A woman standing in front of a bomb shelter in Petrovsky district of Donetsk, area of Trudovskaya mine, where locals have been hiding from attacks since August. February 9, 2015. © 2015 Dmytry Belyakov

(Berlin) – Travel restrictions imposed by the government of Ukraine have contributed to serious delays in the delivery of humanitarian aid, particularly medicines and medical equipment, to civilians in rebel-controlled areas of eastern Ukraine, Human Rights Watch said today. Human Rights Watch released a video based on interviews with medical personnel and patients in eastern Ukraine.

The restrictions also seriously impede access to health care for civilians from rebel-controlled areas who need to use state-funded medical services available only in government-controlled areas, Human Rights Watch said. Human Rights Watch also found that patients receiving treatment for HIV, tuberculosis (TB), and opioid substitution therapy (OST) are facing interruptions of life-saving treatment.

“Delays in delivering medicines, combined with a pass system and military hostilities, have created massive shortages at medical facilities,” said Yulia Gorbunova, Europe and Central Asia researcher at Human Rights Watch. “This is jeopardizing the lives of people with serious medical conditions and others who need medical assistance in rebel-controlled areas.”

Human Rights Watch spent three days in Kiev and seven days in the Donetsk region interviewing, in person or by phone, doctors and other health workers, patients, local residents, volunteers, and members of independent humanitarian groups that provide humanitarian aid to conflict-affected areas.

In a March 9, 2015 letter to Ukrainian officials, Human Rights Watch asked the Ukrainian government to ensure that its restrictions on movement in and out of areas not under government control do not adversely affect the health of the civilian population.

Several local and international humanitarian organizations told Human Rights Watch that since January, they have experienced restrictions and delays when trying to move medicines and medical equipment that are essential for the health of the civilian population into rebel-controlled areas. In some cases these restrictions and delays did not appear to be justified on security grounds, Human Rights Watch said.

In November 2014, the Ukrainian government stopped providing funding for government services and social benefit payments – including budgets for hospitals, pensions, and social security – in rebel-controlled areas. Civilians have to travel to government-controlled territories to get their social benefits. In January 2015, the government also began to enforce travel regulations that require civilians to obtain a special pass to move between rebel-controlled and government-controlled territories. Human Rights Watch found that rebel forces, who exercise effective control over areas of the Donetsk and Luhansk regions, have failed to fill the gap left by the withdrawal of state funding for services and payments from rebel-held areas. People in rebel-controlled areas who need state-funded treatment now have to travel to government-controlled territory, but are often unable to, either because they do not have the financial and other resources to travel and register in government-controlled areas, they have to provide care for sick or elderly family members who are not able to travel, or they fear injury or worse due to the hostilities.

All parties to the conflict should uphold their obligations under international humanitarian law and their commitments under the February 13 Minsk ceasefire agreements to ensure access to humanitarian relief for civilians who need it, Human Rights Watch said.

The Ukrainian government has the right to control movement in and out of rebel-controlled areas, but all parties to the conflict must allow and facilitate the rapid and unimpeded access for impartial humanitarian relief for civilians in need, Human Rights Watch said. Consent for access to humanitarian operations cannot be withheld for arbitrary reasons, and neither side should seek to impose intolerable conditions on the civilian population as a tactic of war.

The government also maintains its obligations under international human rights law to respect the right to health and other economic and social rights, as well as rights such as freedom of movement for the civilian population. This includes, in particular, rights provided for in the treaties to which it is a party, such as the European Convention on Human Rights, the International Covenant on Civil and Political Rights, and the International Covenant on Economic, Social and Cultural Rights.

In areas under effective control of rebel forces, those forces have the primary responsibility to ensure that civilians have humanitarian essentials, including medical supplies, Human Rights Watch said. And, while the Ukrainian government has no obligation under international humanitarian law to provide direct financial assistance to authorities operating under the control of rebels, its human rights obligations to the civilian population do not cease due to the current conflict.

