Mortality before and after the 2003 invasion of Iraq: cluster sample survey
Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi, Gilbert Burnham
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.
Comment: 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 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.
Published online October 29, 2004.