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Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis [1]

['Thomas J Bollyky', 'Council On Foreign Relations', 'Washington', 'Dc', 'Emma Castro', 'Institute For Health Metrics', 'Evaluation', 'University Of Washington', 'Seattle', 'Wa']

Date: 2023-04

Evidence before this study

The USA has captured researchers' attention for its suboptimal response to the COVID-19 pandemic. Despite having ranked the highest in pandemic preparedness out of 195 countries in the Global Health Security Index and scoring very well in WHO's Joint External Evaluation, the USA maintains the highest number of recorded COVID-19 deaths and has one of the highest per capita fatality rates from COVID-19 globally. However, the pandemic did not affect all US states equally. Between June 1, 2022 and Feb 14, 2023, we searched for published articles in Web of Science, Scopus, and PubMed using the terms “state,” “county,” “COVID-19,” and “United States”. We identified several studies that have sought to answer policy questions to help explain differences in individual states' performance during the COVID-19 pandemic, but a broad assessment of these questions and the mechanisms behind cross-state variation in SARS-CoV-2 infections and COVID-19 mortality has yet to be done. Some studies have highlighted the role of partisanship in the adoption of responsive policies such as physical distancing, mask use, and vaccine mandates, while others have examined links between racial, social, and economic inequities and state differences in COVID-19 outcomes. Many of these studies assess only a subset of US states or brief periods, do not adjust for factors outside of policy makers' immediate control (eg, age or population density), and fall short of explaining whether better COVID-19-related outcomes offset the economic, educational, and employment losses associated with these mandates.

Added value of this study

We analysed government policy responses and population behaviours in each US state to assess their associations with cumulative SARS-CoV-2 infections, total COVID-19 deaths, and economic and educational performance measures. We controlled for factors with known direct and biological connection to SARS-CoV-2 infection and COVID-19 death rates: age patterns, population density, and comorbidities such as obesity and diabetes. This study adds to the existing literature by conducting these analyses on all 50 US states and Washington, DC, and over a long study period—Jan 1, 2020, to July 31, 2022—to answer fundamental policy questions about US interstate variation in COVID-19 outcomes. The cross-state differences in COVID-19 infection and mortality rates suggest that the USA had the capacity to perform better than observed. There were a number of key policy-relevant findings. First, a subset of social and economic inequities were statistically associated with more SARS-CoV-2 infections and worse COVID-19 mortality rates, most notably poverty, lower educational attainment, higher rates of key comorbidities, limited access to quality health-care services, and lower interpersonal trust. This cluster of traits exists in states with large racial disparities and where most voters voted for the 2020 Republican presidential candidate. Second, access to quality health care was associated, on average, with fewer total COVID-19 deaths and SARS-CoV-2 infections, but higher public health spending and more public health personnel per capita were not associated with infection or death rates, at least not at the state level. Third, there was no association between the political affiliation of the state governor and lower SARS-CoV-2 infections or COVID-19 deaths, but there was an association between worse COVID-19 outcomes and the fraction of a state's voters who voted for the 2020 Republican presidential candidate. Fourth, our results suggest that vaccine coverage is linked to fewer COVID-19 deaths, and protective mandates and behaviours were associated with fewer infections. Fifth, we found no evidence of a choice between a state having a relatively strong economy or better COVID-19 health outcomes, but there were trade-offs with better employment rates. Moreover, several policy mandates were associated with lower fourth-grade mathematics test scores.

Implications of all the available evidence

Our analysis yields important insights for policy makers seeking to construct a more resilient and realistic response to future pandemic threats. COVID-19 magnified the polarisation and persistent social, economic, and racial inequities that already existed across US society, but the next pandemic threat need not do the same. Recognising the local contexts in which SARS-CoV-2 infections and COVID-19 deaths in the USA have disproportionately clustered in this pandemic enables policy makers to design and target clinical and policy interventions towards facilitating better health outcomes in future crises. Improving US pandemic preparedness and response should start with investing in those disproportionately affected communities and their local organisations, such as local clinics or faith-based institutions, to engage in ongoing public health promotion and data collection, solicit feedback, and communicate with constituents about vaccines and other public health interventions. The potential trade-offs in this pandemic warrant closer, transparent investigation so as to better target such protective measures in future health crises and to develop US job retention schemes and educational policies that can mitigate against unwelcome societal consequences. With those investments and others, more US states will be able to match the best-performing nations globally when the next pandemic arises.

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[1] Url: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00461-0/fulltext

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