The weapons that kill civilians--deaths of children and noncombatants in Iraq, 2003-2008

Peripheral extremity surgery performed during the Syrian conflict - A scoping review

The protracted Syrian conflict has devastated healthcare infrastructure across Syria with impacts on both the conflict and non-conflict related surgical needs of patients. This review summarises the literature related to peripheral limb surgery performed in Syria between March 2011 to January 2024 to determine the influence of the conflict on surgical capacity and provision. A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines was performed using six academic and one grey literature database. Studies that included clinical-epidemiological descriptions of procedures in orthopaedic, vascular and plastic surgery were included for quantitative and narrative analysis. The search resulted in 3951 papers, of which 7 met inclusion criteria. Studies varied widely in sample size (range: 25-3835; total: 7749), design, and outcomes. Procedures spanned orthopaedic (1285, 31%), vascular (741, 18%), and plastic surgery (2145, 51%), totalling 4171 cases. Common procedures included wound management (51%), external fixation (26%), and lower limb amputation (15%). There was prevalence of emergency over elective surgery, performed in rudimentary, secret field hospitals by practitioners lacking formal specialist training or aid-workers. Inadequate documentation and incomplete data capture, due to the conflict, hindered the availability of high-quality, comprehensive surgical datasets within Syria. The focus on emergency surgery is a natural consequence of the prioritisation required with conflict-related pathology, however poor resource availability resulted in challenges in providing basic surgical care. Further research is needed to address gaps in evidence regarding the current state of surgery, training needs, and the quality of care provided.

Pediatric Blast Trauma: A Systematic Review and Meta-Analysis of Factors Associated with Mortality and Description of Injury Profiles

Introduction:

Blast polytrauma is among the most serious mechanisms of injury confronted by medical providers. There are currently no specific studies or guidelines that define risk factors for mortality in the context of pediatric blast injuries or describe pediatric blast injury profiles.

Objective:

The objectives of this study were to evaluate risk factors for pediatric mortality and to describe differences in injury profiles between explosions related to terrorism versus unrelated to terrorism within the pediatric population.

Methods:

A PRISMA systematic review and meta-analysis was performed where articles published from the years 2000-2021 were extracted from PubMed. Mortality and injury profile data were extracted from articles that met inclusion criteria. A bivariant unadjusted odds ratio (OR) analysis was performed to establish protective and harmful factors associated with mortality and to describe the injury profiles of blasts related to terrorism. Statistical significance was established at P < .05.

Results:

Thirty-eight articles were included and described a total of 222,638 unique injuries. Factors associated with increased mortality included if the explosion was related to terrorism (OR = 32.73; 95% CI, 28.80-37.21; P < .05) and if the explosion involved high-grade explosives utilized in the Global War on Terror ([GWOT] OR = 1.28; 95% CI, 1.04-1.44; P < .05). Factors associated with decreased mortality included if the patient was resuscitated in a North Atlantic Treaty Organization (NATO)-affiliated combat trauma hospital (OR = 0.48; 95% CI, 0.37-0.62; P < .05); if the explosive was fireworks (OR = 3.20×10-5; 95% CI, 2.00×10-6-5.16×10-4; P < .05); and if the explosion occurred in the United States (OR = 2.40×10-5; 95% CI, 1.51×10-6-3.87×10-4; P < .05). On average, victims of explosions related to terrorism were 10.30 years old (SD = 2.73) with 68.96% (SD = 17.58%) of victims reported as male. Comparison of victims of explosions related to terrorism revealed a higher incidence of thoracoabdominal trauma (30.2% versus 8.6%), similar incidence of craniocerebral trauma (39.5% versus 43.1%), and lower incidence of extremity trauma (31.8% versus 48.3%) compared to victims of explosions unrelated to terrorism.

Conclusion:

Explosions related to terrorism are associated with increased mortality and unique injury profiles compared to explosions unrelated to terrorism in the pediatric population. Such findings are important for optimizing disaster medical education of pediatric providers in preparation for and management of acute sequelae of blast injuries—terror-related and otherwise.

