Seven year-old Tiana Shelton gets her first COVID-19 vaccination in November at the Howard County Health Department clinic at the Kokomo Event & Conference Center. Her mother, Whittney Carie, holds her as nurse Suzannah Leight gives her the shot. Staff photo by Tim Bath
Seven year-old Tiana Shelton gets her first COVID-19 vaccination in November at the Howard County Health Department clinic at the Kokomo Event & Conference Center. Her mother, Whittney Carie, holds her as nurse Suzannah Leight gives her the shot. Staff photo by Tim Bath
More than 3 million Americans died in 2020, the most recent year the National Center for Health Statistics has been able to publish mortality reports.

According to the NCHS, heart disease, cancer and COVID-19 were the leading causes of death that year. By population, Indiana ranks among the top states most affected by each of those factors.

Hoosiers contributed to roughly 2% of American deaths in 2020 — a total of 78,038 people. Various organizations shared thoughts on why Hoosiers were more likely to die from the top three mortality contributors than people from other states.


COVID was the third-largest cause of death in America and, more specifically, Indiana, where 9,490 people died from the disease.

Unlike the other two leading causes of death, the percentage of Hoosiers who died from the coronavirus was higher than the national percentage. Of all 2020 deaths recorded in Indiana, 12.2% were attributed to COVID. Nationally, the virus was attributed to 10.4% of deaths.

By population, Indiana had the 12th most COVID deaths across the nation.

Indiana University–Purdue University Indianapolis Professor Daniel Johnson studied the relationship between the coronavirus, social vulnerability and environmental measurements.

During his research, Johnson found that hot spots for COVID cases didn’t match hot spots for COVID deaths.

“Sometimes we have areas with very few cases, but a lot of deaths,” Johnson said, explaining the inverse was also true.

In areas that have high infection rates but low death rates, Johnson said the region likely has a population that has better access to quality healthcare or has fewer people who are at risk.

Demographic and environmental variables play a large role in the difference between infection and death hot spots, Johnson said.

For example, throughout various models that predict where coronavirus hot spots will emerge, the Shelby County area appears to struggle with the coronavirus. So far, the predictive models have been accurate. One possible reason for that, Johnson said, is an abundance of senior living communities in that area.

Populations over 65 years old have a higher chance of catching the virus. They also have a higher chance — roughly 50% higher — of dying from the virus.

“If we’ve got a census tract with about 10%, more aged 65 and over people than a tract next door, the census tract is probably going to have 50% more fatality rate,” Johnson said.

Single-parent households also stood out to Johnson in his research. Although single- parent households had a slightly higher rate of infection, the death rates were significantly higher.

The strong correlation between single-parent households and mortality rates doesn’t apply to the entire nation, though. In Indiana, the risk for those households is likely more than double compared to national mortality rates.

Living in a multi-unit dwelling also contributes to a slightly higher rate of infection and death in Indiana than nationwide. But populations without high school diplomas have a lower rate in Indiana than the rest of the nation.

Johnson isn’t entirely sure why Indiana’s vulnerable populations are affected differently than the rest of Americans.

He has a hypothesis for impoverished Hoosier communities, though. Johnson said impoverished Hoosiers likely had less mobility, so they were less likely to come into contact with people who had COVID.

“It’s taught us especially how poorly prepared we were for an event like this,” Johnson said of the various studies he’s worked on. He would like to see more funding and planning put toward predictive models that could prepare communities months before viruses make an impact.

“We have the capability of doing that,” Johnson said. “It’s just a matter of getting the funding and lining everything up.” Getting people to listen is another challenge, he added.

Although Johnson was applying the CDC’s Social Vulnerability Index — a system that identifies at-risk communities using 15 U.S. Census variables such as age, education and income — to research COVID, he said the same types of models could be used for other diseases or ailments.

Different variables would likely apply to other diseases, though.

“People that would be susceptible to cardiovascular conditions, there’ll be a different distribution to them relative to those susceptible to whatever type of cancer,” Johnson said.


Cancer was the second largest cause of death among Hoosiers in 2020 and contributed to 17.5% of total Hoosier deaths (13,664 people).

It was also the second largest factor for Americans in general. By population, Indiana had the seventh most cancer deaths in the country.

The Cancer Prevention and Control research program at Indiana University has been looking at genetic, biological and behavioral factors that lead to cancer.

Dr. David Haggstrom, a member of the research program and director of the Regenstrief Institute Center for Health Services Research, weighed in on the topic.

