Age Differentiation is Key to Re-opening the Economy
We all understand that COVID-19 is deadlier for the very old. But there are significantly different risks across all age groups which escalate precipitously with age. This varies from a nearly non-existent risk for people under 20 years old to about a 10% risk of death for those 85+. This age-based difference is so significant, that it should be a key component of differentiating policies for how we open up the economy with older, retirement-age, people asked to isolate for much longer than the majority of working-age Americans. It’s time for this to become a serious part of the discussion.
Trade-offs with Re-opening the Economy
We are finally having meaningful discussions about the trade-offs of continuing on in lockdown to reduce COVID-19 deaths versus the real costs to the well-being and quality of life of the economic destruction that lockdown is inducing in the US and most other nations. Given the polarized and hyper-partisan state of the US, the two sides of this trade-off are being positioned as Republicans focused on opening up the economy and Democrats focused on keeping it locked down to reduce COVID-19 deaths. Since President Trump is the biggest champion of opening up as soon as possible and Democrats tend to stand against whatever he stands for, there may be some basis for that and certainly, the media likes a simple division. That said, it’s safe to assume that all parties want to minimize the damage from COVID-19 and the damage from the economic shutdown but the devil is in the details.
The New York Times pulled together a panel on this trade-off and published the resulting discussion last weekend, aptly titled, “Restarting America Means People Will Die. So When Do We Do It?” It was a decidedly liberal panel that did an excellent job of elucidating the tremendous damage being done by this economic shut down particularly to the most vulnerable in our society who live paycheck to paycheck. This panel, came to the same conclusion that a group of conservatives would have come to, we need to get this economy opened up as soon as we possibly can while also trying to minimize resulting COVID-19 deaths but there will certainly be many more deaths to come. Many small business owners are losing their businesses and their life savings. We are seeing an unprecedented loss of jobs at all levels of society but particularly lower-level jobs that don’t allow for remote work. Many poor children are fed by school lunch (and often breakfast) programs that are no longer available to them. These same poor children are less likely to have broadband Internet or a computer to do remote learning. In addition to crushing the poor, we are hallowing out the middle class running with the very real risk of exasperating income inequality issues which were already simmering in this country.
On April 16th we learned that 22 million jobs had been lost in the prior four weeks. That should be compared to the 21.5 million jobs that were added to the economy in the prior 10 years. Estimates are that we are probably at an unemployment rate of 15%-20% already. Since the Great Depression, we have had 10% unemployment at two times for one month each, one month in 1982 and one month during the great recession. With expectations that we will reach 20–30% unemployment, it’s safe to say that we have very little basis for comparison as to how devastating the economic situation is becoming.
It’s important to ask what was the purpose of closing the economy? This may seem obvious but part of the challenge in opening the economy depends on what it was we were trying to accomplish and determining if it’s been accomplished and the risk of recreating the problem if we open back up. The main thing was to prevent a tremendous loss of life. Early projections suggested we might lose up to 1.7 million Americans to COVID-19. That’s a good enough reason to lock down the economy. The lockdown has substantially reduced that projection which is now closer to 60,000. So, we’ve accomplished that goal. But remember the idea was to “Flatten the Curve” which meant avoiding a spike that would overwhelm the hospital system and instead stretch the number of people getting infected over a longer period of time; not to reduce the number of people being infected.
So, when we open the economy back up more people will be infected and that was always the plan. Extending the lockdown for months and months, doesn’t change that fact. But, if we open the economy too quickly and broadly, we will almost certainly see a huge spike in new cases in which case, what did shutting the economy down buy us? Well, it bought us a lot, mostly time. Time to increase hospital capacity (see the dotted line in the chart above), ventilator availability, vaccine development, curative medicine development, developing testing for COVID-19, developing contact tracing, developing testing for anti-bodies, learning about the disease, learning about how other countries are opening their economies and time to develop strategies for managing the risks. Opening up will almost certainly involve wearing of masks, social distancing, testing, contact tracing and other restrictions on a gradual path toward something closer to normal. More on all of these items in a subsequent article.
Risk of Dying from COVID-19
In a recent PEW Research survey, “About twice as many Americans say their greater concern is that state governments will lift restrictions on public activity too quickly (66%) as say it will not happen quickly enough (32%).” An important item in any decision about how to move forward is good data on what the risks actually are. According to the Understanding Coronavirus in America Study conducted by the University of Southern California in mid-April, “Nationally, people estimate they have a 25% chance of dying from the virus if they are infected, up from 15% in the earlier survey period in March.” It makes sense that if people believe they have a 25% chance of dying from COVID-19 that they are concerned about opening up too soon. But what is the real risk?
