Countering International Terrorism (SIOI, N.° 4/2019)
QUARTERLY JOURNAL OF THE ITALIAN SOCIETY FOR INTERNATIONAL ORGANIZATIONS, N.° 4/2019
COUNTERING INTERNATIONAL TERRORISM,WITH PARTICULAR REFERENCE TO THE FOREIGN FIGHTERS PHENOMENON
FRANCO FRATTINI – Introduction
ALESSANDRO POLITI – The Terrorist Next Door
GERMANO DOTTORI – States and Terrorism
MATTEO BRESSAN- The Evolution of the Terrorist Threat after Al-Baghdadi’s Death
CLAUDIO BERTOLOTTI – The Numbers and Geography of Jihadist Terrorism in Europe
CHIARA SULMONI- Perspectives on Radicalisation. Notes from a Journey through Five European Countries
ALESSIA MELCANGI – The Libyan Chaos and the Jihadist Threat: Perspectives and Potential Outcomes
MICHELA MERCURI – Libya: A Black Hole in the Geopolitical Map of Terrorism
CINZIA BIANCO – Visions, Instability, Tensions: Saudi Arabia at a Crossroads
TIZIANO LI PIANI – A Quantitative Assessment of the Mechanical Input for Terrorist Attacks to Soft Targets in Highly Urbanized Settings, based on the Behavioural Analysis of t he Input Carrier
GIUSEPPE CUSIMANO – Cyber and Terrorism
ANDREA MANCIULLI – The Future of Global Jihad. Main Trends, Counter-Terrorism Tools and Prevention Strategies
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Comorbidity Factors (such as heart disease and diabetes) Influence COVID-19 Mortality More Than Age (Chapman University)
by Steven Gjerstad and Andrea Molle – Chapman University, USA
last update 2020.03.30
“It is an extremely important finding, not only because it allows for better decisions in the triage phase. But also because in the following phases, starting from the so-called phase 2 up to the production and distribution of a vaccine, it will be essential to make decisions aimed at protecting those who are the most at risk of serious consequences. Moreover, before the vaccine is distributed, individuals with hypertension, diabetes, heart disease, if not already developed immunity, will necessarily have to be closely monitored. Not only as they are at higher risk, but above all because if the disease is reactivating, we will see it in those with comorbidities, since healthy individuals tend to be asymptomatic and therefore could spread the virus silently.”
The global reaction to the COVID-19 epidemic has rested on a critical assumption, that all persons over the age of 60 face an unacceptable risk of death if they are infected with the virus. Recent evidence from a detailed analysis of individual Chinese, American, and Italian patient data clearly indicates that this assumption is incorrect. Our research indicates that only 0.8% of all coronavirus-related deaths in Italy involved otherwise healthy individuals. The remaining 99.2% of deaths involved individuals who had at least one, and often at least 3 other illness factors. There are significant public policy implications to our quarantine and triage strategies.
Mortality from COVID-19 increases substantially with comorbidity factors, such as heart disease, hypertension, diabetes, stroke, and liver disease. After we control for the high incidence of comorbidity factors among the elderly, we find that mortality from coVid-19 does not vary much with age.
The coronavirus epidemic in Italy has strained hospital resources, including ICU beds and ventilators for those experiencing acute respiratory failure. Studies of COVID-19 in China , Italy , and the United States  show that fatality rates increase rapidly with age, especially beyond age 60. The same studies and others also show that fatalities increase substantially with comorbidity factors, such as heart disease, hypertension, diabetes, stroke, and liver disease [1, 4]. These morbidity factors are known to increase rapidly with age [5, 6, 7]. This paper demonstrates that once we control for comorbidity factors, age has a minor effect on COVID-19 mortality. Among the elderly the higher incidence of heart disease, diabetes, hypertension, and other comorbidity factors lead to their increased mortality form COVID-19. The distinction is an important one for the critical triage decisions that are required now. If it is the comorbidity factors that lead to death with COVID-19 patients and not age, then triage will be more effective if healthy elderly people are provided with treatment, since their chances of survival are good.
