Via commenter JoT we have an interview with Les Roberts about his study. Roberts mentions how surprised he was that was a such a large increase in violent deaths. From his previous studies in other war situations he expected that there would be an increase in deaths, but mainly from indirect causes like disease.
The interview was prompted by a report to the UN Human Rights Commission by Jean Ziegler about the increase in malnutrition in Iraq after the invasion. (It seems to based on last year's UNDP study discussed here.) Needless to say, any report that the invasion might have made things worse is immediately attacked by warbloggers. John B slices and dices them over at Shot by both sides. Kevin E Moley offers this response to Ziegler's report:
"First, he has not been to Iraq, and second, he is wrong,"
First, irrelevant, and second, why? Moley continued with his ad hominem theme:
"He's taking some information that is in itself difficult to validate and juxtaposing his own views - which are widely known," Moley said, referring to Jean Ziegler's opposition of the US military intervention in the country.
Let's see, the 2002 survey found that acute malnutrition in Iraqi under 5s was 4% and the 2004 survey found that it was 7.7%. Apparently, it was only by juxtaposing his anti-war views that Ziegler was able to wrongly attribute the increase to the war. Otherwise people would have instantly spotted that the real reason was something else. Like, ummm, what?
Moley rejected the rate "purported to be accurate by Jean Ziegler" and said malnutrition in Iraq was notoriously difficult to gauge. He noted that some estimates had put it at 11 per cent in 1996 and 7.8 per cent in 2000, while Saddam was still in power.
Moley doesn't seem to have actually gotten around to giving a reason why the findings of the 2004 survey were wrong. The reduction in malnutrition from 1996 to 2002 is generally accepted to be the result of the oil-for-food program.
"The surveys that have been taken ... have indicated that the recent rise in malnutrition rates began between 2002 and 2003 under the regime of Saddam Hussein," Moley noted.
No, the surveys do not indicate that at all. They show that there was a significant increase between 2002 and 2004. They don't tell us when that increase occurred. I don't think you can plausibly claim that the increase (which reversed the decreasing trend up to 2002) started before the war unless you can offer some possible cause. Which Moley doesn't.
Did I mention that Moley is US ambassador to the UN organizations in Geneva? The nonsense above is the US government's response to the increase in malnutrition in Iraq. Denial.
Hmm... yes. Evil Pundit's feeble attack on Jean Ziegler is here.
... and a curious silence, given the number of experts on UNICEF infant malnutrition statistics who we know read Deltoid.
... and a curious silence, given the number of experts on UNICEF infant malnutrition statistics who we know read Deltoid.
No tight historical correlation between acute malnutrition and infant mortality has been shown to exist, certainly no functional relationship capable of reducing infant mortality by three quarters. Both acute and chronic malnutrition were higher in 2002 than in 1991 despite oil for food, yet the Lancet's pre-war infant mortality rate was lower (after a decade of sanctions) than 1991 levels or any other reported rate in Iraq's entire history. Yes, as we've heard 1,000 times, the Lancet study is a cohort study so common-sense observations like these don't matter very much.
"No tight historical correlation between acute malnutrition and infant mortality has been shown to exist"
There most certainly is a clear correlation between malnutrition of all kinds, including acute malnutrition, and infant mortality. This is due, in part, to a strong synergistic relationship between disease, particularly infectious diseases, and malnutrition.
"Both acute and chronic malnutrition were higher in 2002 than in 1991"
That statement is misleadingly incomplete. In 2002 the acute malnutrition rate was only .4% above the reate in 1991. The general malnutrition rate was a mere 1% above 2002, and the chronic malnutrition rate was only 5.1% above the rate for 2002. Further, all three rates were on a downward trend, so it is most likely that they continued downward throughout 2002, and the first weeks of 2003 until the invasion.
