Iraqi Civilians Hit Hard by Suicide Bombs

Suicide bombs have now killed 200 coalition soldiers and more than 12,000 civilians in Iraq, say the authors of a new report focusing on the high number of civilian deaths – particularly child deaths – and injuries from such attacks.

The report, published online Sept. 1 in the Lancet, shows that while U.S.-led coalition forces have adopted successful strategies for avoiding suicide bomb attacks and for treating its own members exposed to them, the noncombatant, civilian population of Iraq has borne a remarkably heavy burden (Lancet 2011;378: 906-14).

Some 30,644 noncombatant civilians were injured and 12,284 killed in more than 1,000 suicide bombings between March 2003, when the Iraq war began, through the end of December 2010 – a ratio of 2.5 injured for every 1 killed, investigators found. Some 19% of all Iraqi civilian casualties and 11% of Iraqi civilian deaths in this period were caused by suicide bombs, with car bombs proving more lethal than those detonated by bombers on foot.

Courtesy U.S. Army/Pfc. Charles Probst

"I think everyone knows that civilians are more exposed to suicide bombs, but the extent to which that’s true was surprising," the study’s lead author, Dr. Madelyn Hsiao-Rei Hicks of King’s College London, said in an interview.

The study by Dr. Hicks and her colleagues also revealed Iraqi children to be particularly vulnerable. Children comprised 14% of suicide bomb fatalities during the study period – a share greater than the 9% dying in all forms of armed violence – and 51% of child casualties from suicide bombs were fatal.

Contributing factors may have included malnutrition, a scarcity of pediatric experts and supplies in clinics, more severe injuries, and greater physiological vulnerability to the type of injuries caused by suicide bombs, Dr. Hicks and her colleagues wrote.

While earlier, smaller studies have suggested that children are more vulnerable to suicide bombs, "I hadn’t seen that before in larger sets of data on children and adults," Dr. Hicks said. "It makes sense anatomically, as their heads and torsos are proportionately larger than adults’, and a bomb is more likely to hit a vital organ."

Why Suicide Attacks Focus on Iraqi Civilians

In an editorial comment accompanying the article, Dr. Gilbert Burnham of Johns Hopkins Bloomberg School of Public Health, Baltimore, offered a broader perspective on why Iraq’s civilian population would bear such a disproportionate brunt of such attacks, and what might be done about it (Lancet 2011;378:855-7).

"Prevention of suicide attacks is difficult because of their complex origins," Dr. Burnham wrote. "The military’s approach of controlling access and attacking suspicious targets has protected coalition forces in Iraq, but the resulting deaths of innocent civilians have alienated many Iraqis. This action has played a part in shifting suicide attacks towards civilian targets."

Attempts to stop bombers are often futile, Dr. Burnham continued. "Most effective is the elimination of conditions that cause popular support for terrorist groups," and targeting of extremist networks.

Dr. Burnham declared that he had no conflicts of interest. Dr. Hicks and colleagues declared that they had no financial conflicts of interest; however, their study, which had no outside funding, used data from Iraq Body Count, an organization founded by three of Dr. Hicks’ coauthors. Dr. Hicks serves as an unpaid director for IBC.

Dr. Hicks said that she had become involved with IBC after discovering that its database contained valuable public health information gotten through exacting methods. Moreover, she said, IBC distinguished between civilians and combatants, which many data sources do not, and had information on specific types of weapons involved in the injuries. "It's the kind of detail that’s very difficult to obtain in clinical settings," she said.

IBC has documented violent deaths of Iraqi civilians since 2003, using media, hospital, government and nongovernmental organization reports. Dr. Hicks and her colleagues also used data from iCasualties, a separate group that tracks coalition military casualties in Iraq and Afghanistan.

While the investigators acknowledged that one potential weakness of their study was its use of a database reliant on media reports, they noted that all IBC’s reports had been cross-checked and represented "documented, verifiable, individual casualties and suicide bomb events," not estimates or extrapolations.

The study appeared as part of a group of articles in the Lancet highlighting the health consequences of actions and conflicts in the decade following the terrorist attacks of Sept. 11, 2001.

How the War Impacts Noncombatants

The effects of the Iraq war on noncombatants was addressed further in separate study led by Dr. Christopher H. Warner of the U.S. Command and General Staff College in Fort Leavenworth, Kan. (Lancet 2011; 378: 915-24).

Dr. Warner and colleagues’ study showed that an Army ethics training program had improved troops’ self-reported behavior toward noncombatants, and increased troops’ stated willingness to report fellow unit members committing misconduct.

