Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Bad4U?
- Robert G. Newcombe (21 December 2001)
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Havn't you neglected a possibility?
- Izhar Ben-Shlomo (22 December 2001)
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Another possibility
- Frank (Yeruham) Leavitt (24 December 2001)
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Surprise, surprise, stress can kill!
- Stephen J Palmer (28 December 2001)
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What's in a Word?
- Roman B. Worobec (3 January 2002)
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What about the good days?
- John H. Glaser, Lexington, MA 02421 USA (25 January 2002)
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Hound of the Baskervilles: Natural or statistical experiment?
- Georgios L. Argyrakos (5 June 2005)
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Robert G. Newcombe, Senior Lecturer in Medical Statistics University of Wales College of Medicine, Cardiff CF14 4XN.
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In a large observational study David Phillips and co-workers note an increase in cardiac mortality on the 4th of the month among Chinese and Japanese Americans, which does not occur in white matched controls. This increase is particularly marked for inpatient deaths from chronic heart disease in California (figure 3). They link this observation to their cultural-linguistic association of the number 4 with death. This effect may well be real, but some important issues remain unaddressed. The authors have addressed a hypothesis which to them clearly relates to one specific day. To be really convincing, we need to be sure that the day 4 mortality really should be regarded as an outlier, relative to other dates, and this is not the foregone conclusion that might be supposed. Directly from figure 3, the most extreme part of the data, the 95% confidence interval for day 4 mortality overlaps the intervals for most of the other dates. Moreover, the relevant rate ratios, 1.07 for all cardiac deaths, 1.13 for chronic heart diseases, and 1.27 restricted to California, are presented with ordinary 95% confidence intervals, but no p-values, in accordance with normal BMJ policy. However, the one situation in which p-values are more directly informative than the corresponding confidence intervals is when we are trying to assess whether a striking observation might be merely a coincidence. For cardiac mortality as a whole, the log rate ratio appears to be 0.068, with standard error 0.021, and z=3.17, p=0.0015. (These figures are reconstructed from the heavily rounded ones given, and hence are only a crude approximation.) While a p-value of 0.0015 seems fairly extreme, this relies heavily on starting with the hypothesis that it is the 4th of the month that is different. A more conservative (i.e. more convincing to sceptics) p-value involves a Bonferroni correction by a factor of 28 (the number of days studied, which are common to all months), giving 0.043, which though technically statistically significant is far from extraordinary. It is true that when a similar process is applied to the more extreme rate ratios of 1.13 and 1.27 above, they remain highly significant. But it is commonly found that by restricting attention to subgroups of the data, one can enhance the nominal statistical significance in this way. It is far from clear whether it was a prior hypothesis that this effect would be much more marked in California than elsewhere. The hypothesis set out by Phillips et al relates exclusively to cardiac mortality, which conveniently squares with both the data presented here and the Baskerville link. But if stress associated with this date is so devastating to Chinese and Japanese, one would expect there would be a marked effect on accidental and suicide deaths also, which do not appear to have been examined. |
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Izhar Ben-Shlomo, Visiting Researcher Laboratory for Reproductive Biology, Dept. Ob/Gyn, Stanford Medical School, Stanford CA
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In their briliant observation Phillips et al. documented an association of higher rate of mortality from heart diseases in Chinese and Japanese Americans during the 4th of every month. In their introduction they refer to the traditional Chinese and Japanese "superstitious" affect towards it. Philosophically, if not practically, one can not rule out the possibility that the accumulating experience of these two large nations gave solid reason to this belief. What if indeed some constituting, traumatic events in the history of these nations took place on the fourth of a given calender and the collective memory later perpetuated and reinforced the effect. |
