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The Mortality Paradox; or, the Health Benefits of Cyanide
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TAC-ChinaAmerica In recent weeks my description of the possible scale of the Vioxx Disaster has begun getting a little coverage on the web and in the British press, leading to some strong “push back” by people who say I can’t possibly be right. They may certainly be correct in their opinion, but I think their reasoning is mistaken, so I thought I’d briefly summarize the analysis once more, emphasizing again that the evidence is purely circumstantial.

I realize most readers may be growing increasingly weary of Vioxx mortality disputes—I certainly am—but given the tens or more likely hundreds of thousands of American deaths at issue, adding a few short paragraphs of text seem not totally unwarranted.

(*) In 1999, Vioxx was marketed to the American people by Merck as a particularly effective anti-pain medication with minimal side-effects, a sort of super-aspirin substitute targeted at arthritis sufferers in the over-65 category. Backed by an eventual half-billion dollars of advertising, it soon became one of the most widely popular—and lucrative—drugs in this country and the world, with some twenty-five million total American prescriptions. As a consequence, it also became one of Merck’s most important revenue sources.

(*) In 2004, a detailed published FDA study proved that Vioxx had deadly consequences in its patients, greatly increasing the risk of sudden cardiovascular death, and had probably killed at least 30,000-60,000 Americans since its introduction. Learning of the pending publication of this study, Merck immediately pulled the drug from the market. The media later discovered that Merck had apparently been aware of these huge cardiovascular health risks from the very beginning, but had decided to ignore them, presumably because the drug was so lucrative. Merck eventually paid some $8 billion dollars in total government fines, legal expenses, and damages for Vioxx-related deaths.

(*) As it happened, the 2004 American death rate unexpectedly dropped by 50,000, the greatest such national decline in sixty years, a decline whose cause completely mystified American health authorities, who searched in vain for some possible logical explanation. This decline was almost entirely due to fewer deaths in 65+ age range, mostly due to a large drop in cardiovascular fatalities.

(*) Interestingly enough, an examination of the American mortality data freely available on the government CDC website reveals a corresponding rise in deaths for Americans 65+ which had previously occurred in 1999, the year Vioxx was introduced. This 1999 mortality rise was the largest in the past fifteen years, and—perhaps coincidentally—a sharp shift in the rate of cardiovascular deaths had once again been the leading factor.

It is completely impossible for me to say whether or not the recall of a an extremely popular but deadly drug proven to cause cardiovascular deaths among its 65+ target population had any direct connection to the huge drop in cardiovascular deaths among Americans 65+ during that same year. Similarly, the earlier sharp rise in 65+ cardiovascular deaths the year the drug had been introduced may or may not be purely coincidental. But one would think these intriguing facts might arouse a bit of curiosity within American media and government circles.


Based on these items, I have advanced a speculative hypothesis suggesting a much higher Vioxx death-toll than is currently accepted. One of the main arguments which various critics have made against my hypothesis is that although the American 65+ death rate did undergo rather surprising upward and downward shifts during 1999 and 2004, the years that Vioxx was introduced and then removed, the behavior of the death rate during the intervening years was far less remarkable. A few people have argued that the widespread use of a deadly drug during 2000-2003 would surely have caused large, continuing changes in the mortality figures, and their absence tends to completely eliminate the possibility.

Unfortunately, this reasoning is incorrect, and confuses an impact upon total longevity with an impact upon mortality rates. This can easily be understood if we consider an extreme thought-experiment.

Suppose, for example, that the government required everyone aged 65 and above to immediately take cyanide tablets, and established this as a permanent policy going forward, with mandatory cyanide doses being a fixture of every 65th year birthday party.

Obviously, this would lead to many premature American deaths and a very substantial change in American lifespans. Indeed, since our current life-expectancy is around 78, the vast majority of Americans henceforth would be killed by government cyanide, instead of dying naturally. Over the next hundred years, the overwhelming majority of all deaths would be from cyanide, and the total cyanide death-toll in America might approach the half billion mark. Clearly, cyanide would become a very major negative health factor in American society.

However, the actual impact upon the annual American death-rate would be small or perhaps even favorable during nearly the entire period in question, a totally astonishing result. This seeming paradox follows from the fact that everyone eventually dies of something, and therefore there would automatically be huge drops in cancer, heart attack, strokes, and car accident fatalities which would almost exactly balance out the rise in cyanide deaths.

Consider, for example, the American population one hundred years from now and compare it with a non-cyanide scenario. In the former case, there would be no one aged 65+, with that portion of the population having succumbed to cyanide; but those would be the *only* differences in total net-fatalities compared to the base-case Every other American death would have been the same under the two scenarios, though certainly with different timing. And if we average that small slice of additional deaths over the one hundred years in question, the average annual impact is fairly small.


