When Stigma, Disclosure, and Access to Care Collide: An Ethical Reflection of mpox Vaccination Outreach

Experiences of stigma in health care encounters among LGBTQ+ populations (lesbian, gay, bisexual, transgender, and queer and questioning) have long been a barrier to care. Marginalization and historically grounded fears of stigmatization have contributed to a reluctance to disclose sexual behavior and/or gender identity to health care providers. We reflect on how student nurses grappled with the ethics of patient disclosure while providing mobile outreach in Chicago for mpox (formerly monkeypox) from fall 2022 to spring 2023. Student nurses addressed how requiring disclosure of sexual behavior or sexual orientation may serve as a barrier to accessing preventive care, such as mpox vaccination. Accounts of stigma and criminalization experienced by LGBTQ+ people provide insight on challenges historically associated with disclosure in health care.

Centering PrEP: utilizing ADAPT-ITT to inform group PrEP care for sex workers in Chicago

BACKGROUND

Sex workers, those who trade sex for monetary or nonmonetary items, experience high rates of HIV transmission but have not been adequately included in HIV prevention and Pre-Exposure Prophylaxis (PrEP) adherence program development research. Community-empowered (C.E.) approaches have been the most successful at reducing HIV transmission among sex workers. Centering Healthcare (Centering) is a C.E. model proven to improve health outcomes and reduce health disparities in other populations, such as pregnant women, people with diabetes, and sickle cell disease. However, no research exists to determine if Centering can be adapted to meet the unique HIV prevention needs of sex workers.

OBJECTIVE

We aim to explain the process by which we collaboratively and iteratively adapted Centering to meet the HIV prevention and PrEP retention needs of sex workers.

METHODS

We utilized the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, Testing (ADAPT-ITT) framework, a model for adapting evidence-based interventions. We applied phases one through six of the ADAPT-ITT framework (Assessment, Decision, Adaptation, Production, Topical Experts, Integration) to the design to address the distinct HIV prevention needs of sex workers in Chicago. Study outcomes corresponded to each phase of the ADAPT-ITT framework. Data used for adaptation emerged from collaborative stakeholder meetings, individual interviews (n = 36) and focus groups (n = 8) with current and former sex workers, and individual interviews with care providers (n = 8). In collaboration with our community advisory board, we used a collaborative and iterative analytical process to co-produce a culturally adapted 3-session facilitator's guide for the Centering Pre-exposure Prophylaxis (C-PrEP +) group healthcare model.

RESULTS

The ADAPT-ITT framework offered structure and facilitated this community-empowered innovative adaptation of Centering Healthcare. This process culminated with a facilitator's guide and associated materials ready for pilot testing.

CONCLUSIONS

In direct alignment with community empowerment, we followed the ADAPT-ITT framework, phases 1-6, to iteratively adapt Centering Healthcare to suit the stated HIV Prevention and PrEP care needs of sex workers in Chicago. The study represents the first time the first time Centering has been adapted to suit the HIV prevention and PrEP care needs of sex workers. Addressing a gap in HIV prevention care for sex workers, Centering PrEP harnesses the power of community as it is an iteratively adapted model that can be piloted and replicated regionally, nationally, and internationally.

Culturally Safe Nursing Care for Black Sex Workers in the Greater Chicago Area, 2020‒2021

Complex structural and social factors have created health inequities for Black sex workers. Black people, including those engaged in transactional sex, report leaning on spiritual beliefs to guide health-related decision-making, including whether to get the COVID-19 vaccine. Public health nurses can improve the health of Black sex workers through culturally safe care, which may include a community-stated vision of spiritual support. (Am J Public Health. 2022;112(S3):S288-S291. https://doi.org/10.2105/AJPH.2022.306836).

"Feeling Safe, Feeling Seen, Feeling Free": Combating stigma and creating culturally safe care for sex workers in Chicago

BACKGROUND

Previous studies have established that sex workers experience discrimination and stigma within healthcare settings, limiting their access and receipt of culturally safe care. These barriers impact sex workers' ability and desire to routinely engage with the healthcare system. Community empowerment interventions that are culturally safe offer an effective strategy to improve access to services and health outcomes for sex workers.

OBJECTIVES

This project was designed to inform the development of community empowerment interventions for sex workers by understanding their self-management, health promotion, and harm reduction needs.

