iabetes killed an increasing number of New York City residents last year, ranking for the first time among the five leading causes of death in an annual summary of vital statistics released yesterday by the health department.

Diabetes was identified as the fourth-leading cause with 1,891 deaths in 2003, an 11 percent increase from the previous year, when the disease was ranked sixth, according to the summary. Of those deaths, 1,024 were women and 867 were men.

Health officials attributed the increase to rising levels of obesity among New Yorkers, and also to a higher risk of the disease in a population that is living longer. Diabetes was the third-leading cause of death among those between 55 and 74.

Health Commissioner Thomas R. Frieden warned that diabetes remained an underdiagnosed condition that had been linked to heart disease. He also said that it was more likely to affect Hispanics and blacks because of the greater incidence of obesity among those groups. “What it means is that we need to do a much better job of both preventing and treating,” he said at a news briefing at City Hall.

The 67-page vital statistics survey (www.nyc.gov/html/doh/pdf/vs /2003sum.pdf) showed that the top three causes of death among city residents remained the same from the year before: Heart disease was again the leading killer, causing 23,875 deaths last year. Cancer was second with 13,826 deaths, and influenza and pneumonia was third with 2,692 deaths.

Alzheimer’s disease was identified for the first time as a leading cause of death in people over age 75.

Still, there were small victories revealed by the data. H.I.V. and AIDS-related deaths slipped two places to seventh last year, accounting for 1,656 deaths, compared with 1,713 the year before. Health officials pointed out that it remained the leading killer of residents between 35 and 44.

Fewer teenagers gave birth last year, continuing a long-term national and citywide trend. But Dr. Frieden said that teenage pregnancy remained a problem, especially in the Bronx, in part because teenagers were not using condoms as often as they should. Teenage births have declined 36 percent in the city over the last decade, the survey found.

In general, the data suggested that New York remained a healthy and safe place to live, Dr. Frieden said. The total number of deaths dipped once again this year to a historic low of 59,213 deaths, compared with 59,651 in 2002.

In addition, the survey studied the aftereffects of the August 2003 blackout and debunked at least one urban myth. “People may have had fun in other ways, but there was no increase in births,” Dr. Frieden said.

The study also found that six people – three men and three women – died from causes associated with the blackout. Those causes included accidental carbon monoxide poisoning, heart attack, excessive heat in the absence of air-conditioning and mechanical respirator failure.

Dr. Nathaniel Clark, a vice president with the American Diabetes Association, said the increase in diabetes-related deaths in New York City was not surprising, since the disease had become more common. He said people could reduce their risk of developing it by losing weight and exercising regularly.

“This type of wake-up call is not necessarily negative,” he said. “The positive message is that we know diabetes can be controlled in those who have it, and prevented or delayed in those who are at risk for it by changes in lifestyle.”

here has been so much violence in Iraq that it’s become hard to distinguish one senseless act from another. But there was a picture that ran on the front page of this newspaper on Monday that really got to me. It showed several Iraqi gunmen, in broad daylight and without masks, murdering two Iraqi election workers. The murder scene was a busy street in the heart of Baghdad. The two election workers had been dragged from their car into the middle of the street. They looked young, the sort of young people you’d see doing election canvassing in America or Ukraine or El Salvador.

One was kneeling with his arms behind his back, waiting to be shot in the head. Another was lying on his side. The gunman had either just pumped a bullet into him or was about to. I first saw the picture on the Internet, and I did something I’ve never done before – I blew it up so it covered my whole screen. I wanted to look at it more closely. You don’t often get to see the face of pure evil.

There is much to dislike about this war in Iraq, but there is no denying the stakes. And that picture really framed them: this is a war between some people in the heart of the Arab-Muslim world who – for the first time ever in their region – are trying to organize an election to choose their own leaders and write their own constitution versus all the forces arrayed against them.

Do not be fooled into thinking that the Iraqi gunmen in this picture are really defending their country and have no alternative. The Sunni-Baathist minority that ruled Iraq for so many years has been invited, indeed begged, to join in this election and to share in the design and wealth of post-Saddam Iraq.

