December 10, 2021
Dear Interested Readers,
COVID Confusion, Worries, and Concerns
The last few weeks have felt like a COVID storm here in New Hampshire as we vaulted over Michigan into first place in the nation with the most COVID cases per 100,000 residents. We have more COVID hospitalizations than we have had at any time during the whole pandemic despite the fact that 65% of our residents are “fully vaccinated.” Everyone here is asking, “What’s happened, and why?” If you study the data presented in the link above you will discover that nationwide there are several hotspots that share our confusion while places in the South where attitudes are quite different and vaccination rates are relatively low are currently experiencing very low rates of infection.
As a New Hampshirite, I never expect my state to be number one in anything, certainly not in COVID statistics! I prefer for us to go on being unnoticed and underappreciated except for those few months every four years when we get the attention of the press and much of the nation as “First in the Nation” in the presidential nomination sweepstakes of both parties. My bias is that we should be considered a great weekend destination and not a COVID hotspot.
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The truth is we are close to number one and at least in the top ten in several categories other than COVID. It may surprise you that we are the ninth oldest state by percentage of the population over 65. Our neighbor Maine ranks number one which may seem strange to you since most people you know retire to Florida or Arizona. Florida is number two, and Arizona is a distant twelfth in the oldest state competition. New Hampshire moves up to number two and Florida drops to fourth if the metric is the oldest median age. Maine remains the champ by either metric.
On a very positive side of all the COVID metrics, New Hampshire has the eighth-lowest (ninth if you count Puerto Rico) death rate at 127 per 100,000 from COVID as of December 3rd. That number doesn’t tell the whole story. It is interesting to consider all the social determinants of health, local medical resources, and a host of other factors that affect COVID statistics when you learn that Mississippi has the highest rate at 346 per 100,000. New York’s rate was 296/100,000. Vermont had the lowest rate at 66 per 100,000.
Everybody knows that New Hampshire is not very diverse. In 2021, our population is 1,372,203. The breakdown is:
- White: 92.88%
- Asian: 2.68%
- Two or more races: 2.10%
- Black or African American: 1.60%
- Other race: 0.56%
- Native American: 0.15%
- Native Hawaiian or Pacific Islander: 0.03%
At 92.88% we rank fourth in whiteness. Maine is number one again at 94.31%. Number 2 is Vermont at 94.16%. West Virginia is third at 93.08%. What does all this mean? It is hard to say, but something tells me that the heterogeneity among the demographic and political statistics from each state does explain some of the variations we see in vaccinations, mask use, and COVID misinformation. What is happening in New Hampshire makes it clear that we still have much to learn before we can be sure which public health and demographic metrics make a difference in vulnerability to COVID rates and outcomes.
There are more “fun facts” about New Hampshire that may or may not explain or confound our analysis about how we gained our number one status with COVID this week. Most people don’t know that at least on paper we are relatively well off financially. We rank number eight in per capita income if you don’t count DC. If you do we are number nine.
- District of Columbia – $84,538
- Connecticut – $79,087
- Massachusetts – $74,967
- New York – $71,440
- New Jersey – $70,979
- California – $66,661
- Maryland – $65,683
- Washington – $64,898
- New Hampshire – $63,880
- Wyoming – $63,316
We are also number nine if the metric is the median income for a family of four. Ours is $99,165. The median income for a family of four is reported by the government in three categories: average, for metropolitan areas, and non-metro areas. For New Hampshire, the numbers are an average of $98,200 with metro areas coming in at $106,200, and non-metro areas at $85,300. For the whole country, the numbers are much lower at an average income of $79,900 with metro areas averaging $82,800, and non-metro areas showing $63,400. Most of us get confused thinking about “mean (average) and median.” These numbers hide the big reality that the cost of living varies widely across the country so that on paper the people of New Hampshire look relatively rich compared to Kansas where the average is $77,400, the number for metro areas is $85,200, and for non-metro areas, it is $65,100. These numbers are for families. It is also true that when there is a bimodal distribution of income with some part of the population being very rich and the other part is very poor all of these statistics can hide bone-crushing poverty.
