In a Comment in this week's edition of The Lancet, a former US naval captain and interim health minister of Iraq criticises the US Department of Defense strategy of analysing "achievement indicators" rather than "outcomes" to judge the success of various initiatives, while a related Editorial says a thoroughly renovated health service in Iraq can only succeed if its many exiled and displaced healthcare workers feel safe enough to return.

The Comment is authored by Professor Frederick M Burkle*, a former US naval captain and Interim Minister of Health for Iraq, now at the Harvard Humanitarian Initiative, Harvard University, MA, USA. He emphasises the importance of using outcome indicators rather than output or achievement indicators, and criticises the US Department of Defense (DoD) for not learning this lesson.

He says: "Politicians decide what the military must do and often how the military must do it; yet when these missions fall short, as many humanitarian assistance efforts have, it is the military that is blamed. The blame here lies with the DoD officials who for political reasons want to focus on achievement indicators rather than outcomes."

Burkle says that although officers in US military medical branches have pushed for adoption of outcome measures, they face an uphill battle with DoD officials to open up programmes to scrutiny. He says: "Not only do outcome measures provide a better picture of what is happening on the ground, they would allow outside agencies with similar measures to coordinate their programmes with those of the DoD. Otherwise, without common yardsticks, DoD programmes no matter how brief, cannot be efficiently handed to non-governmental organisations who are then compelled to start their assessments from scratch. There is an evidence-based science and common language behind humanitarian assistance which requires appropriate scrutiny and research to keep such assistance honest. DoD studies on this process have ignored the bevy of peer-reviewed literature that exists. Reinventing the wheel is inefficient and unnecessary."

The linked Editorial says that the recent Iraq Family Health Survey (IFHS) Report confirms that far too many civilians have been killed during the US-led occupation. It says: "The sooner this fact is accepted, the sooner the crucial issue of rebuilding the shattered lives that lie behind such numbers can begin."

The IFHS was of Iraqis, by Iraqis, and for Iraqis-and showed the effects of years of repression, sanctions, and conflict on the health of over 9000 representative households.

Particularly disturbing are the findings in relation the country's women, including an increase in the maternal mortality from 47 to 84 per 100 000 live births since 2003. The report is the first systematic measure of domestic violence in Iraq, and found 83% of women complained of controlling behaviour by their husbands (such as permission to attend a health facility). Over a third of women had experienced emotional cruelty, and a more than a fifth suffered physical violence.

The Editorial also refers to the recently released report Rehabilitation Under Fire, from the UK charity Medact. It contains estimates from the Iraq Medical Association that half the country's 34 000 doctors fled (along with 2•2 million other Iraqis) during the invasion; 2000 doctors have been killed; and other doctors will be among the 2•4 million internally displaced citizens. As a result, as few as 9000 doctors and 15 000 nurses remain to look after a population of 28 million people.

It concludes: "Disturbingly, the IFHS indicates that the violence and security endemic in Iraq is now reflected by violence and anxiety within households. Although a thoroughly renovated health-care system is required urgently to address the consequences of these behaviours, such a system cannot succeed without parallel improvements in security and the confidence of exiled health workers to return. Without an accessible and effective health system, in which returning health professionals can practise in safety, the coalition's legacy of civilian morbidity will be even greater than its shameful record of civilian mortality."

The Lancet