ON 2 April, the United States and Israel bombed the 106-year-old Pasteur Institute, targeting one of Iran’s oldest and most critical public health institutions. Established in 1920, the institute has long been central to vaccine production, infectious disease surveillance, and epidemiological research in the Middle East and beyond.
But this wasn’t simply a strike on a building. It was much larger than any single incident. It was a brazen attack on the infrastructure that sustains Iran’s public health. And it reflects a broader pattern in modern warfare, where the target is no longer just people, but the systems that keep them alive.
Disease has long been weaponised in war.
In 1346, during the Siege of Caffa, Mongol forces reportedly catapulted plague-infected corpses into a besieged city, turning epidemic disease into a siege tactic. Centuries later, in 1763, during the Fort Pitt smallpox incident, British officers are documented to have distributed blankets from a smallpox infirmary to Native American emissaries, an act widely interpreted by historians as an early attempt to wield disease as a weapon in a bid to wipe out entire populations. By the 20th century, this pattern became industrial. Between 1932 and 1945, the Japanese Unit 731 conducted large-scale experiments and deployed pathogens against civilian populations in China, transforming disease into an instrument of warfare.
Parallel efforts emerged elsewhere: The British government conducted secret biological warfare tests on Gruinard Island (1942–43); the United States developed its offensive biological weapons programme at Fort Detrick (1943–69), and the Soviet biological weapons programme (1928–91) expanded its capacity to produce massive quantities of weaponised agents.
Today, this logic operates differently. Rather than deploying pathogens directly, warfare increasingly targets the physical infrastructures and systems that prevent, detect, and treat disease. This shift has unfolded gradually, but remains endemic.
In Afghanistan, a 2015 US airstrike on a Médecins Sans Frontières hospital in Kunduz demonstrated how even clearly protected medical facilities can be struck in modern warfare, raising serious concerns under international humanitarian law. In Myanmar, both the military and armed groups have repeatedly targeted healthcare workers and facilities. The military government has faced consistent accusations of conducting airstrikes on medical facilities that result in dozens of deaths at a time.
In Pakistan, health workers, particularly those involved in vaccination campaigns, have been deliberately attacked for over a decade. When armed groups carried out a years-long campaign of death against Shi’a Hazara communities in Balochistan, they were accused of deliberately targeting health workers in their killing spree.
The decade-and-a-half-long war in Syria saw the governments of Syria, Russia, the United States, and several armed groups implicated in attacks on health facilities. The most egregious cases came from the government of Syria’s then-president, Bashar al-Assad, and its allies in Moscow. They were accused of conducting more than 601 airstrikes on at least 222 healthcare facilities in the first 11 years of fighting alone.
Repeated and serious attacks on healthcare may, in certain contexts, amount to the systematic targeting of the health system as a whole. This escalation is evident in recent conflicts. In Lebanon, between October 2023 and January 2025, 217 healthcare workers were killed, 177 ambulances were damaged, and at least 68 hospitals were directly attacked, alongside 237 strikes on emergency medical services. All by Israel. In Gaza, nearly 1,581 medical workers have reportedly been killed since October 2023. What was once exceptional has become routine. Sudan has seen more than 285 attacks on healthcare, killing at least 1,204 health workers and patients and wounding over 400 more since the conflict began in 2023. In 2025, an attack on a Saudi-funded maternity hospital in the city of El Fasher killed more than 460 patients and healthcare workers and dealt a massive blow to medical access for women and children in Darfur.
This transformation sits uneasily within existing legal frameworks. The Biological Weapons Convention governs the use of pathogens and toxins, while international humanitarian law prohibits attacks on hospitals, medical personnel, and objects indispensable to civilian life. Both remain essential. Yet neither fully captures a form of harm that is neither microbial nor incidental, but systemic.
In response to this gap, physicians writing in BMJ Global Health in August 2025 proposed a new term, healthocide, defined as the deliberate and systematic destruction of health systems as a method of warfare. Today, weaponising public health means dismantling the infrastructures that sustain health, from water and sanitation networks to pharmaceutical production and distribution chains. The growing integration of AI into military operations is only accelerating this shift, enabling the rapid identification and prioritisation of such systems at an unprecedented scale.
From infrastructure to illness
Recent events in Iran are a particularly visible example of this growing trend. Within a matter of weeks, the country’s health system has sustained widespread damage. According to official and humanitarian reports, at least 24 pharmaceutical factories, medical equipment companies, and distribution centres have been damaged, partially or completely. Around 296 healthcare, pharmaceutical, and emergency facilities have been pushed out of service. More broadly, more than 316 healthcare and emergency centres have been affected since late February.
