April 6, 2010
Instead of a regular blog, I am going to post the beginnings of an article that I have never been able to sell. It is a profile of Les Roberts, one of the EIS officers I wrote about in Inside the Outbreaks, primarily about his nightmare experience in the cholera-ridden refugee camps of Goma following the Rwandan genocide in 1994. He went on to specialize in the epidemiology of war — specifically, in estimating the number of people killed. Hence I called this profile “Body Count Man.” If any readers want to help me place this important article, let me know!
The Body Count Man
by Mark Pendergrast
We all know that statistics can lie in any number of ways, but the controversy over the number of Iraqis who have been killed since United States forces overthrew Saddam Hussein in 2003 is astonishing. Some “experts” say that the figure is less than 100,000, while others aver that over a million Iraqis have died a violent death.
Media outlets have tended to err on the low side. The most widely cited figures have come from the website Iraq Body Count (www.iraqbodycount.org), which says that there have been around 85,000 deaths as of February 2008. The IBC website features a plane unloading bombs with a quote from General Tommy Franks: “We don’t do body counts.” The implication is clear – this is an anti-war site that aims to tell it like it is.
Yet the British IBC organizers base their figures primarily on media reports, supplemented by severely deflated official figures. They make no attempt to do any kind of scientific population-based estimate. They have never sullied their shoe soles with the dirt of Iraq. So what we have is a kind of circular tail-chasing logic in which the media parrot back figures derived from inaccurate media reports.
The British medical journal, The Lancet, published the findings of a US-Iraqi team of epidemiologists, whose random cluster surveys for the periods of September 2004 and May-July 2006 indicated much higher numbers of violent deaths – 100,000 and 600,000 respectively. The Lancet reports were derided by supporters of the war in Iraq.
The Iraqi government commissioned its own study specifically to counter the Lancet conclusions, examining the same time period (through the summer of 2006), and coming up with only 150,000 violent deaths. Published in late January 2008 in the New England Journal of Medicine with the imprimatur of the World Health Organization, this latest survey has been widely hailed as more accurate because of its larger interview base, but it is flawed for a number of reasons – most notably because it shows no increase in violent deaths from 2004 to 2006, while all other studies and reports indicated escalating death tolls over that time period.
The raging controversy, with attendant innuendo and smear campaigns, has been quite an eye-opening experience for Les Roberts, the Johns Hopkins epidemiologist in large part responsible for the Lancet studies. His story is a case study of a public health scientist who, in attempting to change the world for the better, has put himself in harm’s way both literally and politically.
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On September 18, 2004, Professor Les Roberts, 43, was listening to All Things Considered through the satellite radio built into the TV set in his Baghdad hotel room. He heard a familiar voice. Martha Foley, a commentator for North Country Public Radio, was describing an exquisite fall day in upstate New York and how she had picked blackberries with her granddaughter. Roberts smiled, picturing the far-off scene as he looked at bombed-out buildings through the sliding glass door to his balcony.
Many years ago, as an undergraduate at St. Lawrence University, Roberts had reluctantly agreed to accompany his workstudy boss to Martha Foley’s house for dinner, though she had not invited him. As they pulled into the driveway, he had seen her look out her kitchen window, spot him, go to the sideboard, and pull off an extra plate. By the time they got to the kitchen, another place had been set, and she never mentioned that he was an unexpected guest. Roberts subsequently referred to such instances of invisible grace as “Martha Foley moments.”
Roberts could use such a moment now. As the world’s premier expert on mortality in war-torn countries, he had come to Iraq to help conduct a random survey of 33 community clusters throughout the country, with the goal of estimating the number of civilian deaths before and after the March 2003 invasion. Since 1992, he had worked in Bosnia, Rwanda, and the Democratic Republic of the Congo at the height of their genocidal conflicts. He had witnessed people being killed, had seen starving children, had been tortured by nightmares. He was used to dangerous situations. But he had not been prepared for the level of anti-American sentiment here.
After accompanying his Iraqi interviewers a few times, it had become clear that his very presence was a threat to their lives, so he had sequestered himself in this hotel room, descending briefly to the lobby at 5 a.m. each day to use the internet to contact his wife and to email precious data to colleagues. In the evening, his driver brought each day’s interview results along with some humus, fruit, or roasted chicken. Going over the questionnaires, Roberts would call his six Iraqi interviewers on his cell phone to ask for clarifications.
Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony. He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News and Al Jazeera, doing 200 sit-ups and push-ups, and thinking.
As Martha Foley talked about her granddaughter’s blackberry-smeared face, Roberts watched two American helicopters approach an unseen target less than a mile away. As they circled it, he could hear the pop-pop-pop of machine gun fire and could see the spent shell casings falling to the ground. As Foley described making blackberry pie, thick black smoke billowed from the unseen target, as the helicopters continued to circle, flying in and out of the smoke in a surreal scene.
