Bias in Epidemiological Studies of Conflict Mortality

Cluster sampling has recently been used to estimate the mortality in various conflicts around the world. The Burnham et al. study on Iraq employs a new variant of this cluster sampling methodology. The stated methodology of Burnham et al. is to (1) select a random main street, (2) choose a random cross street to this main street, and (3) select a random household on the cross street to start the process. The authors show that this new variant of the cluster sampling methodology can introduce an unexpected, yet substantial, bias into the resulting estimates, as such streets are a natural habitat for patrols, convoys, police stations, road-blocks, cafes, and street-markets. This bias comes about because the residents of households on cross-streets to the main streets are more likely to be exposed to violence than those living further away. Here, the authors develop a mathematical model to gauge the size of the bias and use the existing evidence to propose values for the parameters that underlie the model. The research suggests that the Burnham et al. study of conflict mortality in Iraq may represent a substantial overestimate of mortality. Indeed, the recently published Iraq Family Health Survey covered virtually the same time period as the Burnham et al. study, used census-based sampling techniques, and produced a central estimate for violent deaths that was one fourth of the Burnham et al. estimate. The authors provide a sensitivity analysis to help readers to tune their own judgements on the extent of this bias by varying the parameter values. Future progress on this subject would benefit from the release of high-resolution data by the authors of the Burnham et al. study.