Some critics of previously controversial survey methods praise new approach, while others remain skeptical
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The study, — a collaboration of researchers in the U.S., Canada and Iraq appearing in the journal PLoS Medicine — included a survey of 2,000 Iraqi households in 100 geographic regions in Iraq. Researchers used two surveys, one involving the household and another asking residents about their siblings, in an attempt to demonstrate the accuracy of the data they were collecting. Using data from these surveys, researchers estimated 405,000 deaths, with another 55,800 projected deaths from the extensive migration in and emigration from Iraq occurring as a result of the war.
The researchers estimated that 60 percent of the deaths were violent, with the remaining 40 percent occurring because of the health-infrastructure issues that arose as a result of the invasion — a point they emphasized in discussing their research, since the figure is higher than those found in previous studies.
“I hope that one of the takeaways from this paper will be that when we invade a country, there are many health consequences that aren’t directly related to violence,” said study author Amy Hagopian, program director of the community-oriented public-health practice at the University of Washington School of Public Health. She said approximately half those deaths were attributed to inadequate treatment for cardiovascular disease.
To conduct the household surveys, researchers worked with volunteer Iraqi scientists and improved on the methods used for similar surveys in the past. Because the survey was conducted in mid-2011, researchers were able to access more areas of the country safely. The households surveyed were chosen by a grid placed on Google Maps, and a home was selected by a quadrant in that grid from randomly generated numbers. Ultimately, the researchers were able to survey twice as many areas as previous studies and had a more random selection of homes, avoiding the past problems of home selection by the survey takers on the ground, who may have been more likely to approach homes along more-traveled streets.
The more thorough investigation may negate some of the criticism levied against past studies on Iraqi mortality after the invasion, which were published in the medical journal The Lancet in 2004 and 2006. The 2006 study in particular was a subject of scrutiny because it estimated a toll of 655,000 excess deaths, mostly violent, at a time when other surveys had five-digit death tolls.
New access, new method
The central criticism of that study focused on the number of areas surveyed, with 50 clusters instead of the 100 in the new study, which may have distorted the numbers but was the result of safety concerns at the time.
“The problem in conflict is you’re putting researchers at risk, interviewers at risk in these areas,” said Dr. Gilbert Burnham, a co-director of the center for refugee and disaster response at the Johns Hopkins Bloomberg School of Public Health, who was an author on both Lancet studies and the new one.
Researchers who were critical of earlier work by Burnham and his colleagues praised the new study for improvements in the methods but said there was still something lacking.
“I can see that over the years in this type of research, they made an attempt to be more rigorous, and that is very good,” said Beth Osborne Daponte of Social Science Consultants, who was involved in tallying mortality in Iraq during the first Gulf War. But, she added, “there’s a tremendous amount of uncertainty here.”
“This one is very much better than the last one because they’ve actually eliminated quite a bit of the methodological shortcomings. The result is the numbers plummet,” said Michael Spagat, head of the department of economics at Royal Holloway University of London. “There’s huge vindication for the critics here — the fact that the numbers have gone down so much.”
For his part, Burnham defended the results of both studies.
“From a statistical standpoint, the numbers are not really different from each other,” he said. “These represent estimates, and that’s what we’ve always said.”
Spagat said that while the numbers have become more accurate, he does not feel the authors have done much to address past criticisms, changing methods without acknowledging the flaws of past work. An analyst for the Iraq Body Count, which tracks violent civilian deaths in Iraq using confirmed violent deaths and therefore should be considered a low-end estimate, echoed those sentiments.
“Hopefully, the widespread reporting of this study can contribute towards a more mature and reflective attitude among those who may have too easily latched onto conveniently massive round numbers as political footballs,” said Hamit Dardagan, an analyst for Iraq Body Count, in an email to Al Jazeera. “It might also help if the authors were a little more forthcoming in acknowledging and perhaps exploring the discrepancies between the earlier work and the new study, whose results are much less of an outlier amongst the various existing estimates for deaths from violence.”
Spagat, who was a vocal critic of the 2006 Lancet paper, said that too much of the discussion in the media criticizing the study focused on funding sources (the 2006 study was funded in part by a group funded by left-leaning billionaire George Soros) and that it was not focused where it should have been: on methods in the study that could have been done better and would have made the numbers more accurate.
“I’m sure Soros’ people there would be … pretty happy if the results would come out with a high estimate, but that doesn’t mean instantly the survey is wrong,” he said.
The new study says support “came from pooled internal resources by the American and Canadian researchers without external funding. No funding bodies had any role in study design, data collection and analysis, decision to publish or preparation of the manuscript.”
Public misperception
Spagat said the public should be largely aware of the death toll from the Iraq war by now, but it’s not clear that that is the case. While even the most conservative estimates of mortality in Iraq — including the Iraq Body Count — have reached six figures, polling in the U.S. (PDF) and U.K. (PDF) have shown public perception to be that the civilian death toll from the war is in the neighborhood of 10,000.
Although the Lancet studies may have resulted in a high estimate, others in the field who have conducted similar research have defended them.
“(The Lancet study from 2006) was too high, and the others were too low,” said Dr. Paul B. Spiegel, deputy director of the division of program support and management at the United Nations High Commissioner for Refugees, who has conducted similar research in refugee populations and examined mortality after the war in Kosovo. “In my view, the other surveys that they did should not be discredited, because the methods they used were accepted at the time.”
“They were countering the other, too-low studies. The public may not have been aware of the magnitude of the deaths going on at that time if not for those studies,” Spiegel added.
While the decision to go to war in Iraq and the exact nature of that decision’s consequences are likely to remain a topic of debate for some time, the new study’s editor said the emphasis should be moved to how to lessen the war’s toll going forward.
“We’ll never know the true number of people who died as a result of the war,” said Edward Mills, Canada research chair in global health at the University of Ottawa. “You just can’t come up with a number that’s going to be the absolute number.”
He said at this point the focus should be on rebuilding Iraq, calling on Canada and European nations not involved in the war to become involved in this effort.
“I think that the period of contention is over, and the focus now should not be on putting the blame on anyone,” he said, “but on how do we figure out rebuilding the health structure in this environment.”
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