Over half a million additional deaths in Iraq since US invasion

A new study by American and Iraqi epidemiologists estimates that there have been 665,000 excess deaths in Iraq since the U.S. invasion of 2003. This study, published in the Lancet, is the best scientific estimate of deaths attributable to the invasion. All other methods for estimating the number of deaths pale beside a population based study.

Instead of extrapolating the death toll from police reports or media coverage, Iraqi scientists fanned out over the country and asked Iraqis how many members of their households had died since 2003.

Public health scientist Cervantes explains the methodology behind the Lancet study. As he notes, the scientists observed standard protocols for investigating questions of this type:

So, the researchers set out to estimate deaths by means of a household survey using area probability sampling methods. This is a method used all the time in health surveys. It's a method I have used myself, in fact. To begin, you just need census data -- it actually doesn't even have to be highly accurate as long as any errors are essentially random, or unrelated to your study questions. Then, you pick geographic areas based on probability proportionate to the population they contain. This is usually done in stages. In the Iraq study, they first determined the number of clusters they would select in each province based on population size (Baghdad, with its population of over 6 million, got 12; Muthanna, with a population of 570,000, happened to get none.) Then, towns, blocks, and starting households were selected at random. For each household selected, the 39 nearest houses were also included. This survey had a total of 47 clusters, including 12,801 persons.

The researchers interiewed adult household members between May and June, 2006, to learn about births, deaths, and migration since January 1, 2002. They also asked people to report if an entire neighboring household had been wiped out, to account for households with no-one left to speak for them. They report that for 92% of reported deaths, the respondents were able to produce a death certificate. A substantial omission in the report, I must say, is the failure to state the response rate. The investigators also refer to procedures for substituting areas which were too unsafe to visit. They do not say how often this happened, but if anything, it would tend to bias the results downward.

To arrive at an estimate of total deaths for the country, they simply multiply the deaths in the study population by the appopriate weights for the number of people each cluster represents (i.e., the inverse of the probability that a person living in that province would have been selected). The clustering does not directly affect the estimates, but it does affect the so-called confidence interval. Since people living in a specific area are at greater or lesser risk of violent death than average, the statistical power of the study is less than it would be for a single stage probability sample of 12,801 persons, because of the possibility that the selection of clusters introduced sampling error. Although the manuscript does not discuss the specific calculations that were done to adjust for this, I am willing to give investigators from these institutions the benefit of the doubt that they did it correctly.

To recap: The investigators conducted interviews in 14 of Iraq's 16 districts. Regions were assigned interview sites (clusters) according to their populations. Households within each cluster were selected at random.

Why did the epidemiologists use the cluster technique of a purely random sample? It would have been impractical to conduct a truly random survey in a country the size of Iraq. Instead, the investigators decided how many clusters they were going to have in each region and then picked people at random within their zones. If one person was selected at random, the investigators interviewed all his neighbors to complete the cluster.

The investigators interviewed about 12,800 people out of a population of nearly 30 million. So, of course the 655,000 figure is an estimate. The fundamental question is whether one can meaningfully extrapolate excess death rates for the entire country based on a sample of 12,800. Based on the numbers they observed and the statistical limitations of their methods, the authors estimate that the true number of excess deaths would fall between 426,369 and 793,663 nineteen times out of twenty.

This study estimates the number of excess deaths since the invasion. The investigators compared the death rate shortly before the invasion to the death rate for the years following. The 665,000 is the number of deaths over and above what would have occurred if the pre-invasion death rate held steady over that three-year period.

Of course, there's every reason to believe that the vast majority of deaths go unrreported by the press. After all, most of the country is off-limits to journalists. The authorities who run the morgues keep journalists out, except by special invitation. Thousands of unidentified bodies are being pulled from the Tigris alone.

The the main critique of the study in the right wing blogosphere can be summarized as follows:  But 665,000 is a lot!

The right wing Rick Moran shows off his math skills:

Someone is wildly off base here. Could it be the group that says that the US military has killed 180,000 Iraqis as a direct result of military actions?

Gunshot wounds caused 56 percent of violent deaths, with car bombs and other explosions causing 14 percent, according to the survey results. Of the violent deaths that occurred after the invasion, 31 percent were caused by coalition forces or airstrikes, the respondents said.

The fact that those three percentages totalled up equal 101% isn’t as ridiculous as 31% of deaths were caused by coalition forces or airstrikes. [Emphasis added]

The right wing blogosphere is already whining about how there's uncertainty in this estimate. Well of course there is! It doesn't change the fact that this is the best scientific estimate of the number of excess deaths in Iraq since the invasion. Rick Moran and his buddies are now praising Iraq Body Count to the skies. IBC uses media reports to estimate casualties. As admirable as this effort is, it's no substitute for going out and surveying people directly.

