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Why the COVID-19 death rate varies dramatically across the U.S.

MILES PARKS, HOST:

So Hawaii and New Hampshire - two states that don't have much in common. But according to a new study just published in the medical journal The Lancet, they had the lowest standardized death rates from COVID-19 in the U.S. The places hit hardest - Arizona and Washington, D.C., where death rates were roughly four times higher. Researchers looked into why, and they hope the answers might inform future public health decisions. Thomas Bollyky joins us now. He co-authored the study and directs the Global Health Program at the Council on Foreign Relations. Hi, Thomas.

THOMAS BOLLYKY: Hi. Thanks so much for having me.

PARKS: Thanks for being here. So was there any rhyme or reason as to why individual states were hit harder than others? My initial thought goes to vaccination rates, but tell me what you learned.

BOLLYKY: So it is remarkable, to begin with, just the difference between states. We control for all the obvious relevant biological factors in this comparison. So we look at the differences in the age of a state population - think Florida - or high levels or high rates of preexisting health conditions. And even when you do that apples-to-apples comparison, you have that fourfold spread. And that's not tied to any biological factors. It's tied to something else. And what we found are there are several reasons why states struggled in this pandemic. One, I'm sorry to report, is a very American set of factors, which is a toxic combination of racial disparities and politics - high levels of poverty, low levels of education and low access to quality health care. And you see that really, in particular, in states with a large population that identifies as Black Americans in the last census and states that went very strongly for the former president, the Republican candidate, in 2020.

PARKS: Wow. So there is a clear political angle here. Can you break that down a little bit more? How did you see this connection between people who voted in 2020 for former President Trump and how that played out in the COVID results?

BOLLYKY: Well, it's important to acknowledge, first, that this is about politics, not party. You don't see any affiliation between the party affiliation of the - a state governor and its COVID death rates. In our top 10, half of the states in that top 10 are Republican-led states. Half of them were Democrat states. But you do see this strong association with the degree to which states went for the former president in the 2020 election.

PARKS: And what about trust? I mean, the former president also was criticized a lot early in the pandemic for his role in politicizing some of America's public health institutions.

BOLLYKY: So some of the most fascinating results in this study are around trust because your expectation might be what really drove differences in this pandemic are the trust we have in government or the trust we have in science. But our study does not show that. In fact, most global studies also don't show that. It is really what's referred to as interpersonal trust - the trust we have in one another, how we feel about each other. That seems to have had a large effect on whether or not you were able to mobilize the solidarity to convince people to voluntarily take the measures to protect themselves and others in their community. It really seems to be tied to whether or not we believe others are also doing the right thing and that we're not somehow being taken advantage of in these health policies. That seems to have been a big driver.

PARKS: Can you talk about what we learned about mitigation measures - masks, vaccines? How well did those things work?

BOLLYKY: So mandates worked in this pandemic. The package of mandates that states used, including on masks, were generally associated with fewer infections. And vaccine mandates and vaccine coverage rates had a very large effect on deaths. However, it is important to acknowledge that there were trade-offs between particular mandates and employment. So most notably, restaurant closures had an effect on employment in our study, and many mandates had an effect on educational performance, particularly around math. And this is important to acknowledge because if we're going to rebuild trust in public health response, we also need to talk about what didn't go quite as well.

PARKS: OK. So let's look ahead to the future here for a second. What are the key lessons here for the next public health emergency?

BOLLYKY: Well, the good news is that this study really should be reason for hope. The large variation between states shows that there are some U.S. states that performed as well as any country in the world. And if we can address these specific factors, community-specific factors, that drove those states that struggled in this pandemic - if we can address those ahead of the next health crisis, they may get a little closer to doing as well. Really, these results show that the pandemic is about place. And we need to take those community-specific lessons and lift those poorly performing states so that the U.S. can do as well as some of some states have shown we're capable of in the next crisis.

PARKS: Thomas Bollyky is director of the Global Health Program at the Council on Foreign Relations. Thank you so much.

BOLLYKY: My great pleasure. Thank you so much for having me. Transcript provided by NPR, Copyright NPR.

Miles Parks is a reporter on NPR's Washington Desk. He covers voting and elections, and also reports on breaking news.