今天讓我們聊聊死亡。

不久前，我有幸和鮑勃?安德森暢談。安德森是美國疾病預防與控制中心（CDC）旗下國家衛生統計中心（NCHS）的人口死亡統計部門主任，主管統計美國人死亡數據。

上次我們聊天是在2009年，當時安德森和下屬剛剛整理出2006年美國人死亡數據。他們收集了全美50個州，哥倫比亞特區、波多黎各和關島等五個海外屬地島嶼以及紐約市所有的死亡人口記錄，耗時整整30個月。然后他們查漏補缺（某些州死亡原因全盤做了調整），消除了數據之間不一致之處，以幾百種方法對數據進行分類、交叉引用并制表，最后將大量數據制成一份結構嚴密的報告。

就在2009年，各州死亡人口數據的很多處理工作還都靠人力手工完成，現在聽起來有點不可思議。而今，以上57個匯報死亡數據的美國司法轄區之中，除了五個海外屬地和六個拒絕合作的州（西弗吉尼亞、北卡羅來納、密西西比、田納西、羅德島和康涅狄格）以外，其余都采用電子文件處理大部分數據。現在一名美國公民過世不到十天，47%的相關死亡數據就會發送給安德森的團隊。美國全國的死亡人口記錄現在只需約11個月就可完成。

進步得來不易。

現代人類大概有8000種死法，也就是說世界衛生組織制定的最新版即第十版《國際疾病分類》（ICD）里，將人類死因分為約8000類。安德森和團隊里的統計學家、分析師和疾病分類專家在馬里蘭州海厄茨維爾市一棟七層高的辦公樓工作，辦公地點在第五層。他們很快會發布2015年美國死亡人口報告，詳細記述當年去世的271.1263萬美國人死因是哪些。（去年12月CDC已經發布一份臨時數據概要。）

說到人們離世的原因，其實并非總像白紙黑字的死亡證明一樣直觀。死亡案例都由主治醫生、驗尸官或者法醫判定，而判定的依據往往是死者家人提供的病歷，或者肉眼可見的原因，比如發生車禍或者遭遇槍擊。和罪案電視劇造成的印象截然不同，現實中很少進行正式驗尸。（近來送往實驗室由法醫驗尸的死者不足十分之一。）絕大多數情況下，都是沒受過法醫專門培訓的醫生判定死因。可以想見，判斷失誤在所難免。

不過整體而言，死因判斷錯的還是少數，有時可能是將直接死因和間接死因弄混，有時可能分不清兩種形式的疾病。盡管可能存在種種失誤，但在研究某地人口醫療健康時，死亡證明還是最可靠的文件證據。離開死亡證明，幾乎不可能了解疾病造成的負擔，也幾乎不可能大規模開展流行病學研究。研究美國人傷亡情況時，死亡證明比任何公開或私人的記錄都更詳實。對制定醫療政策的官員而言，死亡證明是最關鍵的參考依據，其他資料都比不上。

外科醫生在死因一欄簽字以后，一般由葬禮承辦人提供死亡證明里的其余信息——死者是誰，年齡多大，何時、何地身故等等，然后將死亡證明表格發送當地或州人口統計署。相關州的工作人員會向安德森在NCHS的團隊發去一份死亡評估記錄。安德森的團隊會根據ICD列舉的8000多種可能死因找到匹配的編碼。ICD實際使用和修訂已有百年，已經成為全球最全面的死亡病例匯總綱要。（諷刺的是，各種努力都無法實現的人類大同，由死亡成功實現了：ICD中各種字母與數字代碼也許是全球唯一的幾乎所有政府通用的語言。）

這就是統計美國死亡人口的方法，簡單直白，純工業化運作。令人稱奇的是，年復一年枯燥數字卻生動又詳盡地描述了很多細節，從中可見一個國家的人們如何告別人世，從某種程度上也能看出人類生活的萬象。

此刻的美國人自畫像什么樣？和此前一年相比，美國人顯得更飽經風霜，有些人仿佛沒什么活力。2015年，美國人均壽命實際上縮短了，從2014年的78.9歲降至78.8歲，相當于減少了一年的十分之一。這是二十多年來首次出現壽命同比下降。也是在2015年，十大死因之中有八個造成的死亡人數均出現增加，因此年齡調整后美國死亡率整體上升了1.2個百分點。

事實上，十大死因中的阿爾茨海默病相關死亡率并沒有小幅上揚，而是大增，死于該病的美國人同比增長了15.7%。CDC的一份報告稱，1999年到2014年，阿爾茨海默病致死的美國人攀升了55%。數字已經拉響警報，是該引起重視了。

“阿爾茨海默癥導致的死亡率上升不單單是死亡的問題，對患者的健康也有直接的影響，”CDC報告坦言，“這種病讓人身體日漸虛弱”，不但使患者本人及家人背負龐大的醫療費用，也給美國州和郡政府帶來巨大的財政負擔。因為地方政府要維持運營公共的長期醫療設施。

在看護阿爾茨海默癥和其他類型老年癡呆癥患者的2590億美元費用之中，三分之二以上都由美國聯邦醫療保險計劃Medicare和醫療補助計劃Medicaid等公費醫療項目買單。但CDC指出：“對無力負擔長期醫療費用的阿爾茨海默癥病患來說，大部分醫護都由家庭成員或者其他免費護工提供。”CDC估算，去年該病得到的免費救助時長合計達到182億小時。（你沒看錯，單位是億。）

通過死亡數據，安德森能清楚看到阿爾茨海默癥患者的困境，也目睹了現實的美國社會：阿片類藥物致死的人數明顯激增，令人恐懼；嬰兒死亡率讓人欣慰地下降；自殺人數持續上升，原因一直不明。

安德森投身死亡數據統計純屬無心插柳。在賓州上大學時，他改過四次專業，畢業時拿到了人口統計學學位。即便畢業那會，他也更有興趣研究婚姻和家庭數據，沒想過要跟死亡數據打交道。他回憶說，當時“統計學家很難找工作”，他又正好看到一條死亡數據統計部門的招聘廣告。也許，只是也許，安德森生來就注定干這份工作。他說：“我祖父曾經是愛達荷州麥迪遜郡的葬禮承辦人，還開過救護車，還做過郡里的驗尸官。”

當我問起20年來統計死亡有何心得，安德森很快回答：“人人都有一死。”

頓了頓，他又說了一句：“通過死亡可以從另一個角度看待生命。”

那句話讓我難以忘懷。（財富中文網）

本文首發于6月6日期《財富》雜志的醫療健康領域每日簡報Brainstorm Health Daily。

譯者：Pessy

審稿：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.