We can expect a bumper crop of straw men in the right wing blogosphere. Some wingnuts are complaining that the authors didn't differentiate between civilians, military personnel, and police. No, they didn't. But you see, they didn't claim to, either. The investigators just wanted to estimate how many Iraqis have died since the invasion and compare that number to what we would have expected to see if pre-invasion death rates had continued. I know it's hard for right wingers to wrap their heads around this but: all those dead people were people. Scientists don't keep separate sets of books for the "good guys" and the "bad guys."

Then there's the correlation/causation thing. The wingnuts will emphasize that just because the death rate shot up dramatically after the US invaded doesn't mean that the US invasion actually caused all those extra deaths. No, it doesn't. However, I'll be curious to see what alternative hypotheses they have for the soaring death rate after the invasion. Global warming? Bird flu? Sun spots?

Glenn Greenwald has more.

Comments

[Count Zero]

Did Saddam ever come close to this number?

[cfrost]

A peer-reviewed journal stakes its reputation on every paper it publishes. When something is missed there’s crow for all involved to eat. That’s why the system works. We can assume that the reviewers the article was farmed out to before publication are competent in the area of epidemiological statistics. A journal with the reputation of the Lancet is not going to publish a paper with this high a profile that has basic methodological errors.

[Uncle Kvetch]

A noble effort, Lindsay, but ultimately pointless. They've already stuck their fingers in their ears and they're yelling "LALALA" loud enough to wake the dead.

Hearing the report about the study on the radio this morning was bad enough. But seeing the predictable right wing reaction (not to mention Dear Leader's "I don't believe it, so it can't be true") is nothing short of sickening.

[Alon Levy]

Rick Moran also touts Iraq Body Count, which will give you accurate estimates of the number of dead Iraqi civilians to about the same extent the Uniform Crime Report will give you an accurate estimate of the number of sexual assaults in the US.

Count Zero, the Lancet study reports excess deaths - that is, the death rate now compared with when Saddam was in power and Iraq was under sanctions.

[Madison Guy]

Bush babbling about "a society which so wants to be free that they’re willing to…you know, that there’s a level of violence that they tolerate." Tell it to Riverbend, Mr. President. If you can find her. She hasn't posted in Baghdad Burning since her haunting The Summer of Goodbyes post August 5.

[cfrost]

Yeah, where is Riverbend? Is she ok?

[Aaron]

frankly Im amazed at the incredibly high death certificate percentage. 92%??? that sounds unbelievably high.
I mean, if dad walks out the door, gets shot on the doorstep, and then the family buries him in the back yard, is there a death certificate?
I was under the impression that Iraqis would simply wrap the body and bury it...
plus youve got large numbers of bodies that are simply unidentifiable...
OTOH- if you stay away from the most violent neighborhoods, maybe people are more likely to go and get death certificats...
is there any indication of some benefit to having a death cert.?
I mean if you have an ID card, you used to be able to get a UN ration. Is there a pension, or someother benefit from getting a death cert.?
still you go with the experts you have....
A

[John Lucid]

To impress everyone with my mastery of 5th grade math, 665,000 excess deaths in Iraq would equal almost 7 million extra deaths in the US. That would be like losing the entire state of Massachusetts. Of course the loss of Massachusetts would be no cause for tears in some conservative circles, which brings me to my point: Who cares about a bunch of dead dang Mooslims? Shit, Bush can't be bothered to go to a single American soldier's funeral, so how much sleep do you think he (or his slavering supporters) will lose over this new statistic? In fact this knowledge will probably get some of his shitstain loyalists all fired up for war with Iran. Our cup runneth over, with blood.

[dk]

I have a hard time believing that Moran quote is legit. He really did add up (?!?!) the percent killed by coalition forces, car bombs and (dear god help us) gunshot wounds?! Did it not occur to him that a death attributed to coalition forces might also be attributed to a gunshot wound? I mean, shouldn't one expect some overlap there? A little, right?

Heads explode at the implications.

[ptcruiser100]

>"is there a death certificate? "

It is my understanding based on the news reports I heard that the researchers did talk with family members who possessed death certificates.

I'm not surprised that so many folks are refusing to accept the report as being statistically valid. These are the same people, by and large, who, in response to being told that three and one-half million Vietnamese perished during our war in that country, continue to argue that the U.S. should have prosecuted that war more vigorously. In other words, we should have killed more, if not all, the Vietnamese in order to win.

Sort of reminds me of Sen. Everett Dirksen's immortal comments about the federal budget: "A few billion here, a few billion there. Pretty soon we're talking about real money."

Iraqis and Vietnamese aren't real people as far as these mortality deniers are concerned. They're just speed bumps on the highway to freedom.

[bob mcmanus]

Best post on the subject I have read today.