METHODS

In-depth interviews (N = 21) were conducted with sex workers in Chicago. Transcripts of individual interviews were analyzed in Dedoose using rapid content analysis.

RESULTS

Participants had a mean age of 32.7 years; 45% identified as White, 20% as Black, 15% as Latinx, and 20% as multiple races; 80% identified as Queer. A total of 52% of participants identified as cisgender women, 33% as transgender or gender fluid, 10% as cisgender men, and 5% declined to answer. Themes of self-management practices, stigmatizing and culturally unsafe experiences with healthcare providers, and the prohibitive cost of healthcare emerged as consistent barriers to routinely accessing healthcare. Despite identifying patient-centered care as a desired healthcare model, many participants did not report receiving care that was respectful or culturally responsive. Themes also included developing strategies to identify sex worker-safe care providers, creating false self-narratives and health histories in order to safely access care, and creating self-care routines that serve as alternatives to primary care.

CONCLUSION

Our findings demonstrate how patient-centered care for sex-workers in Chicago might include holistic wellness exercises, accessible pay scales for services, and destigmatizing healthcare praxis. Focus on culturally safe healthcare provision presents needs beyond individualized, or even community-level, interventions. Ongoing provider training and inbuilt, systemic responsivity to patient needs and contexts is crucial to patient-centered care.

Improving the Knowledge, Attitudes, and Behavioral Intentions of Perinatal Care Providers Toward Childbearing Individuals Identifying as LGBTQ: A Quasi-Experimental Study

BACKGROUND

This study explores the impact of gender and sexuality awareness training on perinatal health care providers' (HCPs') knowledge, attitudes, and intended behavior toward childbearing individuals identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ).

METHOD

A nonrandom convenience sample of HCPs (n = 187) comprised an experimental group (n = 99) who attended grand rounds trainings covering gender and sexuality topics and a control group (n = 88) who attended sessions on other unrelated topics. All participants completed a pre-posttraining questionnaire to assess changes in knowledge, attitudes, and intended behavior toward LGBTQ patients.

RESULTS

Participants in the experimental group demonstrated significant improvement in knowledge, misconception, prejudice, sensitive language, and normativity regarding LGBTQ pregnant patients from pretest to posttest.

CONCLUSION

These findings suggest that a 40-minute gender and sexuality training can immediately improve HCPs' knowledge, attitudes, and intended behavior toward LGBTQ childbearing patients. [J Contin Educ Nurs. 2019;50(7):303-312.].

The first mortality follow-up study: the 1841 Report of William Farr (physician) on the mortality of lunatics

BACKGROUND

In the 1830s in England, there was a great cultural interest in the collection and publishing of all kinds of statistics. The Council of the Statistical Society of London (founded in 1834) commissioned one of its Fellows, Dr William Farr, to investigate and prepare a report on the mortality of patients in the county asylums, with the mortality in a large number of proprietary houses that were licensed to care for patients with mental illness (then called lunatics) ordered for confinement because of their mental condition. Committees of Parliament had investigated the condition of the mentally ill confined to the asylums and taken measures in an attempt to improve their treatment and to correct abuses.

RESULTS

Farr collected data from Hanwell, the Middlesex County asylum opened in 1831, and other asylums on annual admissions, resident patients, deaths, discharges, derived years of residence (exposure to risk), and annual mortality rates by duration and as an aggregate. He used similar data from a recent report on a large number of licensed houses. For the best estimate of comparative mortality, an assumed age distribution by sex and rates from the English Life Table No. 1 (constructed by Farr for 1841).

CONCLUSION

Farr demonstrated that annual mortality rates were higher at durations 0-1.5 years than at durations 1.5-7.5 years, higher in men than in women, higher in paupers than in other patients, higher in licensed houses than in the Hanwell Asylum, and higher in the 4 large licensed houses than in a collection of smaller ones.

COMMENT

A brief sketch of Farr's life is given as a memorial tribute to his pioneer work in vital statistics, life table methodology, public health, and life insurance medicine.

Mortality in various types of osteogenesis imperfecta

BACKGROUND

Osteogenesis imperfecta (OI) is a group of closely related inherited diseases characterized by abnormal bone fragility. The current clinical classification system delineates 6 types, one of which (type II) is so severe that mortality is 100%, either intrauterine or perinatal. The types are differentiated by clinical groups, by severity, and by the presence or absence of other features such as blue sclerae or dentinogenesis imperfecta. There are no known previous studies of mortality in OI.

