Counting the dead in Iraq

BMJ 2005;330:550-551 (12 March), doi:10.1136/bmj.330.7491.550

We need to know how many people have died

Counting the dead is intrinsic to civilised society. Understanding the causes of death is a core public health responsibility. The government's white paper on public health emphasises the vital role of assessing the impact on health of all public policy.1 This is well recognised, and yet neither the public nor public health professionals are able to obtain reliable and officially endorsed information about the extent of civilian deaths attributable to the allied invasion of Iraq. Estimates vary between tens and hundreds of thousands.

These estimates come from reports in the press, or counting bodies admitted to hospitals, (www.iraqbodycount.net) as well as surveys. The former are likely to be inaccurate and to underestimate the true numbers and do not easily allow for reliable attribution between, for example, violent and natural causes. Public access to reliable data on mortality is important. The policy being assessed—the allied invasion of Iraq—was justified largely on grounds of democratic supremacy. Voters in the countries that initiated the war, and others—not least in Iraq itself—are denied a reliable evaluation of a key indicator of the success of that policy. This is unacceptable.

Instead the UK government's policy was first not to count at all, and then to rely publicly on extremely limited data available from the Iraqi Ministry of Health. This follows US government policy; famously encapsulated by General Tommy Franks of the US Central Command "We don't do body counts."2 Its inadequacy was emphasised after the publication of a representative household survey that estimated 100 000 excess deaths since the 2003 invasion.3 The government rejected this survey and its estimates as unreliable; in part absurdly because statistical extrapolation from samples was thought invalid.4 Imprecise they are, but to a known extent. These are unique estimates from a dispassionate survey conducted in the most dangerous of epidemiological conditions. Hence the estimates, as far as they can go, are unlikely to be biased, even allowing for the reinstatement of Falluja. To confuse imprecision with bias is unjustified.

The methods for counting the dead in such circumstances are well established and cannot rely on incidental reports or assessments in hospital mortuaries alone. They require first hand verbal autopsies,5 which should be reliably obtained so that extrapolation to the population is possible, as Roberts et al had done. They also require some linkage with unclassified data on military offensives.6 Although active surveillance of this kind is extremely difficult in the context of such violence, even limited household surveys are essential so long as they are systematic. Such data can then be combined with information from passive sources to establish a more accurate overall assessment.

Counting casualties accurately can help to save lives both currently and in the future. Understanding the burden of death, injury, disease, and trauma that the population is currently suffering enables proper planning of war, and health, and in assessing local responses appropriately. In the future this should help government and military planners to assess the likely humanitarian implications of conflict.

The plain fact is that an estimate of 100 000 excess deaths attributable to the invasion of Iraq is alarming. This is already half the death toll of Hiroshima.7 Apart from the practical arguments, the principled ones stand and will always stand. Have we not learnt any lessons from the history of sweeping alarming numbers of deaths under the carpet? This is not something about which there can be any political discretion 60 years after Auschwitz. The UK government, acting on our behalf, ought to offer reasoned criticism of the existing estimates. It should pursue their public health responsibilities to count the casualties by using modern methods. Democracy requires this, as does proper responsibility under the Geneva Conventions.

The sources the government prefers are likely to be seriously biased for several reasons. They do not take into account deaths during the first 12 months since the invasion8; only violence related deaths reported through the health system are taken into account (very likely to lead to an underestimate9); and non-violent deaths due to the destruction of war are not taken into account. Furthermore, even these limited figures are no longer being released on request.10

Apparently the defence ministry has set up an appraisal group,11 but we urgently await transparency and public accountability. The time elapsed since the announcement is already longer than it took to conduct the field survey last year. Electorates, in Iraq and elsewhere, have a right to know. To procrastinate further for no good reason is to devalue public health processes, not to mention Iraqi lives. As public health professionals we need to know the health costs.

Klim McPherson, visiting professor of public health epidemiology

bmj.bmjjournals.com

[2003-2004] - .over 100,000 have died under Bush & Blairs FAKE WAR...

On Friday 29th October 2004, the Lancet medical journal published a study of post-war mortality in Iraq which estimated that at least 100,000 excess civilian deaths had occurred since the 2003 invasion; that most were caused by violence; and that most of those violent deaths were caused by coalition air strikes.

In his daily press briefing that morning, the Prime Minister's Official Spokesperson (PMOS) dismissed the study since its methodology was, he claimed, inappropriate:

"Asked if the Prime Minister was concerned about a survey published today suggesting that 100,000 Iraqi civilians had died as a result of the war in Iraq, the PMOS said that it was important to treat the figures with caution because there were a number of concerns and doubts about the methodology that had been used. Firstly, the survey appeared to be based on an extrapolation technique rather than a detailed body count. Our worries centred on the fact that the technique in question appeared to treat Iraq as if every area was one and the same. In terms of the level of conflict, that was definitely not the case. Secondly, the survey appeared to assume that bombing had taken place throughout Iraq. Again, that was not true. It had been focussed primarily on areas such as Fallujah. Consequently, we did not believe that extrapolation was an appropriate technique to use."

These criticisms of the Lancet mortality survey were repeated again on 1st November. They are misleading, and almost entirely unfounded. This briefing note examines the claims of the Prime Minister's Official Spokesperson. - casi.org.uk

Mortgage Can be a Health Deficit

Coping with a mortgage can be more than a financial burden, it can also take a toll on your health.

