Faith groups do more to promote "healthy timing and spacing of pregnancies"

The Reverend Cannon Kabana and his wife Damalie Kabanda talk to their congregation about the benefits of family planning at St. Mark's Church in Uganda. More religious institutions are promoting the "healthy timing and spacing of pregnancies to their members. Photo: Mona Bormet, Christian Connections for International Health.

This was originally published on Oct. 31, 2018 on Global Health TV.

The role of religious organizations in promoting and advocating for voluntary modern methods of family planning – once met with skepticism or derision — is gradually gaining more acceptance both in the religious and secular worlds. However, the faith-based community still does not get significant funding for family planning (or global development more broadly) despite a growing consensus that faith-based organizations (FBOs) are vital and trusted development partners at the community level. 

“When family planning is positioned primarily as a major public health contributor to improved maternal, child, and family health, the trend has clearly been for growing support for family planning in most religious communities,” said Ray Martin, who was executive director of Christian Connections for International Health(CCIH), a membership network of faith and secular organizations that promote global health and wholeness from a Christian perspective (full disclosure: I am a board member of CCIH). “When family planning was seen as a tool for old-style versions of population control, it was harder to marshal Christian support.” 

Breastfeeding becomes controversial again even through breast is still best

A woman breastfeeds her child while waiting for health services outside a health center in Nampula, Mozambique.  Copyright 2017 Arturo Sanabria, Courtesty of Photoshare

This was originally published on Sept. 25, 2018 on Global lHealth TV.

Breastfeeding — one of the most documented and proven best practices in global health — has become controversial again.

In the mid-1970s, Swiss-based Nestlé corporation was accused of unethical methods of marketing infant formula over breast milk to poor mothers in developing countries. Legal challenges to these practices by Nestlé and other companies led to a boycott of Nestlé. This led to the 34^thWorld Health Assembly adopting an International Code of Marketing of Breast Milk Substitutes in 1981. Three years later, Nestlé agreed to the code, and the boycott ended.

In May, the U.S. delegation to the World Health Assembly shocked other delegates when they tried to water down a resolution to promote breastfeeding and limit misleading marketing of infant formula. When that failed, according to The New York Times, they threatened Ecuador, the sponsor of the resolution, with trade sanctions and withdrawal of military aid. Russia introduced a similar measure and it was ultimately approved in a slightly altered form that was supported by the U.S. The U.S. ambassador to Ecuador, Todd Chapman, later called reports that the U.S. threatened Ecuador “patently false and inaccurate.” 

Stepping up fight against malaria in Asia to protect gains made everywhere

A mother from Myanmar and her child waiting to be seen at the Wang Pha clinic near Mae Sot, Thailand, near the Thai–Myanmar border. Her son has symptoms of malaria. Photo: Mark Tuschman 

This was originally published on Global Health TV on August. 31, 2018

The future of malaria in sub-Saharan Africa and everywhere else may depend on whether we can stop drug resistant malaria in five countries of the Greater Mekong subregion of Southeast Asia and whether new vaccines will work against it.

Great progress has been made against malaria on both continents. The incidence rate of malaria has decreased 18% globally between 2010 and 2016, according to the World Health Organization. The WHO South-East Region recorded the largest decline (48%) followed by the African Region (20%). Malaria cases worldwide have fallen from 237 million in 2010 to 216 million in 2016.

Two years ago, Sri Lanka became the first country in the region to eradicate malaria. Six more countries (Bhutan, China, Malaysia, Nepal, South Korea, and Timor-Leste) are on track to eradicate it by 2020 and the other 15 nations are targeting 2030. But a few of those 15 countries are struggling – malaria cases increased in six of them in 2016. India has the third largest burden of malaria in the world, accounting for 89% of malaria cases in the Southeast Asia Region.

“We’ve made extraordinary progress in the Asia-Pacific Region,” says Dr. Ben Rolfe, CEO of the Asia Pacific Leaders Malaria Alliance based in Singapore. “Malaria has been halved, and then halved again. Even Myanmar has made extraordinary progress in the most difficult of circumstances. The downside is that we have only bitten off the easy fruit. We are now getting down to dealing with remote communities with very little access to health services. It gets exponentially harder to reach those places.”

New book "Factfulness" asserts that world is much better than most believe

This was originally published on Global Health TV on August 6, 2018.