Exposure to conflict-related violence and nutritional status of children in Iraq

There is limited empirical evidence of the health effects of war-related violence on child nutritional status. Using unique micro-level data from Iraq, we create measures of cumulative exposure to violence since conception for children ages two to five based on their date of birth and geographic location. We examine the relationship between height-for-age z-scores, a measure of chronic malnutrition, and four indicators of violence in a regression framework, adjusting for potential confounders and trends. We find that a child exposed to the maximum number of violent incidents is likely to experience a 0.5 standard deviation reduction in height-for-age z-score compared to a child who is exposed to no incidents. Each type of attack we evaluate is negatively associated with height-for-age. Further analysis reveals that the associations are the strongest for children in the northern and central regions where the bulk of the violent incidents occurred. Contrary to our expectation, the associations are similar for boys and girls. Our findings suggest that, in addition to efforts aimed at decreasing violent conflict in Iraq in general, the government and its development partners should focus relief, recovery, and reconstruction efforts in the central and northern regions of the country.

Syrian Civil War: a systematic review of trauma casualty epidemiology

BACKGROUND

The Syrian Civil War has caused over 400 000 traumatic deaths. Understanding the nature of war casualties is crucial to deliver healthcare improvement. Historic regional conflicts and Syrian mortality data have been characterised by blast injuries. The aim of this novel review is to assess the trauma epidemiology of Syrian Civil War casualties from the perspective of healthcare facilities.

METHODS

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Studies addressing Syria, trauma and war were investigated. Eligibility criteria included being conducted from a healthcare facility, published in English and peer reviewed. The outcomes were demography, mechanism of injury and anatomical injury site.

RESULTS

38 papers satisfied the eligibility criteria. 13 842 casualties were reported across the entire data set. Casualties were 88.8% male (n=4035 of 4544). Children contributed to 16.1% of cases (n=398 of 2469). Mortality rate was 8.6% (n=412 of 4774). Gunshot wound was the most common mechanism of injury representing 66.3% (n=7825 of 11799). Head injury was the most common injured site at 26.6% (n=719 of 2701).

CONCLUSIONS

This conflict has a distinct trauma profile compared with regional modern wars. The prevalence of gunshot wounds represents a marked change in mechanism of injury. This may be related to higher mortality rate and proportion of head injuries identified. This review cannot correlate mechanism of injury, demographics or injuries sustained to outcomes. The quality of data from the included studies lacked standardisation; future research and consistent reporting tools are required to enable further analysis.

Quantifying the future lethality of terror organizations

As terror groups proliferate and grow in sophistication, a major international concern is the development of scientific methods that explain and predict insurgent violence. Approaches to estimating a group's future lethality often require data on the group's capabilities and resources, but by the nature of the phenomenon, these data are intentionally concealed by the organizations themselves via encryption, the dark web, back-channel financing, and misinformation. Here, we present a statistical model for estimating a terror group's future lethality using latent-variable modeling techniques to infer a group's intrinsic capabilities and resources for inflicting harm. The analysis introduces 2 explanatory variables that are strong predictors of lethality and raise the overall explained variance when added to existing models. The explanatory variables generate a unique early-warning signal of an individual group's future lethality based on just a few of its first attacks. Relying on the first 10 to 20 attacks or the first 10 to 20% of a group's lifetime behavior, our model explains about 60% of the variance in a group's future lethality as would be explained by a group's complete lifetime data. The model's robustness is evaluated with out-of-sample testing and simulations. The findings' theoretical and pragmatic implications for the science of human conflict are discussed.

War or health: a four-decade armed conflict in Iraq

Iraq has suffered 40 years of continual conflict, with large-scale traumatic events including successive wars, economic sanctions, sectarian conflict, terrorism, and organized crime. Population health and the health systems and other services and infrastructure that support a population's health usually suffer severe consequences in conflict-affect countries and Iraq has been no exception. In this article we aim to provide a historical narrative of the four decades of successive wars in Iraq and present some of the consequences of this particular situation of persistent violence and how it has reflected on the health status of the Iraqi people, as indicated by increasing morbidity, mortality, injuries, mental health problems and displacement. Continutation of the current situation of insecurity is anathema for health as war and health can never be compatible, it is a choice between war or health.

