Shannon Doocy

Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey

BACKGROUND An excess mortality of nearly 100 000 deaths was reported in Iraq for the period March, 2003-September, 2004, attributed to the invasion of Iraq. Our aim was to update this estimate. METHODS Between May and July, 2006, we did a national cross-sectional cluster sample survey of mortality in Iraq. 50 clusters were randomly selected from 16 Governorates, with every cluster consisting of 40 households. Information on deaths from these households was gathered. FINDINGS Three misattributed clusters were excluded from the final analysis; data from 1849 households that contained 12 801 individuals in 47 clusters was gathered. 1474 births and 629 deaths were reported during the observation period. Pre-invasion mortality rates were 5.5 per 1000 people per year (95% CI 4.3-7.1), compared with 13.3 per 1000 people per year (10.9-16.1) in the 40 months post-invasion. We estimate that as of July, 2006, there have been 654 965 (392 979-942 636) excess Iraqi deaths as a consequence of the war, which corresponds to 2.5% of the population in the study area. Of post-invasion deaths, 601 027 (426 369-793 663) were due to violence, the most common cause being gunfire. INTERPRETATION The number of people dying in Iraq has continued to escalate. The proportion of deaths ascribed to coalition forces has diminished in 2006, although the actual numbers have increased every year. Gunfire remains the most common cause of death, although deaths from car bombing have increased.

The human impact of earthquakes: a historical review of events 1980-2009 and systematic literature review

Introduction. Although rare, tsunamis have the potential to cause considerable loss of life and injury as well as widespread damage to the natural and built environments. The objectives of this review were to describe the impact of tsunamis on human populations in terms of mortality, injury, and displacement and, to the extent possible, identify risk factors associated with these outcomes. This is one of five reviews on the human impact of natural disasters. Methods. Data on the impact of tsunamis were compiled using two methods, a historical review from 1900 to mid 2009 of tsunami events from multiple databases and a systematic literature review to October 2012 of publications. Analysis included descriptive statistics and bivariate tests for associations between tsunami mortality and characteristics using STATA 11. Findings. There were 255,195 deaths (range 252,619-275,784) and 48,462 injuries (range 45,466-51,457) as a result of tsunamis from 1900 to 2009. The majority of deaths (89%) and injuries reported during this time period were attributed to a single event –the 2004 Indian Ocean tsunami. Findings from the systematic literature review indicate that the primary cause of tsunami-related mortality is drowning, and that females, children and the elderly are at increased mortality risk. The few studies that reported on tsunami-related injury suggest that males and young adults are at increased injury-risk. Conclusions. Early warning systems may help mitigate tsunami-related loss of life.

Tsunami mortality in Aceh Province, Indonesia

OBJECTIVE Nine tsunami-affected districts in Aceh, Indonesia, were surveyed between February and August 2005 to characterize tsunami mortality. METHODS The surveys employed a two-stage cluster methodology with probability proportional to size sampling, and encompassed 1653 tsunami-displaced households with a pre-tsunami population of 10 063 individuals. FINDINGS Of the original pre-tsunami population, a total of 1642 people, or 17%, were reported as dead or missing in the tsunami. Crude mortality rates in the four survey areas ranged from a high of 23.6% in Aceh Jaya district on the west coast to 5.3% on the east coast. Age-specific mortality rates followed a similar pattern across the four survey areas, with the highest mortality concentrating in the youngest children (aged 0-9 years) and oldest adults (70+). The risk of mortality was significantly greater among females than males; this difference was most pronounced among individuals between ages 10 and 69 years, and diminished among younger and older age groups. CONCLUSION Mortality risk in the 2004 Asian tsunami varied by geographic location, age and sex. The districts of Aceh Jaya, Banda Aceh and Aceh Besar experienced the greatest mortality. Risk of death was highest among females, and among the oldest and youngest population subgroups. While the full human impact of the Asian tsunami in Aceh Province, in terms of lives lost or damaged, may never be fully measured, the resulting female deficit will likely be the tsunamis most deeply felt and prolonged impact.

Point-of-use water treatment and diarrhoea reduction in the emergency context: an effectiveness trial in Liberia

Communicable diseases are of particular concern in conflict and disaster‐affected populations that reside in camp settings. In the acute emergency phase, diarrhoeal diseases have accounted for more than 40% of deaths among camp residents. Clear limitations exist in current water treatment technologies, and few products are capable of treating turbid water. We describe the findings of a 12‐week effectiveness study of point‐of‐use water treatment with a flocculant–disinfectant among 400 households in camps for displaced populations in Monrovia, Liberia. In intervention households, point‐of‐use water treatment with the flocculant–disinfectant plus improved storage reduced diarrhoea incidence by 90% and prevalence by 83%, when compared with control households with improved water storage alone. Among the intervention group, residual chlorine levels met or exceeded Sphere standards in 85% (95% CI: 83.1–86.8) of observations with a 95% compliance rate.