I first saw Hans Rosling deliver a presentation on facts and fiction on global health in New York in 2010. Like many of his fans, I was swept away by his stunning visual presentations of data, his charming Nordic folksiness and his ability to shed light on some glaring misconceptions of global health and development that he has been working to rectify the last two decades.

He was shocked to discover that people get basic facts on population, health and development wrong, and not just the general public but also highly educated people, even at the World Economic Forum in Davos and Nobel laureates. So this Swedish professor of global health set out to educate people, primarily through his TED talks, which have been viewed more than 35 million times (check out “Let my dataset change your mindset” and “How not be ignorant about the world”), to such an extent that he became a nerdy global health rock star.

In September 2015, Hans and his son Ola Rosling and daughter-in-law Anna Rosling Rönnlund decided to write a book to explain why people do not see the world as it really is, and why we get so many basic facts so wrong. Five months later, he received a diagnosis of incurable pancreatic cancer, and was told he had two or three months to live. He threw himself into finishing this book to such an extent that he was going over printed copies of the latest draft from his hospital bed in the days before he died in February 2017.

Trump's expansion of Global Gag Rule sows chaos in global health

One of Donald Trump’s first acts as U.S. president was the re-imposition of the Global Gag Rule (GGR), also called the Mexico City Policy, a policy that denies healthy options to women and girls, not just safe abortion and contraception but potentially all areas of global health. 

Trump changed its name to “Protecting Life in Global Health Assistance,” but most global health advocates call it the Global Gag Rule because it silences health providers from providing comprehensive reproductive health options to women and girls.

The global gag rule is a failed, outdated and deadly policy,” writes Serra Sippel, the president of the Center for Health and Gender Equity (CHANGE), in the comprehensive new report Prescribing Chaos in Global Health: The Global Gag Rule from 1984 to 2018.

“Throughout this report, CHANGE seeks to document the breadth of the GGR’s impacts on civil society and health systems. For example, CHANGE provides evidence that the GGR under President George W. Bush had consequences outside family planning programs, and that it adversely impacted a wider range of health services provided by foreign NGOs. Some of these impacts were mitigated when President Barack Obama rescinded the policy, but the harmful effects have been shown to linger, particularly as each iteration has become more oppressive, culminating now with the Trump GGR.” 

The policy is having exactly the effect the Trump Administration intended it to have – women are losing health services, programs are being down-sized or closed and advocacy work disrupted. Because of poor communication and miscommunication coming from the U.S. government and prime partners, the CHANGE report says, many organizations are over-interpreting the policy, and going further than they really need to go, out of fear of losing funding and alienating an important donor (the U.S. government).

Brazil anti-tobacco forces score yet another victory but work is not yet done

ACT and their anti-tobacco coalition after an advocacy activity at the National Congress in Brasilia. Photo: ACT Promoção da Saúde

This was originally published on Global Health TV on May 30, 2018.

RIO DE JANEIRO, Brazil — This country has one of the best tobacco control programs in the world, resulting in a series of laws to protect non-smokers that the Brazilian government been put into place over 20 years. During this time, cigarette smoking has fallen by more than half.

And yet smoking is still a huge problem. Almost 15 percent of adult Brazilians still smoke, according to the Ministry of Health, causing 156,000 deaths per year. Every day, second-hand smoke kills seven Brazilians.

Though smoking has fallen dramatically among both men and women, there are still 21.5 million smokers in Brazil, which puts it in the top 10 countries in terms of number of smokers. And for every success achieved by the tobacco control movement – and there have been many – the cigarette industry fights back with all of the considerable resources at its disposal.

Obesity is rising almost everywhere, spurring a rise in chronic disease

This shows MyThali (My Plate), a new campaign of Arogya World to show urban Indian women a healthy diet in order to fight obesity and associated non-communicable diseases. Photo: Arogya World

This was originally published on Global Health TV on April 27, 2018.

The picture above shows the ideal, healthy plate of food for an urban adult woman in India – one cup of vegetable, one cup of rice, one and a half pieces of chapatti, one cup of protein (meat, lentil or sambar) and a half cup of yogurt. 

