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Since February 2022, the Russian Federation鈥檚 attacks on Ukraine鈥檚 hospitals, health care workers, and medical infrastructure have been a signature feature of its brutal war strategy. As of February 2024, more than 1330 attacks have been perpetrated against Ukraine鈥檚 health care system since the start of the full-scale invasion.¹ Such deliberate and indiscriminate attacks have had a devastating effect on Ukraine鈥檚 people and health care system and are now being investigated as war crimes and possibly as crimes against humanity as well.²

Yet, targeted physical destruction of health care facilities is not the only weapon of war that Russia is wielding against Ukrainian civilians and their access to health care. As a new report by Physicians for Human Rights (PHR) and partners illustrates,³ Russian authorities are limiting and conditioning access to health care through a range of coercive practices in Ukraine鈥檚 occupied territories. These practices include not only misusing civilian health facilities for nonmedical and military purposes, but mandating that Ukrainian citizens adopt Russian nationality and acquire Russian passports (ie, passportization) as a precondition for gaining access to health care and threatening and persecuting health care professionals as a way to further limit care and assert control over Ukraine鈥檚 health care system.³

Since February 2022, PHR and other human rights organizations have recorded multiple incidents in these temporarily occupied territories where medical services were denied to Ukrainian citizens if they refuse to become Russian citizens as a precondition to receive health care.^3,4 As the new report details, PHR has reported at least 15 incidents of passportization, where medical care was denied to people without a Russian passport or civilians were coerced into obtaining one to access health care.³

Discrimination based on requirements to have a Russian passport began prior to the full-scale invasion of 2022, dating back to the occupation of Crimea in 2014. Those who did not accept Russian citizenship faced severe obstacles, not only in terms of being denied medical services but also facing other sanctions. For example, in Crimea, Ukrainian citizens reported being denied care at public hospitals because they lacked a compulsory health insurance policy available only to Russian citizens.⁴

On April 27, 2023, the policy of forced change of nationality鈥攐r as it is referred to in Ukraine, passportization鈥攚as officially decreed for all residents of the Russian-occupied territories of Donetska, Khersonska, Luhanska, and Zaporizka oblasts. The decree states that residents have until July 1, 2024, to accept Russian citizenship; otherwise, they will be considered 鈥渇oreigners or stateless鈥� and can be detained or deported.^3,4 Furthermore, in May 2023, Russia announced that residents of the temporarily occupied territories, including children, must obtain insurance policies that require Russian citizenship to receive medical services by the end of 2023.⁴

Even before that new requirement officially went into effect on January 1, 2024, there were numerous cases of denial of medical care throughout the Russian-occupied territories. According to Petro Andriushchenko, the adviser to the mayor of Mariupol, Ukraine, 鈥渘ow [in 2023] people are being denied treatment and/or examination ... without state health insurance. To get insurance, you need to have a Russian passport.鈥�³ In Hornostayivka, Khersonska oblast, according to a report by the Center for Investigative Journalism, a local resident reportedly died because physicians refused to provide him with medical care without a Russian passport.⁵

Medical professionals may face sanctions or reprisals for providing care to people who do not have a Russian compulsory insurance policy and for refusing themselves to secure Russian nationality. For example, in September 2023, Russian forces reportedly abducted and killed 26-year-old Anastasia Saksaganska, a physician from a village in Khersonska oblast, as well as her husband. Their relatives stated that they were killed because they refused to obtain Russian passports and submit to Russian demands.⁶ In June 2023, Russian authorities reportedly closed a health care facility in Zaporizka oblast after most of the employees refused to obtain Russian passports.⁷ Health officials report that in the face of resistance from Ukrainian physicians in Khersonska, Donetsk, and Luhansk oblasts, physicians are being brought in from Russia to implement the policy.³

In some Russian-occupied territories, pressure to secure Russian passports has extended to denial of medications and other humanitarian aid. As one example, in Lazurne, an occupied town in Khersonska oblast, the Russian-appointed administrator Oleksandr Dudka stated, 鈥淢edicines purchased from the budget of the Russian Federation will not be distributed to Ukrainian citizens. This applies to insulin users who have already experienced what it is like to be a citizen of another country.鈥�³ And in Enerhodar, a city in Zaporizka oblast, the Russian administration has prohibited the distribution of all medicines to residents who do not have a Russian passport. According to the mayor, pharmacies in the city were seized and now refuse to provide essential medicines such as insulin to citizens without Russian passports.⁸

The denial of medical care and essential medicines is illegal, barbaric, and cruel; the policy also serves to expand Russia鈥檚 coercion of and control over Ukraine鈥檚 civilian population. Individuals, especially those with acute conditions or chronic illnesses, are forced to make agonizing choices between their well-being, even their lives, and their citizenship. Physicians and other health care professionals are forced to compromise their ethical obligations to provide care without discrimination.

As a state policy, passportization policies violate both international humanitarian law and international human rights law. Under international humanitarian law, occupation law seeks 鈥渢o ensure the protection and welfare of the civilians living in occupied territories.鈥�⁹ The Hague Regulations of 1907, Fourth Geneva Convention of 1949, and Additional Protocol I of 1977, all of which have been ratified by both Russia and Ukraine, require occupying powers to ensure adequate medical supplies and care for affected populations and prohibit discrimination in required humane treatment, including medical care, based on nationality. Indeed, a key tenet of occupation law is that 鈥淸i]t is forbidden to compel the inhabitants of occupied territory to swear allegiance to the hostile power.鈥�⁹

International human rights laws stipulate that 鈥淸e]veryone has the right to a nationality. No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.鈥�¹⁰ The right to a nationality is enshrined in multiple human rights treaties, such as the International Convention on the Elimination of all Forms of Racial Discrimination and the International Covenant on Civil and Political Rights, to which both countries are also party. This includes both the ability to freely change one鈥檚 nationality, without coercion, and the prohibition against arbitrary deprivation of one鈥檚 nationality. Human rights law further obliges states to maintain a functioning health care system in all circumstances, including during armed conflicts and in occupied territories and to provide accessible health care without discrimination.

Passportization represents yet another attack on health perpetrated by the Russian Federation. And these policies oblige the medical community in these territories to be the enforcers of the crime of conditioning access of patients to medical care and medications on their meeting Russia鈥檚 political demands. Health care professionals and their associations throughout the world have a vital role in denouncing these practices and advocating for justice and accountability. First, health care professionals should advocate that these reported abuses be rigorously investigated as possible war crimes through both national and international accountability mechanisms. Second, the medical community in the US and globally should continue to mobilize support to help meet the pressing humanitarian needs in Ukraine and affirm the inviolable right to indiscriminate medical care. Third, the global medical community should extend its support to Ukrainian health care professionals as they seek restitution for the enormous damage done to the country鈥檚 health care system and undertake the difficult task of its rebuilding. The international community overall鈥攁nd especially the medical community鈥攎ust unite to denounce passportization and the multiple other ways Russia is attacking health care and the right to health in Ukraine.

Published: March 8, 2024. doi:10.1001/jamahealthforum.2024.0031

Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2024 Poltavets U et al. JAMA Health Forum.

Corresponding Author: Michele Heisler, MD, MPA, Physicians for Human Rights (PHR), 256 W 38th St, 9th Floor, New York, NY 10018 (mheisler@phr.org).

Conflict of Interest Disclosures: None reported.