# Mortality Studies

Methods for forecasting mortality rates (overall or for time series data cross-classified by age, sex, country, and cause); estimating mortality rates in areas without vital registration; measuring inequality in risk of death; applications to US mortality, the future of the Social Security, armed conflict, heart failure, and human security.

## Forecasting Mortality

Samir Soneji and Gary King. 2012. “Statistical Security for Social Security.” Demography, 3, 49: 1037-1060 . Publisher's version Abstract

The financial viability of Social Security, the single largest U.S. Government program, depends on accurate forecasts of the solvency of its intergenerational trust fund. We begin by detailing information necessary for replicating the Social Security Administration’s (SSA’s) forecasting procedures, which until now has been unavailable in the public domain. We then offer a way to improve the quality of these procedures due to age-and sex-specific mortality forecasts. The most recent SSA mortality forecasts were based on the best available technology at the time, which was a combination of linear extrapolation and qualitative judgments. Unfortunately, linear extrapolation excludes known risk factors and is inconsistent with long-standing demographic patterns such as the smoothness of age profiles. Modern statistical methods typically outperform even the best qualitative judgments in these contexts. We show how to use such methods here, enabling researchers to forecast using far more information, such as the known risk factors of smoking and obesity and known demographic patterns. Including this extra information makes a sub¬stantial difference: For example, by only improving mortality forecasting methods, we predict three fewer years of net surplus, $730 billion less in Social Security trust funds, and program costs that are 0.66% greater of projected taxable payroll compared to SSA projections by 2031. More important than specific numerical estimates are the advantages of transparency, replicability, reduction of uncertainty, and what may be the resulting lower vulnerability to the politicization of program forecasts. In addition, by offering with this paper software and detailed replication information, we hope to marshal the efforts of the research community to include ever more informative inputs and to continue to reduce the uncertainties in Social Security forecasts. This work builds on our article that provides forecasts of US Mortality rates (see King and Soneji, The Future of Death in America), a book developing improved methods for forecasting mortality (Girosi and King, Demographic Forecasting), all data we used (King and Soneji, replication data sets), and open source software that implements the methods (Girosi and King, YourCast). Also available is a New York Times Op-Ed based on this work (King and Soneji, Social Security: It’s Worse Than You Think), and a replication data set for the Op-Ed (King and Soneji, replication data set). Federico Girosi and Gary King. 2007. “Understanding the Lee-Carter Mortality Forecasting Method”. Abstract We demonstrate here several previously unrecognized or insufficiently appreciated properties of the Lee-Carter mortality forecasting approach, the dominant method used in both the academic literature and practical applications. We show that this model is a special case of a considerably simpler, and less often biased, random walk with drift model, and prove that the age profile forecast from both approaches will always become less smooth and unrealistic after a point (when forecasting forward or backwards in time) and will eventually deviate from any given baseline. We use these and other properties we demonstrate to suggest when the model would be most applicable in practice. Gary King and Samir Soneji. 2011. “The Future of Death in America.” Demographic Research, 1, 25: 1--38. Website Abstract Population mortality forecasts are widely used for allocating public health expenditures, setting research priorities, and evaluating the viability of public pensions, private pensions, and health care financing systems. In part because existing methods seem to forecast worse when based on more information, most forecasts are still based on simple linear extrapolations that ignore known biological risk factors and other prior information. We adapt a Bayesian hierarchical forecasting model capable of including more known health and demographic information than has previously been possible. This leads to the first age- and sex-specific forecasts of American mortality that simultaneously incorporate, in a formal statistical model, the effects of the recent rapid increase in obesity, the steady decline in tobacco consumption, and the well known patterns of smooth mortality age profiles and time trends. Formally including new information in forecasts can matter a great deal. For example, we estimate an increase in male life expectancy at birth from 76.2 years in 2010 to 79.9 years in 2030, which is 1.8 years greater than the U.S. Social Security Administration projection and 1.5 years more than U.S. Census projection. For females, we estimate more modest gains in life expectancy at birth over the next twenty years from 80.5 years to 81.9 years, which is virtually identical to the Social Security Administration projection and 2.0 years less than U.S. Census projections. We show that these patterns are also likely to greatly affect the aging American population structure. We offer an easy-to-use approach so that researchers can include other sources of information and potentially improve on our forecasts too. Federico Girosi and Gary King. 2008. Demographic Forecasting. Princeton: Princeton University Press. Abstract We introduce a new framework for forecasting age-sex-country-cause-specific mortality rates that incorporates considerably more information, and thus has the potential to forecast much better, than any existing approach. Mortality forecasts are used in a wide variety of academic fields, and for global and national health policy making, medical and pharmaceutical research, and social security and retirement planning. As it turns out, the