20 January 2008

Shout with the largest: violent disagreement about Iraqi mortality rates

'It's always best on these occasions to do what the mob do.' 'But suppose there are two mobs?' suggested Mr. Snodgrass. 'Shout with the largest,' replied Mr. Pickwick.
~ Charles Dickens, The Pickwick Papers, Chapt. 13

An article in the New England Journal of Medicine was published on January 9, 2008 with new mortality statistics compiled by the Iraqi Ministry of Health under the sponsorship of the World Health Organization [1]. The study, by the innocuously named Iraq Family Health Survey Study Group (IFHSSG), concludes that 151,000 Iraqis suffered violent deaths between March 2003 and June 2006. A previous estimate, the highly controversial study published in the Lancet in October 2006 [2], suggested a much higher number: more than 600,000 deaths.

Les Roberts, a co-author of the Lancet survey (and an earlier one in 2004 [3]), has offered his response on Tim Lambert's Deltoid blog, which generated an enormous number of comments. The entire post reflects very well the politically charged controversy surrounding the issue of Iraqi mortality since the American-led invasion in March 2003. Roberts claims that there is more in common in the results than appears at first glance, and he continues to defend the conclusions of the two Lancet studies.

In an angry attack on the NEJM study in Counterpunch [4], Andrew Cockburn notes how their final tally of "only" 151,000 deaths has been greeted with respectful attention in US press reports, along with swipes at the Lancet effort for having, as the New York Times reminded readers, "come under criticism for its methodology." Cockburn argues forcefully that the IFHSSG study is guilty of sloppy methodology and tendentious reporting. He criticizes the NEJM for "lending its imprimatur to this farrago."

On September 14, 2007, ORB (Opinion Research Business), an independent UK-based polling agency, published a startling estimate of the total casualties of the Iraq war that has received little mention in the mainstream press. The figure suggested by ORB, which was based on survey responses from 1,499 adults, stands at more than 1.2 million deaths. The horrifying figures tallied by ORB — although its survey was conducted independently, using a different polling methodology — are consistent with the Lancet findings. One of the shocking results of the ORB analysis was that almost one in two households in Baghdad have lost a family member, significantly higher than in any other area of the country. The governorates of Diyala (42%) and Ninewa (35%) were next.

The reaction to the ORB report in the US political and media establishment was virtual silence. There was no comment from the Bush White House, the Pentagon, or the State Department; not a single Republican or Democratic presidential candidate or congressional leader made an issue of it; nor was the subject raised on the Sunday morning TV talk shows. Perhaps their attention was diverted by events in Iraq itself, for it was at this same time that eight civilians were reported killed by private US "security contractors" in a ghastly Baghdad shootout. That story was heavily covered by all the media for days afterward.

At the other end of the Iraq mortality scale, the Iraq Body Count website, which has strongly criticized the Lancet studies, estimates the death toll by violence at between 80,000 and 88,000. IBC's results are based on English-language media reports only, and are accurate as far as they go. They do not even attempt to estimate the number of deaths resulting from the dreadful conditions prevailing in Iraq.

As Stalin is said to have observed: A single death is a tragedy; a million deaths is a statistic. Aside from moral considerations and the ideological wars well documented in various sources [5-8], the difficulty with Iraq mortality numbers seems to involve methodological differences with regard to non-violent death. The Lancet studies and the ORB poll include estimates of mortality occasioned by other means than bombs or bullets. Hence the enormous casualty rates reported in those surveys. The problem with this month's NEJM study is that only violent deaths "count," as if people dying from poverty, lamentable public health conditions, poor nutrition, or terrible health care are somehow less dead, or as if the increase in their numbers is any less attributable to the invasion.

Illustrative of how the Iraq mortality debate has become a touchstone for broad ideological differences is that the media reaction to the Lancet studies is even being used by statistics teachers to highlight the role of politics in the framing of statistical findings. Les Roberts himself has commented on the controversy surrounding his research: "It is odd that the logic of epidemiology embraced by the press every day regarding new drugs or health risks somehow changes when the mechanism of death is their armed forces" [5]. De Maio [9] discusses how class discussions can be based around this quotation to explore the complex interplay between hierarchies of credibility, claims of scientific precision, and political standpoints. It is interesting to note the contrasting receptions given in the media to Robert's Iraq surveys and a study that Roberts led in the Congo using a very similar methodology [7]. The conclusions of the latter were accepted unquestioningly by the press and political leaders alike [6].