We examine 73,780 cases of COVID-19 and 6,801 deaths from COVID-19 in Italy through March 26, 2020. Based on estimates of the prevalence of comorbidity factors in Italy by age group and on the frequency of COVID-19 cases and mortality rates for age groups, we estimate the percentage of patients with and without morbidity factor that would be expected to die, first assuming that those with and without comorbidity factors are equally likely to die. Subsequently, we use a maximum likelihood estimate to get mortality probabilities for people in each age group, with and without comorbidity conditions. COVID-19 patients with comorbidity conditions are 10.5 times as likely to die than those without a comorbidity condition. For example, an Italian COVID-19 patient between 70 and 79 years old with no comorbidity factor has about a 1.6% chance of death, whereas a 70 to 79 year-old patient with a comorbidity condition has a 21.4% chance of death.
Triage decisions based on patient age do not account for the large differences between the prognosis for patients with and without morbidity factors. As medical resources become strained during the epidemic, it will be important to take account of the probabilities of survival for patients with different medical histories.
Table 1 in  shows that 50.7% of the fatal cases of COVID-19 in Italy through March 26 had 3 or more of the comorbidity factors. Another 25.9% had 2 of these factors, and 21.3% had one factor. Only 2.1% had no factor. This last statistic is important. If age alone were an independent factor that leads to high mortality, then – we will demonstrate in this paper – there would be many more deaths among those who are elderly but otherwise healthy. In other words, the 2.1% frequency of no comorbidity factors would be much higher.
Tabella 1 in  shows that 19.2% of 73,780 COVID-19 cases in Italy through 4 p.m. on 26 March were among people age 70 to 79. From Tavola 7 in , we can infer that close to 25% of those people have none of the comorbidity conditions. We take death rates for the age groups from Tabella 1 in . We consider the hypothesis that healthy people in each age group are as likely to die as those with 1 or more comorbidity condition. This hypothesis will lead us to the conclusion that there should be approximately 10.5 times as many people with no comorbidity factors as the number that are shown in Table 1 in .
People between 70 and 79 comprise 19.2% of the cases, and 25% of those have no comorbidity condition, so healthy people 70 – 79 years old are 4.8% of the cases. If healthy people between the ages of 70 and 79 are as susceptible to death from COVID-19 as those in their age group who have comorbidity conditions, then their death rate should be 16.9%, like their age group. If they were dying at the same rate as their age group, the fraction of all cases who would be people between 70 and 79 and have no comorbidity factor would be 0.048 x 0.1569 = 0.0081. Now we repeat this analysis for the remaining age groups and fill out Table 1.
Table 1: Column E shows the percentage of the 73,780 total cases that would be healthy people (i.e., no comorbidity factor) in their age group and would die from COVID-19.
The total number of deaths that we would expect for people with no comorbidity factor would be this expected death frequency times the number of cases, which is 0.0209 x 73,780 = 1,542.
Table 2: Column E shows the percentage of the 73,780 cases in each age group that would die who have one or more comorbidity factor.
We now carry out a similar calculation in Table 2, but we consider here those people who have one or more comorbidity factor. This calculation shows that 7.08% of the total cases should be people with one or more comorbidity factor who died. That would result in 0.0708 x 73,780 = 5,223 deaths. As a check, total predicted deaths are 6,765. The total number of deaths from Tabella 1 in  where we get our total number of cases and our lethality factors for age groups (Column D) is 6,801.3
Our hypothesis that healthy people in each age group have the same probability of dying from COVID-19 leads us to the conclusion that of our estimated 6,765 deceased, 1,542 or 22.8% should have no comorbidity factor. Yet Tabella 1 in  shows that only 2.11% had no comorbidity factor. Consequently, the hypothesis that the probability of dying is the same for all people in an age group regardless of their comorbidity factors leads to the conclusion that there would be about 10.8 times as many deaths among those with no comorbidity factor than what we see in the sample of deceased persons in Tabella 1 in .
