透视死亡数据，这是你所不知道的美国

今天让我们聊聊死亡。

不久前，我有幸和鲍勃•安德森畅谈。安德森是美国疾病预防与控制中心（CDC）旗下国家卫生统计中心（NCHS）的人口死亡统计部门主任，主管统计美国人死亡数据。

上次我们聊天是在2009年，当时安德森和下属刚刚整理出2006年美国人死亡数据。他们收集了全美50个州，哥伦比亚特区、波多黎各和关岛等五个海外属地岛屿以及纽约市所有的死亡人口记录，耗时整整30个月。然后他们查漏补缺（某些州死亡原因全盘做了调整），消除了数据之间不一致之处，以几百种方法对数据进行分类、交叉引用并制表，最后将大量数据制成一份结构严密的报告。

就在2009年，各州死亡人口数据的很多处理工作还都靠人力手工完成，现在听起来有点不可思议。而今，以上57个汇报死亡数据的美国司法辖区之中，除了五个海外属地和六个拒绝合作的州（西弗吉尼亚、北卡罗来纳、密西西比、田纳西、罗德岛和康涅狄格）以外，其余都采用电子文件处理大部分数据。现在一名美国公民过世不到十天，47%的相关死亡数据就会发送给安德森的团队。美国全国的死亡人口记录现在只需约11个月就可完成。

进步得来不易。

现代人类大概有8000种死法，也就是说世界卫生组织制定的最新版即第十版《国际疾病分类》（ICD）里，将人类死因分为约8000类。安德森和团队里的统计学家、分析师和疾病分类专家在马里兰州海厄茨维尔市一栋七层高的办公楼工作，办公地点在第五层。他们很快会发布2015年美国死亡人口报告，详细记述当年去世的271.1263万美国人死因是哪些。（去年12月CDC已经发布一份临时数据概要。）

说到人们离世的原因，其实并非总像白纸黑字的死亡证明一样直观。死亡案例都由主治医生、验尸官或者法医判定，而判定的依据往往是死者家人提供的病历，或者肉眼可见的原因，比如发生车祸或者遭遇枪击。和罪案电视剧造成的印象截然不同，现实中很少进行正式验尸。（近来送往实验室由法医验尸的死者不足十分之一。）绝大多数情况下，都是没受过法医专门培训的医生判定死因。可以想见，判断失误在所难免。

不过整体而言，死因判断错的还是少数，有时可能是将直接死因和间接死因弄混，有时可能分不清两种形式的疾病。尽管可能存在种种失误，但在研究某地人口医疗健康时，死亡证明还是最可靠的文件证据。离开死亡证明，几乎不可能了解疾病造成的负担，也几乎不可能大规模开展流行病学研究。研究美国人伤亡情况时，死亡证明比任何公开或私人的记录都更详实。对制定医疗政策的官员而言，死亡证明是最关键的参考依据，其他资料都比不上。

外科医生在死因一栏签字以后，一般由葬礼承办人提供死亡证明里的其余信息——死者是谁，年龄多大，何时、何地身故等等，然后将死亡证明表格发送当地或州人口统计署。相关州的工作人员会向安德森在NCHS的团队发去一份死亡评估记录。安德森的团队会根据ICD列举的8000多种可能死因找到匹配的编码。ICD实际使用和修订已有百年，已经成为全球最全面的死亡病例汇总纲要。（讽刺的是，各种努力都无法实现的人类大同，由死亡成功实现了：ICD中各种字母与数字代码也许是全球唯一的几乎所有政府通用的语言。）

这就是统计美国死亡人口的方法，简单直白，纯工业化运作。令人称奇的是，年复一年枯燥数字却生动又详尽地描述了很多细节，从中可见一个国家的人们如何告别人世，从某种程度上也能看出人类生活的万象。

此刻的美国人自画像什么样？和此前一年相比，美国人显得更饱经风霜，有些人仿佛没什么活力。2015年，美国人均寿命实际上缩短了，从2014年的78.9岁降至78.8岁，相当于减少了一年的十分之一。这是二十多年来首次出现寿命同比下降。也是在2015年，十大死因之中有八个造成的死亡人数均出现增加，因此年龄调整后美国死亡率整体上升了1.2个百分点。