UNICEF (2002): "This erosion of human development - which one can effectively term "de-development" - therefore appears attributable to the lasting effects of the crises of 1990/91 including the resulting sanctions regim attempts by the Security Council to alleviate the impact on the population. De-development on such a scale is unprecedented, and it will require decades of investment for the people of Iraq to reach the point at which they were in 1989."
also this:
"most of the children who are dying in Iraq are dying from preventable illness. Diarrhea leading to death from dehydration, and acute respiratory infections (ARI) together account for 70% percent of child mortality in Iraq."
Note that dehydration is not a subset of acute malnutrition and the two are clearly distinguished in this and every other UNICEF report.
In 2002 the acute malnutrition rate was only .4% above the reate in 1991
Incorrect. Acute malnutrition was 3 per 1000 in 1991. In 2002 UNICEF lists this figure as 4 per 1000, or a 33% increase. Chronic malnutrition goes from 18 to 23, a 28% increase. http://www.unicef.org/publications/files/pub_children_of_iraq_en.pdf
See page 3.
Over this time you expect us to believe that infant mortality declined 75% from its 1999 levels and 39% even from its 1991 level.
correction: the malnutrition rates expressed above are outright percentages, not incidents per 1,000. Their % of change obviously stand.
Pascal, chronic diarrhea causes acute malnutrition. Yes, it's the diarrhea that kills the child, but one episode will not kill a healthy child. The ones that have been weakened by repeating episodes causing acute malnutrition are the ones who are at risk of being killed by another bout of diarrhea or by an infection.
Thanks, Tim. Earlier today I wrote a response to Pascal which included a more lengthy explanation of the synergistic relationship between malnutrition and diarrhea (and other infectious diseases), and I thought I had posted it, but evidently I did not.
I don't have time to try to recreate the whole post, but I will say a few words about the relationship between malnutrition and infectious diseases.
Yes, chronic diarrhea causes malnutrition, and it also works the other way. Malnutrition makes the body more susceptible to disease-causing organisms of all kinds, including those that cause diarrhea and other gastro-intestinal diseases. In addition, the conditions that increase contact with gastro-intestinal disease-causing organisms more often than not accompany malnutrition-causing conditions, so, there is a direct correlation between the two. It is a circular phenomenon, which often leads to death, usually from dehydration caused by diarrhea (and often vomiting). Malnutrition is a factor more often than not.
The dynamic with respect to respiratory disease is a bit different, but here there is also a synergistic relationship. Malnutrition reduces resistance to disease organisms, and the disease often exacerbates malnutrition by reducing appetite. Conditions which lead to malnutrition are often accompanied by conditions which lead to increased exposure to disease organisms. So again, we have a viciously circular phenomenon.
there is a direct correlation between the two
There is no demonstrated, quantifiable correlation between acute malnutrition and infant mortality in the case of Iraq. Your contention that a change in acute malnutrition alone might have been responsible for the lowest infant mortality figure in Iraqi history after 10 years of sanctions remains speculative, and quite far fetched. Again: even acute malnutrition was higher in 2002 than in 1991, 33% higher, while your study suggests the infant mortality rate in the same year was 39% lower. Alluding again and again to the {undemonstrated} interrelationship of malnutrition and infant mortality simply doesn't cut it.
Pascal,
1) All I have said is that there is a known correlation between malnutrition of all kinds and infant mortality. I did not specify Iraq. However, given that we know there is a correlation between the two, given that we know why that correlation exists, and given that malnutrition and infant mortality were problems in Iraq post-1990, it seems very likely that there was/is a correlation.
2) Please do not put words into my mouth. I have never at any time contended that a change in acute malnutrition alone might have been responsible for a reduction in infant mortality. In fact, I have never even contended that acute malnutrition alone causes infant death. What I have spoken about several times is the interaction between infectious diseases, specifically gastro-intestinal disease, and malnutrition, and the way they exacerbate one another.
There are certainly other factors than malnutrition which can contribute to a decrease in infant mortality rates. One of those is an increase in breast feeding as opposed to powdered formula.
3) It is not "my" study.
