Chapter 8

Displacement and Mortality

"we will help you to build a new Iraq that is prosperous and free."

– US President Georges W. Bush [1]

The invasion of Iraq in March 2003 caused many civilian casualties, but it did not create a major humanitarian crisis or set off mass migration. Soon, though, Coalition counter-insurgency operations, including massive attacks on cities like Falluja, Najaf and Tel Afar, caused many violent deaths as well as large displacement, affecting hundreds of thousands of people. [2] Unemployment and poverty rose sharply, too, as state institutions deteriorated or collapsed. Beginning in 2006, sectarian clashes worsened. Inter-communal violence led to rising death and injury, as well as massive new displacement. The international relief system has not been able to respond to the growing humanitarian challenges. Humanitarian NGOs have largely withdrawn and donor governments have stayed away. International relief agencies have themselves faced serious problems in overcoming political pressures, reaching Iraqis at risk, and mobilizing funds for the deepening emergency. [3]

Displacement

Violence and poverty have created an unparalleled movement of population in Iraq . [4] In April 2007, well over 4 million Iraqis had been displaced, about 14% of the total population. Of that number, about 1.9 million Iraqis were internally displaced and over 2.2 million had migrated to other countries. [5] UNHCR, the UN refugee agency, has spoken of "growing concerns over the rapidly deteriorating humanitarian situation" [6] The agency expects many more people to leave their homes as violence and inter-communal strife continue to rise. [7] Large numbers are in urgent need of aid, food and shelter. The international relief system has responded weakly, because of political pressures, serious under-funding and difficulty in reaching the displaced people.

Coalition Operations

Since 2003, Coalition military operations have displaced large numbers of Iraqis, especially through aerial and ground attacks on urban areas. The attacks on Falluja in 2004 displaced over 200,000, [8] while attacks on other cities displaced hundreds of thousands more. Many families have been unable to return, due to the ongoing insecurity, recurrent military offensives, lack of water, electricity and health services, and because their homes and places of business are ruined. [9] According to an estimate by the Falluja Reconstruction Project, about 65,000 people from the city were still displaced in early 2006. [10]

Sectarian Violence

Beginning in 2006, while military operations continued to force people from their homes, sectarian violence became the main cause for displacement, particularly in Baghdad . The UNHCR estimates that sectarian violence had displaced some 730,000 people following the attack on the Samarra Al-Askari shrine between February 2006 and March 2007. [11] Iraqis have been threatened because of their religious affiliation or profession. Sectarian militias and armed groups have attacked mosques, markets and villages of rivals. Mixed neighborhoods are increasingly polarized.

Minorities and Professionals

Minority communities are especially at risk. Reports suggest that religious persecution has led to the displacement of Christians, Turkmens, and Assyrians, among others. The Sabean-Mandeans, a very old community, has dwindled from 13,500 in 2001 to roughly 4,000 in 2006. [12] Half of the 1.5 million Assyrians living in Iraq before 2003 have left the country and the remaining 750,000 are moving into "safe areas" in Zakho and North Ninevah . [13] Many Christians have been leaving for Syria and Jordan ; a significant number has also sought refuge in Iraq 's Kurdistan region. [14]

Palestinian refugees in Iraq are facing very difficult conditions, and are subject to repeated threats and attacks. Palestinian media sources in early 2007 report that there have been over 655 attacks against Palestinians, killing at least 186. [15] Palestinians in Baghdad are extremely fearful for their lives and have expressed their wish to leave as soon as possible. [16] But for many Palestinians leaving Iraq is not an option, as they have no valid travel documents. [17] UNHCR estimates that about 850 Palestinians from Iraq are trapped at the border with Syria . [18] A group of 365 has been living in a no man's land between the borders of Iraq and Syria , refusing to return to Iraq and having been refused entry by the Syrian government. [19] Neighboring countries like Jordan , Kuwait , Saudi Arabia , and Syria refuse to admit them [20] and going back to the Palestinian territories is not an option. Only about 15,000 of an estimated 34,000 Palestinians formerly in Iraq remain in the country. [21]

Many professionals have been targeted because of their work. This includes academics, educators, professors, doctors, journalists, politicians, lawyers and judges. [22] Many have been arrested, kidnapped, killed or forced to flee to protect their lives and their families. According to the Iraqi Ministry of Health, 102 doctors and 164 nurses were killed between April 2003 and May 2006, and some 250 Iraqi doctors were kidnapped between mid-2004 and mid-2006. [23] According to the Brookings Institution's Iraq Index , 2000 Iraqi physicians were killed and about 12,000 left the country from March 2003 through March 2007. [24] The negative effect of violence on professionals has substantially affected educational, judicial and health care systems in the country.