As the Johns Hopkins foreign policy expert Michael Mandelbaum so rightly pointed out to me, “These so-called insurgents in Iraq are the real fascists, the real colonialists, the real imperialists of our age.” They are a tiny minority who want to rule Iraq by force and rip off its oil wealth for themselves. It’s time we called them by their real names.

However this war started, however badly it has been managed, however much you wish we were not there, do not kid yourself that this is not what it is about: people who want to hold a free and fair election to determine their own future, opposed by a virulent nihilistic minority that wants to prevent that. That is all that the insurgents stand for.

Indeed, they haven’t even bothered to tell us otherwise. They have counted on the fact that the Bush administration is so hated around the world that any opponents will be seen as having justice on their side. Well, they do not. They are murdering Iraqis every day for the sole purpose of preventing them from exercising that thing so many on the political left and so many Europeans have demanded for the Palestinians: “the right of self-determination.”

What is terrifying is that the noble sacrifice of our soldiers, while never in vain, may not be enough. We may actually lose in Iraq. The vitally important may turn out to be the effectively impossible.

We may lose because of the defiantly wrong way that Donald Rumsfeld has managed this war and the cynical manner in which Dick Cheney, George Bush and – with some honorable exceptions – the whole Republican right have tolerated it. Many conservatives would rather fail in Iraq than give liberals the satisfaction of seeing Mr. Rumsfeld sacked. We may lose because our Arab allies won’t lift a finger to support an election in Iraq – either because they fear they’ll be next to face such pressures, or because the thought of democratically elected Shiites holding power in a country once led by Sunnis is anathema to them.

We may lose because most Europeans, having been made stupid by their own weakness, would rather see America fail in Iraq than lift a finger for free and fair elections there.

As is so often the case, the statesman who framed the stakes best is the British prime minister, Tony Blair. Count me a “Blair Democrat.” Mr. Blair, who was in Iraq this week, said: “Whatever people’s feelings or beliefs about the removal of Saddam Hussein and the wisdom of that, there surely is only one side to be on in what is now very clearly a battle between democracy and terror. On the one side you have people who desperately want to make the democratic process work, and want to have the same type of democratic freedoms other parts of the world enjoy, and on the other side people who are killing and intimidating and trying to destroy a better future for Iraq.”

n Iraq, as Yogi Berra would say, the future ain’t what it used to be.

Now that the election’s over, our leaders think it’s safe to experiment with a little candor.

President Bush has finally acknowledged that the Iraqis can’t hack it as far as securing their own country, which means, of course, that America has no exit strategy for its troops, who will soon number 150,000.

News organizations led with the story, even though the president was only saying something that everybody has known to be true for a year. The White House’s policy on Iraq has gone from a total charade to a limited modified hangout. Mr. Bush is conceding the obvious, that the Iraqi security forces aren’t perfect, so he doesn’t have to concede the truth: that Iraq is now so dire no one knows how or when we can get out.

If this fiasco ever made sense to anybody, it doesn’t any more.

John McCain, who lent his considerable credibility to Mr. Bush during the campaign and vouched for the president and his war, now concedes that he has no confidence in Donald Rumsfeld.

And Rummy admitted yesterday that his feelings got hurt when people accused him of being insensitive to the fact that he arrogantly sent his troops into a sinkhole of carnage – a vicious, persistent insurgency – without the proper armor, equipment, backup or preparation.

The subdued defense chief further admitted that despite all the American kids who gave their lives in Mosul on the cusp of Christmas, battling an enemy they can’t see in a war fought over weapons that didn’t exist, we’re not heading toward the democratic halcyon Mr. Bush promised.

“I think looking for a peaceful Iraq after the elections would be a mistake,” Mr. Rumsfeld said.

His disgraceful admission that his condolence letters to the families of soldiers killed in Iraq were signed by machine – “I have directed that in the future I sign each letter,” he said in a Strangelovian statement – is redolent of the myopia that has led to the dystopia.

