by Jason S. Brinkley, PhD, MA, MS

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On the Brink addresses topics related to data, analytics, and visualizations on personal health and public health research. This column explores current practices in the health arena and how both the data and mathematical sciences have an impact. (The opinions and views represented here are the author’s own and do not reflect any group for which the author has an association.)

The US healthcare system is often criticized for being too costly and not delivering health outcomes as good as other regions of the world. Indeed, recently President Trump praised the Australian healthcare system, saying they “have better health care than we do.” But as often discussed here at On the Brink, the US system suffers from great regional variation. US News ranks Hawaii as having the best healthcare system in the country, but Hawaii is also one of the smallest in size and has a lower population than other states. So how trustworthy are comparisons between different healthcare systems when regions vary by size and population?

The web is full of great resources for finding out geography and population statistics, but those measures are sometimes difficult to grasp for the uninitiated. Knowing that a state is 50 thousand square miles may not be that useful, so let’s create a different measuring device. I recently stumbled onto this website with land size and population statistics that provide data to help us make some comparisons. Sorting the data, we find that Alabama ranks 28^th in land size (approximately 50 thousand square miles) and 23^rd in population size (approximately 4.8 million residents), which makes it pretty good for comparison because it is close to the middle on both measures.

The table below applies the Alabama reference to the other US states and District of Columbia. Items in green are larger than Alabama and items in red are smaller than Alabama. So, for example, Texas is approximately 5 times the size of Alabama in terms of both land size and in population. Illinois is about the same size as Alabama but has 2.7 times as many residents. Going the other way, it takes 2.1 West Virginias to get an Alabama via land mass and 2.6 West Virginias in terms of population. In total, the lower 48 states break up into roughly 60 Alabamas by both land mass and population.

State	Versus Alabama Land Size	Versus Alabama Pop		State	Versus Alabama Land Size	Versus Alabama Pop
Alaska	11.3	6.7		Nebraska	1.5	2.6
Arizona	2.2	1.3		Nevada	2.2	1.8
Arkansas	1.0	1.6		New Hampshire	5.7	3.6
California	3.1	7.8		New Jersey	6.8	1.8
Colorado	2.0	1.1		New Mexico	2.4	2.3
Connecticut	10.5	1.3		New York	1.1	4.1
Delaware	26.0	5.3		North Carolina	1.0	2.0
Florida	1.1	3.9		North Dakota	1.4	7.1
Georgia	1.1	2.0		Ohio	1.2	2.4
Hawaii	7.9	3.5		Oklahoma	1.4	1.3
Idaho	1.6	3.0		Oregon	1.9	1.2
Illinois	1.1	2.7		Pennsylvania	1.1	2.7
Indiana	1.4	1.4		Rhode Island	48.6	4.5
Iowa	1.1	1.6		South Carolina	1.7	1.0
Kansas	1.6	1.7		South Dakota	1.5	5.9
Kentucky	1.3	1.1		Tennessee	1.2	1.3
Louisiana	1.2	1.1		Texas	5.2	5.3
Maine	1.6	3.6		Utah	1.6	1.7
Maryland	5.2	1.2		Vermont	5.5	7.6
Massachusetts	6.5	1.4		Virginia	1.3	1.7
Michigan	1.1	2.1		Washington	1.3	1.4
Minnesota	1.6	1.1		Washington, DC	826	7.9
Mississippi	1.1	1.6		West Virginia	2.1	2.6
Missouri	1.4	1.3		Wisconsin	1.1	1.2
Montana	2.9	4.8		Wyoming	1.9	8.5

Returning to US News health rankings, Hawaii, Massachusetts, and New Hampshire are all much smaller than Alabama and fall into the top 5 states for healthcare. However, Minnesota and Iowa round out the top 5 and are much closer to Alabama in terms of size and population. But Alabama ranks 47^th on the health ranking list, which suggests land size and population aren’t the only determinants.

Moving beyond the United States, we can also count Alabamas on the world stage. The table below has several major countries and their comparisons to Alabama in the same way we’ve compared other US states.  Putting all that we know above about the US makes interpreting comparisons across the world much easier. We see that Australia has about the same land mass as the lower 48 US states but only 5 times the population of Alabama. (So now imagine the population of Texas spread out across all of the US except Alaska and Hawaii), which might give President Trump’s comments additional meaning or context.

Using the two tables together gives lots of good comparisons. Sweden, with its celebrated health care system, is the land size of California with the population size of North Carolina. Afghanistan is about the size and population of Texas, and North Korea is the size of Alabama with the population of Texas. Israel is about the same size and same population as Massachusetts.

Country	Versus Alabama Land Size	Versus Alabama Pop		Country	Versus Alabama Land Size	Versus Alabama Pop
Afghanistan	4.9	6.2		Iraq	3.3	6.4
Australia	58.5	4.6		Ireland	1.9	1
Cambodia	1.4	3.1		Israel	6.3	1.6
Canada	76	7.1		Italy	2.3	12.8
Chile	5.8	3.5		Japan	2.9	26.5
China	73	279.7		Korea, North	1.1	5.1
Cuba	1.2	2.3		Korea, South	1.3	10.2
Denmark	3	1.2		Mexico	15	23.8
Egypt	7.6	17.2		Pakistan	6.1	39.2
France	4.2	13.7		Russia	129.9	29
Germany	2.7	17		Sierra Leone	1.8	1.1
Greece	1	2.3		Sweden	3.4	1.9
Guatemala	1.2	2.9		Turkey	5.9	16.5
Iran	12.5	16.3		United Kingdom	1.9	13.1

Tables are great, but when it comes to geography, maps are usually better. The issue with many world maps is that they are a two-dimensional representation of a three-dimensional world and as such there usually is some stretching or distortion that occurs. Head on over to www.thetruesize.com (contrary to the sound of its name, the website is absolutely safe for work) for a great and easy-to-use tool that helps you compare the true size of different countries by allowing users to relocate them on a world map for better comparison. Be prepared to waste several hours with this unique and fun website. If you are anything like me, you might end up also wasting a lot of time counting Alabamas. In preparing today’s blog I showed these comparisons to my family, after which my wife responded, “I’m used to counting Mississippis, but I guess I can learn to count Alabamas.”

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Jason S. Brinkley, PhD, MS, MA is a Senior Researcher and Biostatistician at Abt Associates Inc. where he works on a wide variety of data for health services, policy, and disparities research. He maintains a research affiliation with the North Carolina Agromedicine Institute and serves on the executive committee for the NC Chapter of the American Statistical Association and the Southeast SAS Users Group. Follow him on Twitter. [Full Bio]

Previous posts by this author:

• The Third World in Your Own Backyard
• The Unrealistic Gold Standard
• Does MACRA Signal the Beginning of the End for Medicare Claims Data?
• Think You Aren’t Extraordinary? Odds Are You’re Wrong
• Mapping by Words
• Are We Asking Too Much From Surveys?
• Making Better Comparisons
• What Kills Us?