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February 2006

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Burying The Lancet Report

By Nicolas j. s. Davies
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O ver a year ago an international team of epidemiologists, head- ed by Les Roberts of Johns Hop- kins School of Public Health, completed a “cluster sample survey” of civilian casualties in Iraq. Its findings contradicted central elements of what politicians and journalists had presented to the U.S. public and the world. After excluding any possible statistical anomalies, they estimated that at least 98,000 Iraqi civilians had died in the previous 18 months as a direct result of the invasion and occupation of their country. They also found that violence had become the leading cause of death in Iraq during that period. Their most significant finding was that the vast majority (79 percent) of violent deaths were caused by “coalition” forces using “helicopter gunships, rockets or other forms of aerial weaponry,” and that almost half (48 percent) of these were children, with a median age of 8. 

When the team’s findings were published in the Lancet , the official journal of the British Medical Association, they caused quite a stir and it seemed that the first step had been taken toward a realistic accounting of the human cost of the war. The authors made it clear that their results were approximate. They discussed the limitations of their methodology at length and emphasized that further research would be invaluable in giving a more precise picture. 

A year later, we do not have a more precise picture. Soon after the study was published, U.S. and British officials launched a concerted campaign to discredit its authors and marginalize their findings without seriously addressing the validity of their methods or presenting any evidence to challenge their conclusions. Today the continuing aerial bombardment of Iraq is still a dark secret to most Americans and the media present the same general picture of the war, focusing on secondary sources of violence. 

Roberts has been puzzled and disturbed by this response to his work, which stands in sharp contrast to the way the same governments responded to a similar study he led in the Democratic Republic of Congo in 2000. In that case, he reported that about 1.7 million people had died during 22 months of war and, as he says, “Tony Blair and Colin Powell quoted those results time and time again without any question as to the precision or validity.” In fact the UN Security Council promptly called for the withdrawal of foreign armies from the Congo and the U.S. State Department cited his study in announcing a grant of $10 million for humanitarian aid. 

Roberts conducted a follow-up study in the Congo that raised the fatality estimate to three million and Tony Blair cited that figure in his address to the 2001 Labor Party conference. In December 2004 Blair dismissed the epidemiological team’s work in Iraq, claiming, “Figures from the Iraqi Ministry of Health, which are a survey from the hospitals there, are in our view the most accurate survey there is.” 

This statement by Blair is particularly interesting because the Iraqi Health Ministry reports, whose accuracy he praised, have confirmed the Johns Hopkins team’s conclusion that aerial attacks by “coalition” forces are the leading cause of civilian deaths. One such report was cited by Nancy Youssef in the Miami Herald of September 25, 2004 under the headline “U.S. Attacks, Not Insurgents, Blamed for Most Iraqi Deaths.” The Health Ministry had been reporting civilian casualty figures based on reports from hospitals, as Blair said, but it was not until June 2004 that it began to differentiate between casualties inflicted by “coalition” forces and those from other causes. From June 10 to September 10 it counted 1,295 civilians killed by U.S. forces and their allies and 516 kill- ed in “terrorist” operations. Health Ministry officials told Youssef that the “statistics captured only part of the death toll,” and emphasized that aerial bombardment was largely responsible for the higher numbers of deaths caused by the “coalition.” The breakdown (72 percent U.S.) is remarkably close to that attributed to aerial bombardment in the Lancet survey (79 percent). 

BBC World Affairs editor John Simpson, in another Health Minis- try report covering July 1, 2004 to January 1, 2005, cited 2,041 civilians killed by U.S. and allied forces versus 1,233 by “insurgents” (only 62 percent U.S.). Then something strange happened. The Iraqi Health Minister’s office contacted the BBC and claimed, in a convoluted and confusing statement, that their figures had somehow been misrepresented. The BBC issued a retraction and details of deaths caused by “coalition” forces have been notably absent from subsequent Health Ministry reports. 

Official and media criticism of Roberts’s work has focused on the size of his sample, 988 homes in 33 clusters distributed throughout the country, but other epidemiologists reject the notion that this is controversial. 

Michael O’Toole, the director of the Center for International Health in Australia, says: “That’s a classical sample size. I just don’t see any evidence of significant exaggeration…. If anything, the deaths may have been higher because what they are unable to do is survey families where everyone has died.” 

David Meddings, a medical officer with the Department of Injuries and Violence Prevention at the World Health Organization, said that surveys of this kind always have uncertainty, but “I don’t think the authors ignored that or understated. Those cautions I don’t believe should be applied any more or less stringently to a study that looks at a politically sensitive conflict than to a study that looks at a pill for heart disease.” 

Roberts has also compared his work in Iraq to other epidemiological studies: “In 1993, when the U.S. Centers for Disease Control randomly called 613 households in Milwaukee and concluded that 403,000 people had developed Cryptosporidium in the largest outbreak ever recorded in the developed world, no one said that 613 households was not a big enough sample. 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.” 