But too often this is not the typical meal of an Indian. Some people eat too much and become overweight or obese, particularly in urban areas. Obesity increases people’s likelihood of developing diabetes, to which Indians are predisposed. Meanwhile, some people, particularly rural adolescent girls, eat too little putting themselves at risk when they become pregnant at an early age.

So Arogya World, a U.S.-based organization committed to changing the course of non-communicable diseases (NCDs) in India, created MyThali (“My Plate”), inspired by the U.S. Department of Agriculture’s “My Plate” campaign and using the guidelines from India’s National Institute of Nutrition to encourage them to make healthier choices. Arogya World is aggressively implementing this campaign in workplaces across India.

Facing two water crises: Having enough water and ensuring it's safe to drink

A market vendor in Bamako, Mali buys Aquatabs water purification tablets for her shop from a Palladium sales promoter. The tablets are one of several solutions for ensuring safe water at point of use. Photo: David J. Olson

This was originally published on Global Health TV on March 29, 2018.

We talk about a world water crisis like there’s only one but there are really two. The first crisis we see playing out in Cape Town – the growing number of places that do not have enough water of any kind. The second crisis is ensuring that the water people do have is safe to drink.

The city of Cape Town has just dodged a bullet – at least for 2018. Day Zero -- the day when dams levels reach 13.5% of capacity and the taps are turned off – was originally expected to take place in April, then pushed back to July. Now it has been postponed to 2019. This video shows how Capetonians are dealing with the crisis.

The three-year long drought hasn’t ended but severe water rationing has helped postpone disaster. The combined levels of dams supplying Cape Town is down to 22.7%, according to the city’s water dashboard. Capetonians have been asked to limit their water use to 50 liters (13 gallons) per person per day, and many have risen to the occasion (as a point of comparison, the average U.S. resident uses 367 liters per day, or 100 gallons).

Unfortunately, Cape Town is not an anomaly: Fourteen of the world’s megacities now experience water scarcity or drought conditions, according to Ecolab’s Water Risk Monetizer. 

Mental health still grossly underfunded but there are glimmers of hope

A StrongMinds mental health facilitator (center) speaks with former patients in Uganda. StrongMinds has treated more than 25,000 Ugandan women for depression with group talk therapy. Photo: Kevin Di Salvo

This was originally published on Global Health TV on February 28, 2018.

The problem with mental health and substance abuse in Africa and other developing countries is not that awareness has not been raised about these huge contributors to the global burden of disability.

Annually since 2009, the World Health Organization (WHO) Mental Health Gap Action Programme has been meeting to scale up services for mental, neurological and substance use disorders.

In 2013, the World Health Assembly adopted the WHO’s Mental Health Action Plan 2013-2020, which is designed to provide guidance for national action plans in all resource settings.

And most notably in 2015, world leaders recognized the importance of mental health and substance abuse in the newly minted Sustainable Development Goals. Within Goal 3 (the health goal) of the 17 SDGs, there is a target for mental health and another target for substance abuse. Here are the Goal 3 targets.

So mental health has finally been given a hard-fought and much-deserved seat at the global health table. It just has not been given much money or resources.

Global contraceptive use rising but more progress needed to reach target

A DKT Nigeria counselor talks to a group of women in a low-income neighborhood of Lagos, Nigeria about their contraceptive options. Photo: David J. Olson

This was originally published on Global Health TV on January 30, 2018.

By July 2017, more than 309 million women and girls were using modern contraception in 69 focus countries identified by Family Planning 2020 (FP2020), a movement created in 2012 by four core partners, 38.8 million more than in 2012.

This information came out in FP2020’s annual report “The Way Ahead, 2016-2017,” released in December. It reported that use of modern contraception in these 69 countries from July 2016-July 2017 prevented 84 million unintended pregnancies, 26 million unsafe abortions and 125,000 maternal deaths. This is all great news.

It came with some less-than-great news. FP 2020 has set the goal of reaching 120 million new users in the eight years between 2012 and 2020 – or 15 million every year. By that measure, we should have reached 75 million new users by mid-2017, and 38.8 million is only 52% of that.

Clearly, we have a lot more work to do to reach the 120 million target.

For global health, 2017 was a year of progress, near triumphs and threats

A trained community health workers in Bangalore, India takes photos of an oral lesion with a mobile phone during an oral cancer screening. Cancer is growing everywhere in the world. Photo: Biocon Foundation, Courtesy of Photoshare.

