Age and Coronavirus
What if the reason many countries have not identified COVID19 within their borders, is that there's so few people there who might die from it?
First, let me express my opinion: no country in the world is discovering Coronavirus in their borders through random population testing.
They’re not doing it by holding thermometers on airline passengers as they disembark from international travel; not from asking what countries you’ve been to in the past 14 days; not from stopping people in the mall and asking them if they know anyone who has a fever, or a cough.
And to be absolutely clear - I’m not talking here about finding new cases, and managing the population of cases, after the first case has been discovered in each country. I’m talking about discovering that first case in a country, or first several — breaking the dam, the country’s public health officials first seeing the epidemic at its face, staring back at them from the abyss.
I’m talking about countries which don’t know that Coronavirus is in community transmission, and the difference between them and the countries which do.
The list of countries and their case rates shows that countries are not even identifying COVID19, until they break about 1 case per million population. Which means, if the country wanted to detect even one case, they would need to test 1 million people, randomly.
Not a single country has tested 1 million people randomly; the country which has tested the most - South Korea - has tested about 200 thousand. Most other countries pre-select test subjects — do they have a fever? do they have a cough? is breathing shallow? have they travelled? has anyone they’re close to, travelled?
So no country in the world is discovering COVID19 in their borders through random testing. Let’s get that settled.
The way they’re all discovering it is, elderly people (65+ years, say) are presenting themselves at hospital emergency rooms with severe flu-like systems; they get worse, develop pneumonia, have to be put on an artificial respirator, and then they die.
And not just 1 or 2 deaths - or whatever a typical monthly flu or pneumonia caseload is for that country, or the hospital, or whatever reporting entity which keeps track of it in each country. It has to be a breakout number that somebody, at least until recently, would finally say “Hold on - this is too many elderly people dying of pneumonia, they must be connected somehow.” And that’s when they discover COVID19 within the country’s borders.
The elderly are extremely vulnerable to COVID19. The World Health Organization’s report on the China outbreak found that 15.8% of those 80 or over, if they contract COVID19, would die. Meanwhile, younger people were nearly impervious; for 20-29 year olds, the fatality rate was not worse than seasonal flu (about 0.1%), and for 0-9 year olds, fatalities were so small in number, there weren’t any even documented. They couldn’t find any.
Maybe that means something, when we go looking for countries where the epidemic has already broken out.
Youth of the World
Here is a list of fifty countries, sorted in a particular order based on a number I’ll tell you later, and let’s see if you can figure out what the number is that I’m ordering them by:
Niger, Uganda, Mali, Angola, Malawi, Zambia, Burundi, Mozambique, South Sudan, Burkina Faso, Tanzania, Liberia, Chad, Ethiopia, Somalia, Benin, Nigeria, Cameroon, Gabon, Democratic Republic of Congo, Senegal, Guinea, Afghanistan (hah! there goes your hypothesis it has something to do with Africa!), Sierra Leone, Rwanda, Yemen (Yemen?? oh no, this just got harder…), Republic of Congo, MAdagascar, Kenya, Eritrea, Central African Republic, Togo, Equatorial Guinea, Sudan, Comoros, Zimbabwe, Iraq (what?? okay, why is Iraq here in between Zimbabwe and) Ginea-Bissau, Mauritania, Cote d’Ivoire, The Gambia, Ghana, Namibia, Eswatini, Vanuatu, Guatemala (hello, South America!), Solomon Islands, Jordan, Belize, Tonga, Laos.
Give that list a look. Niger has the lowest such number, Laos the highest. There seem to be a lot of African countries at the start, but then in comes Afghanistan — in South Asia — then Yemen on the Arabian Peninsula, Iraq, Guatemala, and Belize. So it’s more complicated than just geography.
Give up?
It’s median age. Niger has the lowest average median age (the age, where half the population is older, half is younger) at 15.4 years old (ah, to be that young again!), and Laos has the highest, 23 years old — still pretty young. Oh, and to be clear —- I’ve only listed countries with 1 million in population or more - so, the youngest populations, with a substantial number of people.
Great, okay. So now that you guessed it (did you?), here’s a second list of fifty countries, sorted in a particular order based on a number — some number, I’m not telling you what it is yet, but I’ll tell you below — and let’s see if you can figure out what number I’m ordering them by:
Japan, Germany, Italy, Greece, Slovenia, Austria, Lithuania, Latvia, Hong Kong, Croatia, Bulgaria, Estonia, Spain, Netherlands, Serbia, Finland, Switzerland, Hungary, Canada, Denmark, Portugal, Bosnia and Herzegovina, Czech Republic, Malta, South Korea, Cuba, Belgium, France, Sweden, Romania, Montenegro, Poland, Taiwan, Ukraine, Slovakia, United Kingdom, Belarus, Russia, Luxembourg, Norway, Australia, Barbados, Georgia, United States, New Zealand, Thailand, China, Cyprus, Ireland, Moldova, Iceland.
Give up?
It’s median age, again! This time, it’s highest median age (Japan - at 47.3 years) down to lowest (Iceland, at 36.5 years).
(You may have noticed I’ve dropped countries smaller than 1 million in population from these lists — I’m focussing on larger population countries, for now. I hope that’s okay with you.)
And here’s where the payoff comes: age is not the only thing which separates these two groups of countries.
So does COVID19.
Of the oldest 50 countries, 43 have identified COVID19 within their borders, as of today (March 15th, 2020).
Of the youngest 50 countries, only 2 have. Those two countries are Iraq - with 2.7 cases per Million population (CPM) — and Senegal - with 1.4 CPM.
43 vs. 2.
Clearly, COVID19 is treating old countries different from young countries.
And here’s the important point: why aren’t the young countries reporting a COVID19 outbreak? Is it completely absent? Or is it harder to detect?
