Elsevier

The Lancet

Volume 364, Issue 9448, 20–26 November 2004, Pages 1857-1864
The Lancet

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Mortality before and after the 2003 invasion of Iraq: cluster sample survey

https://doi.org/10.1016/S0140-6736(04)17441-2Get rights and content

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 100000 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.

Published online October 29,2004 http://image.thelancet.com/extras/04art10342web.pdf

Introduction

The number of Iraqis dying because of conflict or sanctions since the 1991 Gulf war is uncertain.1, 2 Claims ranging from a denial of increased mortality3, 4, 5, 6, 7 to millions of excess deaths8 have been made. The Coalition Provisional Authority and the Iraqi Ministry of Health have identified the halving of infant mortality as a major objective.9 In the absence of any surveys, however, they have relied on Ministry of Health records. These data have indicated a decline in young child mortality since February, 2001, but because only a third of all deaths happen in hospitals, these data might not accurately represent trends.10 No surveys or census-based estimates of crude mortality have been undertaken in Iraq in more than a decade, and the last estimate of under-five mortality was from a UNICEF-sponsored demographic survey from 1999.11, 12

Morgue-based surveillance data indicate the post-invasion homicide rate is many times higher than the preinvasion rate. In Baghdad, a city of 5 million people, 3000 gunshot-related deaths happened in the first 8 months of 2004.13 One project has kept a running estimate of press accounts of the number of Iraqi citizens killed by coalition forces: at present, the estimated range is 13000–15000 (http://www.iraqbodycount.net). Aside from the likelihood that press accounts are incomplete, this source does not record deaths that are the indirect result of the armed conflict. Other sources place the death toll much higher.14 In a recent BBC article decrying the lack of a reliable civilian death count from the war in Iraq, Ken Roth of Human Rights Watch purports that it will not be possible “to come up with anything better than a good guess at the final civilian cost”.14

In the present setting of insecurity and limited availability of health information, we undertook a nationwide survey to estimate mortality during the 14·6 months before the invasion (Jan 1, 2002, to March 18, 2003) and to compare it with the period from March 19, 2003, to the date of the interview, between Sept 8 and 20, 2004.

Section snippets

Methods

We designed the cross-sectional survey as a cohort study, with every cluster of households essentially matched to itself before and after the invasion of March, 2003. Assuming a crude mortality rate of 10 per 1000 people per year, 95% confidence, and 80% power to detect a 65% increase in mortality, we derived a target sample size of 4300 individuals. We assumed that every household had seven individuals, and a sample of 30 clusters of 30 households each (n=6300) was chosen to provide a safety

Results

All 33 randomly selected locations were visited and 988 households were chosen between Sept 8 and 20, 2004. These households contained 7868 residents on the date of interview. Of these residents, 237 (3%) were younger than 1 year, 1004 (13%) were younger than 5 years, and 3084 (39%) were younger than 15 years. Of the 4453 (57%) residents age 15–59 years, 2220 were men. Of the 331 (4%) residents age 60 years or older, 152 were men.

Five (0·5%) of the 988 households refused to be interviewed. In

Discussion

This survey indicates that the death toll associated with the invasion and occupation of Iraq is probably about 100000 people, and may be much higher. We have shown that even in extremely difficult circumstances, the collection of valid data is possible, albeit with limited precision. In this case, the lack of precision does not hinder the clear identification of the major public-health problem in Iraq—violence.

Several limitations exist with this study. Most importantly, the quality of data

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