International Journal of Injury Control and Safety Promotion, 2014 Vol. 21, No. 4, 382–387, http://dx.doi.org/10.1080/17457300.2013.843569
Years of life lost among Iranian people killed in the Iraq–Iran war: the 25-year perspective Batool Mousavia, Maziar Moradi-Lakehb, Mojgan Karbakhshc and Mohammadreza Soroushd* a
Prevention Department, Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran; bDepartment of Community and Preventive Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; cDepartment of Community and Preventive Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; dJanbazan Medical and Engineering Research Center (JMERC), Tehran, Iran (Received 6 March 2013; accepted 9 September 2013) To estimate the years of life lost (YLL), registered deaths due to Iraq–Iran war (1980–2005) were identified considering ICD10 codes of Y36.0 to Y36.9. Estimated YLL was calculated by taking age-weighting options and discount rates. Population life expectancy in each corresponding year was retrieved from the national health database. During 1980–2005, 178,298 Iranian men and 5325 Iranian women died in war. The mean death age was 22.8 9 years, 96.6% occurred during the years of war (September 1980–August 1988). In the years after the war (1988–2005) 6243 (3.4%) of deaths occurred as the result of complication of the war-related injuries or implanted landmines/unexploded ordnances (ICD10 code: Y36.8). YLL in Iraq–Iran war among Iranian victims were calculated as 10,479,405.0 years considering the age weighting and discount rate equal to 0. Age-adjusted YLL were estimated as 10,169,546.2 years in males. Female cases that comprised 2.9% of total victims lost 309,858.8 years. The mean YLL was calculated as 57.1 years for each Iranian victim killed in Iraq–Iran war. The war-related YLL was estimated more than 10 million years that comprised a majority of young men. This study is the first step in estimation of disability adjusted life year (DALY) of Iraq–Iran war on Iranian side. Keywords: years of life lost; burden of disease; Iraq–Iran war
Introduction Injuries are an important cause of death and disability throughout the world. Wars as one of the causes of intentional injury-related deaths are responsible for the increasing burden of intentional injuries in developing countries (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006; Mathers, Lopez, & Murray, 2006). In the year 2000, about 310,000 persons lost their lives throughout the world in wars (Lett, Kobusingye, & Ekwaru, 2006; Murray, King, Lopez, Tomijima, & Krug, 2002), of whom about 90% were in developing countries. The World Health Organisation reported that wars accounted for 10% of injuryrelated deaths (Andrade, 2001). According to WHO estimates for 2008, about 96,000 deaths occurred due to wars or civil conflicts in the Eastern Mediterranean region which accounted to be more than half of all war- and conflict-related deaths in that year throughout the world (World Health Organization, 2008). In fact, wars are among the 10 causes of disability adjusted life year (DALY) for 15–44 years old males (Lopez et al., 2006; Mathers et al., 2006). For every person losing his life in war, many others get injured with ratios ranging from 1.9 to 13 (Coupland & Meddings, 1999; Krug, Sharma, & Lozano, 2000). Moreover, the devastating effect of wars on nations’ health is not limited
*Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
to the period of war. People continue suffering from injuries sustained during the war and some die of these conditions or their complications afterwards. Iraq–Iran war caused hundreds of thousands deaths or injured, millions of displaced, and billions of dollars cost (Zargar, Araghizadeh, Soroush, & Khaji, 2007). There is limited precise information on Iraqi weaponry against Iran on both warlike and civilian zones in the literature (Khateri, Ghanei, Keshavarz, Soroush, & Haines, 2003; Zargar, et al., 2007). Over a period of eight years (1980–1988), Iraq launched a large number of ballistic missiles toward Iranian territories and cities, especially Tehran, the capital city of Iran, as well as other large and small cities (Khaji, Fallahdoost, & Soroush, 2010; McNaugher, 1990). It is also estimated that 1800 metric tonnes of mustard gas, 140 tonnes of tabun and over 600 tonnes of sarin were used against Iran, using munitions that included approximately 19,500 aerial bombs, 54,000 artillery shells and 27,000 short-range rockets (Khateri et al., 2003). Estimation of burden of war is a formidable and thus a neglected task. During wars, the disruptions in management information system functions and infrastructure of the societies hamper precise registration of deaths and disabilities (Levy & Sidel, 2008; Murray et al., 2002).
