On the unreported consequences of sanctions and war on the people of Iraq.
 
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It is the great under-reported consequence of sanctions.

UNICEF in 1999 conducted the first independent study of child mortality in Iraq since the Gulf War. The statistical results of the survey were widely published. Not so, their meaning.

Stated plainly, UNICEF reported that an excess 500,000 Iraqi children under age five had died since sanctions were imposed. This ranks among the largest tolls for a political conflict over the last century. In America, it's among the least acknowledged.

UNICEF's reports

UNICEF's mortality report was released in Adobe Acrobat format, and requires a free viewer for display (available here). View the report by clicking the following link, or download to your local system by right-clicking the link and choosing "Save target as ..." (IE) or "Save link as ..." (Netscape).
>> Mortality report (w/ summary charts; only 15KB)

The mortality report caps a series of analyses released by UNICEF in August, 1999, all which remain available on UNICEF's site. The 1999 reports were published in a context of ongoing UNICEF concern and commentary (see CASI's bibliography).

The raw UNICEF data were analyzed in great detail and the results were published by Mohamed Ali and Iqbal Shah in the May 27, 2000, issue of The Lancet, pp.1851–57. These articles can only be accessed after registering here (it's free).

The language of conflict? Or the distancing statistics of a third-world tragedy?

The summary statement from UNICEF's mortality report is this: "... if the substantial reduction in the under-five mortality rate during the 1980s had continued through the 1990s, there would have been half a million fewer deaths of children under-five in the country as a whole during the eight year period 1991 to 1998."

Caveats

Please note:

  • UNICEF didn't claim that all 500,000 excess deaths could be attributed to the embargo. The period covered by UNICEF's study included the Gulf War, severe fluctuations in the oil market, and waves of Ba'athist repression. These factors -- in addition to sanctions -- all contributed to the observed rise in mortality rates.
  • UNICEF didn't attribute blame, and was in fact careful to avoid this issue. However - although the survey did not directly blame increasing mortality rates on sanctions - it said the Iraqi people "would not be undergoing such deprivations in the absence of the prolonged measures imposed by the (UN) Security Council."
  • 500,000 excess deaths is a statistical estimate whose accuracy is subject to debate. Of this, more needs to be said.

    Sanctions: The dying and the counting

    Economic sanctions are a form of embargo. Because economic sanctions can strangle an economy, they are considered one step shy of war. The sanctions on Iraq -- imposed multilaterally on a country dependent on foreign trade -- are, to quote fomer State Department spokesman James Rubin, "the toughest, most comprehensive sanctions in history".

    Given sanctions' severity it's not surprising that large numbers of Iraqis have died, chiefly among the most vulnerable demographics: children, the elderly, and the poor. The tragically common progression is that, first weakened by malnutrition, they fall prey to respiratory and water-borne diseases (dysentery, cholera, diarrhea).

    Infant mortality is a recognized marker of societal health. It's regularly measured by international organizations, and the epidemiological protocols for its study are well established (as described in the UNICEF and Lancet reports, above).

    Infant mortality is expressed as a rate: the number of deaths per thousand. However, such figures are obscure (Does the average reader know the difference between mortality, fertility, and morbidity rates?) and also meaningless by themselves (as they express a 'rate', then against what base?).

    For clarity, especially when discussing mortality in the context of possibly causal events (drought, AIDS, embargo), mortality rates can be converted to "excess death" estimates: a calculation of the number of people who died, based on the gap between expected and observed mortality rates. Driving this calculation are assumptions about a) baseline mortality rates, and b) population within the target demographic, which is in turn derived from estimates of fertility.

    The UNICEF baseline and fertility estimates are conceded as reasonable, though non-conservative. However, if the goal is to estimate a lower threshold for excess deaths (in other words, to support the claim "at least this many excess deaths occurred"), then more conservative assumptions should be used.

    Following release of the 1999 report, an epidemiologist's private communication to UNICEF's statistician argued that fertility in Iraq declined through the 1990s due to decreased marriage, higher ages at marriage, and emigration of large numbers of fertile adults. Further, the epidemiologist argued that an assumption of continued linear decline in mortality - based on trends observed in the 1980s - was overly aggressive.

    The epidemiologist concluded as follows. Assuming a baseline under-five mortality of 50 which does not decline in the 1990s, and using a conservative estimate for the under-five population in Iraq (2,756,000) ...

    ... one can say with 95% statistical confidence that at least 302,608 excess deaths occurred among Iraqi children aged under five between 1991 and 1998 .

    In other words, even when re-cast by a partial, conservative accounting, this remains one of the larger tolls for a political conflict over the last century.

    Other estimates, including Government of Iraq data

    Prior to the UNICEF survey, several independent estimates of Iraqi mortality were published. These studies were often handicapped by a lack of data. For a fuller discussion of UN agency figures on mortality, see economist Colin Rowat's July 2000 briefing, U.N. Agency reports on the humanitarian situation in Iraq (PDF format).