Obviously, the first year of a mandatory-cyanide scenario would see a huge die-off of all those 65+. But mortality rates after that would generally be pretty ordinary, perhaps even sometimes *lower* than under the normal situation, depending upon the shape of the evolving age-distribution curve. Indeed, it is quite possible that people just looking at the mortality rates for the ninety-nine following years and comparing these with current projections might notice they were somewhat reduced, and wrongly conclude that mandatory cyanide might have significant beneficial properties, since it seemed to cut mortality rates. This rather counter-intuitive result might be termed “The Mortality Rate Paradox.”

However, if at any point, the mandatory-cyanide policy were discontinued, that particular year would see a remarkable *drop* in the annual death rate, followed by smaller changes in subsequent years, until eventually a new age-mortality equilibrium was established. Thus, the only significant signals of a mandatory cyanide policy found in the annual mortality rates would come at the beginning and at the end of the policy.

Obviously, Vioxx did not remotely have the lethality of cyanide, nor was its use universal among the elderly. Moreover, any Vioxx-related mortality shifts were substantially masked by much larger directional mortality trends due to the aging of the population, improvements in life-saving and other medical technology, and all sorts of other factors. Distinguishing signal from noise is not as trivial as examining the slope of a curve.

But it does seem a bit intriguing that the mortality-curve for Americans 65+ followed a very similar trajectory to that of the extreme thought-experiment: a sharp rise in the year of introduction, a few years of relative stability, and then a very sharp drop in the year of recall.

Most of the Vioxx defenders put the total six-year death toll perhaps around 33,000, or roughly 6,000 additional deaths per year. But the actual shifts we find at the crucial starting and stopping points are far higher than this. For example, elderly deaths actually rose 35,000 in the year Vioxx was introduced, a figure several times larger than the average for the preceding few years, and dropped by 67,000 in the year it was withdrawn, which was similarly anomalous and remarkable, many times higher than the recent average change. Both these mortality shifts were heavily driven by the cardiovascular category.

It seems to me that a Vioxx-induced premature American death toll which was well into the hundreds of thousands is the most parsimonious explanation of these surprising mortality statistics.

(Republished from The American Conservative by permission of author or representative)
• Category: Economics • Tags: China/America, Vioxx 
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  1. The sad fact is that no amount of documentation will be sufficient to make Americans care. An aggregate shortening of elderly life doesn’t inspire emotion because a plurality of their offspring are indifferent to their deaths. A minority is saddened, and a smaller yet minority is pleased, but at least a third of boomers don’t care.

    Now if this were a pet food scandal, the tears would run in rivers…

  2. Gives new meaning to mandatory retirement at 65.

  3. From 1998 to 1999 Vioxx prescriptions rose from zero to 4.845 million and death rates rose. From 1999 to 2000 they rose by 15.785 million and death rates fell. Given that the larger change in Vioxx prescriptions was associated with a decline in death rates, this would tend to indicate the Vioxx reduced mortality.

    From 2003 to 2004 Vioxx prescriptions fell by 5.965 million and death rates fell. From 2004 to 2004 Vioxx prescriptions fell by 13.994 million (to zero) and death rates rose. Given that the larger change in Vioxx prescriptions was associated with an increase in death rates, this would tend to indicate the Vioxx reduced mortality.

    Of course, it is unlikely (but not inconceivable) that Vioxx reduced mortality while it was on the market and the withdrawal of Vioxx increased mortality. A more likely explanation for the observed data is that other factors (much) more than offset the impact of Vioxx either way.

    However, it turns out that more sensitive analysis of the data is possible. Vioxx was introduced in late May of 1999 and withdrawn on September 30th of 2004. The CDC publishes monthly mortality statistics that can be used to compare the actual 12 months before and after Vioxx was introduced and the 12 months before and after Vioxx was recalled.

    It turns out that the average monthly death rate was almost identical (70.575 versus 70.599) for the 12 months before and after Vioxx was introduced. This is a better test than using calendar years because Vioxx was only sold for 7 months in calendar 1999. By comparing 1998/06 – 1999/05 to 1996/06 – 2000/05 we are testing 12 months of no Vioxx (some Vioxx in late May 1999 is possible) versus 12 months of full marketing.

    The same approach can be used to analyze the Vioxx withdrawal. For the period from 2003/10 – 2004/09 the average monthly death rate was 69.444. For the 12 months after Vioxx as recalled, the average monthly death rate was 68.708. Net, the average monthly death rate declined by 0.736. By contrast, the average monthly death rate for calendar 2003 was 70.175 versus 68.107 for calendar 2004 (a net decline of 2.068). Using actual 12 month periods is a better test because Vioxx was prescribed for 9 months in 2004 making comparisons with 2003 difficult. Stated differently the death rate decline, using actual 12 month periods was 35.58% of the decline using calendar year periods.

    Was the 0.736 decline in average monthly mortality a consequence of the Vioxx recall? Perhaps, perhaps not. Most of 0.736 decline appears to be related to a large P&I (Pneumonia and Influenza) epidemic in late 2003 / early 2004. Of course, the data is predictably more complex. The monthly death rate in March of 2005 was higher than the death rate in March of 2004. Once again, Vioxx appears to have been a secondary (or lesser) influence on mortality.

    Thank you

    Peter Schaeffer

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