Tsunami Mortality Estimates and Vulnerability Mapping in Aceh, Indonesia

OBJECTIVES We aimed to quantify tsunami mortality and compare approaches to mortality assessment in the emergency context in Aceh, Indonesia, where the impact of the 2004 tsunami was greatest. METHODS Mortality was estimated using geographic information systems-based vulnerability models and demographic methods from surveys of tsunami-displaced populations. RESULTS Tsunami mortality in Aceh as estimated by demographic models was 131066 and was similar to official figures of 128063; however, it was a conservative estimate of actual mortality and is substantially less than official estimates of 168561 presumed dead, which included those classified as missing. Tsunami impact was greatest in the district of Aceh Jaya, where an estimated 27.0% (n=23862) of the population perished; Aceh Besar and Banda Aceh were also severely affected, with mortality at 21.0% (n = 61 650) and 11.5% (n = 25 903), respectively. Mortality was estimated at 23.7% for the population at risk and 5.6% overall. CONCLUSIONS Mortality estimates were derived using methodologies that can be applied in future disasters when predisaster demographic data are not available. Models could be useful in the early stages of disaster response by facilitating geographic targeting and management of humanitarian assistance.

Doctors leaving 12 tertiary hospitals in Iraq, 2004-2007.

Medical doctors leaving less developed countries are now part of a global labour market. This doctor migration has been extensively studied from economic and health systems perspectives. Seldom, however has the specific role of the conflict or the collapsing state been considered as a cause of migration. Using hospital staffing records we measured the changes in numbers of medical specialists at 12 Iraqi tertiary hospitals (in Baghdad, Basra, Erbil and Mosul) between 2004 and 2007. For doctors leaving their posts, we attempted to determine destinations and circumstances of departure. We counted 1243 specialists in the 12 hospitals on January 1, 2004. This declined to 1166 or 94% of the original number by late 2007. In Baghdad, specialists decreased to 78% by late 2007, Outside Baghdad, specialists numbered 134% of the original count by 2007. In Baghdad, replacements kept pace with losses until 2005, with loss rates peaking in 2006 at 29%. Outside Baghdad, gains exceeded losses each year. Violent event rates associated with the migration of doctors were estimated as: threats 30/1000 doctors; kidnappings 6.7/1000; violent deaths 16.5/1000, and any violent event 36.7/1000. Specialists who left Baghdad were 2.5 times more likely to experience a violent event than doctors elsewhere. Specialists departing teaching hospitals were 2.3 times more likely to experience a violent event than those in general hospitals. Of specialists leaving hospital posts for which data were available, 39% went elsewhere in Iraq and 61% left the country. These findings suggest a major loss of human capital from Iraqs hospital sector, a loss that is likely to require some years to fully replace.

Food security and humanitarian assistance among displaced Iraqi populations in Jordan and Syria

The Iraq conflict resulted in the largest displacement in the Middle East in recent history, and provision of health services to the displaced population presents a critical challenge. With an increase in the number of people affected by complex emergencies and the number of people displaced in urban settings, the international community must adapt intervention strategies to meet the specific demands and contexts of this population. The study aimed to provide information on food security and livelihoods for Iraqi refugees in Syria and Jordan to inform humanitarian assistance planning. National cross-sectional cluster sample surveys of displaced Iraqi populations displaced were conducted in Jordan (October 2008) and Syria (March 2009). Clusters of ten households were randomly selected using probability-based sampling; a total of 1200 and 813 Iraqi households in Jordan and Syria, respectively, were interviewed about food security and receipt of humanitarian assistance. In Syria, 60% of households reported the household food situation had declined since the arrival period as compared to 46% in Jordan. Food aid receipt was reported by 18.0% of households in Jordan and 90.3% of households in Syria. In Jordan, 10.2% of households received cash assistance and in Syria 25.3% of households received cash assistance. In Jordan, cash assistance was associated with low socioeconomic status, large household size, and UNHCR registration. In Syria, female headed households, Damascus residents, families with children, and those registered with UNHCR were more likely to receive cash assistance. Food insecurity remains a concern among displaced Iraqi households in both Jordan and Syria. Improved targeting of both food and cash assistance and the expansion of cash-based programs could lead to a more effective use of funds and facilitate the implementation of assistance programs that are sustainable in the context of declining funding availability.