A challenge exists on determining the actual risk as the numbers we see most frequently are COVID-19 deaths divided by confirmed cases (positive tests). But 80% of people have mild symptoms, often so mild they don’t recognize they are infected at all (see chart below). And when people call their doctor’s office and report symptoms, if they are in low-risk groups they are told to stay at home and quarantine themselves, so they are never tested. This means that most of the people who are tested have serious symptoms and risks. Regardless, the true number of cases is much larger than the number of positive tests. How much higher? The consensus among researchers is that positive test numbers should be multiplied by 10 to determine the actual number of infections. Using this multiply by 10 rule would mean that the overall US COVID-19 fatality rate is about .5%. That would be close to the estimates of .6%-1.4% that are the general range of global estimates. So, the estimated 25% chance of dying according to the USC survey of Americans overestimates the risk by about 50 times; of course, they’re concerned about opening up too soon.
How the Risk of Dying from COVID-19 Changes with Age
But there is a further important piece of information that substantially changes how one should think about the risks. According to Mid-March estimates from the CDC (see chart below) it turns out, the risk of dying from COVID-19 for people under 45 is at least 100 times less than it is for people 85 and above. And nearly infinitely less for people below 20. And for those younger cohorts the risk is less than or comparable to the risk of death from the flu. It should be noted, that without social distancing and other measures, you’d have a much higher chance of contracting COVID-19 than the common flu, because COVID-19 spreads about twice as fast as the flu (R0 of 2.2–2.7 for COVID-19 vs. R0 1.3 for flu), which does raise the overall risk. The government and media haven’t said much about these extreme age-based differences presumably because, at this stage of trying to slow the spread of COVID-19, they really want to reduce the risk of these younger people contracting COVID-19 and infecting others.
The chart above was from mid-March, we have a lot more data in the US now so let’s look at what that data tells us. First of all, according to the latest CDC research published on April 17, 2020, there is a tremendous difference in the hospitalization rate between younger and older Americans with risks spiking significantly for those above retirement-age (65). The average hospitalization rate is 4.6 per 100,000 population. But as can be seen in the chart below the rate varies significantly by age. Not seen in the chart below, for the month of March, 74.5% of those hospitalized were 50 years old or older.
As reported in the Washington Post, based on CarePort research, once hospitalized, the rate of death substantially increases with age. This can be seen in the chart below which looks at mortality rate from COVID-19 by age once someone is hospitalized.
By combining the CDC hospitalization rate by age data and the CarePort mortality rate by age data (age groups aren’t a perfect match) and using the estimate that 80% of COVID-19 cases will not require hospitalization, it is possible to approximate the likelihood of death by age group if you contract COVID-19.
These numbers are estimated but quite a bit lower than the March 18th estimates from the CDC above which also show how those rates compare to the flu. In short for those under 20 years old, COVID-19 is less deadly than the flu, posing a negligible risk, but is more deadly for groups above that age group. For the 18–44 group the .036% risk compares quite closely with that age group’s .02% risk of fatality from the flu. The fatality rate continues to grow with age, particularly for those in the retirement-age range.
How Does the Risk of Dying from COVID-19 Compare to Other Causes of Death?
Also as a point of comparison, a typical flu year in the US kills 12,000–61,000 and about 290,000–650,000 globally. Per Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Disease, “The seasonal flu that we deal with every year has a mortality of 0.1%,” whereas COVID-19 is “10 times more lethal than the seasonal flu.” Both those numbers are for the population as a whole but as noted above, both the seasonal flu and COVID-19 have different fatality rates based on age and are more deadly to older people.
For a broader context, per the CDC, in 2018 about 156,960 people in the US died from unintentional injuries (car crashes, etc.). In that same year, about 534,972 people died from heart disease, the leading cause of death. The number two killer was cancer at about 487,557 deaths in 2018.
It’s also useful to look at CDC numbers on death by age group for COVID-19 and from all other causes. The CDC produced these numbers for February 1, 2020 — April 18, 2020 (see chart below). Of the 4,799 children 14 years old or younger who died in that time period, just three were from COVID-19; or .063% of deaths. That’s .0000049% of the 60,885,444 people in that population or a about a .5 in 10 million chance to die from COVID-19 over that period of time. The odds go up slightly in the 15–24 age group where COVID-19 accounts for 17 of the 5,474 deaths (.311% of deaths), out of the population of 42,970,800 or a .0000396% chance of death from COVID-19. And the largest cohort, the 25–34 year old’s has 139 COVID-19 deaths of the total 11,595 deaths (1.199% of deaths) from all causes out of that 45,697,774 population or a .000304% chance of death from COVID-19 over that period of time.
As can be seen below, the number of deaths in each older age group from all causes begins to rise steeply and the Corona Virus deaths also rise steeply. For example, for the age group 35–44 years of age, the COVID-19 deaths are 351 compared to the overall deaths of 16,718 (2.1% of deaths) for that population of 41,277,888. The next group for 45–54 has more than twice as many COVID-19 deaths at 943 but almost twice as many deaths overall at 32,207 (2.93% of deaths) in its only slightly larger population of 41,277,888.
For everyone in the US under 55 years of age, COVID-19 accounted for 1.92% of the 75,592 deaths from all causes in those age groups. 1,453 COVID-19 deaths for that population of 232,463,605 people in the two and half months that ended April 18, 2020.