International Journal of Injury Control and Safety Promotion In Iran, Veterans and Martyrs Affairs Foundation (VMAF) was established from the beginning of Iraq–Iran war. Since then, VMAF has been responsible for registering the relevant data of martyrs (from their family members and all other available sources) and providing services to their families. Families of martyrs usually refer to this organisation to register their martyrs in the database. The reasons are multiple: as martyrs have lost their lives defending the country, it is an honour to the family to have their deceased family member recognised as a ‘martyr’. In addition, some families might be really in need of services that the organisations offer to them (e.g. pension and health services). Nevertheless, this databank has not still been used for estimation of years of life lost due to Iraq–Iran war. This paper aims to estimate the years of life lost (YLL) during and after Iraq–Iran war from 1980 to 2005. Methods For the years 1980–2005, registered Iraq–Iran war-related deaths were obtained from the national registry at the VMAF Database. The data file contained all the warrelated deaths of Iranian victims during and after the years of conflict (1980–2005). The data included both troops and civilians who were killed during or after the fire cessation as a result of war-related injuries. This database can be considered as the main source for estimation of years of life lost in Iraq–Iran war. According to VMAF, which is responsible for registering the relevant data of martyrs during and after the Iraq–Iran war, at least 183,623 Iranians were killed due to the Iraq–Iran war. Some martyrs might not have been recorded in the database as nobody had referred to report disappearance or death. This could also have been the case when all the members of a household were killed in bombardment of civil areas by Iraqi planes or by hitting missiles, which was not common. In addition, if death occurred instantly as an indirect impact of war especially in war zone (e.g. due to myocardial infarction) the death was considered to be related to the war. Thus, the potential for underreporting or misclassification of causes of death was not a major challenge in our dataset. All included cases were classifiable within ICD10 codes of Y36.0–Y36.9. The Y36.8 code of ICD10 referred to the registered deaths in people who survived the war but lost their lives as a result of war-related injuries including veterans with complication (such as veterans with spinal cord or chemical agent exposure injuries). These codes also include civilians who lost their lives as a result of residual unexploded ordnance or landmines injuries after the war. In this study, we did not include cases that lost their lives due to other potential war-related causes that could not be directly attributed to the warrelated injuries.
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Missing troops or civilians with lack of knowledge about their death were not included in the study. For this study, we calculated the total number of war-related deaths and YLL related to it. The YLL as a component of DALY was calculated as the number of cause-specific deaths multiplied by a loss function which specifies the years lost as a function of the age at which death occurs (Lopez et al., 2006; Mathers et al., 2006). In one approach, life expectancy of Iranian population at each age-sex at the year of death was considered as the potential years of life (Anonymous, 2003). In addition, standard life expectancies for men and women were calculated by modelling from Coale-Demeny Model Life Tables West: Levels 25 for men and Level 26 for women to estimate YLL. The estimation of YLL related to the war was done in the corresponding excel template taking age-weighing equal to 0 and discount rate 0 as the recent recommended approach in calculation of YLL. This approach (no discounting) favours preventive interventions due to potential benefits to be gained in the far future. This is while discounting means that less value is assigned to future life years than those lived today and thus implies lower efficiency of preventive programmes (Murray et al., 2012). For estimation of YLL in the martyrs with unknown date of birth, the data were redistributed based on agestructure of martyrs with known date of birth (Naghavi et al., 2009). This estimated YLL was added to the total age-structure calculated YLL. Results In the years 1980–2005, 183,623 including male 97.1% (n ¼ 178,298) and female 2.9% (n ¼ 5325) died as a result of Iraq–Iran war. The mean age at the time of death were calculated as 22.8 9 years. 96.6% of the death occurred during the years of war (September 1980 and August 1988). In the years after the war (1988–2005), 6243 (3.4%) war-related deaths occurred as the result of implanted landmines and unexploded ordnances or war-related injuries and complications. Females comprised 2.9% of the total victims. Age distribution of Iranians killed in Iraq–Iran war and afterwards (1980–2005) according to gender is demonstrated in Figure 1. As shown in this figure, agestructure of male and female was completely different. 73.9% of the cases were within 15–24 years of age. A considerable proportion of cases were from five provinces including Esfahan, Tehran, Khorasan, Khuzestan and Fars. YLL estimated according to different assumptions of discount rate, age weighting and type of standard life tables appears in Table 1. YLL in Iraq–Iran war among Iranian victims were calculated as 10,479,405.0 years considering an age weighting 0 and discount rate of 0. YLL (0, 0) was 10,169,546.2 years in males (97%) and 309,858.8 years in females (3%). YLL mean was
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Figure 1. Comparison of age-standardised expected years of life lost rates by sex among Iranians killed in Iraq–Iran war and its aftermath (1980–2005).
