tag:theconversation.com,2011:/global/topics/death-rates-25337/articlesDeath rates – The Conversation2024-03-18T12:23:59Ztag:theconversation.com,2011:article/2251532024-03-18T12:23:59Z2024-03-18T12:23:59ZBiden and Trump, though old, are both likely to survive to the end of the next president’s term, demographers explain<figure><img src="https://images.theconversation.com/files/581396/original/file-20240312-16-ug5e1v.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C4247%2C2965&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Both Joe Biden and Donald Trump are nearly twice the median age of the U.S. population.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Election2024ChinaUnitedStates/46152c599dd14340abc0595fca447682/photo">AP Photo</a></span></figcaption></figure><p><a href="https://poll.qu.edu/poll-release?releaseid=3890">In a recent poll</a>, 67% of Americans surveyed believe that President Joe Biden, 81, is too old to serve another term as president. But only 41% of respondents said they feel that way about former President Donald Trump, who is 77. Both men have stumbled around and have forgotten or mixed up names and events, <a href="https://www.nia.nih.gov/health/memory-loss-and-forgetfulness/memory-problems-forgetfulness-and-aging">which are behaviors that characterize some older people</a>.</p>
<p><a href="https://scholar.google.com/citations?user=jAfhO2YAAAAJ&hl=en">We</a> are <a href="https://scholar.google.com/citations?user=OBIxsGQAAAAJ&hl=en">demographers</a> – not <a href="https://www.salon.com/2024/02/23/dr-john-gartner-on-a-tale-of-two-brains-bidens-brain-is-aging-brain-is-dementing/">scholars of brain function</a> considering people’s cognitive abilities. But there is a question we can answer, one that speaks to concerns about both men’s ages: their life expectancy.</p>
<p>And it turns out that the four-year age difference between Biden and Trump isn’t really much of a difference when it comes to their respective odds of surviving. The statistical odds are good that both would complete a four-year term as president.</p>
<p>We know this because of one of the most versatile <a href="https://www.cambridge.org/core/books/population-and-society/5D47EB8139ED72FD59F7379F7D41B4FB">tools of demography</a>, which is called a life table. It’s a table of age groups, usually from 0 to 100 years, showing the <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf#page=14">percentages of the population at any age</a> surviving to a later age. It is based on the age-specific death rates of the population.</p>
<h2>Early record-keeping</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A table of figures representing births and deaths." src="https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=716&fit=crop&dpr=1 600w, https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=716&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=716&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=899&fit=crop&dpr=1 754w, https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=899&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/581391/original/file-20240312-28-kj30q1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=899&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A bill of mortality for 1605 and 1606, by John Graunt, an early version of what is now known as a life table.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Bill_of_Mortality_1606.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The life table dates back to <a href="https://www.britannica.com/biography/John-Graunt">John Graunt, a self-educated citizen of London</a> in the 17th century who is known by many as the <a href="https://www.cambridge.org/core/books/abs/population-and-society/references/35C31BCEC27E2B0448B160414E1893BF">founder of demography</a>. <a href="https://www.jstor.org/stable/41138862">In 1662, Graunt produced and distributed the first life table</a>, showing the probabilities of London’s population surviving from one age to the next.</p>
<p>There are two kinds of life tables. The first is a cohort life table, which represents the death rates and ages for a specific group of people. A cohort table could, for example, document the deaths of all males born in the U.S. in 1940. That table would be very precise, but it wouldn’t be complete until every member of the group had died – so it’s not especially useful for examining the prospects of the living.</p>
<p>As a result, demographers more often use life tables for a current time period, such as the year 2021, which is the date of the most <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf">current period life table for the U.S.</a></p>
<p>It shows the probabilities of surviving from one age to another age based on the death rates in 2021. </p>
<h2>Statistical documentation</h2>
<p><a href="https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf">A period life table for 2021</a> indicates that almost 99% of all people born in the U.S. survive from age 0 to age 20; just over 95% of them survive to age 40, and over 85% to age 60. More than 51% of them live to age 80.</p>
<p>But life tables get much more specific. It’s important to examine life tables’ data for each age, race and gender combination. This is because males don’t live as long as females, Black people don’t live as long as white people, and non-Hispanic people don’t live as long as Hispanic people. There are more specialized life tables that focus on education level and income, but they are not as current and complete as the broader tables.</p>
<p>Biden and Trump are both non-Hispanic white men. Biden is 81 and Trump is 77.</p>
<p>Based on the age-specific death rates of non-Hispanic white men in the U.S. in 2021, Biden has a 92.9% probability of surviving at least to age 82. Trump has a 95.1% probability of surviving to at least age 78. These odds are nearly identical, so each man is very likely to be alive on Inauguration Day 2025, regardless of which of them is being sworn in as president.</p>
<p>What about finishing out that four-year term? <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf#page=47">Our calculations from the life tables</a> reveal that there is a 63.3% probability that Biden will survive another five years – to at least 86. And there is a 73.6% probability for Trump to survive that period – to at least age 82. Of course, it’s possible either or both will die, but their odds of death are much lower than their odds of survival.</p>
<p>In general, the chances are a bit more favorable for Trump, because he is slightly younger.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A table of figures showing how many people of one age survive to a future age." src="https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=297&fit=crop&dpr=1 600w, https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=297&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=297&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=373&fit=crop&dpr=1 754w, https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=373&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/581097/original/file-20240311-20-hc2ous.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=373&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The 2021 life table for the U.S. is the most recent available.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf#page=10">U.S. Centers for Disease Control and Prevention</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Precise calculations</h2>
<p>There are two factors that let us demographers get even more specific. </p>
<p>First, we measure age as exact years. Their age gap is not four years, but 3.5: <a href="https://www.whitehousehistory.org/bios/joseph-r-biden-jr">Biden was born on Nov. 20, 1942</a>, and <a href="https://www.whitehousehistory.org/bios/donald-j-trump">Trump on June 14, 1946</a>. That 10 percentage-point survival advantage for Trump over Biden was based on a four-year age difference. The real difference drops one or two points because they’re not quite so far apart in age.</p>
<p>Second, demographers have shown that <a href="https://doi.org/10.2307/2648114">people who attend church regularly live longer</a> than those who don’t. This is not because of some divine favor but because churchgoers tend to have more optimistic attitudes, clearer senses of purpose and more regular social interactions and connections. All of these factors extend people’s lives. Biden is a Catholic and <a href="https://www.reuters.com/article/idUSKBN2AC1X6/">attends Mass weekly, in general</a>. Trump was raised as a Presbyterian but now considers himself to be a “<a href="https://www.deseret.com/2023/10/22/23922731/biden-trump-faith-and-presidential-candidates/">nondenominational Christian</a>,” and he attends religious services very irregularly. So, Biden gets the survival advantage associated with churchgoing. </p>
<p>Other factors come into play with longevity as well, such as marital status, <a href="https://doi.org/10.1007/978-3-031-10936-2">body mass index scores</a>, diets and levels of physical fitness and exercise. </p>
<h2>A comparison with the American people</h2>
<p>Biden and Trump are <a href="https://theconversation.com/candidates-aging-brains-are-factors-in-the-presidential-race-4-essential-reads-223419">two of the three oldest people</a> ever to serve as president. The population they are seeking to lead is also older than ever before.</p>
<p>The median age of the nation’s population was <a href="https://www.census.gov/newsroom/press-releases/2023/population-estimates-characteristics.html">38.9 in 2022</a> compared with <a href="https://www.census.gov/library/publications/1972/dec/pc-s1-10.html">28.1 in 1970</a> and just <a href="https://www2.census.gov/programs-surveys/decennial/2000/phc/phc-t-09/tab07.pdf">16.7 in 1820</a>. </p>
<p>“<a href="https://www.nytimes.com/2024/03/06/opinion/biden-aging-america-population.html">Relative to the age of the population</a>, President Biden is no older than the country’s first presidents,” including Thomas Jefferson, wrote James Chappel, a scholar of aging and history at Duke University, in The New York Times. More recently, Reagan was older than the median American of his time than Biden and Trump are today.</p>
<p>At their second inaugurations, Jefferson was roughly 45 years older than the median age of the U.S. population then, and Reagan 43 years older. If Biden wins a second term, he will be 42 years older than today’s median. If Trump wins in 2024, he will be 38 years older than the current median. </p>
<p>As demographers, we can say it is likely that both Biden and Trump will be alive when the presidential term that begins in 2025 comes to an end in 2029. But as the U.S. population gets older too, the age factor may become less important to voters. This is not an immediate change, however, but one that will likely occur over the next decade or so.</p><img src="https://counter.theconversation.com/content/225153/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Detailed data on the ages at which people die can give good indications of a person’s remaining life span.Dudley L. Poston Jr., Professor of Sociology, Texas A&M UniversityRogelio Sáenz, Professor of Demography, The University of Texas at San AntonioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2046222023-06-13T12:29:56Z2023-06-13T12:29:56ZAnnual numbers of excess deaths in the US relative to other developed countries are growing at an alarming rate<figure><img src="https://images.theconversation.com/files/527599/original/file-20230522-14385-h3se2w.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5100%2C3802&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Homicides and the opioid epidemic both contribute to the rising U.S. death rates.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/people-at-a-funeral-royalty-free-image/104302939?phrase=U.S.+cemetery&adppopup=true">Rubber Ball Productions/Brand X Pictures via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>People in the U.S. are dying at higher rates than in other similar high-income countries, and that difference is only growing. That’s the key finding of a <a href="https://doi.org/10.1371/journal.pone.0283153">new study that I published</a> in the journal PLOS One.</p>
<p>In 2021, more than 892,000 of the 3,456,000 deaths the U.S. experienced, or about 1 in 4, were “<a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm#">excess deaths</a>.” In 2019, that number was 483,000 deaths, or nearly 1 in 6. That represents an 84.9% increase in excess deaths in the U.S. between 2019 and 2021. </p>
<p>Excess deaths refer to the actual number of deaths that occur in a given year compared with expected deaths over that same time period based on prior years or, as in this study, in other countries.</p>
<p>In my study, I compared the number of U.S. deaths with those in the five largest countries in Western Europe: England and Wales, France, Germany, Italy and Spain. Those five countries make for a good comparison because they are nearly, if not quite, as wealthy as the U.S. and their combined population is similar in size and diversity to the U.S. population.</p>
<p>I also chose those countries because they were used in an earlier study from another research team that documented a <a href="https://doi.org/10.1073/pnas.2024850118">34.5% increase in excess deaths</a> in the U.S. between 2000 and 2017. </p>
<p>The acceleration of this already alarming long-term trend in excess deaths in the U.S. was exacerbated by the fact that the U.S. experienced higher death rates from COVID-19 <a href="https://doi.org/10.1136/bmj.n1343">compared with similar countries</a>. However, <a href="https://theconversation.com/279-700-extra-deaths-in-the-us-so-far-in-this-pandemic-year-147887">COVID-19 alone does not account</a> for the recent increase in the number of excess deaths in the U.S. relative to comparison countries.</p>
<h2>Why it matters</h2>
<p>Rising living standards and medical advances through the 20th century have made it possible for people in wealthy countries to live longer and <a href="https://doi.org/10.1257/jep.20.3.97">with a better quality of life</a>. Given that the U.S. is the largest economic power in the world, with cutting-edge medical technology, Americans should have an advantage over other countries in terms of life span and death rates.</p>
<p>But in the last 50 years, many countries around the world have outpaced the U.S. in how fast death rates are declining, as revealed by <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220831.htm#">trends in life expectancy</a>.</p>
<p>Life expectancy is an average age at death, and it represents how long an average person is expected to live if current death rates remain unchanged throughout that person’s lifetime. Life expectancy is based on a complex combination of death rates at different ages, but in short, when death rates decline, life expectancy increases. </p>
<p><iframe id="6Jigb" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/6Jigb/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Compared to about 20 other high-income countries, since around the mid-1970s <a href="https://www.npr.org/sections/health-shots/2023/03/25/1164819944/live-free-and-die-the-sad-state-of-u-s-life-expectancy#">the U.S. life expectancy</a> has been <a href="https://doi.org/10.17226/13497">slipping from about the middle, or median, to the lowest rungs</a> of life expectancy. So the relative stagnation in life expectancy in the U.S. compared with other countries is directly related to the fact that death rates have also declined more slowly in the U.S.</p>
<p>The U.S. has higher death rates than its peer countries due to a variety of causes.