    Shortly before UNICEF's study was published, Columbia University epidemiologist Richard Garfield published a critique of the earlier data, and this review (Morbidity and Mortality Among Iraqi Children from 1990 Through 1998: Assessing the Impact of the Gulf War and Economic Sanctions (July 1999)) remains extremely helpful.

    Regarding Government of Iraq data, it's generally held that Ministry of Health figures are unreliable. An extensive critique of IMoH figures has been published by Amatzia Baram in the The Middle East Journal. Even beyond the suspicion that such figures are inflated for their propoganda value, they are methodologically flawed.

    As Professor Garfield notes elsewhere ("The Public Health Impact of Sanctions" in Middle East Report, Number 215, Summer 2000), IMoH data since 1993 has counted the following hospital deaths as due to sanctions:

  • For children under 5: respiratory infections, diarrhea, gastroenteritis, and malnutrition;
  • For all those over five: cardiac diseases, hypertension, diabetes mellitus, renal diseases, liver diseases, and cancers.

    Of course, not all deaths from these causes are actually due to sanctions (especially for those over five, as heart disease and cancer were common before sanctions). Further, 'diagnostic drift' may occur due to the presumption of causality by those recording the deaths.

    On the other hand, IMoH data doesn't include deaths occuring outside hospitals (a substantial number), and many deaths are attributed to "unknown causes" due to lack of diagnostic equipment.

    These methodological problems may counterbalance, somewhat; surprisingly, in fact, IMoH estimates line up reasonably well with independent data.

    "The Evidence of Silence": The U.S. Press

    To my knowledge, UNICEF's excess death estimate has never appeared in the New York Times or the Washington Post. The omission dates from inception. Neither paper included this figure when reporting on the UNICEF study, though it was included in reports by the BBC, the AP, AFP, and the Sunday Times of London, among others.

    As time has passed - and as the estimate continus to be reported elsewhere (even in the Post's sibling, Newsweek, for example) - the 'language of omission' has become more baroque.

    One of the more desperate tap-dances around this information appeared in the Washington Post (Howard Schneider's "Letter from Baghdad", February 23, 2000, p. C01). Schneider's article refers to "controversial estimates of 'excess deaths'" without ever reporting the actual figure.

    The same report notes that "U.N. officials ... have documented acute problems exacerbated by the sanctions, including a steep rise in infant mortality after the Persian Gulf War and recurrence of diseases due to poor sanitation and the initial collapse of immunization programs". Of course, the excess death estimate is based on these same data ... a fact the Post leaves unsaid.

    Do the Post and Times ever report 'excess deaths'?

    Do the Post and Times ever report 'excess deaths'? Yes, of course they do.

    Consider how both papers dealt recently with excess death estimates in The Congo. Barbara Crossette in The Times mentions the estimate -- 2.5 million deaths -- in passing simply to provide a scale for the impact of the conflict. She does so with none of the obfuscations that characterize her writing on Iraq.

    In the Washington Post, Karl Vick's treatment of the same estimate is exemplary, as it explains the lineage of the data and qualifies it statistically.

    Note that the Congo estimate by the International Rescue Committee is causally similar to UNICEF's Iraq study ("the overwhelming majority of deaths were related to disease and malnutrition—the tragic byproduct of a war that decimated Congo's health care system and economy"). The IRC itself uses the phrase "excess death" estimate in the headline of its press release.

    "The Evidence of Silence": The U.S. Government

    UNICEF's excess death estimates are never mentioned by the U.S. State Department unless its hand is forced. Following is an exchange during a press briefing, which occurred in the context of the second protest resignation by a UN Humanitarian Aid coordinator for Iraq (in this case, Count Hans von Sponeck).

    QUESTION: Yeah, one more (question). Within (von Sponeck's) range of competence, however, were infant deaths.

    MR. RUBIN: Right.

    QUESTION: And (von Sponeck) says - basically he thinks - he says on UN surveys that somewhere between 5 and 6,000 premature infant deaths occur in Iraq each month.

    MR. RUBIN: Right. With respect to infant mortality, there has been numerous reports on this. I would be happy to get you the various conflicting data on it.

    Rubin insinuates that, since the estimates vary, they're not of concern. If in Rubin's rhetorical gambit we hear echoes of Holocaust denial, that impression is only reinforced by Count von Sponeck's family history.

    Count Von Sponeck's father, Lt. General Hans Graf Sponeck, was imprisoned by the Nazis during the second World War for a technical violation when he acted to save the lives of his troops. He was executed on Himmler's orders in 1944.

    • - Commentary by Drew Hamre
    Photos on this page Copyright UNICEF, 1999.
    Background on General Hans Graf Sponeck clarified Feb. 5, 2003.
     
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