This was originally published on Global Health TV on Jan. 2, 2018.

In looking back over my last 12 blog posts here at Global Health TV, it is clear that 2017 was a year of progress, near triumphs and threats to global health.

In September, I reported that great progress has been made against diseases and health conditions that kill us (like respiratory infections, diarrhea, neonatal preterm deaths and communicable diseases like AIDS and malaria) while new threats had emerged  that are generally less fatal — things like obesity and mental illness.

In particular, we have made progress against communicable diseases but now face a rising tide of non-communicable diseases (NCDs) like cancer, diabetes, hypertension and cardiovascular diseases, as I wrote at the beginning of 2017.  Cancer is growing almost everywhere in the world. For example, cervical cancer causes over 500,000 new cases every year, even though vaccination, early screening and treatment of precancerous lesions can prevent most cases.

Polio vaccine switchover: An untold success story in global health

Syed Latif, a polio vaccinator and activist, hands out polio information at the Mansehra Polio Resource Center in Mansehra, Khyber Pakhtunkhwa Province of Pakistan. Photo: Mansehra Polion Research Center.

This was originally published on Global Health TV on November 28, 2017.

In April 2016, something extraordinary happened in global health. Thousands of community health workers in more than 120 countries — from African villages to the Himalayas to the Pacific Islands — all mobilized and synchronized their efforts to switch from one oral polio vaccine to another. Any slip-ups could have resulted in creating more “vaccine-derived” poliovirus cases at a moment when we are down to our last few cases of polio.

The fact that many children receiving such oral vaccines were living in areas of high conflict and low development (which means low levels of health infrastructure) made the accomplishment all the more remarkable.

The feat was accomplished in a single day (each country was told to pick one day within a two-week period in April 2016 to make the change).

The story of this amazing synchronized switch constitutes an untold global health success story and can be told with the backdrop of the current number of wild poliovirus type 1 cases down to only 15 — 10 in Afghanistan and 5 in Pakistan. The polio eradication community had hoped that we would be down to zero by 2017. Now they are hoping it will happen in 2018.

Suelen and her family: A Brazil child health success story

Ricardo, Ana Luiza, Suelen and Luis Ricardo in their newly renovated home in Nova Iguaçu, Brazil. Ana Luiza has a successful food truck and is going to law school but still doesn't feel middle class. Photo: David J. Olson

This was originally published on Global Health TV on October 31, 2017.

NOVA IGUAÇU, Rio de Janeiro State, Brazil — In 2012, Suelen hit rock bottom. She was living in extreme poverty with her husband and young son in a dilapidated house with a roof that was leaking water. While she was pregnant with her second child, her husband left her. When that child, Ana Luiza, was born, she was sick with pneumonia and asthma.

Suelen was at her wit’s end. Every day was a struggle. She made a living selling empanadas out of a canvas tent here in this city of 800,000 about 40 minutes from downtown Rio de Janeiro. “I was working all the time every day just to pay for food for the next day,” said Suelen. “I didn’t think about the future, just how I was going to eat tomorrow.”

Today, the situation of the family is the reverse of what it was five years ago. The health and wealth of the family is thriving. They have a highly successful food truck (that is expanding to home delivery). The children are going to good schools. And Suelen is going to law school so she can defend the rights of other black women who are being oppressed.

10 lessons we've learned from AIDS that we can apply to chronic diseases

An assistant at the Etoug-Ebe Baptist Hospital, a subsidiary of the Cameroon Baptist Convention Health Services, takes a blood sample of a patient participating in the Novartis Access program to fight non-communicable disease. Photo: Anne Mireille Nzouanekeu

This was originally published on the Huffington Post on October 30, 2017.

Communicable diseases like HIV/AIDS and malaria have taken a terrible toll on Kenya and other African countries over the last 20 years. In 2010, an estimated 51,000 Kenyans died from AIDS but that number has declined steadily, to 36,000 in 2016. Kenya is now considered an HIV success story. The same is true in many other countries.

Now there is a new epidemic of non-communicable diseases (NCDs) that is rising just as the world is starting to get a handle on communicable diseases, according to the Institute for Health Metrics and Evaluation. The Institute reports that the largest contributors to the loss of healthy life are now high blood pressure, smoking, high blood sugar and excess body weight.