The British Medical Association (BMA) says people who fall behind on mortgage payments are at increased risk of a number of serious health problems, including stroke and heart disease, BBC News Online reports.

In a report called "Housing and Health," the BMA says "mortgage arrears and home repossessions" must be recognized as a major health issue. It says the government needs to address the issue and ensure assistance for homeowners having trouble meeting their mortgage payments. - HON Highlights

Ready for anything: a capital response [excerpt]

The response to the 9/11 stretched far further than transport, although the railway and the Tube were always considered as the most likely sites to be attacked. The government established London Resilience, a committee encompassing a whole swathe of organisations which would become involved in the event of such an emergency. It is 'an inter-agency team led by a senior civil servant, with experts from the emergency services, transport operators, utilities, NHS and local government [which] was commissioned to review London's preparedness'.

The assessment in the light of 9/11 was that while the emergency services were reasonably well geared up to tackle events which had happened before such as train crashes or major fires, work was needed to develop better coordination and planning for new threats such as those posed by the new form of terrorism. London Resilience was therefore made a permanent body overseen by a forum, chaired by a government minister (originally Nick Raynsford but since the election Phil Woolas) and with Ken Livingstone, the mayor, as his deputy. It has a permanent team at its disposal, based in the Government Office for London with membership of a core of civil servants supplemented by people from 14 organisations including the obvious ones such as the Metropolitan Police and the London Fire Brigade but also British Telecom and the Salvation Army.

The system that has emerged from the work of London Resilience is now well coordinated and rehearsed. That was apparent from the immediate response. By 9am, less than 10 minutes after the first three bombs went off, the various parties involved were having a conference call. Emergency control centres at Network Rail's headquarters in Euston, at London Underground's famous 55 Broadway head office and at the Metropolitan Police's centre at Hendon were opened up. The latter also includes the Fire Brigade and the Ambulance service, ensuring coordination between all three emergency services.

Crucially, liaison officers between these three organisations - codenamed gold, while most other major organisations are silver and local level ones are bronze - were despatched to the other centres in order to improve coordination. As one senior rail manager put it to Public Finance, 'the days of freelance action by one party are over'.

Suggestions in the press earlier this week that there had been a twenty minute delay before a full emergency was declared were roundly dismissed by Transport for London: 'The implication that nothing much happened during that period is pure rubbish', said a spokesman.

The rapid response was helped by good luck too. At the time the bombs went off, a meeting was taking place of paramedics and others involved in emergency plans and they were quickly despatched to the various sites. Speed is crucial in trauma cases, with the treatment in the first 15 minutes often determining life or death. There was also at the time a meeting of senior Network Rail staff in the Russell Hotel, yards from the Tavistock Square and Russell Square tube station, and, donning their emergency jackets, they were quickly able to help out at the two nearby scenes of bombings, King's Cross and Tavistock Square. christian wolmar

A British Medical Journal clinical editor who trained in medicine at the University of Auckland, she was among British Medical Association staff who ran to help after the bus exploded in Tavistock Square outside their office on July 7, killing 13 people.

In the hotel next door that became a makeshift hospital, Dr Oates-Whitehead was checking the blood pressure of a woman with chest pains when a police officer and a fireman asked her in low voices if she would come to the bus.

A second bomb was feared to be in it, they said, and emergency staff were being moved away. But they needed one doctor to assist as firemen cut two badly injured people out of the wreckage. Would she come? They would understand if she declined.

Dr Oates-Whitehead agreed immediately without pondering the risks. "There was no room for hesitation - I wasn't thinking at that level," she told the Weekend Herald from her home in west London. "It was the moral and ethical thing to do." from a now missing news item in the New Zealand Herald [found on this blog]

was their a second bomb alert?

[Up to 100 members of the Church of Scientology in garish yellow jackets?]

[Richmal Oates-Whitehead]

The BMJ Publishing Group released a statement during the week saying it had received queries about Ms Oates-Whitehead's professional qualifications.

"The matter of her professional standing is currently being investigated," it said.

Ms Oates-Whitehead's cousin, Gisborne man Jim Whitehead, said she suffered from epilepsy. She had not qualified as a doctor in New Zealand but was well-qualified, he told NZPA today. "She may well have gone to the UK and done that (trained as a doctor).

"She was certainly no slouch. She was an intelligent person, so for her to have done that would not be unreasonable."

Mr Whitehead said Ms Oates-Whitehead had a brother. - stuff.co.nz

London bomb 'heroine' living a life of make-believe

21 August 2005 By GREG MEYLAN

Richmal Oates-Whitehead always dreamed of being a doctor and for a few chaotic, adrenaline-filled hours she was, tending to the wounded victims of London's deadly July 7 terrorist attacks. But that day's events also uncovered a deception that led to the 35-year-old Kiwi being found dead in her London home on Wednesday. The life of the woman who always carried a stethoscope in her handbag was a mix of truth and fiction. She said she was being stalked, that her partner was a retired professor in obstetrics, that she had given birth to twins who died, was receiving treatment for cancer and suffered from multiple sclerosis, all or some of which were make-believe.

An Auckland medical professional felt threatened by Oates-Whitehead and was concerned she was modelling her fictitious life after her own.

[Note: no names given]

Three weeks ago, Oates-Whitehead smiled from the front page of the Weekend Herald, beside an article about her bravely administering emergency aid to survivors of the Tavistock Square bus bombing.