RESULTS

From a registry created in association with the Brittle Bone Society, 743 patients with OI in England and Wales were observed in the period 1980-1993. These were classified into 3 groups (type IA, type III, and types IB, IVA, and IVB combined). Average annual mortality rates were determined in each group by sex and attained age. These rates were compared with 1981 rates in the population of England and Wales, matched by sex and age. Results are given in terms of exposures, observed and expected deaths, and 2 indices of excess mortality: mortality ratios and excess death rates per 1000 person-years.

CONCLUSION

In type IA, 51.5% of the OI cases overall, there was no significant excess mortality (mortality ratio 108%, based on 15 deaths). In type III, on the other hand, excess mortality was very high in children and still significantly high at ages 15-34 years. In the combined group of types IB, IVA, and IVB, the mortality ratio was 157% in patients aged 45 and up (not significant at the 95% confidence level), but higher ratios at younger ages were significant, even though based on a total of only 5 deaths.

Long-term comparative mortality in hyperthyroid patients treated with radio-iodine, a cohort study in England

BACKGROUND

The focus of this long-term study (entry 1950-1989, follow-up to 1996) on hyperthyroid patients treated with 131I was on all-cause mortality and some specific causes other than cancer. The study was carried out on 7209 patients who were residents of the Midlands area around Birmingham, England. In a total exposure of 105,028 patient-years, 3611 deaths were observed, compared with 3186 deaths expected from age/sex-matched rates in the English life tables.

RESULTS

Data were reported for observed and expected deaths, and SMR values (standardized mortality ratios to one decimal place) by selected causes of death in combinations with duration, age, and 3 dosage groups of 131I. Exposure data were given only for the dosage groups of 131I, not for the results by age or duration.

CONCLUSIONS

Comparative mortality was significantly increased for all-cause mortality (but with an SMR of only 1.13), and also for cardiovascular and cerebrovascular deaths, and deaths from fracture. Excess mortality was greatest in the first year after entry, and decreased thereafter. There was no reported increase in cancer mortality.

Incidence of seizures after traumatic brain injury--a 50-year population survey

BACKGROUND

Records of the Rochester Epidemiological Project were used to determine the incidence of secondary seizures after traumatic brain injury (TBI) in all cases treated for this condition in the population of Olmsted County, Minn, from 1935 to 1984. Medical records of the Mayo Clinic and all other medical facilities in Olmsted County, Minn, are in the database of this Project. Incidence rates after TBI were compared with incidence rates of idiopathic epilepsy previously determined for Olmsted County.

RESULTS

TBI cases were divided into 3 defined severity categories: mild, moderate, and severe. Out of 4541 cases of TBI accumulated in 50 years only 97 cases developed 1 or more seizures (46 cases of seizure secondary to other definite causes were excluded). Incidence rates were highest in the first year after the head injury. The overall excess incidence rate was very low in mild TBI, only 0.3 per 1000 per year, but was higher in severe TBI, with an excess rate of 10 per 1000 per year. Only 7.2% of the TBI cases were classified as severe (loss of consciousness or amnesia for more than 24 hours, subdural hematoma, or brain contusion).

CONCLUSION

The long-term incidence of seizures beyond the incidence rate of idiopathic epilepsy is low after mild or moderate TBI, but is at the rate of 10 excess cases per 1000 per year in the minority of cases with severe TBI.

Long-term comparative cancer mortality after use of radio-iodine in the treatment of hyperthyroidism, a fully reported multicenter study

BACKGROUND

The Cooperative Thyrotoxicosis Therapy Follow-up Study reported cancer mortality after use of radio-iodine (131I), surgery, and other treatments in patients with hyperthyroidism, started during 1946-1964 and followed through 1968. In 1984, the National Cancer Institute initiated a continued follow-up (FU) of the same cohort through 1990, to assess potential carcinogenic effects of 131I through 1990, a potential FU ranging from 26 to 44 years.