I have never at any time contended that a change in acute malnutrition alone might have been responsible for a reduction in infant mortality
Forgive me for implying otherwise. I have seen no other measurable statistic advanced as an explanation. Considering that infant deaths contribute substantially to the study's midpoint, I would hope the question were more readily explained. I recognize that it's a cohort study - this adds nothing to the credibility of the low initial figure.
The authors point out that 3 of the infant deaths were due to coalition bombing (from information provided by the authors outside the study, 2 were ex Fallujah, 1 in Fallujah), another 3 related to births at home, when security concerns prevented travel.
They point out that, therefore, most of the increase is plausibly linked to the conflict.
In turn this means that the acute malnutrition hypothesis is not necessary to explain the increase.
Also, consider random variation. Do the following in a spreadsheet. Put =rand() in 366 cells in column A and =IF (a1<=0.029;1;0) into column B and then add up the values in column B.
You'll get values like: 11 12 16 11 19 3 10 17 18
(the expected average here is about 10.6, based on an assumed rate of 29 in a thousand and 366 births, the sampled value in the Lancet study is 21 infant deaths, out of which 6 have a direct relation with security issues/bombing)
A cursory glance at these figures reveals that random variation is so great that the sampled number of infant deaths will provide a very uncertain measure of the infant mortality rate, even if they got their sampling right, there wasn't recall bias etc....
When you look at the numbers of the Lancet study in detail in a similar fashion, it becomes very obvious how heavily the increase is driven by violence. This is the one cause of death where a clear increase can be statistically shown (assuming that sampling, lack of census data etc... do not cause further error), and this drives the overall excess death.
Even for accidents as a subgroup an increase is far less clearly indicated than for violence. Ex accidents and violence, ie where public health is concerned the study, as the authors themselves say, does not indicate much change.
With accidents there is a plausible link with the invasion, as there are now more than 3 times as many cars on Iraq's roads than before the invasion.
http://washingtontimes.com/upi-breaking/20050330-125645-9380r.htm
With a lot of these in the hands of young male drivers with virtually no driving experience, it wouldn't exactly be surprising, if there now were many more traffic fatalities than before.
dsquared might take this as a sign that the war has made things worse. Terrible all these young men who can suddenly afford cars, and choose to kill themselves through reckless driving. Better if we had listened to dsquared's advice, then they wouldn't have been able to buy cars and would still be alive ... Thinking about this, over the last two years there have been 80,000 needless excess deaths in the US, 40,000 traffic fatalities times 2 years, most presumably preventable by just restricting US car ownership to pre-invasion Iraqi per capita levels.
However, the security situation surely contributes to the accident rate -- driving fast with the lights off because of the danger from bandits and terrorists is likely to be dangerous.
Then again, the security situation should also keep people from driving quite as much, particularly at night ;-)
I don't know whether deaths from accidents have actually increased. The Lancet study's data merely provide a hint in that direction.
The only thing they are crystal clear about is that violent death has in all likelihood gone up.
I am not all that worried about the infant mortality rate estimate at the moment. They've got a very small sample, 8 deaths in less than 300 births is such a small number that random sampling error becomes a huge factor.
Look at the 9 values I got with an assumed infant mortality rate of 29 for 366 births, one of those gives 3 deaths, another 19. That's an absolutely huge span, and means that even if the sampling was perfect, and there was no error of any kind other than random variation, we could easily get an estimate of 10 or an estimate of 50 for the infant mortality rate, when the true figure is 29.
On top of that we've got all sorts of other sources of error, such as for example the potential for recall bias (which the authors explicitly acknowledge, with reference to problems that have plagued similar studies). The pre-war infant mortality estimate therefore has such huge uncertainty attached to it that it doesn't contradict the CIA factbook estimate number.
In truth we don't know the pre- or post-war infant mortality numbers. We can make a fair guess they are somewhere between 20 and 120.
We'll have to wait for the Iraqi government or Unicef to provide an update based on hospital statistics, or a very large sample.
Finally, it bears repeating that murders, traffic fatalities, infant death and bombing victims are not all morally equatable. There are enormous differences.