Cardiovascular disease prevalence has been an <a href="https://doi.org/10.1161/CIRCRESAHA.116.309115">important driver of life expectancy changes across the globe</a> in recent decades. But while death rates from cardiovascular disease have continued to decline in other parts of the world, those <a href="https://doi.org/10.1073/pnas.1920391117">rates have stagnated in the U.S.</a>. </p>
<p>A key reason for this trend is the <a href="https://doi.org/10.1073/pnas.1716802115">rise in obesity</a>, as research shows that <a href="https://doi.org/10.1161/CIR.0000000000000973">obesity increases the risk of death from cardiovascular disease</a>. High prevalence of obesity in the U.S. also likely contributed to the <a href="https://doi.org/10.1136/bmj.n1343">relatively high death rates from COVID-19</a>. </p>
<p>Another cause is that the U.S. has disproportionately high death rates from intentional injuries in the form of homicides, <a href="https://doi.org/10.1097/TA.0b013e3181dbaddf">in particular those caused by firearms</a>. Moreover, it also has high death rates from unintentional injuries, <a href="https://doi.org/10.1111/padr.12228">in particular drug overdoses</a>. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/lmxF2owm3Gg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People are being exposed to fentanyl without knowing it, and because the synthetic opioid is so highly potent, people are dying in unprecedented numbers.</span></figcaption>
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<h2>What other research is being done</h2>
<p>While these specific causes of deaths should clearly be health policy priorities today, there might be more fundamental causes to the elevated U.S. death rates. </p>
<p>In the early 1990s, young people in the U.S. between the ages of 15 and 34 were already dying at <a href="https://doi.org/10.1016/S1054-139X(01)00329-9">higher rates than their peers in other countries</a> from a combination of homicides, unintentional injuries – in large part from motor vehicle accidents – and <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/">deaths from HIV/AIDS</a>. </p>
<p>Research is underway to understand the more <a href="https://doi.org/10.1097/PHH.0000000000001626">fundamental societal causes</a> that may explain the vulnerability of the U.S. population to successive epidemics, from HIV/AIDS and COVID-19 to gun violence and opioid overdoses. </p>
<p>These <a href="https://doi.org/10.1073/pnas.2014750117">include racial</a> and <a href="https://doi.org/10.2105/AJPH.2008.139469">economic inequalities</a>, which combined with a weaker social security net and lack of health care access for all may help explain larger health and death disparities compared to European countries.</p><img src="https://counter.theconversation.com/content/204622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Heuveline does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows that preventable deaths are increasing in the US at the same time that life expectancy keeps dropping.Patrick Heuveline, Professor of Sociology, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1572702021-03-22T16:06:39Z2021-03-22T16:06:39ZCOVID-19: why are people with learning disabilities at greater risk?<p>When it comes to <a href="https://www.mencap.org.uk/learning-disability-explained">people with learning disabilities</a> and COVID-19, the statistics are damning. In the UK, people with learning disabilities are at least four times more likely to die from the disease than the general population, according to a <a href="https://www.gov.uk/government/news/people-with-learning-disabilities-had-higher-death-rate-from-covid-19">government report from November 2020</a>, a death rate that the researchers estimate could in reality be as high as six times more likely. </p>
<p>This overall figure hides even greater disparities among different age groups. During the first lockdown, the death rate for people with learning disabilities aged between 18 and 30 was 30 times higher than those of their non-learning-disabled peers. Even more concerning: a report from the charity Mencap found that <a href="https://www.mencap.org.uk/press-release/eight-10-deaths-people-learning-disability-are-covid-related-inequality-soars">80% of all deaths of people with learning disabilities</a> in the past year were related to coronavirus. </p>
<p>The government report suggests some possible reasons for this. They cite some of the intrinsic challenges that come with living with a learning disability, such as having a higher risk of health conditions like diabetes, being more likely to live in group accommodation or care homes, finding it difficult to socially distance if living in the community and being dependent on home care for day-to-day support. </p>
<p>Another <a href="https://www.cambridge.org/core/journals/bjpsych-open/article/covid19-deaths-in-people-with-intellectual-disability-in-the-uk-and-ireland-descriptive-study/86F8AC26107B8CDA18EA09146B7C762D">small study</a> has found that risks appeared to be higher for those with moderate to profound learning disabilities and other conditions, including epilepsy, mental ill-health, Down’s syndrome and dementia. </p>
<p>But we would caution against relying on simple medical explanations, which could inadvertently perpetuate stereotypes about this group – that they are unwell, vulnerable and in need of “care”. Instead, we need a broader discussion about the causes of this deadly inequality. </p>
<p>We have to consider therefore, the way society views people who do not fit into a narrow view of “normal”, which defines what it is to be human as exclusively non-disabled. This way of thinking makes it harder to create a society that plans for the needs, choices and rights of all of its members. </p>
<p>Throughout the pandemic, we feel there has been a significant lack of consideration given to the needs of people with learning disabilities. </p>
<p>This was made clear in the case of Jo Whiley’s sister, Frances. In February, Jo, a broadcaster with the BBC, <a href="https://www.telegraph.co.uk/women/life/could-give-sister-vaccine-helping-hands/?WT.mc_id=tmgliveapp_iosshare_AwtJb4fqycfj">publicly questioned</a> why she had been offered a COVID vaccine when her sister Frances, who has learning disabilities, had not. Following this, Frances contracted COVID-19 and spent several days in hospital where she became very unwell. </p>
<p>While Frances was in hospital, Jo was <a href="https://twitter.com/jowhiley/status/1362606967760580611">forced to turn to Twitter</a> to ask for help with how to encourage her sister to wear an oxygen mask. It is shocking to us that these sort of issues were still arising one year into the pandemic, given the high numbers of people with learning difficulties who had contracted COVID and who would thus need oxygen like any other patient. </p>
<p>Frances has thankfully now been <a href="https://www.bbc.com/news/uk-england-northamptonshire-56175627">discharged from hospital</a> and Jo’s public advocacy, alongside concerns raised by parents and campaign groups, has led the English government to move <a href="https://www.theguardian.com/world/2021/feb/24/people-with-learning-disabilities-should-be-prioritised-for-covid-vaccines-says-jcvi">all people who are on a GP register for learning disabilities</a> up the priority list for vaccination. </p>
<h2>A history of health inequality</h2>
<p>We may be in exceptional circumstances due to COVID-19, but concerns about the quality of care that people with learning disabilities receive are not new, nor are high death rates among this group. </p>
<p>In 2019, the NHS published a <a href="https://www.england.nhs.uk/wp-content/uploads/2019/05/action-from-learning.pdf">report</a> investigating the deaths of more than 1,000 people with learning disabilities from 2016-2018. The report found that the median age of death for men with a learning disability was 60 compared to 83 for men in the general population. The median age of death for women with a learning disability was 59 compared to 86. </p>
<p>In 2007, a Mencap report, <a href="https://www.basw.co.uk/system/files/resources/basw_121542-4_0.pdf">Death by Indifference</a> had raised concerns about discriminatory attitudes to people with learning disabilities using health care services. In 2012, Mencap documented further significant concerns about the <a href="https://www.mencap.org.uk/sites/default/files/2016-08/Death%20by%20Indifference%20-%2074%20deaths%20and%20counting.pdf">disproportionate numbers of deaths</a> of patients with learning disabilities in hospitals. They argued that the NHS was continuing to fail these patients in terms of basic care, poor communication, delayed diagnosis, and poor adherence to the principles underpinning the Mental Capacity Act. </p>
<p>All this shows a distinct lack of progress, and that early deaths of people with learning disabilities are often unnecessary and avoidable. This is one possible explanation that should be considered when asking why they have a higher COVID death rate.</p>
<p>While celebrity-driven campaigns can make change happen, we need to make a long-term difference. This includes a commitment to listen to people with learning disabilities, seeing their lives as valuable and fulfilling like any other citizen, and working collaboratively to address social exclusion, poor healthcare provision and continued marginalisation beyond the pandemic.</p><img src="https://counter.theconversation.com/content/157270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Finch is a member of the Labour Party, UCU and BASW</span></em></p><p class="fine-print"><em><span>Janet Hoskin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This group has long suffered much higher death rates than the general population due to a poor standard of basic healthcare.Jo Finch, Deputy Director of the Centre for Social Work Research, University of East LondonJanet Hoskin, Senior Lecturer, School of Education and Communities, University of East LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1478872020-10-14T18:39:28Z2020-10-14T18:39:28Z279,700 extra deaths in the US so far in this pandemic year<figure><img src="https://images.theconversation.com/files/363226/original/file-20201013-19-z893ga.jpg?ixlib=rb-1.1.0&rect=4%2C148%2C2896%2C1845&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A girl views the body of her father, who died of COVID-19, while mourners who can't visit in person are onscreen.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/asare-amaya-10-mourns-for-her-father-german-amaya-as-family-news-photo/1264729066">Joe Raedle/Getty Images News via Getty Images</a></span></figcaption></figure><figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="279,700 extra deaths in the U.S. in 2020 through end of September" src="https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363501/original/file-20201014-13-8n3bbb.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>The number of deaths in the United States through September 2020 is at least 10% and likely 13% higher than it would have been if the coronavirus pandemic had never happened, according to Centers for Disease Control and Prevention data. Conservatively, that’s at least 224,173 deaths and probably as many as 279,700 deaths above what was expected, just for the first nine months of the year. That’s 24,000 to 79,000 extra fatalities above the number of deaths <a href="https://www.cdc.gov/nchs/nvss/vsrr/COVID19/index.htm">attributed to COVID-19</a>.</p>
<h2>Tracking deaths</h2>
<p>When someone dies, the death certificate records an immediate cause of death, along with up to three underlying conditions that “<a href="https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf">initiated the events resulting in death</a>.” The certificate is filed with the local health department, and the details are reported to the <a href="https://www.cdc.gov/nchs/index.htm">National Center for Health Statistics</a>. </p>
<p>As part of the <a href="https://www.cdc.gov/nchs/nvss/index.htm">National Vital Statistics System</a>, the National Center for Health Statistics then uses this information in various ways, such as tabulating the <a href="https://www.cdc.gov/nchs/nvss/leading-causes-of-death.htm">leading causes of death</a> in the United States. <a href="https://www.cdc.gov/nchs/fastats/deaths.htm">Currently, heart disease</a> is the leading cause of death, followed by cancer. COVID-19 is now the <a href="https://theconversation.com/how-deadly-is-covid-19-a-biostatistician-explores-the-question-142253">third-largest cause of death</a> for 2020. </p>
<h2>Projecting from the past</h2>
<p>To calculate excess deaths requires a comparison to what would have occurred if COVID-19 had not existed. Obviously, it’s not possible to observe what didn’t happen, but it is possible to estimate it using historical data. The CDC does this using a <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm">statistical model</a> based on the previous three years of mortality data, incorporating seasonal trends as well as adjustments for data-reporting delays. </p>
<p>So, looking at what happened over the past three years, the CDC projects what might have been. By using a statistical model, they are also able to calculate the uncertainty in their estimates. That allows <a href="https://scholar.google.com/citations?user=kWGF578AAAAJ&hl=en&oi=ao">statisticians like me</a> to assess whether the observed number of deaths looks unusual compared to what we expect to see.</p>
<p><iframe id="LWq2f" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/LWq2f/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The number of excess deaths is the difference between the model’s projections and the actual observations. Through September, that gives 279,700 deaths above what was expected. The CDC also calculates an upper threshold for the estimated number of deaths to help determine when the observed number of deaths is unquestionably high compared to historical trends. Even using that threshold as a very conservative standard means there were at least 224,173 excess deaths.</p>
<p><a href="https://datawrapper.dwcdn.net/LWq2f/6/">Clearly visible in a graph</a> of this data is the spike in deaths beginning in mid-March 2020 and continuing to the present. You can also see another period of excess deaths from December 2017 to January 2018, attributable to an <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">unusually virulent flu strain that season</a>.</p>
<p>The magnitude of the excess deaths in 2020 makes clear that COVID-19 is much worse than influenza, even when compared to a bad flu year like 2017-18, when an estimated <a href="https://www.cdc.gov/flu/about/burden/past-seasons.html">61,000 people in the U.S. died</a> of the illness.</p>
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<p>The large spike in deaths in April 2020 corresponds to the coronavirus outbreak in the Northeast, after which the number of excess deaths decreased regularly and substantially until July, when it started to increase again. That uptick in excess deaths is attributable to the outbreaks in the South and West that occurred over the summer.</p>
<h2>The data tell the story</h2>
<p>It doesn’t take a sophisticated statistical model to see that the coronavirus pandemic is causing substantially more deaths than would have otherwise occurred. Mortality in 2020 is clearly different from the previous years’ regular patterns, with substantial increases and unusual trends.</p>
<p>The number of deaths the CDC officially attributed to COVID-19 in the United States <a href="https://www.cdc.gov/nchs/nvss/vsrr/COVID19/index.htm">was 200,499</a> through Oct. 3. </p>
<p>Some people who are skeptical about the impact of the coronavirus suggest these deaths would have occurred anyway, perhaps because COVID-19 is particularly deadly for the elderly. Others believe that, because the pandemic has changed life so drastically, the increase in COVID-19-related deaths is probably offset by decreases from other causes. But neither of these theories is true.</p>
<p>In fact, the number of excess deaths in the U.S. currently exceeds the number attributable to COVID-19 by at least 23,674 and likely up to 79,201. What’s behind those additional deaths is <a href="https://doi.org/10.1001/jama.2020.11787">not yet clear</a>. It could be that COVID-19 deaths are being undercounted, or the pandemic could also be causing an increasing number of deaths due to other causes. What we are starting to learn is that it is probably some of both.</p>
<p>A recent study in the Journal of the American Medical Association found that COVID-19 was documented as a cause of death <a href="https://doi.org/10.1001/jama.2020.19545">in 67% of excess deaths</a> between March and July in the U.S. But the researchers also identified increased mortality rates due to heart disease, as well as two spikes for deaths related to Alzheimer’s disease/dementia. Some people are <a href="https://theconversation.com/i-thought-i-could-wait-this-out-fearing-coronavirus-patients-delayed-hospital-visits-putting-health-and-lives-at-risk-137965">delaying medical treatments for fear</a> of getting infected with the coronavirus.</p>
<p>Another JAMA study found that the 2020 <a href="https://doi.org/10.1001/jama.2020.20717">excess death rate is higher in the U.S.</a> than in other countries hard-hit by COVID-19. That difference is likely the result of multiple factors, including inconsistent public health guidance, a decentralized and sometimes conflicting governmental response, and disruptions triggered by the pandemic.</p>
<p>Regardless of the reasons, this pandemic has resulted in substantially more deaths than would have otherwise occurred – and it is not over yet.</p>
<p><em>This is an updated version of <a href="https://theconversation.com/up-to-204-691-extra-deaths-in-the-us-so-far-in-this-pandemic-year-143139">an article</a> originally published on Aug. 13, 2020.</em></p><img src="https://counter.theconversation.com/content/147887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald D. Fricker Jr. does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health statisticians keep careful tabs on how many people die every week. Based on what’s happened in past years, they know what to expect – but 2020 death counts are surging beyond predictions.Ronald D. Fricker Jr., Professor of Statistics and Interim Dean, College of Science, Virginia TechLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1473932020-10-07T14:56:23Z2020-10-07T14:56:23ZCOVID-19: examining theories for Africa’s low death rates<figure><img src="https://images.theconversation.com/files/362107/original/file-20201007-16-l90d9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As the threat of a COVID-19 pandemic emerged earlier this year, many felt a <a href="https://www.uneca.org/content/covid-19-could-kill-33-million-africans-study-reveals">sense of apprehension</a> about what would happen when it reached Africa. Concerns over the combination of overstretched and underfunded health systems and the existing load of infectious and non-infectious diseases often led to it being <a href="https://www.youtube.com/watch?v=qSVse07y2O4&feature=youtu.be">talked about</a> in apocalyptic terms.</p>
<p>However, it has not turned out quite that way. On September 29th, the world <a href="https://www.worldometers.info/coronavirus/#countries">passed</a> the one million reported deaths mark (the true figure will of course be higher). On the same day, <a href="https://africacdc.org/covid-19/">the count</a> for Africa was a cumulative total of 35,954. </p>
