10/18/13 – Amy Hagopian – The Scott Horton Show

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Visit MyHeroesThink.com Introducing Amy Hagopian.
She is Adjunct Associate Professor of Global Health at the University of Washington's Community Oriented Public Health Practice Program.
And, well, in fact, I guess I'll go ahead and let you introduce yourself more from there.
I know you have more credentials to speak of.
And also you're one of the authors of this Mortality in Iraq study from the Public Library of Science, which is at PLOSMedicine.org.
So welcome to the show, Amy.
And I'm sorry, could you please give us the rest of your bio there?
Thank you, Scott.
Yes, I'm a regular faculty member, not an adjunct, at the University of Washington.
Oh, sorry, that was old.
I was reading there.
That's all right.
And I teach classes in health policy and I supervise graduate student research and I conduct my own research.
Mostly my area in global health is on the issue of health worker migration from poor countries to rich countries.
Very interesting.
Well, that ties right into Iraq.
That's got to be the biggest story of doctors fleeing from one country to another in this century so far anyway, right?
Oh, doctors flee Africa as well because fleeing poverty is as common as fleeing war.
So, yeah, none of it's very reflective of a world in a good situation.
Well, you know, this article is the first study in a long time that anybody has done since opinion business research back in 2008 on the excess death rate in Iraq.
And I think back when the Lancet and Johns Hopkins studies came out, that was one of the the emigration of doctors was one of the things that was being brought up as one of the reasons why the excess death rate had risen.
It wasn't just the violence from the war and it wasn't just people, you know, getting cholera from dirty water or unable to get to the hospital because of the checkpoints and the war situation going on, all of those things.
But also the doctors, you know, they're the kinds of people who can afford a plane ticket.
They were in Jordan.
They got the hell out of there.
And so and especially the very best of them.
So that was one of the I don't know how major of a factor it was where.
But apparently that's been a factor in the excess death rate in Iraq since 03.
Well, we actually don't know the direct line between doctor migration and death rates.
And and this points to an interesting area that I think is worth talking about, which is that there are no science funding agencies, either the U.S. government or any other government or even in the private sector that fund this sort of research.
The twelve authors on our study, who I led across four universities, were all volunteers.
We donated our time to this work because we thought it was important.
But the National Institutes of Health does not invest in researching the effects of war on the public's health for a variety of reasons, no doubt.
And it's time that they did, because we need much better science and much better capacity to measure this major public health problem.
All right.
Well, so there's lies and damn lies and statistics.
And you guys got a pile of statistics here.
How can you assure us that they mean what you think they mean?
How can you assure yourselves?
Well, let me tell you our approach.
This is a public health science approach.
This is a public health science approach to trying to estimate mortality.
There are other approaches out there, and I can talk about those if you want.
But our approach was to randomly select 100 neighborhoods across the nation of Iraq.
We did that in a way that was population weighted.
So we were likely to get a sample that was distributed the way the population is distributed.
And then within each neighborhood, we randomly selected a start household.
And that was kind of an interesting method we used using Google Earth maps.
And we would drop a small mesh grid over the neighborhood that we had chosen and randomly selected a start house by just choosing a rooftop.
And then on the ground, we would go find that house.
So we would survey 20 households in each of those 100 neighborhoods for a total of 2,000 households.
And in each place, we asked the head of household to tell us who lives here, who lived here in 2001 before the war started, and who has been born and who has died.
And if they died, what did they die of?
And through this method, we can calculate death rates for each year.
And we compared the pre-war death rate with the post-war death rate and multiplied those rates times the full population to arrive at estimates of total mortality.
We saw a significant increase in the mortality rate before the war and after.
Interestingly, and our estimate was that probably about a half million people died in this war.
You asked how confident we are in that number.
And I would say we're actually fairly confident that that number is low.
And the reason we think it's low is because many of the families who experienced mortality in Iraq did just as you said, they left.
And when they left, they left no one behind to tell us about the mortality experience in their household.
Right.
Well, and there were approximately four and a half million refugees, and I guess about half of those internally displaced.
Sunnis purged from mostly Baghdad and other now Shiite, at least now Shiite dominated regions.
And then Shiites purged from the Anbar province in response and back and forth like that.
In fact, that might have been first.
Well, we used very conservative estimates of migration to try to adjust our number.
We used the two million out migration figure that the U.N. supplied.
But, you know, again, those are people who tend to register as migrants, which lots of people don't.
And we had a small study out of Syria that suggested 15 percent of those households had experienced death.
