The Dead and the Living in Luhansk

Amid the shells and explosions, there’s little in the way of normal life left in Ukraine’s besieged eastern cities.

LUHANSK, Ukraine — You smell it before you see it. With no electricity and a steady stream of casualties, Luhansk's morgue is struggling to keep up. On Thursday, Aug. 21, lined up on the lawn outside were 17 bodies -- bloated, engulfed in buzzing flies -- while the staff cleaned the refrigerators, hoping that they would soon restart after several weeks of power outage.

Nearly four months after the conflict in eastern Ukraine between government forces and pro-Russian separatists began in earnest, the war grinds on. The Ukrainian army has retaken some towns, closing in on Donetsk, the largest city in the area, which has come under increasingly heavy bombardment. In other places, separatist forces have launched counteroffensives, retaking the city of Novoazovsk and moving in on Mariupol.

But it is, perhaps, the residents of Luhansk who have been in the crossfire the longest. Normally home to nearly half a million people, the city felt like a ghost town when I arrived there recently. Locals arriving on the afternoon train rushed to the relative safety of their homes. There has been virtually no electricity and running water in the city for weeks. Stores are nearly empty. Cell phones and landlines rarely work.

In the morning, it becomes clear that the city is far from empty. Starting at around 6 a.m., hundreds of local residents line up for bread and water at distribution points around Luhansk. Dozens gather at the two points in the city where, if you are patient, you can catch cell-phone reception from a tower in a neighboring town. And they come to the central market as soon as it opens to buy what is left of food and other goods.

By early afternoon, however, the city again goes quiet.

"The shelling in this district always takes place between 2 and 6 p.m.," said the acting head of a local fire station. "On August 15, five shells struck an intersection, killing 18 people. On August 17, shells killed an 80-year-old woman and wounded a 7-year-old boy. On August 17, Grad rockets struck the Epicenter shopping mall where people go to make calls. We tried to extinguish the fire, but artillery shelling started when we arrived and we had to give up. We do nothing else but respond to shelling and rocket attacks these days." He said that in his district alone there had been at least eight incidents of shelling recently that killed civilians.

Luhansk's morgue has received the bodies of about 300 civilians -- about half of them women -- since shelling started in the city in May. The acting head of the morgue said 99 percent had died from shrapnel injuries. A nearby hospital, one of four in the city that receive war-wounded, has treated at least 500 patients, the vast majority with shrapnel wounds.

Anna Dmitrievna, 82, is one such patient. When shelling started one evening in August, she tried to make her way to a basement shelter in the neighborhood. Before she could get to safety, however, a shell exploded nearby and shrapnel tore into her right shoulder, leaving a long gash. She spent the night in the shelter because of continuing shelling, her shoulder bleeding and aching. Only the next day did she receive proper medical treatment at a hospital. Her right hand does not work properly because of her injuries, and she is worried about how she will manage since her family has left the city.

Tamara, 67, is in the same ward. A shell hit her house on Aug. 14, killing her son and husband, burning her house to the ground, and causing serious injury to her back and hip. "My husband is dead, my son is dead, and I can't even bury them because I am here," she said. "Everything was taken in one moment. My house is destroyed. I have no money. I might as well jump from the window. I have nothing left."

There are dozens of victims like Tamara and Anna Dmitrievna in Luhansk. Most of the injured believe that Ukrainian forces fired the shells or the rockets, though some said that they do not know. It is difficult to conclusively establish responsibility for specific attacks, and both the rebels and government forces usually deny responsibility for attacks that kill civilians. The circumstances of several of the attacks in Luhansk do, however, point the finger at Kiev. Because Ukrainian government forces are trying to retake the rebel-controlled city, it is logical that shells and rockets landing in separatist-controlled areas come from government forces and vice versa.

Some attacks also appear to have targeted separatist bases and offices, which would be consistent with government strategy. Some of the initial shelling in Luhansk, for example, struck close to one of the city's military recruitment offices, which had been taken over by rebels. "They tried shelling the recruitment office for a week," a local first responder said. "They hit everything around it, including the bus station and a hospital, but not the office itself."

Several shells also struck the area of Luhansk's central market on Aug. 18, killing four people and burning down a dozen small shops. That area has been shelled repeatedly, including this past week. Most likely, the attacks were directed at the regional administration building, about 300 feet away, which is the rebels' headquarters.

First responders operating under continuing bombardment also said that they could hear the shells being fired from government-controlled areas.

