Correspondence

The Gulf War and Infant and Child Mortality in Iraq

N Engl J Med 1993; 328:1358May 6, 1993

Article

To the Editor:

Ascherio et al. (Sept. 24 issue)1 determined the increase in the mortality rate after January 1, 1991, in a sample of more than 16,000 Iraqi children under five years of age, according to age, mother's education, and region of residence.

Although the text mentions the Gulf war, the trade sanctions, and the civil uprising and its suppression as responsible agents, the conclusions to the abstract summarize and causally interpret the findings as providing “strong evidence that the Gulf war and trade sanctions caused a threefold increase in mortality among Iraqi children under five years of age. We estimate that an excess of more than 46,900 children died between January and August 1991.”

The study data show a significantly higher mortality rate among the children in all three age groups in the three regions of Iraq affected by the civil war (the north, the south, and the neutral zone) than among the children in the two regions not so affected (Baghdad and the central region). It therefore seemed reasonable to separate out the effect of the civil war by assuming that if there had been no civil uprising, the Gulf war and trade sanctions would have caused the same proportional increase in child mortality for a given age group in all five regions that it did in the two regions less affected by the civil war.

From this model and the study data, a recalculation shows that the Gulf war and trade sanctions alone caused a 1.9-fold (rather than a 3-fold) increase in child mortality, which amounts to an excess of about 21,000 pediatric deaths from January through August 1991, rather than the claimed 46,900. In other words, roughly 56 percent of the excess child mortality reported by the study should be attributed to the domestic uprising and its suppression by the Iraqi government.

Arthur Bierman, M.S., Ph.D.
543 Arapahoe Ave., Boulder, CO 80302

1 References

1. 1

   Ascherio A, Chase R, Cote T, et al. Effect of the Gulf war on infant and child mortality in Iraq. N Engl J Med 1992;327:931-936
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Bierman estimates that 56 percent of the excess mortality in Iraqi children between January and August 1991 should be attributed to the domestic uprising. There is merit in trying to establish the contribution to mortality of each of the consequences of the war. There are no data, however, to support Dr. Bierman's assumption that without civilian uprisings the war-related relative increase in mortality would have been the same in each region. Poverty, scarcity of food, lack of access to health care, and cold are among the factors that may have contributed to regional differences in the increase in mortality after the war.

Alberto Ascherio, M.D., Dr.P.H.
Sarah Zaidi, M.Sc.
Harvard School of Public Health, Boston, MA 02115