A Postmortem Examination Of The Pandemic

In Monty Python and the Holy Grail, the cart-master chants “Bring out your dead”and a man carries a plague victim and throws him on the cart. The plague victim cries out “But I’m not dead”. The same is true for the COVID-19 pandemic: we want to bury it and go back to normal life but the pandemic is not quite over yet. Nevertheless, it is not too early to determine which states fared best in the epidemiology of the pandemic. So, let’s take a look at the pandemic losers and winners based on CDC data as of today.

Case numbers

The best way to compare case numbers between different states is by using the number of cases per 100,000 population. The lower the number, the better states did in controlling the spread of the disease.

The Winners:

  1. Maine 12,225. The lowest case rate in the United States was our northeastern-most state. Maine took an early, aggressive approach to slowing the spread of COVID-19 with closure of restaurants and bars to dine-in customers on March 18, 2020 and with institution of a mandatory 14-day quarantine period for visitors from any other state on April 3, 2020. When restaurants re-opened, face masks were required for all customers and even now, face masks are still required for unvaccinated customers.
  2. Hawaii 12,737. On the opposite side of the world, Hawaii took even more aggressive infection control measures, initially prohibiting travelers from other states and then later requiring travelers to provide documentation of vaccination and of a negative COVID test. Because of its isolation, Hawaii was able to maintain tight oversight of anyone coming onto its islands. Currently, Hawaii is considering requiring all visitors to the island to have a booster vaccination.
  3. Oregon 13,039. Early institution of state-wide school closures, a stay-at-home order, and an indoor mask mandate helped Oregon keep its case numbers the third-lowest in the U.S.
  4. Puerto Rico 13,388. Like Hawaii, Puerto Rico benefited by being an island during the COVID-19 pandemic. Additionally, COVID public health measures were far less politicized in Puerto Rico than in the rest of the country, perhaps because Puerto Ricans do not vote in presidential elections and do not have elected members of the U.S. congress. It is notable that there are no full service Fox Network TV channels or Spanish versions of Fox News in Puerto Rico.
  5. Vermont 13,631. Early in the pandemic, Vermont issued a quarantine order for all visitors to the state and also issued a stay-at-home order. Vermont was very aggressive in its vaccination efforts and currently is the most vaccinated state in the country with 78.9% of its population fully vaccinated – Puerto Rico comes in next at 78.5%.

The losers: 

  1. Rhode Island 30,265. I was surprised to find that Rhode Island has had the highest case rate in the country. Throughout the pandemic, the Rhode Island case rate looked quite similar to the rest of the country but during the Omicron surge, Rhode Island’s cases peaked at more than 500 per 100,000 on January 11, 2022 which is the highest daily case rate for any state at anytime during the pandemic. This is despite the state having a very high vaccination rate. The good news for residents of Rhode Island is that their COVID death rate has remained relatively low despite the high case numbers.
  2. North Dakota, 26,551. Intuitively, one might think that North Dakota’s largely rural population would be protected from COVID-19 given how spread out people are from each other. But state-wide resistance to the institution of infection control measures and a very low vaccination rate resulted in North Dakota having the second highest case rate in the U.S.
  3. Utah 25,040. A strongly conservative state, Utah has resisted mask mandates and other infection control measures.
  4. Alaska 24,918. A lack of mask mandates and other infection control measures combined with an influx of tourists in the summer of 2021 resulted in a high early fall surge followed by a high Omicron surge.
  5. Tennessee 24,782. When Michelle Ficus, the Tennessee vaccination director, raised alarm about the rising case rate and suggested that children should get vaccinated, Tennessee Republican lawmakers’ response was to fire her. This is a reflection of the state’s reluctance to institute public health measures during the pandemic which resulted in Tennessee having the fifth highest case rate in the country.

Death rate

Although case rates do give important information about how easily COVID-19 was spread in a given state, the case rate can be influenced by testing availability and by the population’s willingness to get tested. Also, if more tests are done for screening purposes in one state, then infected but asymptomatic people will be identified which can drive case numbers higher than in other states. The death rates are not affected by these factors. However, death rates can be affected by how well a given state protects its vulnerable population (nursing home residents, the elderly, etc.) and can be affected by the availability and quality of health care in that state. The following are the winners and losers with respect to the number of deaths per 100,000 population.