But Dr. Samuel Mwenda, who knows a thing or two about both epidemics, believes there are lessons we have learned in the fight against communicable diseases that can now be applied to NCDs. Mwenda is general secretary and CEO of the Christian Health Association of Kenya (CHAK), a network of Protestant health facilities in Kenya. CHAK now supports 46,000 people living with HIV with antiretroviral therapy, representing about 9 percent of the total number of patients nationally.

In 2015, CHAK turned its attention to NCDs: With the support of Novartis Access, it began offering a portfolio of 15 products to treat cardiovascular disease, diabetes, respiratory illness and breast cancer at a price to governments, NGOs and other institutional customers not to exceed $1.00 per treatment per month. Since then, Novartis Access has also started working in Cameroon, Ethiopia, Pakistan, Rwanda and Uganda.

Dramatic global health improvements save lives but new threats emerge

This was originally published on the Global Health TV on September 26, 2017.

Over the last decade, we’ve made great progress against diseases and health conditions that can kill people, especially children under 5, but because of political and budget challenges, we risk backsliding on those gains. And we’re facing a tsunami from health issues that do not always kills us – namely, obesity, conflict and mental illness – but cause poor health.

Those are my take-aways from two major reports that came out this month, one tracking how we are doing against the Sustainability Development Goals, particularly in global health, and the other a scientific study focused solely on global health.

“Goalkeepers: The Stories Behind the Data 2017,” a report from the Bill & Melinda Gates Foundation, was aimed at last week’s United Nations General Assembly. To draw attention to the report, the Gateses held a high-profile event featuring former President Barack Obama. The report touts the many global health advances that have been made but also cautions about the risks of complacency.

Initiatives to expand access to medicine on the rise, but need better evaluation

In Nairobi, Kenya, parents receive prescription medicines for their children as part of a free medical camp operated by Slums Information Development & Resources Centers. Photo: George Onyango, Courtesy of Photoshare

This was originally published on Global Health TV on August 31, 2018.

In the 1990s and 2000s, AIDS activists and other global health advocates started pressuring pharmaceutical companies to share their largesse with low- and middle-income countries (LMICs) by supplying critical medicines for free or at subsidized prices, especially for HIV/AIDS. The pressure was successful, and led to a series of access-to-medicine (AtM) initiatives.

The international community increasingly recognizes that the pharmaceutical industry must play a leading role in improving access to medicines. And apparently pharma companies themselves also acknowledge this responsibility, according to a study published in Health Affairs by a team of researchers at Boston University Department of Global Health. That study found that the number of these initiatives grew from 17 in 2000 to 102 in 2015. The researchers called this “clear evidence” that pharmaceutical companies had responded to calls to increase their commitment to improving access to medicines.

Most access-to-medicine initiatives are poorly evaluated but moves are afoot to change that

This was originally published on The Lancet Global Health Blog on August 11, 2017.

Two decades ago the World Health Organization and health activists were pressuring global pharmaceutical companies to launch more “access-to-medicine” (AtM) initiatives in low- and middle-income countries. The good news: That has started to happen. The bad news: Startlingly few of these initiatives have any idea what kind of impact they are making.

Those are some of the conclusions of a new study, published in Health Affairs in April. A team of researchers associated with the Boston University Department of Global Health discovered that the number of AtM initiatives from 21 companies had grown from 17 in 2000 to 102 in 2015 but they found published evaluations for only seven of them.

From those seven evaluations, the researchers found 47 articles that met their inclusion criteria for evidence, and all of them were published in peer-reviewed journals. They determined that 62 percent of these were low quality, 32 percent were very low quality and 6 percent were moderate quality. None of them were rated high quality.

The bottom line of the study: “Overall, our findings suggest that current efforts to evaluate the impact of industry-led access-to-medicines initiatives are inadequate.”

Teaching brain surgery in Africa: Compelling book reveals neglected area of health

Dilan Ellegala (left), the central character in "A Surgeon in the Village," supervising brain surgery in Tanzania. Photo: Tony Bartelme

This was originally published on Global Health TV on August 3, 2017.

“In early 2010 Bill Hawkins, then executive editor of the Post and Courier in Charleston, South Carolina, told me, ‘I met this crazy brain surgeon who opened a guy’s head with a wire saw in Africa. Check him out. Maybe we’ll send you to Tanzania.’ Not many reporters get such an invitation, but thanks to Bill, I was soon on my way.’”

