[News] US Air Strikes in Iraq Kill Mostly Women, Children

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Mon Apr 27 18:58:17 EDT 2009

The New England Journal of Medicine

16, 2009  Number 16

The Weapons That Kill Civilians ­ Deaths of 
Children and Noncombatants in Iraq, 2003–2008
Madelyn Hsiao-Rei Hicks, M.D., M.R.C.Psych., 
Hamit Dardagan, Gabriela Guerrero Serdán, M.A., 
Peter M. Bagnall, M.Res., John A. Sloboda, Ph.D., 
F.B.A., and Michael Spagat, Ph.D.

Armed violence, such as that in the ongoing 
conflict in Iraq, is a threat to global 
It causes serious injuries and deaths of 
civilians, makes orphans of children, traumatizes 
populations, and undermines the ability of 
communities to provide adequate medical care even 
as it dramatically increases health care needs. 
Moreover, indiscriminate or intentional harm to 
civilians violates humanitarian principles and 
basic human rights. Believing that a careful 
assessment of the effects of different kinds of 
weapons on civilians in Iraq was needed, we used 
the database of the Iraq Body Count (IBC), a 
nongovernmental organization that documents 
civilian violent deaths in 
to determine the nature and effects of various 
weapons on civilians in Iraq. The patterns we 
found convince us that documenting the particular 
causes of violent civilian deaths during armed 
conflict is essential, both to prevent civilian 
harm and to monitor compliance with international humanitarian law.

Unlike surveys that do not distinguish between 
Iraqi combatants and noncombatants among the 
the large-scale IBC database attempts to 
specifically identify civilians, whose deaths are 
of particular concern from a public health and 
Recent findings from the Iraq Family Health 
Survey support the validity of the IBC database 
by showing similar regional trends and 
distributions of violent 
The IBC has monitored direct civilian deaths 
daily since the Iraq war began on March 20, 2003, 
with the invasion by U.S.-led coalition forces. 
IBC sources are primarily reports in the 
professional media, including reports translated 
from Arabic, supplemented by reports from 
hospitals and morgues. Deaths are added to the 
database when sources report the number of 
civilians killed, with time and location 
described adequately to avoid double counting. 
Also recorded are the perpetrator, the target, 
the weapons used, the primary sources, and 
whenever possible, each victim's age, sex, 
occupation, and name. Although the IBC records 
injuries as well as deaths, we limited our 
analysis to deaths, which are more consistently 
reported by the 
"Civilian" deaths include those of most women, 
children under 18 years of age, noncombatants, 
and police officers killed during regular, but 
not paramilitary, activities, since police are 
considered part of normal civil society. Database 
entries are systematically error-checked by three 
IBC volunteers before publication on the IBC Web 

We based our data set on the number of Iraqi 
civilian deaths recorded as of June 13, 2008, for 
the 5-year period of analysis, March 20, 2003, 
through March 19, 2008. Of the total of 91,358 
Iraqi civilian deaths from armed violence 
recorded for this period, we excluded 10,027 
deaths from prolonged violence (e.g., the two 
sieges of Fallujah and prolonged episodes of 
violence during the invasion of March 20, 2003, 
through April 30, 2003), and 20,850 deaths 
recorded only in aggregate reports from morgues 
and hospitals, since these deaths were not 
reliably linked to specific events of a weapon's 
use. As our 
shows, we focused on the remaining 60,481 deaths 
of Iraqi civilians and the causative weapons in 
14,196 armed-violence events considered to be of 
short duration (lasting up to two calendar 
dates), occurring in an identifiable location, 
and directly causing one or more reported 
civilian deaths. Each death included in the 
is of an individual noncombatant and is linked to 
a type of weapon used in a specific time and 
place; these are not estimates extrapolated from a sample.
The greatest proportion of victims ­ 19,706 of 
60,481, or 33% ­ were killed by execution after 
abduction or capture. Of the bodies of those who 
were executed, 5760, or 29%, showed marks of 
torture, such as bruises, drill holes, or burns. 
(A typical media report about this particularly 
appalling form of violent death reads: "The 
bullet-riddled bodies bore signs of torture and 
their hands were tied behind their backs.") Iraqi 
civilians also suffered heavy tolls from 
small-arms gunfire in open shootings and 
firefights (20% of deaths), apart from executions 
involving gunfire, and from suicide bombs (14% of deaths).

In events with at least one Iraqi civilian 
victim, the methods that killed the most 
civilians per event were aerial bombings (17 per 
event), combined use of aerial and ground weapons 
(17 per event), and suicide bombers on foot (16 
per event). Aerial bombs killed, on average, 9 
more civilians per event than aerial missiles (17 
vs. 8 per event). Indeed, if an aerial bomb 
killed civilians at all, it tended to kill many. 
It seems clear from these findings that to 
protect civilians from indiscriminate harm, as 
required by international humanitarian law 
(including the Geneva 
military and civilian policies should prohibit 
aerial bombing in civilian areas unless it can be 
demonstrated ­ by monitoring of civilian 
casualties, for example ­ that civilians are being protected.

