Violence and Excess Mortality in Iraq

Yes, yes, I know – shouldn’t all mortality be excess? No – this refers to the mortality rates that the invasion/occupation hath wrought, above and beyond the ‘ordinary’ rates of mortality in Iraq. The New England Journal of Medicine is sporting two papers on the subject: Violence-Related Mortality in Iraq from 2002 to 2006, by the Iraq Family Health Survey Study Group; and Estimating Excess Mortality in Post-Invasion Iraq, by Browstein, Catherine A. and John S.

Mortality in Iraq by cause, from the Iraq Family Health Survey Study Group (click for larger version):

NEJM pic

It’s Iraq: it’s not suprising to see mortality escalate – but, honestly, Road Accidents and Unintentional? Surely that’s a bit much.

Excess mortality (per 100,000 population), same:

NEJM pic

The Iraq Family Health Study Group are fairly open about their measurement issues (recall bias is always a problem in household surveys, with or without holistically-debilitating armed conflicts). The Brownstein and Brownstein paper is survey methodological, and says much the same:

There is no set formula for accurately tallying deaths from humanitarian crises. When a population becomes destabilized, estimation of mortality is likely to be severely challenged. In the case of a sudden traumatic event, such as a natural disaster affecting an otherwise stable population, health and human service agencies, though compromised, may well be able to facilitate an accurate assessment of deaths through the use of prospective registries of vital events.

In the event of a military invasion and ongoing war, however, the likelihood of obtaining good demographic data plummets. A death registry is unlikely to be developed or maintained, and as conditions deteriorate, it may become increasingly unlikely that bodies can be counted at all. In Iraq, there is also a strong cultural imperative that bodies be put to rest quickly, which may affect the ability to arrive at accurate estimates.

Although sentinel populations are commonly monitored to rapidly estimate mortality in developing countries when a registry is not available, the impossibility of finding reliably representative populations in countries engaged in armed conflict and the absence of an accurate population count make it difficult to extrapolate from the rates at sentinel sites to produce reliable national estimates.

They – and the IFHS – discuss the clear variation in mortality estimates between this article, the numbers from the Iraq Body Count people and the widely-publicised results from the paper Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey (Burnham G, Lafta R, Doocy S, Roberts L. Lancet 2006;368:1421-1428). Wikipedia too has an excellent page concerning the Lancet mortality studies.

Ultimately the problem won’t go away – this section, from the Brownstein’s paper, is brilliant:

Under the current conditions in Iraq, it is difficult to envision a study that would not have substantial limitations. The circumstances that are required to produce high-quality public health statistics contrast starkly with those under which the IFHS study group worked. Indeed, it must be mentioned that one of the authors of the survey was shot and killed on his way to work

It’s certainly worth having more studies. More information is always going to help stabilise estimates in the face of such uncertainty as this.

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