Additional analyses of secondary data were performed to adjust these estimates to account for migration. In mid we conducted a nationally representative cross-sectional survey of all adults living in 2, randomly selected households in clusters across Iraq. These representative households are then queried about their composition and mortality events over a given time period, to allow researchers to generate crude death rates; these rates are then multiplied by the country's population total to calculate a death estimate .
We used a questionnaire that asked all adults in the household about the births and deaths of their siblings, as well as all births and deaths in the household since The questionnaire is provided as Questionnaire S1. We employed a two-stage cluster sampling method. We used a commercial software product LandScan that contained gridded population data at the 1-km 2 level in a geographic information system, and we linked it to Google Earth imagery.
In the first stage of cluster selection, we randomly selected 1-km 2 areas using a probability-proportional-to-size approach. In each small grid cell, we examined the Google Earth image and selected the residential rooftop that most fully fit in the square to serve as the start household . Our field manual see Manual S1 established protocols for selecting 19 dwellings adjacent to the starting household. Our sample size was established building on experience derived from previous studies. By doubling the number of clusters used in two previous mortality studies  ,  , we were able to reduce the possibility of missing pockets of unusually high or low conflict-related mortality, and by halving the number of households per cluster we were able to keep the operational complexity of conducting the survey manageable, and still visit a reasonable number of households per cluster.
We recruited study collaborators and drafted questionnaires in early Lead researchers from three North American universities and two Iraqi team leaders met in northern Iraq in March to revise data collection instruments and survey processes, finalize the field manual, and gain experience finding start households using Google maps.
The two Iraqi team leaders recruited eight medical doctors with experience in community surveys as interviewers. Author W. Weekly or more frequent teleconferences were held between the North American team and the lead Iraqi investigator during the design and implementation phases.
The entire team met again in Iraq in September to review and interpret preliminary findings. Four two-person teams along with their supervisors for a total of ten surveyors surveyed clusters of 20 households between May 13 and July 2, The supervisor returned to one randomly selected household in each cluster where he or she had not previously visited to repeat the survey as a quality check.
When in governorates outside Baghdad, persons familiar with locations and local security issues joined the teams to help obtain local approvals and find designated clusters. Interviewers asked for causes of death, and coded these from a brief listing of common causes. For war-related deaths, we asked for specific causes such as gunshots or explosions and perceived responsible parties such as coalition forces or criminals.
We trained interviewers to probe for sensitive information about missing or disappeared persons, and about events distant in time among siblings and household members. We compiled qualitative observations about the remoteness and other characteristics of each cluster. We were obliged, however, to drop two remote clusters where our teams were strongly advised by community leaders not to visit dwellings for cultural reasons ; instead, household members were invited to a central location for interviews.
As this violated the study protocol, these households were dropped from the analysis.
Each paper questionnaire contained a household and a sibling component. After obtaining verbal consent following our human subjects protocol, we interviewed the head of household or the most senior member present to complete a household listing. A household was defined as a group of people, not necessarily related, who regularly eat and sleep together in a building with a separate entrance and who share a kitchen. For the household component, household births and deaths between January 1, , and the interview date were recorded.
When deaths were reported, interviewers requested to see death certificates. We recorded whether interviewers were shown the certificate, whether the certificate was reported to be present but not seen, or whether it was absent. The second component of the questionnaire was a sibling history module commonly used in Demographic and Health Surveys in developing countries .
By asking all adults in the household to recall and report on each of their siblings defined as persons born to the same biological mother , we were able to estimate probabilities of death for adults across several decades. Respondents to the sibling history module included all household members aged 18 y and older, and any married people under 18 y. Where necessary, telephone interviews of absent adult household members were conducted while the interviewers were in the household. We allowed limited proxy reporting for siblings. The mother of adult siblings in the home was allowed to report about her own children.
If an adult in the home was incapable of responding because of absence, disability, or refusal , his or her relatives reported on that person's siblings, but only if they said they were fully knowledgeable. Otherwise, the person's response was marked as missing. If two or more siblings lived together in the same home, we interviewed only one whichever one was actually present, or, if all were present, the sibling with the nearest next birthday to the date of our visit. We employed algorithms to scan for systematic interviewer error  , and observed none.
All data records were rechecked against the paper record to identify and correct discrepancies. We estimated crude death rates for the time periods January 1, —February 28, and March 1, —June 30, by counting deaths occurring in all households in each time period and dividing by the person-years lived within the time period. We collected month and year of birth and death information and month and year of household formation. Uncertainty intervals can be interpreted similarly to confidence intervals.
To account for clustering, we first sampled with replacement the 98 existing clusters 1, times, so that each time we selected 98 clusters—with some of the original clusters sampled more than once, and some not sampled at all.
