TY - JOUR
T1 - Mortality in Iraq Associated with the 2003-2011 War and Occupation
T2 - Findings from a National Cluster Sample Survey by the University Collaborative Iraq Mortality Study
AU - Hagopian, Amy
AU - Flaxman, Abraham D.
AU - Takaro, Tim K.
AU - Esa Al Shatari, Sahar A.
AU - Rajaratnam, Julie
AU - Becker, Stan
AU - Levin-Rector, Alison
AU - Galway, Lindsay
AU - Hadi Al-Yasseri, Berq J.
AU - Weiss, William M.
AU - Murray, Christopher J.
AU - Burnham, Gilbert
N1 - Funding Information:
We express gratitude to our interviewers, who visited more than 2,000 Iraqi households at personal risk, and to co-authors who requested anonymity. We are thankful to Johan von Schreeb and Skip Burkle, who reviewed the manuscript. The bioethicist we consulted, Benjamin Wilfond, was a member of the University of Washington's Institute of Translational Health Sciences—Regulatory Support and Bioethics Core, supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR000423). University of Washington administrators Craig Johnson and Sally Weatherford helped with logistics. Shannon Doocy and Linnea Zimmerman at Johns Hopkins University provided consultations on data, and Ben Birnbaum set up the website dashboard to monitor incoming field data. We are grateful to Les Roberts for his encouragement.
PY - 2013
Y1 - 2013
N2 - Background:Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011.Methods and Findings:We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study.Conclusions:Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war.Please see later in the article for the Editors' Summary.
AB - Background:Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011.Methods and Findings:We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study.Conclusions:Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war.Please see later in the article for the Editors' Summary.
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U2 - 10.1371/journal.pmed.1001533
DO - 10.1371/journal.pmed.1001533
M3 - Article
C2 - 24143140
AN - SCOPUS:84886636744
SN - 1549-1277
VL - 10
JO - PLoS medicine
JF - PLoS medicine
IS - 10
M1 - e1001533
ER -