[Marxism] Iraq war study and editorial in The Lancet: 100, 000+ killed

[Andy <esquincle@xxxxxxxxxxx>]

[[this is the editorial from the current edition of The Lancet, one of 
the major medical journals.  It would be interesting to know if the 
authors sought first to publish their findings in US medical 
journals.]]

The war in Iraq, civilian casualties, political responsibilities

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 action 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 preemptive 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 insufficient 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

The war in Iraq: civilian casualties, political responsibilities 
Published online  October 29, 2004 http://image.thelancet.com/ 
extras/04cmt384web.pdf

============
[[The article under discussion above -- abstract follows -- really 
needs to be downloaded in pdf and read carefully! -- please email me if 
you have trouble registering to the Lancet and want to read it in 
full.]]
============

Mortality before and after the 2003 invasion of Iraq: cluster sample 
survey
Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi, Gilbert 
Burnham

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 noncombatant deaths from air strikes.

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

Center for International Emergency Disaster and Refugee Studies, Johns 
Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (L 
Roberts PhD, G Burnham MD); Department of Community Medicine, College 
of Medicine, Al-Mustansiriya University, Baghdad, Iraq (R Lafta MD, J 
Khudhairi MD); and School of Nursing, Columbia University, New York, 
NY, USA (ProfRGarfieldDrPH) Correspondence to:  Dr Les Roberts 
les@xxxxxxxxxx

Mortality before and after the 2003 invasion of Iraq:  cluster sample 
survey Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi, 
Gilbert Burnham


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