Publications

2020
Robert I.S. Macpherson and Frederick M. Burkle Jr. 11/2020. “Humanitarian Aid Workers: The Forgotten First Responders.” Prehospital and Disaster Medicine. Read PublicationAbstract

Humanitarian aid workers are an overlooked population within the structure of posttraumatic stress disorder (PTSD) research and assistance. This negligence is an industry-wide failure to address aid workers’ psychological health issues. The suspected numbers of death by suicide, diagnosed PTSD, depression, anxiety disorders, hazardous alcohol and drug consumption, emotional exhaustion, and other stress-related problems are impossible to quantify but are considered endemic. Tools for establishing organizational frameworks for mental health and psychosocial support are readily available. However, the capacity to implement this assistance requires the creation and practice of an open and non-judgmental culture, based on the realistic acceptance that aid work has become inherently dangerous. The possibility of developing a psychological problem because of aid work has increased along with the rise in levels of disease, injury, kidnapping, and assault. As a result, expressions of traumatic stress have become the norm rather than an exception. This commentary outlines the essential steps and components necessary to meet these requirements.

MPH P. Gregg Greenough, MD, Ravi Goyal, Ruwan Ratnayake, Fatma Rawashdeh, Raeda AbuAlRub, Nahla Al-Ali, Muhammad Fawad, and Mohammad Bani Han. 10/14/2020. “Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan.” JAMA Network Open. Publisher's VersionAbstract

Importance  The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management.

Objective  To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan.

Design, Setting, and Participants  This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019.

Exposures  Primary care delivered through a humanitarian organization since 2012.

Main Outcomes and Measures  The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes.

Results  In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month.

Conclusions and Relevance  During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.

accesscareprevalencehtndmsyrianrefugeesnojordan-jamanetopen-2020.pdf
Krzysztof Goniewicz, Mariusz Goniewicz, Frederick M. Burkle Jr., and Amir Khorram-Manesh. 10/2020. “The Impact of Experience, Length of Service, and Workplace Preparedness in Physicians' Readiness in the Response to Disasters.” Journal of Clinical Medicine.Abstract
With an increasing number of natural and man-made disasters, the need for preparedness in all levels of management is obvious. Among healthcare professionals responding to these emergencies, physicians are of particular importance due to their significant roles as leaders and frontline workers in minimizing morbidity and mortality of the affected population. This study analyses the preparedness of 549 physicians from all medical centers in Lublin, Poland to formulate their observations, suggestions, and recommendations concerning the improvement of the chain of response in disaster management. The results of this study show that the perceived preparedness of physicians for disaster management and response is not as high as it should be, and the majority of the respondents perceived their disaster preparedness insufficient. Training of physicians in disaster management and principles of disaster medicine is needed, by focusing on the specificity of rescue response to emergencies following disasters, and medical and non-medical aspects of the response with particular emphasis on a management approach covering all hazards.
theimpactofexperience.pdf
Phuong Pham, Vincenzo Bollettino, Patrick Vinck, Ariana Marnicio, Lea Ivy Manzanero, Mark Toldo, Rachel Dickinson, Alexis Smart, and Evan Bloom. 10/2020. “Network Analysis of Actors Working to Support Disaster Preparedness and Resilience in the Philippines”.Abstract
The Harvard Humanitarian Initiative (HHI) partnered with Root Change to conduct a network analysis of actors working to support disaster preparedness and resilience in the Philippines. The study design is modeled after a summative phase external evaluation that HHI conducted in 2016-2017 on the START Network’s Disasters and Emergency Preparedness Program (DEPP). Network analysis techniques applied in this evaluation have been adapted from the DEPP work to analyze the disaster resilience network in coastal Bangladesh under the Resilient Communities Program. In this report, we present the network analysis and methods used. We also detail findings and recommendations for HHI and other in-country partners about how these results can inform programs to strengthen disaster resilience and climate change in the Philippines.
ph_drr_network_analysis_hhi_2020.pdf
Amir Khorram-Manesh and Frederick M. Burkle Jr. 10/2020. “Sustainability Editorial Disasters and Public Health Emergencies-Current Perspectives in Preparedness and Response.” Sustainability. Read PublicationAbstract

Disasters and public health emergencies are inevitable and can happen anywhere and anytime. However, they can be mitigated and their impacts can be minimized by utilizing appropriate measures in all four different phases of disaster management, i.e., mitigation and prevention, preparedness, response, and recovery. Several factors are crucial for achieving successful disaster management. In the mitigation and preparation phase, all risks should be reviewed and new ones should be added and analyzed carefully to propose proper solutions and plans. In the preparedness phase, the ability and knowledge of each organization and all individuals in the management system should be tested and evaluated to ensure good readiness in responding to an emergency. Furthermore, plans should be available at all levels of the emergency chain of action to cope with all issues in the response and recovery phases [1,2]. This Issue of Sustainability aimed to cover emergency and public health crisis management from a multiagency perspective, by discussing lessons learned, introducing new ideas about flexible surge capacity, and showing the way it can practice multiagency collaboration.

