Iraq: time to signal a new era for health in foreign policy
Authors: Richard Horton
Journal: The Lancet (2006)

In 2004, Johns Hopkins researcher Les Roberts and colleagues reported findings that suggested the risk of death in Iraq was 2·5-fold greater after the military invasion in 2003 than before.1Roberts L Lafta R Garfield R Khudhain J Burnham G Mortality before and after the 2003 invasion of Iraq: cluster sample survey.Lancet. 2004; 364: 1857-1864Summary Full Text Full Text PDF PubMed Scopus (349) Google Scholar They estimated that there were 98 000 more deaths than expected, with violence accounting for most of these casualties. Their work provoked great political controversy, not least because the 95% CI around the 98 000 figure was wide, ranging from 8000 to 194 000 deaths. Despite rigorous methods, critics found this uncertainty hard to take seriously. Since 2004, and especially recently, independent observers have recognised that the security situation in parts of Iraq has deteriorated dramatically.2Oppel RA UN finds Baghdad toll far higher than cited.New York Times. Sept 21, 2006; : A18Google Scholar, 3Beaumont P Civilian deaths soar to record high in Iraq.Guardian. Sept 22, 2006; : 19Google Scholar, 4Moore S US military casualties surging.San Francisco Chronicle. Oct 4, 2006; : A7Google Scholar, 5Tyson AS 4000 Iraqi police killed in 2 years, US official says.Washington Post. Oct 7, 2006; : A16Google Scholar, 6Moore S Roug L Deaths across Iraq show it is a nation of many wars, with US in the middle.Los Angeles Times. Oct 7, 2006; : 1Google Scholar This week, The Lancet publishes a follow-up to the 2004 study by the same research group.7Burnham G Lafta R Doocy S Roberts L Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey.Lancet. 2006; published online Oct 12. DOI:10.1016/S0140-6736(06)69491-9Google Scholar Their findings corroborate the impression that Iraq is descending into bloodthirsty chaos. Gilbert Burnham and colleagues completed a mortality survey in over 1800 households in Iraq between May and June this year. The death rate in this sample before the 2003 invasion was 5·5 per 1000 a year, rising to 13·3 per 1000 a year for the entire postinvasion period. Interestingly, and reassuringly, the trajectory of the death rate up until September, 2004, closely matched that of their earlier survey. But now the estimated number of excess deaths has increased by an enormous amount. They calculated that 654 965 excess deaths have taken place as a consequence of the war. The lower 95% CI on this figure is still huge, at 392 979 deaths. Violence—gunfire and car bombing in particular—remains the main cause of this excess mortality. Given the controversy surrounding the previous Iraq paper that we published, it is worth emphasising the quality of this latest report as judged by four expert peers who provided detailed comments to editors. All reviewers recommended publication with relatively minor revisions. For example, one adviser noted that "this is an important piece of research which should be published because it is possibly the only non-government funded scientific study to provide an estimate of the number of Iraqi deaths since the US invasion." She underscored the "powerful strength" of the research methods, a view supported by other reviewers. Indeed, this study adds substantially to the new field of conflict epidemiology, which has been evolving rapidly in recent years.8Spiegel DB Salama P War and mortality in Kosovo, 1998–99: an epidemiological testimony.Lancet. 2000; 355: 2204-2209Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar, 9Depoortere E Checchi F Broillet F et al.Violence and mortality in West Dafur, Sudan (2003–04): epidemiological evidence from four surveys.Lancet. 2004; 364: 1315-1320Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 10Coghlan B Brennan RJ Ngoy P et al.Mortality in the Democratic Republic of Congo: a nationwide survey.Lancet. 2006; 367: 44-57Summary Full Text Full Text PDF PubMed Scopus (307) Google Scholar The US administration recognises the peril of the present anarchy in Iraq, albeit in often unrewarding ways. Although a recent US report produced differing interpretations, the US National Intelligence Estimate did conclude that the situation in Iraq was likely to have increased the terrorist threat to the USA at home and abroad. US government officials are now blaming Iraqi leaders for this escalating spiral of violence. "You do not see them taking the levers of sovereignty," Republican senator John Warner declared last week, according to a report in the Washington Post.11White J Warner downbeat after Iraq trip.Washington Post. Oct 6, 2006; : A3PubMed Google Scholar And Secretary of State Condoleezza Rice has impatiently urged the Iraqi government to step up its efforts to quell sectarian violence. The natural response to this deteriorating situation is despair. Military action in Iraq has dragged on, inflaming an