The bombing of hospitals and local violence dynamics in civil wars: Evidence from Syria

Hicn Wp 403

The impact of civilian harm on strategic outcomes in war has been the subject of persistent debate. However, the literature has primarily focused on civilian casualties, thereby overlooking the targeting of civilian infrastructure, which is a recurrent phenomenon during war. This study fills this gap by examining the targeting of healthcare, one of the most indispensable infrastructures during war and peace time. We contend that attacks on medical facilities are distinct from direct violence against civilians. Because they are typically unrelated to military dynamics, the targeting of hospitals is a highly visible form and powerful signal of civilian victimization. To assess its effects, we analyze newly collected data on such attacks by pro-government forces and event data on combat activities in Northwest Syria (2017-2020). Applying a new approach for panel data analysis that combines matching methods with a difference-in-differences estimation, we examine the causal effect of counterinsurgent bombings on subsequent violent events. Distinguishing between regime-initiated and insurgent-initiated combat activities and their associated fatalities, we find that the targeting of hospitals increases insurgent violence. We supplement the quantitative analysis with unique qualitative evidence derived from interviews, which demonstrates that hospital bombings induce rebels to resist more fiercely through two mechanisms: intrinsic motivations and civilian pressure. The results have important implications for the effects of state-led violence and the strength of legal norms that protect noncombatants.

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