A brief note on the blog and on COVID-19

The subject of COVID-19, a virus that burst forth from its rom obscurity in (most likely) one population or another of wild mammals in China to become a global zoonotic pandemic, is well-suited for Demography Matters. Speaking for myself, I have felt unable to address this topic because it is so all-encompassing. It has transformed my life and those of my friends and family, it has wrought remarkable change throughhout the world, and it will inflict a shock with consequences that we are only beginning to realize.

Thirteen thousand people have died of COVID-19 in Canada as I write, and to my country's south well over 300 thousand have died in the United States, with a total of 1.6 million recorded deaths worldwide. This is not the least of it: Over at Quora, Franklin Veaux answering the question of just how a disease with a mortality rate of 1% could paralyze the United States. Even ignoring the terrible mortality that it inflicts, COVID-19 leaves many of its survivors with a host of disabilities.

Vaccines cannot come quickly enough. What will the world be like when an unprecedented global distribution of vaccines is finished, when COVID-19 becomes just another disease that we can handle? (I am struck, as a long-time student of HIV/AIDS, by the prominence of Dr. Anthony Fauci in the American and global efforts to deal with COVID-19; his new prominent appearance in the fight to deal yet another plague shows how history can rhyme strangely.) Mortality and long-term health of populations will be affected, but they will not be alone. Early signs are that the great instability and uncertainty wrought by COVID-19 has helped depressed fertility worldwide, for instance, while cross-border migration has been tamped down almost entirely. The future evolution of the world population has been marked in a way that is not going to disappear quickly.

Demography Matters will be there for it. This blog may stay on Blogger or go elsewhere (Medium looks interesting), but there remains a real need for blogs which take a look at population issues. Demography does indeed matter. Watch this space.

A note on public health, or, how you get what you pay for

Late last month, I blogged about PrEP, an acronym for "pre-exposure prophylaxis", as Wikipedia puts it "the use of prescription drugs by people who do not have HIV/AIDS as a strategy for the prevention of HIV/AIDS". When taken with sufficient frequency, the drug in question--in most studies, either tenofovir or the tenofovir/emtricitabine combination TruvadaSouth Africa and Thailand suggest that PrEP can be an effective anti-HIV strategy in middle-income countries as well.

PrEP is not the only transformative event in the treatment of the pandemic The latest anti-retroviral treatments are not only keeping the HIV-positive in good health, they are radically reducing the chances of further infection, via the strategy of TaSP (treatment as prevention). One thing widely reported in the media with varying levels of incredulity after Charlie Sheen's self-outing as HIV-positive, in Vox and Gawker and MacLean's and New York Magazine, is that Sheen has undetectable levels of the virus in his system and cannot infect people. This was not just Sheen talking: This is the actual science. Multiple research projects, including the ongoing PARTNER study, have so far concluded that the chances someone HIV-undetectable could transmit HIV on to someone HIV-negative are trivial. The PARTNER study has not yet found a single instance of such a transmission happening, not with tens of thousands of sex acts in hundreds of couples in two years. TaSP, treatment as prevention, also works. The approach of systematic testing and universal treatment of HIV, pioneered in Canada in British Columbia by Dr. Julio Montaner, can break the back of the epidemic. Saving people's lives also slows down the spread of HIV radically.

These successes raise an important question. Between PrEP and TaSP, not only is it possible for people infected with HIV to lead normal lifespans--indeed, some recent studies suggest that the sustained engagement with medical systems can give HIV-positive people longer life expectancies tan their HIV-negative peers, their HIV becoming a manageable
Journalist Laurie Garrett's 1995 The Coming Plague remains as relevant a book now as it was when it was published two decades ago. In that book, she made the point that the world was woefully unprepared for pandemics, that sustained underinvestment in public health and medical systems made it very difficult for increasingly fragile states to control infectious diseases within their frontiers. Governments, as she observed caustically in country after country, with disease after disease, simply seemed to have other priorities. The result was the risk of catastrophe. PrEP and TaSP may be effective strategies, but what does it matter if governments opt not to make the investments necessary? The United States is the country that developed PrEP and TaSP, and happily these strategies are becoming increasingly widely adopted in different at-risk communities which have access to them. PrEP and TaSP, though, require significant investments, in medication and in ongoing medical surveillance. Those communities which cannot access these investments are suffering horrifically: a recent Al Jazeera item suggests that HIV is spreading among black men who have sex with men in Atlanta at rates rarely seen in the United States since the 1980s. Similar stories can be told elsewhere in the world, only the details varying.