[Alon Levy]

John, your comparison to the US is misleading. Jordan Ellenberg wrote a while ago about the inappropriateness of scaling numbers, unless they add up to significant fractions of the country's population. 200,000 Iraqi civilians killed by the coalition forces are equivalent to 200,000 dead American civilians. Even 650,000 dead Iraqis are equivalent to 650,000 dead Americans, more or less (and at any rate, you can't localize scaling to "the entire state of Massachusetts").

Everyone, the 650,000 figure is actually based on a higher-than-average baseline. A commenter on Unfogged expressed skepticism about the baseline rate, 5.5, since it's lower than the global death rate, but in fact it's higher than the regional average (explanation available on demand). The occupation has in fact killed 650,000 Iraqis more than a baseline inflated by sanctions and the activities of a brutal dictator.

[NonyNony]

I'm still not seeing why anyone thinks that this is an odd statistic. Our troops are killing people, the insurgents are killing people (not just American troops either - in fact, most of the casualties are Iraqis), the infrastructure is STILL toast, so people with infections and illness aren't able to get proper treatment, water supplies are getting contaminated, food supplies are messed up, fuel is hard to get which leads to air conditioners that don't work and more dead children and elderly.

This is a no brainer - when you turn a highly developed country into a bombed-out wreck, the death rate is going to shoot up, even if you DIDN'T have almost nonstop fighting for 3 years throughout the country. Add together the violence with the lack of infrastructure, and an extra 200,000 deaths per year doesn't sound out of line.

This is why going to war should always be the last possible resort. It's not like the only people who die in and around wars are all soldiers who know what they're getting into. Sometimes I think people forget this, and I'm fairly certain that the warmongers either didn't think or didn't care about the repercussions on the civilian populace before demanding their war.

[1984 Was Not a Shopping List]

I don't know what to say about this. We never wanted it; we loudly protested against it; the administration did it. I sometimes get discouraged because of the loooooooong time it's taken--is it years, already?--for someone to get off their ass and start saying, "something's got to be done about the Sudan!" Yet our own government goes and starts a war like this, and we can't do a thing to stop it.

[otto]

Count Zero,

Estimates for total number of civilian casualties killed by Saddam during the entire period of his leadership, that I have seen, run from 1/4 to 1/3 million (these are not conservative estimates). We must destroy the village to save it . . . Typically, the figures relating to casualties under Saddam show up in right wing sources, though some work has been done by NGO's and the like.

[DavidByron]

Some inaccuracies in your post here. This research isn't the best indication of the death toll -- it's the only one. All the other figures that are being paraded around by the holocaust deniers simply are not estimates of the death toll.

They aren't bad or inaccurate estimates. They simply are not estimates at all, of the total death toll.

Of course the Lancet figure isn't either so to calculate the actual death toll due to the invasion you have to add on the death toll (over normal conditions for Iraq) of the pre-war embargo. This is about 400,000 over the period for a grand total of about 1 million Iraqis killed by America since the war started.

Now the embargo itself was a case of about 2 million Iraqis exterminated by the US embargo over many years. By the end of Bush's tenure the total number of Iraqis exterminated by America will be around 4 million.

So the other item you were wrong about was the comparison with the Holocaust.

[Leo]

That chicagoboyz post you link to is about the 2004 study, not this one.

[Aaron]

just to be clear, I believe the number of dead.
Iraqbodycount.org is fine, but they are only reporting deaths that are reported in papers and in the news.

[Aaron]

Whats the source of the "2 million Iraqis exterminated by the US embargo" claim david Byron?
Last I heard the UN was gauranteeing an daily food ration to each and every Iraqi before the war.
and why is it the US embargo? wasnt this approved by the UN? shouldnt that be the UN embargo?
I call bullsh-t.
A

[otto]

From looking into this over the last decade, my general conclusions are (approx. numbers from 1990 to present): 1) A conservative estimate of Iraqi civilian casualties from sanctions and coalition bullets and bombs: 3/4 million (1 million is not out of the range of probability). 2) Total civilian and military deaths directly related to the war: 1 1/3 to 1 1/2 million. 3) Some estimates run as high as 2+ million, but I find these figures difficult to support based on the info I have seen.

Here is a quick list of a few places to poke around and other relevant studies:

“Annual Mortality Rates and Excess Deaths of Children Under Five in Iraq, 1991-1998” by Mohamed Ali

“Morbidity and Mortality among Iraqi Children from 1990 through 1998: Assessing the Impact of the Gulf War and Economic Sanctions” by Richard Garfield with George Lopez and David Cortright.

Center for Population Studies (University of London)

World Health Organization

“Mortality Before and After the 2003 Invasion of Iraq” Les Roberts

“Effect of the Gulf War on Infant and Child Mortality in Iraq” Alberto Ascherio, et.al.