The Bushies are betting a lot on the January election, even though a Shiite-dominated government will further alienate the Sunnis – and even though Iraq may be run by an Iranian-influenced ayatollah. That would mean that Iraq would have a leadership legitimized by us to hate us.

International election observers say it’s too dangerous to actually come in and monitor the vote in person; they’re going to “assess” the vote from the safety of Amman, Jordan. Isn’t that like refereeing a football game while sitting in a downtown bar?

The administration hopes that once the Iraqis understand they have their own government, that will be a turning point and they will realize their country is worth fighting for. But this is the latest in a long list of turning points that turn out to be cul-de-sacs.

From the capture of Saddam to the departure of Paul Bremer and the assault on Falluja, there have been many false horizons for peace.

The U.S. military can’t even protect our troops when they’re eating lunch in a supposedly secure space – even after the Mosul base commanders had been warned of a “Beirut-style” attack three weeks before – because the Iraqi security forces and support staff have been infiltrated by insurgency spies.

Each milestone, each thing that is supposed to enable us to get some traction and change the basic dynamic in Iraq, comes and goes without the security getting any better. The Los Angeles Times reported yesterday that a major U.S. contractor, Contrack International Inc., had dropped out of the multibillion-dollar effort to rebuild Iraq, “raising new worries about the country’s growing violence and its effect on reconstruction.”

The Bush crowd thought it could get in, get out, scare the Iranians and Syrians, and remove the bulk of our forces within several months.

But now we’re in, and it’s the allies, contractors and election watchdogs who want out.

Aside from his scintilla of candor, Mr. Bush is still not leveling with us. As he said at his press conference on Monday, “the enemies of freedom” know that “a democratic Iraq will be a decisive blow to their ambitions because free people will never choose to live in tyranny.”

They may choose to live in a theocracy, though. Americans did.

E-mail: liberties@nytimes.com

Filed at 2:47 p.m. ET

BAGHDAD, Iraq (AP) — The suicide bomber believed to have blown himself up in a U.S. military dining tent near Mosul this week, killing more than 20 people, was probably wearing an Iraqi military uniform, the U.S. military said Thursday.

The top U.S. general in northern Iraq acknowledged that the bomber may have gotten through the vetting process conducted by U.S. and Iraqi authorities to check the backgrounds of Iraqis joining the security services.

Lt. Col. Paul Hastings, spokesman for Task Force Olympia in Mosul, said a general officer will be flying in from headquarters in Baghdad to take over the investigation into how the devastating attack on the base near Mosul was carried out. The FBI is also participating in the probe.

“He’ll initiate an investigation …then we will be in a better position to find out what happened,” Hastings said in a telephone interview.

The Ansar al-Sunnah Army, the military group that earlier claimed responsibility for the attack, issued a new statement reiterating that it was a suicide bombing.

“God enabled one of your martyr brothers to plunge into God’s enemies inside their forts, killing and injuring hundreds,” the group said in a statement posted on its Web site Thursday. “We don’t know how they can be so stupid that until now they have not figured out the type of the strike that hit them.”

The blast Tuesday was the deadliest single attack on a U.S. base, hitting the dining tent at lunchtime and killing 13 U.S. servicemembers, five American civilians, three Iraqi National Guard members, and one “unidentified non-U.S. person.” Military officials have said it’s not yet known whether that final death was the suicide bomber.

“From preliminary indications of the damage it looks like the guy (the suicide bomber) was wearing an Iraqi military uniform,” Hastings said, adding that it seemed like a “vest-type of explosive.”

Investigators had still not determined whether the attacker was working on the base or whether he had managed to infiltrate it, Hastings said.

Members of the Iraqi interim government’s fledgling security forces routinely operate with U.S. troops in operations against the insurgents. Until now, there have been no reports of serious tensions between the two.

Iraqi government officials said they knew nothing of the report that bomber may have been wearing a uniform. “This was an American declaration, we don’t know any thing about it, they did not contact us,” said Salih Sarhan, a spokesman for the Iraqi Defense Ministry.

