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Across the U.S., nearly 20% more people have died since the start of the pandemic than would be expected in normal times, according to a . In some places “excess deaths” have been even higher, as much as 60%.

This includes those known to have died of COVID-19, of course, but also undetected COVID deaths and other possible effects of the pandemic, such as people with conditions that might not normally lead to death being afraid to seek care or higher rates of drug overdoses.

In Hawaii, however, the fatality rate has barely budged.

It’s a product, first and foremost, of the pandemic being less severe in Hawaii than in almost any other state.

“We have fared remarkably well compared to the rest of the country,” said Tonya Lowery St. John, a public health epidemiologist at the Hawaii Health Data Warehouse. “Our lockdowns when they happened and the safeguards that were put in when we reopened Hawaii all seem to be working.”

But other, sometimes surprising factors have come into play, experts say, including the drastic reduction in tourism, disappearance of the seasonal flu and reduced traffic deaths. Even fewer suicides have occurred.

Fatality records from the federal show Hawaii recorded approximately 260 more deaths between April and December 2020 than it did the same nine-month period a year prior. That’s about 3% more. Considering that the increase includes 320 Hawaii COVID-19 fatalities, deaths from other causes seem to have even fallen slightly.

Hawaii’s numbers are particularly surprising when one takes into account the fact that its population skews older, which might have been expected to make it more vulnerable to COVID-19 deaths.

“Due to the fact that we’re older, you’d absolutely think there were going to be proportionally more deaths in the population,” said Daniel Galanis, an epidemiologist for the EMS & Injury Prevention System Branch of the Hawaii Department of Health. “We have the lowest COVID-19 fatality rate of any state. That in itself is remarkable.”

A Normal Death Toll During An Abnormal Year

Surveying all deaths recorded in 2020 — not just the COVID-19 deaths — can illuminate other lethal effects of the pandemic.

Scientists look for what they call “excess” deaths, or an unusual increase in mortality, to determine the toll of a crisis. Some COVID-19 deaths may not be counted because they are misclassified. Annual fatality records can account for that.

“If we know more than the expected number died, then we know something is going on,” said St. John.

In general, the leading causes of death in Hawaii are “relatively constant,” said Thomas Lee, an associate professor of epidemiology at the University of Hawaii and co-chair of the Hawaii Pandemic Applied Modeling Group. At least on paper, last year in Hawaii looks pretty much like just another year.

That’s not to say the disease did not take a toll. A month-by-month analysis shows Hawaii experienced two peaks in excess deaths during surges in the summer and winter, according to data from

It’s just that Hawaii’s peaks in mortality look like blips compared to severe spikes in excess deaths in other states such as

Experts say there could be several reasons for this phenomenon.

The first is the most obvious, Lee said. Hawaii has recorded 30 deaths per 100,000 residents, the second lowest in the nation as of Friday, according to a .

Unusual Trends

Other fatality trends aren’t as obvious.

When Hawaii imposed mandatory quarantines for travelers, visitor numbers dropped dramatically. An average of 300 non-resident deaths occur in Hawaii per year, according to the Hawaii Health Data Warehouse.

“We didn’t have the 20 million extra tourists so we’d expect to see fewer deaths,” St. John said.

There have been other unusual patterns in Hawaii.

The that fewer suicides occurred in Hawaii during the COVID-19 pandemic than in previous years, although there was an uptick in suicides among women. Suicides fell in other states such as and , but overall figures will be uncertain until all the data is vetted. In Japan, death by

Driving fatalities usually cause a third of all deaths in Hawaii, but the reported in November there had been 27 fewer traffic-related deaths in 2020 compared to 2019, as fewer people drove, especially during lockdowns.

The COVID-19 pandemic has also altered the typical path of another typically deadly respiratory illness in Hawaii: the flu. This flu season basically never happened.

“The last time a specimen was found to be influenza-positive was back in July,” Chris Whelen, vice president and technical director at Diagnostic Laboratory Services, said at a recent press conference. “One could perhaps suggest that the measures that we’ve been taking to prevent the spread of COVID are pretty effective at preventing other viruses such as influenza.”

That’s significant, considering flu and pneumonia deaths are the third leading cause of death in Hawaii, according to Lee. The only causes that outrank the flu are cardiovascular diseases and cancer, followed by accidents and unintentional injuries.

“With COVID-19, our flu cases have drastically dropped and typically they tend to hit our elderly populations more,” Lee said. “Schools are not in session and that’s a huge transmission vector. So that means kids are not taking it home to kupuna.”

Hawaii’s Unique Demographics

Hawaii’s death rate during the pandemic is especially surprising considering its demographics. About 18.4% of the population is 65 and older, compared to 15.7% nationwide.

While Hawaii’s population has held steady at around 1.4 million people since 2014, mortality tends to tick up every year as Hawaii’s population gets “demographically grayer,” Galanis said.

So an increase in deaths might have been expected even absent the pandemic, he said.

Some trends in death rates are likely not yet apparent. Data for different populations are not yet available for 2020.

Some of last year’s deaths may not be accounted for yet, as verifying death certificates can take weeks or even months. Hawaii’s 2020 dataset likely won’t be complete until mid-2021, St. John said, and the data warehouse is still waiting to receive complete records for 2019 to post on its public database.

Until data collection is complete, a full picture of which causes of death went up and which went down won’t be possible, said Catherine Pirkle, an associate professor of public health at the University of Hawaii.

And if, as a result of the pandemic, some people sought care too late or not at all for conditions such as cancer, heart disease, diabetes or kidney disease, mortality rates could spike in future years, especially in light of job losses that might have left people without insurance.

Pirkle suspects mortality could be higher among populations that have already been documented to have been affected by COVID-19 disproportionately, including Pacific Islanders and Filipinos, but more data is needed.

“Crude mortality numbers can hide important and meaningful variation,” she said. “The picture may not be that rosy once we have had time for the full effects of this year to be observed.”