The Bombing of Hospitals and Rebel Responses in Civil War. Evidence from Syria

Does targeting civilians suppress or intensify insurgent violence? Existing research presents contradictory findings, focusing primarily on direct civilian targeting. We examine how government attacks on civilian infrastructure – specifically medical facilities – affect rebel behavior. We argue that hospital bombings trigger rebel escalation through civilian pressure and reputation-seeking. Analyzing novel data on hospital attacks in northwestern Syria (2017-2020), we use matching methods combined with difference-in-differences estimation to assess effects on combat intensity. Distinguishing between rebel- and government-initiated fighting, we find that hospital attacks increase insurgent violence within one week. Interviews with medical workers, activists, and rebels confirm that hospital bombings intensify attacks through our hypothesized mechanisms. These findings demonstrate that infrastructure targeting backfires strategically, echoing broader evidence on punishment strategies’ limitations in counterinsurgency. Our results also highlight concerns about the erosion of legal norms protecting medical facilities and civilians in armed conflict.