calculated as 57.1 years for each Iranian victim killed in Iraq–Iran war. The mean YLL for males was same for all killed victims, but for females were 58.2. The highest estimated YLL was observed in 1986. During 1983–1984, estimated YLLs were lower compared to the other years of the war (Figure 2). During the years of 1989–2005, YLLs decreased year by year except for the years 2000 and 2003 which were slightly higher from their preceding years. The total YLLs were higher for ages between 20 and 24 years. Total YLLs according to age groups by the year of deaths for both male and female are demonstrated in Figure 3. As shown in Figure 4 for males, most estimated YLL belonged to young ages between 15 and 24, which was followed by 25–34. The female YLLs in contrast to male YLLs were mainly through ages 1–39 with the highest ranges between 1 and 19 (Figure 5).
Discussion In this paper for the first time, burden of war has been calculated for the period of Iraq–Iran war and afterwards (1980–2005). Iraq–Iran war is known as of one the most devastating human conflicts in the late twentieth century which was responsible for loss of more than hundred thousands of lives (Khaji et al., 2010). According to our results, at least 183,623 Iranians were killed due to war. The phrase ‘at least’ indicates that some martyrs might not have been registered in VMAF. This could have happened when all the members of a family were killed in bombardment of civil areas by Iraqi’s airplanes or by hitting missiles. This should be added to the general possibility of unregistered cases in the situation of war. As showed in other reports, most of the people losing their lives in wars are young (Spiegel & Salama, 2000).
Table 1. Years of life lost due to Iraq–Iran war on Iranian side by different approaches. Reference Iranian nationwide life tables for the same year YLL Approach (discount rate, age weighing) YLL (0% & 1) YLL (0% & 0) YLL (3% & 1) YLL (3% & 0) YLL (6% & 1) YLL (6% & 0)
West level 26 standard life tables
Male (years)
Female (years)
Total (years)
Male (years)
Female (years)
Total (years)
9,632,375.5 7,961,433.1 5,615,500.0 4,345,244.0 3,720,482.0 2,739,763.7
282,138.3 244,965.8 151,897.8 126,904.6 96,695.8 79,381.8
9,914,513.8 8,206,398.8 5,767,397.8 4,472,148.5 3,817,177.8 2,819,145.5
10,930,871.3 10,169,546.2 5,873,521.0 4,826,193.3 3,759,903.4 2,852,175.0
319,048.2 309,858.8 159,337.1 140,872.5 98,523.8 83,469.8
11,249,919.6 10,479,405.0 6,032,858.1 4,967,065.9 3,858,427.2 2,935,644.8
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Figure 2. Years of life lost due to Iraq–Iran war by the year of deaths (no age-weighting, discount rate ¼ 0).
This is the main reason of high burden of wars throughout the world. The war-related years of life lost in our study was estimated to be between 30,000 and 110,000 centuries. Our study showed that males comprised the majority of cases killed. This pattern is observed in the most conflicts and wars (Pl€ umper & Neumayer, 2006; Spiegel & Salama, 2000). Women are usually killed or injured during the war as civilians. Females killed during Iraq–Iran war were mostly from the provinces near borders. Distribution of age groups who lost their lives in this war was different according to gender. Most of the years of life lost belonged to males who lost their lives in front line. This is also shown in the male age groups with the highest proportion of YLL (15–24 years old). In comparison, females had been civilians and this is also depicted in their YLL being higher in early childhood. About one third of female cases who lost their lives due to Iraq–Iran war were under 15 years of age. This proportion was considerably insignificant in males (less than 3%).