RESULTS

With an initial cohort of 35,630 hyperthyroid patients, a mean entry age of 46 years and 738,831 patient-years of FU, the 2950 observed cancer deaths were only minimally over the 2858 expected cancer deaths from US population rates, after exclusion of first-year deaths. In the 64.7% of patients receiving 131I, the total cancer deaths were significantly above expected (258 versus 208), only at durations of 1-5 years, not thereafter. Thyroid cancer deaths were significantly elevated, but the number was very small, only 24 deaths in all exposures, as compared with 5.89 expected. The overall thyroid cancer mortality was higher in cases of toxic nodular goiter than in patients with Graves' disease.

CONCLUSIONS

Despite the small early increase in total cancer deaths and the relatively higher increase in thyroid cancer deaths (only 18 excess deaths), the authors conclude that therapy with the doses of 131I used is a safe procedure. The interpretation of cause-specific excess mortality is greatly influenced by the prevalence of the cause of death.

Structured settlement annuities, part 1: overview and the underwriting process

Structured settlement underwriting is the underwriting of medically impaired lives for the purchase of an annuity to fund the settlement. Other than risk assessment, structured settlement (SS) underwriting has little in common with traditional life insurance underwriting. Most noteworthy of these differences is the relative lack of actuarial data on which to base decisions about mortality and the necessity for prospective thinking about risk assessment. The purpose of this paper is to provide a foundation for understanding the structured settlement business and to contrast the underwriting of structured settlements with that of traditional life insurance. This is the first part of a two-part article on SS annuities. Part 2 deals with the mortality experience in SS annuitants and the life-table methodology used to calculate life expectancy for annuitants at increased mortality risk.

Structured settlement annuities, part 2: mortality experience 1967--95 and the estimation of life expectancy in the presence of excess mortality

BACKGROUND

the mortality experience for structured settlement (SS) annuitants issued both standard (Std) and substandard (SStd) has been reported twice previously by the Society of Actuaries (SOA), but the 1995 mortality described here has not previously been published. We describe in detail the 1995 SS mortality, and we also discuss the methodology of calculating life expectancy (e), contrasting three different life-table models.

RESULTS

With SOA permission, we present in four tables the unpublished results of its 1995 SS mortality experience by Std and SStd issue, sex, and a combination of 8 age and 6 duration groups. Overall results on mortality expected from the 1983a Individual Annuity Table showed a mortality ratio (MR) of about 140% for Std cases and about 650% for all SStd cases. Life expectancy in a group with excess mortality may be computed by either adding the decimal excess death rate (EDR) to q' for each year of attained age to age 109 or multiplying q' by the decimal MR for each year to age 109. An example is given for men age 60 with localized prostate cancer; annual EDRs from a large published cancer study are used at duration 0-24 years, and the last EDR is assumed constant to age 109. This value of e is compared with e from constant initial values of EDR or MR after the first year. Interrelations of age, sex, e, and EDR and MR are discussed and illustrated with tabular data.

CONCLUSIONS

It is shown that a constant MR for life-table calculation of e consistently overestimates projected annual mortality at older attained ages and underestimates e. The EDR method, approved for reserve calculations, is also recommended for use in underwriting conversion tables.

Mortality in two recent reports of clinical trials on patients with congestive heart failure compared with mortality in three previous clinical trials

BACKGROUND

Several clinical trials of drug treatment of patients with congestive heart failure (CHF) have previously been reported as Mortality Abstracts in the Journal of Insurance Medicine. Results are presented here for two similar clinical trials reported in September 1999 and compared with the previous results.

RESULTS

In a recent international multicenter clinical trial, excess mortality in terms of excess death rates (EDRs) was reduced from 195 per 1000 per year in the placebo group to 139 in the group treated with Spironolactone. There was no significant reduction in the Danish multicenter study of Dofetilide to convert the atrial fibrillation (AF) to a normal rhythm in the 25% of the CHF patients who had AF (EDR was 224 in the placebo group and 216 in the Dofetilide group). In both of these studies, there were more patients with severe CHF than in the previous studies and the EDR values were higher. Results from the Danish study by severity according to the New York Heart Association (NYHA) classification show a progressive increase in EDR from 173 in class 2 to 237 in class 3 to 392 in class 4.

CONCLUSION

Excess mortality in symptomatic CHF is far outside the issue limits for individual life insurance, but these results are of potential utility for the underwriting of such cases for structured settlement annuities.

