Ella Does Squamish

The figure for the number of deaths attributable to the conflict - which amounts to around 2.5% of the population - is at odds with figures cited by the US and UK governments and will cause a storm, but the Lancet says the work, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, has been examined and validated by four separate independent experts who all urged publication.

In October 2004, the same researchers published a study estimating that 100,000 Iraqis had died as a result of the war since the beginning of the March 2003 invasion, a figure that was hugely controversial. Their new study, they say, reaffirms the accuracy of their survey of two years ago and moves it on.

"Although such death rates might be common in times of war, the combination of a long duration and tens of millions of people affected has made this the deadliest international conflict of the 21st century and should be of grave concern to everyone," write the authors, Gilbert Burnham and colleagues.

"At the conclusion of our 2004 study we urged that an independent body assess the excess mortality that we saw in Iraq. This has not happened. We continue to believe that an independent international body to monitor compliance with the Geneva conventions and other humanitarian standards in conflict is urgently needed. With reliable data, those voices that speak out for civilians trapped in conflict might be able to lessen the tragic human cost of future wars."

The epidemiological research was carried out on the ground by teams of doctors moving from house to house, questioning families and examining death certificates. Between May and July this year, they visited 1,849 households in 47 separated clusters across the length and breadth of Iraq. The doctors asked about deaths among members of the household in a period before the invasion, from January 2002 to March 2003, and about deaths since. In 92% of cases, they were shown death certificates confirming the cause.

A total of 629 deaths were reported, of which 547 - or 87% - occurred after the invasion. The mortality rate before the war was 5.5 per 1,000, but since the invasion, it has risen to 13.3 per 1,000 per year, they say. Between June 2005 and June 2006, the mortality rate hit a high of 19.8 per 1,000.

Thus they calculate that 654,965 Iraqis have died as a consequence of the invasion. It is an estimate and the mid-point, and most likely of a range of numbers that could also be correct in the context of their statistical analysis. But even the lowest number in the range - 392,979 - is higher that anyone else has suggested. Of the deaths, 31% were ascribed to the US-led forces. Most deaths were from gunshot wounds (56%), with a further 13% from car bomb injuries and 14% the result of other explosions.

"Since 2004, and especially recently," writes the Lancet editor, Richard Horton in a commentary, "independent observers have recognised that the security situation in Iraq has deteriorated dramatically." The new study, he continues, "corroborate the impression that Iraq is descending into bloodthirsty chaos".

Yet, he writes, "absolute despair would be the wrong response. Instead, the disaster that is the west’s current strategy in Iraq must be used as a constructive call to the international community to reconfigure its foreign policy around human security rather than national security, around health and wellbeing in addition to the protection of territorial boundaries and economic stability.

"Health is now the most important foreign policy issue of our time. Health and wellbeing - their underpinning values, their diverse array of interventions and their goals of healing - offer several original dimensions for a renewed foreign policy that might at least be one positive legacy of our misadventure in Iraq."

BANGALORE, India, Oct. 10 — A few weeks ago, Carl Garrett, a 60-year-old North Carolina resident, was packing his bags to fly to New Delhi and check into the plush Indraprastha Apollo Hospital to have his gall bladder removed and the painful muscles in his left shoulder repaired. Mr. Garrett was to be a test case, the first company-sponsored worker in the United States to receive medical treatment in low-cost India.

But instead of making the 20-hour flight, Mr. Garrett was grounded by a stormy debate between his employer, which saw the benefits of using the less expensive hospitals in India, and his union, which raised questions about the quality of overseas health care and the issue of medical liability should anything go wrong.

“I was looking forward to the adventure of being treated in India,” Mr. Garrett said the other day. “But my company dropped the ball.”

The union, the United Steelworkers, stepped in after it heard about Mr. Garrett’s plans, saying it deplored a “shocking new approach” of sending workers to low-cost countries as a way to cut health care costs. Its officials insisted that Mr. Garrett be offered a health care option within the United States.

“No U.S. citizen should be exposed to the risks involved in traveling internationally for health care services,” Leo W. Gerard, the president of the union, said in a recent letter to the Senate and House committees that oversee health care. He expressed his concern about the willingness of employers to offer incentives to employees to go overseas.

Mr. Garrett, who works for Blue Ridge Paper Products in Canton, N.C., had volunteered to get his treatments in India in return for a share in the company’s savings. Blue Ridge now says it will find Mr. Garrett a treatment alternative in the United States and will offer the overseas option only to its salaried employees.

IndUShealth, a company based in North Carolina that arranges health care in India for Americans, would have made Mr. Garrett’s medical arrangements. The company acknowledged that its plan to send Blue Ridge workers to India was “on hold” but said it was exploring deals with other employers.

The union’s resistance has brought to the fore a critical question in the path of the globalization of the health care industry — who is liable if something goes wrong in an overseas hospital? And underlying all this is the even more explosive issue of potential job losses in the American health care industry, in an economy already sensitive to the large-scale shift of jobs to cheaper overseas locations.

Even as the debate continues about insurers’ role in health care outsourcing, hundreds of uninsured and under-insured Americans have already gone on their own to India for treatments.

With medical costs in India routinely 80 percent lower than in the United States, experts predict that globally standardized health care delivered in countries like India and Thailand will eventually change the face of the health care business.

Providing health care to foreigners could generate $20 billion for India by 2012, according to a study by McKinsey & Company, the consulting firm, although McKinsey did not say how many patients that figure represents. With 150,000 overseas patients last year — though only a small fraction of them Americans — India is already the global leader in importing foreign patients for low-cost treatment. Its best hospitals have Western-trained doctors and are equipped with modern equipment.

Still, cross-border medical liability in countries like India could prove to be a major hurdle, the experts say. In the case of Mr. Garrett, Blue Ridge Paper asked him to sign a release saying that he was “on his own as far as medical liability,” said Bonnie Blackley, the benefits director at Blue Ridge.

Tom Keesling, president of IndUShealth, said “the Indian physician and hospital would be directly responsible for any malpractice.”

Zubin Daruwalla, health care analyst at the consulting firm Frost & Sullivan, said there was no uniform code in India on what could be considered medical negligence and what compensation ought to be paid. “Compared with the huge payouts in the United States, Indian courts award small amounts,” Mr. Daruwalla said.

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