This report also revealed that even after ceasefire, the impact of war still continued and took lives (Figure 3). This is what had been documented by others that wars even kill people after they are apparently finished (Gold, Siegel, Russell, & Weinstein, 1996). By dividing the total YLL (10,479,405.0) to the total number of people losing their lives in war (n ¼ 183,623), it can be said that every Iranian killed in war has lost 57.1 years of his/her life due to war. Our study had some limitations and also some advantages. This is the first published report on burden of Iraq– Iran war and is based on the most valid available source of data regarding martyrs in Iran. Estimation of burden of diseases in developing countries is generally difficult due to scarcity of valid morbidity and mortality data registration, lack of insight into importance of data and sometimes technical incompetency. In fact, this study is the first report on quantification of years of life lost due to wars and mass conflicts throughout the world. Nevertheless, it seems that underestimation of years of life lost due to wars is a general and at the same time a real possibility.
Figure 3. Total years of life lost according to age groups (no age-weighting, discount rate ¼ 0).
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Figure 4. Total years of life lost according to age groups in males (no age-weighting, discount rate ¼ 0).
It should be emphasised that Iraq–Iran war has also had unpleasant impacts on Iraqi side as well, which has not been the focus of this research in the current article. From the public health point of view, all outcomes of wars are completely preventable. The burden of Iraq–Iran war is also affected by various war-related short-term or long-life disabilities especially amputations, spinal cord injuries, head traumas, blindness as well as chemical warfare exposures. This study could be a first step in estimation of DALY of Iraq– Iran war on Iranian side. What is already known on the subject? Wars are among the 10 major causes of disability adjusted life years (DALYs). Estimation of burden of war is a neglected task.
Epidemiological studies on estimating the burden of the Iraq–Iran war on both sides have not been accomplished yet. In the years 1980–2005, 178,298 Iranian men and 5325 Iranian women lost their lives due to the war. Deaths occurred as the result of implanted landmines and unexploded ordnances as well as complication of severe injuries after the war. What this study adds? This study is the first report of burden of Iraq–Iran war (the largest war after the Second World War) at national and international level. Epidemiological estimation of the years of lost life on Iranian side from 1980 through 2005 was calculated as 10,479,405.0 years.
Figure 5. Total years of life lost according to age groups in females (no age-weighting, discount rate ¼ 0).
International Journal of Injury Control and Safety Promotion Age-adjusted YLL were estimated as 10,169, 546.2 years in males. Every Iranian killed in war has lost 57.1 years of his/her life due to war. This is the first step in estimation of DALY of Iraq–Iran war. List of abbreviations VMAF: Veterans and Martyrs Affairs Foundation YLL: Years of life lost DALY: Disability adjusted life year Acknowledgements The data for this study were retrieved from the Veterans and Martyrs Affairs Foundation (VMAF) Database. The authors gratefully acknowledge the support for the thoughtful comments received from Dr Hamid Shokoohi.
Funding The Veterans and Martyrs Affairs Foundation (VMAF) funded this study.
References Andrade, A. (2001). FACTS about injuries. Preventing global injuries. Retrieved from http://www.who.int/violence_ injury_prevention/resources/publications/en/injury_factsheet. pdf Anonymous. (2003). Child mortality in Iran: Trends and indices (1956–2021). Tehran: Statistical Center of Iran. Coupland, R.M., & Meddings, D.R. (1999). Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: Literature review. British Medical Journal, 319(7207), 407–410. Gold, M.R., Siegel, J.E., Russell, L.B., & Weinstein, M.C. (1996). Cost effectiveness in health and medicine. New York: Oxford University Press. Khaji, A., Fallahdoost, S., & Soroush, M.R. (2010). Civilian casualties of Iranian cities by ballistic missile attacks during the Iraq–Iran war (1980–1988). Chinese Journal of Traumatology, 13(2), 87–90. Khateri, S.H., Ghanei, M., Keshavarz, S., Soroush, M., & Haines, D. (2003). Incidence of lung, eye, and skin lesions
