Commentary: Why warring factors target hospitals

On Thursday the Syrian government and its allies conducted air strikes on a hospital in a rebel-held area of Aleppo, killing 27 people. The victims included three children and the city’s last remaining pediatrician.

As Syria’s fragile ceasefire continues to unravel, Syrian President Bashar al-Assad and his Russian allies can lay claim to a dubious achievement: participating in the deadliest assault on healthcare facilities the world has ever seen.

As of March, 730 medical workers have died in 359 attacks on medical facilities in Syria, according to the nonprofit Physicians for Human Rights (PHR). The vast majority of attacks were conducted by Syrian government or Russian forces, using weapons that can target a specific location - such as missiles, rockets and car bombs. In February, missiles hit five medical centers and two schools in rebel-held towns, killing close to 50 civilians.

The attacks have had a cascade effect on Syria’s people, killing them directly and indirectly, when they die because their illnesses or injuries go untreated. As of February more than half of Syria’s 30,000 doctors had left the country, leaving entire communities with no healthcare.

In Syria, bombing hospitals is one of many brutal tools of war - from government sieges designed to starve entire communities, to chemical weapons attacks. It is a violation of the laws of war: the Fourth Geneva Convention’s “Protection of Civilian Persons in Time of War” prohibits warring factors from targeting hospitals, as well as facilities dedicated to religion, art, science and charitable purposes.

Actually prosecuting the Assad regime for war crimes - related to hospital attacks or otherwise - is a massive challenge. It requires first, proof of intent, and secondly, to bring those charges within the jurisdiction of the International Criminal Court. Since Syria is not a party to the statute that created the ICC, it can only be referred to the tribunal by the UN Security Council. Russia, a Security Council member, has already blocked a draft resolution that would have allowed the court to try Syrian President Bashar al-Assad.

Carried out in Aleppo, Hama and elsewhere, hospital attacks have been part of a broader military strategy to ensure that Assad - himself a former eye doctor - stays in power, experts say. And weapons such as ballistic missiles - more sophisticated than indiscriminate carpet bombing common in earlier conflicts - have allowed pro-Assad forces to make that strategy brutally effective.

More than 50 percent of Syrians have been displaced from their homes since the start of the civil war five years ago, and more than 900,000 refugees have applied for asylum in Europe. Bombing hospitals is one way to guarantee that that flow continues, putting continued pressure on Europe in a way that a true ceasefire would not. “It creates a power dynamic: In order to stop the flow of refugees – which is what Europe wants – leaders must accept the fact that Assad stays in power,” says Widney Brown, Director of Programs at Physicians for Human Rights in New York. The strategy, if it works, would help Assad maintain his hold on power even though Syria’s civil war has claimed 470,000 lives.

Destroying hospitals helps to weaken the resolve of Assad’s opponents. Together with sieges and other tactics, it is meant to make civilians and opposition forces so desperate that will submit to Assad’s rule. The message: “This is what life is like when you’re trying to turn against the state,” says Fotini Christia, an associate professor of Political Science at the Massachusetts Institute of Technology.

Syria and Russia are not the only countries responsible for recent attacks on hospitals. In October, U.S. forces bombed a Médicins Sans Frontières (MSF) hospital in Kunduz, Afghanistan, killing 42 people. The medical nonprofit says that the bombing continued for more than an hour after it informed NATO and U.S. officials that the hospital was under attack. After investigating the attacks, the U.S. military said they were an accident caused primarily by human error and on March 22 issued an apology to the families of victims. MSF, which has called the airstrikes a war crime, has been demanding an independent investigation.

In Syria and other conflicts, journalists, aid workers and other civilian groups are also under threat. But they are targeted for different reasons than doctors. Killing a journalist allows a warring party to prevent news from reaching the public. Destroying a hospital can devastate an entire community. “When you kill a doctor you don’t just kill them,” says PHR’s Brown. “You destroy the lives of people they could have saved.”