Soldiers from an infantry brigade team participated in the program, which used clips from popular movies and other unconventional teaching methods to highlight dilemmas involving noncombatants, and instruct on legal and ethical ways of resolving them.

The training, which lasted between 60 and 90 minutes, occurred during a 15-month deployment in Iraq that lasted until 2008. Randomly selected members of the brigade (n=421) completed anonymous surveys 3 months after the training, and their results were compared with anonymous surveys from randomly chosen members (n=397) completed before the training.

Only 5% of troops who had completed training reported having damaged or destroyed private property, compared with 14% before. A majority – 59% – reported being willing to report a unit member for mistreating a noncombatant, compared with 36% before. Combat frequency and intensity was the strongest predictor of unethical behavior, the investigators found, and posttraumatic stress disorder was not seen as predictive of unethical behavior after controlling for combat experiences.

In an editorial comment accompanying Dr. Warner and colleagues’ article, Dr. Jennifer Leaning of Harvard School of Public Health, Boston, and Michael Lappi, Ph.D., of Harvard Medical School, praised the design of both the training program, which can be used in a war zone, and the study (Lancet 2011;378:857-9). The study’s weaknesses, they wrote, "derive in some measure from its strengths, in that frequent entries and exits of soldiers from the deployment zone introduced sampling issues ... and concerns about self-report."

Still, Dr. Leaning and Dr. Lappi wrote, "soldiers deployed in counter-insurgency operations will always need to fall back on their own capacity, buttressed by sound training, for resilient and nuanced legal and moral choice."

Dr. Warner reported no conflicts of interest related to the study, and Dr. Leaning and Dr. Lappi also reported no conflicts of interest.

Suicide bombs have now killed 200 coalition soldiers and more than 12,000 civilians in Iraq, say the authors of a new report focusing on the high number of civilian deaths – particularly child deaths – and injuries from such attacks.

The report, published online Sept. 1 in the Lancet, shows that while U.S.-led coalition forces have adopted successful strategies for avoiding suicide bomb attacks and for treating its own members exposed to them, the noncombatant, civilian population of Iraq has borne a remarkably heavy burden (Lancet 2011;378: 906-14).

Some 30,644 noncombatant civilians were injured and 12,284 killed in more than 1,000 suicide bombings between March 2003, when the Iraq war began, through the end of December 2010 – a ratio of 2.5 injured for every 1 killed, investigators found. Some 19% of all Iraqi civilian casualties and 11% of Iraqi civilian deaths in this period were caused by suicide bombs, with car bombs proving more lethal than those detonated by bombers on foot.

Courtesy U.S. Army/Pfc. Charles Probst

"I think everyone knows that civilians are more exposed to suicide bombs, but the extent to which that’s true was surprising," the study’s lead author, Dr. Madelyn Hsiao-Rei Hicks of King’s College London, said in an interview.

The study by Dr. Hicks and her colleagues also revealed Iraqi children to be particularly vulnerable. Children comprised 14% of suicide bomb fatalities during the study period – a share greater than the 9% dying in all forms of armed violence – and 51% of child casualties from suicide bombs were fatal.

Contributing factors may have included malnutrition, a scarcity of pediatric experts and supplies in clinics, more severe injuries, and greater physiological vulnerability to the type of injuries caused by suicide bombs, Dr. Hicks and her colleagues wrote.

While earlier, smaller studies have suggested that children are more vulnerable to suicide bombs, "I hadn’t seen that before in larger sets of data on children and adults," Dr. Hicks said. "It makes sense anatomically, as their heads and torsos are proportionately larger than adults’, and a bomb is more likely to hit a vital organ."

Why Suicide Attacks Focus on Iraqi Civilians

In an editorial comment accompanying the article, Dr. Gilbert Burnham of Johns Hopkins Bloomberg School of Public Health, Baltimore, offered a broader perspective on why Iraq’s civilian population would bear such a disproportionate brunt of such attacks, and what might be done about it (Lancet 2011;378:855-7).

"Prevention of suicide attacks is difficult because of their complex origins," Dr. Burnham wrote. "The military’s approach of controlling access and attacking suspicious targets has protected coalition forces in Iraq, but the resulting deaths of innocent civilians have alienated many Iraqis. This action has played a part in shifting suicide attacks towards civilian targets."

Attempts to stop bombers are often futile, Dr. Burnham continued. "Most effective is the elimination of conditions that cause popular support for terrorist groups," and targeting of extremist networks.

Dr. Burnham declared that he had no conflicts of interest. Dr. Hicks and colleagues declared that they had no financial conflicts of interest; however, their study, which had no outside funding, used data from Iraq Body Count, an organization founded by three of Dr. Hicks’ coauthors. Dr. Hicks serves as an unpaid director for IBC.

