Fast track — ArticlesMortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey
Introduction
There has been widespread concern over the scale of Iraqi deaths after the invasion by the US-led coalition in March, 2003. Various methods have been used to count violent deaths, including hospital death data from the Ministry of Health, mortuary tallies, and media reports.1, 2 The best known is the Iraq Body Count, which estimated that, up to September 26, 2006, between 43 491 and 48 283 Iraqis have been killed since the invasion.1 Estimates from the Iraqi Ministry of the Interior were 75% higher than those based on the Iraq Body Count from the same period.2 An Iraqi non-governmental organisation, Iraqiyun, estimated 128 000 deaths from the time of the invasion until July, 2005, by use of various sources, including household interviews.3
The US Department of Defence keeps some records of Iraqi deaths, despite initially denying that they did.4 Recently, Iraqi casualty data from the Multi-National Corps-Iraq (MNC-I) Significant Activities database were released.5 These data estimated the civilian casuality rate at 117 deaths per day between May, 2005, and June, 2006, on the basis of deaths that occurred in events to which the coalition responded. There also have been several surveys that assessed the burden of conflict on the population.6, 7, 8 These surveys have predictably produced substantially higher estimates than the passive surveillance reports.
Aside from violence, insufficient water supplies, non-functional sewerage, and restricted electricity supply also create health hazards.9, 10 A deteriorating health service with insecure access, and the flight of health professionals adds further risks. People displaced by the on-going sectarian violence add to the number of vulnerable individuals. In many conflicts, these indirect causes have accounted for most civilian deaths.11, 12
In 2004, we did a survey of 33 randomly selected clusters of 30 households with a mean of eight residents throughout Iraq to determine the excess mortality during the 17·8 months after the 2003 invasion.8 The survey estimated excess mortality of at least 98 000 (95% CI 8000–194 000) after excluding, as an outlier, the high mortality reported in the Falluja cluster. Over half of excess deaths recorded in the 2004 study were from violent causes, and about half of the violent deaths occurred in Falluja.
To determine how on-going events in Iraq have affected mortality rates subsequently, we repeated a national household survey between May and July, 2006. We measured deaths from January, 2002, to July, 2006, which included the period of the 2004 survey.
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Participants and procedures
To measure mortality we did a national cross-sectional cohort study of deaths from January, 2002, through July, 2006. Household information was gathered about deaths that occurred between January 1, 2002, and the invasion of March 18, 2003, in all households and these data were compared with deaths that occurred from the time of the invasion through to the date of survey. A sample size of 12 000 was calculated to be adequate to identify a doubling of an estimated pre-invasion crude mortality
Results
The survey was done between May 20 and July 10, 2006. Only 47 of the sought 50 clusters were included in this analysis. On two occasions, miscommunication resulted in clusters not being visited in Muthanna and Dahuk, and instead being included in other Governorates. In Wassit, insecurity caused the team to choose the next nearest population area, in accordance with the study protocol. Later it was discovered that this second site was actually across the boundary in Baghdad Governorate. These
Discussion
We estimate that, as a consequence of the coalition invasion of March 18, 2003, about 655 000 Iraqis have died above the number that would be expected in a non-conflict situation, which is equivalent to about 2·5% of the population in the study area. About 601 000 of these excess deaths were due to violent causes. Our estimate of the post-invasion crude mortality rate represents a doubling of the baseline mortality rate, which, by the Sphere standards, constitutes a humanitarian emergency.17
Our
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