Suicide bombers in Iraq are mainly used 
strategically by sectarian or insurgent forces, 
with deployment at targets after apparently 
Although the bomb's blast is undiscriminating, 
the individual bomber is not. A suicide bomber on 
foot acts as a precision weapon ­ a 
close-quarters "smart bomb" whose pattern of 
killing many civilians at a time can result only 
from either disregard for civilians when 
targeting opposition forces or direct targeting 
of civilians. When combatant forces intentionally 
target civilians, they commit a war crime and 
violate international humanitarian law pertaining 
to both international and civil armed 

Among victims of known sex ­ that is, those 
identified as male or female, regardless of age ­ 
the proportion of female civilians killed varied 
according to the weapon used, as did the 
proportion of children killed among victims of 
known age. Because the media may tend to 
specifically identify female and young victims 
more readily than male adults among the dead, 
which could inflate our findings for the 
percentages of female civilians and children 
killed, these findings should not be considered 
absolute proportions; they are, however, 
relatively robust indicators of the varying 
demographic characteristics of civilians killed 
by different weapons. Female Iraqis and Iraqi 
children constituted the highest proportions of 
civilian victims when the methods of violence 
involved indiscriminate weapons fired from a 
distance: air attacks and mortars. That air 
attacks, whether involving bombs or missiles, 
killed relatively high proportions of female 
civilians and children is additional evidence in 
support of the argument that these weapons, like 
mortars, should not be directed at civilian areas 
because of their indiscriminate nature.

By contrast, the methods that resulted in the 
highest proportions of male civilians among 
victims of known sex were the relatively 
close-quarter, precise methods of gunfire (91% 
male civilians), execution (95% male civilians), 
and execution with torture (97% male civilians). 
Execution with torture, the most intimate, brutal 
method of killing, was used the most selectively 
against male (rather than female) civilians and 
against adults (rather than children). By nature, 
execution is precise and deliberate ­ the highly 
controlled, usually planned killing of a captured 
person. The character of this form of killing, 
combined with our findings that a great many 
civilians were killed by execution, in many 
events, with strong selection according to the 
sex and age of potential victims, supports the 
assessment that executions have been applied 
systematically and strategically to civilians in 

Certainly, different perpetrators can use similar 
weapons in different ways, with different effects 
on civilians. Nevertheless, our findings 
regarding the rates of Iraqi civilian death 
resulting from different types of weapons reveal 
stark differences in the effects of various 
weapons on civilians, in terms of both the 
numbers and the demographic characteristics of 
those killed. Weapons that kill relatively high 
proportions of Iraqi civilians, female civilians, 
or children are particularly hazardous to public health.

Such indiscriminate or intentional effects from 
armed conflict must be radically curtailed to 
comply with international humanitarian 
We believe that all combatant forces and 
governments should implement policies of routine 
and transparent collection and release of 
verifiable data on the civilian casualties of 
military actions. Such monitoring would 
facilitate timely reparative action and must 
inform planning if armed combat is to be 
prevented ­ as much as possible ­ from harming 
noncombatants. Policymakers, war strategists of 
all persuasions, and the groups and societies 
that support them bear moral and legal 
responsibility for the effects that particular 
combat tactics have on civilians, including the 
weapons used near and among them.

No potential conflict of interest relevant to this article was reported.

Source Information
Dr. Hicks is an honorary lecturer in the 
Department of Health Service and Population 
Research, Institute of Psychiatry, King's College 
London, London, and is an unpaid nonexecutive 
board member of Conflict Casualties Monitor, the 
nonprofit organization that manages the IBC. Mr. 
Dardagan is a cofounder and principal analyst, 
Mr. Bagnall a software architect and developer, 
and Dr. Sloboda a cofounder and analyst at the 
IBC. Dr. Sloboda is also a professor at the 
Department of Politics and International 
Relations, Royal Holloway College, University of 
London, London. Ms. Guerrero Serdán is a Ph.D. 
candidate and Dr. Spagat a professor in the 
Department of Economics, Royal Holloway College, University of London, London.

1- Coupland R. Security, insecurity and health. 
Bull World Health Organ 2007;85:181 184. 
2- Iraq Body Count home page. (Accessed March 27, 
2009, at <http://www.iraqbodycount.org>http://www.iraqbodycount.org.)
3- Iraq Family Health Survey Study Group. 
Violence-related mortality in Iraq from 2002 to 
2006. N Engl J Med 2008;358:484-493. 
Full Text]
4- Hicks MH, Spagat M. The Dirty War Index: a 
public health and human rights tool for examining 
and monitoring armed conflict outcomes. PLoS Med 
5- Hafez MM. Suicide terrorism in Iraq: a 
preliminary assessment of the quantitative data and documentary evidence.
Stud Conflict Terrorism 2006;29:591-619.

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