Facilities such as Tofigh Daru – a major producer of specialised medicines, including cancer treatments, anaesthetic drugs, and medications for chronic and rare diseases – have been directly targeted. The destruction of its production and research units has removed critical capacity from an already constrained system. Individually, these incidents can be assessed as potential violations of international humanitarian law. Collectively, they point to something more structured: the degradation of a national health ecosystem.
What is being eroded is not only the ability to treat illness, but the capacity to prevent, detect, and contain it, turning manageable risks into systemic vulnerabilities over time.
The strike on the Pasteur Institute brings this into sharp focus. To damage such an institution is not simply to interrupt research. It is to degrade a century-long accumulation of scientific knowledge, field data, and institutional capacity.
Vaccine development pipelines are set back. Disease surveillance weakens. Early warning systems for outbreaks, including those with regional spillover potential, are degraded. The loss is not only national but regional, with implications for cross-border disease control and global health security. Established as one of the leading scientific institutions in the Middle East, the institute has long played a central role in infectious disease control and vaccine production, supplying vaccines to Afghanistan, Iraq, and Egypt, and contributing to major public health efforts such as smallpox eradication.
Immediately prior to the conflict, teams from the institute were deployed to Iraq for the detection and control of infectious diseases, while broader laboratory capacity in Iran was routinely supporting healthcare systems in western Afghanistan.
These effects are compounded by parallel strikes on pharmaceutical production and supply chains. Iran produces around 97% of its medicines domestically, yet a significant share of these rely on imported active pharmaceutical ingredients and key inputs. Damage to domestic production facilities, combined with disruptions in access to imported components, does not simply reduce output. It amplifies shortages across the entire system. Patients face delayed surgeries due to shortages of anaesthetic drugs, interrupted chemotherapy, and limited access to essential medicines. Even basic post-treatment medications are becoming harder to obtain. What is being eroded is not only the ability to treat illness, but the capacity to prevent, detect, and contain it, turning manageable risks into systemic vulnerabilities over time.
The quiet logic of systemic harm
The full impact becomes clearer when placed in context. Even before these attacks, Iran’s health system was operating under pressure. Sanctions formally exempt medicine, yet in practice, financial restrictions and compliance risks have created barriers across the supply chain. Transactions are delayed, procurement becomes uncertain, and access narrows.
Warnings had already been issued. Prior to the current escalation, professional bodies reported that Iran’s drug reserves could cover only two to three months, with around 800 medicines at risk of shortage. In such conditions, domestic production is not optional. It is essential. Facilities like Tofigh Daru form part of a fragile infrastructure that sustains access to treatment.
When that infrastructure is damaged, the effects cascade. Shortages intensify. Prices rise. Informal markets expand, often supplying counterfeit or substandard drugs. Access becomes uneven, shaped by resources rather than need. This is no longer a shortage. It is a systemic disruption of the conditions that make care possible.
Some analysts describe this as biological harm by indirect means. No pathogen is deployed. Yet the conditions in which disease spreads, and in which it cannot be treated, are actively produced.
At times, the logic is explicit. US President Donald Trump has spoken of bringing Iran “back to the Stone Age” by targeting its infrastructure. Such rhetoric may be dismissed as exaggeration. But infrastructure includes the systems that are essential to daily life: water, medicine, and health. To dismantle those systems is not only to destroy. It is to degrade the conditions of survival.
International humanitarian law recognises elements of this reality. It protects medical infrastructure and objects indispensable to civilian life. Deliberate attacks on such protected objects are war crimes. However, as Afghanistan, Gaza, Myanmar, Syria, and Sudan have shown, the perpetrators (the US, Israel, Russia, Myanmar’s military leaders, Bashar al-Assad, and Sudan’s warring parties and their backers) rarely face real consequences even for those heinous actions. When such acts are carried out on a widespread or systematic basis, they constitute crimes against humanity. Yet the framework remains fragmented. It evaluates individual acts, but struggles to capture the broader strategy that connects them.
Healthocide does not replace existing legal categories. It reframes how harm is understood, shifting the focus from incidents to patterns and from isolated targets to entire systems. There is precedent for this kind of conceptual shift. Terms such as genocide and apartheid emerged to describe realities that law could not yet fully articulate. Over time, they reshaped both legal interpretation and political accountability. Healthocide may be approaching a similar moment.
War is no longer only about killing or territory. It is increasingly about the long-term viability of societies. When the systems that prevent disease, treat illness, and sustain life are dismantled, the damage becomes structural.
If the law continues to treat these acts as isolated violations, it risks missing the transformation. And if we fail to name it, we risk accepting it.
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