In an interview with CNN, Brig. Gen. Carter F. Ham — commander of Task Force Olympia, the main U.S. force in northern Iraq — also reported the bomber was likely wearing an Iraqi uniform and said the attacker may have gotten through the vetting process run by U.S. and Iraqi authorities.

“The vetting process I think is sound, but clearly we have now at least one instance where that was likely not satisfactory. So we have to redouble our efforts there,” he said.

Ham said the bomber likely had help, though he did not say whether it was known if the bomber had accomplices in the camp.

“It is very difficult to conceive that this would be the act of a lone individual. It would seem to me reasonable to assume that this was a mission perhaps sometime in the planning, days perhaps,” he said.

Amid the investigation, the military is reassessing security at bases across Iraq in light of the bomber’s success in apparently slipping into the camp, entering a tent crowded with soldiers eating lunch and detonating his explosives.

The attack’s apparent sophistication indicated the bomber probably had inside knowledge of the base’s layout and the soldiers’ schedule.

Jeremy Redmon, a reporter from the Richmond Times-Dispatch embedded with troops at the Mosul base, said Iraqis working on the base show identification to get in to the base, but once inside move with relative freedom.

At the targeted dining hall “there was no security that I saw,” Redmon told CNN. He said that during the Muslim holy month of Ramadan — in October and November, when authorities had increased concern of attacks — civilians were screened as they entered “but that stopped after Ramadan.”

Reports earlier Thursday indicated that security had been boosted in at least several U.S. bases and other facilities following the suicide bombing.

Hastings said that armed guards were posted at the entrances and exits from dining halls and other communal areas at his base in northern Mosul.

Early Thursday, hundreds of U.S. troops, Iraqi National Guards and Kurdish militiamen were seen in the streets of Mosul moving around in Bradley Fighting vehicles. In some eastern neighborhoods they searched homes for weapons. One of the city’s five bridges over the Tigris River reopened Thursday, after all were blocked off by U.S. troops a day earlier.

Iraqi National Guards manned a checkpoint near another U.S. base, the former palace of Saddam Hussein, stopping passing cars and searching them.

AGHDAD, Iraq, Dec. 22 – A suicide attacker wearing a bomb-laden vest most likely set off the explosion at a military mess tent that killed 22 in the northern city of Mosul on Tuesday, American officials said Wednesday, raising the possibility that the bomber was an Iraqi or foreign worker employed at the base.

“At this point it looks like it was an improvised explosive device worn by an attacker,” Gen. Richard B. Myers, the chairman of the Joint Chiefs of Staff, said at a Pentagon news conference.

In the hours after the explosion, which included 14 American troops and four American civilian contractors among the dead, military officials speculated that the blast was caused by a rocket.

But F.B.I. and other allied forensic experts later discovered parts of a torso and an explosives belt that they believed were from a suicide bomber, according to a senior law enforcement official in Washington.

A senior defense official in Washington, speaking on condition of anonymity because the broader investigation is in progress, added that investigators found “material consistent with a backpack or suicide vest, as well as ball bearings,” which bombers have used to spread the devastation of the blast.

In the hours before the news conference, soldiers from at least two battalions in Mosul riding in armored vehicles fanned out in a broad offensive sweep to hunt for insurgent and terrorist leaders, shutting down bridges over the Tigris River, searching insurgent-friendly neighborhoods and interrogating drivers at impromptu checkpoints.

The governor of Nineveh Province also appeared on Mosul television to warn residents of a crackdown, though American officials maintained that it was not related to the bombing. The governor said anyone who tried to cross the bridges over the river, which bisects the city, would face a “hard punishment” that could include being shot.

Late on Wednesday, another car bomb killed 9 Iraqis and wounded 13 others at an Iraqi forces checkpoint at the entrance to the town of Latifiya, south of Baghdad, the National Guard told Reuters. That area is among the most violent and insecure as the country prepares for elections at the end of January.