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as late complications in 34,000 Iranians with wartime exposure to mustard agent. Journal of Occupational and Environmental Medicine, 45(11), 1136–1143. Krug, E.G., Sharma, G.K., & Lozano, R. (2000). The global burden of injuries. American Journal of Public Health, 90(4), 523–526. Lett, R.R., Kobusingye, O.C., & Ekwaru, P. (2006). Burden of injury during the complex political emergency in northern Uganda. Canadian Journal of Surgery, 49(1), 51–57. Levy, B.S., & Sidel, V.W. (2008). War and public health. New York: Oxford University Press. Lopez, L.D., Mathers, C.D., Ezzati, M., Jamison, D.T., & Murray, C.H.J.L. (2006). Global burden of disease and risk factors. Washington, DC and New York: The World Bank and Oxford University Press. Mathers, C.D., Lopez, A.D., & Murray, C.J.L. (2006). The burden of disease and mortality by condition: Data, methods and results for 2001. In L.D. Lopez et al., Global burden of disease and risk factors (pp. 45–240). Washington, DC and New York: The World Bank and Oxford University Press. McNaugher, T.L. (1990). Ballistic missiles and chemical weapons. The legacy of the Iraq–Iran war. International Security, 15(2), 5–34. Murray, C.J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A.D., Michaud, C., . . . Memish, Z.A. (2012). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380(9859), 2197–2223. doi:10.1016/S0140-6736(12)61689-4 Murray, C.J.L., King, G., Lopez, A.D., Tomijima, N., & Krug, E. G. (2002). Armed conflict as a public health problem. British Medical Journal, 324(7333), 346–349. Naghavi, M., Abolhassani, F., Pourmalek, F., Moradi Lakeh, M., Vaseghi, S., Mahdavi, N., & Kazemeini, H. (2009). The burden of disease and injury in Iran 2003. Population Health Metrics, 7(9), 1–21. doi:10.1186/1478-7954-7-9 Pl€ umper, T., & Neumayer, E. (2006). The unequal burden of war: The effect of armed conflict on the gender gap in life expectancy. International Organization, 60(3), 723–754. Spiegel, B., & Salama, P. (2000). War and mortality in Kosovo, 1998–99: An epidemiological testimony. Lancet, 355(9222), 2204–2209. World Health Organization. (2008). Disease and injury regional mortality estimates for 2008: Causes of death 2008 summary tables. Geneva, Switzerland: Author. Zargar, M., Araghizadeh, H., Soroush, M.R., & Khaji, A. (2007). Iranian casualties during the eight years of Iraq–Iran conflict. Revista de Sa ude P ublica, 41(6), 1065–1066.
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Years of life lost among Iranian people killed in the Iraq–Iran war: the 25-year perspective Batool Mousavia, Maziar Moradi-Lakehb, Mojgan Karbakhshc and Mohammadreza Soroushd* a
Prevention Department, Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran; bDepartment of Community and Preventive Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; cDepartment of Community and Preventive Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; dJanbazan Medical and Engineering Research Center (JMERC), Tehran, Iran (Received 6 March 2013; accepted 9 September 2013) To estimate the years of life lost (YLL), registered deaths due to Iraq–Iran war (1980–2005) were identified considering ICD10 codes of Y36.0 to Y36.9. Estimated YLL was calculated by taking age-weighting options and discount rates. Population life expectancy in each corresponding year was retrieved from the national health database. During 1980–2005, 178,298 Iranian men and 5325 Iranian women died in war. The mean death age was 22.8 9 years, 96.6% occurred during the years of war (September 1980–August 1988). In the years after the war (1988–2005) 6243 (3.4%) of deaths occurred as the result of complication of the war-related injuries or implanted landmines/unexploded ordnances (ICD10 code: Y36.8). YLL in Iraq–Iran war among Iranian victims were calculated as 10,479,405.0 years considering the age weighting and discount rate equal to 0. Age-adjusted YLL were estimated as 10,169,546.2 years in males. Female cases that comprised 2.9% of total victims lost 309,858.8 years. The mean YLL was calculated as 57.1 years for each Iranian victim killed in Iraq–Iran war. The war-related YLL was estimated more than 10 million years that comprised a majority of young men. This study is the first step in estimation of disability adjusted life year (DALY) of Iraq–Iran war on Iranian side. Keywords: years of life lost; burden of disease; Iraq–Iran war
Introduction Injuries are an important cause of death and disability throughout the world. Wars as one of the causes of intentional injury-related deaths are responsible for the increasing burden of intentional injuries in developing countries (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006; Mathers, Lopez, & Murray, 2006). In the year 2000, about 310,000 persons lost their lives throughout the world in wars (Lett, Kobusingye, & Ekwaru, 2006; Murray, King, Lopez, Tomijima, & Krug, 2002), of whom about 90% were in developing countries. The World Health Organisation reported that wars accounted for 10% of injuryrelated deaths (Andrade, 2001). According to WHO estimates for 2008, about 96,000 deaths occurred due to wars or civil conflicts in the Eastern Mediterranean region which accounted to be more than half of all war- and conflict-related deaths in that year throughout the world (World Health Organization, 2008). In fact, wars are among the 10 causes of disability adjusted life year (DALY) for 15–44 years old males (Lopez et al., 2006; Mathers et al., 2006). For every person losing his life in war, many others get injured with ratios ranging from 1.9 to 13 (Coupland & Meddings, 1999; Krug, Sharma, & Lozano, 2000). Moreover, the devastating effect of wars on nations’ health is not limited
*Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
to the period of war. People continue suffering from injuries sustained during the war and some die of these conditions or their complications afterwards. Iraq–Iran war caused hundreds of thousands deaths or injured, millions of displaced, and billions of dollars cost (Zargar, Araghizadeh, Soroush, & Khaji, 2007). There is limited precise information on Iraqi weaponry against Iran on both warlike and civilian zones in the literature (Khateri, Ghanei, Keshavarz, Soroush, & Haines, 2003; Zargar, et al., 2007). Over a period of eight years (1980–1988), Iraq launched a large number of ballistic missiles toward Iranian territories and cities, especially Tehran, the capital city of Iran, as well as other large and small cities (Khaji, Fallahdoost, & Soroush, 2010; McNaugher, 1990). It is also estimated that 1800 metric tonnes of mustard gas, 140 tonnes of tabun and over 600 tonnes of sarin were used against Iran, using munitions that included approximately 19,500 aerial bombs, 54,000 artillery shells and 27,000 short-range rockets (Khateri et al., 2003). Estimation of burden of war is a formidable and thus a neglected task. During wars, the disruptions in management information system functions and infrastructure of the societies hamper precise registration of deaths and disabilities (Levy & Sidel, 2008; Murray et al., 2002).
International Journal of Injury Control and Safety Promotion In Iran, Veterans and Martyrs Affairs Foundation (VMAF) was established from the beginning of Iraq–Iran war. Since then, VMAF has been responsible for registering the relevant data of martyrs (from their family members and all other available sources) and providing services to their families. Families of martyrs usually refer to this organisation to register their martyrs in the database. The reasons are multiple: as martyrs have lost their lives defending the country, it is an honour to the family to have their deceased family member recognised as a ‘martyr’. In addition, some families might be really in need of services that the organisations offer to them (e.g. pension and health services). Nevertheless, this databank has not still been used for estimation of years of life lost due to Iraq–Iran war. This paper aims to estimate the years of life lost (YLL) during and after Iraq–Iran war from 1980 to 2005. Methods For the years 1980–2005, registered Iraq–Iran war-related deaths were obtained from the national registry at the VMAF Database. The data file contained all the warrelated deaths of Iranian victims during and after the years of conflict (1980–2005). The data included both troops and civilians who were killed during or after the fire cessation as a result of war-related injuries. This database can be considered as the main source for estimation of years of life lost in Iraq–Iran war. According to VMAF, which is responsible for registering the relevant data of martyrs during and after the Iraq–Iran war, at least 183,623 Iranians were killed due to the Iraq–Iran war. Some martyrs might not have been recorded in the database as nobody had referred to report disappearance or death. This could also have been the case when all the members of a household were killed in bombardment of civil areas by Iraqi planes or by hitting missiles, which was not common. In addition, if death occurred instantly as an indirect impact of war especially in war zone (e.g. due to myocardial infarction) the death was considered to be related to the war. Thus, the potential for underreporting or misclassification of causes of death was not a major challenge in our dataset. All included cases were classifiable within ICD10 codes of Y36.0–Y36.9. The Y36.8 code of ICD10 referred to the registered deaths in people who survived the war but lost their lives as a result of war-related injuries including veterans with complication (such as veterans with spinal cord or chemical agent exposure injuries). These codes also include civilians who lost their lives as a result of residual unexploded ordnance or landmines injuries after the war. In this study, we did not include cases that lost their lives due to other potential war-related causes that could not be directly attributed to the warrelated injuries.