tools we developed in pursuit of this goal also have broader statistical implications, in addition to their use for forecasting mortality or other variables with similar statistical properties. First, our methods make it possible to include different explanatory variables in a time series regression for each cross-section, while still borrowing strength from one regression to improve the estimation of all. Second, we show that many existing Bayesian (hierarchical and spatial) models with explanatory variables use prior densities that incorrectly formalize prior knowledge. Many demographers and public health researchers have fortuitously avoided this problem so prevalent in other fields by using prior knowledge only as an ex post check on empirical results, but this approach excludes considerable information from their models. We show how to incorporate this demographic knowledge into a model in a statistically appropriate way. Finally, we develop a set of tools useful for developing models with Bayesian priors in the presence of partial prior ignorance. This approach also provides many of the attractive features claimed by the empirical Bayes approach, but fully within the standard Bayesian theory of inference. ## Estimating Overall and Cause-Specific Mortality Rates Inexpensive methods of estimating the overall and cause-specific mortality rates from surveys when vital registration (death certificates) or other monitoring is unavailable or inadequate. ## Hidden Region 1 A method for estimating cause-specific mortality from "verbal autopsy" data that is less expensive, more reliable, requires fewer assumptions, and will normally be more accurate. Edward Goldstein, Benjamin J Cowling, Allison E Aiello, Saki Takahashi, Gary King, Ying Lu, and Marc Lipsitch. 2011. “Estimating Incidence Curves of Several Infections Using Symptom Surveillance Data.” PLoS ONE, 8, 6: e23380. Abstract We introduce a method for estimating incidence curves of several co-circulating infectious pathogens, where each infection has its own probabilities of particular symptom profiles. Our deconvolution method utilizes weekly surveillance data on symptoms from a defined population as well as additional data on symptoms from a sample of virologically confirmed infectious episodes. We illustrate this method by numerical simulations and by using data from a survey conducted on the University of Michigan campus. Last, we describe the data needs to make such estimates accurate. Link to PLoS version Gary King, Ying Lu, and Kenji Shibuya. 2010. “Designing Verbal Autopsy Studies.” Population Health Metrics, 19, 8. Abstract Background: Verbal autopsy analyses are widely used for estimating cause-specific mortality rates (CSMR) in the vast majority of the world without high quality medical death registration. Verbal autopsies -- survey interviews with the caretakers of imminent decedents -- stand in for medical examinations or physical autopsies, which are infeasible or culturally prohibited. Methods and Findings: We introduce methods, simulations, and interpretations that can improve the design of automated, data-derived estimates of CSMRs, building on a new approach by King and Lu (2008). Our results generate advice for choosing symptom questions and sample sizes that is easier to satisfy than existing practices. For example, most prior effort has been devoted to searching for symptoms with high sensitivity and specificity, which has rarely if ever succeeded with multiple causes of death. In contrast, our approach makes this search irrelevant because it can produce unbiased estimates even with symptoms that have very low sensitivity and specificity. In addition, the new method is optimized for survey questions caretakers can easily answer rather than questions physicians would ask themselves. We also offer an automated method of weeding out biased symptom questions and advice on how to choose the number of causes of death, symptom questions to ask, and observations to collect, among others. Conclusions: With the advice offered here, researchers should be able to design verbal autopsy surveys and conduct analyses with greatly reduced statistical biases and research costs. Gretchen Stevens, Gary King, and Kenji Shibuya. 2010. “Deaths From Heart Failure: Using Coarsened Exact Matching to Correct Cause of Death Statistics.” Population Health Metrics, 6, 8. Abstract Background: Incomplete information on death certificates makes recorded cause of death data less useful for public health monitoring and planning. Certifying physicians sometimes list only the mode of death (and in particular, list heart failure) without indicating the underlying disease(s) that gave rise to the death. This can prevent valid epidemiologic comparisons across countries and over time. Methods and Results: We propose that coarsened exact matching be used to infer the underlying causes of death where only the mode of death is known; we focus on the case of heart failure in U.S., Mexican and Brazilian death records. Redistribution algorithms derived using this method assign the largest proportion of heart failure deaths to ischemic heart disease in all three countries (53%, 26% and 22%), with larger proportions assigned to hypertensive heart disease and diabetes in Mexico and Brazil (16% and 23% vs. 7% for hypertensive heart disease and 13% and 9% vs. 6% for diabetes). Reassigning these heart failure deaths increases US ischemic heart disease mortality rates by 6%.Conclusions: The frequency with which physicians list heart failure in the causal chain for various underlying causes of death allows for inference about how physicians use heart failure on the death certificate in different settings. This easy-to-use method has the potential to reduce bias and increase comparability in cause-of-death data, thereby improving the public health utility of death records. Key Words: vital statistics, heart failure, population health, mortality, epidemiology Gary King and Ying Lu. 2008. “Verbal Autopsy Methods with Multiple Causes of Death.” Statistical Science, 23: 78–91. Abstract Verbal autopsy procedures are widely used for estimating cause-specific mortality in areas