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POSTPONING DEATH |
From the Department of Economics, Pomona College, Claremont, CA.
Address correspondence and reprint requests to Gary Smith, PhD, Department of Economics, Pomona College, Claremont, CA 91711. E-mail: gsmith{at}pomona.edu
ABSTRACT
OBJECTIVE: Reexamine the claim that elderly Chinese-American women are able to prolong their lives until after the celebration of the Harvest Moon Festival.
METHODS: See if independent 1985 to 2000 data for Chinese-, Korean-, and Vietnamese-Americans replicate results that were reported using 1960 to 1984 data for Chinese-Americans.
RESULTS: The original 1960 to 1984 data do not support the death-postponement theory unless deaths that occur on the festival day are classified as having occurred after the festival. The new data do not support the theory, no matter how deaths on the festival day are classified.
CONCLUSIONS: These data do not support the hypothesis that elderly Chinese-, Korean-, or Vietnamese-American women are able to prolong their lives until after the celebration of the Harvest Moon Festival.
Key Words: death postponement, • mortality dip, • Harvest Moon Festival.
INTRODUCTION
Numerous studies have investigated the theory that stressful life events can be unhealthy, even fatal (1–4). A very different theory is that the anticipation of a meaningful event, such as a birthday or religious holiday, can prolong life. If this theory is valid, health care providers should be sensitive to the effects of symbolically meaningful occasions on at-risk patients, and medical researchers should interpret their data with care when deaths occur near symbolically meaningful events.
To date, the data have not supported the death-postponement theory conclusively. For example, Phillips and King report a dip in Jewish death rates preceding Passover; however, the decedents in this study were not necessarily Jewish, but rather Californians whose names seemed Jewish (5). A study using data from a large Jewish mortuary in California found no evidence that Jews were able to postpone death until after the celebration of religious holidays (6). For deaths that occurred near Passover, there were somewhat more deaths (particularly male deaths) during the weeks before Passover than during the weeks afterward.
Another example is a study by Idler and Kasl of elderly New Haven residents, which indicated that some Christians and Jews postponed their deaths until after the celebration of religious holidays (7). However, the p values were calculated incorrectly and the correct p values are larger than reported and make their conclusions less convincing, especially for Jews (8).
One of the most important Chinese holidays is the Harvest Moon Festival (HMF), which occurs on the 15th day of the 8th moon of the lunar calendar. The family customarily gathers for bonding and celebration and eats a festival meal including traditional moon cakes outdoors in the moonlight at midnight. Phillips and Smith analyzed California mortality data for the years 1960 to 1984 and concluded that some elderly Chinese-American women evidently postpone their deaths until after the celebration of the HMF (9). Their strongest evidence is a death dip in the week preceding the HMF and a rise in the week afterward for Chinese women at least 75 years of age. However, they also observe that, "It is a scientific truism that statistical significance alone is not sufficient to justify substantial confidence in the reliability of a finding. It is crucial that the finding be replicated also." (p. 1947)
We now have 16 years of independent data on mortality near the HMF that can be used to test the theory that elderly Chinese women are able to postpone their deaths. In addition, Koreans and Vietnamese also use the Chinese lunar calendar and celebrate the HMF on the same day as the Chinese. According to the PBS show Hidden Korea: "Perhaps the greatest Korean holiday is Ch’usok, or HMF" (10). The AdoptVietnam web site says that, "The Mid-Autumn Moon Festival is rated second only to Tet as the most favorite Vietnamese holiday" (11). Independent mortality data for Korean-, and Vietnamese-Americans can also be used to determine whether the earlier finding is replicated.
METHODS
Phillips and Smith analyzed deaths recorded by the California Department of Health Services for the years 1960 through 1984. Records are now available through the year 2000 (12). The entries for racial and ethnic status identify Chinese for the entire period, Vietnamese since 1978, and Koreans since 1985. All deaths from natural causes that occurred within 7 days of the HMF are analyzed. Any day-of-the-week mortality patterns are avoided by examining two 7-day periods, each of which contains every day of the week.
The most straightforward test of the research hypothesis that there is a difference in the number of deaths during the 7 days before and after the festival is a test of the null hypothesis that for each death within 7 days of the festival, there is a 0.5 probability that it occurs in the week before the festival. The binomial distribution gives the appropriate p value.
