Hawaii was one of the top-performing stats when it came to responding to the COVID-19 pandemic, according to study recently published in The Lancet.

Hawaii had the lowest death rate in the nation, at 147 per 100,000, when age and underlying illnesses were taken into account, four times less than states such as Arizona, which had the highest, at 581 per 100,000.

On the other hand, Hawaii did not fare so well when it came to employment and economic health, which tanked during the pandemic. Hawaii ranked second to last in gross domestic product, or GDP, and last in employment, with one of the highest rates of job loss.

The peer-reviewed study — dubbed the most comprehensive state-by-state analysis of the impacts of COVID- 19 across the United States — looked at publicly available data sources between Jan. 1, 2020, and July 31, 2022, and found the pandemic played out in vastly different ways across the nation.

It examined pandemic policies, plus the economic and educational trade-offs for each state, with the aim of seeing what worked and what could be improved.

“Hawaii was a top performer across many of the categories we looked at, which I think is part of why the death rate was able to be maintained at this low level,” said co-lead author Emma Castro, a researcher at the University of Washington’s Institute for Health Metrics and Evaluation.

Hawaii ranked second overall in trust, which researchers found to be an important factor in performance against COVID-19.

“The whole idea with trust was if you feel that your neighbors will do right by you, they’re more motivated to take those social behaviors to protect your peers in the same way,” she said.

Also, Hawaii was the biggest user of restrictions on gatherings, according to Castro, and had a mask mandate longer than most states, earning it a No. 6 ranking for a variable called “mandate propensity.”

That variable was based on a state’s use of mask mandates and physical distancing, as measured by stay-at-home orders; bar, restaurant, gym and school closures; and restrictions on gatherings.

Castro said the study found that states with higher mandate propensities tended to have lower coronavirus infection rates but also worse employment rates. Masks appeared to work in reducing infections, and Hawaii ranked No. 1 in mask use.

“We saw states with higher rates of mask use tended to have lower infection rates,” she said, “so we did see that masks were an effective tool in reducing the infection rate.”

Hawaii’s statewide mask mandate for indoor public spaces expired on March 25, 2022, along with the state’s emergency proclamation.

Hawaii, under the leadership of former Gov. David Ige, held out longer on the indoor mask mandate than other states and even after federal guidelines no longer required them in low- and medium-risk communities.

Higher mandate propensity, however, did not translate into lower death rates, and the authors attribute this to many other factors that affect death rates, such as poverty, vaccine uptake and access to high-quality health care.

Hawaii, New Hampshire and Maine had the lowest death rates per 100,000, while Arizona, the District of Columbia and New Mexico had the highest.

The numbers were adjusted to account for age and overall health of the state, according to Castro, since those who are older or have underlying conditions are at higher risk of dying from COVID-19.

“Our lowest performer was Arizona,” said Castro. “We see generally that states in the American Southwest like New Mexico, Colorado, Nevada and Arizona tended to struggle during the pandemic. I think a lot of that is related to poor access to health care in those states, higher rates of uninsured and especially high rates of uninsured among the Hispanic population in those states. We tend to think COVID was disproportionately clustered in those communities.”

There was also — with the exception of Hawaii — little correlation between higher mandate propensity and economic loss, which researchers measured using a combination of employment figures and state gross domestic product.

“Our results suggest that the local economy was neither hindered nor helped by the differences in the policy mandates that states adopted to reduce COVID- 19 deaths or slow the spread of SARS-CoV-2 infections,” said co-lead author Thomas Bollyky. “For example, maintaining mask mandates for longer did not translate, on average, into a state experiencing a greater reduction in GDP than its less restrictive neighbours.”

INCREASED MASK use, however, was associated with higher unemployment rates, indicating there may have been less severe job losses in states where people were more willing to shop and dine out.

Researchers found that Hawaii, New York and Washington, D.C., had the largest reduction in employment and that Hawaii, Wyoming and New Mexico fared worst economically.

But Hawaii’s educational test scores appeared to suffer less than other states, even though public schools here moved to remote learning. Hawaii’s average fourth grade math scores declined two points between the fall of 2019 and fall of 2022, earning it a No. 5 ranking.

The study also took political affiliations into account, said Castro, because they could not be ignored as a factor in pandemic response.

“So the paper itself is nonpartisan,” she said, “but we felt it was really important to look at political party, because all of the tools that governments were using to stem the spread of COVID became very politically charged. Even at the individual level, behavioral decisions like masks and vaccines became very politicized.”

The political affiliation of the governor of the state did not appear to have any association with outcomes, the study found. Five of the 10 states with the lowest death rates were Republican-­led, while the other five were led by Democratic governors.

But states with a higher proportion of the population that voted for former President Donald Trump, a Republican, in 2020 tended to have worst outcomes.

AND WHILE Hawaii performed well out of all the states, the nation itself did not perform well overall against COVID-19.

Despite having the largest economy and spending more on health care than any other country, the United States reported one of the highest per-capita COVID-19 fatality rates globally.

“Even after accounting for age and underlying illnesses, we observed a nearly four-fold difference in COVID-19 death rates across states, suggesting that the country as a whole could have performed much better,” Castro said separately in a news release. “Examining how specific states fared and identifying commonalities of states that performed well offers important insights about how we can and must respond better to this and future pandemic threats.”

Health officials and leaders need to reestablish public trust and offer clear, transparent and timely communication.

“Critically important is promoting trust in the population among peers, and that’s very tractable, something that we can work on immediately,” she said. “We ought to prioritize clear communication about what works and what didn’t work, what those trade-offs are so that we have an environment that is receptive to interventions.”

Addressing social, racial and economic disparities is also critically important in the long run.

The study was funded by the Bill & Melinda Gates Foundation, J. Stanton, T. Gillespie, J. and E. Nordstrom, and Bloomberg Philanthropies.

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Where Hawaii ranked in its COVID-19 pandemic response

Best

>> No. 1 in COVID-19 deaths (lowest, at 147 per 100,000)

>> No. 1 in mask use

>> No. 2 in trust

>> No. 6 in mandate propensity

>> No. 10 in vaccine uptake

Worst

>> No. 50 in GDP

>> No. 51 in employment

Note: First is best, 51st is worse.

Source: Institute for Health Metrics and Evaluation