Editorial / The Lancet – 2004-11-05 09:52:09

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LONDON (October 29, 2004) — The present conflict in Iraq signals a contrast of paradoxical proportions. The Iraqi people, their interim government, and their largely US and British occupiers are preparing for landmark elections early in the new year. Yet a ruthlessly violent insurgency is successfully destabilising these arrangements, murdering foreign civilians and Iraqi law enforcement officers in the most brutal ways imaginable, and exploiting the world’s media in doing so.

Amid this deep national uncertainty, it is hard to judge what is happening among Iraqis themselves. This week The Lancet publishes the first scientific study of the effects of this war on Iraqi civilians.

In a unique US-Iraqi collaboration, Les Roberts and his colleagues report substantially more deaths in Iraq since the war began than during the period immediately before the conflict. Much of this increased mortality is a consequence of the prevailing climate of violence in the country, and many of the civilian casualties that are described were attributed to the actions of coalition forces. These findings (and the tentative countrywide mortality projections they support) have immediately translatable policy implications for those charged with managing the aftermath of invasion.

The research we publish today was completed under the most testing of circumstances — an ongoing war. And therefore, certain limitations were inevitable and need to be acknowledged right away.

The number of population clusters chosen for sampling is small; the confidence intervals around the point estimates of mortality are wide; the Falluja cluster has an especially high mortality and so is atypical of the rest of the sample; and there is clearly the potential for recall bias among those interviewed.

This remarkable piece of work represents the efforts of a courageous team of scientists. To have included more clusters would have improved the precision of their findings, but at an enormous and unacceptable risk to the team of interviewers who gathered the primary data.

Despite these unusual challenges, the central observation — namely, that civilian mortality since the war has risen due to the effects of aerial weaponry — is convincing.

This result requires an urgent political and military response if the confidence of ordinary Iraqis in the mostly American-British occupation is to be restored.

Roberts and his colleagues submitted their work to us at the beginning of October. Their paper has been extensively peer-reviewed, revised, edited, and fast-tracked to publication because of its importance to the evolving security situation in Iraq. But these findings also raise questions for those far removed from Iraq — in the governments of the countries responsible for launching a pre-emptive war.

In planning this war, the coalition forces (especially those of the US and UK) must have considered the likely effects of their actions for civilians. And these consequences presumably influenced deployments of armed forces, provision of supplies, and investments in building a safe and secure physical and human infrastructure in the post-war setting.

With the admitted benefit of hindsight and from a purely public health perspective, it is clear that whatever planning did take place was grievously in error. The invasion of Iraq, the displacement of a cruel dictator, and the attempt to impose a liberal democracy by force have, by themselves, been insuf- ficient to bring peace and security to the civilian population.

Democratic imperialism has led to more deaths not fewer. This political and military failure continues to cause scores of casualties among non-combatants. It is a failure that deserves to be a serious subject for research.

But this report is more than a piece of academic investigation. A vital principle of public health is harm reduction. But harm cannot be diminished by individual members of society alone. The lives of Iraqis are currently being shaped by the policies of the occupying forces and the militant insurgents.

For the occupiers, winning the peace now demands a thorough reappraisal of strategy and tactics to prevent further unnecessary human casualties. For the sake of a country in crisis and for a people under daily threat of violence, the evidence that we publish today must change heads as well as pierce hearts.

— Richard Horton The Lancet, London NW1 7BY, UK

Report Summary
Background: In March, 2003, military forces, mainly from the USA and the UK, invaded Iraq. We did a survey to compare mortality during the period of 14·6 months before the invasion with the 17·8 months after it.

Methods: A cluster sample survey was undertaken throughout Iraq during September, 2004. 33 clusters of 30 households each were interviewed about household composition, births, and deaths since January, 2002.

In those households reporting deaths, the date, cause, and circumstances of violent deaths were recorded. We assessed the relative risk of death associated with the 2003 invasion and occupation by comparing mortality in the 17·8 months after the invasion with the 14·6-month period preceding it.

Findings: The risk of death was estimated to be 2·5-fold (95% CI 1·6-4·2) higher after the invasion when compared with the preinvasion period. Two-thirds of all violent deaths were reported in one cluster in the city of Falluja.

If we exclude the Falluja data, the risk of death is 1·5-fold (1·1-2·3) higher after the invasion. We estimate that 98000 more deaths than expected (8000-194000) happened after the invasion outside of Falluja and far more if the outlier Falluja cluster is included.

The major causes of death before the invasion were myocardial infarction, cerebrovascular accidents, and other chronic disorders whereas after the invasion violence was the primary cause of death.

Violent deaths were widespread, reported in 15 of 33 clusters, and were mainly attributed to coalition forces. Most individuals reportedly killed by coalition forces were women and children. The risk of death from violence in the period after the invasion was 58 times higher (95% CI 8·1-419) than in the period before the war

Interpretation: Making conservative assumptions, we think that about 100,000 excess deaths, or more have happened since the 2003 invasion of Iraq. Violence accounted for most of the excess deaths and air strikes from coalition forces accounted for most violent deaths.

We have shown that collection of public-health information is possible even during periods of extreme violence. Our results need further verification and should lead to changes to reduce non-combatant deaths from air strikes.