So writes Tony Bartelme in “A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa,” an informative and highly engaging book about a neglected area of global health – the dearth of surgeons in low- and middle-income countries. The book, published in March, is based on hundreds of hours of interviews that the author conducted in the U.S. and during five trips to Tanzania between 2010 and 2015.

When I started reading this book, I approached it as an obligation – something I had to do to inform myself, and possibly my readers, about an area of global health I knew nothing about.

But to my great surprise, I not only found it informative, I enjoyed it. The book is written in short chapters and in more of a novelistic style than most pieces of non-fiction. What I thought would be a chore turned into a pleasure. Perhaps that is because Bartelme is an experienced journalist who knows how to tell a good yarn.

How to promote contraceptives to teens in Latin America? Don't be boring

DKT Health Counselor Victor Tapia Orijel (center, white shirt) and a group of high school students who attended his sex talk in the Iztacalco neighborhood of Mexico City. Photo: David J. Olson

This was originally published on the Huffington Post on August 1, 2017.

MEXICO CITY, Mexico — Health Counselor Victor Tapia Orijel starts his presentation almost like a stand-up comedian, humorously citing different situations in the reproductive life of a teenager, from first sexual relations to different contraceptive methods.

• “If you get horny in school or your best friend’s house, you need to carry condoms.”
•  “If you make a booty call, it’s obvious you need condoms."
• “If you drink a lot and then have a one-night stand and don’t remember if you used a condom or not, you should get emergency contraception and condoms.”

His audience was a roomful of 65 high school students in the Iztacalco delegation of Mexico City. They were entertained and educated at the same time.

“Most of these young people learned about sex from their friends,” said Orijel. “It is difficult for them to talk about sex with their family. The women are the least likely to talk to their families, due to the burden of machismo that we live with in Mexico.”

That lack of information is prevalent throughout Latin America and the Caribbean: Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. In Central America, 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.

Budget debates in US, UK could augur poorly for global health funding

This was originally published in Global Health TV on July 25, 2017.

Global health financing has not been in such jeopardy since the large investments in it started in 1991 – the year in which global health funding started an upward trajectory that moved higher in all but three years.

In particular, the rise of Donald Trump of the United States and Theresa May of the United Kingdom —the leaders of the two largest donor nations — have raised concerns about the prospects for development assistance broadly, and global health specifically.

In 2016, development assistance for health (DAH) reached $37.6 billion, eking out a miniscule 0.1% increase from 2015 that followed a pattern of little growth since 2010 (DAH grew 11.4% annually from 2000 to 2010 but only 1.8% since 2010), according to “Financing Global Health 2016,” published by the Institute for Health Metrics and Evaluation in April. DAH peaked at $38 billion in 2013, dropped to $36 billion in 2014 and has recovered slightly in the two subsequent years. This infographic provides a snapshot.

The U.S. and the U.K. have been the two top contributors to DAH but both countries have political environments that have called into question their future commitments to foreign aid and global health.

Health workers, facilities under attack in 23 nations; UN accused of inaction

This hospital was damaged by clashes during a 79-day curfew from late 2015 to early 2016 in the city of Cizre in southeastern Turkey. Photo: Physicians for Human Rights.

This was originally published on Global Health TV on May 23, 2017.

In 2012, two Pakistani health workers were out vaccinating children against polio when they were both shot by extremists. One of them died. The other, shot in the leg, had 11 metal rods inserted into his leg and was hospitalized for three months.

In November, I met this remarkable man named Latif (his surname is withheld to protect his security). He is now fully recovered and back to work on the polio vaccination campaign. He told me he never considered giving up. Pakistan reported only two cases of wild poliovirus in 2017 as of May 17 and Latif is determined to see the polio campaign through to the end.

The attack on Latif is only one example of a tragic phenomenon that is not getting better – violence against heath workers and health facilities. In 2016, the extent and intensity of such violence “remained alarmingly high,” according to a new report released by the Safeguarding Health in Conflict Coalition.” The report also found that accountability for committing these attacks remains inadequate or non-existent.

The violence isn’t always perpetrated by terrorists. Sometimes it is committed by the police or the country’s military — institutions that should be ensuring tranquility.