without medical death certification. Data on symptoms reported by caregivers along with the cause of death are collected from a medical facility, and the cause-of-death distribution is estimated in the population where only symptom data are available. Current approaches analyze only one cause at a time, involve assumptions judged difficult or impossible to satisfy, and require expensive, time consuming, or unreliable physician reviews, expert algorithms, or parametric statistical models. By generalizing current approaches to analyze multiple causes, we show how most of the difficult assumptions underlying existing methods can be dropped. These generalizations also make physician review, expert algorithms, and parametric statistical assumptions unnecessary. With theoretical results, and empirical analyses in data from China and Tanzania, we illustrate the accuracy of this approach. While no method of analyzing verbal autopsy data, including the more computationally intensive approach offered here, can give accurate estimates in all circumstances, the procedure offered is conceptually simpler, less expensive, more general, as or more replicable, and easier to use in practice than existing approaches. We also show how our focus on estimating aggregate proportions, which are the quantities of primary interest in verbal autopsy studies, may also greatly reduce the assumptions necessary, and thus improve the performance of, many individual classifiers in this and other areas. As a companion to this paper, we also offer easy-to-use software that implements the methods discussed herein. ## Hidden Region 2 Evidence of the massive selection bias in all data on mortality from war (vital registration systems rarely continue to operate when war begins). Uncertainty in mortality estimates from major wars is as large as the estimates. Christopher JL Murray, Gary King, Alan D Lopez, Niels Tomijima, and Etienne Krug. 2002. “Armed Conflict as a Public Health Problem.” BMJ (British Medical Journal), 324: 346–349. Abstract Armed conflict is a major cause of injury and death worldwide, but we need much better methods of quantification before we can accurately assess its effect. Armed conflict between warring states and groups within states have been major causes of ill health and mortality for most of human history. Conflict obviously causes deaths and injuries on the battlefield, but also health consequences from the displacement of populations, the breakdown of health and social services, and the heightened risk of disease transmission. Despite the size of the health consequences, military conflict has not received the same attention from public health research and policy as many other causes of illness and death. In contrast, political scientists have long studied the causes of war but have primarily been interested in the decision of elite groups to go to war, not in human death and misery. We review the limited knowledge on the health consequences of conflict, suggest ways to improve measurement, and discuss the potential for risk assessment and for preventing and ameliorating the consequences of conflict. Unbiased estimates of mortality rates from surveys about sibling and others' survival; explains and reduces biases in existing methods. Emmanuela Gakidou and Gary King. 2006. “Death by Survey: Estimating Adult Mortality without Selection Bias from Sibling Survival Data.” Demography, 43: 569–585. Abstract The widely used methods for estimating adult mortality rates from sample survey responses about the survival of siblings, parents, spouses, and others depend crucially on an assumption that we demonstrate does not hold in real data. We show that when this assumption is violated – so that the mortality rate varies with sibship size – mortality estimates can be massively biased. By using insights from work on the statistical analysis of selection bias, survey weighting, and extrapolation problems, we propose a new and relatively simple method of recovering the mortality rate with both greatly reduced potential for bias and increased clarity about the source of necessary assumptions. ## Uses of Mortality Rates Samir Soneji and Gary King. 2012. “Statistical Security for Social Security.” Demography, 3, 49: 1037-1060 . Publisher's version Abstract The financial viability of Social Security, the single largest U.S. Government program, depends on accurate forecasts of the solvency of its intergenerational trust fund. We begin by detailing information necessary for replicating the Social Security Administration’s (SSA’s) forecasting procedures, which until now has been unavailable in the public domain. We then offer a way to improve the quality of these procedures due to age-and sex-specific mortality forecasts. The most recent SSA mortality forecasts were based on the best available technology at the time, which was a combination of linear extrapolation and qualitative judgments. Unfortunately, linear extrapolation excludes known risk factors and is inconsistent with long-standing demographic patterns such as the smoothness of age profiles. Modern statistical methods typically outperform even the best qualitative judgments in these contexts. We show how to use such methods here, enabling researchers to forecast using far more information, such as the known risk factors of smoking and obesity and known demographic patterns. Including this extra information makes a sub¬stantial difference: For example, by only improving mortality forecasting methods, we predict three fewer years of net surplus,$730 billion less in Social Security trust funds, and program costs that are 0.66% greater of projected taxable payroll compared to SSA projections by 2031. More important than specific numerical estimates are the advantages of transparency, replicability, reduction of uncertainty, and what may be the resulting lower vulnerability to the politicization of program forecasts. In addition, by offering with this paper software and detailed replication information, we hope to marshal the efforts of the research community to include ever more informative inputs and to continue to reduce the uncertainties in Social Security forecasts.

