"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 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

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Commentary in The Australian:
Iraq civilian toll 'more than 100,000'
Correspondents in Baghdad
October 30, 2004

MORE than 100,000 Iraqi civilians have died since the US-led invasion of Iraq in March last year, according to a new scientific study.

The toll far exceeds all previous estimates, and the survey's publication yesterday - just days before the US presidential election - was bound to cause controversy by reinforcing the impression that events in Iraq were out of control.

The research, done in Iraq this September by a team of US and Iraqi scientists, was published on the online edition of The Lancet.

It suggests that the majority of civilian deaths have been due to military activity, with those caused by violence rising sharply in recent months.

The coalition forces keep records of casualties among their own troops, but neither the US nor Britain has attempted to count how many civilians have been killed.


British Foreign Secretary Jack Straw has previously estimated 10,000 civilian deaths.

A group of British academics called Iraq Bodycount, which compiles figures from witness accounts and media reports, recently put the number at between 14,160 and 16,289. Britain's Defence Ministry was yesterday sceptical about the new study's findings. "No figures that are produced are reliable at this stage," a spokesman said.

The report was compiled by a team led by Les Roberts, a public health expert from the Johns Hopkins Bloomberg School of Public Health in Baltimore in the US.

They surveyed households in 33 regions of the country. They then compared civilian mortality rates before and after the invasion.

Independent statisticians who have analysed the data said yesterday that the scientists' methodology was strong, and the civilian death count could well be conservative.

They said the work effectively rubbished suggestions by US authorities that civilian bodycounts were impossible to conduct. In coming to a total of 100,000 civilian deaths, the team excluded Fallujah, where two-thirds of violent deaths recorded had occurred.

Experts said that including this area, where collecting data remains highly dangerous, would push the number of civilian deaths much higher.

Dr Roberts said yesterday that the death toll from bombing suggested a pressing need to alter air strike strategies.

"We can say with absolute confidence that both mortality and violent deaths have gone way up," he said. "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."

Overall, the risk of death was found to be 2.5 times greater after the invasion. The risk was 1.5 times higher if mortality around the hotspot of Falluja was excluded.

The survey's publication came as Japan's embassy in Baghdad said it was checking a report that the body of an Asian had been found in Iraq, as fears mounted over the fate of a Japanese hostage threatened with death. Japanese news agency Kyodo reported the body had been found in Tikrit, 180km north of Baghdad, but was unable to say whether it was kidnapped Japanese Shosei Koda, 24. Tokyo had rejected demands by the al-Qa'ida-linked insurgents holding Koda that Japan withdraw its 600 soldiers from Iraq by late Thursday, local time.

The Times, AFP