What exactly the intentions of the authors of the NEJM article were when they undertook their survey is a matter for debate. While to some their results will look like a whitewash, it does not appear that their work was dishonest or deliberate propaganda. Unfortunately, it has entered public discourse primarily in terms of its disapprobation of the Lancet survey (the ORB report is still under the radar). That is the way it is going to be used, and almost all the attention given to the problems and complications pointed out by Roberts and others will be confined to a small number of commentators and scholars. Lenin's Tomb commented: "Whatever the intentions of the ministry of health workers who carried out this study, its findings are now out of their hands. It is now a weapon for neutralising the findings of the Lancet survey."

Counterspin on the Lancet studies is still in full swing. Witness the oddball critique just published in the National journal [10], which goes so far as to suggest that The Lancet was a victim of "wartime fraud." The article's author, Neil Munro, also claims that jihadists "used this research as a justification for killing Americans." (In 2001 Munro looked forward to the destruction of Iraq in an enthusiastic opinion piece for the right-wing National review online entitled "The Iraqi opportunity: Berlin '45. Tokyo '45. Baghdad '02." He was off by a year.)

Meanwhile, in numbers that still remain undetermined — but that everyone agrees are horribly excessive — Iraqis continue to die. Kieran Healy at Crooked Timber has nicely summed up the disagreements among epidemiologists, politicians, statisticians, ideologues, intellectuals, and wing-nuts:

The main challenge facing those doing this sort of research is that there is a war going on, and wars kill a lot of people, bring about the dissolution of households, and compel very large numbers of people to flee the region. All of this makes the machinery of statistical science rather difficult to apply. None of the available numbers look any good, both on their own and given what they imply about what’s happening in Iraqi society. If you find yourself really delighted that a war of choice has resulted in the deaths of a population the size of Jersey City, or maybe Oakland, instead of one the size of Baltimore, you probably need to rethink your priorities.


1. Iraq Family Health Survey Study Group. Violence-related mortality in Iraq from 2002 to 2006. N Engl J Med. [Internet]. 2008 Jan 9 [cited 2008 Jan 20]. Available from: http://content.nejm.org/cgi/content/full/NEJMsa0707782

2. Burnham G, Lafta R, Doocy S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006 Oct 21;368(9545):1421-8.

3. Roberts L, Lafta R, Garfield R, Khudhairi J, Burnham G. Mortality before and after the 2003 invasion of Iraq: cluster sample survey. Lancet. 2004 Nov 20-26;364(9448):1857-64.

4. Cockburn A. Gross distortions, sloppy methodology and tendentious reporting: how the New England Journal Of Medicine undercounted Iraqi civilian deaths. Counterpunch [serial on the Internet]. 2008 Jan 12/13. [cited 2008 Jan 20]. Available from: http://www.counterpunch.org/andrew01122008.html

5. Medialens. Burying the Lancet – Part 1. [blog on the Internet] 2005 Sep 5 [cited 2008 Jan 20]. Available from: http://www.medialens.org/alerts/05/050905_burying_the_lancet_part1.php.

6. Medialens. Burying the Lancet – Part 2. [blog on the Internet] 2005 Sep 6 [cited 2008 Jan 20]. Available from: http://www.medialens.org/alerts/05/050906_burying_the_lancet_part2.php

7. Guterman L. Researchers who rushed into print a study of Iraqi civilian deaths now wonder why it was ignored. The Chronicle of Higher Education. 2005 Jan 27. [cited 2008 Jan 20]. Available from: http://chronicle.com/free/2005/01/2005012701n.htm.

8. Wikipedia. Lancet surveys of Iraq War casualities. [Internet]. [cited 2008 Jan 20]. Available from:

9. De Maio F. Statistics in the news: estimating mortality in war-time Iraq: a controversial survey with important lessons for students. Teaching statistics. 2007 Jun;29(2):34-7.

10. Munro N, Cannon CM. Data bomb. National journal [serial on the Internet]. 2008 Jan 4 [cited 2008 Jan 20]. Available from: http://news.nationaljournal.com/articles/databomb/index.htm