I see three possible explanations. The first seems very likely to me; the second, cannot be excluded; and the third is probably already strongly excluded.
Explanation 1: The Elderly are Being Used as Canaries in a Coal Mine.
2.7% of the population of Niger — the youngest of the youngest countries — is 65 years or older. In Japan — the oldest of the oldest — 30% are. That’s the difference between a “young country” and an “old country”. For Italy, it’s 22%. For South Korea, it’s 16%. China, 12%.
When countries are not doing a sufficient number of random confirmation tests for COVID19 to detect it as it becomes prevalent, they identify COVID19 when the number of victims is too great to not be noticed on public health reports.
The oldest countries are reporting COVID19 because their elderly population is dying from it — deaths so numerous, they are impossible to ignore - let alone, to miss, when you are searching for them.
Once COVID19 is identified by a country’s health authorities, the authorities kick into action, become closely watched by political forces — politicians, newspapers, people — and begin testing more marginal cases in earnest. And that is when the discoveries begin to happen.
The youngest countries in the world each do not have a large enough population of elderly people to serve as the trigger.
Size of population plays a role, too. A small, old country might well have already seen significant numbers of elderly die from COVID19.
San Marino has a median age of 44 years, and a population of only 33 thousand people. With 101 identified cases of COVID19, it has the highest case rate in the world today: 3000 CPM, compared with #2 Iceland at 442 CPM (itself, with median age 37 years, and population of only 356 thousand).
Meanwhile, large, young countries can have no identified COVID19 among their elderly populations, because those populations are so small. Nigeria is the largest country among the 50 youngest countries, with population 206 million, and the 16th lowest median age in the world - 18.4 years. As of today, there are 0 identified cases of COVID19 in Nigeria.
Consider that Nigeria is 3.3% aged 65 or older — an elderly population of 6.8M. Even if they have a case rate of 1 CPM, that’s only elderly 7 people in a nation of 206M who have contracted it (assuming everyone of every age is equally likely to contract it - which may well not be the case, and there’s evidence that it’s not - but we’ll assume this as approximately correct, for now). Based on the 15.8% fatality rate (valid only for 80+ years, but conservatively apply it to the full 65+ group), that’s just 1 death. In order for there to be ~2 dozen deaths among the elderly in Nigeria - at which point, it would likely be obvious that COVID19 is the culprit, even without testing - Nigeria would need to have 24 CPM - which would place it among the top 25 nations worldwide in COVID19 case rates.
There just aren’t enough elderly - in raw numbers - in the youngest countries in the world, to serve as the alarm bell ringing, which causes a country to take notice of the arrival of COVID19 within its borders. At least, it cannot do so, until the epidemic is in a very advanced state in that country.
The tiny canary bird, exposed to toxic gas will suffer and die well before humans do. That’s why historically, coal miners would take them with them into mines - and when they noticed them dying, they could bolt out of the coal mine, potentially saving their own lives. The problem being, the canaries, of course, did not survive.
If this explanation is correct - and it’s not clear if it is - then COVID19 is running just as rampant through these young countries, too. It’s just infecting the largely young population, which suffers few-to-no severe cases.
No one is dying of COVID19 in the young countries.
Explanation 2: Not Age, but Correlated with Age.
It may be that their tiny elderly populations is not why the young countries have not identified COVID19 within their borders.
It may be they are doing vigorous randomized testing in the population, and there’s just no COVID19 cases there to be discovered. However, there are some reports that very few tests in young countries are being given: only 40-50 tests in Ethiopia, for example.
It may be that COVID19 is simply not present in the young countries, for some reason other than, but itself is related to, youth.
I have no good ideas what that thing, correlated with age, might be. But as anyone who has taken a statistics course knows, “correlation is not causation”. There may be a secondary consideration, which is itself correlated with the primary consideration (in this case, median age), and which is the real underlying cause.
But it should be noted as a possible, second explanation.
Explanation 3: Young People Can’t Catch Coronavirus? Definitely the Wrong Explanation.
If the younger the person is, the more difficult it is for an infection of COVID19 to take place, that might explain why young countries aren’t discovering COVID19 within their borders. But this is definitely wrong.
(Table Source: Korea Center for Disease Control, “The updates on COVID-19 in Korea as of 15 March”, Accessed March 15 2020.)
Data from South Korea seems to exclude this possibility. The Korea Center for Disease Control has found that people ages 0-39 years make up almost half of all cases in South Korea. Notably, of 75 identified fatalities, only 1 person has died.
So the data from South Korea seems to firmly exclude this explanation: young people can and do catch COVID19.
Conclusions.
Of the oldest 50 countries, 43 have identified COVID19 within their borders, as of today (March 15th, 2020). Of the youngest 50 countries, only 2 have.
The absence of any detected cases in a large number of countries may be related to their low median age. If a COVID19 outbreak is indeed typically first discovered in a country due to significant numbers of fatalities of elderly (65+) from pneumonia, who had presented with flu-like systems, then the absence of a large (in numbers) population of elderly would make it less likely that a COVID19 outbreak would be identified.
This would mean that “young countries” can have a high COVID19 infection rate, which has not been noticed yet through confirmation testing. The example of Nigeria is instructive: with a total population of 206 million, only 3.3% of which (6.8M) are 65+ years, Nigeria would have to have an infection rate which would rank in the top 25 globally (about 24 CPM), for it to become obvious that COVID19 is in the population only by the number of people dying from it.
In young countries, the most efficient way to identify COVID19 may be to require a post-mortem test on every single person who dies, above 65 years age. If they died of cancer, or heart disease, but with a co-morbidity of COVID19, that would soon show up. This would require far fewer tests than randomly testing the population. Young countries should immediately begin systematic post-mortem testing of all aged 65+ who die.