Comparative mortality in cerebral palsy patients in California, 1980-1996

BACKGROUND

The large database of the California Department of Developmental Services provides a data source for mortality rates in persons with mental retardation by age, sex, severity, cause and associated conditions. This study involves patients with a diagnosis of cerebral palsy.

RESULTS

After a table of demographic data, four tables are used to show detailed age-related observed and expected mortality rates for Cerebral Palsy patients by sex and a severity factor that divides the patients into two groups of approximately equal size. The factor used was quadriplegia (all four limbs involved in motor dysfunction). Spasticity was the predominant feature of the motor dysfunction.

CONCLUSION

Excess mortality was moderate in the less severe Cerebral Palsy patients, but was higher in those with quadriplegia (overall EDR--Excess Death Rate--about 6 per 1000 and 16 per 1000, respectively). In less severe cases EDR was higher at ages 1-4 years, the almost constant to age 49, then rose with advancing age. In case with quadriplegia EDR decreased in childhood and young adults to a relatively stable minimum at ages 25-49, then increased at older ages. There was little sex difference in EDR.

Mortality in rheumatoid arthritis: experience in four clinical series compared with the experience in the 1983 medical impairment study

BACKGROUND

Survival curves and decimal Standardized Mortality Ratios (SMRs) were reported in 1994 for four clinical series of patients with Rheumatoid Arthritis (RA), with use of a common data processing system. It was felt to be desirable to compare the excess mortality observed in clinical patients with the excess mortality found in substandard policyholders with RA in the 1983 Medical Impairment Study.

RESULTS

The weighted mean SMR was 2.25 for the male RA patients and 2.42 for the females. Although similar in magnitude to the percentage male and female Mortality Ratios (MRs) in the 1983 Medical Impairment Study, the derived Excess Death Rate (EDR) was higher for the clinical RA patients, despite the lower select mortality versus the population mortality, even after adjustment for difference in mean age between the clinical and insurance series.

CONCLUSION

The higher EDR in four clinical series of RA patients probably reflects a higher proportion of more severe cases, who are declined for insurance or do not accept a highly rated offer.

How to construct a Mortality Abstract (number 497M-1 as an example)

BACKGROUND

Since the 1976 publication of the first Medical Risks volume of analyses of mortality follow-up (FU) studies (called "mortality abstracts"), members of the American Academy of Insurance Medicine have sought to extend this method of using FU studies in the medical literature to produce comparative mortality data useful for medical underwriting. Seminars on life table methodology started in 1977 and courses are now sponsored by the Board of insurance Medicine. The Journal of Insurance Medicine has published many mortality abstracts and methodology articles, and methodology is further pursued by the Editor in this issue of the Journal. TEXT: Retrieval of the source data (Annual Reports) is described and the source tables are evaluated. These are related to a previous 1976 Abstract. The design of the Abstract is described: other sources, tables, background, expected mortality, descriptive text, and comment. Aspects of life table methodology are used throughout the description.

SUMMARY

The construction of the current Mortality Abstract 497M-1 on mortality in cystic fibrosis is described in detail.

Randomized trial of carvedilol in treatment of congestive heart failure

BACKGROUND

Members of the U.S. Cardevivol Study Group at Lovelace Scientific Resources, Albuquerque, NM, designed and carried out a large multicenter randomized clinical trial of Cardevilol vs placebo in patients with clinical heart failure and ejection fraction < 0.35.

RESULTS

Derived exposure and death data at 50-day intervals to 400 days were used to construct tables of comparative mortality, all ages, both sexes and all durations to 400 days combined, in the Carvedilol and the placebo groups Derivation of expected mortality is explained in detail.

CONCLUSIONS

Excess mortality, measured as mortality ratio or excess death rate, was much higher in the placebo than in the Cardevilol-treated group.

Cystic fibrosis mortality: registry data of cystic fibrosis

BACKGROUND

The Cystic Fibrosis Foundation has been collecting mortality and other data on cystic fibrosis patients from over 100 U.S. clinical centers since 1966, and publishes annual reports of the data. Cystic fibrosis is an important autosomal recessive genetic disease, affecting multiple body systems, with disability and early mortality as very common complications.

RESULTS

Observed data by age in the 1994 and 1995 REports are compared with the earliest Registry experience. 1966-1972, after age-matching observed with expected mortality in the U.S. population. Observed and expected results are given in four tables of comparative mortality.

