By Judith A. Weinstein
March 16, 2008
Epidemiologist Les Roberts has measured death and disease in more than a dozen countries while working for the Centers for Disease Control and Prevention, the World Health Organization and the International Rescue Committee.
His studies of postinvasion mortality in Iraq, published in the British medical journal The Lancet, caused great controversy in the United States. President Bush and conservative commentators disputed the findings, saying the estimates of Iraqi deaths were far too high. Reaction in the scientific community was mixed. Many experts supported the methods Roberts and his colleagues used; others found fault with the size of the sample and other aspects of the survey.
Roberts, who teaches at the Mailman School of Public Health at Columbia University, recently returned from Zimbabwe, where he studied the aftermath of President Robert Mugabe's forced displacement of at least 700,000 people.
Following is an edited transcript of a conversation with the Tribune.
Q: What is the purpose of collecting death statistics?
A: First, knowing how many people are dying, and from what, helps us fund and guide humanitarian programs. Second is to monitor how things are going over time. Finally ... in crises such as Darfur and Iraq, it's important to bring political attention to a problem. When we measured mortality in the Congo, three diseases -- malaria, diarrheal disease and acute respiratory infections -- accounted for almost all deaths. In Zimbabwe, tuberculosis and HIV were the main causes of death. Those death profiles beckon dramatically different public health responses.
Q: What did you expect when you went to Iraq in 2004? What did you find?
A: In every war where I had worked until then -- I think that was seven -- except in Bosnia, far more people had died from the indirect consequences of war than from violence. In war, water systems stop working, hospitals may close, more women die in childbirth because they can't get to a hospital when things go wrong. All sorts of bad health effects occur. Some are from social dysfunction or stress.
In Iraq, that indirect mortality was what we expected to find. But most of the increase in the death rate was from violence. At that point we estimated that roughly 60 percent of the 100,000 excess deaths [deaths not expected to have occurred were there not a war] were from violence.
Q: Your studies, including the two in Iraq, are household cluster mortality surveys. What is that methodology?
A: Instead of picking a sample of individual houses across a country, you pick a sample of villages or neighborhoods and then many houses within each area, to make the logistics of sampling much easier. At each home you ask, "Who lives here?" Our question in Iraq was, "Who has slept under your roof for most of the last 60 nights?" then, "Who in the household has been born and who has died in recent months?" From that you calculate a death rate.
Q: Why did you go there, knowing how dangerous it would be?
A: The human cost of the war is important for us as a nation to know. And I find this question a little bizarre because it implies that it's reasonable that a couple of hundred thousand soldiers would risk their lives to go, but inexplicable that someone would take that risk purely for the goal of promoting peace and health.
Q: What had changed in Iraq when you conducted the follow-up mortality study in 2006?
A: I initiated the second study but only played a supportive role from New York. It was similar in design, but instead of going to only 33 places, we tried to go to 50. The death rate had gone way up, so that study ended up being more precise. At that time we found that about 650,000 excess deaths had occurred, with 90 percent of those "extra" deaths from violence.Q: The Iraqi government's study of violence-related mortality was published in January by the New England Journal of Medicine. How does that study compare with the 2006 Lancet study?
A:
This new study is very similar in general conclusion to the Lancet study. They found mortality doubled in the three years after the invasion. We found that mortality went up 2.4-fold after the invasion. They estimated a before-and-after death rate very close to that reported in our study....
Q: Why should Americans care how many people are dying in Iraq?
A: First, it is very bad for our national security to have the president say, in December 2005, that 30,000 Iraqis more or less have died and now to have the Iraqi government, his partner, say that he was four times too low at that time. That drives a wedge between the people in the Middle East and us.
Second, if our commander in chief doesn't know to within a factor of 4 or 10 how many Iraqis have died, how can we know if the surge has worked or not? How can we be truly monitoring trends if we're only capturing the tip of the iceberg?
Third, and most important, is that this was a pre-emptive war.
As a democracy, how can we assess if the costs outweighed the benefits if we do not know the true costs?
Q: How do you differentiate being a scientist from being an advocate?
A: As a scientist, you're willing to collect evidence and change your mind about anything. Advocates are more interested in acting and finding evidence for their positions. I'm primarily a scientist in spite of the fact that everything I've been working on lately is fundamentally political. I'm driven by data, not by preconceptions. The appropriate public health response to violence is stopping the violence, and that process is more blatantly political than most of what my scientist peers need to undertake.
Q: Given all of your experiences in Iraq, what is the one you would most like Americans to understand or appreciate?
A: When I was in Iraq in 2004, I asked everyone I could, "Why do you think the Americans came?" The first word out of every individual's mouth was "Oil!" It does not matter if this is true; it is what is perceived to be true. If we think of the 9/11 attacks on New York and realize that Iraq has just about the same population as the greater metropolitan New York area, this new report from the Iraqi government suggests they experienced violent deaths equal to two 9/11 attacks per month for the first three years of occupation. That's according to the Iraqi government! Our study suggests the equivalent of six 9/11 attacks per month.Whether this was from the actions of our nation or the indirect and unforeseeable consequences of the invasion is of little importance.
There is no question that hundreds of thousands have died. Which of our leaders has expressed contrition for this? I fear that pride and political bravado on this issue are creating a role for us in the world that is almost the opposite of how we see ourselves.
http://www.chicagotribune.com/news/opinion/chi-poi-robertsmar16,0,40492.story
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