Frederick M. Burkle Jr., David A. Bradt, Joseph Green, and Benjamin J. Ryan. 10/2020. “Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part II: The Database.” Prehospital and Disaster Medicine. Read PublicationAbstract

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

Frederick M. Burkle Jr., David A. Bradt, and Benjamin J. Ryan. 10/2020. “Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part I: The Concept.” Prehospital and Disaster Medicine. Read PublicationAbstract
This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.
Krzysztof Goniewicz, Frederick M. Burkle Jr., and Amir Khorram-Manesh. 9/2020. “The gap of knowledge and skill – One reason for unsuccessful management of mass casualty incidents and disasters.” American Journal of Emergency Medicine. gap of knowledge and skill.pdf
Sonny Patel, Omar Moncayo, Kristina Conroy, Doug Jordan, and Timothy Erickson. 9/2020. “The Landscape of Disinformation on Health Crisis Communication During the COVID-19 Pandemic in Ukraine: Hybrid Warfare Tactics, Fake Media News and Review of Evidence.” Journal of Science Communication. Read PublicationAbstract

The COVID-19 pandemic has impacted the world in ways not seen since the 1918–1920 Spanish Flu. Disinformation campaigns targeting health crisis communication during this pandemic seek to cripple the medical response to the novel coronavirus and instrumentalize the pandemic for political purposes. Propaganda from Russia and other factions is increasingly infiltrating public and social media in Ukraine. Still, scientific literature has only a limited amount of evidence of hybrid attacks and disinformation campaigns focusing on COVID-19 in Ukraine. We conducted a review to retrospectively examine reports of disinformation surrounding health crisis communication in Ukraine during the COVID-19 response. Based on the themes that emerged in the literature, our recommendations are twofold: 1) increase transparency with verified health crisis messaging and, 2) address the leadership gap in reliable regional information about COVID-19 resources and support in Ukraine.

Asha Devereaux, Holly Yang, Gilbert Seda, Viji Sankar, Ryan C. Maves, Navaz Karanjia, John Scott Parrish, Christy Rosenberg, Paula Goodman-Crews, Lynette Cederquist, Frederick M. Burkle Jr., Jennifer Tuteur, Chiara Leroy, and Kristi L. Koenig. 9/2020. “Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California.” Disaster Medicine and Public Health Preparedness. Read PublicationAbstract

Successful management of an event where healthcare needs exceed regional healthcare capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams manage the allocation of scarce resources during COVID-19 are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of healthcare care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Utilization of our regional healthcare coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required.

Ann M. Nguyen, Attila J. Hertelendy, Melinda Ashton, and Frederick M. Burkle Jr. 9/2020. “Workflow Solutions for Primary Care Clinic Recovery During the COVID-19 Pandemic: A Primer.” Journal of Public Health Management and Practice. workflowpatternsforofficesincovid.pdf
Alan Parnell, Krzysztof Goniewicz, Amir Khorram-Manesh, Frederick M. Burkle Jr., Ahmed Al-Wathinani, and Attila J. Hertelendy. 8/2020. “COVID-19 a health reform catalyst? -Analyzing single-payer options in the U.S.: Considering economic values, recent proposals, and existing models from abroad.” Journal of Hospital Administration.Abstract

The United States has continued to face severe health coverage and spending challenges that have been attributed to a fragmented multi-payer and fee-for-service delivery system which has become even more exposed by the COVID-19 pandemic. Legislators and healthcare professionals have tried to answer the challenges faced by the U.S. health system through the introduction of several state and federal proposals for a "Medicare-for-all" like system, which have failed to be adopted likely due to the lack of consideration for free-market economic values. Looking to existing models abroad can provide the U.S. with different ways to understand how to achieve the benefits of single-payer models with universal coverage while maintaining the integrity of free-market values. The health systems in wealthy, industrialized countries are closely referenced in this article because of the variation of methods in which each achieves a single-payer/universal coverage model as well as the contrast in their health outcomes compared to that of the U.S. The biggest considerations for any reform effort to achieve an efficient single-payer system with universal coverage is the maintenance of private health insurers and the degree to which expanded government influence would be accepted. The future state of health care remains uncertain and unstable as a result of the COVID-19 pandemic, therefore a window of opportunity exists now for leveraging this uncertainty to achieve reform.