In its letter, Human Rights Watch said the Ukrainian government and de facto authorities in rebel-controlled areas should not impede humanitarian assistance and should facilitate access to it for civilians in need. The government of Ukraine and rebel forces controlling those areas should issue instructions to troops and forces staffing checkpoints, and their commanders, to ensure that delivery of medication and medical assistance for civilians in rebel-controlled areas are not subject to arbitrary or unreasonable delays, in line with humanitarian law and the Minsk agreements.

“Some of the most vulnerable civilians in rebel-controlled areas have no choice but to rely on humanitarian groups for certain medications and medical services,” Gorbunova said. “Impediments to delivering medications, such as arbitrary delays at checkpoints, can have a severe negative impact on their health with dire, and in some cases deadly, consequences.”

Restrictions and Their Impact
In November 2014 the Ukrainian government halted the provision of government services to rebel-controlled areas. Funds from the government budget for hospitals, including staff salaries, are no longer disbursed in rebel-controlled areas. On February 9, 2015, the Kiev District Court of Appeal partially annulled the decision, but it is not clear what steps the government has taken either to comply with the decision or to appeal.

Travel regulations introduced by the Ukrainian government in January require a special pass, issued by a coordination group of the Security Service of Ukraine, to move between rebel and government-controlled territories. Civilians living in rebel-controlled areas need to apply for the pass at a government checkpoint in a bureaucratic process requiring a minimum of two visits. Many complained of long lines to hand in their documents. The regulations set out a maximum 10-day waiting period for a pass, but several people who live in or near Donetsk said they had been waiting for up to three weeks and some still had not received a pass.

Independent humanitarian groups operating in the area, including Doctors Without Borders (MSF) and others, have said that they have been able to operate in rebel-held areas and successfully obtained these passes. But some spoke of difficulties they faced in delivering humanitarian aid and medical supplies.

Volunteer groups in rebel-controlled areas that provide targeted assistance to the most vulnerable groups reported difficulties connected with delays or refusals to let humanitarian aid through at checkpoints. One of the organizers of the local group Responsible Citizens, Dmytro Shibalov, told Human Rights Watch of instances where both Ukrainian forces at government checkpoints and rebel forces at rebel checkpoints refused to let their cargo pass without a reasonable explanation.

Treatment for Tuberculosis and HIV
People receiving treatment for tuberculosis (TB) or HIV and those on opioid substitution therapy (OST) are among the most vulnerable in the rebel-held areas of Donetsk and Luhansk regions. The travel restrictions and the protracted fighting have severely impacted their treatment and put some of them at great risk. Treatment of HIV, TB, and viral hepatitis in eastern Ukraine is under great strain, with hospitals lacking both medicine and diagnostic equipment.

According to data provided to Human Rights Watch by the International HIV/AIDS Alliance in Ukraine, over 16,000 people are living with HIV/AIDS in rebel-held areas in eastern Ukraine, including over 7,000 people who receive antiretroviral therapy. At least 2,300 people there have active forms of TB, including about 500 people with multi-drug-resistant TB.

Doctors who work with people receiving treatment for HIV and TB in rebel-controlled areas told Human Rights Watch in February that their staff had faced long delays in getting permission to move new supplies of these medications from government-controlled to rebel-controlled territories.

The government has yet to approve a regulation drafted in January that would allow humanitarian groups to deliver methadone and buprenorphine, used in OST, to rebel-controlled areas. Medical centers in Donetsk and Luhansk regions may have to shut down these treatments when the supply runs out, which could have a devastating impact on patients receiving this therapy who would be at significant risk of relapsing into illicit drug use and of accidental overdoses.

The Donetsk Regional Center for AIDS Prevention and Control is registered in Sloviansk, on Ukrainian government-controlled territory, and continues to operate its facility in Donetsk, in rebel-controlled territory. In early February, the center’s chief medical officer, Nikolai Grazhdanov, told Human Rights Watch that the travel pass system has significantly delayed the delivery of both diagnostic test kits and antiretroviral medicine to the region, including Donetsk and nearby towns such as Horlivka and Makeevka.