Haggstrom explained cancer incidence and mortality rates vary across geographical regions and populations.

“It’s a complex interaction of factors,” Haggstrom said.

In terms of geographic locations, water and air quality play a role in cancer rates. Rural areas are also farther from healthcare facilities, which affects emergent care, treatment options and a population’s access to screening services.

“I think that we can think globally, but act locally,” Haggstrom said, adding partnerships between community organizations, health departments and health care providers allow groups to tailor treatment to their patients.

Looking at populations, he said, socially vulnerable people and those who have reduced access to health care are most at risk.

Health behaviors, such as smoking, alcohol consumption, physical activity and diet, all play a role as well.

“Take the state of Indiana. Our median income, our education levels are lower than national averages,” Haggstrom said. “Oftentimes, those types of social markers correlate with health outcomes as well.” He added Indiana also struggles with tobacco use rates, levels of physical activity and healthy diet.

Investing in programs and campaigns that address modifiable risk factors, such as tobacco consumption, could help, Haggstrom said. Although, he added, Indiana historically invests less in public health than other states.

Public health investments, he said, could range from infrastructural developments to track cancer outcomes, tailored interventions for disproportionately affected communities and educational public health initiatives.

“There’s much work to be done,” Haggstrom said. “Through changes in healthy behaviors, reductions in smoking and alcohol use, we can make great progress.”

He added increased access to existing technology, like cancer screening, would also help Hoosiers lower Cancer mortality rates.

“Many of the factors that influence cancer are modifiable. So I think there’s reason for hope if we have the focus and the will to change these things in our culture and communities,” Haggstrom said.


Nationally and statewide, heart disease was the leading cause of death in 2020, claiming 15,169 Hoosier lives (19.4% of deaths in Indiana).

According to data from the World Health Organization, heart disease was also the leading factor for death internationally in 2019 (the most recent data).

By population, Indiana had the 14th most deaths attributed to heart disease in the nation.

Tim Harms, senior director of communications with the Indiana American Heart Association, said there are multiple issues that contribute to Indiana’s struggle with heart disease.

“We have a lot of work to do in Indiana to help people become healthier and live longer, healthier lives,” Harms said. Part of that work, he said, includes teaching people how to prevent heart disease.

During the 2019-2020 fiscal year, 33.4% of donations to the American Heart Association were allocated to public health education.

The American Heart Association has identified eight key concerns, titled “Life’s Essential 8,” that Hoosiers should focus on to keep their hearts healthy. The list includes diet; physical activity; nicotine exposure; sleep duration; weight; cholesterol; blood sugar and blood pressure.

Working with various programs across the state, the organization is trying to teach the public how to address each of the eight heart disease contributors.

In terms of physical activity, the American Heart Association recommends Hoosiers complete at least 150 minutes of exercise every week. The exercise can be as simple as taking a brisk walk, Harms said.

Harms added a balanced diet is also important, encouraging people to cut back on sodium and added sugars while increasing the amount of fruits, vegetables and whole grains they consume.

“Most people will tell you ‘Well, I never even pick up the salt shaker, I never add salt,’” Harms said. “But the fact of the matter is, so much of our food that we consume is processed food, and is loaded with sodium that we don’t even see.”

The American Heart Association also works with various federally-qualified health centers throughout the state to bring more blood pressure testing to people in low income areas.

“Those people are also folks that oftentimes do have more chronic disease … and are in the most need of care, but have the least access to care,” Harms said. “Even the fact that then they are aware of their high blood pressure starts the process of them being able to manage it and improve their health.”

He also attributed Indiana’s high smoking rates to the high number of heart disease problems. According to a 2020 study by the CDC, the Midwest has the highest concentration of smokers with 15.2% of adults classified as current smokers.

On a national level, the American Heart Association has been working with lawmakers trying to raise taxes on nicotine products. The organization also contributed to efforts that raised the legal smoking age and removed some flavored vaporizer products from stores.

Despite the challenges, Harms said he’s optimistic about reducing the rate of heart disease.

“The majority of heart disease is preventable,” Harms said, adding millions of dollars are allocated every year to research heart disease and the benefits of diet and exercise.

Over the years, Harms said, there’s been a drop in mortality rates. He attributed the drop to medical advancements and a nation-wide effort to reduce public smoking.

“We have made great progress in reducing mortality rates,” Harms said. “However, when you look at risk factors, such as high blood pressure and obesity and diabetes, those numbers are climbing … there’s still work to be done.”
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