COVID-19 a health reform catalyst.pdf
Attila J. Hertelendy, Gregory R. Ciottone, Cheryl L. Mitchell, Jennifer Gutberg, and Frederick M. Burkle Jr. 8/2020. “Crisis Standards of Care in a Pandemic: Navigating the Ethical, Clinical, Psychological, and Policy-making Maelstrom.” International Journal for Quality in Health Care.Abstract

The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options, and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting Crisis Standards of Care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation, and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually-focused clinical decisions) which form their moral compass.

crisis_standards_of_care_in_a_pandemic.pdf
Amir Khorram-Manesh, Eric Carlström, Attila J. Hertelendy, Krzysztof Goniewicz, Carter B. Casady, and Frederick M. Burkle Jr. 8/2020. “Does the Prosperity of a Country Play a Role in COVID-19 Outcomes?” Disaster Medicine and Public Health Preparedness.Abstract

Objective: This study aims to clarify the association between prosperity and novel coronavirus disease 2019 outcomes and its impact on the future management of pandemics.

Methods: This study is an observational study using information from two online registries. The numbers of infected individuals and deaths and the prosperity rank of each country were obtained from worldometer.info and the Legatum Institute’s Prosperity Index, respectively.

Results: There is a combination of countries with high and low prosperity on the list of coronavirus disease 2019 infected countries. The risk of the virus pandemic seems to be more extensive in countries with high prosperity. A Spearman’s rho test confirmed a significant correlation between prosperity, the number of coronavirus disease 2019 cases, and the number of deaths at the 99% level.

Conclusion: New emerging pandemics affect all nations. In order to increase the likelihood of successfully managing future events, it is important to consider pre-existing health security, valid population-based management approaches, medical decision-making, communication, continuous assessment, triage, treatment, early and complete physical distancing strategies, and logistics. These elements cannot be taught on-site and on occasion. There is a need for innovative and regular educational activities for all stakeholders committed to safeguarding our future defense systems concerning diagnostic, protection, treatment, and rehabilitation in pandemics as well as other emergencies.

prosperityandcovid-19_dmphp.pdf
Emmanuel Tronc and Anaïde Nahikian. 7/21/2020. “Ukraine - Conflict in the Donbas: Civilians Hostage to Adversarial Geopolitics”. Read PublicationAbstract
Since 2014, the war in the Donbas, fueled and sustained by local and regional political priorities, has inflicted a heavy burden of civilian death, injury, displacement, destruction, and lasting trauma. As the conflict continues, the people of Donbas are more isolated than ever from the rest of their country, subjected to discrimination and stigmatization by both the Ukrainian authorities and separatist leaders. Today, a confluence of factors continues to drive conflict in Eastern Ukraine. Triggered by the 2013 Euromaidan protests in Kyiv, the rupture between the post-Maidan Ukrainian government and local elites in the Donbas over aspirations of independence and self-determination highlighted the growing schism between those with Russian-oriented ambitions and those supporting the new Ukrainian regime. As clans, warlords, and oligarchs within Ukraine fight for political influence and financial gain, Russian influence continues to destabilize the Westward-leaning Ukrainian authorities in Kyiv, reinvigorating the enduring geopolitical rivalry between Russia and the West. Humanitarian operations in Eastern Ukraine are also under significant pressure by the separatist authorities. Agencies struggle to bridge the gap between critical needs and their response capacity, while being forced to rely almost exclusively on local organizations. In the process of humanitarian and access negotiations, agencies must guard against the instrumentalization of aid, the blurring of lines between political, military, and relief operations, and an ever-shrinking humanitarian space. What drives this protracted conflict? How have global politics and local agendas contributed to sustaining a “frozen” conflict at the expense of communities and in the interest of asserting nationalist independence at all costs? How have the hopes of local communities in the Donbas withered over time, as they navigate the dissonance in geopolitical rhetoric and their lived reality? What avenues exist for reconciliation and unity amidst this violent divisiveness? This report explores these questions and offers reflections based on more than 250 interviews undertaken during two field visits to Ukraine, in both government and separatist-controlled areas, and one visit to Russia, between November 2019 and January 2020. It also draws on an extensive desk analysis of relevant literature to complement the findings of these interviews and consultations.
Frederick M. Burkle Jr. 7/2020. “Ahmadreza Djalali, MD, PhD is Dying.” Prehospital and Disaster Medicine. ahmadreza_djalali_md_phd_is_dying.pdf
Krzysztof Goniewicz, Beata Osiak, Witold Pawłowski, Robert Czerski, Frederick M. Burkle Jr., Dorota Lasota, and Mariusz Goniewicz. 7/2020. “Bioterrorism Preparedness and Response in Poland: Prevention, Surveillance, and Mitigation Planning.” Disaster Medicine and Public Health Preparedness.Abstract

