Your research on mortality in Iraq, published in the prestigious Lancet journal, made headlines across the globe last November. What motivated you to conduct the survey?
This is about the ninth “hot war” I’ve worked in. In most wars people are killed more by disease and disruption than by bullets and bombs. But when I read the newspaper reports on the war, all I heard about were the bullets and bombs. I didn’t think the reports were describing the suffering of the Iraqis very well.
I thought it would serve the interests of Iraqis if I described what they were really dying of. So, if we found they were dying of diarrhoea we could do something about that.
If they were dying at home in childbirth because they were too scared to go to hospital, we could do something about that. Much to our surprise we found that these things weren’t what they were dying of. Most were dying violent deaths.
Tommy Franks from US Central Command told the press that the US army “don’t do body counts”, despite the duty of care the Geneva Convention imposes on occupying forces. You showed it is possible to make mortality estimates.
Absolutely. I was smuggled across the border into Iraq. I went with just a suitcase and $20,000 in my pocket. All it took was six Iraqis brave enough to do the survey.
During a war things are messy and the Geneva Convention imposes very few constraints. But during an occupation things are quite different.
As I understand it there are obligations for the occupying forces that are similar to the obligations of a police officer on the streets here towards the local population — to arrest them if they step out of line, but to protect them the rest of the time.
Most of the people killed by the coalition were women and children, which implies the use of a lot of force, and perhaps too much.
As far as I’m concerned the exact number of dead is not so important. It is many tens of thousands. Whether it’s 80,000 or 140,000 dead, it’s just not acceptable.
What methods did your survey use?
What we did is not really that complicated. First we went to the ministry of health and asked them how many people were in each city and each village on 1 January 2003.
Then we randomly picked 33 neighbourhoods to visit. In each of these neighbourhoods we randomly picked a house and visited the 30 houses nearest to it.
Some of the mathematical detail may be complex, but the basic idea was to find almost 1,000 households representing the whole of Iraq.
How would you summarise your main findings?
The bottom line is that by any measure the death rate after the invasion was far higher than the death rate before.
Most of the deaths were violent and most of those deaths were caused by the coalition forces. There is little doubt that these “excess deaths” are as a result of the invasion and not some new flu epidemic or something else.
Are there other surveys of death rates in Iraq? Do they back up your findings?
In a very prestigious journal called the New England Journal of Medicine there was an article published on 1 July 2004. Military doctors interviewed soldiers returning from Iraq.
They interviewed them because they were interested in post-traumatic stress disorder, so they asked the soldiers about stressful things that might have happened to them.
Among other things they found that 14 percent of the ground forces in the army had killed a non-combatant and 28 percent of returning Marines had killed a non-combatant.
If you work through the numbers you come up with a figure pretty darn close to our estimate in the Lancet.
There have been other surveys with similar findings. But when the media talk about our figure they almost always compare it to the lowest estimate. That estimate — the Iraq Body Count — was calculated by academics based on press reports.
Even though the Iraq Body Count under-reports the total number of deaths, the patterns in your Lancet survey seem to mirror the patterns in their count.
Yes, the patterns in our findings are extremely consistent. The academics that do the Iraq Body Count estimate have said right from the start that their surveillance network is not, and could not be, complete. It’s made up of the deaths that get reported in the press.
But I’m very grateful that for a year and a half, when the rest of us were afraid to go to Iraq and do anything on the ground, they were reminding the world that civilians were dying.
What was it like going round and talking to Iraqis on the ground? Did security get in the way?
Americans are so hated that I couldn’t go around talking to people. We would pick a random point in each “cluster” — each village or town we surveyed.
I would show our Iraqi team how to pick a random point in a town, how to use a Global Positioning System to draw a map of the town and drive to the right point, how to find the few houses closer to the point.
Always in the first few houses there’s some that are a bit quirky. There might be a cousin visiting and you have to decide whether you include him in the sample. We worked through the first few clusters together to go through those issues.
I’d walk around on the street with our interview team. Then I’d go get in a car and hide, and the Iraqis would visit the houses by themselves. I was almost never out in public.
My driver had three brothers so he had access to four different cars and he would pick me up in a different one each morning. We’d leave at different times and use different routes.
I only went out with the interviewers for the first eight days. On the eighth day the police picked up our interviewers while I was in the car watching and that was a pretty bad experience.
After that we were convinced that interviewers knew what they were doing, and they didn’t want me there. For about 15 days I just stayed in a hotel room and didn’t go out.
Did the US forces cause trouble?
Things then, and I think still now, were so stressful that any vehicle would be searched by local police, in some areas by insurgents and by coalition forces or their Iraqi colleagues.
In many areas the police are unofficially on the opposite side to the local Iraqi forces. It’s always stressful when you come up to a checkpoint.
Did you get a sense of the wider cost of war, beyond the question of mortality?
I study mortality — that’s something I know. Talking to workers from non-governmental organisations, my colleagues and my driver, I would ask if things were better. They said some things were better but they were really worried about security.
Most of them hate the Americans, most want the coalition troops gone. But because things are in such a flux they are also surprisingly hopeful about the future.
Two thirds of all violent deaths in your survey were in one city — Fallujah. Why were the deaths so concentrated in this city?
The city was shelled extensively in the weeks before we were interviewing. We went and attempted to interview 30 households. Almost half of the houses we went to were empty.
We skipped over them and went to other houses. We think that our findings, if anything, underestimated the number of deaths because of the number of empty and destroyed houses. Some of the families probably fled, but many are probably dead.