事实上，十大死因中的阿尔茨海默病相关死亡率并没有小幅上扬，而是大增，死于该病的美国人同比增长了15.7%。CDC的一份报告称，1999年到2014年，阿尔茨海默病致死的美国人攀升了55%。数字已经拉响警报，是该引起重视了。

“阿尔茨海默症导致的死亡率上升不单单是死亡的问题，对患者的健康也有直接的影响，”CDC报告坦言，“这种病让人身体日渐虚弱”，不但使患者本人及家人背负庞大的医疗费用，也给美国州和郡政府带来巨大的财政负担。因为地方政府要维持运营公共的长期医疗设施。

在看护阿尔茨海默症和其他类型老年痴呆症患者的2590亿美元费用之中，三分之二以上都由美国联邦医疗保险计划Medicare和医疗补助计划Medicaid等公费医疗项目买单。但CDC指出：“对无力负担长期医疗费用的阿尔茨海默症病患来说，大部分医护都由家庭成员或者其他免费护工提供。”CDC估算，去年该病得到的免费救助时长合计达到182亿小时。（你没看错，单位是亿。）

通过死亡数据，安德森能清楚看到阿尔茨海默症患者的困境，也目睹了现实的美国社会：阿片类药物致死的人数明显激增，令人恐惧；婴儿死亡率让人欣慰地下降；自杀人数持续上升，原因一直不明。

安德森投身死亡数据统计纯属无心插柳。在宾州上大学时，他改过四次专业，毕业时拿到了人口统计学学位。即便毕业那会，他也更有兴趣研究婚姻和家庭数据，没想过要跟死亡数据打交道。他回忆说，当时“统计学家很难找工作”，他又正好看到一条死亡数据统计部门的招聘广告。也许，只是也许，安德森生来就注定干这份工作。他说：“我祖父曾经是爱达荷州麦迪逊郡的葬礼承办人，还开过救护车，还做过郡里的验尸官。”

当我问起20年来统计死亡有何心得，安德森很快回答：“人人都有一死。”

顿了顿，他又说了一句：“通过死亡可以从另一个角度看待生命。”

那句话让我难以忘怀。（财富中文网）

本文首发于6月6日期《财富》杂志的医疗健康领域每日简报Brainstorm Health Daily。

译者：Pessy

审稿：夏林

Happy Monday. Let’s talk about death.

I had the privilege of chatting with Bob Anderson on Friday. Anderson is the director of the Mortality Statistics Branch at the CDC’s National Center for Health Statistics, the group responsible for counting America’s dead.

The last time we had spoken was in 2009, and Anderson and his crew had just finished compiling the official tally of 2006’s fatalities. It had taken a full 30 months to gather records from all 50 states, the District of Columbia, the five island territories from Puerto Rico to Guam, and New York City—which, for odd reasons, maintained its own vital records—then plug the many holes (recoding the cause of death for some states entirely), clear up discrepancies, sort, cross-reference, tabulate the numbers in hundreds of ways, and summarize the lot into a single, cohesive report.

Back then, much of the processing of mortality data at the state level, almost unthinkably, was being done by hand. Now, with the exception of eleven of the 57 reporting jurisdictions above—the five territories and six holdout states (West Virginia, North Carolina, Mississippi, Tennessee, Rhode Island, and Connecticut)—the process has become mostly electronic. Currently, 47% of death records are sent to Anderson’s team within 10 days of the person’s passing. The entire national tally now takes about eleven months to complete.

It’s no mean feat.

There are roughly 8,000 ways to die—which is to say there are about 8,000 categories in the 10th and latest edition of the International Classification of Diseases. And Anderson and his crew of statisticians, analysts, and nosologists on the fifth floor of a seven-floor office building in Hyattsville, Maryland, will soon publish their report detailing precisely which of those ways took the lives of 2,712,630 U.S. residents in 2015. (An interim data brief was released last December.)

