Arizona had the highest COVID-19 death rate in U.S.

Arizona experienced the highest adjusted death rate in the United States during the COVID-19 pandemic, according to an analysis published in The Lancet.

What they found: Arizona's COVID death rate was 581 deaths per 100,000 people, when adjusting the data to account for age and comorbidities. The District of Columbia (526 per 100,000) and New Mexico (521 per 100,000) were the second and third worst.

• Meanwhile, Hawaii had the lowest adjusted rate with 147 COVID deaths per 100,000 people, followed by New Hampshire (215 per 100,000) and Maine (281 per 100,000), respectively.

The intrigue: Arizona's COVID-19 death rate was about the same as the world's hardest hit countries — Russia, Bulgaria and Peru — per the report.

Why it matters: The new report is among the first explorations of the social and economic factors at play during the pandemic in the U.S., and it found a nearly four-fold variation in COVID infection and death rates between states, Axios' Tina Reed reports.

State of play: States with higher poverty, lower rates of educational attainment, less access to quality health care and lower levels of interpersonal trust saw disproportionately higher rates of COVID infections and deaths.

• The report also found high vaccination rates were linked to fewer deaths.

What they're saying: Former Arizona Department of Health Services director Will Humble, who was critical of former Gov. Doug Ducey's pandemic response, told Axios Phoenix the new analysis provides compelling evidence that Arizona should have pushed residents to get vaccinated through incentives or employment requirements.

• Instead, Ducey issued executive orders prohibiting vaccine mandates.

The big picture: Previous studies connected state politics with better or worse COVID outcomes or honed in on racial disparity linked to poorer outcomes. But this study offers a more nuanced view of how the combination of factors made certain states more vulnerable than others.

• For example, the analysis found no association between the political affiliation of the state governor and death rates. But one key predictor of infections and total COVID deaths was the share of people who voted for President Trump in the 2020 presidential election.

Between the lines: The analysis found that states with mandates encouraging mask use, mobility restriction and vaccination — and mandates kept in place longer — experienced lower infection rates.

• But, they said, only vaccine coverage had a strong association with state-by-state variation in COVID death rates.
• "Ultimately our public health policies seem capable of preventing transmission, but other societal factors like poverty, education attainment, and access to high-quality healthcare might have muddled the response and led to death rates being highest in some states that didn't have tremendously high infection rates," the authors wrote.