already volatile atmosphere. Diplomacy seems to have broken down. The absence of any plan for reconstruction after the 2003 invasion has provided an inviting vacuum that continues to suck in violence and terror. And the rhetoric of democracy and freedom sounds little more than empty hope. Of most serious concern must surely be the collapse of a foreign policy based, in UK Prime Minister Tony Blair's words, on "progressive pre-emption". His doctrine of international community was forged on the humanitarian crisis in Kosovo. At that time he claimed that "The most pressing foreign policy problem we face is to identify the circumstances in which we should get actively involved in other people's conflicts". A longstanding principle of non-interference in the affairs of other states was no longer credible, he argued. Intervention based on values as much as territorial ambition was to be the new military strategy. "The answer to terrorism", he has said, "is the universal application of global values." And in August, 2006, he called for "a complete renaissance of our strategy to defeat those who threaten us…by showing that our values are stronger, better, and more just, more fair than the alternative". Yet the splinter of our presence in Iraq is increasing, not reducing, violence. By making this a battle of values, Tony Blair and US President George Bush risk pitting one culture against another, one religion against another. This could rapidly become—and for many it already is—the politics of humiliation. Yet absolute despair would be the wrong response. Instead, the disaster that is the West's current strategy in Iraq must be used as a constructive call to the international community to reconfigure its foreign policy around human security rather than national security, around health and wellbeing in addition to the protection of territorial boundaries and economic stability. I would go as far as to say that health is now the most important foreign policy issue of our time. The advantages of using health as an instrument of foreign policy are at least four-fold. First, focusing on health is strategically correct. By protecting nations against health threats (eg, HIV/AIDS, emerging infections, non-communicable disease epidemics), governments will promote internal stability.12Horton R Public health as a counterterrorist measure.Lancet. 2001; 358: 1112-1113Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Second, focusing on health will produce unequivocally positive benefits—social cohesion, equity, and a strengthened national infrastructure. Third, focusing on health is a valuable diplomatic tool in its own right to promote good bilateral relations and to signal good leadership. Finally, focusing on health will encourage trust between nations and across global multilateral organisations. This strategic reappraisal of foreign-policy thinking would introduce important new actors into policy formulation, including academic leaders in global health, health-related non-governmental organisations, human development institutions, and new strands of public and media opinion. Traditionally, public health becomes an important foreign-policy matter only when there is an immediate crisis—eg, the outbreaks of severe acute respiratory syndrome—or when the scale of a health problem seems too large to ignore (eg, HIV/AIDS). Yet the longitudinal importance of health as a human security concern argues against this kind of discontinuous thinking. And the signs are hopeful that agencies and governments are beginning to lay the foundations for health as a broader policy instrument. WHO is taking a promising interest.13Fidler DP Drager N Health and foreign policy.Bull World Health Organ. 2006; 84: 687Crossref PubMed Scopus (19) Google Scholar A welcome joint ministerial initiative led by the Norwegian and French Governments aims to produce a preliminary analysis of the value of health in foreign policy early next year. And the issue has even surfaced in the debate about who should become WHO's new Director-General.14Horton R The next Director-General of WHO.Lancet. 2006; 368: 1213-1214Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Globalisation has changed the terms of human engagement at many levels—in trade, aid, economic development, environmental protection, and agriculture. Yet foreign policy is still governed by principles that had their origin in the 19th century, based, as they were, around notions of national sovereignty and economic and geographical self-interest. Those principles need to be radically revised. Health and wellbeing—their underpinning values, their diverse array of interventions, and their goals of healing—offer several original dimensions for a renewed foreign policy that might at least be one positive legacy of our misadventure in Iraq. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample surveyThe 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. Full-Text PDF