<p>Africa <a href="https://www.un.org/en/sections/issues-depth/population/">accounts for</a> 17% of the global population but only 3.5% of the reported global COVID-19 deaths. All deaths are important, we should not discount apparently low numbers, and of course data collected over such a wide range of countries will be of variable quality, but the gap between predictions and what has actually happened is staggering. There has been much discussion on what accounts for this.</p>
<p>As leads of the COVID-19 team in the African Academy of Sciences, we have followed the unfolding events and various explanations put forward. The emerging picture is that in many African countries, transmission has been higher but severity and mortality much lower than originally predicted based on experience in China and Europe.</p>
<p>We argue that Africa’s much younger population explains a very large part of the apparent difference. Some of the remaining gap is probably due to under reporting of events but there are a number of other plausible explanations. These range from climatic differences, pre-existing immunity, genetic factors and behavioural differences.</p>
<p>Given the enormous variability in conditions across a continent – with 55 member states – the exact contribution of any one factor in a particular environment is likely to vary. But the bottom line is that what appeared at first to be a mystery looks less puzzling as more and more research evidence emerges. </p>
<h2>The importance of age</h2>
<p>The most obvious factor for the low death rates is the population age structure. Across multiple countries the risk of dying of COVID-19 for those aged 80 years or more <a href="https://ourworldindata.org/mortality-risk-covid#case-fatality-rate-of-covid-19-by-age">is around</a> a hundred times that of people in their twenties. </p>
<p>This can best be appreciated with a specific example. As of September 30th, the UK <a href="https://www.statista.com/statistics/1093256/novel-coronavirus-2019ncov-deaths-worldwide-by-country/">had reported</a> 41,980 COVID-19 specific deaths while Kenya, by contrast, had reported 691. The population of the UK is around 66 million with a median age of 40 compared with Kenya’s population of 51 million with a median age of 20 years.</p>
<p>Corrected for population size the death toll in Kenya would have been expected to be around 32,000. However if one also corrects for population structure (assumes that the age specific death rates in the UK apply to the population structure of Kenya), we <a href="https://www.ispionline.it/it/pubblicazione/how-africas-age-structure-will-affect-impact-covid-19-25703">would expect</a> around 5,000 deaths. There is still a big difference between 700 and 5,000; what might account for the remaining gap?</p>
<h2>Other possible contributors</h2>
<p>One possibility is the failure to identify and record deaths. </p>
<p>Kenya, as <a href="https://ourworldindata.org/coronavirus-testing">with most</a> countries, initially had little testing capacity and specific death registration is challenging. However, Kenya <a href="https://ourworldindata.org/coronavirus-testing">quickly built up</a> its testing capacity and the extra attention to finding deaths makes it unlikely that a gap of this size can be fully accounted for by missing information.</p>
<p>There has been no shortage of ideas for other factors that may be contributing.</p>
<p>A recent large multi-country <a href="https://www.medrxiv.org/content/10.1101/2020.07.11.20147157v2">study</a> in Europe reported significant declines in mortality related to higher temperature and humidity. The authors hypothesised that this may be because the mechanisms by which our respiratory tracts clear virus work better in warmer more humid conditions. This means that people may be getting less virus particles into their system.</p>
<p>It should be noted however that a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238339">systematic review of global data</a> – while confirming that warm and wet climates seemed to reduce the spread of COVID-19 – indicated that these variables alone could not explain most of the variability in disease transmission. It’s important to remember that there’s considerable weather variability throughout Africa. Not all climates are warm or wet and, if they are, they may not stay that way throughout the year.</p>
<p>Other suggestions <a href="https://www.bmj.com/content/370/bmj.m3563">include</a> the possibility of pre-existing protective immune responses due either to previous exposure to other pathogens or to <a href="https://www.mdpi.com/1660-4601/17/15/5589/htm">BCG vaccination</a>, a vaccine against tuberculosis provided at birth in most African countries. A large analysis – which involved 55 countries, representing 63% of the world’s population – showed significant correlations between increasing BCG coverage at a young age and better outcomes of COVID-19.</p>
<p>Genetic factors may also be important. A <a href="https://www.nature.com/articles/s41586-020-2818-3">recently described</a> haplotype (group of genes) associated with increased risk of severity and present in 30% of south Asian genomes and 8% of Europeans is almost absent in Africa. </p>
<p>The role of these and other factors – such as potential differences in social structures or mobility – are subject to ongoing investigation.</p>
<h2>More effective response</h2>
<p>An important possibility is that <a href="https://qz.com/africa/1862585/how-covid-19-is-impacting-africas-healthcare-systems/">public health response</a> of African countries, prepared by previous experiences (such as outbreaks or epidemics) was simply more effective in limiting transmission than in other parts of the world.</p>
<p>However, in Kenya it’s <a href="https://www.medrxiv.org/content/10.1101/2020.09.02.20186817v1">estimated</a> that the epidemic actually peaked in July with around 40% of the population in urban areas having been infected. A similar picture <a href="https://science.sciencemag.org/content/369/6505/756">is emerging</a> in other countries. This implies that measures put in place had little effect on viral transmission per se, though it does raise the possibility that herd immunity is now playing a role in limiting further transmission. </p>
<p>At the same time there is another important possibility: the idea that viral load (the number of virus particles transmitted to a person) is a <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2026913">key determinant</a> of severity. It has <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2026913">been suggested</a> that masks reduce viral load and that their widespread wearing may limit the chances of developing severe disease. While WHO recommends mask wearing, uptake has been variable and has been lower in many <a href="https://www.euronews.com/2020/07/14/coronavirus-how-the-wearing-of-face-masks-has-exposed-a-divided-europe">European countries</a>, compared with many parts of <a href="https://aasopenresearch.org/articles/3-36">Africa</a>.</p>
<p>So is Africa in the clear? Well, obviously not. There is still plenty of virus around and we do not know what may happen as the interaction between the virus and humans evolves.</p>
<p>However, one thing that does seem clear is that the secondary effects of the pandemic will be Africa’s real COVID-19 challenge. These stem from the severe interruptions of social and economic activities as well as the potentially devastating effects of <a href="https://blogs.worldbank.org/health/covid-19-coronavirus-ensuring-continuity-health-services-middle-east-and-north-africa">reduced delivery of services</a> which protect millions of people, including routine vaccination as well as malaria, TB and HIV control programmes.</p>
<h2>Research agendas</h2>
<p>Major implications of the emerging picture include the need to re-evaluate African COVID-19 research agendas. While many of the priorities originally identified may still hold, their relative importance is likely to have changed. The key point is to deal with the problems as they are now rather than as they were imagined to be six months ago. </p>
<p>The same thing applies for public health policy. Of course, basic measures such as hand washing remain essential (regardless of COVID-19) and wearing masks should be continued while there is any level of COVID-19 transmission. However, other measures with broader effects on society, especially restrictions on educational and economic activity, should be under continuous review. </p>
<p>A key point now is to increase surveillance and ensure that flexible responses are driven by high quality real time data.</p><img src="https://counter.theconversation.com/content/147393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Marsh is a senior advisor and co-lead of the COVID-19 team at The African Academy of Sciences. He is also a Professor of Tropical Medicine and Director of the Africa Oxford Initiative at the University of Oxford.</span></em></p><p class="fine-print"><em><span>Moses Alobo is the programme manager for Grand Challenges Africa at the African Academy of Sciences and is co-lead for the Covid-19 effort. He is a Tutu fellow.</span></em></p>The gap between predictions of COVID-19 deaths in Africa and what has actually happened is staggering.Kevin Marsh, Professor of Tropical Medicine, University of OxfordMoses Alobo, Programme Manager for Grand Challenges Africa, African Academy of SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1444942020-09-13T19:51:31Z2020-09-13T19:51:31ZNow everyone’s a statistician. Here’s what armchair COVID experts are getting wrong<figure><img src="https://images.theconversation.com/files/355980/original/file-20200902-16-1gtx7vk.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C678&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concentrated-bearded-man-browsing-laptop-looking-1746168092">Shutterstock</a></span></figcaption></figure><p>If we don’t analyse statistics for a living, it’s easy to be taken in by misinformation about COVID-19 statistics on social media, especially if we don’t have the right context. </p>
<p>For instance, we may cherry pick statistics supporting our viewpoint and ignore statistics showing we are wrong. We also still need to correctly interpret these statistics.</p>
<p>It’s easy for us to share this misinformation. Many of these statistics are also interrelated, so misunderstandings can quickly multiply.</p>
<p>Here’s how we can avoid five common errors, and impress friends and family by getting the statistics right.</p>
<h2>1. It’s the infection rate that’s scary, not the death rate</h2>
<p><a href="https://twitter.com/EthicalSkeptic/status/1263660512102973441">Social media posts</a> comparing COVID-19 to other causes of death, such as <a href="https://www.facebook.com/deon.coetzee.77770/posts/10158515376871941">the flu</a>, imply COVID-19 <a href="https://fee.org/articles/npr-mounting-evidence-suggests-covid-not-as-deadly-as-thought-did-the-experts-fail-again/">isn’t really that deadly</a>.</p>
<p>But these posts miss COVID-19’s infectiousness. For that, we need to look at the infection fatality rate (IFR) — the number of COVID-19 deaths divided by all those infected (a number we can only estimate at this stage, see also point 3 below).</p>
<p>While the <a href="https://theconversation.com/how-deadly-is-the-coronavirus-the-true-fatality-rate-is-tricky-to-find-but-researchers-are-getting-closer-141426">jury is still out</a>, COVID-19 has a <a href="https://www.medrxiv.org/content/10.1101/2020.05.03.20089854v4">higher IFR</a> than the flu. <a href="https://www.facebook.com/sharontay.huff/posts/3037891612946957">Posts implying</a> a low IFR for COVID-19 most certainly underestimate it. They also miss two other points.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1233765212030996482"}"></div></p>
<p>First, if we compare the <a href="https://www.bloomberg.com/opinion/articles/2020-08-06/revisiting-how-covid-19-ranks-with-seasonal-flu-and-1918-pandemic">typical flu IFR</a> of <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200306-sitrep-46-covid-19.pdf?sfvrsn=96b04adf_4">0.1%</a> with the <a href="https://www.medrxiv.org/content/10.1101/2020.05.13.20101253v2.full.pdf">most optimistic COVID-19 estimate</a> of 0.25%, then COVID-19 remains more than twice as deadly as the flu.</p>
<p>Second, and more importantly, we need to look at the basic reproduction number (R₀) for each virus. This is the number of extra people one infected person is estimated to infect.</p>
<p>Flu’s R₀ <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-480">is about 1.3</a>. Although COVID-19 estimates vary, its R₀ sits around a <a href="https://academic.oup.com/jtm/article/27/2/taaa021/5735319">median of 2.8</a>. Because of the way infections grow exponentially (see below), the jump from 1.3 to 2.8 means COVID-19 is vastly more infectious than flu.</p>
<p>When you combine all these statistics, you can see the motivation behind our public health measures to “limit the spread”. It’s not only that COVID-19 is so deadly, it’s deadly <em>and</em> highly infectious.</p>
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Read more:
<a href="https://theconversation.com/how-deadly-is-the-coronavirus-the-true-fatality-rate-is-tricky-to-find-but-researchers-are-getting-closer-141426">How deadly is the coronavirus? The true fatality rate is tricky to find, but researchers are getting closer</a>
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<h2>2. Exponential growth and misleading graphs</h2>
<p>A simple graph might plot the number of new COVID cases over time. But as new cases might be reported erratically, statisticians are more interested in the rate of growth of total cases over time. The steeper the upwards slope on the graph, the more we should be worried.</p>
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Read more:
<a href="https://theconversation.com/coronavirus-is-growing-exponentially-heres-what-that-really-means-134591">Coronavirus is growing exponentially – here’s what that really means</a>
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<p>For COVID-19, statisticians look to track <a href="https://www.forbes.com/sites/startswithabang/2020/03/17/why-exponential-growth-is-so-scary-for-the-covid-19-coronavirus/#65115f274e9b">exponential growth</a> in cases. Put simply, unrestrained COVID cases can lead to a continuously growing number of more cases. This gives us a graph that tracks slowly at the start, but then sharply curves upwards with time. This is the curve we want to flatten, as shown below.</p>
<figure>
<img src="https://cdn.theconversation.com/static_files/files/890/Flatten_the_curve1.gif?1583941324">
<figcaption><span class="caption">“Flattening the curve” is another way of saying “slowing the spread”. The epidemic is lengthened, but we reduce the number of severe cases, causing less burden on public health systems. The Conversation/CC BY ND</span></figcaption>
</figure>
<p>However, social media posts routinely compare COVID-19 figures with those of other causes of death that show:</p>
<ul>
<li><p>more <a href="https://www.facebook.com/SimonCLord/photos/a.451887838292858/1556333767848254">linear patterns</a> (figures increase with time but at a steady rate)</p></li>
<li><p>much slower-growing <a href="https://twitter.com/realdonaldtrump/status/1237027356314869761">flu deaths</a> or </p></li>
<li><p><a href="https://www.facebook.com/mydocfrank/posts/2132408190237845">low numbers from early stages of the outbreak</a> and so miss the <a href="https://mycovidjourney.com/2020/03/30/what-is-exponential-growth/">impact of exponential growth</a>.</p></li>
</ul>
<p>Even when researchers talk of exponential growth, they can still mislead.</p>
<p>An Israeli professor’s <a href="https://www.timesofisrael.com/the-end-of-exponential-growth-the-decline-in-the-spread-of-coronavirus/">widely-shared</a> analysis claimed COVID-19’s exponential growth “fades after eight weeks”. Well, he was clearly wrong. But why?</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1252671468128866308"}"></div></p>
<p>His model assumed COVID-19 cases grow exponentially over a number of days, instead of over a succession of transmissions, each of which may take several days. This led him to plot only the erratic growth of the outbreak’s early phase.</p>
<p>Better visualisations truncate those erratic first cases, for instance by starting from the 100th case. Or they use estimates of the number of days it takes for the number of cases <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30260-9/fulltext">to double</a> (about six to seven days).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-bar-necessities-5-ways-to-understand-coronavirus-graphs-135537">The bar necessities: 5 ways to understand coronavirus graphs</a>
</strong>
</em>
</p>
<hr>
<h2>3. Not all infections are cases</h2>
<p>Then there’s the confusion about COVID-19 infections versus cases. In epidemiological terms, a “case” is a person who is diagnosed with COVID-19, mostly by a positive test result. </p>
<p>But there are many more infections than cases. Some infections don’t show symptoms, some symptoms are so minor people think it’s just a cold, testing is not always available to everyone who needs it, and testing <a href="https://www.bmj.com/content/369/bmj.m1808">does not pick up all infections</a>.</p>
<p>Infections “cause” cases, testing discovers cases. US President Donald Trump was close to the truth <a href="https://twitter.com/realDonaldTrump/status/1293163704188645385">when he said</a> the number of cases in the US was high because of the high rate of testing. But he <a href="https://twitter.com/realistgeo/status/1295701536979525633">and others</a> still got it totally wrong.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1293163704188645385"}"></div></p>
<p>More testing does not <em>result</em> in more cases, it allows for a <em>more accurate estimate</em> of the true number of cases.</p>
<p>The best strategy, epidemiologically, is not to test less, but to test as widely as possible, minimising the discrepancy between cases and overall infections. </p>
<h2>4. We can’t compare deaths with cases from the same date</h2>
<p><a href="https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article">Estimates vary</a>, but the time between infection and death could be as much as <a href="https://www.nationalgeographic.com/science/2020/07/coronavirus-deadlier-than-many-believed-infection-fatality-rate-cvd/">a month</a>. And the variation in <a href="https://edition.cnn.com/2020/04/04/health/recovery-coronavirus-tracking-data-explainer/index.html">time to recovery</a> is even greater. Some people get really ill and take a long time to recover, some show no symptoms. </p>
<p>So deaths recorded on a given date reflect deaths from cases recorded several weeks prior, when the case count may have been <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30260-9/fulltext">less than half</a> the number of current cases.</p>
<p>The rapid case-doubling time and protracted recovery time also create a large discrepancy between counts of <a href="https://twitter.com/Nutty_Lulu/status/1239817225860775937">active and recovered cases</a>. We’ll only know the true numbers in retrospect.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1239817225860775937"}"></div></p>
<h2>5. Yes, the data are messy, incomplete and may change</h2>