Internally Displaced Persons

As of March 2007, an estimated 730,000 Iraqis had fled their homes for other parts of Iraq since the Samarra bombings and UNHCR estimates that the pace has increased to 50,000 per month. [25]

Most of these "internally displaced persons," or IDPs, have sought refuge with relatives, or in mosques, empty public buildings, or tent camps. [26] With limited access to food, health services, education and employment, IDPs live in very poor conditions. [27] Public buildings are particularly unsanitary, often overcrowded, without access to clean water, proper sanitation and basic services, in conditions especially conducive to infectious diseases. [28] In addition, occupants are constantly under threat of being evicted without being provided with alternative accommodation. Those living in camps often have to choose between locations away from military or militia operations, and locations more at risk but nearer education and health facilities.

Families and acquaintances have supported their displaced relatives and shared limited supplies. But this has created a "rising tension between families over scarce resources" according to UNHCR. [29]

Humanitarian agencies are facing great difficulties in assisting IDPs. UN operations are mostly managed from Amman and Kuwait . The lack of security and military-imposed restrictions has prevented access to those in need of assistance and protection. Coalition forces have denied access of local aid groups to displaced communities. [30] Aid groups are also subject to intimidation from militias for helping displaced families of other religious backgrounds. [31]

Refugees in Neighboring Countries

In addition to the 1.9 million IDPs, over 2.2 millions Iraqis have sought refuge in other countries. At least 1.2 million Iraqis have fled to Syria , and an estimated 750,000 to Jordan . In addition, there are over 100,000 Iraqi refugees in Egypt , 54,000 in Iran , 40,000 in Lebanon , 10,000 in Turkey , about 200,000 in the Gulf States and around 200,000 have moved to Europe, Northern America and New Zealand . [32] UNHCR reports that asylum applications by Iraqis in industrialized countries rose by 77 percent in 2006, making Iraq the leading country of origin in 2006. [33]

In neighboring countries, tensions are rising as the growing number of refugees overwhelms public services. Syria has tightened restrictions. It now charges for health care and has reduced entry visas from six to three months, forcing refugees to exit the country for renewal. [34]Lebanon has closed its borders to Iraqi refugees and Lebanese authorities have increased arrests for illegal presence, forcing refugees to choose between prison and deportation. [35]Jordan , worried about risks of instability, has tightened its immigration rules, now requiring Iraqis to hold a new type of passport. [36] The measure has increased Iraqis' feeling of insecurity in the country. Amman had already closed its borders to young men, obliging families to separate, [37] and made it difficult for Iraqi children to access public schools. [38] Refugees International reports that in certain cases border officials have issued transit visas that expire after a few days, leaving Iraqis subject to deportation. [39]

Long-Term Crisis and Broader Consequences

Hundreds of thousands of displaced Iraqis – both within and outside the country - are in dire need of assistance – for shelter, healthcare, education, legal aid, food and medicine. UNHCR predicts that Iraq 's humanitarian crisis will last for years. [40] The UN agency predicts that for most Iraqi IDPs, "this is not a temporary" but a "permanent displacement." [41] The displacement has consequences beyond the country's borders, affecting Syria , Jordan , Egypt , Turkey , Iran and other countries outside the region.