And so we made a very modest adjustment in our calculations to try to account for the migration.
But we think it's low and it's conservative.
Right.
Well, and that's the best way to approach something like this, obviously.
Anyway, to go back, it was in 2004 and then again in 2006 when Lancet and Johns Hopkins did their studies and they had almost 700000 by 2006.
And then I noticed.
Well, I didn't I wasn't able to read the whole thing, but I didn't notice any reference to opinion business research in their study that concluded that as many as a million had died in 2007 and 2008.
And they even did the study twice to try to make sure that, wow, because that sure is a pretty high number.
But so how conservative do you think is your estimate?
And I wonder why no mention of OBR there?
We did actually mention OBR.
We have a paragraph in the discussion section where we talk about how our results compared to others.
Opinion business research is a business firm that used its polling capacity to try to estimate mortality.
And and that was fascinating.
And that that's the high watermark.
The other two Lancet studies that were done involved some of the same people who were involved in this study.
And, you know, this we were doing our study in the middle of 2011.
A long time had passed since 2001, just before the war.
So we were asking people to remember a very long period of time and people tend to forget things.
And so we're pretty sure our estimate is low.
The other sort of brand of research out there trying to estimate mortality is the Iraq body count.
And those people clip newspaper articles and try to count up the dead from reports in the press and other places.
We know that those reports are low.
They recently tried to adjust their reports based on the WikiLeaks data that had been released, which was sort of an interesting exercise.
Still, it's very low.
And they are estimating around one hundred and twenty five thousand.
Of course, those deaths don't include the indirect deaths.
The people who died, who didn't need to die, but didn't die of being shot or blown up, rather died of a heart attack or some other indirect cause of the war.
Right.
Yeah.
And just the deprivation from living in a wartime society for eight years.
And it's so easy to imagine.
Right.
The heart attack is the perfect example.
A situation where even under the sanctions regime, he could have made it to the hospital and been fine.
But in this case, he got stuck behind a checkpoint and didn't make it.
That kind of thing.
That's correct.
But multiplied over thousands and thousands of times.
Same thing for the cholera in the water, right?
That's right.
War wreaks havoc on a society in many, many countless ways.
I think it wreaks havoc on the invader as well as the invaded.
Certainly it redirects resources from what might have been something that produces health like education and directs it towards something that destroys health.
Now, talk about the significance of asking them about their siblings.
You did this in a way to try to weight their other responses.
Well, it wasn't a weighting so much.
We asked about siblings because as long as we were in the household, we wanted to try a new method.
And this is a method that's used in many low income countries to try to estimate infant mortality rates.
Those sorts of things in countries where they don't have a census.
So this hasn't been done in a war setting before and we were experimenting with it.
Again, like I said, the science in this is just so undeveloped.
But when you knock on a door in Iraq, there's a lot of people who live there.
Household size is around six.
So what we did was ask every adult in the household to tell us about their siblings.
So we were able to learn about 25,000 additional people by way of doing this.
And we were able to calculate the risk of mortality for adults.
Again, it's just one segment of the population.
It's adults, which are about a third of the deaths in the population are attributable to the 15 to 60 age group.
And these 25,000 people told us about their siblings, if they were alive or dead, if they were dead, what they died of.
And we were able to see then the proportion of deaths that were attributable to violence, which in the case of adults was about 70 percent the excess death.
Now, that was actually surprising to me.
I mean, as violent and horrible as that war was, I guess I just imagined that the excess death rate, it would mostly be that, right?
All the kind of unintended consequences all over the place.
But no, it was really the violence of the American and Iraqi armies and the militias, the various militias and Sunni insurgents.
And I think you say even the super majority of those are by bullets, not bombings, right?
Yes.
So of excess deaths, the majority are due to violence.
And of the violence, it's mostly shooting.
And then now that counts crime, too, right?
Because obviously, kidnapping became a epidemic there.
You know, in wars like this, it's very hard to figure out who is who and what their motivations are.
And, you know, whose side are they on?
One of the questions I get asked by the media is, well, were you counting combatants in your totals?
And the answer is yes, because combatants live in households and households are who is doing the reporting.
And we didn't ask that question for a variety of good reasons.
Was this person a combatant or not?
Because if somebody is a baker all day long and in the evening, a couple nights a week, they go make incendiary devices, is that person a baker or a bomb maker?
I don't know.
And I wouldn't want to be in the position to try to categorize that person.
And we don't know whose side they're on or what interests they're representing.