This work builds on our article that provides forecasts of US Mortality rates (see King and Soneji, The Future of Death in America), a book developing improved methods for forecasting mortality (Girosi and King, Demographic Forecasting), all data we used (King and Soneji, replication data sets), and open source software that implements the methods (Girosi and King, YourCast).  Also available is a New York Times Op-Ed based on this work (King and Soneji, Social Security: It’s Worse Than You Think), and a replication data set for the Op-Ed (King and Soneji, replication data set).

Konstantin Kashin, Gary King, and Samir Soneji. 2015. “Systematic Bias and Nontransparency in US Social Security Administration Forecasts.” Journal of Economic Perspectives, 2, 29: 239-258. Publisher's Version Abstract

The financial stability of four of the five largest U.S. federal entitlement programs, strategic decision making in several industries, and many academic publications all depend on the accuracy of demographic and financial forecasts made by the Social Security Administration (SSA). Although the SSA has performed these forecasts since 1942, no systematic and comprehensive evaluation of their accuracy has ever been published by SSA or anyone else. The absence of a systematic evaluation of forecasts is a concern because the SSA relies on informal procedures that are potentially subject to inadvertent biases and does not share with the public, the scientific community, or other parts of SSA sufficient data or information necessary to replicate or improve its forecasts. These issues result in SSA holding a monopoly position in policy debates as the sole supplier of fully independent forecasts and evaluations of proposals to change Social Security. To assist with the forecasting evaluation problem, we collect all SSA forecasts for years that have passed and discover error patterns that could have been---and could now be---used to improve future forecasts. Specifically, we find that after 2000, SSA forecasting errors grew considerably larger and most of these errors made the Social Security Trust Funds look more financially secure than they actually were. In addition, SSA's reported uncertainty intervals are overconfident and increasingly so after 2000. We discuss the implications of these systematic forecasting biases for public policy.