The campaign to discredit Roberts, the Johns Hopkins team, and the Lancet used the same methods that the U.S. and British governments have employed consistently to protect their monopoly on “responsible” storytelling about the war. By dismissing the study’s findings out of hand, U.S. and British officials created the illusion that the authors were suspect or politically motivated and discouraged the media from taking them seriously. This worked disturbingly well. Even opponents of the war continue to cite much lower figures for civilian casualties and innocently attribute the bulk of them to Iraqi resistance forces or “terrorists.” 

The figures most often cited for civilian casualties in Iraq are those collected by Iraqbodycount, but its figures are not intended as an estimate of total casualties. Its methodology is to count only those deaths that are reported by at least two “reputable” international media outlets in order to generate a minimum number that is more or less indisputable. Its authors know that thousands of deaths go unreported in their count and say they cannot prevent the media misrepresenting their figures as an actual estimate of deaths. 

Beyond the phony controversy regarding the methodology of the Lancet report, there is one issue that does cast doubt on its findings. This is the decision to exclude the cluster in Fallujah from its computations due to the much higher number of deaths that were reported there (even though the survey was completed before the wide- ly reported assault on the city in November 2004). Roberts wrote, in a letter to the Independent , “Please understand how extremely conservative we were: we did a survey estimating that 285,000 people have died due to the first 18 months of invasion and occupation and we reported it as at least 100,000.” 

The dilemma he faced was this: in the 33 clusters surveyed, 18 reported no violent deaths (including one in Sadr City), 14 other clusters reported a total of 21 violent deaths and the Fallujah cluster reported 52 violent deaths. This last number is conservative because, as the report stated, “23 households of 52 visited were either temporarily or permanently abandoned. Neighbors interviewed described widespread death in most of the abandoned homes but could not give adequate details for inclusion in the survey.” 

Leaving aside this last factor, there were three possible interpretations of the results from Fallujah. The first, and indeed the one Roberts adopted, was that the team had randomly stumbled on a cluster of homes where the death toll was so high as to be totally unrepresentative and therefore not relevant to the survey. The second possibility was that this pattern among the 33 clusters, with most of the casualties falling in one cluster and many clusters reporting zero deaths, was an accurate representation of the distribution of civilian casualties in Iraq under “precision” aerial bombardment. The third possibility was that the Fallujah cluster was atypical, but not sufficiently abnormal to warrant total exclusion from the study, so that the number of excess deaths was somewhere between 100,000 and 285,000. Without further research, there is no way to determine which of these three possibilities is correct.

No new survey of civilians killed by “coalition” forces has been produced since the Health Ministry report last January, but there is strong evidence that the air war has intensified during this period. Independent journalists have described the continuing U.S. assault on Ramadi as “Fallujah in slow motion.” Smaller towns in Anbar province have been targets of air raids for the past several months, and towns in Diyala and Baghdad provinces have also been bombed. Seymour Hersh has covered the “under-reported” air war in the New Yorker and writes that the current U.S. strategy is to embed U.S. Special Forces with Iraqi forces to call in air strikes as U.S. ground forces withdraw, opening the way for heavier bombing with even less media scrutiny (if that is possible). 

One ignored feature of the survey’s results is the high number of civilian casualties reported in Fallujah in August 2004. It appears that U.S. forces took advantage of the media focus on Najaf at that time to conduct very heavy attacks against Fallujah. This is perhaps a clue to the strategy by which they have conducted much of the air war. The heaviest bombing and aerial assault at any given time is likely to be somewhere well over the horizon from any well-publicized U.S. military operation, possibly involving only small teams of Special Forces on the ground. But cynical military strategy does not let the media off the hook for their failure to find out what is really going on and tell the outside world about it. Iraqi and other Arab journalists can still travel through most of the country and news editors should pay close attention to their reports from areas that are too dangerous for Western reporters. 

A second feature of the epi- demiologists’ findings that has not been sufficiently explored is the one suggested above by Michael O’Toole. Since their report establishes that aerial assault and bombardment is the leading cause of violent death in Iraq and, since a direct hit by a 500 pound Mark 82 bomb will render most houses uninhabitable, any survey that disregards damaged, uninhabited houses is sure to underreport deaths. This should be taken into account by any follow-up studies. 

Thanks to Roberts, his international team, Johns Hopkins School of Public Health, and the editorial board of the Lancet , we have a clearer picture of the violence taking place in Iraq than that presented by “mainstream” media. Allowing for 16 months of the air war and other deaths since the completion of the survey, we have to estimate that somewhere between 185,000 and 700,000 people have died as a direct result of the war. Coalition forces have killed anywhere from 70,000 to 500,000 of them, including 30,000 to 275,000 children under the age of 15. 

Roberts has cautioned me to remember that whether someone is killed by a bomb, a heart attack during an air strike, or a car accident fleeing the chaos, those who initiated the war and who “stay the course” bear the responsibility. 

As someone who has followed this war closely, I find the results of the study to be consistent with what I have seen gradually emerging as the war has progressed, based on the work of courageous, mostly independent reporters, and glimpses through the looking glass as more and more cracks appear in the “official story.”

Nicolas J.S. Davies is indebted to Med- ialens, a British media watchdog group, for some of the material in this report. This article was first published by Online Journal. 
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