America’s post-9/11 wars have led to more than 4.5 million deaths, according to a major new report from the Costs of War Project at Brown University.

Roughly 1 million of these deaths came from direct combat in war zones across Afghanistan, Pakistan, Iraq, Libya, Syria, Somalia, and Yemen, while the remaining 3.5 million are “indirect deaths” that resulted from the conflicts’ “destruction of economies, public services, and the environment,” according to the report.

The sobering findings highlight the long-term effects of the Global War on Terror, which has been the deadliest fight of the 21st century so far. The death toll, which Brown researchers described as a “reasonable and conservative estimate,” rivals that of major post-WWII conflicts, including the wars in Korea and Vietnam.

“In a place like Afghanistan, the pressing question is whether any death can today be considered unrelated to war,” said Stephanie Savell, the report’s author, in a statement. “Wars often kill far more people indirectly than in direct combat, particularly young children.”

Savell explained on Twitter that, while each war has complex causes, she chose to include conflicts where “U.S. counterterrorism has played a vital role in at the very least intensifying the violence.”

The impacts of those wars have yet to subside. As the report notes, an additional 7.6 million young children suffer from acute malnutrition today in post-9/11 war zones. And both locals and U.S. veterans continue to face physical and mental health challenges arising out of the conflicts.

Notably, the research does not attempt to assign responsibility for each death to any single party, opting instead to identify leading drivers of mortality. One key factor was the destruction of different types of key infrastructure, including hospitals and other healthcare facilities.

“[A]t the height of the U.S.-led war in Iraq, the disastrous state of roads and traffic systems led to as many if not more fatalities than the conflict itself,” the report notes, adding that the “destruction of ports, urban buildings, and electrical systems also have negative effects.”

The war in Libya led to a nine-year drop in life expectancy for men and a six-year drop for women. In Afghanistan, one in ten newborn babies died during the first three months of 2022.

The report concludes by calling on the United States and other involved countries to “alleviate human suffering resulting from the post-9/11 wars.”

“These wars are ongoing for millions around the world who are living with and dying from their effects,” Savell wrote. “Reparations, though not easy or cheap, are imperative.”