People elect governments, governments make choices, and too often these governments don't bother trying to deal with significant public health problems. The results, when crises erupt, can be catastrophic. I remain thankful that the West African Ebola epidemic has been fought back, though I wonder how many lives, how much wealth, how much potential could have been saved had the concerned governments and organizations behaved prudently. False economies are, by definition, false.

Tuberculosis, Canadian first nations, and pandemics

Over at my blog, I linked to a startling news item pointing to the Proceedings of the National Academy of Science paper "Dispersal of Mycobacterium tuberculosis via the Canadian fur trade". The abstract?

Patterns of gene flow can have marked effects on the evolution of populations. To better understand the migration dynamics of Mycobacterium tuberculosis, we studied genetic data from European M. tuberculosis lineages currently circulating in Aboriginal and French Canadian communities. A single M. tuberculosis lineage, characterized by the DS6Quebec genomic deletion, is at highest frequency among Aboriginal populations in Ontario, Saskatchewan, and Alberta; this bacterial lineage is also dominant among tuberculosis (TB) cases in French Canadians resident in Quebec. Substantial contact between these human populations is limited to a specific historical era (1710–1870), during which individuals from these populations met to barter furs. Statistical analyses of extant M. tuberculosis minisatellite data are consistent with Quebec as a source population for M. tuberculosis gene flow into Aboriginal populations during the fur trade era. Historical and genetic analyses suggest that tiny M. tuberculosis populations persisted for ∼100 y among indigenous populations and subsequently expanded in the late 19th century after environmental changes favoring the pathogen. Our study suggests that spread of TB can occur by two asynchronous processes: (i) dispersal of M. tuberculosis by minimal numbers of human migrants, during which small pathogen populations are sustained by ongoing migration and slow disease dynamics, and (ii) expansion of the M. tuberculosis population facilitated by shifts in host ecology. If generalizable, these migration dynamics can help explain the low DNA sequence diversity observed among isolates of M. tuberculosis and the difficulties in global elimination of tuberculosis, as small, widely dispersed pathogen populations are difficult both to detect and to eradicate.

This finding documents any number of things, such as the underlying and continuing vulnerability of Canada's indigenous peoples to epidemic disease, the long-standing ties between French Canadians--then, as commenters at CBC point out, simply Canadiens--and First Nations, the highly contingent nature of the transmission of pandemic diseases, and the extent to which these pandemics can remain below public attention for decades or even centuries. Parallels with the the evolution and spread of HIV, reconstructed from fossil viruses and genetic data, are entirely merited.

The data point to 1908 as the year that HIV group M (which now infects more than 31 million people worldwide) began its assault — somewhat earlier than the previous best estimate of 1931. Though 1908 is an approximation, the evidence suggests that the true date almost certainly falls sometime between 1884 and 1924.