But the rebels bear responsibility as well. Outgoing heavy artillery fire could be heard in several places in the city, including near a hospital, which exposed civilians to the risk of return fire. Under the laws of war, warring parties must take all possible measures to avoid endangering civilians, such as, where feasible, not locating military targets within or near densely populated areas. In other places, such as in villages to the north of Luhansk currently under government control, Human Rights Watch has documented that rebels used explosive weapons in a way that injured and killed civilians and destroyed houses, shops, and infrastructure.

As the morgue and hospital staff explained, the vast majority of civilian deaths and injuries in Luhansk is due to the use of explosive weapons. As a matter of policy, these weapons shouldn't be used in populated areas such as Luhansk because of the risk to civilians. The use of some of the weapons documented here, such as unguided Grad rockets, is a clear violation of the laws of war; combatants cannot accurately distinguish military from civilian targets -- which may amount to war crimes.

I asked the acting head of the morgue what his biggest problem is, given the lack of electricity, shortage of water, and reduced staff,. After pausing for a second, he said: "These problems I can deal with. My biggest problem is that the fighting keeps killing too many civilians."

Fabio Bucciarelli AFP


No Place to Heal

South Sudan's hospitals have become targets for both sides in the brutal, ongoing civil war. How can you save lives when doctors and patients are living under the gun?

MALAKAL, South Sudan — Outside the pediatric wing of Malakal's teaching hospital, a human skull lies in the yellowing blades of knee-high grass. "We are finding these all the time," said a groundskeeper, who asked not to be named. "We found two yesterday," he said, shoveling the remains into a cream-colored body bag. 

Malakal is a ghost town. Once South Sudan's second-biggest city with a population of 150,000, it is now home to more soldiers than civilians. Residential areas have suffered an extraordinary amount of damage since civil war broke out in December 2013, and the teaching hospital, which occupies a once-idyllic compound near a stone mosque built by Egypt in the 1940s, has been laid waste on multiple occasions. The trail of corpses now being discovered on the premises points to a disturbing trend in the country's eight-month-old rebellion: the systematic targeting of hospitals and medical personnel. 

"Hospitals and clinics have been targeted to a staggering degree," said Daniel Bekele, the executive director of the Africa division of Human Rights Watch, adding that South Sudan's "entire health system" has been destroyed "because of unlawful tactics used by both sides across the conflict areas." Cosmas Chanda, the representative for the Office of the U.N. High Commissioner for Refugees in South Sudan, called the level of violence directed at hospitals and aid workers "unprecedented" in an interview in Juba, South Sudan's capital.

South Sudan's latest paroxysm of violence has exacted a devastating toll on civilians. Looting, rape, and ethnically motivated mass killings have been unleashed in a relentless pattern of attack and counterattack. The subsequent displacement of 1.5 million people, along with the inability of aid agencies to reach many of them, threatens to push the country over the brink into famine.

Since the first shots were fired in December 2013, at least 58 people have been killed on hospital grounds, while hospitals themselves have been attacked or looted on six occasions, according to the medical charity Doctors Without Borders (Médecins Sans Frontières, or MSF). Countless clinics and pharmacies have also been plundered or damaged, and medical supplies have been stolen or destroyed.

The logic of targeting hospitals is sickeningly simple: Not only do attackers kill civilians, but they ensure that survivors cannot seek medical care. In the current conflict -- which began as a power struggle between President Salva Kiir and former Vice President Riek Machar but quickly morphed into an ethnic conflict, primarily between the country's two largest ethnic groups, the Dinka and the Nuer -- this logic has become intertwined with that of ethnic slaughter. In hospitals across the country's northeast, victims have reportedly been singled out for execution based on their tribal identity. In Bentiu, the capital of oil-producing Unity state, a local radio station went as far as calling for acts of "vengeful sexual violence" against women of other communities when rebel forces overran the city in April, according to the U.N. Mission in South Sudan. A total of 28 people were killed in the hospital there.

At the teaching hospital in Malakal, at least 14 people, including 11 patients, were murdered in their beds when rebel forces overran the city in February of this year. Other patients, mostly ethnic Nuers, were killed on the premises by government soldiers in January. Nobody knows for sure how many people have died here; nobody knows whose remains are being shoveled into the cream-colored bag.

Today, much of the hospital is still in ruins. The neonatal ward is burned and gutted. In the main surgical theater, one of the operating tables is missing, and the contents of ransacked supply shelves spill haphazardly onto the floor -- syringes, antiseptic solution, now-useless vaccines. In one of the patient wards, a single woman's shoe, its rhinestones still in place, rests on a filthy bedside table. 