Federal poverty numbers that determine eligibility for benefits do not adequately factor in the variation in the cost of living from state to state or metro to non-metro areas which may mean that a family may be better off in Kansas where the average income is $77,400 than in New Hampshire where the average income is $85,300. We live in a complicated world that easily generates inequities that sometimes arise out of complexity and ineptitude more than human intent. The analysis of the social determinants of health in any one place, as well as its vulnerability to COVID, quickly becomes a complex task with a huge number of variables including economics, racial demographics, culture, political attitudes, and much more.
I could go on and on, but in all honesty, I should give you the one category where we have the lowest ranking of all fifty states. In some stage way, it may explain everything, especially our sense of responsibility to one another. We are a solid number fifty when it comes to “religiosity.” Our New England neighbors don’t go to church very often either and as a region New England leads the nation in the percent of citizens who say that they don’t believe in God. Massachusetts, Vermont, and Maine have virtually the same disregard for religion. Ironically, we love our churches with their tall steeples for their ability to make a pretty New England postcard picture (see my church in the picture below). If we don’t “go to church” we are using the facilities for other purposes. My church is used by AA, the Boy Scouts, local choral groups, the Boys’ and Girls’ Club for after-school programs, the local garden club, the local food pantry, many civic meetings, concerts, as well as weddings and funerals for people who never attend one of our services. You would probably not be surprised to hear that Alabama and Mississippi are the leaders in the “religiosity” competition.
Most appropriate to this letter is the percent of New Hampshire citizens who have health insurance. We don’t make the top ten, but we do make the top fifteen, and there are only 3.3 percentage points between us and the state with the highest rate of insured citizens, Massachusetts. The uninsured rate just south of our border in Massachusetts is 3%. Our uninsured rate is 6.3%.
All my attention to rankings and demographics has been precipitated by the strange and difficult problem of trying to explain how it is possible that over the last few weeks we have vaulted into number one in the category of active cases of COVID per 100,000. I have spoken to several friends and neighbors, and we are all at a loss to understand how this has happened. It is not another example of misinformation or “fake news.” It is real. Everyone knows someone who has had or does have a COVID infection. This week we hit number one with the highest rate of COVID per 100,000 at 96, and that causes some fear and a need to know why. Perhaps the rankings are like college football polls or the New York Times bestseller list in that the leads are constantly changing. Last week we were number two and were trailing Michigan. Now Michigan is trailing us by ten points at 84/100,000, and Rhode Island has slipped in between us and Michigan at 87/100,000. All I can say is that I don’t understand why.
The human mind does not tolerate uncertainty very well. By nature, we want to explain everything, but we are especially interested in explanations for those things which threaten us. If you hear that your next-door neighbor has cancer, it is reassuring to know that it is from some genetic origin that you don’t share rather than some environmental toxin in your neighborhood (think Love Canal) that you do share. When we are uncertain we are uncomfortable in the least, and if the uncertainty is associated with a risk of death, we are terrified and can be irrational. Holding an open mind is hard. Denial has never appealed to me, but for some, it is also a comfortable respite from uncertainty. I have always held to the position that if you don’t understand something, it is better to continue to search for explanations rather than latch on to the first unfounded explanation you are offered.
As we painfully learned from President Trump’s strange approach to COVID and science, false reassurances don’t protect us and often lead to even greater losses. The real question becomes what is prudent to do when you are uncertain about the extent of risk. In retrospect, I think it is possible to say that we were offered very prudent pathways to follow at the start of the pandemic. We have gotten sloppy with our adherence to the simple things as we moved from our ignorance about what to expect from COVID to a more complete understanding of our challenge and the reassurance we received from being vaccinated. It is sad to contemplate the unnecessary loss of life that occurred because we all did not wear masks, practice social distancing, and limit our exposure to others before we had vaccines, and did not convince everyone to be vaccinated when vaccines became available. Perhaps now, even if getting vaccinated is the best move, we should return to the strict adherence to social distancing, wearing masks, washing our hands frequently, and avoiding indoor gatherings.
A disturbing analysis was published this week that suggests that COVID death rates are significantly higher in the counties that Trump won. The Trump factor is hard to measure in New Hampshire. We are a “purple state” that Biden won carrying eight of our ten counties. The two counties that Trump won, Belnap (around Lake Winnipesaukee) and Coos (the most northern and undeveloped area of the state beyond the White Mountains and bordering on Canada), are not the leaders in the recent surge of cases. As the article suggests, scanning maps of the states for evidence of COVID activity does suggest that there may be some relationship between misinformation about COVID, political attitudes about government mandates for mask use, vaccination rates, political affiliation, and the risk for acquiring COVID.