When such evolutionary studies are overlaid with the history of human societies in Africa, a detailed picture of the origins of HIV group M comes into focus. Historically, chimpanzees in west-central Africa have been hunted for food. Many of them are also infected with the virus that HIV evolved from, Simian Immunodeficiency Virus (SIV). Butchering chimps probably repeatedly exposed local hunters to SIV. The virus may have made the leap to infect people many times — but only at the turn of the century did this viral invasion gain a foothold in the population. Around that time, a hunter seems to have picked up the virus from a chimp in the southeast corner of Cameroon and carried the pathogen along the main route out of the forest at the time, the Sangha river, to Leopoldville (modern-day Kinshasa). Mirroring the growth of the cities in Africa, the virus spread slowly in Leopoldville until around 1950, when it began to proliferate rapidly. Still undetected, the virus continued to evolve and to diversify, leapfrogging through burgeoning cities. With the increasing ease of global travel, HIV was carried out of Africa and around the world — and the rest, as they say, is history.

This reconstruction of HIV's origins certainly satisfies our curiosity — but it also serves as a practical reminder of the conditions that foster the emergence of new diseases. We cannot stop evolution. Pathogens regularly make the leap to infect new hosts, and we increase our chances of being victimized by one of these host switches, when we take on lifestyles that put us in close contact with other species — especially ones closely related to us — like chimpanzees. The early history of HIV also illustrates that the virus is not invincible. For more than 50 years, HIV infected human populations but had such a small impact that it wasn't noticed against the backdrop of other diseases. In comparison to pathogens like malaria (which is carried by mosquitoes) and the common cold (which can travel through the air), HIV is pretty terrible at getting from one person to the next, relying on the direct transfer of body fluids. The virus only got its start in humans through a confluence of opportunity and history — the practice of hunting chimpanzees, the rise of densely populated cities in Africa, and a correlated increase in high-risk behaviors involving the exchange of body fluids (e.g., injection drug use, prostitution). The fact that changes in human societies were so critical in the rise of the virus suggests that changes in human societies could snuff it as well.

The lead author notes that in the case of tuberculosis, isolated early cases produced an epidemic only when living conditions deteriorated sharply from the late 19th century on, as traditional lands were confiscated, children sent to residential schools, and living conditions on reserve became--and remained--Third World. If these conditions didn't occur, then presumably tuberculosis would be much less of a problem on Canada's reserves.

On Zimbabwe's declining HIV infection rate

The HIV/AIDS epidemic in southern Africa is something this blog has dealt with before, though mainly specifically relating to South Africa. Back in September 2006, Edward Hugh identified South Africa as having a very unusual mortality pattern--elevated mortality in younger cohorts--that wouldn't help its future. Zimbabwe hasn't featured, even though it was once the second industrial economy of southern Africa and a regional leader in apartheid, even though the impact of the epidemic on the country's population was horrible. With a prevalence of 27% concentrated in the working-age demographics, this deficit worsened by mass emigration to stabler and wealthier countries like South Africa or Botswana or even the United Kingdom, Zimbabwe's badly off.

Things have gotten better, surprisingly enough. Kate Kellers' Reuters article observes that there has been a steep decline.

British researchers said Zimbabwe’s epidemic was one of the biggest in the world until the rate of people infected with HIV almost halved, from 29 per cent of the population in 1997 to 16 per cent in 2007.

Their findings show that Zimbabweans have primarily been motivated to change their sexual behaviour because of increased awareness about AIDS deaths which heightened their fears of catching the human immunodeficiency virus (HIV) that causes it.

[. . .]

The United Nations AIDS program said last year that young people in Africa were starting to lead a “revolution” in HIV prevention and driving down rates of the disease by having safer sex and fewer sexual partners.

The Imperial College researchers found that in Zimbabwe, a change in attitudes towards numbers of sexual partners was helped by HIV/AIDS prevention programs, which were reinforced through mass media, church leaders and employers.

The poor economic situation in Zimbabwe from the early 2000s would also have driven down the number of concurrent partners a man could have, due to constraints on his wallet, they said.

The study in question goes into more detail, suggesting that exposure--through education and through personal experiences with the suffering and dying--was key.