There may be confounding influences due to the timing of a deadly event (such as an earthquake) during the weeks studied. It is also true that, particularly with elderly people, the probability of death increases with each passing day though the number of people still living diminishes. It is unlikely that death rates will change much over such a short interval of time. Nonetheless, a way to control for confounding influences is to compare the death patterns to a control group, such as white Californians, for whom the HMF has no special significance. To compare Asian-American deaths to the white control group, Fisher’s exact test for a 2-by-2 contingency table was used with the data separated by race and by whether the death occurred during 7 days before or after the festival.
Phillips and Smith argue that one-sided p values are appropriate; however, Phillips et al. argue that holidays can be either a lifeline (prolonging death) or a deadline (provoking death) (13). If true, two-sided p values should be used, and these are reported here.
Phillips and Smith justify their focus on women at least 75 years of age by arguing that, "The senior woman of the household takes charge of preparing an elaborate meal." However, age 65 was used by one of the coauthors to identify elderly Jewish males in the study mentioned earlier of Jewish deaths near Passover. The present paper examines ages 65 to 74 and at least 75 for the original 1960 to 1984 data and at least 75 for the 1985 to 2000 replication tests.
Another issue is how to categorize deaths that occur on the HMF day. The Passover study notes that, "The main ceremonial ritual of Passover (the retelling of the Exodus story at a large family meal) takes place on the evening before [emphasis added] the first day of Passover." (p. 729); the authors consequently count deaths that occur the following day as having been postponed until after the celebration of Passover. The main ceremonial ritual of the HMF occurs at midnight at the end of the HMF day. The logic used in the Passover study implies that deaths occurring before the HMF’s main ceremonial ritual should be categorized as before the ceremony and deaths that occur after midnight should be counted as after the celebration. Instead, Phillips and Smith count deaths that occur on the HMF day as having occurred after the celebration. The present results are tabulated both ways.
RESULTS
For the 1960 to 1984 period studied by Phillips and Smith, Table 1 shows that the data are not statistically persuasive for women in the age group 65 to 74, no matter how deaths on the festival day are recorded. Contrary to the postponement hypothesis, the p values are actually above 0.5 for binomial tests comparing Chinese deaths before and after the festival and for Fisher tests comparing Chinese deaths to the white control group. For women 75 and older, the data are not statistically persuasive unless a death on the HMF day is considered to have occurred after the festival.
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DISCUSSION
It is possible that the day of death may sometimes be misreported. However, it is unclear which way this bias would work and how it might be quantified. Phillips and Smith do not consider this possibility, and the objective of the present paper is simply to see whether the application of their methodology to new data supports their conclusion.
An odd feature of the 1960 to 1984 data used by Phillips and Smith is that 15 elderly Chinese women died on the HMF day, which was the most deaths on any day within a week of the festival. One explanation might be that the stress associated with the festival is sometimes fatal; another possibility is that this was a fluke—which is supported by the fact that there is no similar spike in the 1985 to 2000 data.
The statistical significance of the results reported for 1960 to 1984 hinges on whether the 15 women who died on the festival day are counted as having successfully prolonged their lives. Since the main festival activity is the midnight meal in the moonlight, it seems reasonable to count these people as not having been able to postpone their deaths for the festival celebration. If a person is really able to postpone death until after the celebration of an important ceremonial occasion, shouldn’t she be able to postpone death until after the main ceremonial activity?
In situations where there is no compelling theoretical rationale for categorizing the data, it is especially important to determine whether the statistical results are replicated with independent data. Here, the results reported for elderly Chinese women for the years 1960 to 1984 are not replicated for elderly Chinese, Korean, or Vietnamese women for the years 1985 to 2000.
ACKNOWLEDGMENTS
The author is very grateful for the careful reading and detailed suggestions of the editor and three expert referees.
Received for publication June 11, 2003.
REFERENCES
This article has been cited by other articles:
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  D. C. Young and E. M. Hade Holidays, Birthdays, and Postponement of Cancer Death JAMA, December 22, 2004; 292(24): 3012 - 3016. [Abstract] [Full Text] [PDF]
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75 years)
