Reasons many for fewer NH infections than Mass.
April 19-- Apr. 19--Politically they are dissimilar, but economically, culturally, even genetically, New Hampshire and Massachusetts are mirror images.
One in four New Hampshire residents was born in the Bay State.
Before this pandemic, more than 100,000 who live here got in their cars, bus or train each day and headed to jobs south of the border.
"Southern New Hampshire is a tax-free suburb of Boston," said Gov. Chris Sununu, who grew up in Salem and whose father, John H., was a Tufts University professor before becoming governor and White House chief of staff.
Yet when it comes to COVID-19, it's as if these neighboring states are on different continents.
Proportionally, Massachusetts has five times as many positive tests for the coronavirus, three times as many hospitalizations and seven times as many deaths as New Hampshire.
That stark contrast has heightened tensions as the inevitable relaxation of pandemic restrictions here draws closer. Many New Hampshire residents fear the northward spread of the virus by a large influx of Bay Staters running from their own restrictions.
"I think it is a real concern, especially in small lake or mountain towns that do not have large hospitals or ambulance services," said Lisabritt Solsky Stevens of Concord, the state's former deputy Medicaid director.
"Many out-of staters flock here and even have second homes here, but bringing the virus to some of these small towns could have serious consequences to the local infrastructure."
Hillary Seeger of Meredith said that while worried, she understands the desire to come here.
"I find myself getting viscerally annoyed when I see an out-of-state plate," said Seeger, who has done public relations for the Veterans of Foreign Wars and been a diagnostic engineer. "However, if I lived down there and I owned a place up here, I would probably have been the first one racing across the border. It's tough."
Consider: 6.95 million people live in the Commonwealth of Massachusetts, compared to 1.36 million in New Hampshire.
But those two numbers alone aren't enough to form conclusions about the dangers of COVID-19 transmission, analysts say.
It's the density
Dr. Ben Locwin of Portsmouth, an infectious disease expert, said it's population density, rather than raw population numbers, that drives the risk of the virus exploding in any community.
"Just because you have 10 times more people doesn't mean you get 10 times more virus. The population density is driving this inevitability," said Locwin, whose resume includes time as a senior consultant to the Centers for Disease Control. "It's all about so much high-rise living, people stacked up, all sharing volumes of air, touching the same doorknobs.
"There is, generally speaking, a lot more space and air volume in New Hampshire," said Locwin.
That's the first point Sununu and State Epidemiologist Dr. Benjamin Chan turn to when pressed why they think New Hampshire's incidence of disease has been lower.
"Areas like Boston, you have an apartment building, close confined coffee shops, everyday living and workplace environments that can be very dangerous, and that makes it very difficult to mitigate the spread," Sununu said.
But congestion alone doesn't tell the story.
Boston lies in Suffolk County, which doesn't have the state's most COVID-19 cases, according to its Department of Public Health.
The largest number is in Middlesex County, which includes most of the Merrimack Valley, just south of the New Hampshire border, to Cambridge, just north of Boston.
Essex County, from Lawrence to Gloucester on the coast and north to the state line, and Norfolk County, from Quincy south of Boston to the foot of Cape Cod, each have almost three times as many COVID-19 cases as all of New Hampshire.
State officials said contact by New Hampshire residents working or visiting south and then coming home is a major reason New Hampshire's southeastern border counties, Hillsborough and Rockingham, have 74% of New Hampshire's COVID-19 cases.
Two weeks ago the state installed signs on the interstates telling out-of-state residents who come to stay in New Hampshire that they must quarantine for 14 days before venturing out. "It's not complicated. If you're passing through, fine, but if you intend to stay for a while, we need you to self-quarantine," Sununu said.
It's also why cases from community spread have surpassed travel-related cases and contact with someone infected as the leading cause of COVID-19 in New Hampshire.
"I think we are still seeing a lot of community transmission taking place here in venues like liquor stores, grocery stores and other retail places. People who are asymptomatic, they are going to the liquor, grocery stores, not wearing masks and spreading the virus," said Dr. Rich DiPentima, a 30-year health executive with two stints at the New Hampshire Division of Public Health, including one as chief of communicable disease epidemiology.
Poverty plays a part
Over his long career, DiPentima, 75, helped fight swine flu in the 1970s, AIDS in the 1980s and the SARS outbreak in 2002-04.
"The biggest risk factor for almost any untoward health event is poverty, and we are seeing that nationally as well," DiPentima said.
"If you are poor, you have fewer resources and access to what it takes to remain healthy during an outbreak. It's that simple."
According to 2019 U.S. Census department numbers, Massachusetts had the 25th-lowest poverty rate, at 10.4%.