The Winners:

  1. Vermont 75. There is no surprise here. Vermont also had the 5th lowest case numbers in the country and the fewer cases of COVID occur in a state, the fewer people will die of COVID in that state. Vermont also has one of the lowest rates of obesity in the country and obesity is a major risk factor for dying if a person does get COVID. Vermont has the 5th lowest percentage of the population that is uninsured. Together, these factors resulted in Vermont having the lowest COVID mortality rate in the U.S.
  2. Hawaii 78. Once again, having a low number of COVID cases results in a low COVID mortality rate. Hawaii’s strict infection control measures including quarantine of incoming visitors kept its COVID deaths much lower than the rest of the country.
  3. Puerto Rico 111. Living on an island provided some of the best protection against getting COVID and consequently from dying of COIVD.
  4. Utah 124. The state of Utah is a paradox with the third highest case rate but the fourth lowest mortality rate. Utah benefited by having a higher proportion of its cases occurring in the later stages of the pandemic, when the more contagious but less fatal Omicron variant replaced the considerably more lethal Delta variant.
  5. Maine 125. The same measures that gave Maine the lowest case rate in the country also gave it the fifth lowest death rate in the country. This is despite Maine having the highest percentage of its population over age 65 compared to all other states. The implications is that community infection control measures are effective, even when you have an inherently high-risk population.

The losers: 

  1. Mississippi 359. The state with the highest rate of obesity has had the highest COVID mortality rate. Mississippi also has the fifth highest percentage of its population being uninsured. In addition, Mississippi has the lowest per capita income in the U.S. which likely contributed to barriers to healthcare access. Relative to its population, more Mississippians died than residents of any other state.
  2. Arizona 349. On the surface, Arizona should not have the second highest death rate in the country. It is closer to average when it comes to the rate of obesity, population over age 65, income, and vaccination rate. Despite this, COVID has become the state’s most common cause of death.  Arizona’s high death rate has been attributed to its lawmaker’s unwillingness to adopt COVID mitigation measures and its governor has been called the “anti-science governor”.
  3. Alabama 342. Factors that contributed to Alabama having the third highest death rate include having the second lowest vaccination rate in the country and the third highest obesity rate in the country. For the first time in history, the annual number of deaths in Alabama exceeded the annual number of births in Alabama.
  4. New Jersey 341. Early in the pandemic, there were no vaccines, there were no monoclonal antibody treatments, and infection control measures were not yet fully instituted. The bulk of New Jersey’s deaths occurred in the first 3 months of the pandemic, coincident with the surge in deaths in adjacent New York City. Since then, New Jersey’s death rate has been lower than average but so many people in New Jersey died early in the pandemic that it results in the state having the fourth highest death rate for the pandemic overall.
  5. Louisiana 327. Like its neighbor Mississippi, Louisiana has a high rate of obesity and a low per capita income. Like New Jersey, Louisiana experienced a much higher surge in COVID in the first 3 months of the pandemic when we understood less about how COVID is transmitted and about how to treat COVID infection. When COVID hit New Orleans in March 2020, the number of cases overwhelmed the city’s healthcare system and many residents died.

Case fatality rate

If a state had a high case rate, it would be expected to also have a high mortality rate, simply because more people were infected with COVID. The case fatality rate overcomes this by telling us how good a state’s health care systems were in protecting its most vulnerable populations and about how good the health care systems were in treating patients who became ill with COVID. The case fatality rate is the percentage of people infected with COVID who then died of COVID. The case fatality rate averaged 1.2% for the United States as a whole.

The Winners:

  1. Utah 0.50%. Having a lower percentage of the population over age 65 than any other state, Utah benefited by being the youngest state in the country. Utah also has a low percentage of the population that is obese. As a consequence, the population of Utah as a whole is considerably less vulnerable to severe COVID and death-by-COVID than other states.
  2. Vermont 0.55%. Vermont is one of the clear winners in the COVID pandemic and its second to the lowest case fatality rate is a result of having the highest vaccination rate in the U.S.
  3. Alaska 0.56%. Alaska has had one of the highest case number rates in the country but Alaskans who got infected were less likely to die. Because a large portion of Alaska’s COVID cases occurred in the latter portion of the pandemic, a larger number of Alaska’s cases occurred in vaccinated individuals with those vaccines conferring protection against death from COVID. Additionally, a large percentage of its infections were due to the Omicron variant which has a lower case fatality rate than other variants. Alaska also has the second lowest percentage of its population over age 65 in the country meaning that its population was less vulnerable to death, even before vaccines were available.
  4. Hawaii 0.61%. With early institution of visitor quarantining and public health measures, Hawaii was able to keep its case numbers very low in the first half of the pandemic and as a consequence, most of Hawaii’s COVID cases occurred in the latter portion of the pandemic, when a large portion of its population was vaccinated and thus protected from COVID death. Hawaiians have good healthcare with only 4.1% of its population uninsured, second only to Massachusetts. Hawaii also has the third lowest rate of obesity and fifth highest rate of vaccination in the country.
  5. Puerto Rico 0.83%. Like Hawaii, Puerto Rico was able to keep its case numbers exceptionally low in the first stages of the pandemic when COVID was more likely to be fatal. It has only been in recent months that the territory has seen its cases surge from the less lethal Omicron variant in the setting of having a larger percentage of its population vaccinated than most states.

