The bombing of hospitals and local violence dynamics
in civil wars

Can coercive airpower quell a rebellion? Existing literature on the effects of counterinsurgent
violence focuses predominantly on casualties resulting from attacks on civilians. It thus
overlooks the targeting of civilian infrastructure, which is a frequent phenomenon in war. We fill
this gap by examining the targeting of healthcare as one of the most essential infrastructures in
war and peace time. We argue that attacks on medical facilities are distinct from direct violence
against civilians. Because they are usually unrelated to military dynamics, the targeting of
hospitals is a widely 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 shows 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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