Levels of combatant control and the patterns of non-incumbent/insurgent violence experienced by civilians living in Sunni-Arab communities in Iraq (2004-2009)

This study explores how one social-structural variable, control over Sunni-Arab communities during the Iraq civil war, affected the types of violence used by insurgent/non-government actors that killed and injured civilians in these communities from January 2004 to December 2009. The study classifies three levels of control: (1) incumbent (government-supported) control, (2) insurgent control and (3) actively contested control. It uses Iraq Body Count (IBC) fatality data to characterize two general types of violence (selective and indiscriminate) evident during the Iraq conflict. It demonstrates that the type of violence committed by non-government actors was significantly (P > .01) different as related to the level of control insurgents had over territory. Primarily, insurgents/non-governmental actors used more selective forms of violence when insurgents controlled territory and more indiscriminate violence when incumbent (government-supported) forces controlled territory. Also, acts of indiscriminate violence cause considerably more injuries and death per act as compared to selective violence. Importantly, if control over territory has broadly generalizable effects on the types of violence that civilian's experience during civil war, than understanding this relationship could be useful when determining the types of medical assistance, medical supplies and training most needed in combat zones.

Childhood casualties during civil war: Syrian experience

In war areas a lot of children die as well as adults. According to UNICEF, almost 2 million children have died in the wars took place in the last 10 years. In this study, we aimed to evaluate demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey. Postmortem examination and autopsy reports of 985 forensic deaths from Hatay -a Syrian neighborhood city of Turkey-between January 2012 and August 2014 were analyzed retrospectively. Among 763 Syrian people who were wounded in the war and died while being treated in Turkey, 140 cases (18.3%) who were younger than 18 years of age were taken into the scope of this study. Among those cases 77.9% (n = 109) were male and 22.1% were female. Median ages of female cases are 14 (min-max: 2-18) and median age of female cases are 9 (min-max: 1-18). Frequency distribution is highest between 13 and 18 years of age (n: 71, 50.7%). In 70% (n: 98) of cases, cause of death is bombing and shrapnel injuries, 13.6% (19) of them were killed by gunshot wounds. According to injury sites most of the injuries were reported to be on multiple body parts (54.3%, n: 76) and only head and neck injuries (%30). Cause of death was intracranial bleeding and cerebral parenchymal injury in most of the cases (n: 66, %47.1) followed by vascular damage with external bleeding (n: 15, %10.7) and internal organ damage with internal bleeding (n: 15, %10.7). The cases had very high level Abbreviated Injury Scales and Injury Severity Sores. In conclusion, a lot of children have died in the Civil War of Syria. Their average abbreviated injury scale and injury severity score values reported very high. Children that we evaluated were mostly died of head and neck injuries predominantly caused by bombing attacks and Autopsies of them revealed fatal intracranial hemorrhages and parenchymal injuries.

Violent deaths of media workers associated with conflict in Iraq, 2003-2012

Background. The violent deaths of media workers is a critical issue worldwide, especially in areas of political and social instability. Such deaths can be a particular concern as they may undermine the development and functioning of an open and democratic society. Method. Data on the violent deaths of media workers in Iraq for ten years (2003-2012) were systematically collated from five international databases. Analyses included time trends, weapons involved, nationality of the deceased, outcome for perpetrators and location of death. Results. During this ten-year period, there were 199 violent deaths of media workers in Iraq. The annual number increased substantially after the invasion in 2003 (peaking at n = 47 in 2007) and then declined (n = 5 in 2012). The peak years (2006-2007) for these deaths matched the peak years for estimated violent deaths among civilians. Most of the media worker deaths (85%) were Iraqi nationals. Some were killed whilst on assignment in the field (39%) and 28% involved a preceding threat. Common perpetrators of the violence were: political groups (45%), and coalition forces (9%), but the source of the violence was often unknown (29%). None of the perpetrators have subsequently been prosecuted (as of April 2014). For each violent death of a media worker, an average of 3.1 other people were also killed in the same attack (range 0-100 other deaths). Discussion. This analysis highlights the high number of homicides of media workers in Iraq in this conflict period, in addition to the apparently total level of impunity. One of the potential solutions may be establishing a functioning legal system that apprehends offenders and puts them on trial. The relatively high quality of data on violent deaths in this occupational group, suggests that it could act as one sentinel population within a broader surveillance system of societal violence in conflict zones.