Dr. Hicks said that she had become involved with IBC after discovering that its database contained valuable public health information gotten through exacting methods. Moreover, she said, IBC distinguished between civilians and combatants, which many data sources do not, and had information on specific types of weapons involved in the injuries. "It's the kind of detail that’s very difficult to obtain in clinical settings," she said.

IBC has documented violent deaths of Iraqi civilians since 2003, using media, hospital, government and nongovernmental organization reports. Dr. Hicks and her colleagues also used data from iCasualties, a separate group that tracks coalition military casualties in Iraq and Afghanistan.

While the investigators acknowledged that one potential weakness of their study was its use of a database reliant on media reports, they noted that all IBC’s reports had been cross-checked and represented "documented, verifiable, individual casualties and suicide bomb events," not estimates or extrapolations.

The study appeared as part of a group of articles in the Lancet highlighting the health consequences of actions and conflicts in the decade following the terrorist attacks of Sept. 11, 2001.

How the War Impacts Noncombatants

The effects of the Iraq war on noncombatants was addressed further in separate study led by Dr. Christopher H. Warner of the U.S. Command and General Staff College in Fort Leavenworth, Kan. (Lancet 2011; 378: 915-24).

Dr. Warner and colleagues’ study showed that an Army ethics training program had improved troops’ self-reported behavior toward noncombatants, and increased troops’ stated willingness to report fellow unit members committing misconduct.

Soldiers from an infantry brigade team participated in the program, which used clips from popular movies and other unconventional teaching methods to highlight dilemmas involving noncombatants, and instruct on legal and ethical ways of resolving them.

The training, which lasted between 60 and 90 minutes, occurred during a 15-month deployment in Iraq that lasted until 2008. Randomly selected members of the brigade (n=421) completed anonymous surveys 3 months after the training, and their results were compared with anonymous surveys from randomly chosen members (n=397) completed before the training.

Only 5% of troops who had completed training reported having damaged or destroyed private property, compared with 14% before. A majority – 59% – reported being willing to report a unit member for mistreating a noncombatant, compared with 36% before. Combat frequency and intensity was the strongest predictor of unethical behavior, the investigators found, and posttraumatic stress disorder was not seen as predictive of unethical behavior after controlling for combat experiences.

In an editorial comment accompanying Dr. Warner and colleagues’ article, Dr. Jennifer Leaning of Harvard School of Public Health, Boston, and Michael Lappi, Ph.D., of Harvard Medical School, praised the design of both the training program, which can be used in a war zone, and the study (Lancet 2011;378:857-9). The study’s weaknesses, they wrote, "derive in some measure from its strengths, in that frequent entries and exits of soldiers from the deployment zone introduced sampling issues ... and concerns about self-report."

Still, Dr. Leaning and Dr. Lappi wrote, "soldiers deployed in counter-insurgency operations will always need to fall back on their own capacity, buttressed by sound training, for resilient and nuanced legal and moral choice."

Dr. Warner reported no conflicts of interest related to the study, and Dr. Leaning and Dr. Lappi also reported no conflicts of interest.

Suicide bombs have now killed 200 coalition soldiers and more than 12,000 civilians in Iraq, say the authors of a new report focusing on the high number of civilian deaths – particularly child deaths – and injuries from such attacks.

The report, published online Sept. 1 in the Lancet, shows that while U.S.-led coalition forces have adopted successful strategies for avoiding suicide bomb attacks and for treating its own members exposed to them, the noncombatant, civilian population of Iraq has borne a remarkably heavy burden (Lancet 2011;378: 906-14).

Some 30,644 noncombatant civilians were injured and 12,284 killed in more than 1,000 suicide bombings between March 2003, when the Iraq war began, through the end of December 2010 – a ratio of 2.5 injured for every 1 killed, investigators found. Some 19% of all Iraqi civilian casualties and 11% of Iraqi civilian deaths in this period were caused by suicide bombs, with car bombs proving more lethal than those detonated by bombers on foot.

Courtesy U.S. Army/Pfc. Charles Probst

"I think everyone knows that civilians are more exposed to suicide bombs, but the extent to which that’s true was surprising," the study’s lead author, Dr. Madelyn Hsiao-Rei Hicks of King’s College London, said in an interview.

The study by Dr. Hicks and her colleagues also revealed Iraqi children to be particularly vulnerable. Children comprised 14% of suicide bomb fatalities during the study period – a share greater than the 9% dying in all forms of armed violence – and 51% of child casualties from suicide bombs were fatal.