“It was a schizophrenic moment,” Roberts recalls. “Into my ears and into my eyes were coming two facets of America that couldn’t have been further apart. One was about nature, tradition, love, and nurturing. The other was about anger, aggression, and violent technology. It occurred to me that both Martha and the gunner were like people I went to high school with.”
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Roberts was born and reared near Syracuse, New York. His father repaired furnaces, while his mother raised four children. Young Les was an alarmingly fearless child, the first to jump off a ledge into water without knowing how deep it was. He was raised Catholic, with heavy sermons on sin. “Most of my life is driven by guilt,” he observes. After graduating from Saint Lawrence University with a physics degree, he taught high school in Mattapoisett, Massachusetts. “I was the only teacher under 30. It was quite a poor school. I was a terrible disciplinarian but good at getting them excited – why the sky was blue, things like that.”
In June 1984, when the financially strapped school laid him off after a year, Roberts decided to join his brother in Kenya, where he was on an exchange program. A month later, his brother went home, but Roberts stayed, trying unsuccessfully to find a teaching position. “Everywhere I went, as a white guy from the North American suburbs, I didn’t fit in. Everyone wanted a bribe. I got malaria. I was an idiot and took no prophylaxis. I was staying in Mrs. Roche’s Guest House in Nairobi, where tourists could pitch tents for $5 a night. I had spikes of fever, couldn’t tell which way was up or down in my tent.”
After he recovered, Roberts saw a thief grab a woman’s necklace, chased him 20 blocks and caught him. The police threw them both in a car. “As we drove to the station,” Roberts recalls, “the guy in the front seat bashed the thief in the testicles with a club. No one had even asked me what happened. I realized the police were far worse than the guy I had caught. I didn’t know what I was doing. Everything I touched I messed up.”
Roberts decided he needed a specialized technical skill. Every day he saw women carrying huge buckets of polluted water on their heads for miles. “It seemed so crazy. Meanwhile we could put a man on the Moon and spend money on Pet Rocks.” He returned to New York to teach high school for a year near Syracuse, saving enough to enter the Tulane School of Public Health and Tropical Medicine, where he earned a masters in public health.
“At the end of my Tulane time, all I knew was that I didn’t know much.” He went on to earn a Ph.D. at Johns Hopkins in environmental engineering, specializing in sanitation engineering and diarrhea prevention. For his dissertation, he spent a year in Peru proving that chicken coops helped prevent the spread of disease. Just before he left in May 1991, a cholera epidemic struck Peru – the first reappearance of the dreaded diarrheal disease in South America.
He met two Epidemic Intelligence Service (EIS) officers dispatched to Peru from the Centers for Disease Control to study cholera. They told him about the two-year training EIS program which required that the disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak.
Intrigued, Roberts applied and joined the Epidemic Intelligence Service in July 1992. The EIS is a two-year CDC program which requires that disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak. With the EIS, he worked on cholera control in Malawi, assessed the health crisis in war-torn Bosnia, then documented the 1994 Rwandan genocide and worked in the mass cholera/dysentery outbreak in Goma, Zaire, among Rwandan refugees. With the International Rescue Committee (IRC), he conducted mortality surveys in the Democratic Republic of the Congo.
In late August 2004 he snuck into Iraq to help conduct the first nation-wide mortality survey. In Bosnia, Rwanda, and the Congo, Roberts had witnessed people being killed, had seen starving children, had been tortured by nightmares. He was used to dangerous situations. Still, he was not prepared for the level of anti-American sentiment he encountered in Iraq, nor did he realize that his very presence would imperil his team of Iraqi investigators. But his most painful learning experience would come later, when his hard-won mortality estimates, published in The Lancet, were dismissed by the Bush administration and most of the U. S. media, and then undermined by the WHO/Iraq government report.
In contrast, Roberts’ previous work in the Democratic Republic of the Congo had a major impact. In 2000, that survey estimated 1.7 million Congolese deaths. These numbers, cited by Kofi Annan, eventually led to doubled aid and peace talks. During his subsequent 2001 Congo survey, which estimated 2.5 million deaths, Roberts’ foot was shattered when it hit a hidden log as he rode a motorcycle along a narrow jungle path. He had to continue anyway. (His foot is still deformed. Every step hurts.)
When the IRC leadership decided to accept money from the U. S. government just prior to the Iraq invasion in March 2003, Roberts resigned in protest, since he felt that it compromised the mission’s objectivity and tacitly provided “humanitarian” cover for the war. With $40,000 from Johns Hopkins and other sources he decided to go to Iraq to study mortality on his own. Through email, he arranged to work with Farzad (a pseudonym to protect him), a professor at Baghdad’s most prestigious medical school.
On August 22, 2004, Roberts flew to Jordan, where he found an expatriate Iraqi taxi driver willing to take him to Baghdad. The driver advised him to give him his passport and lie on the floor in the back of the SUV when they got to the border. There, the driver happened to encounter an old military friend, who took one look at the American passport and said, “Are you crazy? Put that away! Good luck, I don’t know you, go.” So Roberts entered Iraq without having his passport stamped, a circumstance that would come back to haunt him.