Adverse health consequences of the Iraq War

The adverse health consequences of the Iraq War (2003-11) were profound. We conclude that at least 116,903 Iraqi non-combatants and more than 4800 coalition military personnel died over the 8-year course. Many Iraqi civilians were injured or became ill because of damage to the health-supporting infrastructure of the country, and about 5 million were displaced. More than 31,000 US military personnel were injured and a substantial percentage of those deployed suffered post-traumatic stress disorder, traumatic brain injury, and other neuropsychological disorders and their concomitant psychosocial problems. Many family members of military personnel had psychological problems. Further review of the adverse health consequences of this war could help to minimise the adverse health consequences of, and help to prevent, future wars.

WikiLeaks and Iraq Body Count: the sum of parts may not add up to the whole-a comparison of two tallies of Iraqi civilian deaths

Introduction The number of civilians killed in Iraq following the 2003 invasion has proven difficult to measure and contentious in recent years. The release of the Wikileaks War Logs (WL) has created the potential to conduct a sensitivity analysis of the commonly-cited Iraq Body Count's (IBC's) tally, which is based on press, government, and other public sources. Hypothesis The 66,000 deaths reported in the Wikileaks War Logs are mostly the same events as those previously reported in the press and elsewhere as tallied by iraqbodycount.org.

METHODS

A systematic random sample of 2500 violent fatal War Log incidents was selected and evaluated to determine whether these incidents were also found in IBC's press-based listing. Each selected event was ranked on a scale of 0 (no match present) to 3 (almost certainly matched) with regard to the likelihood it was listed in the IBC database.

RESULTS

Of the two thousand four hundred and nine War Log records, 488 (23.8%) were found to have likely matches in IBC records. Events that killed more people were far more likely to appear in both datasets, with 94.1% of events in which ≥20 people were killed being likely matches, as compared with 17.4% of singleton killings. Because of this skew towards the recording of large events in both datasets, it is estimated that 2035 (46.3%) of the 4394 deaths reported in the Wikileaks War Logs had been previously reported in IBC.

CONCLUSIONS

Passive surveillance systems, widely seen as incomplete, may also be selective in the types of events detected in times of armed conflict. Bombings and other events during which many people are killed, and events in less violent areas, appear to be detected far more often, creating a skewed image of the mortality profile in Iraq. Members of the press and researchers should be hesitant to draw conclusions about the nature or extent of violence from passive surveillance systems of low or unknown sensitivity.

A Survey of National Physicians Working in an Active Conflict Zone: The Challenges of Emergency Medical Care in Iraq

Introduction

There has been limited research on the perspectives and needs of national caregivers when confronted with large-scale societal violence. In Iraq, although the security situation has improved from its nadir in 2006-2007, intermittent bombings, and other hostilities continue. National workers remain the primary health resource for the affected populace.

Problem

To assess the status and challenges of national physicians working in the Emergency Departments of an active conflict area.

Methods

This study was a survey of civilian Iraqi doctors working in Emergency Departments (EDs) across Iraq, via a convenience sample of physicians taking the International Medical Corps (IMC) Doctor Course in Emergency Medicine, given in Baghdad from December 2008 through August 2009.