A method to estimate total and within-group inequality in health (all prior research is about mean differences between groups).
Emmanuela Gakidou and Gary King. 2002. “Measuring Total Health Inequality: Adding Individual Variation to Group-Level Differences.” BioMed Central: International Journal for Equity in Health, 1. Abstract
Background: Studies have revealed large variations in average health status across social, economic, and other groups. No study exists on the distribution of the risk of ill-health across individuals, either within groups or across all people in a society, and as such a crucial piece of total health inequality has been overlooked. Some of the reason for this neglect has been that the risk of death, which forms the basis for most measures, is impossible to observe directly and difficult to estimate. Methods: We develop a measure of total health inequality – encompassing all inequalities among people in a society, including variation between and within groups – by adapting a beta-binomial regression model. We apply it to children under age two in 50 low- and middle-income countries. Our method has been adopted by the World Health Organization and is being implemented in surveys around the world and preliminary estimates have appeared in the World Health Report (2000). Results: Countries with similar average child mortality differ considerably in total health inequality. Liberia and Mozambique have the largest inequalities in child survival, while Colombia, the Philippines and Kazakhstan have the lowest levels among the countries measured. Conclusions: Total health inequality estimates should be routinely reported alongside average levels of health in populations and groups, as they reveal important policy-related information not otherwise knowable. This approach enables meaningful comparisons of inequality across countries and future analyses of the determinants of inequality.
Konstantin Kashin, Gary King, and Samir Soneji. 2015. “Explaining Systematic Bias and Nontransparency in US Social Security Administration Forecasts.” Political Analysis, 3, 23: 336-362. Publisher's Version Abstract

The accuracy of U.S. Social Security Administration (SSA) demographic and financial forecasts is crucial for the solvency of its Trust Funds, other government programs, industry decision making, and the evidence base of many scholarly articles. Because SSA makes public little replication information and uses qualitative and antiquated statistical forecasting methods, fully independent alternative forecasts (and the ability to score policy proposals to change the system) are nonexistent. Yet, no systematic evaluation of SSA forecasts has ever been published by SSA or anyone else --- until a companion paper to this one (King, Kashin, and Soneji, 2015a). We show that SSA's forecasting errors were approximately unbiased until about 2000, but then began to grow quickly, with increasingly overconfident uncertainty intervals. Moreover, the errors are all in the same potentially dangerous direction, making the Social Security Trust Funds look healthier than they actually are. We extend and then attempt to explain these findings with evidence from a large number of interviews we conducted with participants at every level of the forecasting and policy processes. We show that SSA's forecasting procedures meet all the conditions the modern social-psychology and statistical literatures demonstrate make bias likely. When those conditions mixed with potent new political forces trying to change Social Security, SSA's actuaries hunkered down trying hard to insulate their forecasts from strong political pressures. Unfortunately, this otherwise laudable resistance to undue influence, along with their ad hoc qualitative forecasting models, led the actuaries to miss important changes in the input data. Retirees began living longer lives and drawing benefits longer than predicted by simple extrapolations. We also show that the solution to this problem involves SSA or Congress implementing in government two of the central projects of political science over the last quarter century: [1] promoting transparency in data and methods and [2] replacing with formal statistical models large numbers of qualitative decisions too complex for unaided humans to make optimally.

Provides a rigorous and measurable definition of human security; discusses the improvements in data collection and methods of forecasting necessary to measure human security; and introduces an agenda to enhance human security that follows logically in the areas of risk assessment, prevention, protection, and compensation.
Gary King and Christopher J.L. Murray. 2002. “Rethinking Human Security.” Political Science Quarterly, 116: 585–610. Abstract

In the last two decades, the international community has begun to conclude that attempts to ensure the territorial security of nation-states through military power have failed to improve the human condition. Despite astronomical levels of military spending, deaths due to military conflict have not declined. Moreover, even when the borders of some states are secure from foreign threats, the people within those states do not necessarily have freedom from crime, enough food, proper health care, education, or political freedom. In response to these developments, the international community has gradually moved to combine economic development with military security and other basic human rights to form a new concept of "human security". Unfortunately, by common assent the concept lacks both a clear definition, consistent with the aims of the international community, and any agreed upon measure of it. In this paper, we propose a simple, rigorous, and measurable definition of human security: the expected number of years of future life spent outside the state of "generalized poverty". Generalized poverty occurs when an individual falls below the threshold in any key domain of human well-being. We consider improvements in data collection and methods of forecasting that are necessary to measure human security and then introduce an agenda for research and action to enhance human security that follows logically in the areas of risk assessment, prevention, protection, and compensation.

A Perspective article on the effect of the IMF on increasing tuberculosis mortality rates:
Megan Murray and Gary King. 2008. “The Effects of International Monetary Fund Loans on Health Outcomes.” PLoS Medicine, 5. Abstract
A "Perspective" article that discusses an article by David Stuckler and colleagues showing that, in Eastern European and former Soviet countries, participation in International Monetary Fund economic programs have been associated with higher mortality rates from tuberculosis.