Date Published: May 15, 2018
Publisher: Public Library of Science
Author(s): Riyadh Lafta, Maha A. Al-Nuaimi, Gilbert Burnham, Peter Byass
Abstract: BackgroundMeasurement of mortality and injury in conflict situations presents many challenges compared with stable situations. However, providing information is important to assess the impact of conflict on populations and to estimate humanitarian needs, both in the immediate and longer term. Mosul, Iraq’s second largest city, was overrun by fighters of the Islamic State of Iraq and Syria (ISIS) on June 4, 2014. In this study, we conducted household surveys to measure reported deaths, injuries, and kidnappings in Mosul, Iraq, both during the occupation of the city by fighters of ISIS and the months of Iraqi military action known as the liberation.Methods and findingsMosul was overrun by ISIS forces on June 4, 2014, and was under exclusive ISIS control for 29 months. The military offensive by Iraqi forces, supported by coalition artillery and airstrikes, began on October 17, 2016, in east Mosul and concluded in west Mosul with the defeat of ISIS on June 29, 2017. We conducted a 40-cluster population-based survey as soon as the security forces permitted access for the survey team. The objective of the survey was to measure reported deaths, injuries, and kidnappings in Mosul households during 29 months of ISIS-exclusive control (June 2014–October 2016) and the nine months of Iraqi military action known as the liberation (October 2016–June 2017). In east Mosul, the survey was conducted from March 23 to March 31, 2017, and in west Mosul from July 18 to July 31, 2017. Sampling was based on pre-ISIS population distribution, with revisions made following the extensive destruction in west Mosul. The 1,202 sampled households included 7,559 persons: 4,867 in east Mosul and 2,692 in west Mosul. No households declined to participate. During the time from June 4, 2014, to the time of the survey, there were 628 deaths reported from the sampled households, of which 505 were due to intentional violence, a mortality rate of 2.09 deaths per 1,000 person-months. Over the entire time period, the group with the highest mortality rates from intentional violence was adults aged 20 to 39: 1.69 deaths per 1,000 person-months among women and 3.55 among men. In the 29 months of ISIS-exclusive control, mortality rates among all males were 0.71 reported deaths per 1,000 person-months and for all females were 0.50 deaths per 1,000 person-months. During the nine months of the military liberation, the mortality rates jumped to 13.36 deaths per 1,000 person-months for males and 8.33 for females. The increase was particularly dramatic in west Mosul. The leading cause of reported deaths from intentional violence was airstrikes—accounting for 201 civilian deaths—followed by 172 deaths from explosions. Reported deaths from airstrikes were most common in west Mosul, while reported deaths from explosions were similar on both sides of Mosul. Gunshots accounted for 86 cases, predominantly in west Mosul where ISIS snipers were particularly active. There were 35 persons who were reported to have been kidnapped, almost entirely prior to the military offensive. By the time of the survey, 20 had been released, 8 were dead, and 7 still missing, according to household reports. Almost all of the 223 injuries reported were due to intentional violence. Limitations to population-based surveys include a probable large survivor bias, the reliance on preconflict population distribution figures for sampling, and potential recall bias among respondents.ConclusionsDeath and injuries during the military offensive to liberate Mosul considerably exceeded those during ISIS occupation. Airstrikes were the major reported cause of deaths, with the majority occurring in west Mosul. The extensive use of airstrikes and heavy artillery risks an extensive loss of life in densely populated urban areas. The high probability of survivor bias in this survey suggests that the actual number of injuries, kidnappings, and deaths in the neighborhoods sampled is likely to be higher than we report here.
Partial Text: Measurement of mortality in conflict situations using epidemiological methods presents many challenges . Numbers of deaths can be counted by observers, as has been done in the Syrian crisis . Such counts, even if meticulously done, risk both substantial undercounting and potential double counting. With extensive displacement, accurate denominators may not be available or based on out-of-date census data, making sampling difficult. Where households are fragmented, key informants may be missing. Even when the household is intact, recall bias may occur. Survival bias, in which households have been destroyed and are not present to report, can cause serious underreporting . Assessing causes of death is also difficult because populations may be unable or unwilling to report causes . Prevailing political opinions may result in findings being maligned or dismissed .
This population survey was conducted as soon as ISF allowed the survey team entry into Mosul and before large-scale population return began, even though the security situation was still unsettled. Forty neighborhoods or administrative units were randomly selected from Mosul’s established residential administrative units. A typical neighborhood would have contained 200 to 400 dwellings before Mosul’s seizure by ISIS. There were 25 neighborhoods selected on the east side of the Tigris River and 15 selected on the west side, representative of the population distribution of Mosul before seizure by ISIS. There were no data on population shifts or remaining population during ISIS occupation and the subsequent liberation. In each neighborhood, a “start house” was identified by a random method that used a 10-m grid overlay of the selected neighborhood on an aerial map of Mosul. From the start house, 30 adjacent houses were visited, constituting a cluster. Reserve neighborhoods with start houses were identified should the selected neighborhood be inaccessible. The 4 interviewers were physicians with a doctoral degree in community medicine. Three were female, and all were natives of Mosul but had left as ISIS seized Mosul. Training was provided for this specific survey.
This survey from the households of Mosul presents a picture of death and injury, most pronounced during the nine-month military campaign to drive ISIS fighters from the city. The mortality rate per 1,000 person-months jumped from a rate of 0.58 deaths per 1,000 person-months during the 29 months of exclusive ISIS control to a rate of 6.29 in east Mosul during the nine months of liberation. In west Mosul, the numbers increased from an ISIS rate of 0.64 to a rate of 15.54 during the nine months of the military liberation. However, the true numbers of deaths and injuries that occurred in Mosul during this time cannot be known. In some west Mosul clusters, the survey team found nearly as many empty or destroyed dwellings as occupied ones, indicating a large survivor bias potential. These clusters were likely to have sustained a much larger loss of life than surviving households reported. The actual population of Mosul in the time of ISIS and during the military offensive is not known, making it not possible to estimate the numbers of dead and injured for the city as a whole. The study was conducted immediately after ISIS had been driven from east Mosul and then again in west Mosul as soon as it had been secured. The households included had been present in Mosul during the entire 29 months of ISIS control and during the nine months of Iraqi military action. The population characteristics themselves create a remarkable pyramid. Teenage and younger women were underrepresented, most likely related to an increased rate of early marriages driven by the fear that daughters would be forced to marry ISIS fighters, a common situation in conflicts . It is likely that after marriage they left Mosul, either escaping entirely or moving to one of the small towns or villages surrounding Mosul. Persons aged 50 and above constituted 19.3% of the sample, compared with an estimated 10.7% for the Iraqi population as a whole . The percentage of older persons was higher in west Mosul (22.0%) compared with east Mosul (17.8%). Although west Mosul was the older and poorer part of the city, the population pattern suggests that younger persons there may have been better able to flee the battlefront as it moved from east to west. Although some may have managed to escape the city, others fled across the Tigris River into east Mosul as the nature of the final struggle with ISIS became evident.