Results

The 148 physician respondents came from 11 provinces and over 50 hospitals in Iraq. They described cardiovascular disease, road traffic injuries, and blast and bullet injuries as the main causes of death and reasons for ED utilization. Eighty percent reported having been assaulted by a patient or their family member at least once within the last year; 38% reported they were threatened with a gun. Doctors reported seeing a median of 7.5 patients per hour, with only 19% indicating that their EDs had adequate physician staffing. Only 19% of respondents were aware of an established triage system for their hospital, and only a minority had taken courses covering ACLS- (16%) or ATLS-related (24%) material. Respondents reported a wide diversity of prior training, with only 3% having some type of specialized emergency medicine degree.

Conclusions

The results of this study describe some of the challenges faced by national health workers providing emergency care to a violence-stricken populace. Study findings demonstrate high levels of violent behavior directed toward doctors in Iraqi Emergency Departments, as well as staffing shortages and a lack of formal training in emergency medical care.

Donaldson RI, Shanovich P, Shetty P, Clark E, Aziz S, Morton M, Hasoon T, Evans G. A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq. Prehosp Disaster Med. 2012;27(2):1-9.

Global comparison of warring groups in 2002-2007: fatalities from targeting civilians vs. fighting battles

Background

Warring groups that compete to dominate a civilian population confront contending behavioral options: target civilians or battle the enemy. We aimed to describe degrees to which combatant groups concentrated lethal behavior into intentionally targeting civilians as opposed to engaging in battle with opponents in contemporary armed conflict.

Methodology/Principal Findings

We identified all 226 formally organized state and non-state groups (i.e. actors) that engaged in lethal armed conflict during 2002–2007: 43 state and 183 non-state. We summed civilians killed by an actor's intentional targeting with civilians and combatants killed in battles in which the actor was involved for total fatalities associated with each actor, indicating overall scale of armed conflict. We used a Civilian Targeting Index (CTI), defined as the proportion of total fatalities caused by intentional targeting of civilians, to measure the concentration of lethal behavior into civilian targeting. We report actor-specific findings and four significant trends: 1.) 61% of all 226 actors (95% CI 55% to 67%) refrained from targeting civilians. 2.) Logistic regression showed actors were more likely to have targeted civilians if conflict duration was three or more years rather than one year. 3.) In the 88 actors that targeted civilians, multiple regressions showed an inverse correlation between CTI values and the total number of fatalities. Conflict duration of three or more years was associated with lower CTI values than conflict duration of one year. 4.) When conflict scale and duration were accounted for, state and non-state actors did not differ. We describe civilian targeting by actors in prolonged conflict. We discuss comparable patterns found in nature and interdisciplinary research.

Conclusions/Significance

Most warring groups in 2002–2007 did not target civilians. Warring groups that targeted civilians in small-scale, brief conflict concentrated more lethal behavior into targeting civilians, and less into battles, than groups in larger-scale, longer conflict.

Casualties in civilians and coalition soldiers from suicide bombings in Iraq, 2003-10: a descriptive study

BACKGROUND

Suicide bombs in Iraq are a major public health problem. We aimed to describe documented casualties from suicide bombs in Iraq during 2003-10 in Iraqi civilians and coalition soldiers.

METHODS

In this descriptive study, we analysed and compared suicide bomb casualties in Iraq that were documented in two datasets covering March 20, 2003, to Dec 31, 2010--one reporting coalition-soldier deaths from suicide bombs, the other reporting deaths and injuries of Iraqi civilians from armed violence. We analysed deaths and injuries over time, by bomb subtype and victim demographics.