In January 2007, UNHCR launched a $60 million appeal to fund its programs for the year, [42] a significant increase from the $29 million appeal in 2006. Yet, "even $60 million does not go very far," [43] warned Andrew Harper, Senior Manager for UNHCR's Iraq Operation Unit. He added that addressing Iraq 's total humanitarian needs in the long-term would range in the "hundreds of millions, if not billions, of dollars." "This is a [humanitarian] operation that is going to have to go on for years," he said. [44]

Mortality

Iraq 's death rate has increased significantly since March 2003. Obviously, many Iraqis have been dying of violent causes, given the Coalition's non-stop military operations and the rising tide of sectarian violence. But a debate rages over how many Iraqis have died and how the statistics should be interpreted. Washington insists that the lowest numbers are the most accurate, while refusing to publish its own official statistics. The Iraqi government also prefers to downplay the situation. Still, all serious studies show that the death toll has been high and growing. Iraq 's people have paid a steep price in loss of life.

Studies

The US and the UK governments have publicly insisted that they "don't do body counts," and thus have no reliable estimates of Iraqi civilian or military deaths. [45] Several studies have nonetheless sought to measure Iraq 's mortality during the occupation:

• Iraq 's Ministry of Health provides figures for bodies brought to morgues and hospitals; [46]

• UNAMI publishes periodic human rights reports, which provide figures based on "the number of casualties compiled by the Iraqi Ministry of Health from hospitals throughout the country and the Medico-Legal Institute in Baghdad "; [47]

• Iraq Body Count, an independent and public database, tracks civilian deaths reported in English-language news sources; [48]

• The UN Development Programme carried out the "Iraq Living Conditions Survey" (ILCS), [49] measuring living conditions in Iraq between April 2002 and April 2004, including a section on mortality;

• Johns Hopkins University 's Bloomberg School of Public Health has sponsored two studies on Iraq mortality that have been published in The Lancet , Britain 's most respected medical journal. The first study [50] appeared in 2004 and estimated excess deaths between March 2003 and September 2004. The second study [51] was published in October 2006 and covered the much longer period from March 2003 to June 2006.

The 2004 and 2006 Hopkins surveys are the only studies designed exclusively to assess mortality in Iraq since the invasion. [52] By contrast, the ILCS study analyzed general living conditions [53] and UNAMI reports cover a wide range of human rights issues.

The Hopkins studies have aroused controversy because their estimates were high, and because they identified Coalition violence as responsible for a large proportion of the deaths. The first Hopkins study estimated about 98,000 "excess deaths" (deaths above the pre-2003 mortality rate) had occurred in the 18 month period from March 2003 to September 2004. The report concluded that "violence was the primary cause of death" since the invasion and "mainly attributed [it] to Coalition forces." [54]

The second Hopkins study estimated that 655,000 excess deaths had occurred from March 2003 through June 2006: a shockingly high number. [55] The survey was based on a large sample of 1,849 households in 47 different, randomly-selected "clusters" representing all regions of the country. The survey asked respondents about deaths in the family and verified responses by asking for death certificates, which were produced in 92 percent of cases when requested. [56] The study's conclusions showed an increase in violent deaths overall, and a proportional shift toward violence by actors other than Coalition forces. However, Coalition violence continued to account for the largest reported known source of violence – 31% of all deaths. [57]

Unsurprisingly, both Hopkins studies have been hotly contested by the White House, Downing Street and many other defenders of the war and occupation. President Bush dismissed the second study out of hand, saying: "I do not consider it a credible report. Neither does General Casey and neither do Iraqi officials." [58] When asked later about the report, the president stated that the number of those who had died in Iraq during the occupation had been "30,000, more or less," giving no evidence for this figure. [59] White House Spokesman Scott McClellan later announced that the number quoted by the president was "not an official government estimate." [60]

Other critics, including some opposed to the occupation, have questioned the plausibility and methodology of the Hopkins survey. The authors of the report have extensively defended their study and have pointed out that the US State Department has favorably used conflict mortality surveys by the same investigators, using the same methodology. [61] Many experts in epidemiology, public health, and statistics at leading institutions , including the UK 's Department for International Development , have stated that this survey was well-constructed and reliable, and that in spite of difficult circumstances it is highly credible. [62] The Chief scientific adviser of the British Ministry of Defence, Sir Roy Anderson, defended the study design as being "robust" and affirmed the survey's methods were "close to best practice." [63]

This is not the place to rehearse the debates about the Hopkins studies, but it is clear that alternative sources such as Iraq Body Count, the UNDP study, and UNAMI cannot be directly compared, as they gathered numbers of deaths in different and much more restricted ways. Iraq Body Count only tallies non-combatants killed in the fighting and reported in at least two English-language news sources. [64] Given the problem of field reporting in Iraq , English news sources probably report on only a fraction of those killed and they are probably biased in favor of interpreting those killed as combatants. In spite of those limits, as of January 2007, IBC estimated that between 54,000 and 60,000 Iraqi civilians had been killed by Coalition military operations.