More and more, I am thinking not only about those who die of COVID but also of those added to the pain of the moment who could be said to have died because of COVID. If you become acutely ill and need an ICU bed that is occupied by a COVID patient on a respirator, you might die of an event that you perhaps could have survived. Likewise, if the surgery for your cancer is delayed until it has had time to spread to other organs because elective surgeries have been canceled because of COVID strains on the system, then perhaps it is fair to say that your death was because of COVID. If you are afraid to go to the emergency room when you are experiencing severe abdominal pain because of a concern that the ER is full of patients who might have COVID, then any complications that occur could be attributed to COVID even if your pain was actually related to a dissecting aneurysm. Finally, if your hospital has closed beds because it can’t staff them because many of the staff have quit after becoming depressed and exhausted by the volume of COVID patients they see, or because they no longer want to expose themselves and their families to COVID, then can we say that COVID must have an impact on the health of the nation that goes far beyond the statistics that we keep? One way to estimate the “because of COVID” impact on deaths is to look at the current variation between “expected deaths” at any period in a population and actual deaths. When that is done we are experiencing more deaths than just the extra deaths attributed to COVID. By that methodology, we may have already had more than a million deaths from the combination of COVID and what I call “because of COVID.”
As I ponder just why my state is facing such a significant challenge from COVID, it feels like I should reconsider some basics local attitudes beginning with our state motto, “Live Free or Die.” I doubt that General John Stark, hero of the Battle of Bennington, was thinking about defiantly going maskless when he paraphrased Patrick Henry, author of “Give me liberty or give me death” fame, but Libertarians on the right now proudly claim that their fundamental freedoms include not wearing a mask even if they might die. Since the prime benefit of a mask is to prevent the transfer of virus from you to others and less to prevent you from getting the virus, these later day patriots are saying that they should be free to be the potential agent of your death rather than submit to the agony of wearing a mask when in close contact with you and others. The second and third lines of defense are social distancing and hand washing. We have all sorts of signs that remind us of these simple and life-saving strategies. When I visited New York recently I think I saw more containers of hand sanitizer than water fountains or bathrooms. They were ubiquitous. I was also continually asked to show proof of my vaccination. Rather than feel that my basic freedoms were being violated, I was reassured that my risk of becoming a COVID statistic was being lowered by the collective adherence to common-sense strategies. These things don’t happen in New Hampshire.
I shudder each time I see a Patriots home game on television that I know is attended by fans from New Hampshire. Sitting cheek to jowl next to a semi intoxicated fan does not feel like an activity that I would recommend if you want to avoid COVID, nor is crowding into a Walmart on Black Friday to hustle for bargains. We do all these things as if COVID was just a bad memory since we all got vaccinated. We are tired of it all, and that makes us an easy mark for the virus and ensures that we will experience more grief.
Of all the reasons that we are in harm’s way because of our lack of respect for reasonable public health strategies, nothing comes close to the pain that awaits us since many of our neighbors did not get vaccinated. Another sad reality and reason to maintain all the precautions even after being vaccinated is that it is becoming clear that vaccinations don’t prevent you from getting a very mild infection that you may not even recognize before you pass COVID on to someone else who may not be vaccinated. Throughout the pandemic, our governor, Chris Sununu, has given weekly updates on COVID even though he left issues like wearing a mask or getting vaccinated as issues of personal freedom in the “live free and die while you infect your neighbor” state.
I was delighted to learn last week that the governor announced that one could obtain eight home tests for free through a combined program of the National Institutes of Health and our state government—as long as the supply lasted. The program is called the Say Yes! COVID Test initiative. My wife and I were lucky to hear about the offer before the supply was exhausted. We immediately applied online and it was just a few days before a box of eight tests arrived. My wife used one the next day because she was feeling sick, and we were to be with friends who were completely vaccinated including boosters the next evening. Fortunately, the test was negative. It is interesting to remember that back in April of 2020 I reported that Nobel Prize-winning economist Paul Romer had suggested, based on complex modeling, a massive program of testing as the best way to return to a more normal existence while we waited for the vaccines. He wrote:
Until a vaccine is developed and deployed, the simplest and safest path to this outcome is a national testing strategy that marshals our existing resources to test everyone in the U.S. once every two weeks and isolates all those who test positive. It does not rely on any new technologies, is far less disruptive and costly than our current policy, and will work even in a worst-case scenario.