383
Missing troops or civilians with lack of knowledge about their death were not included in the study. For this study, we calculated the total number of war-related deaths and YLL related to it. The YLL as a component of DALY was calculated as the number of cause-specific deaths multiplied by a loss function which specifies the years lost as a function of the age at which death occurs (Lopez et al., 2006; Mathers et al., 2006). In one approach, life expectancy of Iranian population at each age-sex at the year of death was considered as the potential years of life (Anonymous, 2003). In addition, standard life expectancies for men and women were calculated by modelling from Coale-Demeny Model Life Tables West: Levels 25 for men and Level 26 for women to estimate YLL. The estimation of YLL related to the war was done in the corresponding excel template taking age-weighing equal to 0 and discount rate 0 as the recent recommended approach in calculation of YLL. This approach (no discounting) favours preventive interventions due to potential benefits to be gained in the far future. This is while discounting means that less value is assigned to future life years than those lived today and thus implies lower efficiency of preventive programmes (Murray et al., 2012). For estimation of YLL in the martyrs with unknown date of birth, the data were redistributed based on agestructure of martyrs with known date of birth (Naghavi et al., 2009). This estimated YLL was added to the total age-structure calculated YLL. Results In the years 1980–2005, 183,623 including male 97.1% (n ¼ 178,298) and female 2.9% (n ¼ 5325) died as a result of Iraq–Iran war. The mean age at the time of death were calculated as 22.8 9 years. 96.6% of the death occurred during the years of war (September 1980 and August 1988). In the years after the war (1988–2005), 6243 (3.4%) war-related deaths occurred as the result of implanted landmines and unexploded ordnances or war-related injuries and complications. Females comprised 2.9% of the total victims. Age distribution of Iranians killed in Iraq–Iran war and afterwards (1980–2005) according to gender is demonstrated in Figure 1. As shown in this figure, agestructure of male and female was completely different. 73.9% of the cases were within 15–24 years of age. A considerable proportion of cases were from five provinces including Esfahan, Tehran, Khorasan, Khuzestan and Fars. YLL estimated according to different assumptions of discount rate, age weighting and type of standard life tables appears in Table 1. YLL in Iraq–Iran war among Iranian victims were calculated as 10,479,405.0 years considering an age weighting 0 and discount rate of 0. YLL (0, 0) was 10,169,546.2 years in males (97%) and 309,858.8 years in females (3%). YLL mean was
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Figure 1. Comparison of age-standardised expected years of life lost rates by sex among Iranians killed in Iraq–Iran war and its aftermath (1980–2005).
calculated as 57.1 years for each Iranian victim killed in Iraq–Iran war. The mean YLL for males was same for all killed victims, but for females were 58.2. The highest estimated YLL was observed in 1986. During 1983–1984, estimated YLLs were lower compared to the other years of the war (Figure 2). During the years of 1989–2005, YLLs decreased year by year except for the years 2000 and 2003 which were slightly higher from their preceding years. The total YLLs were higher for ages between 20 and 24 years. Total YLLs according to age groups by the year of deaths for both male and female are demonstrated in Figure 3. As shown in Figure 4 for males, most estimated YLL belonged to young ages between 15 and 24, which was followed by 25–34. The female YLLs in contrast to male YLLs were mainly through ages 1–39 with the highest ranges between 1 and 19 (Figure 5).
Discussion In this paper for the first time, burden of war has been calculated for the period of Iraq–Iran war and afterwards (1980–2005). Iraq–Iran war is known as of one the most devastating human conflicts in the late twentieth century which was responsible for loss of more than hundred thousands of lives (Khaji et al., 2010). According to our results, at least 183,623 Iranians were killed due to war. The phrase ‘at least’ indicates that some martyrs might not have been registered in VMAF. This could have happened when all the members of a family were killed in bombardment of civil areas by Iraqi’s airplanes or by hitting missiles. This should be added to the general possibility of unregistered cases in the situation of war. As showed in other reports, most of the people losing their lives in wars are young (Spiegel & Salama, 2000).
Table 1. Years of life lost due to Iraq–Iran war on Iranian side by different approaches. Reference Iranian nationwide life tables for the same year YLL Approach (discount rate, age weighing) YLL (0% & 1) YLL (0% & 0) YLL (3% & 1) YLL (3% & 0) YLL (6% & 1) YLL (6% & 0)
West level 26 standard life tables
Male (years)
Female (years)
Total (years)
Male (years)
Female (years)
Total (years)
9,632,375.5 7,961,433.1 5,615,500.0 4,345,244.0 3,720,482.0 2,739,763.7
282,138.3 244,965.8 151,897.8 126,904.6 96,695.8 79,381.8
9,914,513.8 8,206,398.8 5,767,397.8 4,472,148.5 3,817,177.8 2,819,145.5
10,930,871.3 10,169,546.2 5,873,521.0 4,826,193.3 3,759,903.4 2,852,175.0
319,048.2 309,858.8 159,337.1 140,872.5 98,523.8 83,469.8
11,249,919.6 10,479,405.0 6,032,858.1 4,967,065.9 3,858,427.2 2,935,644.8
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Figure 2. Years of life lost due to Iraq–Iran war by the year of deaths (no age-weighting, discount rate ¼ 0).