"They took some things, and they destroyed what remained here," said Yumo Arop Ying, the acting director general of Upper Nile state's health ministry, referring to the three separate instances in which rebel forces seized control of Malakal.

Damage also occurred during periods of government control, according to rights groups like Amnesty International and Human Rights Watch.

While the raids themselves have been brutal, it is their effect on the broader system of health care that is even more troubling. "Attacks against hospitals and medical facilities in South Sudan have led to a collapse of the health system across much of the conflict zone," said Stephen Cornish, MSF's executive director for Canada, who is currently visiting South Sudan. "This in turn creates a number of silent victims to the conflict who perish from diseases which would otherwise have been possible to treat, such as malaria," he said.

On multiple occasions, MSF has been forced to evacuate its medical teams and temporarily suspend the operation of its clinics. According to a report published by the medical charity in July, hundreds of thousands of people have been cut off from medical care because of the violence. Where MSF cannot obtain guarantees of security, or at least of non-interference, "we may simply be unable or unwilling to risk responding," said Cornish.

Despite the recent surge in intensity, violence against health care is not a new problem in South Sudan. It was a regular feature of the north-south civil wars that raged from 1955 to 1972 and from 1983 to 2005, as well as of the conflicts in Darfur, South Kordofan, and Blue Nile that continue to grind along today. In 2000, for example, Sudanese armed forces bombed the Samaritan's Purse hospital in Lui, a town in what is now South Sudan's Western Equatoria state, three times in the span of a few months. Akec Khoc, a medical doctor who later served as South Sudan's ambassador to the United States, was shot in the shoulder while attending to wounded SPLA fighters in a field hospital during the second civil war. 

Not that Khartoum was the only one targeting medical facilities. Southern guerrilla forces, known as the Sudan People's Liberation Army (SPLA), also attacked hospitals and clinics -- those run by the government of Sudan as well as those run by rival SPLA factions. "From the beginning of the SPLA in 1983, it attacked hospitals, health workers, and aid agencies," said Alex de Waal, the executive director of the World Peace Foundation at Tufts University, who disputed the notion that attacks on medical facilities have grown any more frequent. The SPLA was "exceptionally brutal and matched the government of Sudan and pro-[government of Sudan] militias in this regard," he said in an email.

This long history of medical violence, coupled with Khartoum's deliberate policy of neglect for the south, is largely responsible for the abysmal state of South Sudan's health-care system today. In his first address to the U.N. General Assembly, President Kiir spoke of "construction" rather than "reconstruction" of South Sudan's institutions: "Even before the ravages of war could set in, our country never had anything worth rebuilding," he said. Although he was speaking generally, the president might as well have been referring specifically to the health-care sector. In 2012, the country of roughly 9 million had only 120 doctors and even fewer registered nurses. As a result, nongovernmental organizations provided as much as 80 percent of basic health services, even before the outbreak of civil war. Today, that figure is almost certainly higher. 

Still, a few brave doctors and medical professionals are enduring extraordinary hardship as they work to resuscitate the country's network of hospitals -- and to keep alive the pretense that the government is doing something to care for its citizens in areas contested by the rebels. Despite the damage and persistent insecurity, the teaching hospital in Malakal is now back up and running out of a few rooms that have been restored. Without electricity or sufficient staff, however, it is only able to provide outpatient care for those with relatively minor ailments, such as malaria.

That does not mean the skeleton crew manning the hospital doesn't have to deal with more serious emergencies. "We get trauma patients, sometimes soldiers with gunshot wounds," said Olany Alew Akol, the only physician currently working at the hospital. But without electricity or proper surgical equipment -- the generators and the operating theater were looted in February -- he is forced to stabilize them by the light of a flashlight before he can transfer them to the nearby U.N. base for surgery. "So many things aren't working," he said, "but we are just trying to go ahead." 

For now, progress toward rebuilding the teaching hospital can feel as fleeting as security here in Malakal. Many of the staff members fled to the bush when the fighting broke out, and none of the nurses will work the night shift. Often, rumors of an impending attack will sweep the city, prompting staff and patients alike to seek refuge on the U.N. base, where roughly 17,000 civilians are living in camps. "There were rumors yesterday that rebels are coming, so many people left the town last night," said Olany, adding that only a slow trickle of patients had visited the hospital that morning.

Before the civil war turned his workplace into a graveyard, Olany said the hospital was "too busy." Today, things are also hectic, but only because he's the only doctor on staff. "I am working day and night," he said, shaking his head. "Too busy." 

This reporting was made possible in part by the Pulitzer Center on Crisis Reporting.