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Frank (Yeruham) Leavitt, Chairman, Centre for Asian and International Bioethics, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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Another alternative, similar but different to ben Shlomo's, is as follows. Philips and colleagues say: "It is unlikely that the fourth day is objectively more hazardous than the six days surrounding it because no increased mortality on the fourth was found in white controls." But in these days of genetic medicine, the hypothesis might have been considered that perhaps the fourth day is objectively more hazardous to Japanese and to Chinese than to Europeans. A further point which is difficult for me to understand as a Jew, is that all dates with respect to which my people have religious or folk beliefs about being unlucky or lucky or whatever, are dates in the Jewish traditional lunar calendar. The Japanese and the Chinese also have traditional calendars. It is surprising that they should have any beliefs whatsoever about the fourth day of the Gregorian month. |
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Stephen J Palmer, Director, Centre for Stress Management; Vist. Prof. of Work Based Learning & Stress Management NCWBP SE3 7DH
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Although a number of methodological issues should be considered regarding this research paper, overall, if the findings are accurate, then they probably do not surprise anybody. If we ask any member of the public for their view, we are likely to receive the response, 'Of course unlucky days are stressful'. Perhaps the most important issue to have been raised by these findings is that health practitioners may need to take beliefs and superstitions into account when treating patients. |
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Roman B. Worobec, Team Leader, Med. Sci. & Biotech. Team Library of Congress, Washington, DC 20540, USA
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To: The Editor What's in a Word? Phillips et al. reported elevated cardiac mortality on the 4th day of the month for Chinese and Japanese Americans as a group, which may be related to cultural ambiguity about number 4 because the words 4 and death are homonyms. An interesting corollary might be whether this also applies to the 4th hour (am/pm) and/or the 4th month of the year? The Japanese language, however, has four alternative pronunciations for 4 that are not homonymic--more accurately, homophonic--with death. Accordingly, some Japanese practice linguistic "prevention" by avoiding the anxiety-laden term insofar as possible. The Mandarin and Cantonese speakers, apparently, have no such option. It might, therefore, be of interest to ascertain whether there is a difference between the Chinese and Japanese patients in terms of day 4 mortality. One of the responders raised the interesting issue of Gregorian vs. traditional calendars. It would seem, at a guess, that if the negative connotation is tied to the number 4 alone, the nature of the calendar would be immaterial. Sincerely, RB Worobec
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John H. Glaser, Data Analysis Consultant 4 Woodpark Circle, Lexington, MA 02421 USA
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Editor--Phillips et al have uncovered a fascinating relationship between the day of the month and the mortality rate for Chinese-Americans and Japanese-Americans. There clearly is an increase in chronic heart disease deaths of Chinese and Japanese on the fourth day of the month. The authors attribute this to the similarity in the Chinese and Japanese languages of the spoken words "death" and "four." Have the authors considered whether days with a pleasurable association might have a beneficial impact? Their analysis shows a decrease in mortality for Chinese and Japanese on days twenty, twenty-six, and possibly day twelve. Is there any resemblance, either spoken or pictorially, between the words for those days and words evoking feelings of relaxation, wellness, or happiness? John H. Glaser
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Georgios L. Argyrakos, Agronomist, Ministry of Agric. Development Athens, Greece
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In their paper “Psychology and survival” (The Lancet, 1993, vol. 342, pp. 1142-1145) Phillips et al. examined the correlation between year of birth and survival (average age of death, AAD) of Chinese Americans who died of cancer, heart diseases and pulmonary diseases. They found that the birth year of “fire” (years ending in 6 or 7), which is “bad” for heart, does not make a significant change in AAD in the case of chronic ischaemic heart disease (drop by only 0.14 years) but is more significant in acute myocardial infarction (drop by 1.22 years), while in “all other heart diseases” the AAD increases by 0.67 years. Questions: - Why does “bad” birth year not have a significant psychosomatic effect in chronic heart diseases while the number of the day has? An interesting statistical problem would be to superimpose the two effects, i.e. birth year and day number. No question, any chinese astrologist has the answer. - Have the authors studied the effect of “Day 4” on other sources of death (cancer etc)? Also, in case that the birth year counts in the Baskerville effect, some correction may be needed in this study, because the studied period of 1973 – 1998 includes three pairs of “bad heart” years (1976-’77, ’86- ’87 and ’96-’97), three pairs of “bad liver” years, two and half pairs of “bad tumour” years and two pairs of “bad lungs” years. I mean, that period was (astrologically) worse for heart than for lungs. George Argyrakos
Competing interests: None declared |
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