This is the main reason of high burden of wars throughout the world. The war-related years of life lost in our study was estimated to be between 30,000 and 110,000 centuries. Our study showed that males comprised the majority of cases killed. This pattern is observed in the most conflicts and wars (Pl€ umper & Neumayer, 2006; Spiegel & Salama, 2000). Women are usually killed or injured during the war as civilians. Females killed during Iraq–Iran war were mostly from the provinces near borders. Distribution of age groups who lost their lives in this war was different according to gender. Most of the years of life lost belonged to males who lost their lives in front line. This is also shown in the male age groups with the highest proportion of YLL (15–24 years old). In comparison, females had been civilians and this is also depicted in their YLL being higher in early childhood. About one third of female cases who lost their lives due to Iraq–Iran war were under 15 years of age. This proportion was considerably insignificant in males (less than 3%).
This report also revealed that even after ceasefire, the impact of war still continued and took lives (Figure 3). This is what had been documented by others that wars even kill people after they are apparently finished (Gold, Siegel, Russell, & Weinstein, 1996). By dividing the total YLL (10,479,405.0) to the total number of people losing their lives in war (n ¼ 183,623), it can be said that every Iranian killed in war has lost 57.1 years of his/her life due to war. Our study had some limitations and also some advantages. This is the first published report on burden of Iraq– Iran war and is based on the most valid available source of data regarding martyrs in Iran. Estimation of burden of diseases in developing countries is generally difficult due to scarcity of valid morbidity and mortality data registration, lack of insight into importance of data and sometimes technical incompetency. In fact, this study is the first report on quantification of years of life lost due to wars and mass conflicts throughout the world. Nevertheless, it seems that underestimation of years of life lost due to wars is a general and at the same time a real possibility.
Figure 3. Total years of life lost according to age groups (no age-weighting, discount rate ¼ 0).
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Figure 4. Total years of life lost according to age groups in males (no age-weighting, discount rate ¼ 0).
It should be emphasised that Iraq–Iran war has also had unpleasant impacts on Iraqi side as well, which has not been the focus of this research in the current article. From the public health point of view, all outcomes of wars are completely preventable. The burden of Iraq–Iran war is also affected by various war-related short-term or long-life disabilities especially amputations, spinal cord injuries, head traumas, blindness as well as chemical warfare exposures. This study could be a first step in estimation of DALY of Iraq– Iran war on Iranian side. What is already known on the subject? Wars are among the 10 major causes of disability adjusted life years (DALYs). Estimation of burden of war is a neglected task.
Epidemiological studies on estimating the burden of the Iraq–Iran war on both sides have not been accomplished yet. In the years 1980–2005, 178,298 Iranian men and 5325 Iranian women lost their lives due to the war. Deaths occurred as the result of implanted landmines and unexploded ordnances as well as complication of severe injuries after the war. What this study adds? This study is the first report of burden of Iraq–Iran war (the largest war after the Second World War) at national and international level. Epidemiological estimation of the years of lost life on Iranian side from 1980 through 2005 was calculated as 10,479,405.0 years.
Figure 5. Total years of life lost according to age groups in females (no age-weighting, discount rate ¼ 0).
International Journal of Injury Control and Safety Promotion Age-adjusted YLL were estimated as 10,169, 546.2 years in males. Every Iranian killed in war has lost 57.1 years of his/her life due to war. This is the first step in estimation of DALY of Iraq–Iran war. List of abbreviations VMAF: Veterans and Martyrs Affairs Foundation YLL: Years of life lost DALY: Disability adjusted life year Acknowledgements The data for this study were retrieved from the Veterans and Martyrs Affairs Foundation (VMAF) Database. The authors gratefully acknowledge the support for the thoughtful comments received from Dr Hamid Shokoohi.
Funding The Veterans and Martyrs Affairs Foundation (VMAF) funded this study.
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