearable so the government is put under pressure to capitulate or at least seek negotiations on unfavourable terms. Russia might prefer to win by simply occupying more territory but its efforts are continually thwarted, so the attacks on civilian life may reflect frustration – lashing out to show that they can damage what they cannot take.
Russian media is not short of examples of attacks such as the one on the hospital being welcomed as part of an effort to hurt Ukraine so that life in the country is no longer worth living. Here there are none of the contortions that accompany attempts to pretend that only military-related targets are struck.
Try this from the Christian nationalist channel of Konstantin Malofeev, who financed much of the original subversion in Ukraine in 2014.
First the dehumanisation of Ukrainians:
“You have to be aware that it’s simple and scary: there are no people on the other side. Not a single person. Our missiles do not kill people. Not a single person. There are no people there.”
“If we do not accept this as a given, if we do not forbid ourselves to consider them people, to feel sorry for them, to take care of them, we will weaken ourselves. We will limit our ability to save our children. We will make it difficult for ourselves to win.”
Then the description of the aim of the attacks:
“the surviving Nazis and all their relatives must flee to the West in panic. For the Polish border. From under shelling. From the ruins of their cities and homes. Losing yellow and blue flags and slippers on the move.”
Malofeev is quoted as describing the “only solution” as being:
“to strike with the most powerful weapons we have at enemy cities. Out of humanity, you can, probably, offer to start evacuation towards Poland 48 hours in advance.”
The conclusion:
“So it’s simple and scary, but you don’t have to make excuses for ending up in a children’s hospital. We must say: do you want this to stop? Surrender. Capitulate. And then, perhaps, we will spare you.”
Here as so often in Russian commentary is the presumption that Russia is not only entitled to bully others but must do so remorselessly. This bullying is expected to work so long as it is sufficiently vicious.
The conviction that brutal and unforgiving force can be effective against any population daring to resist Russia might be the result of the apparent success of this approach in Chechnya and then Syria. In the Chechen War defenders were battered with intense firepower. During the Russian intervention in Syria to keep Bashar al-Assad in power, Mark Galeotti described their tactics as implementing a lesson learnt in the destruction of the Chechen capital Grozny: “All war is terrible; sometimes the art is to be the most terrible.” In Syria in late 2016 Russian forces sought to move rebels out of the besieged city of Aleppo by making life miserable for all inhabitants, including systematically bombing hospitals.
Eventually both the residents and rebel fighters evacuated the city. They followed this up later in Idlib Province. Russia therefore came away from both these conflicts with the view that cities can be cleared of hostile populations by these means, and so they have applied this lesson to Ukraine.
Can they succeed? The Second World War was seen as the great test of the idea that civilian morale was the weak link in any country’s war effort, so that if centres of population were attacked in a systematic way the people would eventually demand of their government that they do anything necessary to stop the slaughter, including surrender. The advent of nuclear weapons complicated the analysis because these moved the horrors of war to a completely new level, threatening the obliteration of whole civilisations. But the experience from before their arrival was that so-called “strategic bombing” had not lived up to pre-war claims. People blamed the enemy for their suffering rather than their own government and the regular attacks hardened their resolve. It was remarkable how much societies could absorb punishment. This led to the ethically comforting conclusion that targeting innocent civilians would not only be shameful it would also be counterproductive.
Thus far the experience of Ukraine has confirmed these conclusions. It has suffered great hurt while still refusing to be cowed. If we look at recent polling there is no evidence that the Ukrainian will to resist has been significantly weakened. A poll conducted in March 2024, when Ukraine was on the backfoot in the land war, the American supplemental aid had yet to come through, and the attacks on the energy grid were being felt, found the notion that Russia was winning the war to be rejected overwhelmingly (only 5 per cent believe it is). The rest were split between those who thought Ukraine is winning and those who thought neither side is winning, but still, when it came to war outcomes, 73 per cent believed that Ukraine would eventually liberate all its territories. This general belief in eventual victory is consistent across recent polls. It has been true from early in the war that civilians have fled those cities and towns in contention, but they are still left defended and all Russian advances have come at a high cost. These tactics have not helped Russia gain much territory. Outrage at the recent attacks has led to greater international efforts to find more air defence systems for Ukraine.
The most remarkable feature of the battle map of Ukraine is how little has changed over the last eighteen months. If Russia’s failure to achieve more with their weight in numbers and firepower has led to greater reliance on these more vicious methods, there is no reason to suppose that they will make Ukraine more ready to make concessions in any future negotiations. If anything, they will have the opposite effect.
The effect of Russian atrocities thus far has been to harden Ukrainian attitudes. In his angry book, The Language of War, the writer Oleksander Mykhed (interviewed here in the Financial Times) blames all Russians, and not just Putin, for the cruelty and remorselessness of the attacks on his country. As he discusses those on critical infrastructure – the “terrorist blackmail before the onset of cold weather” – he describes Ukrainians coping in evenings without electricity. “And if the evenings are to be spent without light,” he notes, “so be it. All the better to see how Russia itself is slipping into darkness.”
Lawrence Freedman is a regular contributor to The New Statesman. This piece originally ran on his Substack “Comment is Freed“.
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