Harvard School of Public Health

Global Policy Forum

Global Security

PBS Frontline

PubMed Central

(many others if you need them)

Note:
Much work has been done on infant mortality since 1990. Less has been done regarding war-related deaths among the elderly, but this is also a group highly prone to suffer from the impact of war (if you are a sixty-five year old diabetic and you can’t get insulin due to sanctions, your days are numbered).

[j swift]

When you usurp the self-determination of a nation, even if previous government was despotic, it would seem that you are morally responsible for every death no matter whether it is related to the war you started or not.

[mateo luiz]

I like how the Lancet report omits half the data: we only get total births during the 5.5 years.
the number indicates that at some point the birth rate plummeted more than 33%. This does not jive with other studies. Obtaining the birth rate in Iraq should be more precise than mortality... If they are consistent, then why surpess it.
The data is fishy....

[otto]

Aaron,

Quite a lot has been written on the impact of the UN sanctions (though I have not seen evidence to indicate the number is 2 million). For example, the initial figures on the affects of war and sanctions on infant mortality have since been revisited several times so that estimates of between 1/4 and 1/2 million through the 1990s seem probable based on what I’ve seen. Quite a bit of info on sanctions can be accessed via some of the sources I listed above. You may also like to check out the sources provided by CASI at

http://www.casi.org.uk/

or

http://www.gulflink.osd.mil/gwv_bib/mortality.html.

There is also a good article from 2001 by David Cortright, one of the leading experts on the subject: “A Hard Look at Iraqi Sanctions”

http://www.thenation.com/doc/20011203/cortright

Don’t take anyone’s word: check sources, go with conservative estimates, and do a lot of compare and contrast as far as the various studies go.

[Alon Levy]

This is about 400,000 over the period for a grand total of about 1 million Iraqis killed by America since the war started.

Now the embargo itself was a case of about 2 million Iraqis exterminated by the US embargo over many years. By the end of Bush's tenure the total number of Iraqis exterminated by America will be around 4 million.

This is misleading. To calculate excess deaths, you need to add to 655,000 not the number of people killed during Saddam's entire reign, but the number of people killed during the last 3 years and 4 months before the war; it would be more accurate to multiply the number of people killed in the last 12 months before the war, which I believe is the baseline period, by 10/3, but the total number of deaths in the last 40 months before the war is a good approximation.

To see why, let's round the number of excess deaths down to 600,000, to simplify calculations; this translates to 180,000 excess deaths every year since the invasion. The estimates I've seen peg Saddam's kill rate at about 12,000 per year and the sanctions' at 60,000. So we get an annual rate of 252,000 deaths plus a background level due to normal diseases, traffic accidents, ordinary crime, old age, and other causes we can take to be unaffected by tyranny, war, or sanctions. In that case, the total number of war-associated deaths would be 252,000*10/3 = 840,000 = 600,000 + (72,000)*10/3.

Bottom line: the number of deaths you can associate with the war and occupation doesn't even come close to 2 million, which is itself an inflated figure supplied by Saddam's propaganda; a better figure is 60-70 thousand civilians per year of sanctions. The highest figure is 655,000 excess deaths plus 40,000 people who would have been killed by Saddam's regime plus 200,000 who would have been killed by the sanctions, which is about 900,000.

[John Lucid]

Alon, I know that 665,000 people = 665,000 people, regardless of their national origins. When I use the figure of 7,000,000 I am talking about proportionate loss of population. I did it to give a better understanding of how this loss must impact Iraqi society. The US lost almost the same amount of men (over 623,000) in the American Civil War. However, the combined American deaths from ALL of its wars is approximately 1.26 million, FAR less than 7,000,000. That is why I thought that showing the proportional number would help drive the point home. Of course, I also know that all casualties can't be localized to one region. Again, I did this to give a sense of the scale of the loss for the Iraqi populace. I also mentioned Massachusetts to segue into my opinion of how some conservatives will react to the deaths of 665,000 Iraqis: Anywhere from indifference to happiness.

665,000 deaths out of 28.8 million people is 2.3% of the Iraqi population, dead from a war that should never have taken place. I would say that 2.3% is a significant fraction, regardless of the country being discussed. I work with about 250 people in my office. If 2.3% were killed, that would be six dead people above and beyond other causes of death like accidents or natural causes. Could my workplace recover from this? Yes, I think so, but it would be very traumatizing, even if those six deaths took place over the course of 3.5 years. That's the point I'm trying to make. I read Mr. Ellenberg's article, and while I generally agree with his thesis I think he overlooks the psychological impact caused by death on this order of magnitude. Because of my job I know quite a few people (outside of my 250 coworkers). If one out of every 40 of them died from war you better believe it's going to affect me. I think it would affect most people. That's what I'm trying to say.