When Hospitals Become Battlegounds

Amid rising geopolitical threats to democratic resilience, Robert Schuett and Susanne Schuett argue that protecting hospitals must become a core priority of both global policy and national defense planning.

Writing in the mid-1930s, as the clouds of fascism darkened ever more ominously over the Continent, the great jurist and classical liberal philosopher Hans Kelsen reminded his contemporaries of the enduring value of science. From exile in Geneva, he published a powerful op-ed titled “Science and Democracy” in the Neue Zürcher Zeitung. Echoing the sentiment of then–Harvard President James Bryant Conant, Kelsen described universities as the inner sanctuaries of a nation’s life—institutions indispensable not only for the pursuit of knowledge, but for the resilience of democratic order itself.

Today, the same can be said not only of universities but of hospitals as well.

When missiles strike hospitals, such as the 2024 Russian attack on Okhmatdyt Children’s Hospital in Kyiv, the world rightly recoils in moral horror. Yet amid the justified outcry, a crucial dimension is often overlooked. These attacks are not only clear violations of international humanitarian law and devastating humanitarian tragedies. They are also calculated attempts to undermine a nation’s power and resilience. In times of crisis and war, hospitals are not merely places of healing. They are central components in the machinery of state continuity. Protecting them is not just a moral obligation. It is a matter of national security.

Since the start of Russia’s full-scale invasion in February 2022, Ukraine has become one of the most dangerous places in the world for healthcare infrastructure, workers and patients. The World Health Organization has documented, as of early May 2025, 2,381 confirmed attacks on healthcare facilities, patients, personnel, transport and supplies—by far the highest number ever recorded in any humanitarian emergency globally to date (see also the reports of the Safeguarding Health in Conflict Coalition and the International Committee of the Red Cross).

The consequences for Ukraine’s health system have been profound. Trauma wards near the frontlines are overwhelmed, routine surgeries are postponed, and entire regions are left without obstetric, pediatric, or chronic care. Many hospitals operate under blackout conditions or rely on emergency generators. The July 2024 missile strike on Kyiv’s Okhmatdyt Children’s Hospital was merely the most high-profile of these incidents, emblematic of a broader, systematic pattern.

Healthcare in Ukraine is not just collateral damage but increasingly a battlefield. These attacks represent not only a humanitarian crisis but a direct challenge to international law, civilian protection norms, and the resilience of national infrastructure under siege.

Equally alarming is the growing risk that attacks on healthcare may be becoming normalised. When hospitals are bombed and ambulances destroyed without legal or political consequence, a dangerous precedent is set: that healthcare workers and their patients can be treated as legitimate targets in war. This tacit acceptance threatens the core principles of international humanitarian law and undermines the legitimacy of the Geneva Conventions themselves. If left unchallenged, this erosion of norms could usher in a new era of impunity, where the protection of medical facilities is viewed as optional rather than inviolable.

Already, evidence from recent conflicts suggests a declining restraint among belligerents when it comes to safeguarding medical neutrality. The risk is not only legal but deeply practical: as trust in health systems erodes, civilians delay or avoid seeking care, worsening medical outcomes and increasing population displacement. Healthcare must not be seen as collateral damage—it must be defended as a cornerstone of humanitarian values and societal continuity. Reaffirming and enforcing protections for hospitals is not just a moral obligation; it is an urgent necessity to prevent the slide into a world where even the most basic sanctuaries of care are fair game in war.

The growing vulnerability of healthcare systems is not confined to active war zones. In countries not currently at war, like Germany, policymakers and medical leaders are increasingly sounding the alarm about the need to prepare hospitals for a range of future threats—including military conflict. In March 2025, Bavaria’s Health Minister Judith Gerlach called for a national emergency plan to ensure the continuity of medical care in the event of war. Citing Russia’s military posture and the potential weakening of transatlantic security guarantees, Gerlach emphasised that a functioning healthcare system is as vital to national defense as the armed forces themselves.

Echoing this, the German Medical Association (Bundesärztekammer) has urged the federal government to adopt a comprehensive “resilience strategy” for healthcare, warning that Europe can no longer treat major conflict as a remote or implausible scenario.

This call for hospital preparedness reflects a broader strategic reassessment in the face of geopolitical instability, hybrid warfare, cyber threats, and supply chain vulnerabilities. German medical experts have argued that health and security policy must be more closely integrated, noting that military tensions, cyber sabotage, and natural disasters all pose existential risks to healthcare infrastructure. Proposals include “crisis- and war-proofing” at least 100 hospitals nationwide, securing medical supply chains, and reinforcing digital infrastructure against foreign attacks. Other countries are already advancing on this front: Sweden, Norway, and Denmark have designated specific civilian hospitals to take on responsibilities in national health security.

These efforts illustrate a key lesson from Ukraine: the time to strengthen healthcare resilience is before a crisis begins. If healthcare is essential to national stability, then safeguarding it must become a central pillar of modern security strategy, whether in war or peace.

To ensure hospitals are no longer treated as soft targets in times of crisis, governments must adopt a comprehensive policy framework that treats healthcare as critical national infrastructure. This involves both practical investment and a reorientation of strategic priorities—bridging international humanitarian law and national security.

First, hospitals must be formally designated as strategic infrastructure. Just as military installations, energy grids, and communication systems are protected and prioritised, so too should hospitals be recognised as indispensable to the functioning of the state. This designation should serve as a basis for investment, planning, and crisis preparedness.

Second, governments must develop and fund dedicated hospital resilience strategies. These should include structural fortifications, blast-resistant retrofitting, and the relocation of intensive care and trauma units to protected zones. In regions vulnerable to conflict or disaster, infrastructure must be designed with disruption in mind—not as an afterthought, but as a baseline.

Third, essential utilities and logistics chains must be secured. Hospitals should be equipped with off-grid power sources, independent water supplies, and secure communication networks. Pre-positioned stockpiles of trauma kits, medications, and fuel can make the difference between a functioning hospital and a humanitarian collapse during prolonged emergencies.

Fourth, civil-military coordination must be institutionalised. Joint planning between healthcare and defense actors is essential to ensure medical facilities remain operational in crises. Examples from Nordic countries, where certain civilian hospitals are assigned national health security roles, provide useful templates.

Fifth, international humanitarian law must be enforced, not just endorsed. The Geneva Conventions prohibit attacks on healthcare facilities, but these prohibitions are only meaningful if violations are investigated and prosecuted. Governments should invest in evidence-gathering tools, such as satellite monitoring and digital forensics, and support international legal cooperation to hold perpetrators accountable.

Sixth, hospital protection must be incorporated into broader deterrence strategies. Planners must assume that healthcare infrastructure is a likely target. Diplomatic, legal, and strategic responses must be developed in advance to dissuade adversaries from testing international resolve.

Finally, governments must reframe hospital resilience as an element of national power. In a realist framework, the ability to absorb and recover from crisis is not a humanitarian luxury but a strategic necessity. Hospitals are at the center of that resilience. Protecting them is not simply an act of compassion and justice—it is an act of democratic statecraft.

Robert Schuett is co-founder and managing partner at STK Powerhouse, a global risk advisory firm. A former Defence civil servant, he also serves as Chairman of the Austrian Political Science Association and is a long-standing Honorary Fellow at Durham University.

Susanne Schuett is a senior executive at a Viennese outpatient mental health clinic. A psychologist by training, she holds the habilitation (venia docendi) in psychiatry from the Medical University of Vienna and serves on the advisory board of STK Powerhouse.

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