Next, for each of the 1, sets of clusters, we resampled the original number of households with replacement within each of the 98 sampled clusters. For each of these 1, replicates, we calculated annual crude death rates. The 2. To estimate excess deaths caused by conflict, we calculated the war-related death rate to be the difference between the crude death rate for each time period and the crude rate during the baseline time period January 1, , to February 28, To create a war-related death count for the total population, we used the yearly United Nations Population Division estimates  for Iraq multiplied by the war-related crude death rate.
To estimate upper and lower uncertainty bounds, we used the bootstrapping method described above. Because the bootstrap process randomly chooses 1, possible scenarios, and we did not limit the assumptions otherwise, the occasional random selection could and did show a protective effect of conflict which served to lower our final death rates.
These effects of cluster sampling were not particularly large, ranging from 1. Data about adult mortality using the sibling report method are subject to predictable biases. Sibships that experience a higher mortality risk are underrepresented at the time of the survey, because these siblings are less likely to survive to be able to report survival bias. Additionally, larger sibships are overrepresented in the sample, because there are more siblings in the sampling frame.
We used the ICSS method to adjust for these biases . Further details are in Text S1. We calculated mortality rates for 5-y age groups between the ages of 15 and 59 y for the time periods January 1, —February 28, ; March 1, —December 31, ; the full years —, —, —; and January 1—June 30, Our summary metric of adult mortality is 45 q 15 , which is the risk that an individual will die before his or her 60th birthday given that he or she has lived to age 15 y.
Pan traps are also not restricted to flower-visitors of plants species on a transect, but can sample an area dependent on the flight range of invertebrate species, which is usually less than several hundred meters for solitary bees . Giannakis and Y. Kirshner, Y. Proportions of pollen collected from crop flowers e. Flowering was usually focused along dune crests, and so sampling along transects was effective at capturing the full floral diversity and abundance, enabling efficient collection of flower-visitors with nets. Solomon, R.
For example, male 45 q 15 ranges from below 0. Uncertainty intervals were calculated using the same bootstrapping method as in the household analysis. Unlike the adult sibling survival method, there is no accepted method for adjusting household figures to account for households entirely destroyed subsequent to the death of all members, or lost to migration out of the country, especially for households that experienced a death. There is evidence that the killings in Iraq were disproportionately targeted towards the higher-income intelligentsia, a group typically in a better position to migrate to a safer setting if under attack .
We therefore reviewed a number of secondary data sources to estimate the number of Iraqis who migrated out of the country over the course of the war, to arrive at a total estimate of the missing households that left the country and were therefore no longer available in our sampling frame. We then divided this total by an estimated household size, and multiplied total households by the average fraction of deaths per household  to estimate the total deaths our household survey would have missed, and added this number to our total death count.
We had review board approval from each participating institution in the study. Methods were reviewed to ensure they complied with the ethical guidelines for epidemiological research set out by the Council for International Organizations of Medical Sciences and other guidance, including the professional responsibility code of the American Association for Public Opinion Research  — .
An ethicist experienced in international research associated with the Institute of Translational Health Sciences at the University of Washington, Benjamin Wilfond, further reviewed the protocols to ensure the safety of participants and interviewers was adequately protected. We collected data from 2, households in clusters, distributed across Iraq's 18 governorates. After removing the two clusters previously mentioned, the total household count was 1,, with an average of 5.
The study population was distributed similarly to Iraq's estimated total population as reported by COSIT, which based its estimate on projections from the census for the 15 southern governorates and on the census for the three Kurdish governorates. See Table 1. Interviewers reported that 24 households refused to participate in the study, and five households were not interviewed because of hostile or threatening behavior resulting in a This low refusal rate is not uncommon for surveys in similar countries .
An additional buildings were occupied by a business or other establishment, rather than a household, and four previously selected start dwellings were found to have been destroyed. In all these cases, replacement households were chosen using our established study protocol, to ensure total households numbered 20 per cluster. At the beginning of the first time period January , 1, of these households were already established, and contained approximately 6, members. A total of 2, births and deaths were reported during the study period. Sex and cause of death were reported for On average, households had existed as a unit for a mean of The crude birth rate was Estimated wartime crude death rates ranged from 2.
See Table 2 for violent deaths reported by type and responsible party. Despite receiving the most press coverage, explosive devices were not the leading proximate cause of death among war casualties—rather, gunshots were  , . Gunshot deaths were most common for the period March 1, —December 31, , and dropped precipitously thereafter. While militia were reportedly responsible for the most adult male deaths in the sibling survey, coalition forces were reportedly responsible for killing the most women.
See Figure 1 for the number of household deaths by year and cause, — Counts of deaths reported by respondents to the household mortality questionnaire, by year and cause. The survey concluded July 2, , so the final bar reflects data for only half of the year.
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