The center’s deputy director, Valentina Pavlenko, MD, said in early February that her staff had been waiting three weeks for the travel passes to bring antiretroviral medicine and diagnostic kits from Sloviansk to rebel-held Donetsk. Although they eventually received the passes in early March, over 6,000 HIV-positive patents in the rebel-controlled territory of Donetsk were at risk of running out of medicine, Pavlenko said. A humanitarian aid convoy was eventually able to deliver treatment that is expected to last until April. Stopping the treatment may result in patients’ conditions deteriorating, with dire, and possibly deadly, consequences.

Vladimir Mozgovoi, the chief doctor of the Donetsk Regional Center for Tuberculosis, said in early February that the center had enough first-line medications to provide uninterrupted treatment for another month. But the stocks of second-line treatment for TB resistant to first-line therapy, as well as drugs to treat TB-related conditions were almost depleted. The center currently treats over 500 patients, including 40 children.

The center also ran out of rapid diagnostic tools for TB in December 2014, and diagnosis can now take months instead of days. Fast diagnosis is essential to combating drug-resistant TB.

Mozgovoi also said that since the beginning of the conflict, more patients seeking treatment had advanced forms of TB because many who remained in conflict-affected areas either could not afford to travel to see a doctor or were trapped in active war zones. They sometimes have spent weeks or months in unsanitary, underground shelters, which exacerbated their condition and created the risk of infecting others. Mozgovoi also said that for several weeks at the end of 2014, the center did not have general anaesthetics for surgery, but received a supply from humanitarian organizations in January 2015.

Opioid Substitution Therapy
Opioid substitution therapy (OST) is available in government-controlled territory but the government has not yet approved a regulation, drafted in January, to allow independent humanitarian groups to deliver the methadone and buprenorphine used in this therapy to rebel-controlled areas. In the meantime, the stock of buprenorphine in rebel-controlled parts of Donetsk and Luhansk regions has been depleted completely and methadone supplies are running out.

Igor Tsiba, the chief doctor of the regional drug treatment center in Donetsk treating patients in rebel-controlled areas, said in early February that while the center has been sporadically receiving necessary supplies and medicine with humanitarian convoys, delivery of OST therapy stopped in September 2014. The center had to discontinue treatment with buprenorphine in early January 2015 when the supplies ran out, and was in the process of drastically reducing methadone treatment.

Tsiba said that some of the most vulnerable patients who receive opioid substitution treatment, including those who are living with HIV, also have TB or various forms of hepatitis. Discontinuing their opioid substitution treatment will result in significant deterioration of their condition and could possibly have fatal consequences for some of them.

Yulia Drozd, MD, the head of the department for OST at the center, and head of Donbass Without Drugs, a nongovernmental group that provides medical treatment and social rehabilitation for patients in the Donetsk region, said in early February: “The most shocking thing is that these drugs are readily available but there is no way of getting them here because there is no procedure in place for delivering them.” Seventy percent of the patients who receive this therapy are also HIV-positive, and 25 percent have TB and are vulnerable to other infections, Drozd said.

According to data provided to Human Rights Watch by the International HIV/AIDS Alliance in Ukraine, as of early March, at least 600 patients in rebel-held areas of Donetsk and Luhansk regions had to discontinue their opioid substitution treatment due to shortages of medicines.

Human Rights Watch interviewed three patients receiving OST. Elena, who had used heroin for over 30 years, said she turned her life around after she started OST a year ago and is terrified to think that she could lose it. Rita, 35, who has been receiving methadone therapy for six years and is living with HIV, said she could not leave Donetsk because she had no money and no relatives anywhere else. She looks after her 7-year-old son and her elderly mother, who recently had a stroke and cannot travel. “If I can’t receive treatment, I will not survive,” she said.