<p>Some social media users <a href="https://twitter.com/CAdamMartin/status/1293642172324077570">get angry</a> when the <a href="https://www.bbc.com/news/health-53722711">statistics are adjusted</a>, <a href="https://archive.is/WX4RO">fuelling</a> <a href="https://www.facebook.com/photo.php?fbid=10156807927231394&set=a.85311241393&type=3&theater">conspiracy theories</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1293642172324077570"}"></div></p>
<p>But few realise how <a href="https://www.usnews.com/news/health-news/articles/2020-04-02/why-are-us-coronavirus-recovery-numbers-so-low">mammoth, chaotic</a> and <a href="https://www.nationalgeographic.com/science/2020/07/coronavirus-deadlier-than-many-believed-infection-fatality-rate-cvd/">complex</a> the task is of tracking statistics on a disease like this. </p>
<p>Countries and even states may count cases and deaths differently. It also takes time to gather the data, meaning retrospective adjustments are made.</p>
<p>We’ll only know the true figures for this pandemic in retrospect. Equally so, early models were not necessarily wrong because the modellers were deceitful, but because they had insufficient data to work from. </p>
<p>Welcome to the world of data management, data cleaning and data modelling, which many armchair statisticians don’t always appreciate. Until now.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-a-virus-goes-viral-pros-and-cons-to-the-coronavirus-spread-on-social-media-133525">When a virus goes viral: pros and cons to the coronavirus spread on social media</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/144494/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacques Raubenheimer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pandemic has exposed many of us to new statistical concepts, on the news, in everyday conversations and on social media. But how many are you getting wrong?Jacques Raubenheimer, Senior Research Fellow, Biostatistics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1431392020-08-13T12:07:41Z2020-08-13T12:07:41ZUp to 204,691 extra deaths in the US so far in this pandemic year<figure><img src="https://images.theconversation.com/files/351789/original/file-20200807-14-11bn919.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic leaves its mark in the number of lives ended.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/luis-fernandez-an-employee-at-stitzel-family-funeral-homes-news-photo/1219251811">Ben Hasty/MediaNews Group/Reading Eagle via Getty Images</a></span></figcaption></figure><p><em>An updated version of this article was published on Oct. 14, 2020 to include data through the end of September. <a href="https://theconversation.com/279700-extra-deaths-in-the-us-so-far-in-this-pandemic-year-147887">Read it here</a>.</em></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="204,691 extra deaths in the U.S. in 2020 through end of July" src="https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352589/original/file-20200812-18-kjesp3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The number of deaths in the United States through July 2020 is 8% to 12% higher than it would have been if the coronavirus pandemic had never happened. That’s at least 164,937 deaths above the number expected for the first seven months of the year – 16,183 more than the number <a href="https://www.cdc.gov/nchs/nvss/vsrr/COVID19/index.htm">attributed to COVID-19</a> thus far for that period – and it could be as high as 204,691.</p>
<h2>Tracking deaths</h2>
<p>When someone dies, the death certificate records an immediate cause of death, along with up to three underlying conditions that “<a href="https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf">initiated the events resulting in death</a>.” The certificate is filed with the local health department, and the details are reported to the <a href="https://www.cdc.gov/nchs/index.htm">National Center for Health Statistics</a>. </p>
<p>As part of the <a href="https://www.cdc.gov/nchs/nvss/index.htm">National Vital Statistics System</a>, the NCHS then uses this information in various ways, such as tabulating the <a href="https://www.cdc.gov/nchs/nvss/leading-causes-of-death.htm">leading causes of death</a> in the United States – <a href="https://www.cdc.gov/nchs/fastats/deaths.htm">currently heart disease</a>, followed by cancer. Sometime this fall, COVID-19 will <a href="https://theconversation.com/how-deadly-is-covid-19-a-biostatistician-explores-the-question-142253">likely become the third-largest cause of death</a> for 2020.</p>
<h2>Projecting from the past</h2>
<p>To calculate excess deaths requires a comparison to what would have occurred if COVID-19 had not existed. Obviously, it’s not possible to observe what didn’t happen, but it is possible to estimate it using historical data. The Centers for Disease Control and Prevention does this using a <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm">statistical model</a>, based on the previous three years of mortality data, incorporating seasonal trends as well as adjustments for data-reporting delays. </p>
<p>So, looking at what happened over the past three years, the CDC projects what might have been. By using a statistical model, they are also able to calculate the uncertainty in their estimates. That allows <a href="https://scholar.google.com/citations?user=kWGF578AAAAJ&hl=en&oi=ao">statisticians like me</a> to assess whether the observed data look unusual compared to projections.</p>
<p><iframe id="LWq2f" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/LWq2f/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The number of excess deaths is the difference between the model’s projections and the actual observations. The Centers for Disease Control and Prevention also calculates an upper threshold for the estimated number of deaths – that helps determine when the observed number of deaths is unusually high compared to historical trends.</p>
<p>Clearly visible in a graph of this data is the spike in deaths beginning in mid-March 2020 and continuing to the present. You can also see another period of excess deaths from December 2017 to January 2018, attributable to an <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">unusually virulent flu strain that year</a>. The magnitude of the excess deaths in 2020 makes clear that COVID-19 is much worse than influenza, even when compared to a bad flu year like 2017-18, when an estimated <a href="https://www.cdc.gov/flu/about/burden/past-seasons.html">61,000 people in the U.S. died</a> of the illness.</p>
<p><iframe id="5lVsu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/5lVsu/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The large spike in deaths in April 2020 corresponds to the coronavirus outbreak in New York and the Northeast, after which the number of excess deaths decreased regularly and substantially until July, when it started to increase again. This current uptick in excess deaths is attributable to the outbreaks in the South and West that have occurred since June.</p>
<h2>The data tell the story</h2>
<p>It doesn’t take a sophisticated statistical model to see that the coronavirus pandemic is causing substantially more deaths than would have otherwise occurred.</p>
<p>The number of deaths the CDC officially attributed to COVID-19 in the United States <a href="https://www.cdc.gov/nchs/nvss/vsrr/COVID19/index.htm">exceeded 148,754</a> by Aug. 1. Some people who are skeptical about aspects of the coronavirus suggest these are deaths that would have occurred anyway, perhaps because COVID-19 is particularly deadly for the elderly. Others believe that, because the pandemic has changed life so drastically, the increase in COVID-19-related deaths is probably offset by decreases from other causes. But neither of these possibilities is true.</p>
<p>In fact, the number of excess deaths currently exceeds the number attributable to COVID-19 by more than 16,000 people in the U.S. What’s behind that discrepancy is <a href="https://doi.org/10.1001/jama.2020.11787">not yet clear</a>. COVID-19 deaths could be being undercounted, or the pandemic could also be causing increases in other types of death. It’s probably some of both.</p>
<p>Regardless of the reason, the COVID-19 pandemic has resulted in substantially more deaths than would have otherwise occurred … and it is not over yet.</p><img src="https://counter.theconversation.com/content/143139/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald D. Fricker Jr. does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health statisticians keep careful tabs on how many people die every week. Based on what’s happened in past years, they know what to expect – but 2020 death counts are surging beyond predictions.Ronald D. Fricker Jr., Professor of Statistics and Interim Dean, College of Science, Virginia TechLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1413632020-06-26T03:51:09Z2020-06-26T03:51:09ZHave there been uncounted coronavirus deaths in Australia? We can’t say for sure, but the latest ABS data holds clues<p>The Australian Bureau of Statistics this week released a <a href="https://www.abs.gov.au/ausstats/abs@.nsf/0/0E25B19FEA63D324CA25859000222EBD?Opendocument">provisional tally</a> of the changes in Australia’s overall death rate amid the coronavirus epidemic.</p>
<p>The figures record 33,066 doctor-certified deaths in Australia from January 1 to March 31, 2020 – compared with an average of 32,249 during the corresponding months during the years 2015-19.</p>
<p>What’s more, the final week of March 2020 featured the highest weekly death rate of the entire three-month period, with 2,649 recorded deaths. That week also featured the highest numbers of deaths from respiratory diseases, diabetes and dementia.</p>
<p>Australia has had 103 known COVID-19-related deaths, with 21 reported before the end of March. The ABS death counts for respiratory diseases do not include these known cases, but might include COVID-19 deaths that were not recognised or confirmed as such at the time.</p>
<p>Overall, there were more than 800 “excess deaths” in the first quarter of 2020, compared with the average of the previous five years. The 103 confirmed COVID-19 deaths represent just a small fraction of these deaths. But my analysis shows that even in the early days of the pandemic, there are some signs that the impact of COVID-19 on Australia’s death rate may be bigger than the official tally suggests. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-calculus-of-death-shows-the-covid-lock-down-is-clearly-worth-the-cost-137716">The calculus of death shows the COVID lock-down is clearly worth the cost</a>
</strong>
</em>
</p>
<hr>
<p>Death data allow us to monitor death rates by age, gender, location and cause, and to assess how death rates are changing over time. “Excess deaths” – those that exceed the long-term average – are particularly important to understand, not least during a pandemic but also because they could be due to preventable causes. </p>
<p>The coronavirus death toll has become a feature of media coverage during the COVID-19 outbreak. Unlike in many other countries, the epidemic has stayed within the capacity of Australia’s health system, so we might reasonably expect all COVID-19-related deaths to have been counted accurately. </p>
<p>However, analysis of <a href="https://www.bbc.com/news/world-europe-53106444">sewage</a> and <a href="https://www.bbc.com/news/world-europe-52526554">swab samples</a> in Europe suggest SARS-CoV-2 (the coronavirus that causes COVID-19) may have been responsible for infections as early as December, before the world became aware of the emerging crisis in Wuhan. </p>
<p>Given the uncertainty about when the coronavirus actually entered Australia, it is possible Australia had COVID-19 cases before official counts began. If so, they may have been recorded as a death from another cause in the death register, most likely as pneumonia.</p>
<p>A death can only be officially attributed to COVID-19 if that patient had been tested for the coronavirus. Australia had a limited supply of test kits initially, and the rules for testing were strict in the early days, mainly focused on returned travellers and their immediate contacts. Testing rules did include hospitalised patients with community-acquired pneumonia, but this recommendation may not always have been followed.</p>
<h2>What do the new data show?</h2>
<p>The newly released ABS data are raw counts that only include deaths which occurred in January-March and were registered by the end of April. On average, 98% of deaths are reported to the ABS by the end of the following month.</p>
<p>The data compare the weekly death rates against the five-year average death counts for those same weeks from 2015 to 2019. There has been some population growth over this time, which in itself might lead to a rise in expected deaths, but is not yet factored in here. These counts only relate to the deaths that a doctor has certified (in home or hospital), but this is likely to include most deaths directly associated with COVID-19 patients, diagnosed or not.</p>
<p>The 33,066 recorded deaths in the first three months of 2020 is well above the five-year average of 32,249. But overall, the 2020 deaths follow a similar pattern to previous years, with the count rising as we enter the cooler months.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343922/original/file-20200625-33569-1qxr742.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">ABS</span></span>
</figcaption>
</figure>
<p>We do expect death counts to increase with population growth and population ageing. These changes will not be particularly pronounced from year to year in Australia, but certainly could account for the small rise in overall deaths seen in these three months. There are no obvious differences between states, but the smaller population in the Australian Capital Territory and Northern Territory actually show slight declines. </p>
<p>Australia reported its first COVID-19 death on March 1, and has 103 confirmed COVID-19 deaths so far – a small proportion of the total number of deaths. Can we learn more by breaking down the new data?</p>
<h2>Delve deeper into the data</h2>
<p>One possible way to spot significant changes is to focus on groups known to be at most risk of dying from COVID-19. </p>
<p>First, let’s consider age at death. Older people are most vulnerable to COVID-19, but also have the highest death rates in normal circumstances too. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=227&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=227&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=227&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=286&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=286&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344219/original/file-20200626-33563-u6uxs9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=286&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Bars on the left show the 2020 counts by age, and the five-year average to the right of that.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Differences from week to week are subtle, but we do see a slight trend by the end of January for the 2020 count to exceed the average. This could simply represent other factors contributing to the slight increase in all deaths, but will be worth watching over subsequent weeks.</p>
<p>Focusing just on those 65 and older in the ABS data, we see once again that 2020 counts are generally higher than average for all weeks for both males and females. Male deaths spiked in the final week of march, which is interesting as males represent 65% of confirmed COVID-19 deaths in Australia. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=273&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=273&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=273&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=342&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=342&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343938/original/file-20200625-33511-pi4en5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=342&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>These are preliminary numbers, but there is no clear evidence of COVID-19 deaths in Australia before March 1, or before the first known incursion of SARS-CoV-2 into Australia. However, this might be obscured by the “noise” of looking at deaths from all causes at the same time. </p>
<p>It is therefore worth taking a closer look at deaths attributed to respiratory causes (the ABS states that these counts do not include the confirmed 103 COVID-19 deaths). The ABS data split the total respiratory deaths into two categories: chronic conditions such as asthma, and acute infections like influenza and pneumonia. It’s in this latter category (shown in the lowermost set of lines on the graph below) where any excess, uncounted deaths due to COVID-19 should be evident.</p>
<iframe title="Respiratory deaths in January-March" aria-label="Interactive line chart" id="datawrapper-chart-7dn9Q" src="https://datawrapper.dwcdn.net/7dn9Q/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="605"></iframe>
<p>So far this year there have been 43 excess deaths due to influenza and pneumonia, relative to the average, and the ABS notes that most of these are pneumonia deaths. The excess deaths were mainly in the final two weeks of March, with the preceding weekly fluctuations largely cancelling each other out. This compares with 21 COVID-19 deaths reported by March 21, and 48 total by the end of the first week of April (ABS data are recorded by date of death; COVID-19 counts by the day publicly reported). </p>
<p>Some of these extra deaths may indeed be due to factors such as population growth, but it does open up the possibility of unaccounted COVID-19 deaths in the early days of the epidemic in Australia that might match, or exceed, those confirmed cases we know about. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/has-australia-really-avoided-14-000-coronavirus-deaths-139465">Has Australia really avoided 14,000 coronavirus deaths?</a>
</strong>
</em>
</p>
<hr>
<p>The issue of undetected COVID-19 deaths is not the only important question. Has the deferral of elective surgeries affected the death rate? Has there been a death toll associated with people being discouraged from visiting clinics or hospitals for other illnesses? Have the stresses of lockdown and financial uncertainty led to a rise in domestic violence or suicide? </p>
<p>We don’t know the answers yet. But hopefully the forthcoming ABS data will reveal the answers as 2020 continues to unfold.</p><img src="https://counter.theconversation.com/content/141363/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Bennett receives funding from Medical Research Future Fund</span></em></p>Australian Bureau of Statistics figures suggest there have been more than 800 ‘excess deaths’ in Australia in January-March 2020, relative to the average, but only 103 confirmed COVID-19 deaths so far.Catherine Bennett, Chair in Epidemiology, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1399472020-06-05T10:44:52Z2020-06-05T10:44:52ZWhy coronavirus death rates won’t fall as quickly as they rose<p>Coronavirus deaths shocked us with how rapidly they rose from a base of none at the start of the year, to many thousands within the space of mere weeks. At the peak for England and Wales on April 8, more than 1,300 people died in a single day (as <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales">revealed later</a> when all death registrations were reported).</p>