Objectives: Biological weapons are one of the oldest weapons of mass destruction used by man. Their use has not only determined the outcome of battles, but also influenced the fate of entire civilizations. Although the use of biological weapons agents in a terrorist attack is currently unlikely, all services responsible for the surveillance and removal of epidemiological threats must have clear guidelines and emergency response plans.

Methods: In the face of the numerous threats appearing in the world, it has become necessary to put the main emphasis on modernizing, securing, and maintaining structures in the field of medicine which are prepared for unforeseen crises and situations related to the use of biological agents.

Results: This article presents Poland’s current preparation to take action in the event of a bioterrorist threat. The study presents both the military aspect and procedures for dealing with contamination.

Conclusions: In Poland, as in other European Union countries fighting terrorism, preparations should be made to defend against biological attacks, improve the flow of information on the European security system, strengthen research centers, train staff, create observation units and vaccination centers, as well as prepare hospitals for the hospitalization of patients—potential victims of bioterrorist attacks.

bioterrorism_preparedness_and_response.pdf
Frederick M. Burkle Jr. 7/2020. Robert Fox Interview with Frederick M. Burkle on Population-based Triage Management.Abstract
Interview: At first sight, Population-based Triage, PBT for short, isn't the most enticing social formula-but it may be the key to how the UK manages the next stages of the current Corona quagmire-and prepare for the next one, when and not if it happens. It could, and probably should, become standard operating procedure in public health population-based management decisions in the outbreak of widespread pestilence and disease. We need that new Public Health Strategy now. Under the PBT plan the population as a whole is treated to the triage technique familiar in accident and emergency, and battlefield medicine. Medical and rescue teams concentrate on treating the salvageable in preference to those most likely to die. "Traditional health care systems care systems care for patients individually, while public health is caring for an entire population," says Professor Frederick Burkle, Senior Scholar and Scientist of Public Health at Harvard. He published his plan for a population-based approach to pandemic in 2006. It was used in the major desk-top exercise by Public Health England for tackling a major influenza pandemic, Operation Cygnus, in 2016. The report partly adopted the professor's clear-eyed approach to running a major pandemic operation, but left many questions open. If they had been addressed in the present Covid crisis, thousands of lives might have bene saved. Much the same goes for Exercise Isis carried out by National Health Scotland in 2018, focused on a major outbreak of MERS (Middle East Respiratory Syndrome). The lessons of both exercises have been taken aboard, according to Matt Hancock, but as they say in Scots law, it looks like a case of not proven. Both the Cygnus and Isis reports of 2017 and 2018 cannot conceal the serious shortcomings in preparation against a major public health emergency. The Cygnus exercise, for instance concentrates on the role of the Local Resilience Forums in coordinating emergency services-yet the representatives of the eight LRFs were explicit about their lack of resources. The LRFs have proved vital since March, but they have no statutory powers and no funding. More ominously the Isis report for the Scottish Health flags up the lack of availability of protective equipment-PPE-for a nationwide viral outbreak. The problem of managing a workable Public Health Emergency strategy for this coronavirus crisis is brilliantly illustrated BBC1's drama documentary, The Salisbury Poisonings. It tells the real events of the attack by the nerve agent Novichok on the Skripals in Salisbury two years ago. The heroine is the Wiltshire Public Health Officer Tracy.
robertfoxinterviewonpopulationbasedmanagement_1.docx
Abdulrazzaq Al-Saiedi, Kevin Coughlin, Muslih Irwani, Waad Ibrahim Khalil, Phuong Pham, and Patrick Vinck. 6/2020. “English Version: "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"”.Abstract

This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq’s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq’s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

neverforget_eng3.pdf
Abdulrazzaq Al-Saiedi, Kevin Coughlin, Muslih Irwani, Waad Ibrahim Khalil, Phuong Pham, and Patrick Vinck. 6/2020. “الترجمة العربية (Arabic Version): "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"”.Abstract

This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq’s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq’s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

neverforget_ar3.pdf

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