When Roberts arrived in Baghdad unannounced and called Farzad’s cell phone, the Iraqi doctor was astonished that he had made it across the border from Jordan. “Only Allah could have done this for you,” he said. Unable to afford the secure luxury high-rises other Americans stayed in, Roberts rented a room in a small local hotel, where he tried to dye his light brown hair and beard black, then looked in the mirror. “My hair was black black black. My beard, tinged with grey, looked sort of blue, my thicker mustache remained brown and grey,” he recalls. “I looked ridiculous, like a chocolate rainbow.”
The following day, he donned a long white Arab robe and flip-flops to meet his survey team. As soon as Roberts got out of the car, Farzad burst out laughing. From then on, he wore nondescript Western clothing, as did most Iraqis, and carried a fake ID saying that he was Dr. Abdul Salam from the Bosnian National University, so that he could have blue eyes, look European, speak no Arabic, and still not be seen as an American.
Farzad had recruited six interviewers, two of whom were women. Five had medical degrees, one a near-Ph.D., and all spoke English. Farzad had arranged for them to do test interviews in one of Baghad’s safest neighborhoods. For the only time, Roberts stood with them during the interviews. “I wanted to see their body language,” he says.
Two interviewers refused to ride in a car with him. Roberts wanted them to ask to see death certificates in order to remove any doubt about mortality reports. “No way,” the interviewers said. “People will think we don’t believe them. They might pull out a gun and shoot us!” After two days of practice, during which the questionnaire was refined, they split into two teams, one led by Roberts, the other by Farzad. Then they began to interview the first household clusters.
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The art of mortality survey epidemiology is not rocket science, but it is nonetheless a science, involving a fair amount of math, probability theory, and gumshoe experience. In an ideal world, each death would be counted as it occurred. But in the chaos of a war-torn country, what is the quickest, most efficient way to estimate mortality? It turns out that 30 is a kind of magic number. For any given population – refugee camp, city, region, or nation – you need to sample at least 30 clusters of people to achieve statistically reliable results. These clusters should be chosen at random, but areas with greater population are allocated more clusters, which is why Roberts had chosen seven clusters in Baghdad itself.
Within each cluster, you need to sample at least 30 random households. So, in total, the surveyors needed to visit 900 or more houses around Iraq. Each team carried a Global Positioning System to find a predetermined random point. From there, the three members on each team would interview the 30 households closest to that GPS point. To make sure at least 30 locations were visited, Roberts had chosen 33 clusters throughout Iraq.
The Baghdad cluster interviews went well, as did the first few outside the city. Roberts accompanied his team to the eighth cluster in the city of Balad, 50 miles north of Baghdad. Entering town, he encountered two huge pictures of the anti-American Shi’a cleric Muqtada al-Sadr and his father. The first random spot chosen by the GPS turned out to be the governor’s home. Waiting in the car with his driver, Roberts watched his two interviewers go into the house. A few minutes later, a police car pulled up. Roberts watched as the police took his two interviewers away. They will be killed, he thought.
After an hour and a half, the two interviewers returned unharmed. The team completed its 30 households and drove back to Baghdad. But Roberts never accompanied them again, realizing that it would only put the surveyors in danger. He sequestered himself in his hotel room, descending briefly to the lobby at 5 a.m. each day to use the Internet to contact his wife and to email precious data to colleagues. In the evening, his driver brought each day’s interview results along with something to eat. Going over the questionnaires, Roberts would call the six Iraqi interviewers on his cell phone to ask for clarifications.
Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony. He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News (and occasionally Al Jazeera), doing 200 sit-ups and push-ups, and thinking.
Les Roberts barely got out of Iraq because his passport was not stamped. This first survey estimated that 100,000 Iraqis had been killed since the war began. The results, published in The Lancet just before the U. S. elections in November, were ignored or dismissed as overestimates.
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In May-June 2006, Roberts helped from afar (without returning to Iraq, since his colleagues insisted it was too dangerous for him and for them) as the same Iraqi team conducted another mortality survey. This time, it revealed that an estimated 600,000 Iraqis had suffered violent deaths since the invasion. Again, the study was published in The Lancet. Again, it was ignored. “If these assertions are true,” the Iraq Body Count website argued in dismissing the results, they implied “incompetence and/or fraud on a truly massive scale by Iraqi officials” as well as “an abject failure of the media.” Roberts would certainly agree.
Now, despite the recent WHO/Iraq government report, Roberts remains quite sure that the mortality in Iraq since the invasion is well over a million deaths. He is skeptical of the claims that violence in Iraq is down by half. While violence may have been reduced in Baghdad, no one is tracking what is going on in the rest of the country. No one wants to know.
Les Roberts teaches public health at Columbia University and Johns Hopkins and continues to agitate for change in American policy and to roam the world to try to prevent unnecessary deaths.
TO BE CONTINUED….(IF I FIND A SYMPATHETIC MAGAZINE EDITOR).