special articleT h e n e w e n gl a n d j o u r n a l o f m e d i c i n en engl j med 358;5 www.nejm.org january 31, 2008484Violence-Related Mortality in Iraq from 2002 to 2006Iraq Family Health Survey Study Group*The members of the writing committee (Amir H. Alkhuzai, M.D., Ihsan J. Ahmad, M.D., Mohammed J. Hweel, M.D., Thakir W. Ismail, M.D., Hanan H. Hasan, M.D., Abdul Rahman Younis, M.D., Osman Shawani, M.B., Ch.B., Vian M. Al-Jaf, M.D., Mahdi M. Al-Alak, Ph.D., Louay H. Rasheed, M.Sc. (deceased), Suham M. Hamid, M.B., Ch.B., Naeema Al-Gasseer, Ph.D., Fazia A. Majeed, M.D., Naira A. Al Awqati, M.D., Mohamed M. Ali, Ph.D., J. Ties Boerma, Ph.D., and Colin Mathers, Ph.D.) assume responsibility for the over-all content and integrity of the article. Ad-dress reprint requests to Dr. Ali at the Department of Measurement and Health Information Systems, World Health Or-ganization, Geneva, Switzerland, or at [email protected].*Affiliations of the Iraq Family Health Survey study group are listed in the Ap-pendix.This article (10.1056/NEJMsa0707782) was published at www.nejm.org on January 9, 2008.N Engl J Med 2008;358:484-93.A b s t r ac tBackgroundEstimates of the death toll in Iraq from the time of the U.S.-led invasion in March 2003 until June 2006 have ranged from 47,668 (from the Iraq Body Count) to 601,027 (from a national survey). Results from the Iraq Family Health Survey (IFHS), which was conducted in 2006 and 2007, provide new evidence on mortality in Iraq.MethodsThe IFHS is a nationally representative survey of 9345 households that collected information on deaths in the household since June 2001. We used multiple methods for estimating the level of underreporting and compared reported rates of death with those from other sources.ResultsInterviewers visited 89.4% of 1086 household clusters during the study period; the household response rate was 96.2%. From January 2002 through June 2006, there were 1325 reported deaths. After adjustment for missing clusters, the overall rate of death per 1000 person-years was 5.31 (95% confidence interval [CI], 4.89 to 5.77); the estimated rate of violence-related death was 1.09 (95% CI, 0.81 to 1.50). When underreporting was taken into account, the rate of violence-related death was estimated to be 1.67 (95% uncertainty range, 1.24 to 2.30). This rate translates into an estimated number of violent deaths of 151,000 (95% uncertainty range, 104,000 to 223,000) from March 2003 through June 2006.ConclusionsViolence is a leading cause of death for Iraqi adults and was the main cause of death in men between the ages of 15 and 59 years during the first 3 years after the 2003 invasion. Although the estimated range is substantially lower than a recent survey-based estimate, it nonetheless points to a massive death toll, only one of the many health and human consequences of an ongoing humanitarian crisis.Copyright © 2008 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org at UNIVERSITY OF WASHINGTON on August 7, 2009 .Violence-related Mortali t y in Ir aq from 2002 to 20 0 6n engl j med 358;5 www.nejm.org january 31, 2008485Without reliable death-registra-tion systems, the estimation of mortal-ity relies mostly on household surveys, which are subject to many biases, even in peace-time.1,2 In conflict situations, the estimation of the rate of death either from violence or from indirect causes has another level of complexity: since data collection is difficult, events may be clustered in small areas, and traditional models of adjustment do not apply.3The death toll in Iraq after the U.S.-led inva-sion in March 2003 has been the subject of much discussion, with numbers differing by as much as a factor of 10. A national survey of a sample of population clusters that was conducted in mid-2006 estimated that an additional 654,965 persons had died during the 40 months since the U.S.-led invasion, as compared with prewar numbers. This number included 601,027 excess deaths due to violence.4 The Iraq Body Count, a project that is based on a continuous count of screened and validated press reports of casualties, registered 47,668 violent deaths among civilians from March 2003 through June 2006.5In 2006 and 2007, the Iraq Family Health Survey (IFHS), a cross-sectional, nationally rep-resentative survey of 9345 households, was con-ducted by relevant federal and regional ministries in Iraq in collaboration with the World Health Organization (WHO). We present the results on rates and causes of death, compare the results with other data sources, and provide new plausible esti-mates of violence-related mortality for the 3-year period after the 2003 invasion (March 2003 through June 2006).M e t hod sData SourcesThe IFHS is a two-stage, stratified survey of households, with an original target sample size of 10,080 households. The originally allocated sample sizes for the Baghdad–Karkh domain and for Anbar and Nineveh provinces were increased by the addition of census enumeration areas or clus-ters before the survey fieldwork was undertaken: 6 areas for the Baghdad–Karkh region (a 33.3% increase), 54 areas for Anbar (a 100% increase), and 18 areas for Nineveh (a 33.3% increase). The addition of the census enumeration areas was done to compensate for the expected difficulties in ac-cessing some of the selected clusters because of security problems. The additional enumeration ar-eas increased the target sample size to 10,860 households located in 1086 clusters.Because of different selection probabilities of households in the sample, design weights were calculated on the basis of projected population numbers according to province and stratum and were further adjusted for nonresponses at both the cluster and household levels. The sampling frame that was used in the southern and central provinces was derived from the 1997 census, which had been updated for the Iraq Living Con-ditions Survey 20046; the frame that was used in Kurdistan was based on information provided by the Statistical Offices in the region. Population estimates for Iraq for the survey period were projected by the Central Organization for Statis-tics and Information Technology. (For details on the survey design and implementation, see the Supplementary Appendix, available with the full text of this article at www.nejm.org.)All deaths that occurred in the