This analysis can be augmented by assuming different probabilities of mortality for those with and without comorbidity factors. If we multiply every element in Column D in Table 1 by 0.0925 we would get 143 deaths among those with no comorbidity factor. If we multiple every element in Column D, Table 2 by 1.2677 we would get 6,622 deaths among those with one or more comorbidity factor. We would then have 143/6,765 = 2.11% of the deceased having no comorbidity factor, as in Tabella 1 in . The probabilities of death are then those in Table 3.
Table 3: These mortality probabilities produce fatalities in each age group that match total fatalities and match the frequency of comorbidities found in Tabella 1 in .
From this we conclude that age is most likely only a moderate factor leading to COVID-19 mortality. Of course, healthy elderly patients are not dying in large numbers from COVID-19, so triage decisions that ignore the elderly healthy are not likely to lead to large numbers of deaths within this group. These patients are likely to recover, but they are likely to recover more quickly and with less physical damage if they are provided treatment. They also are unlikely to require critical care for much longer than a healthy young person, since like the healthy young, they are recovering. For these reasons, we believe that triage decisions should be made without regard to a patient’s age.
About the authors
Steven Gjerstad, PhD, Economic Science Institute, Chapman University, 1 University Drive, Orange, California, 92866 USA, E-mail: email@example.com; Tel: 714-628-7282
Andrea Molle, PhD, Institute for the Study of Religion, Economics and Society, Chapman University, Orange, California, 92866 USA
 Wu, Zunyou and Jennifer M. McGoogan, “Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China,” Journal of the American Medical Association, Feb. 24, 2020.
 Livingston, Edward and Karen Bucher, “Coronavirus Disease 2019 (COVID-19) in Italy,” Journal of the American Medical Association, March 17, 2020.
 “Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020.” Centers for Disease Control, Morbidity and Mortality Weekly Report (MMWR), 18 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e2
 “Report sulle caratteristiche dei pazienti deceduti positivi a COVID-19 in Italia,” Instituto Superiore di Sanita, 20 Marzo 2020.
 “Age-adjusted percentages of selected circulatory diseases among adults,” Centers for Disease Control, Summary Health Statistics: National Health Interview Survey, 2018. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_A-1.pdf
 “Diabetes prevalence and glycemic control among adults,” Centers for Disease Control, 2018. https://www.cdc.gov/nchs/data/hus/2015/040.pdf
 “Patologie croniche in costante aumento in Italia con incremento della spesa sanitaria. La cronicità non colpisce tutti allo stesso modo: si confermano le diseguaglianze di genere, territoriali, culturali e socio economiche,” Istituto di Sanità Pubblica, Roma, 15 febbraio 2019. https://www.osservatoriosullasalute.it/wp-content/uploads/2019/02/Focus-1-Osservasalute-La- cronicità-in-Italia-feb-2019.pdf
 “Epidemia COVID-19 Aggiornamento nazionale,” Istituto Superiore di Sanità (ISS), Roma, 26 Marzo 2020.
Strategic Analysis 2019: Mashreq, Greater Maghreb, Egypt and Israel
The full report Strategic Analysis 2019: Mashreq, Gran Maghreb, Egypt and Israel by C. Bertolotti is now available
Introduction: factors and challenges in Maghreb and Mashreq areas
The 2011 Arab uprisings’ represents a breaking point announcing the need for a regime overhaul in the region; the consequences of these strong aftershocks still have the potential to undermine the entire Arab state system.
Dramatic changes in the Maghreb and Mashreq area after 2011 underline the need for external actors to forge a new policy approach to address the region’s long-term challenges. In tackling the region’s increasingly intersecting and conflicting politics, aggravated by external interventions, international policy makers should keep their attention on both old and new conflict drivers, or risk fighting symptoms rather than causes, and thus potentially do more harm.
