Scared to death?

Phillips et al report a “Hound of the Baskervilles effect” among Chinese-Americans and Japanese-Americans, who have abnormally high cardiac mortality on the fourth day of each month because they think the number 4 is unlucky.¹ Is it plausible that the number 4 is regarded with the same terror that the fictional Charles Baskerville felt as he was pursued in the dark by a huge hound “with its flaming jaws and blazing eyes”? We encounter the number 4 every day. Could one more 4, the fourth day of a month, be fatal?

Methods and results

A natural test is to compare deaths on the third, fourth, and fifth days of each month. A longer horizon is flawed because a systematic cycle that causes deaths to peak near day 4 may show statistical significance that reflects a bulge near the day rather than any special importance of day 4 itself.

California's computerised mortality records include the racial status recorded on death certificates. The first section of the table shows deaths in California caused by heart disease during 1989-98—the data used by Phillips. Of the Chinese-American and Japanese-American deaths on days 3, 4, and 5, 34% occurred on day 4 (P=0.652). Our comparison of deaths of Chinese and Japanese people with deaths of white people produced a P value of 0.664.

Phillips et al argued that recorded death dates were more reliable for inpatient data, which have lower P values. Their 1989-98 data were classified according to ICD-9 (international classification of diseases, ninth revision). In their studies of Jewish deaths near Passover² and Chinese deaths near the Harvest Moon Festival,³ Phillips and colleagues used all heart disease categories (390-398, 402, 404-429). In a study of Chinese-Americans with unlucky birth years,⁴ Phillips et al divided heart diseases into three groups: 410; 412 and 414; and 390-398, 402-409, 411, 413, and 415-429. In the Baskervilles paper, however, Phillips et al considered only categories 410-414, which they called “chronic heart diseases.” These categories have more deaths on day 4 than on days 3 or 5, whereas the categories they omitted do not.

We now have data for 1999-2001; we also have the 1969-88 data that Phillips used in his other studies. (Pre-1969 data are classified by ICD-7 and are not directly comparable with later revisions.) The table shows no statistically persuasive peaks on day 4 for total coronary deaths, inpatients, or Phillips et al's subset of heart diseases. In the 1969-88 data there were more deaths on day 5 than on day 4; in the 1999-2001 data there were more deaths on day 3.

Newcombe noted that, if day 4 is sufficiently stressful to affect cardiac mortality, it should also affect suicides and accidental deaths.⁵ Our table shows that Chinese and Japanese people had relatively few suicides on day 4, which casts doubt on the theory that day 4 is fatally stressful.

If the number 4 affected mortality, we should find similar effects with other lucky and unlucky numbers. In Chinese culture number 7 can signify death, whereas white Americans generally consider 7 to be lucky; white Americans consider 13 to be unlucky, while the luckiest Chinese number is 8. We applied Fisher's test to cardiac mortality on all these days, using data for the period 1969-2001. None of the suggested days (4, 7, 8, or 13) was statistically persuasive.

Comment

It seems implausible that Chinese-Americans and Japanese-Americans are scared to death by the number 4. Californian death records do not show statistically persuasive patterns unless several types of cardiac mortality are omitted. The higher mortality in this pruned subset of the 1989-98 data is not present in 1969-88 or 1999-2001 data, nor are there statistically persuasive patterns in suicides or accidental deaths or on other lucky or unlucky days.

Figure.

HENNY RAY ABRAMS/AFP

Different cultures, different fears?

Table.

Deaths on day 4 of each month as a percentage of deaths on days 3, 4, and 5 (with number of deaths on days 3, 4, and 5 in parentheses)

	Day 4 deaths			Two sided P values
	White Americans	Chinese or Japanese Americans		Binomial*	Fisher's exact test†
1989-98
Total coronary deaths:	33.3 (60 839)	33.9 (1391)		0.652	0.664
Inpatients	33.8 (20 658)	36.5 (540)		0.133	0.211
Inpatients, “chronic”‡	33.8 (15 084)	38.9 (404)		0.022	0.040
1999-2001
Total coronary deaths:	33.2 (18 598)	30.9 (505)		0.264	0.293
Inpatients	32.6 (6 061)	31.8 (195)		0.710	0.873
Inpatients, “chronic”‡	32.2 (4 273)	34.6 (133)		0.822	0.626
1969-1988
Total coronary deaths:	33.4 (120 301)	34.9 (992)		0.317	0.353
“Chronic”‡	33.5 (98 257)	35.0 (734)		0.353	0.399
1969-2001
Suicides	33.5 (11 150)	27.8 (198)		0.110	0.100
Accidents	33.7 (30 508)	36.2 (390)		0.259	0.326

^*Binomial test of null hypothesis that, for each Chinese or Japanese death on days 3, 4, or 5 of a month, there is a 33% probability that it occurs on the day 4. 

^†Fisher's exact test with data separated by race and by whether death occurred on day 4 or on adjacent days. 

^‡The heart diseases selected by Phillips et al¹—ICD-8 410-414; ICD-9 410-414; ICD-10 I20-I24, I25.1-I25.9.