The losers: 

  1. Mississippi 1.61%. The combination of being the most obese state and the fifth least vaccinated state proved lethal to Mississippi residents who became infected with COVID who were more likely to die of their infection than residents of any other state. A high percentage of the state’s population is uninsured with the result of disparities in access to healthcare as well.
  2. Pennsylvania 1.54%. Compared with other states, Pennsylvania is fairly average with respect to risk factors such as population over age 65, obesity, vaccination rates, per capita income, and percentage of the population that is uninsured. Pennsylvania was also able to keep its case rate relatively low in the first half of the pandemic. So why were Pennsylvania residents second only to Mississippi residents with respect to likelihood of dying if they became infected with COVID? One possibility is that there was less testing done in Pennsylvania compared to other states with the result that fewer asymptomatic or mildly symptomatic COVID infections were identified, thus driving up the fatality rate among those people who were actually diagnosed. This is suggested by the fact that Pennsylvania’s death rate of 3.2 per 100,000 is closer to average among the states.
  3. Arizona 1.52%. The same reasons that Arizona has had the second highest death rate in the country have contributed to it having the third highest case fatality rate. A relatively high case number rate suggests that there was plenty of testing being down (as opposed to Pennsylvania). Arizona did not have a disproportionate number of cases occurring early in the pandemic (as opposed to New Jersey). Arizona’s high case fatality rate may be more a result of its lawmaker’s public health policy and less a result of an inherently more vulnerable population.
  4. Alabama 1.52%. A very high rate of obesity coupled with a low vaccination rate resulted in Alabama residents being the fourth most likely to die if they contracted COVID.
  5. New Jersey 1.50%. Although New Jersey currently has one of the highest vaccination rates in the country, a large percentage of its cases and deaths occurred in March 2020, before vaccines were available resulting in a high case fatality rate early in the pandemic. In recent months, however, New Jersey’s case fatality rate has been much lower than average and as a result, New Jersey’s experience provides strong evidence that vaccinations prevent deaths.

Vaccination rate

In the preceding analysis, it is pretty clear that states with higher vaccination rates fared better during the COVID pandemic than states with lower vaccination rates. In a previous post, I showed how political party voting patterns are strongly associated with how likely a state’s residents are to be vaccinated. The five states with the highest percentage of the population vaccinated all voted Democrat in the last presidential election and the five states with the lowest vaccination rates all voted Republican in the last presidential election.

The vaccination rate is important not only for keeping a state’s residents alive, but may also be a determining factor for business development in the future. Businesses do want their employees to all be vaccinated in order to control expenses by reducing absenteeism and reducing health care costs. Vaccination also translates into fewer dead employees. But businesses are loath to unilaterally impose mandates for fear of losing some employees and for fear of negative public opinion. Therefore, many businesses may chose to expand their operations in those states where their employees are likely to be vaccinated without having to impose an employee vaccine mandate. In this sense, the vaccine winner states today could become the business winner states in the future.

The Winners:

  1. Vermont 78.9%
  2. Puerto Rico 78.5%
  3. Rhode Island 78.1%
  4. Maine 77.1%
  5. Connecticut 76.0%

The losers: 

  1. Idaho 47.6%
  2. Alabama 48.9%
  3. Wyoming 49.5%
  4. Mississippi 49.7%
  5. Louisiana 51.4%

How you can be a winner

Overall, Americans who get COVID have a 1.2% chance of dying from it. In other words, 1 out of every 83 people who become infected will die. So, when you get infected, you are taking a gamble with life and death. By looking at those states that fared well during the pandemic and those that fared poorly, you can determine how to improve your odds of surviving the pandemic:

  • Live in a state where lawmakers take science seriously
  • Get vaccinated
  • Don’t be obese
  • Live on an island
  • Have health insurance
  • It was more important to be strict with infection control measures early in the pandemic than later in the pandemic

January 22, 2022

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital