Like Conflict Health? Consider Hiring Me.
For the last four years I have written Conflict Health while completing a Ph.D. in political science. Now that I have my doctorate, I am looking for a job in the D.C. area. If your organization could use a smart thinker with extensive research and writing experience, consider hiring me. Thanks and enjoy Conflict Health!
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I Finished My PhD! And You Should Hire Me.

by Christopher R. Albon on January 17, 2012

Phd

In 2008, I published the first post on a new blog called War & Health on hospital guards in Iraq. Over the next four years over 500 articles and posts have appeared on the site (now called Conflict Health). I have written about polio vaccinations in counterinsurgency, rebel health systems, humanitarian neutrality, and hundreds of other topics. My work on Conflict Health has taken me to locations around the world and even a few warships. I firmly believe that the process of researching and writing the posts on this site has been one of the most important parts of my graduate and professional education.

Today, just after Conflict Health’s four year anniversary, I am happy to make two announcements. First, a week ago I received my Ph.D. in political science from the University Of California, Davis. My dissertation research examined the determinants of health system destruction and reconstruction during and after civil wars. Second, I am looking for a job in the D.C. area. If your think tank, NGO, IGO, government agency, or consultancy could use a smart thinker with extensive research and writing experience, consider hiring me:

  • Over five years of self-directed research on armed conflict and public health (Writing Sample).
  • Written in major publications including TheAtlantic.com and ForeignPolicy.com (Writing Sample).
  • Launched a blog on armed conflict and health that is widely read by researchers and practitioners.
  • Extensive social media experience with over 600 blog posts and four years on Twitter.
  • Broad international living and research experience, including a year in South Africa.

Thank you all! And expect some great new posts in the coming days!

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Health Systems 101

by Christopher R. Albon on December 23, 2011

While health systems vary in the role of the private sector, the priority given to primary and specialized care, the level of access enjoyed by citizens, and a host of other characteristics, most health systems (particularly in less developed states) share a basic structure based on a hierarchical organization of health care provision. Most citizens’ primary point of contact with health systems is usually through health posts, health clinics, and health centers. Health posts are the smallest facility in many health systems. They are staffed with one or more nurses and provide basic medical services to small communities. Health clinics are larger than health posts and provide a wider range of primary health care services including community health, basic diagnostics, ambulatory and emergency care, immunizations, and pharmaceuticals. These facilities are often are staffed by a small number of nurses with regular visits from a doctor shared by multiple clinics. The largest sub-hospital facilities are health centers, offering a greater range of primary care services than clinics and are assigned one or more dedicated doctors. In urban areas, health centers can provide care to populations of around 50,000 (Westwood and Power 2007). Health posts, clinics, and centers are particularly common in rural areas, providing governments with an affordable means to expand health care access to underserved areas without the expense of a full hospital. In addition to providing health care, these facilities often play a critical part in health surveillance and data collection, from which health interventions are derived.

Minor urban areas are often served by a district hospital. These hospitals are responsible for offering a range of primary care services within their catchment area and are staffed by general practice doctors and other health workers. District hospitals are responsible for addressing the most common conditions. In addition, district hospitals often provide the laboratory services (e.g. blood and tissue tests) for nearby health posts, clinics, and centers.

Patients with conditions requiring specialized care are referred to regional hospitals. Regional hospitals are located in major urban areas and – like district hospitals – provide primary care for their local catchment area. However, regional hospitals are also responsible for providing secondary care services to large geographic regions. Therefore, in addition to general practitioners, regional hospitals are also staffed by pediatricians, surgeons, and other specialists. Regional hospitals often also provide other important health system functions. These additional functions can include health administration, medical education, and public health programs. A district hospital is “the powerhouse of the region” and a vital node in the national health system (Westwood and Power 2007, 215).

The heart of most health systems is located in the capital and major urban centers. These areas often receive a disproportionate share of the health system’s budget (Macrae 1995). In addition to having their own health clinics, centers, and district hospitals, these cities have other critical components of the health system. First, major urban areas contain the state’s tertiary care referral hospitals, housing the country’s sub-specialists medical professionals (e.g. cardiologists, oncologists, and neurologists). Not only are these health professionals often the sole providers of sub-specialized care in the country, they also have a central role in improving care nationally by driving research and innovation. Central hospitals are also key nodes of international partnerships with health professionals abroad through cross-national medical exchange programs and research projects. Thus, these facilities are a major source of knowledge, education, and capacity building.

Second, capitals contain the health system’s main administrative center: the Ministry of Health (MoH). The Minister of Health and his staff conduct unglamorous – yet critical – bureaucratic functions. They manage the distribution of resources and plan the organization of the health system. Furthermore, the ministry is the primary point of connection between the political leadership of the state and the health system. Finally, the organization is a point of contact between the domestic health system and the international health community.

The entire system is organized hierarchically. At the bottom are health posts, clinics, and centers. Patients requiring more specialized care or equipment are referred to district and regional hospitals. If these facilities cannot provide treatment, the patient is referred to a tertiary hospital. The number of facilities of each type becomes less numerous as patients move up the hierarchy. Liberia’s health system exemplifies this type of hierarchical organization. Before Liberia’s civil war, the country’s public and private health system included 761 health clinics and health centers, 25 county (district) hospitals, and a single tertiary referral hospital in the capital (Joint Needs Assessment Report 2004). The capital also contained the Ministry of Health and the country’s only medical school (International Medical Education Directory 2010).

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The Broadening And Deepening of Security

by Christopher R. Albon on December 20, 2011

What is human security? Here is a brief introduction. As the domain of security enlarged to incorporate new threats and actors, it increasingly overlapped with the field of development. The threats from poverty, environmental scarcity, famine, infectious disease and others began to be explored in both development and security communities. The growing intersection between the two was captured under the concept of human security. Broadly, human security formalized the belief that security studies should “shift from the state to the individual and should encompass military as well as nonmilitary threats” (King and Murray 2001-2002, 588-589).

The concept of human security first received widespread attention in 1994 when it appeared in the United Nation Development Program (UNDP) Human Development Report (HDR). While, as Axworthy (2001) points out, the idea that populations have certain security concerns and rights is old, the HDR is the first major attempt to push the concept into the mainstream development, foreign policy, and security communities. Under the UN’s definition, human security constitutes seven security dimensions: economic, food, health, environmental, personal, political, and community. This broad definition addressed many of the main concerns of vulnerable populations, but also made operationalizing the term troublesome for two reasons. First, the expansive domain covered by HDR’s definition of human security could offer little information on how the seven dimensions should be prioritized (Axworthy 2001). Should governments, international organizations (IGOs), and non-governmental organizations (NGOs) focus their limited resources on public health, peace-building, or economic development? Is infectious diseases or income inequality a greater threat to human security? Paris argues the vague and expansive definition of human security was encouraged by some parties, who found it a convenient avenue to argue their area of focus (health, environment, culture etc…) constituted a threat to the security of individuals and deserved greater mainstream attention (Paris 2001). This definition of human was security was “slippery by design” (Paris 2001, 88).

Second, the imprecision of HDR’s definition makes research into the human security of populations difficult. Allowing human security to include a set of vague dimensions, often with overlapping areas of concern, limits the ability to measure and study concepts in order to make policy recommendations. Under this definition “virtually any kind of unexpected or irregular discomfort could conceivably constitute a threat to one’s human security” (Paris 2001, 89).

King and Murray highlight the imprecision of HDR’s definition through a series of off-the-record interviews with politicians and government officials. The two authors find almost universal concern “that there existed no widely accepted or coherent definition of human security” (2001-2002, 591-592). The only consensus around the definition of human security seems to be an agreement to the lack there of. Before continuing, a selection of human security definitions is reviewed below.

While sharing the concerns of other scholars regarding the HDR’s definition, King and Murray develop a similar but operationalized concept. The authors propose that human security can be thought of as “generalized poverty”. In their framework, individuals experience generalized poverty anytime they fall below some established threshold in a central aspect of “human well-being” (King and Murray 2001-2002, 585). In this way, human security addresses only the more at-risk individuals who fall below some acceptable minimum standard in a vital area. For example, a family could be considered impoverished if their daily caloric intake is less than the recommended minimum. The central appeal of King and Murray’s definition is measurability. With the proper data and a set of thresholds for each domain of well being, it is theoretically possible to construct a quantitative index of human security. For this purpose King and Murray propose a measure they call Years of Individual Human Security (YIHS) defined as “the expect number of years of life spent outside the state of generalized poverty” (King and Murray 2001-2002, 595). The disadvantage of this approach is that King and Murray’s concept of well-being suffers from the same problems of broadness found in the HDR’s definition. The authors propose including “those domains of well-being that have been important enough for human beings to fight over or to put their lives or property at great risk” (King and Murray 2001-2002, 593). However, it is clear what each of these domains are and how they can be measured. The selection and number of the domains would have a significant effect on the outcome level of generalized poverty.

Mary Kaldor’s (2007) monograph offers another conceptualization of human security. Kaldor posits a new definition of security that “is about confronting extreme vulnerability not only in wars but in natural and man-made disasters…” (Kaldor 2007, 183) and a new definition of development that goes beyond improving standards of living to include “feeling safe on the streets or being able to influence political decision-making” (Kaldor 2007, 183). Based on these new definitions, she proposes five principles of human security. First, human security places human rights above all else. Second, the local population must consider a state’s political institutions legitimate. Third, human security operations must 1) work with international organizations, 2) create and enforce common rules, and 3) focus on coordination. Fourth, human security approaches must be bottom-up and decisions must be made in coordination with the local population. Finally, modern conflict does not follow borders thus they must be examined at the regional, rather than the state level. While an impressive contribution, for empirical researchers Kaldor’s approaches offer little advantage over the 1994 HDR’s definition. It is unclear how Kaldor’s human security could be operationalized, since it covers three levels of analysis: states, conflicts, and operations. Furthermore, the approach is simultaneously a set of threats to be addressed and ideals to be achieved.

Finally, Roland Paris (2001) argues that attempts to define human security suffer from an inability to separate causes and effect. Specifically, because human security has been defined so broadly, incorporating violence, famine, poverty, social marginalization, ill-health, and others it is impossible to identify a causal relationship between any socioeconomic factor and human security (Paris 2001, 93). Instead, Paris proposes a definition of human security as a category of security research “concerned with military and nonmilitary threats-or both to the security of societies, groups, and individuals” (Paris 2001, 100). This paper follows Paris’ approach to human security; as a class of security studies examining threats to populations rather than states. Thus, while the theory addresses threats to individuals, it does not claim to offer any comprehensive measures of society’s vulnerability.

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Civil Wars And Private Health Care Sectors

by Christopher R. Albon on November 30, 2011

Civil wars can create a boom for private sector health care providers. The destruction of the state health system during war creates a power-vacuum of health care provision, incentivizing private actors to establish themselves in domains previously the responsibility of the government. In Uganda and Colombia, this privatization was at least partially caused by a decrease in public-sector health worker salaries during the war to below subsistence levels. This forced health workers to supplement their income with private practices. The private sector boom was more pronounced in Lebanon. Much of Lebanon’s government health facilities were destroyed during the country’s civil war. The destruction created an opportunity for private health care providers to fill the void left by the crumbling public health system. After the war this system became the norm, with much of the population relying on a large private health sector and the government mostly relegated to the role of subsidizing the cost of private health care. Before the war only ten percent of the Ministry of Health’s budget was spent on caring for patients in private facilities, however by the late 1990s it had risen to 80 percent.

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Wartime Health Reconstruction: An Example

by Christopher R. Albon on November 26, 2011

Throughout their civil war, the Mozambican government continued to repair and build health facilities. During the first five years of major RENAMO activities (starting in 1982), 822 health units were destroyed by RENAMO while 567 were reconstructed by FRELIMO. FRELIMO was, in a very real sense, racing to build health facilities faster than they could be destroyed or forced to close. The struggle between the destruction and wartime reconstruction of the health system is apparent in the number of health facilities in Mozambique during almost a decade of war, shown in Figure 3.2. Before the start of major RENAMO operations in 1982, the rapid expansion of the health system that started in the pre-war era continued to increase the number of health facilities in the country. However, after 1982 the total number of each type of health facility stayed the same or decreased as RENAMO attacks and collateral damage took their toll on the health system.

Along with continuing to construct the health system, the government maintained a vigorous medical education program during the war. From 1976 to 1985, the Mozambican government trained thousands of health workers, including 569 medical aids, 818 midwives and maternal/child health nurses, 2181 nurses, 268 preventative medicine workers, 486 pharmaceutical personnel, 406 laboratory personnel, 76 health administrators, 384 specialized nurses, and 1,402 village health workers. In addition, around the same time 6,242 paramedical workers were trained. The training of these health workers represented a significant cost for the wartime government. The result of this training program during the first years of the war was that the number of health workers in semi-rural and rural areas increased from 8,163 to 10,593 between 1980 and 1984. While the number of health workers in these areas likely decreased as RENAMO stepped up its attacks after 1982, the numbers demonstrate the high priority the FRELIMO government gave the operations of the health system. In addition to training new health workers, the government invested in the improvement of its existing personnel. After the civil war made it impossible to train enough new health workers to provide child and maternal health, the Ministry Of Health started new education and training programs for the country’s existing health workers, including training medical technicians to conduct emergency obstetric surgeries and educating traditional birth attendants.

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Weak Institutions And Post-Conflict Health Reconstruction

by Christopher R. Albon on November 23, 2011

Weak government institutions can also negatively impact the coordination of international assistance in reconstruction efforts. The end of civil war often brings a surge of financial and technical assistance from foreign governments, NGOs, and IGOs. While this assistance is often a positive event — granting governments access to far more resource than domestically available — and while it is almost always eagerly accepted by post-conflict regimes, the influx of support can come with unintended pitfalls. The sheer number of organizations offering assistance can overwhelm governments. After Kosovo’s war, more than 400 organizations flooded into the country. In 1995, Rwanda’s post-conflict Ministry of Health had to manage 89 NGOs in the health sector alone. The responsibility to oversee and coordinate the myriad of organizations most often falls on the shoulders of the government bureaucracy. Many states would have difficulty effectively managing such a sudden and large increase in responsibilities even during peacetime. After having their capacity reduced by civil war, these institutions often have little chance of successfully managing the relief effort.

Post-conflict governments often face an imbalance of power between themselves and providers of international assistance. Crippled by war, government institutions lack the de facto authority or capacity to work with NGOs and IGOs in the reconstruction process as equals, much less as leaders. This is due in no small part to the large share of reconstruction funds coming from international donors. Near the end of the Mozambique’s civil war, much of the reconstruction funds were managed the European Union and UNHCR, and not by the Mozambican government. The more the government is dependent on the support of international donors for health financing, the more leverage those donors and the NGOs they support have in shaping national health policies. While NGOs have shown to be better equipped to ramp up services quickly than state institutions, a valuable capacity when operating in crisis environments, they are self-interested actors whose interests are not necessarily parallel to those of the government. Ideally, reconstruction funds would be channeled through the Ministry of Health, which would disperse them as part of a unified national strategy for health system reconstruction; however many post-war governments lack the capacity to do so.

When this happens, international donors often select and fund health efforts independent of any central coordinating body. The end result is a proliferation of disorganized health projects funded by international donors and operated by NGOs, each with their own small area of operation and with minimal coordination with any national reconstruction strategy. This “project-based” reconstruction is particularly likely when the regime lacks legitimacy in the eyes of the international community. During the early 1990s, Cambodia’s interim government was seen as lacking political legitimacy, leading many donors to sidestep state institutions and directly fund some seventy NGOs in the health sector, “some with little or no official recognition and no obligation to locally account for how resources were disbursed, this uncontrolled environment was, to take a common phase, a ‘free for all’”. A similar problem is seen in Somalia, where decades of ineffective government institutions created a uncoordinated project-based effort which placed more emphasis on short-term relief than long term health system reconstruction. Nowhere is this problem more apparent than in the statements of one health professional in Bosnia and Herzegovina who described international involvement in his country’s health reconstruction process this way:

The magic word that opened all doors was “project.” In those days, anyone with a modicum of self-respect had to have a project. Rushing to submit their project proposals, the experts would sometimes forget to change the name of the country in the project title and we would suddenly have to decide on a Breast Feeding Campaign in Moldavia or AIDS Prevention in Georgia. But, mistakes happen, no harm done. There were a lot of other projects, such as Doctors’ Associated against the Torture and International Physicians against Nuclear War (although we did not have one), and Role of Nurse in the Sequence of the Rape, and of course – anti-smoking projects. If somebody wanted to help but had no idea what to do, a non-smoking campaign always came in handy. We had at least a hundred anti-smoking actions of all sorts. Millions of dollars were spent, but to no avail. The locals still smoke. It does not matter that at this moment only 30% of the inhabitants of Bosnia and Herzegovina have a safe water supply (Simunovic 2007, 5).

The inability of weak institutions to manage a unified health reconstruction effort has significant detriments to health care delivery: health providers become more fragmented and the population becomes more dependent on health care directly from NGOs. In post-war Uganda this effect was dramatic. The Ugandan health system was bifurcated; the government became responsible for secondary and tertiary care while internationally funded NGOs provided primary care. This type of health care system fragmentation can lead to inefficiencies in the health care delivery. Thus, during post-conflict reconstruction, a critical component is the government’s capacity to integrate the myriad of international assistance efforts into the national health system.

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Brain Drain: A Short Literature Review

by Christopher R. Albon on November 9, 2011

Health worker flight, “brain drain”, often occurs during civil war — triggered by threats to personal safety. Attacks on the health system often take the form of targeting health workers. RENAMO frequently attacked health professionals in the Mozambique, both mutilating (Hanlon 1992) and killing them outright (Summerfield 1988). In Nicaragua, Contra rebels used a similar strategy, attacking and kidnapping doctors, health technicians, nurses, medical students, health educators and volunteers — often in rural areas (Garfield 1985, Garfield et al. 1987). Similar attacks were seen during Nepal’s civil war where health workers were harassed, threatened, and assaulted by both the Maoist rebels and government security forces (Devkota And van Teijlingen 2009).

Fear for their personnel safety often causes health workers — especially those working close active fighting — to abandon their posts (Brentlinger 1996). During the Ivorian civil war, many regions experienced a pronounced drop in health workers of all types. In country’s north, central, and west there was a decrease of 66 percent, 88 percent, and 88 percent of health workers during the conflict respectively (Betsi et al. 2006). This brain drain was most significant in doctors. One region saw a 98 percent reduction in the number of physicians, who fled to government held areas in the south or to other countries (Betsi et al. 2006). During the 1992 war in Bosnia and Herzegovina, two-thirds of health workers left their posts (Bagaric 2000). Areas with a Croat majority were particularly hard hit, the number of doctors before the war compared to after in Jajce, Fojnica, and Travnik dropped from 79 to 4, 37 to 1, and 137 to 18, respectively (Bagaric 2000). In Uganda, 50 percent of doctors and 80 percent of pharmacists left the country between 1972 and 1985, during a period when the country had experienced both an interstate and civil war (Dodge and Wiebie 1985). The result of this health worker brain drain is an inability to staff health positions to provide adequate care. Worse still, the training of a single health worker takes years — even decades. Replacing a lost generation of health professionals is a slow and difficult process.

Work Cited

Hanlon, Joseph. 1991. Mozambique: Who Calls the Shots? Indiana University Press.

Summerfield, D. 1988. “MOZAMBIQUE: HEALTH AND WAR.” The Lancet 331(8581): 360.

Devkota, Bhimsen, and Edwin R van Teijlingen. 2009. “Politicians in apron: case study of rebel health services in Nepal.” Asia-Pacific Journal of Public Health / Asia-Pacific Academic Consortium for Public Health 21(4): 377-384.

Brentlinger, Paula E. 1996. “Health sector response to security threats during the civil war in El Salvador.” BMJ 313(7070): 1470-1474.

Dodge, Cole P., and P. D. Wiebie. 1985. Crisis in Uganda: The Breakdown in Health Services. Pergamon.

Bagaric, I. 2000. “Medical services of Croat people in Bosnia and Herzegovina during 1992-1995 war: losses, adaptation, organization, and transformation.” Croatian Medical Journal 41(2): 124-40.

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When Rebels Become Governments: One Post-Conflict Health Example

by Christopher R. Albon on November 2, 2011

In June 1975, after a military coup in Lisbon, Mozambique achieved independence and FRELIMO took control of the government. The health care system FRELIMO inherited was small and dysfunctional. During the colonial period most health workers were Portuguese settlers and these Europeans started leaving en mass at independence. Within a month, 85 percent of Mozambique’s doctors had left the country. Despite FRELIMO’s attempts to stem the flight of European health workers with offers of Mozambican citizenship, the fledgling state was left with only 30 doctors in the entire country. This exodus left many hospitals and other health facilities abandoned or crippled by understaffing. The problem was particularly damaging in rural areas that were often isolated during the chaotic first few months of independence. Health care in these areas was often provided by untrained orderlies and by the remnants of FRELIMO’s liberation zone health care network.

The new Mozambican government also lacked a pool of skilled and semi-skilled workers they could draw upon to manage the health care system. There were six economists, two agronomists, and fewer than 1000 African high school graduates in the country. The lack of capable senior and middle level technocrats made it difficult for the government to manage the disorganized health system it took over at independence. Decision-making was often deferred to a small cadre of administrators with little room for outside opinion or flexibility.

Despite these difficulties, in July 1975 Mozambique nationalized health care and launched a major effort to transform the disparate collection of private, public, military, and missionary health facilities into a single effective health system. The new health system was to be guided by the Marxist principles of FRELIMO and the health policies started before independence. Health reforms focused on expanding health care to rural regions of the country where a majority of the population lived through primary and preventative health care programs). FRELIMO political leaders believed that the country’s political and economic future lay in improving the country’s largest industry: agriculture. More specifically, FRELIMO hoped a rapid expansion of Mozambique’s health system would improve the productivity of rural agricultural workers and thus the entire economy.

FRELIMO’s post-independence health reforms were based around the concept of primary health care, a doctrine giving priority to the provision of basic health services and preventative care over specialized and curative care. Primary health care was seen by FRELIMO as the only way the government could improve the health of the vast majority of the population that had previously been without any health care access. To accomplish this, FRELIMO radically increased health care spending: from 4.6 percent of the government’s budget to 9.7 percent only a year later. By 1981, government health spending would reach 11.9 percent.

FRELIMO’s focus on expanding health care was rooted in both political strategy and ideology. Even before independence FRELIMO enjoyed widespread support amongst the population. This support was a valuable resource during the guerilla war against the colonial Portuguese Army who “faced fighting in a hostile country against a people overwhelmingly antagonistic to them” (Walt and Cliff 1986, 149). Furthermore, during the war while FRELIMO did receive some support from abroad, it relied heavily on the population for information and supplies. The close connection between FRELIMO and the population during the war had a profound impact on the development of national health policy after independence. Furthermore, FRELIMO’s Marxist roots played a role in the high priority given to health. FRELIMO believed western capitalism and colonialism were the enemies of the Mozambican people, and that improvements in the new state’s health and education systems were the key to escaping that poverty (Robinson 2006).

The FRELIMO government’s focus on the well being of the population was responsible for a rapid expansion of the health system in the years before and at the start of the country’s civil war. Between 1975 and 1982, over 2000 nurses, 110 x-ray technicians, 290 pharmacists, 272 midwives, and 1011 village health workers were trained. Similar improvements were seen in health facilities. In roughly that same period, the government built 593 health posts, 161 health centers, 130 laboratories, and 80 stomatology departments. The government also instituted a national drug formulary to reduce the amount the government and patients spent on pharmaceutical products. Mozambique’s drug formulary was considered to be one of the country’s most important reforms and was credited for keeping pharmaceutical spending significantly lower than other developing states. The effect on the health of Mozambican citizens was significant. By 1980, 30 percent of the population had access to health care facilities, up from 7 percent in 1974. Furthermore, by the early 1980s Mozambique had the highest vaccination rates for children under the age of five years old in any African country.

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Houses Of God And Health

by Christopher R. Albon on October 27, 2011

With violence in Yemen quickly approaching a full-blown civil war, the New York Times has a piece out on the use of one Sana mosque as field hospitals:

In its early days, the field hospital was much less organized; doctors would trip over the wounded laid out on the stone floor. But the government’s continued reliance on lethal force has given the staff practice, and so the doctors and nurses move more easily around the small space now, practiced in the chaotic choreography of battlefield medicine.

“The most important thing is to be in the field of the injury — immediate care saves lives,” said Tarek Noman, a Western-educated doctor who conducts triage on the patients, to determine who needs to be treated first.

Religious institutions have a long history of sheltering medical facilities during conflicts. From Bastogne to Tahrir Square, churches and mosques have provided ideal locations for setting up field clinics. First, the open interiors of most religious buildings, used in more peaceful times for believers to gather, offers an excellent area to setup medical equipment. Second, the connection between religion and sanctuary makes religious building a natural destination for those needing help and protection. Third, the prominence (and often sheer size) of religious buildings means their location is often common knowledge amongst residents. Finally, religious institutions often have a strong norm of neutrality and protection from violence. Combatants are more likely to think twice about firing on a house of God than on an office building.

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