During the 1990s, a wide range of prevention and information programs were implemented utilizing the national media along with school-, workplace-, and church-based activities, peer education, and other inter-personal communication interventions. Community-based activities were intensified following establishment of the National AIDS Council in the late 1990s. This range of broader HIV education and prevention programming could have had impact. Focus group and interview participants mentioned a number of prevention programs and awareness/education efforts and many reported that the “B” part of “ABC” was promoted by churches in particular and was “heard” by many community members yet no specific intervention was cited consistently.

One question arising from this review is why similarly high AIDS mortality and extensive coverage of HIV prevention programs (resulting in similarly high levels of reported condom use, early and large reductions in STI incidence, etc.) in several other countries in the region have not yet led to substantial declines in HIV prevalence (or multiple sexual partnerships). Our comparative analysis of eight southern African countries revealed few patterns of association. The HIV epidemic in Zimbabwe is somewhat older than in some other countries in the region, yet HIV prevalence has been declining markedly for over a decade now, which has not occurred to nearly the same extent, for example, in Malawi and Zambia (where HIV arrived even earlier). In addition to the severe economic decline, where Zimbabwe does stand out is in having high levels of both secondary education and marriage, especially in urban men, among whom the greatest level of behavior change evidently has occurred. It appears that this unique combination helped facilitate: 1) a clearer understanding and acceptance of how HIV is sexually transmitted (once such information became widely available through various AIDS education and prevention programs commencing in the early 1990s), as some studies of schooling levels and HIV determinants have suggested and 2) a greater ability to act upon “be faithful” messages, given the stronger marriage pattern in Zimbabwe than that in neighboring countries also having relatively well-educated populations, such as Botswana and South Africa.

In addition, national survey data suggest that between the mid-1990s and the early 2000s, Zimbabweans increasingly received information about AIDS from their friends, churches, and other inter-personal (as compared to official media) sources. A similar pattern has been linked to behavior change in Uganda. Furthermore, the Zimbabwean government's early adoption of a home-based care policy may inadvertently have accelerated the process of behavior change. It has been hypothesized that, when people die at home, this direct confrontation with AIDS mortality is more likely to result in a tangible fear of death among family and friends than when patients are primarily cared for in clinical facilities, such as in Botswana.

Certainly HIV transmission in North American queer male communities halted altogether in the late 1980s when the mass dying of the infected began.

On South Africa's wasted human capital

A post on Egypt's population is coming up, I assure you all. The importance of the subject merits doing it right. For now Suffice it to say that Egypt's key to the future of the regions of Nasser's Three Circles, the Arab world, Africa, and wider Islamic civilization.

In the meantime, let's take a look at South Africa, the other middle-income African country of global import. South Africa's invitation and eventual admission to the BRIC organization was perplexing.

[T]he man who coined the BRIC acronym, economist Jim O’Neill from Goldman Sachs, even interrupted his holiday to write a head-scratching note to investors about this development.

“While this is clearly good news for South Africa, it is not entirely obvious to me as to why the BRIC countries should have agreed,” O’Neill wrote. To give a sense of scale: South Africa’s economy is only a quarter of the size of Russia’s, the next-smallest of the group.

South Africa has a relatively small population of about 50 million, an economy worth $286 billion and growth of only about 3 percent last year — far from scorching. There are many other emerging markets that would better fit the BRIC grouping, O’Neill wrote, including South Korea, Turkey, Mexico and Indonesia, all of which have GDPs that are two or three times bigger than that of South Africa, and much larger populations.

“How can South Africa be regarded as a big economy? And, by the way, they happen to be struggling as well,” O’Neill told a recent investment summit.

I'd have invited Indonesia, myself. (It's difficult for me to understand how South Korea could possibly be an emerging market when it's richer per capita than Spain or Italy.) South Africa's admission to the BRIC group seems to be a matter of geographic parity, of having the group of the world's expected future world powers have representation from the African continent and South Africa's relative wealth and stability making it a much more attractive than the only other possibility of Nigeria. Whether or not the rest of Africa wants to be represented by South Africa is another question, notwithstanding the South African suggestion that their country is a suitable proxy for the continent. South Africa may be a more suitable proxy for the Southern African Development Community--ironically, founded during the apartment era to provide alternatives to trade with South Africa---but despite South Africa's economic weight its population is only a sixth of the 233 million-odd SADC residents, and the SADC itself is not very integrated.

Still, South Africa is going to have to bet its future on its ties to the rest of the continent: the country's population is expected to start shrinking after 2030, according to a local think tank.

By 2030 South Africa’s population will be 53.81 million. The population will then decrease to 53.74 million by 2035, and to 53.28 million by 2040, according to data from the Institute of Futures Research at the University of Stellenbosch cited in the Survey.

One of the main reasons for this is the long term impact of HIV/AIDS.

In South Africa, the number of deaths in a year is making up an increasingly higher proportion of the number of births. In 1985, deaths were 25% of births. This was expected by the Actuarial Society of South Africa to increase to 87% of births by 2021.

Thuthukani Ndebele, a researcher at the Institute, said, ‘If this trend continues, there will soon be more deaths than births in South Africa. It is evident that the HIV/AIDS pandemic has resulted in an increasing number of deaths. These deaths are mostly among people in the child-bearing age group, which will result in decreasing numbers of births.’

However, a lower fertility rate will also contribute to population shrinkage. Between 2001 and 2010, South Africa’s fertility rate decreased from 2.86 to 2.38 births per woman.

By 2040, the fertility rate will have dropped to 1.98 births per woman. This is lower than the replacement rate of 2.1 births per woman, which is needed for the population to reproduce itself.

Ndebele said, ‘Lower fertility rates are related to an increase in access to education and contraceptives, which results in women having fewer children.

‘A combination of increasing deaths as a result of the HIV/AIDS pandemic, as well as lower fertility rates will result in population shrinkage after 2030. This can be positive as there will be less strain on resources in South Africa. However, it will also be negative, as there will be fewer people to contribute to the economy and its internal consumer markets.’

As people in the comments there noted, these projections don't seem to take into account the possibility of new treatments for HIV/AIDS, or the near-certainty of continued immigration from South Africa's hinterland: high levels of income inequality in relatively wealthy Botswana and Namibia, never mind very low incomes elsewhere in southern Africa, practically ensure a continued economic incentive for migrants. Assuming that the South African population will start to age significantly over the next three decades is a safe bet, even if it mightn't be wise to bet in favour of a contracting population.

This projection has implications for the country's economic growth. With an aging population shifting towards rapid aging and below-replacement fertility, South Africa's continued economic growth in aggregate would require increased consumption per capita and productivity. The former is possible; the latter, with the historical record, may not be a good bet. The country's dependence on high-skills but capital-intensive industrial and service sectors and low-skills and low-productivity primary sectors, not to mention the profound disconnect between the formal and informal segments of the economy, does not bode well.

South Africa's economic growth record certainly hasn't been impressive, a recent news report placing the country's growth in GDP per capita at 0.6% per annum from 1970 to 2008. (This compares to 5.9% in Botswana, 7.9% in China, 3.6% in India, 4.3% in Indonesia, 3.5% in Ireland, and 1.9% in both the United Kingdom and the United States). South Africa has slid rapidly down world tables: A quick glance at the Penn World Tables and Wikipedia, comparing GDP per capita and HDIs in South Africa relative to the four founding BRIC members in Indonesia, suggests that Brazil and China have nearly caught up, with Russia staying in the lead and the remaining two countries making progress. South Africa's lead over the rest of the non-North Atlantic world has vanished.