CONCLUSION

Excess mortality as a rate difference has shown a marked decrease during this time period, ranging from 96% at age 0-1 to 52% at ages 20-25 years. This can be attributed to improvements in medical treatment.

First-year acute coronary event rates in patients with acute myocardial infarction evaluated 5-7 days post-MI for ST depression in an ambulatory monitored ECG

BACKGROUND

To present rates for fatal and non-fatal acute coronary events (ACE) in patients monitored 5-7 days after acute myocardial infarction, for abnormal ST depression in a continuous ambulatory ECG, with follow-up to the end of the first year after hospital admission. Comparative first-year mortality rates are also derived.

RESULTS

The comparative mortality in the ischemic group is at an excess death rate of 92 per 1,000 per year as opposed to the nonischemic group where it was 15 per 1,000 per year. Nonfatal ACE rates were 346 and 154 per 1,000 per year, respectively, in the two groups.

CONCLUSION

The risk of death is extremely high in the first few minutes and the first hour after the onset of an acute MI, and the risk diminishes steadily over the ensuing days weeks and months.

Comparative mortality in mentally retarded patients in California, with and without Down's syndrome, 1986-1991

BACKGROUND

The large database of the California Department of Developmental Services provides a data source for mortality rates in persons with mental retardation by age, sex, severity, cause and associated conditions.

RESULTS

Data for 1986-1991 were used to determine age-related mortality rates in cases with and without Down's Syndrome, in three severity levels of mental retardation. Distribution data for the data-base population are also given.

CONCLUSION

In both Down's and non-Down's patient groups excess mortality increased with severity of mental retardation at all ages. In both groups excess mortality tended to decrease with advancing age to age 35-39 years, and to increase at the older ages. The age increase in excess death rate at age 40 years and up was steeper in the patients with Down's Syndrome.

Pitfalls of inferring annual mortality from inspection of published survival curves

In many FU articles currently published, results are given primarily in the form of graphs of survival curves, rather than in the form of life table data. Sometimes the authors may comment on the slope of the survival curve as though it were equal to the annual mortality rate (after reversal of the minus sign to a plus sign). Even if no comment of this sort is made, medical directors and underwriters may be tempted to think along similar lines in trying to interpret the significance of the survival curve in terms of mortality. However it is a very serious error of life table methodology to conceive of mortality rate as equal to the negative slope of the survival curve. The nature of the error is demonstrated in this article. An annual mortality rate derived from the survival curve actually depends on two variables: a quotient with the negative slope (sign reversed), delta P/ delta as the numerator, and the survival rate, P, itself as the denominator. The implications of this relationship are discussed. If there are two "parallel" survival curves with the same slope at a given time duration, the lower curve will have a higher mortality rate than the upper curve. A constant slope with increasing duration means that the annual mortality rate also increases with duration. Some characteristics of high initial mortality are also discussed and their relation to different units of FU time.(ABSTRACT TRUNCATED AT 250 WORDS)

Examples of early mortality follow-up studies

Numerous mortality studies may be found in publications of the life insurance industry dating back about a century. Examples presented include mortality in asthma history (1903), overweight (1844-1905), and hypertension (1907-11). The favorable effect of underwriting selection on mortality was recognized early, and standard insurance mortality tables in North America have always distinguished between select and ultimate mortality rates. The mortality ratio has been the traditional measure of excess mortality in insurance follow-up studies. Similar mortality studies in the medical literature before 1920 are extremely difficult for investigators to locate. One important exception with regard to methodology and completeness of comparative mortality and survival results was a 20-year follow-up of pulmonary tuberculosis patients after discharge that was reported in 1908.

Mortality in an insured population with atrial fibrillation

In a cooperative study of 3,099 life insurance applicants with atrial fibrillation (AF), 71 deaths over an average duration of 3.3 years were observed and compared with deaths expected and derived from standard insurance mortality tables. A normal mortality was observed in cases of paroxysmal AF with no other identified cardiovascular impairment. Paroxysmal AF with associated mitral stenosis or coronary disease was found to have a significantly increased mortality. Chronic AF with or without other impairments entails a much higher risk than paroxysmal AF, those cases associated with mitral stenosis showing very high excess mortality.