This piece was written in response to the release of the findings of the Chilcot inquiry by former Medact Directors Mike Rowson and Marion Birch, along with Jane Salvage, who all worked on Medact’s series of Iraq reports

One political commentator’s view of the Chilcot report, summarised in a tweet, was that it missed the sweep of history and context and read more like a Whitehall Mandarin’s diary.

Reviewing the 20,000 word chapter (of this 2.6 million word, 12 volume report) devoted to the subject of civilian casualties, it is tempting to agree – go elsewhere for a rigorous analysis of the different casualty estimates.

But the diary approach has one important advantage – it shows, step by step, how attention to the level of civilian casualties rose within government. This was largely due to the outside pressure applied by brave academic researchers and their assistants working in the field trying to estimate death tolls, and NGOs, including UK NGOs Medact and Iraq Body Count.

During 2002 the British and American governments built the case for war. This culminated in two dossiers highlighting the barbaric nature of Saddam Hussein’s regime, and the supposed security risk he posed to the region and world through his alleged possession of chemical and biological weapons.

Medact felt it had to draw attention to the potential health effects of a war in the region, as a contribution to the public debate on the merits of launching a war against Iraq. So in November 2002 we published a report setting out the likely consequences of an attack. Using a scenario-based approach we grimly tried to estimate the number of deaths, and drew attention not just to mortality associated with violence, but also to the indirect deaths and morbidity caused by the potential disruption or collapse of the health sustaining infrastructure – the health system, water supplies and electricity networks. We were convinced that despite the acknowledged abuses committed by Saddam’s regime, alternatives to war should be thoroughly explored before any invasion was contemplated.

The report had worldwide attention, and was soon followed by leaks from official sources that estimated similar consequences to the ones we outlined. Hundreds of academics and students at the London School of Hygiene and Tropical Medicine published a letter in the media highlighting our messages.

The war went ahead despite these and the broader concerns about destabilising an already volatile region raised by politicians and millions of people around the world.

The allied forces declared an early victory with Saddam Hussein toppled and on the run, but disturbing trends, including widespread looting and rising sectarian violence, dampened the triumphalist tone.

Medact followed up on its 2002 report by actively monitoring the effects of the war that had now begun. As well as the physical and mental health of the Iraqi population, we paid particular attention to the Iraqi health system – already in a parlous state as result of the first Gulf War in 1990-91 and a decade of sanctions – and the impact of war on the social determinants of health. Altogether, we produced five reports about the impact of war on health in Iraq.

The sectarian violence and resistance to the occupying forces was gaining constant media attention. The Chilcot report demonstrates the desire of the British government – and particularly Prime Minister Tony Blair – to create its own estimate of the number of casualties, particularly as passive and active surveillance efforts were constantly picking up far greater numbers of deaths than official sources were admitting. An article in The Lancet published in autumn 2004 caused major controversy by suggesting that there might have been as many as 100,000 excess deaths in Iraq since the war began.

The chronological ‘diary approach’ of Chilcot gives an object lesson in the politics of evidence. In public the government still went with lower estimates provided by the Iraqi Ministry of Health that clearly only accounted for a small proportion of the mortality burden.

How much better it would have been if the occupying forces had delivered on their duties towards the population under its control and, as part of a comprehensive health effort, established a health information system that could accurately monitor the state of health and track people’s needs. But the capability and willingness to do this (which had seemed remote even before the war started), all but disappeared when responsibility for post-war planning was suddenly and inexplicably passed from the US State Department to the Department of Defense, budgets for post-conflict recovery slashed, and contracts with UNICEF and WHO for health surveillance cancelled.

Medact’s report at the end of 2004 also showed the chaos and deterioration in the health system. We then decided to mount a campaign to “Count the Casualties”. An open letter to Blair signed by 46 prominent diplomats, public health experts and religious leaders called for an independent inquiry into Iraqi deaths.

Sadly, more than a decade later, and with a likely death toll far exceeding our initial estimates, no such inquiry has happened. Worsening violence and social division has left a health system with chronic shortages of staff and supplies, and the indirect effects of war – including on mental health – have mounted on top of the direct effects of violence.

Medact and other NGOs stayed on the case in the coming years, speaking at numerous events, publishing new reports and submitting evidence to both the Iraq Commission and the Chilcot inquiry.

What lessons learned? For its role in destabilising the country and the disastrous consequences that followed, the UK owes the Iraqi people a debt that we should continue to pay through assistance to its health system and other collaborative actions to support people’s livelihoods and peace.

We also have to look at ourselves. Chilcot has put the political, security and diplomatic communities under the microscope, but we also need to consider whether there was enough critical public health debate – inside and outside government – about the likely and then real health consequences of war. Looking forward, organisations such as Medact need to network more effectively with others so that a stronger public health voice can be created to help prevent such disastrous miscalculations happening again.

Mike Rowson was Director of Medact from 2001 to 2005

Jane Salvage is an independent health consultant and worked on the Medact reports

Marion Birch was Director of Medact from 2005-2013

Acknowledgements:

Gill Reeve, who led much of the Iraq project work, and advisers Jack Piachaud and Douglas Holdstock have sadly died, as has Guy Hughes of Crisis Action, who helped us launch the Count the Casualties campaign. All would have been demanding government accountability today, and urging Medact to take further action. We had invaluable input from Iraqi colleagues and others directly involved in attempts to improve post-conflict recovery. Many other Medact members advised our work on Iraq, and acknowledgements of their contributions can be found in the reports featured on these webpages.