THE LANCET:
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The most comprehensive state-by-state analysis of the impacts of COVID-19 in the US, published today in The Lancet , reveals the underlying reasons why the pandemic has unfolded in very different ways across the country.
Although the US has the largest economy, spends more on healthcare than any other country, and was ranked best prepared for a pandemic in the Global Health Security Index in 2020 (data collected before the pandemic), it maintains the highest number of recorded deaths from COVID-19 and one of the highest per capita COVID-19 mortality rates globally. But the pandemic did not affect US states equally.
The new analysis finds that between January 1, 2020 and July 31, 2022, cumulative COVID-19 death rates varied widely in the US per 100,000, respectively) with Arizona and Washington, D.C. having the highest (581 and 526 deaths per 100,000, respectively).
"The tragic human cost of the COVID-19 pandemic in the US challenged conventional assessments of pandemic preparedness and exposed existing vulnerabilities in our social fabric that were not identical across states," says co-lead author Emma Castro, researcher at the Institute of Health Metrics and Evaluation (IHME), USA. "Even after taking into account age and underlying diseases, we observed a nearly four-fold difference in COVID-19 mortality rates between states, suggesting that the country as a whole could have performed much better. Examining how specific states fared and identifying the commonalities of states that performed well offers important insights into how we can and should better respond. to this and future pandemic threats.
The researchers emphasize that states with the lowest standardized COVID-19 death rates come from different geographies and partisan influence. And the same goes for states with the highest standardized COVID-19 death rates.
The study is the first time researchers have comprehensively examined the driving forces behind the wide variations in SARS-CoV-2 infections and COVID-19 deaths across states over an extended period and adjusted for factors outside of control. immediate information from policymakers (e.g., age, population density, key comorbidities).
Using state-level data from public databases, researchers analyzed government policy responses and population behaviors (e.g., mask use, vaccination, mobility) in all 50 U.S. states and Washington, DC, from January 1, 2020 to July 31, 2022, to evaluate states’ efforts to mitigate the impact of SARS-CoV-2 infections and COVID-19 deaths, and whether Better COVID-19-related outcomes offset economic, educational and employment losses.
The results of this analysis were used to answer five key policy questions that emerged during the pandemic around the wide state-by-state variations in COVID outcomes: 1) the role of social, racial, and economic inequalities; 2) whether states with greater health care and public health capacity performed better; 3) the influence of politics on results; 4) whether states that imposed more political mandates and sustained them longer did better; and 5) whether there were trade-offs between a state having fewer cumulative SARS-CoV-2 infections and total COVID-19 deaths and better economic and educational outcomes.
COVID-19 has magnified existing social, economic and racial inequalities
Analyzes found that U.S. states with higher poverty, lower rates of educational attainment, less access to quality health care, and lower levels of interpersonal trust (trust in others) experienced disproportionately higher rates of coronavirus infections. SARS-CoV-2 and deaths from COVID-19. .
This set of factors was found to exist in the states where COVID-19 has caused the most damage: those with the highest populations of people who identify as Black and where a high percentage of people voted for the Republican presidential candidate in the election. 2020, such as Texas, Mississippi, Georgia and Alabama.
"What is clear from our study is that COVID-19 exploited and aggravated local racial inequalities, health disparities, and existing partisan politics to create a syndemic , a combination of local factors that interact, increasing the disease burden of this pandemic and the likelihood of bad outcomes," says co-senior author Thomas J. Bollyky, director of the Global Health Program at the Council on Foreign Relations in the US. "This combination of racial disparities and politics largely explains why the United States "United States struggled particularly in the pandemic."
Additionally, the study found that while states with greater access to quality health care tended to perform better, with, on average, fewer COVID-19 deaths and SARS-CoV-2 infections, higher state spending on public health and more public health personnel per capita were not associated with better health outcomes, at the state level.
States’ political orientation played a nuanced role in COVID-19 outcomes. The analysis suggests that partisan politics played a nuanced role in state-level COVID-19 outcomes. No association was found between the political affiliation of the state governor and COVID-19 mortality rates. Five of the 10 states with the lowest standardized death rates (Vermont, New Hampshire, Maryland, Ohio and Nebraska) were led by Republicans, and the other five best-performing states were led by Democratic governors. However, a key predictor of total COVID-19 infections and deaths was the share of the state that voted Republican in the 2020 presidential election.
Political partisanship also influenced local decisions about how Americans use the health care system. In states that voted overwhelmingly Democratic in the 2020 presidential election, vaccine coverage was associated with stronger health systems (e.g., more health care workers and doctors, fewer uninsured people). However, in strongly Republican states, the analysis found no link between health system factors and the adoption of protective behaviors, such as vaccination.
"Importantly, our results suggest that the stronger a health system is, the better a state performs in the pandemic, but only in states where the public was willing to use health care services to get vaccinated or receive early treatment." for their conditions". "explains lead author Dr. Joseph Dieleman of IHME. "Going forward, it is critical that public health officials as well as other leaders (elected officials, community organizers, leaders of religious institutions) work together to ensure that key messages about access to care and preventive measures reach all populations and are broader. adopted."
Trade-offs between public health restrictions, jobs, and student test results
States that imposed more protective mandates, such as those encouraging mask-wearing, mobility restrictions and higher vaccination rates, and kept them in place longer, experienced lower infection rates. Only vaccine coverage had a strong association with state variation in COVID-19 death rates.