UNAMI figures are based on morgue counts and information provided by the Iraqi Ministry of Health. This, too, is a limited universe, since many of those who die do not make it to the morgue and are not reported to the authorities. In its November-December 2006 Human Rights Report, UNAMI estimates that over 34,000 civilians had been killed during the year 2006, bringing the yearly average of civilian deaths to 94 every day. [65] Such methods of "passive surveillance" are useful, but provide data that are generally incomplete, especially during conflicts, and thus probably undercount the true number of deaths, as Iraq Body Count and other passive surveillance efforts themselves insist. [66] In addition, UNAMI and UNDP studies have covered much shorter time periods.

Critics have used the divergent estimates to argue that the studies' results are inconsistent. But all these estimates reflect high and rising death rates every year of the occupation. Whether the number for the 39 month period covered by the Hopkins study is 655,000 or 500,000, or another number, the overwhelming reality is that the occupying forces have failed to protect Iraqi civilians from violence under their Geneva Convention obligations. [67] Not a single published mortality statistic shows that the well-being of the Iraqi people has improved since the start of Operation Iraqi Freedom.

Causes of Death

Lack of data makes it difficult to know precisely the causes of the increased deaths in occupied Iraq – including such factors as armed conflict, damaged infrastructure, limited access to food and water, disease, and internal displacement. The 2003 war destroyed vital infrastructure for water, food and sanitation, already weakened by the 1991 Gulf War and thirteen years of sanctions. [68] However, armed violence is clearly the leading cause of excess death since 2003, whether from the Coalition's military operations, insurgent operations, or – especially since early 2006 – violence of armed sectarian militias, death squads and criminal gangs. UNAMI's report for September-October 2006 notes "a large number of indiscriminate and targeted killings." [69] UNAMI further reports that according to the Iraqi Ministry of Health, 7,054 civilians were violently killed [during the period] with no less than 4,984 in Baghdad , most of them as a result of gunshot wounds." [70]

The disintegration of Iraq 's health system has been an aggravating factor. The Iraqi medical service, once amongst the finest in the region, has declined so far that it cannot meet the needs of the population. According to an article in the British Journal of Medicine , "more than half" of those who have died in Iraq 's hospitals might have been saved if trained staff were available and hospital conditions were sufficient. [71] Many Iraqi physicians have left the country due to the security crisis, [72] leaving hospitals under-staffed or staffed with doctors "who do not have the proper experience or skills to manage emergency cases." [73] Hospitals and clinics also lack basic medical supplies, including equipments and drugs. [74] The US announced early in the occupation that it would rebuild and re-equip Iraq 's hospitals and primary care clinics. But delays, bad planning and corruption-riddled reconstruction projects have meant that Washington has failed to deliver on these promises. [75]

Conclusion

Iraq faces a growing humanitarian emergency, with unprecedented death and displacement. As of April 2007, the United Nations estimated that up to 8 million people were vulnerable and in need of immediate assistance. [76] Hundreds of thousands of Iraqis have been forced to flee from their homes and hundreds of thousands more are casualties of the violence through death and injury. Education has broken down. [77] Unemployment has reached about 60% [78] and the annual inflation rate peaked at about 70% in July 2006. [79] An estimated 54% of the Iraqi population lives on less than a dollar a day, among which 15% live in extreme poverty. [80] The public health system is weak and losing capacity. [81] Electricity is in short supply. [82] Only 32% of Iraqis have access to clean drinking water. [83]The Public Distribution System food ration has stopped functioning in certain areas of the country, leaving 4 million Iraqis acutely vulnerable due to food insecurity. [84] Severe malnutrition doubled between 2003 and 2005. [85]Iraq 's humanitarian emergency has reached a crisis level that compares with some of the world's most urgent calamities.