<p>But the other side of the peak will look very different: death rates will fall much slower than they rose.</p>
<p>The latest data for England and Wales shows that <a href="https://www.theguardian.com/world/2020/jun/02/uk-coronavirus-death-toll-nears-50000-latest-official-figures-show">44,401 people</a> had died with COVID-19 mentioned on their death certificates by May 22. For the majority of these people, the disease will have been the primary cause of death. </p>
<p>The first graph below shows the number of deaths daily by date of death in England and Wales as a whole. There has been no sudden break in slope. This is because the national curve is an amalgam of many smaller, <a href="https://theconversation.com/coronavirus-why-we-need-local-models-to-successfully-exit-lockdown-138358">local curves</a>. </p>
<p>Most of these local curves will be symmetrical, with deaths falling at the same rate as they rose, but with the outbreak affecting different areas, at different times, together they create the long tail we see in the graph below. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339885/original/file-20200604-67364-5zcjl2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><span class="source">Danny Dorling</span></span>
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<p>To illustrate how the overall national trend will fall more slowly than it rose, I have taken all 339 local authority districts in England and Wales for which data has been released and sorted them into groups by the week in which COVID-19 deaths peaked. </p>
<p>Doing this gives us seven groups, starting with the week of March 21 to March 27 and ending with the week of May 2 to May 8. The first such grouping is of those districts which recorded their highest number of coronavirus-related deaths in the first of these weeks.</p>
<p>The places in which COVID-19 peaked first are a disparate set of areas, only one of which was a London borough, which indicates just how widespread the disease had become by March. They included Wolverhampton, Lambeth, Newport (in Wales), Chiltern, Fareham, South Staffordshire, Broxbourne, Erewash, Rochford, South Bucks and Tunbridge Wells. </p>
<p>Grouping local authority districts by the week in which mortality with COVID-19 peaked helps break down the national pattern into a series of smaller, local curves. Only the first four graphs are shown as 92% of all deaths occurred in these district groupings. Each appears to be very similar to the next except that the vertical scales on each graph vary because more areas saw deaths peak in early April. </p>
<p>The numbers of deaths in these different sets of districts rise quickly and then fall slightly more slowly over time. But they do not fall as slowly as the first graph shown in this article. </p>
<hr>
<p><strong>Local coronavirus deaths grouped by time of peak</strong></p>
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<a href="https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=301&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=301&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=301&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=378&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=378&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339880/original/file-20200604-67377-1p0jukv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=378&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><span class="source">Danny Dorling</span></span>
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<hr>
<p>The full lockdown in England and Wales began on March 24, during the week in which deaths peaked in the first set of areas shown above. People were already social distancing to some extent before that date, so we should not expect to see any sudden drop in mortality two or three weeks after that date in the graphs above, and we do not. </p>
<p>The final graph in this series shows the regional distribution of the spread of the pandemic. The regions are sorted from lowest overall rates of mortality (south-west England) to highest (London). Rates have fallen the most in London because – by region – the disease peaked there earlier. It fell more slowly in south-east England.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=527&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=527&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339886/original/file-20200604-67387-5c1bfg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=527&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><span class="source">Danny Dorling</span>, <span class="license">Author provided</span></span>
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</figure>
<p>Slowly the pattern is becoming more clear. Deaths are falling slower than they rose, but they are falling steadily. Only very occasionally does an area report a rise in mortality and almost always, the week after, numbers fall again very rapidly. </p>
<p>Despite fears of an immediate <a href="https://theconversation.com/uk/topics/second-wave-85229">second wave</a> there are no signs of this yet from the mortality data that is being released each week, and no sign that we should greatly fear one in the coming weeks. </p>
<p>The degree of surveillance of COVID-19 is unprecedented in comparison to previous epidemics. In this article I have only considered deaths from the disease, but there is also close monitoring of hospital admissions, testing, even internet searches for symptoms. Much of this effort has been criticised as not being enough, but it should be good enough to spot a second wave beginning, if one does.</p>
<p>As lockdown is only lifting now, many people wouldn’t expect to see a possible second wave yet. But the fact that we have not yet seen second waves in similar countries that locked down earlier than the UK, such as <a href="https://www.nytimes.com/interactive/2020/world/europe/france-coronavirus-cases.html">France</a>, <a href="https://www.nytimes.com/interactive/2020/world/europe/spain-coronavirus-cases.html">Spain</a> and <a href="https://www.nytimes.com/interactive/2020/world/europe/italy-coronavirus-cases.html">Italy</a>, should give us some hope.</p>
<p>The disease will fall away more slowly than it rose. But at least it is now safe to say that it is falling everywhere.</p><img src="https://counter.theconversation.com/content/139947/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Danny Dorling does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The national curve is made up of much smaller local curves with their own peaks at different times – but deaths are still definitely falling.Danny Dorling, Halford Mackinder Professor of Geography, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1336052020-04-17T12:11:15Z2020-04-17T12:11:15Z1918 flu pandemic killed 12 million Indians, and British overlords’ indifference strengthened the anti-colonial movement<figure><img src="https://images.theconversation.com/files/327346/original/file-20200412-8893-1ihy43t.jpg?ixlib=rb-1.1.0&rect=0%2C56%2C4200%2C4011&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cremation on the banks of the Ganges river, India.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/crémation-sur-les-bords-du-gange-à-benarès-inde-circa-1920-news-photo/833384176?adppopup=true">Keystone-France via Getty Images</a></span></figcaption></figure><p>In India, during the 1918 influenza pandemic, a staggering <a href="https://doi.org/10.1007/s13524-012-0116-x">12 to 13 million people died</a>, the vast majority between the months of September and December. According to an eyewitness, “There was none to remove the dead bodies and the jackals made a feast.” </p>
<p>At the time of the pandemic, India had been under British colonial rule for over 150 years. The fortunes of the British colonizers had always been vastly different from those of the Indian people, and nowhere was the split more stark than during the influenza pandemic, as I discovered while researching <a href="https://scholar.google.com/citations?user=zQnyI1cAAAAJ&hl=en&oi=ao">my Ph.D. on the subject</a>. </p>
<p>The resulting devastation would eventually lead to huge changes in India – and the British Empire. </p>
<h2>From Kansas to Mumbai</h2>
<p>Although it is commonly called the Spanish flu, the 1918 pandemic likely <a href="https://www.cambridge.org/us/academic/subjects/history/twentieth-century-american-history/americas-forgotten-pandemic-influenza-1918-2nd-edition?format=PB">began in Kansas</a> and <a href="https://doi.org/10.1093/aje/kwy191">killed between 50 and 100 million people</a> worldwide. </p>
<p>During the early months of 1918, the virus incubated throughout the American Midwest, eventually making its way east, where it <a href="https://www.army.mil/article/210420/worldwide_flu_outbreak_killed_45000_american_soldiers_during_world_war_i">traveled across the Atlantic Ocean</a> with soldiers deploying for WWI. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=639&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=639&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=639&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=803&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=803&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327347/original/file-20200412-138728-1tayb5b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=803&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Indian soldiers in the trenches during World War I.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/indian-soldiers-in-the-trenches-world-war-i-1914-1918-news-photo/463957843">Print Collector / Contributor via Getty Images</a></span>
</figcaption>
</figure>
<p>Introduced into the trenches on Europe’s Western Front, the virus tore through the already weakened troops. As the war approached its conclusion, the virus followed both commercial shipping routes and military transports to infect almost every corner of the globe. It <a href="https://www.macmillanlearning.com/college/us/product/Influenza-Pandemic-of-1918-1919/p/0312677081">arrived in Mumbai in late May</a>.</p>
<h2>Unequal spread</h2>
<p>When the first wave of the pandemic arrived, it was not particularly deadly. The only notice British officials took of it was its effect on some workers. A report noted, “As the season for cutting grass began … people were so weak as to be unable to do a full day’s work.” </p>
<p>By September, the story began to change. Mumbai was still the center of infection, likely due to its position as a commercial and civic hub. On Sept. 19, an English-language newspaper reported 293 influenza deaths had occurred there, but assured its readers “The worst is now reached.” </p>
<p>Instead, the virus tore through the subcontinent, following trade and postal routes. Catastrophe and death overwhelmed cities and rural villages alike. Indian newspapers reported that crematoria were receiving between 150 to 200 bodies per day. According to one observer, “The burning ghats and burial grounds were literally swamped with corpses; whilst an even greater number awaited removal.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327348/original/file-20200412-1397-po6zou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Members of the British Raj out for a stroll, circa 1918.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/members-of-the-british-raj-walking-together-in-an-indian-news-photo/3398825?adppopup=true">Fox Photos/Stringer via Getty images</a></span>
</figcaption>
</figure>
<p>But influenza did not strike everyone equally. Most British people in India lived in spacious houses with gardens and yards, compared to the lower classes of city-dwelling Indians, who lived in densely populated areas. Many British also employed household staff to care for them – in times of health and sickness – so they were only lightly touched by the pandemic and were largely unconcerned by the chaos sweeping through the country. </p>
<p>In his official correspondence in early December, the Lieutenant Governor of the United Provinces did not even mention influenza, instead noting “Everything is very dry; but I managed to get two hundred couple of snipe so far this season.”</p>
<p>While the pandemic was of little consequence to many British residents of India, the perception was wildly different among the Indian people, <a href="https://www.saada.org/item/20130823-3118">who spoke of universal devastation</a>. A letter published in a periodical lamented, “India perhaps never saw such hard times before. There is wailing on all sides. … There is neither village nor town throughout the length and breadth of the country which has not paid a heavy toll.” </p>
<p>Elsewhere, the Sanitary Commissioner of the Punjab noted, “the streets and lanes of cities were littered with dead and dying people … nearly every household was lamenting a death, and everywhere terror and confusion reigned.” </p>
<h2>The fallout</h2>
<p>In the end, areas in the north and west of India saw death rates between 4.5% and 6% of their total populations, while the south and east – where the virus arrived slightly later, as it was waning – generally lost between 1.5% and 3%. </p>
<p>Geography wasn’t the only dividing factor, however. In Mumbai, almost seven-and-a-half times as many lower-caste Indians died as compared to their British counterparts - <a href="https://doi.org/10.1177/001946468602300102">61.6 per thousand</a> versus 8.3 per thousand. </p>
<p>Among Indians in Mumbai, socioeconomic disparities in addition to race accounted for these differing mortality rates.</p>
<p><iframe id="9Mq9o" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/9Mq9o/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The Health Officer for Calcutta remarked on the stark difference in death rates between British and lower-class Indians: “The excessive mortality in Kidderpore appears to be due mainly to the large coolie population, ignorant and poverty-stricken, living under most insanitary conditions in damp, dark, dirty huts. They are a difficult class to deal with.” </p>
<h2>Change ahead</h2>
<p>Death tolls across India generally hit their peak in October, with a slow tapering into November and December. A high ranking British official wrote in December, “A good winter rain will put everything right and … things will gradually rectify themselves.” </p>
<p>Normalcy, however, did not quite return to India. The spring of 1919 would see the <a href="https://www.britannica.com/event/Jallianwala-Bagh-Massacre">British atrocities at Amritsar</a> and shortly thereafter the launch of <a href="https://www.britannica.com/event/noncooperation-movement">Gandhi’s Non-Cooperation Movement</a>. Influenza became one more example of British injustice that spurred Indian people on in their fight for independence. A <a href="https://www.saada.org/item/20130128-1271">nationalist periodical stated</a>, “In no other civilized country could a government have left things so much undone as did the Government of India did during the prevalence of such a terrible and catastrophic epidemic.”</p>
<p>The long, slow death of the British Empire had begun.</p>
<hr>
<p><em>This article has been updated to correct that the final quote is not from a periodical published by Mahatma Gandhi, but rather a separate nationalist publication of the same name based in New York.</em></p><img src="https://counter.theconversation.com/content/133605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maura Chhun does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When the 1918 influenza pandemic struck India, the death toll was highest among the poor.Maura Chhun, Community Faculty, Metropolitan State University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1357582020-04-10T12:16:34Z2020-04-10T12:16:34ZWhy coronavirus death rates can’t be summed up in one simple number<figure><img src="https://images.theconversation.com/files/326637/original/file-20200408-128829-7u6d8m.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1972%2C1315&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When leaders make public health decisions, such as how long social distancing should be maintained to reduce the coronavirus death toll, they often use mathematical models. The numbers aren't always as simple as they seem.</span> <span class="attribution"><a class="source" href="http://apimages.com">Alex Brandon/AP</a></span></figcaption></figure><p>When people fall seriously ill from the new coronavirus, death rates become a highly personal matter. Yet we talk about them in the most impersonal of ways: with numbers.</p>
<p>We are told, for instance, that the case-fatality ratio from COVID-19 is 1%-2% (or is it <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext">0.66%, or 3.28%?</a>). And that there could be 100,000 to 240,000 COVID-19 deaths in the U.S. by mid-June, or perhaps far fewer.</p>
<p>I trained in medicine and now work as a <a href="http://www.hps.pitt.edu/people/jonathan-fuller">philosopher of science</a>. Over the past several years, I’ve been trying to understand how epidemiological evidence influences thinking in health care. Epidemiological data are critical in deciding public health action, such as when to ease up on social distancing.</p>
<p>But how should we think about the ever-shifting COVID-19 statistics as individuals and as public health decision-makers? Answering this question requires diving deeper into the meaning of the numbers.</p>
<h2>Populations, individuals and case-fatality ratios</h2>
<p>Epidemiological numbers like infection rates and death counts have been a grim presence in this pandemic, represented by circular tumors growing outward on <a href="https://www.npr.org/sections/health-shots/2020/03/16/816707182/map-tracking-the-spread-of-the-coronavirus-in-the-u-s">maps</a>. </p>
<p>The case-fatality ratio is the proportion of deaths from COVID-19 among those infected. In the three weeks leading up to April 7, the U.S. counted 11,014 COVID-19 deaths and 368,909 confirmed cases, for a case-fatality ratio of 11,014/368,909 = 3.0%.</p>
<p>As individuals, we have a psychological and practical need to make sense of population figures for individual lives. However, it is a mistake to conclude that your individual risk of death would be 3.0% if you were to contract COVID-19.</p>
<p>The factors that make one vulnerable to death from COVID-19 are <a href="https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-03-16-COVID19-Report-9.pdf">distributed unevenly</a> in the population. They are greatly underrepresented in the very young, for example, and greatly overrepresented in the very old.</p>
<p>The case-fatality ratio – like all epidemiological numbers – is a measure of a population, not an individual. Epidemiological numbers should inform your beliefs about your future but probably don’t reveal your <a href="http://philsci-archive.pitt.edu/17046/1/PSA2018%20Submission%20-%20FINAL.pdf">“individual risk</a>.”</p>
<p>Epidemiological numbers are also relative to a particular population at a particular point in time. It was recently <a href="https://www.cnn.com/2020/03/30/health/coronavirus-lower-death-rate/index.html">reported in the media</a> that a <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext">new study</a> showed that the infection-fatality ratio for COVID-19 is 0.66%, not the 2% previously quoted. But 0.66% is the estimate for the population of China. The same study estimated the ratio in China’s population under age 60 to be 0.145%, and 3.28% in China’s population over 60.</p>
<p>The case-fatality ratio, like all epidemiologic figures, is neither a property of the individual nor the virus. It emerges from the interaction among a particular population, pathogen and place.</p>
<h2>Hypothetical futures and the effectiveness of social distancing</h2>
<p>At a somber press briefing at the end of March, the White House coronavirus team <a href="https://www.npr.org/sections/health-shots/2020/04/01/824744490/5-key-facts-the-white-house-isnt-saying-about-their-covid-19-projections">said statistical modeling had projected</a> that there would be between <a href="https://www.nbcnews.com/science/science-news/what-we-know-about-coronavirus-model-white-house-unveiled-n1173601">100,000 and 240,000</a> COVID-19 deaths in the U.S. through mid-June. That’s with the current mitigation efforts in place through April 30, including policies to promote social distancing. </p>
<p>The estimate was based on the results of several statistical models produced around the world, and it inherits the uncertainty of those results.</p>
<p>In deciding how to slow the spread of the new coronavirus, including when to ease up on social distancing, forecasters must compare hypothetical futures.</p>
<p>Imagine what would happen in the future if social distancing measures had never been implemented. According to <a href="https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf">models cited</a> by the White House, 1,500,000-2,200,000 people would die from COVID-19 in the U.S.</p>
<p>The estimate of 100,000-240,000 COVID-19 deaths occurs in a very different hypothetical future, one in which social distancing is maintained for a few more weeks. <a href="https://covid19.healthdata.org/united-states-of-america">Another model</a>, which assumes all states use social distancing measures until June, has a lower projection of around 60,000 COVID-19 deaths by August. Dr. Anthony Fauci, who serves on the White House coronavirus task force, <a href="https://www.today.com/video/dr-anthony-fauci-virus-death-toll-may-be-more-like-60-000-than-100-00-to-200-000-81825861735">said Thursday</a> that he now believes the toll will be closer to that lower number.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326854/original/file-20200409-87491-1sw6jss.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Statistical models project how interventions might lower the death toll from pandemics.</span>
<span class="attribution"><span class="source">CDC</span></span>
</figcaption>
</figure>
<p>How effective will our current interventions be at saving lives? To answer that question, we compare hypothetical futures and calculate the difference in number of deaths. The answer changes depending on which futures are compared.</p>
<p>For example, if we compare the two futures presented by the White House, between 1,260,000 and 2,100,000 lives will be saved in the U.S. by preventing COVID-19 infections. Those numbers are why we should stay home for now and continue social distancing.</p>
<p>To determine <a href="https://www.statnews.com/2020/03/25/coronavirus-experts-craft-strategies-to-relax-lockdowns/">when to let up on social distancing</a>, one must similarly compare hypothetical futures. But we also must consider what else will be going on in these hypothetical worlds.</p>
<p>Will public health surveillance and contact tracing be scaled up? Will everyone be wearing face masks in public? The answers to these further questions will determine what will happen when social distancing measures are relaxed. As the number of modifiable variables rises, so does the number of hypothetical futures to contemplate.</p>
<h2>Which number matters most?</h2>
<p>In comparing deaths, outbreak modeling typically focuses only on those deaths that result from the direct physiological effects of the pathogen. However, there are other deaths to consider, due to other effects of the virus and our interventions. </p>
<p>A steep, unchecked rise in infections would overwhelm the health system, risking further deaths not only among patients with COVID-19 but also among other sick people who need health care. </p>
<p><a href="https://www.nytimes.com/2020/03/23/opinion/coronavirus-depression.html">Prolonged social distancing</a> has economic implications, as does an <a href="https://www.theguardian.com/commentisfree/2020/mar/25/there-is-no-trade-off-between-the-economy-and-health">uncontrolled outbreak</a> or a secondary outbreak that might occur if social distancing measures are lifted in the wrong circumstances. An economic downturn, including job losses, has far-reaching and sometimes surprising effects on <a href="https://www.sciencedirect.com/science/article/pii/S0091743514001224">health and survival</a>.</p>
<p>Another important caveat is that the effects of our interventions, like all epidemiological numbers, <a href="https://theconversation.com/why-a-one-size-fits-all-approach-to-covid-19-could-have-lethal-consequences-134252">also depend on population and place</a>. </p>
<p>When comparing <a href="https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-Global-Impact-26-03-2020v2.pdf">higher-income countries with lower-income</a> countries, distributions of age and diseases and patterns of social interaction and health care resources often differ substantially, which can influence the effects of COVID-19 interventions like social distancing policies. Their effectiveness can’t be <a href="https://link.springer.com/article/10.1007/s11229-019-02255-0">simply extrapolated</a> from one context to another.</p>
<p>Ultimately, deciding which effects of our interventions to measure and how to measure them is not a purely scientific problem; it is also an <a href="https://www.nejm.org/doi/full/10.1056/NEJMsb2005114">ethical</a> problem. Summing deaths assigns moral worth to life and treats all lives equally. Counting life-years lost and effects on quality of life assumes that how much life is lived and how it is lived also matters. Some effects are more difficult to quantify or predict but must not be ignored, especially when we have the ability to offset them with further action.</p>
<p>We must think more broadly than an outbreak model thinks.</p>
<p>In a pandemic, numbers can tell us a lot. They speak more to us the more deeply we understand them.</p>
<p>[<em>The Conversation’s newsletter explains what’s going on with the coronavirus pandemic. <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-daily">Subscribe now</a>.</em>]</p><img src="https://counter.theconversation.com/content/135758/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Fuller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A lot of numbers are being tossed around about COVID-19 and what to expect in the future. They’re being used to make critical public health decisions, but they aren’t as simple as they appear.Jonathan Fuller, Assistant Professor, Department of History and Philosophy of Science, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1345802020-03-26T11:10:25Z2020-03-26T11:10:25ZCoronavirus: why lockdown may cost young lives over time<figure><img src="https://images.theconversation.com/files/323223/original/file-20200326-133040-4hdlwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/flying-colors-against-cheerful-fans-photographing-1041429991">vectorfusionart/Shutterstock</a></span></figcaption></figure><p>COVID-19 will <a href="https://www.gov.uk/government/news/coronavirus-covid-19-scientific-evidence-supporting-the-uk-government-response">cause a lot of deaths</a> if we don’t curb the spread of infection successfully by <a href="https://www.theguardian.com/world/2020/mar/24/uk-coronavirus-lockdown-rules-what-you-can-and-cannot-do">lockdowns and other recently announced measures</a>. The pandemic is anticipated to disproportionately impact older people in the “baby boomer” generation – those aged between 55 and 74. In terms of fatalities, individuals over 70 years old are at the greatest risk, alongside those with underlying health conditions.</p>
<p>But what about the young? Some in the millennial and generation Z groups have bluntly described the pandemic as a “<a href="https://www.ft.com/content/6a880416-66fa-11ea-800d-da70cff6e4d3?fbclid=IwAR0fT6_f6CRNY8RtVZ1adcV1hibDGy7NNthft4TPKSngSbbfKPjAmfDtwFo">boomer removal</a>” on some social media channels. There have also been cases of young people ignoring social distancing rules and <a href="https://www.theguardian.com/world/2020/mar/18/fears-lockdown-parties-will-increase-global-spread-of-coronavirus">throwing wild parties</a>, both in Europe and North America – creating an escalating conflict between generations.</p>
<p>This may be partly fuelled by long, simmering resentment among the young of perceived widespread <a href="https://www.theguardian.com/society/2018/apr/29/millennials-struggling-is-it-fault-of-baby-boomers-intergenerational-fairness">boomer entitlements</a>, such as easier access to property ownership, secure pensions and affluent retirement. Their neglect of climate change impacts is another trigger. </p>
<p>But there are other legitimate reasons for concern. In the long run, we may see death rates among young as well as old people go up as a consequence of long periods of lockdown and isolation – something we must mitigate against.</p>
<h2>Economy and death rates</h2>
<p>It is extremely difficult to estimate the net impact on death rates from the COVID-19 crisis. We know that lockdown measures will save thousands of lives. This isn’t just in terms of reducing infection, but also due to improved air quality and a reduction in traffic accidents. But we also know that the pandemic will have a <a href="https://www.weforum.org/agenda/2020/03/coronavirus-covid-19-cost-economy-2020-un-trade-economics-pandemic/">severe impact on the economy</a> over a <a href="https://www.bbc.co.uk/news/business-52000219">number of years</a>. This is also likely to cost lives. </p>
<p>Past downturns and crises have led to increasing unemployment but also growing mental health problems and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953615301350">spikes in suicide rates</a> in many countries. In the UK, 6,507 people killed themselves in 2018 – that’s nearly twice the number of deaths seen in Spain from the coronavirus. And research estimates that the 2007 economic crisis in Europe and North America <a href="https://www.bbc.co.uk/news/health-27796628">led to more than 10,000 extra suicides</a>.</p>
<p>What’s more, in the early stages of the COVID-19 crisis, before the UK government offered financial help to support employees, many firms conveniently made people redundant and activated rapid plant or outlet closures. A number of studies have shown that substantial job displacement in other contexts <a href="https://academic.oup.com/qje/article-abstract/124/3/1265/1905153?redirectedFrom=fulltext">significantly increased mortality rates</a> over time, possibly through stress and income shocks.</p>
<p>Generally, the young have been more resilient to these problems, <a href="https://psycnet.apa.org/record/2015-23321-001?doi=1">enjoying greater success in reemployment</a> following job loss. They are also better placed to <a href="https://www.tandfonline.com/doi/full/10.1080/13676261.2016.1166192">migrate to places</a> with stronger economies. At the moment, though, poor economic prospects are becoming globally widespread – most likely for some time to come. And research has shown that poverty kills, with poor people <a href="https://www.imperial.ac.uk/news/189149/poorest-dying-nearly-years-younger-than/">dying nearly ten years earlier</a> than rich people in the UK.</p>
<h2>Current mitigation</h2>
<p>The UK government has already increased and redirected resources to the National Health Service (NHS) and civil emergency authorities. It has also put forward a substantial <a href="https://www.cityam.com/government-launches-330bn-coronavirus-business-loan-scheme/">business</a> and <a href="https://www.bbc.co.uk/news/business-51982005">labour market</a> rescue and mitigation package. </p>
<p>While these measures will go some way to sustain business continuity and income for company employees, they are not yet comprehensive in coverage. At the time of writing, the package excludes many young adults, including those who work as freelancers, are self-employed or in “gig” economic sectors. More of the young also rent their accommodation, or live where they work (such as nannies).</p>
<p>And if lockdown measures including closed shops and restaurants remain active for several months, this will cost the economy. Despite the Bank of England lowering interest base rates to 0.1%, their lowest ever level, this is unlikely to cause an uplift or acceleration in investment plans anytime soon. </p>
<p>While the government’s package of measures <a href="https://www.bbc.co.uk/news/business-51935467">comprise some 15% of current UK GDP</a>, this may well turn out not to be enough. It will need to inject huge additional sums into the NHS and other direct expenditures for managing the virus.</p>
<p>Inevitably, the crisis will <a href="https://www.weforum.org/agenda/2020/03/covid-19-economic-crisis-recession-economists/">cause the economy to further contract</a> and the scale of the dip in economic activity could be unprecedented in peacetime – decimating the quality of life and labour market prospects of the young in particular. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=604&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=604&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323224/original/file-20200326-132965-1ffmv7u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=604&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Poverty kills.</span>
<span class="attribution"><span class="source">Matthew Woitunski</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Despite this, Boris Johnson, the UK prime minister, has boldly suggested the country will be able to “<a href="https://www.bbc.co.uk/news/uk-51966721">turn the tide</a>” of the crisis in three months. It is not entirely clear if he means peak infection or the end of the crisis, but this view seems unduly rosy. The Spanish flu pandemic (1918-1920) <a href="https://www.jstor.org/stable/44446153?seq=1">featured three peaks</a>, so getting to the other side quicker may simply lead to the upside of a second peak a bit faster. </p>
<h2>Living with threat</h2>
<p>Young people are <a href="https://www.ucl.ac.uk/ioe/news/2019/feb/depression-rise-among-young-people-antisocial-behaviour-down-new-research-shows">already struggling with depression</a>. There is now a new dread to add to the list of existing crises – climate change, Brexit, housing and pensions. That’s another zoonotic virus pandemic. The economy will have to develop resilience to that, and it will come with a considerable price tag.</p>
<p>What’s more, for those identified as “key workers”, this is a time of very high job stress. Will younger key workers get burnt out? The risk is that they may consider complete career, lifestyle and location changes going forward. If so, without incentives to stay put, it would further degrade the UK’s resilience to a similar crisis. </p>
<p>It is reasonable to ask what the likely scale of these negative consequences will be across the generations after the crisis. Is there anything we could do now to help flatten the expected spikes in unemployment, poverty, mental health problems and suicide in the aftermath of this crisis?</p>
<p>We think that access to retraining and education without the associated burden of debt will be important. The government should also consider writing off existing education debts and create measures supporting geographical relocation within the UK and across borders. This would provide a basis for enabling freedom – socially and geographically. </p>
<p>The government should obviously do whatever it can to protect as many lives as possible. But it is important that the challenge of COVID-19 isn’t framed simply in terms of lives at risk from the virus versus the economy. Prolonged periods of unemployment, the stress of job fragility and poverty can also claim lives. Timely thought and action is needed to reduce that risk too.</p><img src="https://counter.theconversation.com/content/134580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We must put in measures to protect the young as well as the old.Alan Collins, Professor of Economics and Public Policy, Nottingham Trent UniversityAdam Cox, Principal Lecturer, University of PortsmouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/979522018-06-11T15:03:29Z2018-06-11T15:03:29ZPuerto Rico hurricane death toll: how the official and unofficial figures got it so wrong<p>A Puerto Rican judge <a href="https://edition.cnn.com/2018/06/05/us/puerto-rico-hurricane-maria-death-records/index.html">has ordered</a> the government to release detailed information on deaths during and after <a href="https://en.wikipedia.org/wiki/Hurricane_Maria">Hurricane Maria</a>, which ravaged the US territory in September 2017. The judge’s decision follows a saga that began when <a href="https://theconversation.com/why-puerto-ricos-death-toll-from-hurricane-maria-is-so-much-higher-than-officials-thought-97488">several sources challenged</a> the official <a href="https://edition.cnn.com/2017/12/09/us/puerto-rico-hurricane-deaths-and-assistance/index.html">death toll of 64</a>, estimating there had actually been more than 1,000 hurricane-related deaths.</p>
<p>Puerto Rico’s governor, Ricardo Rosselló, then attempted to kneecap further independent research by <a href="http://latinousa.org/2018/02/28/data-puerto-rico-institute-statistics-confirms-excess-deaths-hurricane-maria/">suspending further data releases</a>. This led to <a href="https://www.vox.com/2018/6/5/17429708/puerto-rico-hurricane-maria-death-toll-records-cnn-cip">a lawsuit</a> by CNN and the <a href="http://periodismoinvestigativo.com/category/english/">Center for Investigative Journalism</a> demanding access to detailed data.</p>
<p>The media coverage of the unofficial studies has, unfortunately, fuelled the confusion over how many people actually died. A typical headline about one widely covered Harvard survey misleadingly blared: “<a href="https://www.nytimes.com/reuters/2018/05/29/us/29reuters-puertorico-casualties.html">Study Hikes Hurricane Maria Death Toll to 4,645</a>.”</p>
<p><iframe id="T0ZRy" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/T0ZRy/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>But the pressure this publicity generated led to a more accurate estimate of around <a href="https://www.princetonpolicy.com/ppa-blog/2018/6/3/pr-releases-new-data-deaths-1400-not-4600">1,400 more deaths</a> than would normally be expected for the time period of September to December. This solid number is less than one-third of the much-hyped 4,645 estimate from the Harvard study, an unsurprising update of the independent studies <a href="https://www.researchgate.net/publication/325539271?channel=doi&linkId=5b13c1cda6fdcc4611dfebc4&showFulltext=true">including mine</a> and more than 20 times the official figure of 64. US lawmakers have <a href="https://www.vox.com/2018/6/10/17442578/puerto-rico-hurricane-death-toll-bill-congress">now proposed a bill</a> to standardise the way natural disaster death tolls are counted to prevent such disparities in the future.</p>
<p>But why was there so much confusion? Drawing on material from my <a href="https://www.futurelearn.com/courses/accounting-death-war/1/steps/347574">new online course</a> about accounting for war deaths, it’s possible to sort through the discrepancies and learn some vital lessons for how we should think about death tolls and the problems that arise with them more generally.</p>
<h2>Survey estimates are inherently uncertain</h2>
<p>The <a href="https://github.com/c2-d2/pr_mort_official/blob/master/misc/faq.md">Harvard researchers</a> interviewed 3,299 households and found roughly 15 deaths beyond predictions based on death rates in pre-hurricane years. They then scaled up this number to estimate that among the entire population between 793 and 8,498 people had died either directly or indirectly because of the hurricane, with the midpoint of this range being the 4,645 estimate.</p>
<p>The 793 to 8,498 range is known as a 95% uncertainty interval. Broadly, this means that there is a 95% chance that a random sample will represent the population well enough so that the actual figure is within this stated range. To put it mildly, this is a <a href="https://www.washingtonpost.com/news/fact-checker/wp/2018/06/02/did-4645-people-die-in-hurricane-maria-nope/?noredirect=on&utm_term=.67826a1c45e7">lot of uncertainty</a>. It’s as if a public opinion poll came out estimating that Donald Trump’s approval rating stood at 40%, with a margin of error of plus or minus 33 percentage points. There would be laughter. </p>
<p>But while the media tends to be savvy about error margins in opinion polls, it lowered its standards for the Harvard study. Even high-quality outlets <a href="https://www.vox.com/science-and-health/2018/5/29/17405046/hurricane-maria-puerto-rico-deaths-harvard-study">treated uncertainty as an afterthought</a> or <a href="https://slate.com/news-and-politics/2018/05/harvard-study-finds-high-hurricane-maria-death-toll.html">characterized the 4,645 midpoint as a minimum</a> without even mentioning uncertainty. These reports look especially silly compared to the 1,400 figure we now have. </p>
<h2>Don’t expect a definitive list of victims</h2>
<p>Above, I was a little unkind to Governor Rosselló, because he partially offset his decision to shut down the data flow by hiring <a href="https://gwtoday.gwu.edu/sph-research-project-study-hurricane-mortality-puerto-rico">researchers from George Washington University</a> to investigate all post-hurricane deaths. But we shouldn’t expect this team to divide these deaths neatly into two groups of those that were caused by the hurricane and those that weren’t. If they try to do this then the work will not be compelling. </p>
<p>I have no idea what the GWU team is actually doing but I think they should find some direct deaths, some fairly clear indirect deaths and some murkier candidates for indirect deaths. The direct category should include, for example, people killed instantly by flying debris.</p>
<p>The clear indirect category might cover heart attack victims who died at home because the phone network was down and they couldn’t get to hospital. Even this type of classification must involve judgements that can be challenged. For example, some heart attack victims may have died anyway, even under optimal conditions.</p>
<p>There will be still murkier cases where something related to the hurricane might be just one among several potential causes of death. For example, our heart attack victim could die after his ambulance was a little late and the available nurse was a little inexperienced but makes no major error. Both these factors could be related to the hurricane but it would be difficult to prove they were the ultimate cause of the death.</p>
<h2>Transparency is key</h2>
<p>The official death count <a href="https://theconversation.com/why-puerto-ricos-death-toll-from-hurricane-maria-is-so-much-higher-than-officials-thought-97488">comes from</a> hurricane-related causes of deaths listed on death certificates. But “hurricane” is not a standard cause-of-death classfication and hurricane-related factors may not even be visible to a person filling out a death certificate.</p>
<p>For example, a doctor may just see a heart attack and correctly note this on a death certificate. Adding that the hurricane was a factor might require an investigation that would have to be conducted under adverse circumstances.</p>
<p>So it is not surprising that hurricane-related factors would not appear in many death certificates even when they might have really been present. The main mistake here is not that the tally of 64 exists in the first place but, rather, the idea that it might cover all the hurricane-related deaths</p>
<p>It was a bad idea for the the Puerto Rican government to stand behind the official death count, a worse idea for Governor Rosselló to <a href="http://latinousa.org/2018/02/28/data-puerto-rico-institute-statistics-confirms-excess-deaths-hurricane-maria/">suspend data releases</a> and an atrocious idea to <a href="https://docs.wixstatic.com/ugd/da1946_aab61ab3b7ea44c3bed97b5edafb8160.pdf">remove the independence</a> of the Puerto Rico Institute of Statistics. This authoritarian secrecy temporarily deprived us of data and bred suspicion and a truth-seeking impulse.</p>
<p>The Harvard study and the CNN-CIJ law suit both attempted to fill the data void. We now have the monthly data and soon should have all the death certificates and perhaps, other detailed information that was made available to the GWU team. Such forced openness will improve our understanding of Maria and future disasters, but these benefits come late and the damage to public trust will endure. I suspect that we will never quite shake a suspicion that there are 3,000 missing bodies that have not been found, but whose existence was proved by a crack Harvard team.</p><img src="https://counter.theconversation.com/content/97952/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Spagat does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government said 64, journalists said 4,645. What went wrong?Michael Spagat, Professor of Economics, Royal Holloway University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/878282017-12-01T11:29:01Z2017-12-01T11:29:01ZAusterity is linked to increased deaths – the data is clear<figure><img src="https://images.theconversation.com/files/196782/original/file-20171128-28913-hkh45j.jpg?ixlib=rb-1.1.0&rect=0%2C78%2C1022%2C688&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-uk-1st-july-2017-thousands-669759178?src=VLoSFxEkSf6-OyUfR0d3Pw-1-33">Thabo Jaiyesimi/Shutterstock</a></span></figcaption></figure><p>A recent <a href="http://bmjopen.bmj.com/content/7/11/e017722">BMJ study</a> showed that government cuts in England have caused extra deaths compared with trends before 2010. But how reliable are studies that link austerity with increased deaths?</p>
<p>There is strong evidence that budget cuts affect health. In Greece, the recent economic crisis led to large cuts in government spending. Spending on health was capped at six per cent of rapidly falling gross domestic product (GDP). A single example of the effect of this policy is on drug users and needles. In 2009, cuts were made in the number of syringes and condoms distributed by the government. In just three years, the number of new HIV infections <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62291-6/abstract">increased from 15 to 484</a> a year.</p>
<p>In Eastern Europe, the collapse of communism led to mass privatisations of key industries. This was strongly linked to increased deaths in men of working age. This was partly due to an <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60005-2/abstract">increase in alcohol consumption</a>, some of which was not produced for human use.</p>
<p>There is also a link between spending cuts and increases in suicide. This was seen in the US <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60102-6/abstract">during the Great Depression</a> and during the recent <a href="http://www.sciencedirect.com/science/article/pii/S0277953615301350#abs0010">Eurozone crisis, particularly in Greece</a>.</p>
<h2>Limitations</h2>
<p>We see that there is good evidence linking cuts to deaths, but these studies have limitations. The first is that we don’t see the alternative scenario. What would have happened if the cuts had not been made; we see increases in deaths, but could they have been avoided? A partial solution is to look at countries that avoided austerity. </p>
<p>One example is Iceland, which rejected an International Monetary Fund rescue package in a referendum. This led to a collapse in their currency, but <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60102-6/abstract">little or no ill effect on health</a>. So we can only guess how a similar policy would have affected Greece. And would a much larger country in the Eurozone have had a similar experience?</p>
<p>It is also well known that association does not imply causation. An association only needs two outcomes to be correlated. Causation means there is a direct link from one outcome to another, which is difficult to prove. </p>
<h2>Plausible causation</h2>
<p>There are many examples of outcomes that are <a href="http://www.tylervigen.com/spurious-correlations">spuriously correlated</a>. However, it is plausible that austerity caused extra deaths. This suggests that governments should at the very least consider whether their policies are causing unnecessary deaths.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=237&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=237&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=237&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=297&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=297&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196787/original/file-20171128-28892-xeavf7.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=297&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Example of a spurious correlation.</span>
<span class="attribution"><a class="source" href="http://www.tylervigen.com/spurious-correlations">Tylervigen.com</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Although some studies have attempted to predict future mortality and life expectancy, the findings may be implausible or depend heavily on certain assumptions. Even sophisticated statistical models can give quite different answers, and <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32381-9/abstract">can be affected by quirks in the data</a>.</p>
<p>There are also issues with the data these assumptions are based on. Current mortality data in wealthy countries is known to be generally accurate. This was not the case in the past, and is <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61719-X/abstract">not the case now in poorer countries, for example in sub-Saharan Africa</a>.</p>
<p>To say what caused deaths is much harder than counting them, particularly for older patients who may be <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61347-7/abstract">suffering from several illnesses</a>. </p>
<p>Much of the data and analysis is at national level. This may hide important differences between cities or regions. It may also miss unnecessary illnesses or deaths in certain social groups. </p>
<p>Finally, there will not be any data on the long-term effects of recent austerity for several decades.</p>
<p>These issues are either unavoidable or difficult to resolve. This means scientists, including in academia and at bodies like the World Health Organisation, need to study the effects of economic policies in as much detail as they can. As statisticians, we have much more data than in the past and can analyse it more easily. We need to give governments and the media as much evidence as possible. This will will help politicians and voters to make informed choices during the next economic crisis.</p><img src="https://counter.theconversation.com/content/87828/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Bentham does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A look behind the statistics that link government spending cuts with increases in death.James Bentham, Lecturer in Statistics, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/752062017-04-03T19:22:49Z2017-04-03T19:22:49ZHealth-care spending has only a modest effect on lifespan and premature death<figure><img src="https://images.theconversation.com/files/163260/original/image-20170330-15595-y9p3he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new analysis found spending on health doesn't have a big effect on whether people die prematurely. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><a href="http://www.sciencedirect.com/science/article/pii/S0277953617301132">A new analysis has found</a> spending more on health care has little impact on improving key health outcomes. It found that a 10% increase in health-care spending reduces the number of deaths by only 1.3%, and increases life expectancy by only 0.4%. </p>
<p>Our new meta-analysis, which pooled results from 65 studies, looked at health-care spending by both the private and public sectors including preventive and curative care.</p>
<p>Health-care spending as a share of GDP has nearly doubled in <a href="http://www.oecd.org/els/health-systems/health-data.htm">OECD countries</a> since 1970. Death rates fell in OECD countries by 86% during this period. While this is a great achievement, given our study found health spending improves death rates by only a small amount, the doubling of spending explains only a small fraction of this large improvement in health. This is because health-care spending is only one of many factors that affect health. </p>
<p>Our analysis looked at two measures of health: life expectancy and death rates, which are major health status indicators. These are two of the most important measures of health status, but health care treats a large number of diseases and conditions not investigated by our study.</p>
<p>Our analysis also showed public health-care spending is more effective in reducing death than private spending, contrary to <a href="http://www.tandfonline.com/doi/abs/10.1080/00036840210135665?journalCode=raec20">some earlier studies</a>. We found no real difference between the effect of spending on health in developed and developing countries, or between genders.</p>
<h2>Wealthier countries spend more on health</h2>
<p>Health-care spending per person has risen throughout the world. In 2014, the high-income OECD countries spent, on average, the equivalent of <a href="http://api.worldbank.org/v2/en/indicator/SH.XPD.PCAP.PP.KD?downloadformat=excel">US$4,698</a> per person on health. In Australia we spent US$4,357 per person. These amounts are significantly higher than the global average of US$1,276 per person. </p>
<p>Over time, spending on health has been diverging between high-income countries and the rest of the world, with spending in high-income countries growing faster than in other countries. This raises the issue of value for money, especially in the USA where spending is US$9,403 per person. This is despite having pretty <a href="https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus">poor outcomes</a> compared to money spent.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Richer countries spend more on health care. Data here are in international dollars, adjusted for inflation and purchasing power price differences.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Even though spending is diverging among countries, some health outcomes are becoming similar over time between developed and developing countries. For example, child mortality has fallen throughout the world but the fall has been greater in non-OECD countries.</p>
<p>In 1960, <a href="http://api.worldbank.org/v2/en/indicator/SH.DYN.MORT?downloadformat=excel">child mortality</a> in OECD countries was 63 deaths per 1,000, compared to 183 in the world as a whole. This is a difference of 120 deaths. By 2015, mortality in the OECD countries fell to seven deaths per 1,000 and in the world as whole mortality fell to 43.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The gap in child mortality between the OECD and all nations is narrowing.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>And while <a href="http://api.worldbank.org/v2/en/indicator/SP.DYN.LE00.IN?downloadformat=excel">life expectancy</a> has increased globally, the gap between OECD countries and all countries has remained largely unchanged.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Life expectancy has increased globally but a large gap remains between nations.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>So where should the money go?</h2>
<p>So it follows from our study that household income, education, wealth inequality, demographics and lifestyle choices play a collectively more important role in improving health. Lifestyle choices include nutrition, physical activity, and the consumption of alcohol and tobacco. </p>
<p>Some health-care spending is <a href="http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/tackling-wasteful-spending-on-health_9789264266414-en#page1">wasted</a> on <a href="https://theconversation.com/why-were-wasting-money-on-medical-tests-and-how-behavioural-insights-can-help-72801">unnecessary procedures</a>, <a href="https://theconversation.com/how-to-slash-half-a-billion-dollars-a-year-from-australias-drugs-bill-73050">slow uptake of generic drugs</a> and administrative inefficiencies. Some of this is possibly due to the influence of powerful interest groups such as the pharmaceutical industry and medical bureaucracies.</p>
<p>The finding that public funding of health care results in a slightly larger reduction in premature death than private funding highlights the importance of directing funding to government hospitals and other public health measures. Progress in medical technology – for example, in fighting cancer and heart disease – is especially important and warrants additional funding.</p><img src="https://counter.theconversation.com/content/75206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Doucouliagos does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our new meta-analysis, which pooled results from 65 studies, looked at health-care spending by both the private and public sectors including preventive and curative care.Chris Doucouliagos, Professor of Economics, Department of Economics, Deakin Business School and Alfred Deakin Institute for Citizenship and Globalisation, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/677012016-10-26T09:15:05Z2016-10-26T09:15:05ZDeaths at Dreamworld theme park could lead to safety changes for amusement rides<p>Investigations are under way following the tragic accident at the <a href="https://www.dreamworld.com.au/">Dreamworld</a> theme park on the Gold Coast on Tuesday that <a href="http://www.theaustralian.com.au/news/latest-news/large-investigation-into-dreamworld/news-story/a2e6337e39e0f6e2604b17d3f95c64da">left four people dead</a>.</p>
<p>Queensland Police <a href="http://mypolice.qld.gov.au/blog/2016/10/26/update-2-critical-incident-death-investigation-coomera-gold-coast-2/">say initial investigations show</a> that six people were on board one of the rafts on the Thunder River Rapids ride when it “impacted” with another raft. This caused the raft to upturn.</p>
<p>Luke Dorsett, 35, and his sister Kate Goodchild, 32, Dorsett’s partner, Roozi Araghi, 38, and Cindy Low, 42, from New Zealand, died at the scene.</p>
<p>A 10-year-old boy and a 12-year-old girl escaped uninjured in what one police officer described as a “<a href="http://www.sbs.com.au/news/article/2016/10/26/dreamworld-tragedy-victims-identified-major-investigation-underway">miracle</a>”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"790816954315640833"}"></div></p>
<p>There will be a coronial investigation into the four tragic deaths. The coroner has wide powers of investigation and can request additional reports, statements or information about the death.</p>
<p>Additional information may be obtained from investigators, police, doctors, engineers, workplace health and safety inspectors, mining inspectors, air safety officers, electrical inspectors or other witnesses.</p>
<p>Once the coroner has completed these enquiries, he will consider whether to hold <a href="http://www.courts.qld.gov.au/courts/coroners-court/common-questions/inquests">an inquest</a> into the deaths. The coroner will consult with the family about this and the families can also request the coroner to hold an inquest.</p>
<h2>Safe rides</h2>
<p>That the deaths occurred at a place designed for fun and amusement makes it all the more tragic. But statistically, amusements rides are very safe. </p>
<p>Figures <a href="http://www.hse.gov.uk/risk/theory/r2p2.pdf">from the Health Safety Executive</a> in the UK confirm that there is one death in 834,000,000 rides.</p>
<p>This is very small when compared with deaths from aircraft travel, where the HSE reports there is one death for each 125,000,000 passenger journeys, or scuba diving where there is one death for every 200,000 dives.</p>
<p>In Australia amusement rides and devices are controlled by the Work Health and Safety Legislation. </p>
<p>The rules vary between jurisdictions, but have their origins in the old Machinery Acts, as amusement rides are for all intents and purposes potentially hazardous pieces of machinery to which the general public is exposed.</p>
<p>Worksafe Australia <a href="http://www.safeworkaustralia.gov.au/sites/swa/about/publications/pages/guidance-amusement-devices">defines</a> an <a href="http://www.safeworkaustralia.gov.au/sites/swa/about/publications/pages/guidance-amusement-devices">amusement device</a> as:</p>
<blockquote>
<p>[…] an item of plant operated for hire or reward that provides entertainment, sightseeing or amusement through movement of the equipment, or part of the equipment, or when passengers or other users travel or move on, around or along the equipment.</p>
</blockquote>
<h2>Standards of design</h2>
<p>The Dreamworld Thunder River Rapids Ride has been operating since December 1986. At the time of installation there was no Australian Standard specifying the minimum design and construction safety requirements for any amusement rides in Australia.</p>
<p>The first Amusement Rides and Devices Australian Standard was published some two years later, as AS 3533:1988. This Standard has been constantly updated and amended with more and more detail and guidance.</p>
<p>It is worth noting that this Standard is classified as mandatory, as it is called up in legislation. This means that amusement ride operators are breaking the law if they do not <a href="http://www.austlii.edu.au/cgi-bin/sinodisp/au/legis/qld/consol_reg/whasr2011309/sch5.html?stem=0&synonyms=0&query=(as3533%20or%20%22as%203533%22%20or%20australian%20standards%20w/3%203533)">comply with its requirements</a>.</p>
<p>There is a separate Australian Standard AS 3533.2:2009 that is dedicated to the operation and maintenance of rides, where Section 5 says:</p>
<blockquote>
<p>All maintenance, replacements, repairs and inspections of amusement rides and devices, including discrete systems and components within them, shall be carried out by competent persons and shall be —</p>
<p>a) wherever possible, in accordance with the designer or manufacturer’s instructions;</p>
<p>b) fully documented; and</p>
<p>c) recorded in the log with the device or recorded and kept elsewhere for future reference (see also Clause 5.5).</p>
</blockquote>
<p>In the absence of instructions from the designer or manufacturer, those competent persons involved in the maintenance, replacement, repair and inspection of amusement rides should be able to demonstrate a knowledge of the original intentions of the designer or manufacturer.</p>
<h2>Safety checks</h2>
<p>Planned maintenance programs and inspection routines should be implemented for the moving and load-bearing components and structural members of an amusement device. </p>
<p>This is to maintain mechanical and structural integrity. It is also designed to identify areas where excessive rust, wear, fatigue or any other condition could lead to the failure of such components and compromise the safety of patrons and operating staff.</p>
<p>Maintenance plans should be reviewed based on the results of previous inspections and updated to address any identified needs.</p>
<p>Following major maintenance and repair, and at random intervals on other occasions, a hazard identification and risk assessment procedure should be completed to make sure new hazards are not present and residual risks identified by the designer or manufacturer are not increased.</p>
<p>Provided an amusement ride is adequately maintained in accordance with the relevant Australian Standard, it should be able to operated safely indefinitely.</p>
<p>So what went wrong at Dreamworld yesterday? It’s too early to say what the investigation will uncover.</p>
<p>But it is important to note that it is the norm for the coroner to make recommendations about broader issues connected with the deaths. This could include amendments to the Standards Australia AS 3533 to ensure that a tragedy such as this can never happen again.</p><img src="https://counter.theconversation.com/content/67701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Eager is a Fellow of Engineers Australia and represents them on the Standards Committee ME-051 Amusement Rides and Devices.</span></em></p>Investigations into the tragic accident which left four people dead at an amusement park could lead to changes in the safety regulations.David Eager, Assistant Student Ombud and Associate Professor, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/622882016-08-25T20:21:21Z2016-08-25T20:21:21ZWhy males are more likely to die from conception to old age<figure><img src="https://images.theconversation.com/files/134062/original/image-20160815-15267-1t0eiz0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the animal kingdom, males are somewhat dispensable, which might explain why males are more likely to die. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Sexual inequality begins in the womb, but not in the way you might think. In a <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158807">study of more than 574,000 births</a> in South Australia between 1981 and 2011, we found boys are more likely to be born preterm and the risk is greater for boys the earlier the birth.</p>
<p>Mothers expecting boys <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158807">are also more likely</a> than mothers of girls to suffer pre-eclampsia (a serious disorder of pregnancy characterised by high blood pressure, fluid retention and protein in the urine), gestational high blood pressure or gestational diabetes late in pregnancy.</p>
<p>Many more boys are conceived than girls. Despite this the sex ratio at birth is only slightly in boys’ favour. <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129554140">For every 100 girls born in Australia</a> 106 boys are born, a statistic that <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_20.pdf">holds across most human populations</a>. But males are more likely to die before females at all ages from conception to old age, which we think explains why Australia is around 51% female despite fewer girls being born.</p>
<p>Miscarriages and stillbirths are <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(99)05061-8/fulltext">more likely to involve males</a>. After birth, <a href="http://www.aihw.gov.au/publication-detail/?id=10737423343">male babies are also more likely to die</a> or suffer major illness. <a href="http://www.aihw.gov.au/child-health/health/#chronic">Australian Institute of Health and Welfare</a> data show boys make up 75% of SIDS deaths, 54% of cancer diagnoses, 60% of infant deaths and are more likely to be disabled (often associated with preterm birth).</p>
<p>As males and females age, <a href="http://www.aihw.gov.au/publication-detail/?id=60129556205">disparities in the burden of diseases</a> are prevalent in Australia. Greater numbers of men suffer heart disease (59%), endocrine disorders including type 2 diabetes (57%) and cancer (56%). </p>
<p><a href="http://www.aihw.gov.au/publication-detail/?id=60129556205">Some conditions, however, are more likely in women</a>. These include blood and metabolic disorders (59%), neurological disorders including dementia (58%) and musculoskeletal conditions including arthritis (56%). There is also a female predominance in many auto-immune diseases.</p>
<h2>Why are men more likely to die earlier?</h2>
<p>We don’t know for sure why there are differences in disease prevalence, severity, age of onset and even symptoms between the sexes, but <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158807">our research suggests</a> genetic differences between males and females could contribute to differences in the uterus. </p>
<p>Males have XY sex chromosomes and females have XX sex chromosomes. We found 142 genes are expressed differently between normal male and female placentas delivered at term. About a third of the genes are on the sex chromosomes, but two-thirds are on the autosomes (non-sex chromosomes) and <a href="http://molehr.oxfordjournals.org/content/20/8/810.full.pdf+html">only a small number</a> are associated with hormones.</p>
<p>The greatest sex differences are in the brain, specifically in the anterior cingulate cortex, which controls things such as heart rate and blood pressure as well as some emotion and decision-making (1,818 genes), followed by the heart (375 genes), kidney (224 genes), colon (218 genes) and thyroid (163 genes). In other organs, sex differences were mostly confined to genes on the sex chromosomes and those involved in hormone production.</p>
<p>Since defects in how the placenta develops and functions are associated with pregnancy complications, it is likely the placenta is a key contributor to the different outcomes we see between pregnancies carrying boys versus girls. These probably hark back to our evolution. </p>
<h2>Evolution and the battle of the sexes</h2>
<p>In the animal kingdom, males are somewhat dispensable, with the dominant male the most likely to breed with multiple females each season. Thus, in many species, it is only the biggest, strongest and fittest males who reproduce. </p>
<p>Bigger babies are more likely to survive birth and infancy and grow up to reproduce. So maintaining fetal and post-natal growth makes the male more likely to pass on his genes. </p>
<p>Females, conversely, will almost always reproduce and pass on their genes – assuming they survive to adulthood. So the growth strategies of the male and female fetus focus on passing on their genes to the next generation.</p>
<p><a href="http://ac.els-cdn.com.proxy.library.adelaide.edu.au/S0143400409003737/1-s2.0-S0143400409003737-main.pdf?_tid=c5f8de8c-63f8-11e6-9884-00000aacb35e&acdnat=1471383261_e12969438f886b805a73f3e0d72efbf0">Research has found</a> sex differences in how the fetus responds to maternal asthma. Asthma attacks in pregnancy, which are akin to an inflammatory storm, cause the female fetus to taper her growth in response. In so doing, the female fetus is more likely to survive. </p>
<p>However, a maternal asthma exacerbation does not affect the growth of the male fetus. He keeps growing at the same rate but places himself at risk of preterm birth and stillbirth should another asthma attack occur.</p>
<p>The <a href="http://journals.cambridge.org.proxy.library.adelaide.edu.au/download.php?file=%2FDOH%2FDOH1_01%2FS2040174409990171a.pdf&code=078d4b518ca27fa79a5cdd4ecca8b84c">developmental origins of health and disease</a> thesis links the growth and development of the fetus to the health of the infant, child and adult. How well we grow in utero strongly influences our propensity for adult onset diseases. The fetus is said to be programmed in utero for health or disease across the life course.</p>
<p>So how well you grow in the uterus is influenced by your genetics but also by environmental factors. Together these shape your health for life and sex matters.</p><img src="https://counter.theconversation.com/content/62288/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Roberts receives funding from the National Health and Medical Research Council (NHMRC), the Channel 7 Children's Research Council and the University of Adelaide.</span></em></p>Miscarriages and stillbirths are more likely to involve males. After birth, male babies are also more likely to die or suffer major illness.Claire Roberts, Senior Research Fellow, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/549462016-02-29T02:44:57Z2016-02-29T02:44:57ZYour local train station can predict health and death<p>The association between life expectancy and postcodes, neighbourhood locations or train stations has been demonstrated in many different locations around the world. These include <a href="http://life.mappinglondon.co.uk/">London</a> and <a href="http://jech.bmj.com/content/65/1/94.extract">Glasgow</a> in the UK and <a href="http://www.rwjf.org/en/library/infographics/life-expectancy-maps.html">across the US</a> including <a href="http://www.californiamuseum.org/health-happens-here-california-museum">California</a>. </p>
<p>These studies paint a powerful picture of health inequalities across neighbourhoods and cities. They also concisely communicate the importance of social determinants of health. More simply, they tell us that <a href="http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023">health starts where we live, work, learn and play</a>.</p>
<p>In an <a href="https://theconversation.com/how-do-we-create-liveable-cities-first-we-must-work-out-the-key-ingredients-50898">earlier article</a>, we have argued that the liveability of an area is closely associated with the social determinants of health. A liveable neighbourhood should include the following key ingredients:</p>
<ul>
<li><p>is safe, socially cohesive and inclusive</p></li>
<li><p>environmentally sustainable and supported by trees and biodiversity</p></li>
<li><p>has affordable and diverse housing supported by public transport, walking and cycling</p></li>
<li><p>is linked to employment, education, public open space, local shops, health and community services, leisure, arts and culture. </p></li>
</ul>
<p>So what happens if you live in an area with more or less of these key ingredients? </p>
<p>The answer is postcode-related differences in health outcomes. These differences can be measured by death rates and life expectancy.</p>
<p>This has led to the development of clever communication tools that map life expectancy to train stations. Until now, such maps have not been produced for Australian cities.</p>
<h2>Living on the line in Melbourne</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1014&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1014&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1014&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1275&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1275&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112711/original/image-20160224-16436-1ulctv9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1275&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p><a href="http://www.communityindicators.net.au/">Community Indicators Victoria</a> at the University of Melbourne seeks to translate data into action. The project has developed a map that demonstrates the existence of health inequalities across Melbourne using data from the Australian Bureau of Statistics (ABS). We have mapped area-level disadvantage using the Index of Relative Socio-Economic Disadvantage (<a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/2033.0.55.001main+features100052011">IRSD</a>) with <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3302.0">age-standardised death rates</a> and linked these data to the Melbourne metropolitan rail network. </p>
<p>Large cities in the UK and US have large populations that enable the development of life expectancy data for small areas. In Australian cities we don’t have the population numbers to reliably create these same life expectancy statistics at very small neighbourhood areas. </p>
<p>We have chosen age-standardised death rates as the best statistical approximation to life expectancy to create our map for Melbourne. The map investigates the relationship between area-level deprivation (IRSD), death rates (taking into account age differences for areas) and nearest train station as an approximation for location.</p>
<p>The map shows that areas with greater disadvantage (shown in darker grey) tend to have higher death rates. This is most easily seen in the western and northern areas of Melbourne, but can also be seen along the Dandenong-Pakenham train line.
In comparison, the majority of areas across the eastern suburbs have both low death rates and low levels of area-based disadvantage.</p>
<h2>Mapping other cities</h2>
<p>With the support of publicly available ABS data, such maps can be reproduced for cities across Australia. These will no doubt produce more interesting and thought-provoking results, which should stimulate future debate about area-based health inequities across the country. </p>
<p>Health-based inequities occur for many reasons. They are exacerbated, however, by a lack of access to job opportunities and services – such as public transport and mental and physical health care – which determine health outcomes. </p>
<p>These services are harder to access in outer suburb growth areas such as those in the western, northern and southern areas of Melbourne. Without these services people’s livelihoods and health suffer as shown in the Melbourne version of the “Living on the Line” map.</p>
<p>Such maps are a powerful reminder that good health planning should be integrated across government portfolios. Health budgets also need to be spent on broader public health promotion and planning that extends well beyond hospital funding and basic health service provision.</p><img src="https://counter.theconversation.com/content/54946/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Davern receives funding from the Victorian Health Promotion Foundation.</span></em></p><p class="fine-print"><em><span>Lucy Gunn receives funding from the NHMRC Centre for Research Excellence in Healthy Liveable Communities.</span></em></p><p class="fine-print"><em><span>Rebecca Roberts does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Where you live affects your health and life expectancy. This makes it possible to map health outcomes against train stations, so that you can readily see the inequalities across cities like Melbourne.Melanie Davern, Senior Research Fellow, McCaughey VicHealth Community Wellbeing Unit, and Director, Community Indicators Victoria, The University of MelbourneLucy Gunn, Research Fellow, Community Indicators Victoria, McCaughey VicHealth Community Wellbeing Unit, The University of MelbourneRebecca Roberts, Academic Specialist (GIS Analyst), Community Indicators Victoria, McCaughey VicHealth Community Wellbeing Unit, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.