That same year, New Hampshire's poverty rate was the nation's lowest at 7.7%.
Infection and death rates from COVID-19 have soared among the African American communities in Detroit and Chicago and among Hispanics in New York City and even Oregon.
In 2020, 25 states had more white residents per capita than Massachusetts (72.1%) according to World Population Review.
Only Maine and Vermont had more white residents per capita than New Hampshire (90.3%).
More tests, more positives
Since the outbreak began, some public health advocates and even business leaders conclude that New Hampshire's relatively low testing rate for the virus is masking a much greater level of the disease in the state.
"If you don't test, you don't know it is there. That doesn't mean we have less COVID; it means we are finding less COVID," said Mindi Messmer, an environmental consultant, former state rep and former candidate for Congress.
"I believe the differences in testing is the artifact for why there is this striking profile between New Hampshire and Massachusetts."
The COVID Tracking Project reports Rhode Island (third), Massachusetts (fourth) and Vermont (fifth) are all in the top five of testing in the nation, each sampling at least 18 for every 1,000 residents for the virus.
New Hampshire was last in New England and 25th in the nation, testing about nine of every 1,000 residents.
Health and Human Services Commissioner Lori Shibinette said New Hampshire has given physicians the power to order anyone to be tested, no matter how symptomatic they are.
New testing regimens are ramping up this week with plans to offer a mobile unit to conduct rapid tests in Nashua and the testing of all long-term care residents and staff in Hillsborough and Rockingham counties.
A month ago, the state hired additional workers to do more contact tracing of those who tested positive to investigate who else they could have infected.
The experts say this is a critical prerequisite to any reopening of activity in any state.
"All along we have talked about and we have carried out expansions of our testing," Shibinette said.
Hospitalization as a metric
Sununu said testing is one metric but hospitalization rates tell the true incidence of serious disease from COVID-19.
"Mass. might have a higher rate of testing; we know there are a lot of folks who have COVID who have yet to have been identified here," Sununu began.
"But hospitalization is the great equalizer. If you get really sick with COVID, you're going to end up there whether you have been tested or not."
Infectious disease expert Locwin said getting hospitalized is often about proximity.
"If you are in New Hampshire, Portsmouth Regional Hospital might be 10, even 20 miles away. We know advertising drives behavior and in Boston, you are heading down to the clinics, you are going to get tested, that is going to drive up the numbers including that of serious illness," Locwin said.
"You know the saying: 'If you want to stay healthy, you stay out of the hospital. How many of our residents are staying home even with real illness, not calling out until they have difficulty breathing? I suspect quite a few."
Are all deaths counted?
Last week, New York classified 3,700 past deaths as COVID-19-related, even as the CDC advised all state public health leaders to examine whether they have attributed deaths to pneumonia or other illnesses that were really linked to the virus.
"It gets really dodgy with the gamed numbers per state. We are calling things COVID which aren't and we aren't calling COVID when it is," Locwin said.
"The people calling it are gaming the numbers, not intentionally, but there's no uniform standard. When you say a fatality rate in Mass. is 4%, I say that's probably plus or minus 4%."
Shibinette said the state might have missed a few cases, but she doubts the numbers here are large.
"We have worked very, very closely with our medical examiner to create a plan around untimely deaths and whether they could be COVID-related," Shibinette said.
"It may happen, but based on all the planning we have done, I don't think it's a factor here."
Caution on 'opening up'
On a Union Leader social media chat last week, more than 80% of participants urged Sununu to be cautious about reopening New Hampshire while the virus is still peaking in Massachusetts.
"It's a major concern and the main reason why New Hampshire cannot ease up on stay-at-home orders until Mass. is under control," said Shawn Scott, a Merrimack native who lives in Manchester.
Former state Senate candidate and businessman Steve Kenda thinks otherwise, after signing a petition calling on the governor to "Reopen New Hampshire" next Friday.
"Let those of us that want to go work out, eat out, to movies, to sporting events, have our freedom back. If those concerned here are right, then we individuals choosing a different path will suffer the Darwinian consequences of our decision," Kenda said.
"If you're at risk, have a compromised immune system, are elderly, you're welcome to take a different path. Wait for the vaccine and serological tests. Stick with Netflix and avoid us, but let those of us that value our liberty over safety get on with living and dying."
Some, like Jon Christenson of Salem, a Boston TV graphic designer, thinks New Hampshire residents need to be even more careful. "What concerns me more is what I see when I do have to go out. People are not taking social distancing seriously and are oblivious to others in some cases," Christenson said. "I see people without masks or gloves, standing around you or walking very close to you, touching everything. I wonder if they think it's all a hoax."