Iraq Body Count: Don't Ask, Don't Tell

At the intersection of global health and politics is the most recent estimate of excess deaths among Iraq's population, published in the Lancet, by researchers from the Johns Hopkins School of Public Health. The estimate of about 650,000 deaths, with an uncertainty range of roughly 300,000 to 900,000, has been summarily dismissed by government officials who cite far lower mortality estimates from sources that depend on limited counts (Baghdad-only) and/or ad hoc methods of measurement (toting up casualties in media reports). The new figures have also been derided in parts of the blogosphere, with outraged commentaries based in part on the proposition that public health is a bastion of left wing ideologues. However, as highlighted by the Chicago Tribune's Judith Graham, one the few journalists who took the estimates seriously enough to talk to a range of experts in survey methodology and statistics, this may well be the best estimate out there; few if any other estimates are based on any scientific method whatsoever.

The U.S. Administration, despite its elaborate efforts to quantify the benefits of state-building (.pdf), has made no serious attempts to scientifically estimate the direct and indirect civilian casualties in this war. And the Congress appears to be more interested in budgeting for a $20 million celebration of the war than in devoting a few dollars to get a decent estimate of the losses.

Discourse in public health, particularly when it's about the health of the public in countries other than our own, is often a numbers game. "What counts is what gets counted" when real-world, highly contentious policy questions are answered by invoking body counts. The number of deaths and/or illnesses from particular causes or in certain countries is used to justify priorities in resource allocation. Just watch the advocacy for AIDS, TB and malaria to see this in action.

It is right that facts should inform how much money we spend and how we spend it. And when information is so important for policy making, we have to place priority on getting the numbers as close to right as possible, so they become tools for good decisions not instruments of advocacy. Investments must be made to develop and apply methods that are widely vetted, and to collect and analyze data in way that is beyond the influence of a particular political perspective.

There is a long way to go toward perfection, but the burden of disease approach that first came into common usage with the 1993 World Development Report and has been refined and applied more recently in Disease Control Priorities in Developing Countries represents a major contribution to a standard metric of the public health significance of different diseases, which has proven very useful as a point of reference. And the work on developing core public health data, particularly by the Pan American Health Organization, shows what can be done when a concerted effort is put into systematic data collection, technically verified, that permits comparisons across countries and over time.

The cluster survey methods used in the Lancet article do represent standard science that is used when typical surveillance and vital registration systems are absent. As Les Roberts, one of the co-authors of the study, put it in an interview Thursday on the radio program Democracy Now:

What we did, this cluster survey approach, is the standard way of measuring mortality in very poor countries where the government isn't very functional or in times of war. And when UNICEF goes out and measures mortality in any developing country, this is what they do. When the U.S. government went at the end of the war in Kosovo or went at the end of the war in Afghanistan and the U.S. government measured the death rate, this is how they did it. And most ironically, the U.S. government has been spending millions of dollars per year, through something called the SMART Initiative (.pdf), to train NGOs and UN workers to do cluster surveys to measure mortality in times of wars and disasters.

But standard methods or no, in this overheated and underenlightened moment the new estimates are seen by some as politically tainted. Because no international body has the mandate to independently and scientifically measure the health costs of war, as Les Roberts himself has recommended in the past, it's up to individual academics to take on the task -- and the debate sinks to one about whether their motivations are pure.

This incident has shown just how high the stakes are around the accuracy of information about death and disability.