Why? South Africa's population history--more precisely, the reaction of South African whites to their country's population history--is to blame. Apartheid did terrible things, especially (from the demographic perspective) the systematic destruction of cultural capital and sustained efforts at disdevelopment among the non-white majority. Left-wing miners early in the 20th century opposing black employment; the country had a public education systems that provided much more funding for white students than for black students (who, it should be noted, were discouraged from being professionals); the scandalously poor public health system that let tuberculosis run rampant with (according to Laurie Garrett in The Coming Plague) official claims that South African non-whites suffered so badly from tuberculosis not because of horrible living standards because they were genetically predisposed to catch the illness. The South African apartheid state even stripped most non-blacks of South African citizenship, creating a nightmare world of overpopulated rural slums, ill-serviced urban slums, and a tradition of oscillatory labour that helped HIV/AIDS spread so rapidly. In its 1994 Human Development Report, the UN observed that while South African whites enjoyed the human development indices of Spain, despite their country's wealth South African blacks suffered the levels of human development found in Congo-Brazzaville.

The sheer wastage of human capital over generations, all pursued in the name of a protectionist labour policy, is a tragedy. Botswana, at the time of apartheid's inception much less developed than its larger neighbour, went on to surpass South Africa in terms of GDP per capita and human development, even with its more severe HIV/AIDS epidemic. If--if, granted--South Africa's government hadn't decide to protect the living standards of a minority at the expense of everyone else, and had abandoned anti-non-white labour protectionism and disdevelopment for more rational policies, given South Africa's relatively higher level of development immediately after the Second World War than the BRICs it's easy to imagine a South Africa where many more people would have been able to exercise their talents for the betterment of all. The improvements in life chances in South Africa and its neighbourhood are scarcely imaginable. Such a South Africa--richer, less unequal, more developed broadly-- would have a significantly stronger claim to BRIC membership. As things stand now, South Africa is caught up in a desperate race to improve its human capital stock, to give more people chances, before its already-attenuated demographic sweet spot disappears.

On the vulnerability of indigenous peoples to the H1N1 virus (and other diseases)

In Canada, the latest issue surrounding the H1N1 virus surrounds a rather spectacularly insensitive gaffe made by the ministry of health under the current Conservative minority government, which shipped body bags along with medical supplies to at least one Manitoba First Nations reserve. At the same time that this happened, however, significant outbreaks on First Nations reserves in British Columbia's Vancouver Island, while reports from around the world suggest that Indigenous Australians are also vulnerable and, indeed, some fear that indigenous peoples around the world could suffer a disproportionately high toll.

(Here, for brevity's sake, I'll go with Wikipedia's definition of indigenous peoples, as ethnocultural groups established on a particular territory before more recent states and migrants arrive. Here, I suppose that this definition can apply broadly for groups in areas as far separated as Siberia and Patagonia, the Northern Territory and Yukon.)

What's going on? It's a well-known fact that epidemic disease played a huge role in determining the future populations of indigenous peoples of the Americas as well as in also in Australia and the Maori, among other indigenous peoples. Epidemic diseases like measles and smallpox which entered populations entirely without immune defenses on account of their isolation from the Eurasian disease pool could easily inflict apocalyptic death tolls. To be considered, too, is the possibility that at least in the Americas the founder effect--the limited number of forebears--in the settlers of the Western Hemisphere may have produced a population lacking certain immune system-related genetic traits which could have at least hindered the spread of the disease. Finally, there's the effect of poverty: in Canada, at least, someone of First Nations background is much more likely to live in relative deprivation than a member of the general population, with lower incomes, higher unemployment, worse housing, and greater problems in accessing social capital. It might not be too far out of line to say that, for First Nations and other indigenous peoples elsewhere in the world, the flu in the 21st century might play something like the same iconic role as cholera in the 19th century or tuberculosis in the 20th, as a marker of the problems of urbanization and poverty.

I've a post stored up somewhere on my laptop describing how indigenous peoples are generally in an earlier stage of the demographic transition than the other citizens of the countries where they live, with substantially higher birth rates and cohort fertility. Sadly, it's also true that mortality among indigenous peoples is likewise quite a bit higher. Dispatching the body bags was rather insensitive, but some sort of in-depth planning to deal with this and other epidemic diseases here already and yet to come.