Of those families sticking around in Fallujah, a quarter lost a family member in the few months leading up to the interview. Who knows how many have died since the assault on the city in November.
I get very angry about the coverage of Fallujah. I heard a show last week on public radio in the US. They said that it is believed that half the 200,000 people who used to live in the city had returned. Well, the ministry of health told us the population used to be 310,000.
The US press has been manipulated. Things don’t sound as bad if you say that 50 percent rather than 30 percent of the population are back.
During the invasion of Fallujah, Pentagon spokespeople said again and again that they believed 3,000 to 5,000 mainly foreign combatants were left in the city and that most of the civilian population had left.
Well, they went in, they killed a lot of people — estimates range from 600 to 2,100 — and they captured 1,600 prisoners.
Only 30 of the prisoners were identified as foreign combatants — only 2 percent of those captured. In my country no one was held to account for what was either a lie or an absurd intelligence failure.
I know terrible things happened in Fallujah, but no one has been given a chance to get good information about what is going on.
What was the reaction to your survey when it was published?
The coverage in the press varied enormously. It was very different in the US and in Europe. I had more interviews with European newspapers and radio shows than I did with American ones. The interviews I had in America were with the left wing, marginal media, which doesn’t have a very wide audience.
What about political responses?
In Britain foreign secretary Jack Straw issued a press statement attacking the findings. I was quite pleased that in Britain the compassion of the British people demanded an explanation from what was the second biggest member of the coalition that invaded Iraq.
I’m disappointed that there has been no similar protest or demand for explanation in the US. On the day of the presidential elections, if you believe the polls, 60 percent of the US public believed that evidence of weapons of mass destruction had been found in Iraq.
In Britain I understand that almost no one believes that.
Right from the start the US public was behind the invasion. After 9/11 there was a certain retaliatory mentality in the public which didn’t exist in Britain. People in Britain were against it from the start.
Our press is also much more “embedded” than yours. If you listen to the BBC you get a less jaundiced view than in the mainstream US media.
Your survey was published just before the US presidential election. You might have expected the Democrats to have an interest in raising its profile.
I can’t really speculate about that, but they didn’t. Democratic presidential candidate John Kerry voted in favour of the invasion of Iraq. Most of the Democratic Party went along with this. That makes them at the least complacent in this fiasco.
I get the impression from things you’ve said that you were opposed to the war. What impact did the survey have on you personally?
I’m not a pacifist. I’ve worked in places where I’ve wanted UN peacekeepers to come. I think there are problems in the world for which a military response might be appropriate.
But I think that in my country, in particular among the leaders of my country, there is a grossly inadequate understanding of what a horrible thing war is, and all the misery and suffering that goes with it. My country went to war much too flippantly. Our data strongly supports that.
I went to Iraq hoping I’d find fewer deaths. It certainly never occurred to me that I’d find more deaths caused by coalition forces than by non-coalition forces. Listening to the press in my country that would have been an unbelievable thing.
I’m convinced that the war has been a dismal failure. People in my country might not know that for years to come. But we’ve sown the seeds of hatred to an enormous extent.
- The survey found that the risk of death in Iraq was 2.5 times greater after the invasion.
- Two thirds of all violent deaths were reported in the city of Fallujah. But even if this data is excluded, the risk of death still increased 1.5 times.
- The survey estimates that 98,000 more deaths than would normally be expected took place in Iraq in the 17.8 months following the invasion. This figure excludes the Fallujah data. The figure is higher if the Fallujah data is included.
- Before the invasion the main causes of death were from natural causes like heart attacks, but after the invasion violent deaths increased by 58 times. These violent deaths accounted for most of the “excess deaths” in Iraq in the period studied.
- Most of the violent deaths were at the hands of the coalition forces, mainly through air strikes. Violent deaths were widespread and reported in 15 of the 33 areas studied. Most of the people said to have been killed were women or children, according to those interviewed.
- Mortality Before and After the 2003 Invasion of Iraq: Cluster Sample Survey was published in the Lancet. The authors are Les Roberts, Riyadh Lafta, Richard Garfield, Jamal Khudhairi and Gilbert Burnham. The report is available from the Lancet website. Go to www.thelancet.com (requires free online registration).
Speaking at a special lecture at London’s School of Hygiene and Tropical Medicine last week, Les Roberts said that the Lancet was chosen because it was the most highly regarded medical journal in the world, with the tightest peer-review procedures.
Two other estimates for those killed are mentioned in the interview.
Iraq Body Count
The Iraq Body Count is compiled by academics from press reports of deaths in Iraq. Go to www.iraqbodycount.net to see the latest figures.
According to the Lancet survey, Iraq Body Count gives a much lower figure because it is based on “passive surveillance” of news reports. However, “as a monitor of trends, it closely parallels the results found in this survey: most casualties arose after the end of major hostilities in May 2003, and the rate of civilian deaths has been rising in recent months up to November 2004”.
Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care
This paper was published in the New England Journal of Medicine. Go to www.nejm.org to read it online. This paper is based on interviews with army ground forces and returning Marines.
It estimates that 14 percent of US army ground forces and 28 percent of marines claimed responsibility for “the death of a non-combatant” in Iraq. According to Pentagon figures, by January 2005 1,048,884 US troops had served in Iraq.
These figures suggest that tens of thousands of Iraqis have died at the hands of US ground troops. And, as Les Roberts points out, most of the violent deaths in Iraq were caused by air strikes rather than ground troops.