The human impact of tropical cyclones: a historical review of events 1980-2009 and systematic literature review

Background. Cyclones have significantly affected populations in Southeast Asia, the Western Pacific, and the Americas over the past quarter of a century. Future vulnerability to cyclones will increase due to factors including population growth, urbanization, increasing coastal settlement, and global warming. The objectives of this review were to describe the impact of cyclones on human populations in terms of mortality, injury, and displacement and, to the extent possible, identify risk factors associated with these outcomes. This is one of five reviews on the human impact of natural disasters. Methods. Data on the impact of cyclones were compiled using two methods, a historical review from 1980 to 2009 of cyclone events from multiple databases and a systematic literature review of publications ending in October 2012. Analysis included descriptive statistics and bivariate tests for associations between cyclone characteristics and mortality using Stata 11.0. Findings. There were 412,644 deaths, 290,654 injured, and 466.1 million people affected by cyclones between 1980 and 2009, and the mortality and injury burden was concentrated in less developed nations of Southeast Asia and the Western Pacific. Inconsistent reporting suggests this is an underestimate, particularly in terms of the injured and affected populations. The primary cause of cyclone-related mortality is drowning; in developed countries male gender was associated with increased mortality risk, whereas females experienced higher mortality in less developed countries. Conclusions. Additional attention to preparedness and early warning, particularly in Asia, can lessen the impact of future cyclones.

Incidence and risk factors for malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: A retrospective study

BackgroundUnited Nations High Commissioner for Refugees (UNHCR) refugee camps are located predominantly in rural areas of Africa and Asia in protracted or post-emergency contexts. Recognizing the importance of malaria, pneumonia and diarrheal diseases as major causes of child morbidity and mortality in refugee camps, we analyzed data from the UNHCR Health Information System (HIS) to estimate incidence and risk factors for these diseases in refugee children younger than five years of age.MethodsData from 90 UNHCR camps in 16 countries, including morbidity, mortality, health services and refugee health status, were obtained from the UNHCR HIS for the period January 2006 to February 2010. Monthly camp-level data were aggregated to yearly estimates for analysis and stratified by location in Africa (including Yemen) or Asia. Poisson regression models with random effects were constructed to identify factors associated with malaria, pneumonia and diarrheal diseases. Spatial patterns in the incidence of malaria, pneumonia and diarrheal diseases were mapped to identify regional heterogeneities.ResultsMalaria and pneumonia were the two most common causes of mortality, with confirmed malaria and pneumonia each accounting for 20% of child deaths. Suspected and confirmed malaria accounted for 23% of child morbidity and pneumonia accounted for 17% of child morbidity. Diarrheal diseases were the cause of 7% of deaths and 10% of morbidity in children under five. Mean under-five incidence rates across all refugee camps by region were: malaria [Africa 84.7 cases/1000 U5 population/month (95% CI 67.5-102.0), Asia 2.2/1000/month (95% CI 1.4-3.0)]; pneumonia [Africa 59.2/1000/month (95% CI 49.8-68.7), Asia 254.5/1000/month (95% CI 207.1-301.8)]; and diarrheal disease [Africa 35.5/1000/month (95% CI 28.7-42.4), Asia 69.2/1000/month (95% CI 61.0-77.5)]. Measles was infrequent and accounted for a small proportion of child morbidity (503 cases, < 1%) and mortality (6 deaths, < 1%).ConclusionsAs in stable settings, pneumonia and diarrhea are important causes of mortality among refugee children. Malaria remains a significant cause of child mortality in refugee camps in Africa and will need to be addressed as part of regional malaria control and elimination efforts. Little is known of neonatal morbidity and mortality in refugee settings, and neonatal deaths are likely to be under-reported. Global measles control efforts have reduced the incidence of measles among refugee children.

Chronic disease and disability among Iraqi populations displaced in Jordan and Syria.

The Iraq conflict resulted in the largest displacement in the Middle East since the Palestinian crisis, and provision of health services to the displaced population presents a critical challenge. The study aimed to provide information on chronic medical conditions and disability to inform humanitarian assistance planning. Nationally representative cross-sectional surveys of Iraqi populations displaced in Jordan and Syria were conducted in late 2008 and early 2009. Clusters of 10 household were randomly selected using probability-based sampling; a total of 1200 and 813 Iraqi households in Jordan and Syria, respectively, were interviewed. The majority of respondents in both countries perceived healthcare as unaffordable but accessible; cost was an important barrier to care. In Jordan, most routine health expenditures were for medications where in Syria, expenses were divided between medical consultations and medication. Chronic disease prevalence among adults was 51.5% (confidence interval (CI): 49.4-53.5) in Syria and 41.0% (CI: 39.4-42.7) in Jordan, most common were hypertension and musculoskeletal problems. Overall disability rates were 7.1% (CI: 6.3-8.0) in Syria and 3.4% (CI: 3.0-3.9) in Jordan. In both countries, the majority of disability was attributed to conflict, prevalence was higher in men than women, and depression was the leading cause of mental health disability. Chronic illnesses, disabilities and psychological health are key challenges for the Iraqi population and the health systems in Jordan and Syria. Continued attention to the development of systems to manage conditions that require secondary and tertiary care is essential, particularly given reported difficulties in accessing care and the anticipated prolonged displacement.