"Our estimates suggest that the use of gathering mandates and restrictions was statistically associated with lower infection rates, but not mortality rates," Dieleman says. "Many other factors affect mortality rates. Ultimately, our public health policies appear capable of preventing transmission, but other social factors such as poverty, educational attainment, and access to high-quality health care could have confounded the response and led to higher death rates in some states that did not have tremendously high infection rates." [1]
New estimates suggest that, if these associations are causal, then the state with the lowest use of protective mask mandates and social distancing (Oklahoma) had the same policy response as the state with the highest use (California), would have experienced almost a third (32%) fewer infections. Similarly, estimates suggest that if the state with the lowest vaccination coverage (Alabama) adopted vaccine acceptance from the state with the highest vaccination coverage (Vermont), cumulative infections (30%) and deaths ( 35%) would have been reduced by around a third.
To determine the economic situation of each state, researchers looked at employment figures and state gross domestic product (GDP). They found that Hawaii, Washington DC, and New York had the largest declines in employment, while Wyoming, Hawaii, and New Mexico tended to have worse economic outcomes.
Despite wide variation across the U.S. in the relative decline of local GDP, the employment rate, and math and reading test scores, the study found no evidence of a trade-off between a state having a relatively strong or good health performance in the pandemic. Specifically, the analysis found no links between GDP and most health mandates, lower infections or fewer total deaths in the pandemic.
"Our results suggest that the local economy was neither hindered nor helped by differences in the policy mandates that states adopted to reduce COVID-19 deaths or slow the spread of SARS-CoV-2 infections," Bollyky says. . "For example, maintaining mask mandates longer did not, on average, result in a state experiencing a greater reduction in GDP than its less restrictive neighbors."
Dieleman adds: "Most states had reductions in economic activity during the pandemic, especially in 2020, but those reductions were not systematically related to state policy mandates or COVID infection and death rates. Looking at the pandemic As a whole, many things, including federal policy responses were put in place to prevent the economy from doing worse than it was. And the sectors that did worse, such as transportation and leisure, constitute a relatively small part of the economy, although they represent a disproportionately large fraction of the workforce."
But there was a trade-off with jobs. Mandatory restaurant closures and increased mask-wearing were associated with larger declines in employment rates. Likewise, less mask use, more infections and more deaths from COVID-19 were closely related to higher employment. The study estimates that, on average, there were 1,574 additional infections per 10,000 inhabitants with each percentage point increase in the employment rate.
This suggests that job losses may have been less severe in states where the population was more willing to risk contracting COVID-19 and participate in activities outside the home, such as retail shopping and restaurants.
One of the most controversial issues related to the COVID-19 pandemic, statewide school closures , did not appear to play a role in lower student test scores in most U.S. states. Instead, the study suggests that declines in fourth-grade math scores on the National Assessment of Educational Progress (NAEP) exam were linked to several policy mandates, including increased mask wearing and vaccine mandates for state employees. and schoolchildren.
"It is possible that in states that were more cautious about COVID-19 transmission, more parents chose remote education. Another possibility is that mask and vaccine mandates affected school attendance and closures in ways that our study did not. designed to measure," explains Bollyky. "Our immediate priority should be to help support the lowest-performing students to catch up and address gaps in U.S. educational achievement to address these social trade-offs."
Rebuild public trust with clear, transparent and timely communication
The authors emphasize that understanding the contexts in which infections and deaths were disproportionately clustered in this pandemic will be crucial in designing and targeting clinical and policy interventions to ensure better health outcomes in future crises. For example, policies such as paid sick and family leave and expanded insurance and Medicaid coverage would help lower-income people get vaccinated and get effective treatment. And states are investing in community-based organizations, such as local clinics or faith-based institutions, to continue to engage in ongoing public health promotion, build relationships with constituents, and encourage broader vaccine acceptance among partisan and marginalized groups.
"To rebuild trust in public health and the future response to the pandemic, we must improve transparency around political contexts and social, economic, and racial inequalities. "Our results suggest that US states that mitigated "These structural inequalities, implemented science-based measures, and mobilized the solidarity that exists in American society were able to match the best performing nations in the world."
Implications of all available evidence
Our analysis yields important insights for policymakers seeking to build a more resilient and realistic response to future pandemic threats. COVID-19 magnified the polarization and persistent social, economic, and racial inequalities that already existed in American society, but the next pandemic threat does not have to do the same. Recognizing the local contexts in which SARS-CoV-2 infections and COVID-19 deaths in the US have been disproportionately clustered in this pandemic allows policymakers to design and target clinical and policy interventions. to facilitate better health outcomes in future crises.
Improving pandemic preparedness and response in the US must begin with investing in disproportionately affected communities and their local organizations, such as local clinics or faith-based institutions, to engage in ongoing health promotion public and data collection, solicit feedback, and communicate with constituents about vaccines. and other public health interventions. Potential trade-offs in this pandemic warrant closer and more transparent research to better target such protective measures in future health crises and develop job retention schemes and educational policies in the US that can mitigate unintended social consequences. With those investments and others, more U.S. states will be able to match the world’s best-performing nations when the next pandemic emerges.
This study was funded by the Bill & Melinda Gates Foundation, J Stanton, T Gillespie, J and E Nordstrom, and Bloomberg Philanthropies. A complete list of authors and their institutions is available in the article.