The announcement on Wednesday of the likely cause of the Mosul attack produced a new source of concern by leaving a crucial question unanswered: How was the attacker able to infiltrate a heavily guarded military base in one of the most hostile regions of Iraq?

It also raised the possibility that one of the most commonly discussed fears of American soldiers stationed at forward operating bases in Iraq had come true – that an Iraqi or other foreign worker had been able through special access, knowledge and privileges to sabotage the troops he was supposed to be serving.

Other heavily guarded compounds have been infiltrated, including the main American governmental zone in Baghdad, where suicide bombers killed five people in October. But the attack on Tuesday far exceeded the size and devastation of any previous strike on American troops within a secured compound.

“I’ve been expecting it,” said Wayne Downing , a retired four-star Army general who headed the inquiry into the bombing at the Khobar Towers housing complex in Saudi Arabia in 1996. “They’re trying to get in. We have a terrible problem. We have all this indigenous labor. We don’t wash our dishes, cook our own food. When you bring indigenous laborers into camps, you immediately have a security problem.”

No Iraqis are currently working at the mess tent, said Wendy Hall, a spokeswoman for Halliburton, whose KBR subsidiary operates dining halls for the military. In an e-mail message, she said that vetting for employees who worked at the site was “conducted entirely by the United States Army, and KBR security escorts them through the process.”

Military officials had received intelligence that insurgents in Mosul might have been planning an attack on American troops. In late November, soldiers from the same base that was hit on Monday – Forward Operating Base Marez – detained a suspect in western Mosul carrying what military officials said appeared to be notes of a meeting where insurgents discussed a proposal for a large-scale attack on American troops.

At the news conference on Wednesday, Defense Secretary Donald H. Rumsfeld, emphasized the difficulty American troops faced defending against suicide bombers.

“Someone who’s attacking can attack at any place at any time using any technique, and it is an enormous challenge to provide force protection, something that our forces worry about, work on constantly,” Mr. Rumsfeld said.

The militant Sunni group that took credit for the attack, Ansar al-Sunna, said that that one of its members carried out a “martyrdom operation” against forces it described as infidels and occupiers.

The finding that the explosion was probably caused by a suicide bomber was first reported by ABC News.

Investigators say the bomb appeared to have been laced with ball bearings or similar projectiles that punctured steel appliances and other surfaces near the blast, which occurred near the serving line.

The Marez base is home to about 3,500 troops, most of them attached to the Stryker Brigade Combat Team, based in Fort Lewis, Wash.

Initially, the military had said that as many as 19 American service members and 5 others had perished in the explosion. But by Wednesday afternoon they had reduced the death toll to 14 United States troops, 4 American civilians, 3 Iraqi national guardsmen, and an unidentified person from outside the United States.

Sixty-nine people were wounded. Twenty-five of them were treated and released Tuesday, and many of the more seriously injured were sent to Landstuhl Army Medical Center in Germany.

[The military said on Thursday that the wounded being treated at Landstuhl - a total of 35 people - were all expected to survive, the Associated Press reported. The patients were suffering from a range of injuries including abdominal and shrapnel injuries, broken bones and burns.]

Senior military officials said Wednesday that the Pentagon had been examining ways to better protect soldiers at forward bases.

With dozens of bases, small and large, scattered around Iraq, and many in the center of the country where the insurgency is most active, the military is under growing pressure to extend its patrols. At the same time, it must continue to guard against infiltrators, possibly among the thousands of Iraqis who work inside the bases.

“We have been looking at force protection parameters not only for dining facilities but for other places we have our large gatherings,” Lt. Gen. Thomas Metz, the ground commander in Iraq, told CNN.

Identification checks of people entering mess halls are spotty at many forward bases. But many mess halls already forbid anyone from entering with backpacks or bags.

Military officials were loath to describe the precautions in detail. “At every level of command constant assessments are made on status of force protection and what the vulnerabilities are and how to mitigate them,” said Lt. Col. Daniel Baggio, a military spokesman.

Richard A. Oppel Jr. reported from Baghdad for this article, and Eric Schmitt from Washington. David Johnston contributed reporting from Washington.