At the time, his critics were quick to point out that his suggestion was logistically impossible. Now, we have the vaccine, which many don’t take, but home testing is possible. As the number of COVID cases in the Northeast rise to levels that are higher than the peak numbers of last January, is it time to try Romer’s suggestion? We are expanding testing. This week Governor Phil Scott of Vermont directed all insurance companies doing business in his state to pay for home testing. The other piece of Romer’s strategy was contact notification and follow-up. That is plausible, but will we do it?
All the reports on the local news suggest that the large majority of those who are in hospital now are unvaccinated. They have been doubly infected. First, they were infected with a massive misinformation campaign that at some level was politically motivated. In many instances, the limp response of politicians who did not want to offend a base that preferred conspiracy theories over science helped propagate that pandemic of misinformation. Naked of the vaccinations they could have had, they were then secondarily victims of COVID. The piece of misinformation that I found hardest to understand was that COVID was a hoax! In this state, the politicians should have seen the light when the newly elected Speaker of the New Hampshire House died of COVID last December.
This week our governor is scrambling to keep our hospitals from collapsing under the weight of the COVID explosion which has thrown our system of care out of control. He is begging for medical support from other states and has called up the National Guard, but he refuses to consider mask mandates or vaccine mandates. His office did release the vaccination status of the state showing the percent in each town with a single shot and the percentage that were fully vaccinated in each of our 10 counties, 13 cities, 221 towns, and 25 unincorporated places. I combed through all of the reports and was surprised by what I found. There are many towns where less than a third of the population has had a single shot. The little town of Easton, population 292, is picturesque, but probably should be considered toxic since the governor reported that only 14.2 % had received a single shot, and 13.1% were fully vaccinated. That means that 41 people got the first shot but 3 did not get the follow-up injection or perhaps had the J&J. Who knows? What is important is that there are about 250 people in the quaint little town who are sitting ducks for COVID. Good luck to them since they are over fifty miles from Dartmouth Hitchcock Medical Center.
There were also many towns, like my town, where over 75% of the population is reported to be fully vaccinated. Jackson, NH reported that it was 88.6% fully vaccinated. Grantham, where I once had a weekend home, reported that 93.4% had received one shot and that 83.8% were fully vaccinated. Despite the fact that 65% of the state is fully vaccinated, there are still plenty of people, almost 500,000, sometimes in large clusters, who are vulnerable because they have not been vaccinated for whatever personal reason.
Most of the people in the state’s ICUs are unvaccinated. But even that is not the whole story since being vaccinated does not prevent you from getting infected or passing the virus along to someone who is not vaccinated. I know several people who were fully were vaccinated before boosters were available, but did catch COVID. Some were very sick. Fortunately, no one in this cohort that I know has been hospitalized, but at least one passed the infection on to a fully vaccinated spouse. What has happened in New Hampshire should humble us and remind us that as desperately as we want this pandemic to end, it still confounds us as we approach 800,000 deaths and 50 million infections.
The Omicron variant has not yet arrived in New Hampshire. I hope that Dr. Fauci is right when he suggests that although Omicron is more infectious, and that we all need a third shot, it may still cause less severe disease. We live in uncertain times, but we also have a lot of knowledge that has not been optimally applied to the problem. I am tired of elected leaders who are afraid to establish policies that are in the public interest for fear that they might offend some percentage of the base they depend upon for reelection.
It is distressing that we are entering our second COVID compromised holiday season. Perhaps the best gift for the holiday season for the people you love is a box of home COVID tests. I know that many of you will be traveling. I hope that you get your booster in time for it to protect you as you gather with family and friends. I plan to travel. I have had my booster, and thanks to the NIH and the State of New Hampshire I have my tests to use before I see my grandchildren. What is your plan?
Be wise with your COVID precautions. Be well,
Gene