The answers are not always as black-and-white as the death certificates they’re written on. The cause, in each case, is determined by an attending physician or coroner or medical examiner, who in turn often relies on medical histories provided by the families—or, say in the case of a car accident or gunshot wound, on the sheer apparentness of injury. Contrary to the impression left by television crime dramas, formal autopsies are seldom done. (Fewer than one in ten bodies these days are hauled to the lab and cut open by a medical examiner.) Nor, in the vast majority of cases, are so-called pronouncing doctors trained in forensic pathology. Mistakes are as inevitable as they are expected.

On the whole, though, they tend toward the minor—conflating the “immediate” and “underlying” causes of death, for instance, or confusing two related forms of disease. Such flaws notwithstanding, death certificates are the best documentary evidence there are when it comes to studying the health and well being of any population. It is almost impossible, for instance, to understand disease burden or do major epidemiological studies without them. No public or private record offers a more definitive account of the extent of illness and injury in the country. To health policy officials, certainly, no nationwide set of data is anywhere near as essential.

Once a physician has signed off on the cause of death, it’s the task of a funeral director to supply the rest of the information on the legal certificate—the who, when, where, how old, and more—and send the form to the local or state registrar. State workers then send a record of this assessment to Anderson’s team at the NCHS who code it with one of those 8,000 or so potential causes in the ICD—which over a century of use and revision has become the globe’s single compendium to mortality. (Death, ironically, has managed to unite the world where the commonality of life cannot: ICD’s expansive alphanumeric code is perhaps the only language shared by nearly every government on the planet.)

These are the blunt, industrial-scale mechanics of counting death in the U.S. The marvel is in how such painting-by-numbers can yield, year after year, an image of near-animate detail: a national portrait of death—and to some extent, its inverse, a portrait of life.

So what do we see right now in that self-portrait of America? A face that’s a little more weathered than it was in the previous year, and perhaps a fraction less vital, too. From 2014 to 2015, life expectancy for the U.S. population actually dipped one-tenth of a year, from 78.9 years to 78.8—its first drop in more than two decades. The age-adjusted death rate in America rose for eight of the 10 leading causes of mortality and increased 1.2% overall.

Indeed, for one of those causes—Alzheimer’s disease—the rate didn’t merely creep upward, it leaped, shooting up 15.7% year over year. This, after climbing 55% between 1999 and 2014, according to a CDC report. Those numbers are a shout of warning, or ought to be.

“The increasing rates of Alzheimer’s deaths are not only problematic because of their obvious direct health effects on persons with Alzheimer’s,” says the CDC, plainly. “The debilitating nature of Alzheimer’s” translates into mammoth financial costs that are “borne by patients and their families, and by states and counties that operate publicly funded long-term care facilities.”

More than two thirds of the $259 billion cost of caring for those with Alzheimer’s and other forms of dementia will be paid by Medicare, Medicaid, and other public sources. But “most care provided to older adults with Alzheimer’s who do not live in long-term care facilities is provided by family members or other unpaid caregivers,” the CDC points out. And the agency calculates that this care amounted to 18.2 billion hours of unpaid assistance last year. (Yes, that’s billion with a “b.”)

Anderson has seen this and other American storylines unfold in real-time in the data of death: the stark and scary rise in opioid-related fatalities, the happy decline in infant mortality, the still-unexplained rise in suicides in the country.

A soft-spoken fellow from Sugarland, Texas, Anderson fell into his role by accident. After changing his undergraduate major four times, he pursued a graduate degree in demography at Penn State—but even then he was more interested in studying statistics about marriage and family than death. But “the job market was poor for demographers,” he says, and an ad for a position at the mortality branch just happened to land in his lap. And maybe, just maybe, the job was in his blood anyway: “My grandfather was a funeral director, mortician, ambulance driver, and county coroner, in Madison County, Idaho,” he says.

When I ask him what he’s learned in 20 years of counting bodies, Anderson answers quickly: “Everybody dies,” he says.

Then he pauses for a moment and offers something else: “Death gives life perspective.”

That one stuck with me.

This essay appears in today's edition of the Fortune Brainstorm Health Daily.