FINDINGS

In 2003-10, 1003 documented suicide bomb events caused 19% (42,928 of 225,789) of all Iraqi civilian casualties in our dataset, 26% (30,644 of 117,165) of injured civilians, and 11% (12,284 of 108,624) of civilian deaths. The injured-to-killed ratio for civilians was 2·5 people injured to one person killed from suicide bombs. Suicide bombers on foot caused 43% (5314 of 12,284) of documented suicide bomb deaths. Suicide bombers who used cars caused 40% (12,224 of 30,644) of civilian injuries. Of 3963 demographically identifiable suicide bomb fatalities, 2981 (75%) were men, 428 (11%) were women, and 554 (14%) were children. Children made up a higher proportion of demographically identifiable deaths from suicide bombings than from general armed violence (9%, 3669 of 40,276 deaths; p<0·0001). The injured-to-killed ratio for all suicide bombings was slightly higher for women than it was for men (p=0·02), but the ratio for children was lower than it was for both women (p<0·0001) and men (p=0·0002). 200 coalition soldiers were killed in 79 suicide bomb events during 2003-10. More Iraqi civilians per lethal event were killed than were coalition soldiers (12 vs 3; p=0·004).

INTERPRETATION

Suicide bombers in Iraq kill significantly more Iraqi civilians than coalition soldiers. Among civilians, children are more likely to die than adults when injured by suicide bombs.

FUNDING

None.

An agent-vector-host-environment model for controlling small arms and light weapons

Armed violence is a significant public health problem. It results in fatal and non-fatal injuries and disrupts social and economic processes that are essential to the health of individuals and communities. We argue that an agent-vector-host-environment model can be helpful in understanding and describing the availability and misuse of small arms and light weapons. Moreover, such a model can assist in identifying potential control points and in developing mitigation strategies. These concepts have been developed from analogous vector control programs and are applied to controlling arms to reduce their misuse. So-called 'denormalization' and 'de-legitimization' campaigns that focus on the vector - including the industry producing these commodities - can be based on the experience of public health in controlling tobacco use and exposure. This model can assist health professionals, civil society and governments in developing comprehensive strategies to limit the production, distribution and misuse of small arms and light weapons.

''What are you?'' A recurring question in a cross-cultural psychiatrist's life and career

This article contributes to the Transcultural Psychiatry special issue of autobiographical articles on: ''The Personal and the Professional: Lives and Careers of Cultural Psychiatrists.'' The author describes influences and themes in her professional development as a cross-cultural psychiatrist and academic. Growing up as a part-Chinese, part-white child in rural Midwestern America resulted in frequently being asked: ''What are you?'' This abrupt, bald, but essential question eventually became a useful tool in the productive, repeated re-working of identity, values, and goals throughout her personal and professional life. Experiences of being an outsider, family histories, and early observations of racism are linked to later interests in cross-cultural psychiatry, ethics, and the protection of vulnerable populations. She describes her research on cross-cultural measurement, depression, suicidality, domestic violence and violence in war. Issues of career advancement and internal conflict are described for women academics who occupy three simultaneous, primary roles: academic, doctor and mother. The theme of ''crossing,'' as in ''cross-cultural,'' indicates the effort and intention required to move between races, cultures, classes, intellectual disciplines, personal and professional identities, clinical and academic roles, and social roles allocated to men and women.

Measuring the true costs of war: consensus and controversy

Robert Muggah discusses the costs of war and a new analysis published in PLoS Medicine by Madelyn Hsiao-Rei Hicks and colleagues that documents the number of Iraqi civilian violent deaths during 2003-2008.

Violent deaths of Iraqi civilians, 2003-2008: analysis by perpetrator, weapon, time, and location

BACKGROUND

Armed violence is a major public health and humanitarian problem in Iraq. In this descriptive statistical analysis we aimed to describe for the first time Iraqi civilian deaths caused by perpetrators of armed violence during the first 5 years of the Iraq war: over time; by weapon used; by region (governorate); and by victim demographics.