Contributing factors may have included malnutrition, a scarcity of pediatric experts and supplies in clinics, more severe injuries, and greater physiological vulnerability to the type of injuries caused by suicide bombs, Dr. Hicks and her colleagues wrote.

While earlier, smaller studies have suggested that children are more vulnerable to suicide bombs, "I hadn’t seen that before in larger sets of data on children and adults," Dr. Hicks said. "It makes sense anatomically, as their heads and torsos are proportionately larger than adults’, and a bomb is more likely to hit a vital organ."

Why Suicide Attacks Focus on Iraqi Civilians

In an editorial comment accompanying the article, Dr. Gilbert Burnham of Johns Hopkins Bloomberg School of Public Health, Baltimore, offered a broader perspective on why Iraq’s civilian population would bear such a disproportionate brunt of such attacks, and what might be done about it (Lancet 2011;378:855-7).

"Prevention of suicide attacks is difficult because of their complex origins," Dr. Burnham wrote. "The military’s approach of controlling access and attacking suspicious targets has protected coalition forces in Iraq, but the resulting deaths of innocent civilians have alienated many Iraqis. This action has played a part in shifting suicide attacks towards civilian targets."

Attempts to stop bombers are often futile, Dr. Burnham continued. "Most effective is the elimination of conditions that cause popular support for terrorist groups," and targeting of extremist networks.

Dr. Burnham declared that he had no conflicts of interest. Dr. Hicks and colleagues declared that they had no financial conflicts of interest; however, their study, which had no outside funding, used data from Iraq Body Count, an organization founded by three of Dr. Hicks’ coauthors. Dr. Hicks serves as an unpaid director for IBC.

Dr. Hicks said that she had become involved with IBC after discovering that its database contained valuable public health information gotten through exacting methods. Moreover, she said, IBC distinguished between civilians and combatants, which many data sources do not, and had information on specific types of weapons involved in the injuries. "It's the kind of detail that’s very difficult to obtain in clinical settings," she said.

IBC has documented violent deaths of Iraqi civilians since 2003, using media, hospital, government and nongovernmental organization reports. Dr. Hicks and her colleagues also used data from iCasualties, a separate group that tracks coalition military casualties in Iraq and Afghanistan.

While the investigators acknowledged that one potential weakness of their study was its use of a database reliant on media reports, they noted that all IBC’s reports had been cross-checked and represented "documented, verifiable, individual casualties and suicide bomb events," not estimates or extrapolations.

The study appeared as part of a group of articles in the Lancet highlighting the health consequences of actions and conflicts in the decade following the terrorist attacks of Sept. 11, 2001.

How the War Impacts Noncombatants

The effects of the Iraq war on noncombatants was addressed further in separate study led by Dr. Christopher H. Warner of the U.S. Command and General Staff College in Fort Leavenworth, Kan. (Lancet 2011; 378: 915-24).

Dr. Warner and colleagues’ study showed that an Army ethics training program had improved troops’ self-reported behavior toward noncombatants, and increased troops’ stated willingness to report fellow unit members committing misconduct.

Soldiers from an infantry brigade team participated in the program, which used clips from popular movies and other unconventional teaching methods to highlight dilemmas involving noncombatants, and instruct on legal and ethical ways of resolving them.

The training, which lasted between 60 and 90 minutes, occurred during a 15-month deployment in Iraq that lasted until 2008. Randomly selected members of the brigade (n=421) completed anonymous surveys 3 months after the training, and their results were compared with anonymous surveys from randomly chosen members (n=397) completed before the training.

Only 5% of troops who had completed training reported having damaged or destroyed private property, compared with 14% before. A majority – 59% – reported being willing to report a unit member for mistreating a noncombatant, compared with 36% before. Combat frequency and intensity was the strongest predictor of unethical behavior, the investigators found, and posttraumatic stress disorder was not seen as predictive of unethical behavior after controlling for combat experiences.

In an editorial comment accompanying Dr. Warner and colleagues’ article, Dr. Jennifer Leaning of Harvard School of Public Health, Boston, and Michael Lappi, Ph.D., of Harvard Medical School, praised the design of both the training program, which can be used in a war zone, and the study (Lancet 2011;378:857-9). The study’s weaknesses, they wrote, "derive in some measure from its strengths, in that frequent entries and exits of soldiers from the deployment zone introduced sampling issues ... and concerns about self-report."

Still, Dr. Leaning and Dr. Lappi wrote, "soldiers deployed in counter-insurgency operations will always need to fall back on their own capacity, buttressed by sound training, for resilient and nuanced legal and moral choice."

Dr. Warner reported no conflicts of interest related to the study, and Dr. Leaning and Dr. Lappi also reported no conflicts of interest.