The Arab uprisings underlined the notion that existing conditions in the Maghreb and Mashreq area had become unmaintainable and announced the region-wide expiry of a socioeconomic order that had underwritten relative stability for decades. Today, the grievances that led to the near collapse of the regional order persist, and economic trends paint a bleak picture of further decline. Within the area, political dynamics will continue to feed frustrations among the mass of the population, fueling unrest and outmigration. At the same time, the 2011 uprisings produced a certain momentum for change, and in some places provided new opportunities.
At social level, the countries within the Maghreb and Mashreq area have significant population growth and concentration in a largely challenging environment both physically and in terms of infrastructure and socio-economic development. This means that in many places there is an excess of water food and energy demand over supply. This is particularly the case in areas of extreme population concentration, along rivers and coasts for example, in otherwise dry and climatically challenging environments. Dense populations in a few areas surrounded by vast expanses of virtually uninhabited land create pressures in the concentrated spaces and challenges in governance over the more remote areas.
At economic level, as reported by the World Bank, growth in the Maghreb and Mashreq area is projected to remain subdued, at 1.3 percent. Activity in oil exporters has slowed due to weak oil sector output and the effects of intensified U.S. sanctions on Iran, despite an easing of fiscal stance and positive prospects in non-oil sectors in some countries. Many oil importers continue to benefit from business climate reforms and resilient tourism activity. Regional growth is projected to pick up to around 3 percent a year in 2020-21, supported by capital investment and policy reforms.
Risks to the outlook are tilted to the downside, including geopolitical tensions, reform setbacks, and a further escalation of global trade tensions.
Download the ITA/ENG full report Strategic Analysis 2019: Mashreq, Greater Maghreb, Egypt and Israel, by C. Bertolotti (pdf version)
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Introduction: factors and challenges in Maghreb and Mashreq areas
Algeria. Instabilità politica: tra opposizione e repressione
The political consequences of the mass protests
Who will succeed to Bouteflika?
Analysis, assessments and forecasts
Libya: Turkey’s strategic interest and the military support to Islamists. Russian expansion in Libya
The siege of Tripoli and the activism of the Libyan “Islamic State”
The political front
The military front
Turkish activism in support to Islamists: between financial interests and military aid
Turkey’s activism in Misurata and the bombing of the airport hosting the Italian contingent
Italian military presence in Misrata
As the competition for the Libyan oil assets becomes harsher, the Italian interests are affected
Russian expansion in Libya
Syria. “Peace spring”: the third Turkish military operation in Syria. The weakening of the Kurdish-Syrian YPG and the death of Abu Bakr al Baghdadi
“Peace spring”, October 9-23
Conflict history: the battlefield moves to the border
The US-Turkey and Russia-Turkey agreements. US flexibility and strengthening of the Moscow-Ankara axis
Analysis, assessments and forecasts
Tunisia. A new political balance after Béji Caïd Essebsi?
The legacy of Béji Caïd Essebsi
Analysis, assessment and forecasts
Israel. Political uncertainty and attacks by the “Palestinian Islamic Jihad” group
The terrorist “Palestinian Islamic Jihad” group attacked Israel after the death of one of its leaders
Egypt. Popular protests do not weaken the government
Lebanon. Popular protests force the prime minister to resign
Morocco: new approach to combating terrorism and greater security efforts
The strategic priorities and the pillars
Fighting regional terrorism
Broadening the scope of defense to include security challenges
Morocco wants women, minors held in Iraq, Syria to come home
BCIJ Discovers Hideout of Dismantled, IS-linked Terror Cell
Consequences, risks and opportunities of oil price changes in the Maghreb and Mashreq countries
Impact on major North African oil producers
Impact on Morocco, the major North African fuel importer
Military expenditure in the Maghreb and Mashreq areas: different trends
Download the ITA/ENG full report Strategic Analysis 2019: Mashreq, Gran Maghreb, Egypt and Israel, by C. Bertolotti, (pdf version)
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