100,000 Iraqi civilians have died as a result of the March 2003 invasion

Public-health experts from the USA and Iraq estimate that around 100,000 Iraqi civilians have died as a result of the March 2003 invasion-the majority being violent deaths among women and children relating to military activity. Results of the research, done among clusters of Iraqi households last month, is published online by THE LANCET.

Les Roberts (Johns Hopkins Bloomberg School of Public Health, Baltimore, USA) and colleagues did a survey to investigate the effect of the Iraq war on civilian deaths by comparing mortality during the 14.6 months before the March 2003 invasion with the 17.8 months after it. The investigators interviewed a total of 988 households from 33 randomly selected neighbourhoods of Iraq; in those households reporting deaths since January 2002, the date, cause, and circumstances of violent deaths were recorded.

Overall, the risk of death was 2.5 times greater after the invasion, although the risk was 1.5 times higher if mortality around Falluja (where two-thirds of violent deaths were reported) is excluded. The investigators estimate that a 1.5 times increase in deaths equates to an excess of 98,000 deaths relating to the Iraq conflict, although this estimate would be much greater if Falluja data is included.

Violence was the primary cause of death after the invasion; Violent deaths were widespread, reported in 15 of 33 clusters surveyed, and were mainly attributed to coalition forces (predominantly air strikes). Most individuals reportedly killed by coalition forces were women and children. The risk of death from violence in the period after the invasion was 58 times higher than in the period before the war. The major causes of death before the invasion were heart attack, stroke, and chronic illness.

Dr Roberts comments: "Making conservative assumptions, we think that about 100 000 excess deaths or more have happened since the 2003 invasion of Iraq. Violence accounted for most of the excess deaths and air strikes from coalition forces accounted for most violent deaths. We have shown that the collection of public-health information is possible even during periods of extreme violence. Our results need further verification and should lead to changes to reduce non-combatant deaths from air strikes."

Lancet Editor Richard Horton adds in an accompanying commentary: "The research we publish today was completed under the most testing of circumstances - an ongoing war. And therefore certain limitations were inevitable and need to be acknowledged right away. The number of population clusters chosen for sampling is small; the confidence intervals around the point estimates of mortality are wide; the Falluja cluster has an especially high mortality and so is atypical of the rest of the sample; and there is clearly the potential for recall bias among those interviewed. This remarkable piece of work represents the efforts of a courageous team of scientists. To have included more clusters would have improved the precision of their findings, but at an enormous and unacceptable risk to the team of interviewers who gathered the primary data. Despite these unusual challenges, the central observation - namely, that civilian mortality since the war has risen due to the effects of aerial weaponry - is convincing. This result requires an urgent political and military response if the confidence of ordinary Iraqis in the mostly American-British occupation is to be restored."

He continues: "Roberts and his colleagues submitted their work to us at the beginning of October. Their paper has been extensively peer-reviewed, revised, edited, and fast-tracked to publication because of its importance to the evolving security situation in Iraq. But these findings also raise questions for those far removed from Iraq - in the governments of the countries responsible for launching a pre-emptive war. In planning this war, the coalition forces - especially those of the US and UK - must have considered the likely effects of their actions for civilians. And these consequences presumably influenced deployments of armed forces, provision of supplies, and investments in building a safe and secure physical and human infrastructure in the post-war setting. With the admitted benefit of hindsight and from a purely public-health perspective, it is clear that whatever planning did take place was grievously in error. The invasion of Iraq, the displacement of a cruel dictator, and the attempt to impose a liberal democracy by force have, by themselves, been insufficient to bring peace and security to the civilian population. Democratic imperialism has led to more deaths not fewer. This political and military failure continues to cause scores of casualties among non-combatants. It is a failure that deserves to be a serious subject for research. But this report is more than a piece of academic investigation."

Dr Horton concludes: "A vital principle of public health is harm reduction. But harm cannot be diminished by individual members of society alone. The lives of Iraqis are currently being shaped by the policies of the occupying forces and the militant insurgents. For the occupiers, winning the peace now demands a thorough reappraisal of strategy and tactics to prevent further unnecessary human casualties. For the sake of a country in crisis and for a people under daily threat of violence, the evidence that we publish today must change heads as well as pierce hearts."