Within the United States, the experience of individual states in managing COVID-19 contagion and outcomes ranged widely, with some states having death rates more than three times higher than others. As a result, the overall U.S. death rate from COVID-19 was 372 per 100,000 people, significantly worse than comparable developed nations.
To account for these state-to-state variations in infection and mortality rates, a multinational group of researchers looked at the possible influences of racial and economic factors, local public health system capacity, political orientation and leadership, and state government policy. All 50 states and the District of Columbia were included in the analysis, which was based on data from January 1, 2020, to July 31, 2022, and published in the April 22 Lancet.
The researchers found that certain government policies, economic conditions, and population characteristics were associated with poorer outcomes. Poverty, lower educational attainment, higher comorbidity rates (notably obesity and diabetes), limited access to health care, and lower interpersonal trust were associated with more infections and higher mortality rates. States with worse outcomes also had higher percentages of people identifying as Black and Hispanic-racial groups known to experience socioeconomic barriers and health disparities.
Overall, states where a majority of voters voted for the 2020 Republican presidential candidate, Donald Trump, suffered worse COVID-19 outcomes, according to the researchers, though they noted that the political affiliation of state governors had no effect on outcomes. Indeed, some states with Republican governors, such as New Hampshire, had among the lowest rates of infection and mortality (215 per 100,000 people).
Socioeconomic factors associated with poorer outcomes also tended to be prevalent in states where a majority of residents voted for Trump, but this was not characteristic of all Trump-leaning states. Only states with both income inequality and a majority of Trump voters had worse COVID-19 outcomes, according to the statistical analysis.
State mandates related to masking, social distancing, and vaccination were associated with significantly lower infection rates; lower death rates, however, correlated solely with vaccine mandates. Interestingly, states with lower unemployment-an indicator of economic strength-tended to also have less mask use and, consequently, higher rates of COVID-19 infection and death.
The researchers' analysis characterized the overall U.S. experience during COVID-19 as the product of a syndemic-a phenomenon where "pre-existing local health conditions and socioeconomic disparities drive the spread of disease and worsen its adverse outcomes." In this case, the syndemic was "centred around the combination of race and politics."
If all states had a cumulative death rate similar to that of New Hampshire, over 500,000 lives would have been saved and the United States would have had a death rate lower than 12 high-income nations. Indeed, Vermont (111 reported deaths per 100,000 people), Utah (157 per 100,000), and Washington (193 per 100,000) had rates similar to those of the highest performing countries: Denmark (115 per 100,000), Switzerland (155 per 100,000), and Germany (170 per 100,000). Meanwhile, Mississippi (551 deaths per 100,000), Arizona (539 per 100,000), and West Virginia (575 per 100,000) nearly matched death rates recorded in the three worst-performing countries: Russia (537 per 100,000), Bulgaria (539 per 100,000), and Peru (631 per 100,000). "The nearly four-fold differences that existed across states in COVID-19 death rates, even when standardised for factors such as age and comorbidities, suggest that lower death rates were achievable," the researchers concluded.-Karen Roush, PhD, RN, FNP-BC, news director