METHODS AND FINDINGS

We analyzed the Iraq Body Count database of 92,614 Iraqi civilian direct deaths from armed violence occurring from March 20, 2003 through March 19, 2008, of which Unknown perpetrators caused 74% of deaths (n = 68,396), Coalition forces 12% (n = 11,516), and Anti-Coalition forces 11% (n = 9,954). We analyzed the subset of 60,481 civilian deaths from 14,196 short-duration events of lethal violence to link individual civilian deaths to events involving perpetrators and their methods. One-third of civilian violent death was from extrajudicial executions by Unknown perpetrators; quadratic regression shows these deaths progressively and disproportionately increased as deaths from other forms of violence increased across Iraq's governorates. The highest average number of civilians killed per event in which a civilian died were in Unknown perpetrator suicide bombings targeting civilians (19 per lethal event) and Coalition aerial bombings (17 per lethal event). In temporal analysis, numbers of civilian deaths from Coalition air attacks, and woman and child deaths from Coalition forces, peaked during the invasion. We applied a Woman and Child "Dirty War Index" (DWI), measuring the proportion of women and children among civilian deaths of known demographic status, to the 22,066 civilian victims identified as men, women, or children to indicate relatively indiscriminate perpetrator effects. DWI findings suggest the most indiscriminate effects on women and children were from Unknown perpetrators using mortar fire (DWI  = 79) and nonsuicide vehicle bombs (DWI  = 54) and from Coalition air attacks (DWI  = 69). Coalition forces had higher Woman and Child DWIs than Anti-Coalition forces, with no evidence of decrease over 2003-2008, for all weapons combined and for small arms gunfire, specifically.

CONCLUSIONS

Most Iraqi civilian violent deaths during 2003-2008 of the Iraq war were inflicted by Unknown perpetrators, primarily through extrajudicial executions that disproportionately increased in regions with greater numbers of violent deaths. Unknown perpetrators using suicide bombs, vehicle bombs, and mortars had highly lethal and indiscriminate effects on the Iraqi civilians they targeted. Deaths caused by Coalition forces of Iraqi civilians, women, and children peaked during the invasion period, with relatively indiscriminate effects from aerial weapons. Please see later in the article for the Editors' Summary.

Management of war-related burn injuries: lessons learned from recent ongoing conflicts providing exceptional care in unusual places

Thermal injury is a sad but common and obligatory component of armed conflicts. Although the frequency of noncombat burns has decreased, overall incidence of burns in current military operations has nearly doubled during the past few years. Burn injuries in the military environment do not need to be hostile in nature. Burns resulting from carelessness outnumber those resulting from hostile action. Unfortunately, civilians are becoming the major targets in modern-day conflicts; they account for more than 80% of those killed and wounded in present-day conflicts. The provision of military burn care mirrors the civilian standards; however, several aspects of treatment of war-related burn injuries are peculiar to the war situation itself and to the specific conditions of each armed conflict. Important aspects of management of burned military personnel include triage to ensure that available medical care resources are matched to the severity of burn injury and the number of burn casualties, initial management and resuscitation in the combat zone, and subsequent evacuation to higher echelons of medical care, each with increasing medical capabilities. Care of military victims is usually well structured and follows strict guidelines for first aid and evacuation to field hospitals by military personnel usually having had some form of training in first aid and resuscitation and for which necessary equipment and material for such interventions are more or less available. Options available for civilian injury intervention in wartime, however, are limited. Of all pre-hospital transport of civilian victims, 70% are done by lay public and 93% receive in the field, or during transport, some form of basic first aid administered by relatives, friends, or other first responders not trained for such interventions. Civilian casualties frequently represents 60% to 80% of all injured admitted to the level III facilities of overseas forces stationed throughout the host country. Unlike military personnel who are rapidly evacuated to higher echelons IV and V for definitive and long-term care, civilians must receive definitive burn treatment at these level III military facilities. The present review was intended to highlight peculiar aspects of war-related burn injuries of both military personnel and civilians and their management based on the most recently published material that, for the most part, is related to the recent conflicts in Iraq and Afghanistan.

Commentary: Ensuring health statistics in conflict are evidence-based

The author argues that measuring mortality in conflict settings is fraught with limitations which mostly result in under-estimation of mortality. Some recent publications on this subject have been based upon convenient surveillance processes, or even press reports. The author calls for vigilance against such studies and argues that war related surveillance-based mortality estimates should include measures of sensitivity and representativeness.