Risk of Death from COVID-19 Changes Based On Where You Live
It also seems important to note that as of April 21, 2020, 39.83% of US deaths from COVID-19 were in New York City and the States of New York and New Jersey account for 63.06% of all US COVID-19 deaths. By comparison, California had 575 deaths in its population of over 40 million people or 3.34% of COVID-19 deaths in the US. This implies any policy to re-open should probably recognize regional differences and adjust accordingly.
Prior-Existing Illness Greatly Increase the Risk of Death from COVID-19
It should also be noted that pre-existing underlying conditions play a substantial role in increasing the risk of death in addition to age. The CarePort data shows an odds ratio of increased risk based on underlying condition, controlling for age. For example, in the table below, someone hospitalized with COVID-19 who also has Chronic Kidney Disease, has a 2.5 times increased risk of death compared to someone without that condition, regardless of their age.
This finding on the importance of underlying conditions is consistent with what has been seen in other countries. For example, in Italy, where the average age of COVID-19 deaths was 79.5 years of age, 99.2% of COVID-19 deaths had one or more pre-existing condition. As can be seen below, almost half of Italians who died of COVID-19 had three or more prior illnesses like those listed above, a quarter had two, and another quarter had one with only .8% having none.
Differentiating Policies by Age is Key
As we look to open the economy, we should begin to differentiate between what we demand of the younger, less at-risk cohort of Americans versus older Americans. For the vast majority of “healthy”, working-age people and children COVID-19 poses minimal risk which would suggest we shift to policies that aren’t one size fits all. We need to have older people, mostly retired, stay locked down and we need to ensure that we are supporting them. The same can be said for people with compromised immune systems and other health conditions that put them at increased risk. This isn’t to imply that it’s completely easy but based on health risks the vast majority of workers can work and students can attend school if they don’t intermingle with older and other at-risk people.
The risk to students is so extremely low that it should be recognized that keeping them out of school isn’t to protect them but to protect older people they come in contact with. The tricky part is older teachers/professors and administrators are at risk or at least much more at risk than students. It’s going to be challenging but due to the unique age effects, it seems like we should find a way to move forward with opening schools at least by this fall.
Relative to the flattening of the curve, this age-based approach, would result in those most likely to be infected being those who are at the least risk of complications and death. Which presumably would advance us towards herd immunity, the point of time at which the virus no longer spreads because most people have it. Herd immunity generally occurs when a majority of a population has developed an immunity to a disease making it hard for the disease to spread in the population so it dies out. It’s estimated by Johns Hopkins that we’d need about 70% of the US population to be immune to COVID-19 for herd immunity to kick in. If we have about 850,000 confirmed cases and the actual number of cases is 10 times that (as noted earlier), then we really have about 8.5 million cases. With a US population of 327 million people, we’re only at about 2.6% of the population; not even close.
Sweden is currently the only country that is sort of trying this more open, age differentiated approach on a path towards herd immunity. They are asking their at-risk population to stay secluded, are working from home as much as possible and social distancing but have not really closed much down. They’ve left open schools, gyms, cafes, bars, and restaurants. People are urged to practice social distancing and act responsibly. And the Swedish alternative approach seems to be working as cases are plateauing. Per a recent Bloomberg article, “At no stage did Sweden see a real shortage of medical equipment or hospital capacity, and tents set up as emergency care facilities around the country have mostly remained empty.” Sweden’s COVID-19 cases are higher than other Scandinavian countries “but much less than in Italy, Spain and the U.K., both in absolute and relative terms.” It should be noted that Swedish culture is much different than the US. They are much more likely to follow rules, act communally and trust their government but they do provide a rare example of a country that has taken a less dramatic approach to locking down their country with results that are no worse than that of countries who have acted in a more draconian manner.
As previously mentioned, masks, social distancing, testing for COVID-19, testing for antibodies (immunity), contact tracing, effective medicines and eventually vaccines are all part of the equation for opening up the economy and will be covered in a different article. The best near-term hope for avoiding a lot more deaths, may lie in promising medicines that substantially decrease the risk of death from COVID-19. But differentiating based on age and prior-existing illnesses should also be key component of a smart plan for opening the economy.
About the Author: Geoff writes about digital innovation, politics, policy, business, and life.
After founding and running one of the world’s largest and most successful digital agencies for 18 years, Geoff now works with start-ups and enterprises as a board member, advisor, and investor. Geoff was a founder of pioneering digital agency Roundarch, which became Isobar US in 2012. Geoff has spent 25+ years helping companies create transformational digital platforms and experiences. Under Geoff’s leadership, Isobar was recognized as a Leading Digital Agency by analysts Gartner and Forrester, a Top Ten Innovation Agency by Forrester, by Fast Company as one of the Most Innovative Companies in the World 2018 and won numerous awards including a Cannes Lion Grand Prix for Digital Craft in 2018.
You can read more of his writings on his blog: Avalanche of Cognition.
