In The Lancet's special 9/11 issue, a report details the devastating impact of suicide bombs on both Iraqi civilians and coalition troops. The editorial is by Dr Madelyn Hsiao-Rei Hicks, Institute of Psychiatry, King's College London, UK, and Iraq Body Count, London, UK, and colleagues.

In Iraq, two data sets recorded suicide bomb casualties from March 20, 2003 to December 31, 2010, and examined and compared by investigators. One set documented coalition-soldier deaths from suicide bombs and the other documented deaths and injuries of Iraqi civilians caused by armed violence. 19% (42,928 of 225,789) of overall civilian casualties were caused by documented suicide bomb events, 26% (30,644 of 117,165) of injured civilians, and 11% (12,284 of 108,624) deaths.

For civilians the injured-to-killed ratio was 2-5 individuals injured to one person killed from suicide bombs. 43% of recorded suicide bomb deaths were caused by suicide bombers on foot, suicide bombers using cars cause 36% of documented deaths and 40% of civilian injuries.

75% of the 3,963 identifiable suicide bomb fatalities were men, 11% women, and 14% children. Children made up for a higher ratio of demographically identifiable deaths caused by suicide bombings compared to general armed violence (9%). For women the injured-to-killed ratio for all suicide bombings was a little higher than for men, however, for children the ratio was lower than for both women and men, revealing lower survival of children from suicide bombings.

In at least 159 (16%) of 1,003 suicide bombing events documented, an Iraqi child died, and at least 211 (21%) women or children died of the 1,003 bombings documents. 14% of civilian deaths recorded were police officers, an occupational category overlapping with the demographic category of men and to some degree women.

During 2003 to 2010, 200 coalition soldiers were killed in 79 suicide bomb attacks. Compared to coalition soldiers, more Iraqi civilians were killed per suicide bombings. These were documented as follows: 175 US soldiers killed in 76 suicide bombs, 16 Italian soldiers killed in one event, three British killed in one event, and four Bulgarian and two Thai soldiers killed in one event.

The researchers explain:

"Rapid access to adequate hospital treatment is crucial for survival of blast injuries, but such access can be difficult for civilians in Iraq. Survival and recovery of Iraqis injured by suicide bombs could possibly have been worsened by Iraq's severe shortage of adequate emergency rooms, diagnostic equipment, trained paramedics and doctors, senior and specialty surgeons needed for complex blast injuries, intensive care units, rehabilitation, and supplies."

They conclude:

Our findings suggest that the Iraqi civilian population suffers a substantial public health burden because it is a primary chosen target of suicide bombers and those who deploy them. Our findings about the likelihood of surviving injuries, which was particularly low for children recorded in our dataset, need further study and draw attention to the need for improved monitoring, prevention, and interventions to reduce mortality from suicide bombs in Iraq."

In a joint comment, Dr Gilbert Burnham, Johns Hopkins School of Public Health, Baltimore, MD, USA (and co-author on the 2006 Lancet report on deaths in Iraq) states:

"Prevention of suicide attacks is difficult because of their complex origins. The military's approach of controlling access and attacking suspicious targets has protected coalition forces in Iraq, but the resulting deaths of innocent civilians have alienated many Iraqis. This action has played a part in shifting suicide attacks towards civilian targets. Attempts to stop bombers are often futile.

Most effective is the elimination of conditions that cause popular support for terrorist groups. Interruption of jihadist networks and their financial support is also a successful approach. The changing habits of populations exposed to terror attacks (eg, the avoidance of high-risk locations) build resilience and individual coping capacities. Eventually, suicide attacks lose their strategic and psychological effect on a population, and insurgent groups shift to other methods."

Written by Grace Rattue