And it's complicated.
Well, you didn't count the Iraqi army casualties from the first three weeks of the war in the actual invasion, though, right?
We counted whoever lived in those households.
Well, I guess that would have been a very small proportion of the numbers.
Oh, yes.
Certainly, yes.
The vast majority of the violence took place after the Americans fired the army and turned them all into civilians.
Well, the conduct of the war was its own sad story.
And we didn't.
Well, I'm just saying that made civilians out of the vast numbers of privates in Saddam's army became bakers again or whatever they they should have been doing with their life anyway at that point.
Yes.
Well, now, OK, so how many neighborhoods did you go to in Kurdistan?
And I wonder whether, you know, it seems like if you go to the average Kurd household and ask them, relatively speaking, they've done a lot better than not just Arabs in the rest of Iraq, but certainly better than Arabs in Kurdistan, who there was a much less covered, but still a constant kind of ongoing, not so I don't know, silent war, but sort of low level war of ethnic cleansing of the Arabs out of Kurdistan.
So I wonder, you know, you take that into account when you go into a neighborhood of of which kind of people you're talking to here, to put it bluntly and rudely.
We weighted the population by and randomly chose by size.
So the larger the geographic area, the larger a chance it had of being chosen.
And we did go to every governorate in Iraq.
And there's a table in the paper.
You know, by the way, for your listeners, this paper is completely freely available on the Internet at PLOS Medicine.
And you can see the table of each governorate and how many people we interviewed in that place and how that compares to the most recently available census, which it was actually conducted a long time ago, regrettably.
Well, you know, I have to say it seems like the media reaction to this study is, wow, would you look at that?
Rather than the vicious denunciations and denials that came with the Lancet studies, for example.
I guess the OBR report was mostly agreed with silence, but.
Yes, it is interesting that I I think people's.
The response has not been hostile from politicians have sort of not said anything, which is kind of interesting.
And the people who critique this sort of science haven't said much either.
We made our data completely available on the Internet for people to analyze.
So the response is always interesting.
You know, public opinion polling shows that Americans and British people believe that only about ten thousand people died in the war.
And of course, that's woefully low in relation to what's actually the case.
And probably reflects the great efforts that the US and British government went to to try to keep people from knowing how many people died.
Right.
Yeah.
I wonder.
I wonder how well this is going to get through.
You know, it's not like they're giving it that much attention, but.
Well, I don't know.
Did it make the cover a USA Today or anything where, you know, the average American might see it on the bus ride?
Not so much.
No.
Well, but yeah, I mean, that really is that alone is almost as bad as the casualties, the denial that the American and British people get to indulge in about the consequences of sort of their actions, the government's actions that they're somewhat responsible for anyway.
You know, that's not right.
Well, interestingly.
When you know, I'm old enough that I was a kid during the Vietnam War, a teenager, and the way progress in that war was measured was by the body count.
And we'd hear about the body count on our TV every night and we would see film footage from Vietnam of our soldiers killing people.
And, you know, it didn't take too long to turn the tide against that war to be seeing it on our television and to be hearing the body counts.
And I think the war wagers have learned this, that people really don't have much appetite for body count.
And, you know, I think it's to the public's credit that the people who waged this war felt they really couldn't report high body counts and sustain public support for it.
Right.
Yeah.
I mean, that was the whole thing.
The argument was, OK, yeah, there's some problems, but it's going to be worth it at some point.
We can't leave now because then it will get worse.
Now is better than if we left for them.
That was the argument the whole time.
So they couldn't be honest about how many people they were getting killed.
You know, on the other hand, you look at Iraq today and it is worse than it was a year ago.
And, you know, that's not because we were protecting people particularly, but, you know, we launched a war that left that country in shambles and in chaos and people fighting amongst themselves.
And it's just a tragedy.
Sure.
Certainly not worse than it was in 2006, seven and eight.
No.
Well, I don't know, eight so much, but five, six, seven, those were the worst years of it.
But anyway, so listen, I've already kept you over the time.
I promise you I'd keep you at 20 minutes.
So thanks very much.
I really appreciate your work on this and I appreciate your time on the show.
Thank you so much, Scott.
All right, everybody.
That is Amy Hagopian.
The study is at PLOSmedicine.org.
That's the Public Library of Science.
PLOSmedicine.org.
You can read the whole study there.
Mortality in Iraq associated with the 2003 through 2011 war and occupation.
And you can read all about it at America.
Aljazeera.com and Antiwar.com and a few other places as well.
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