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Why is Maryland’s COVID death rate so much higher than California’s? | COMMENTARY

People exercise at the Rose Bowl community recreation loop reopened to the public after coronavirus closure in Pasadena, Calif., May. 13. Los Angeles County reopened its beaches Wednesday in the latest cautious easing of coronavirus restrictions that have closed most California public spaces and businesses for nearly two months. The move comes as California tentatively eases some stay-at-home restrictions.
People exercise at the Rose Bowl community recreation loop reopened to the public after coronavirus closure in Pasadena, Calif., May. 13. Los Angeles County reopened its beaches Wednesday in the latest cautious easing of coronavirus restrictions that have closed most California public spaces and businesses for nearly two months. The move comes as California tentatively eases some stay-at-home restrictions.(Damian Dovarganes/AP)

The governors of Maryland and California took similarly aggressive actions to deal with the coronavirus pandemic. They are now taking similarly methodical steps to gradually open their states by lifting or modifying some of the restrictions they put in place to stop the spread of the disease.

But Maryland and California are not comparable when it comes to outcomes from those efforts. Not by a lot.

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As of midweek, Maryland’s death rate from the disease was four times that of California’s. California has more than six times the population of Maryland, but has reported only about twice as many cases of coronavirus.

What’s the difference? Why would Californians fare better, in terms of infections and death per capita, than people in Maryland?

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I saw the question raised in social media by someone less than impressed by Maryland Gov. Larry Hogan’s response to the greatest public health threat of our lifetimes, suggesting that California’s governor, Gavin Newsom, had been more effective overall.

But I don’t know that respective gubernatorial actions entirely explain the difference in outcomes. I reviewed timelines and found that both governors did many of the same things in early March — issuing executive orders, coordinating responses among government agencies and announcing states of emergency.

There was, however, a difference in timing of stay-at-home orders: Newsom issued his on March 19, Hogan on March 30. That could explain some of the contrast in results.

But let’s leave the governors aside for the moment.

My reason for tunneling into this subject is to better understand how epidemiologists study health patterns, what they look at when they track a disease and how they might compare one part of the country, or one state, to another.

Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, was willing to help. She suggested a number of factors to consider and agreed with some that I threw into the mix. We’ll start with the obvious: Population and demographics, according to the U.S. Census Bureau.

California has more than 39 million residents, according to the most recent census, while Maryland has just over 6 million.

California’s median age (36.1 years) makes it younger than Maryland (38.6), but both states have almost exactly the same percentages of people over 65, an age category considered particularly vulnerable to the virus.

About 72% of Californians are white,; Maryland’s population is 58% white. Thirty-nine percent of Californians are Hispanic, and that’s four times Maryland’s Hispanic population. African Americans, who have suffered disproportionately in the pandemic, make up 6.5% of California’s population, but 30% of Maryland’s. That, says Nuzzo, would be an important factor in looking at outcomes.

“Another thing we’d look at is [population] density,” she says.

According to census data, California has 239 residents per square mile while Maryland has 594. That’s a huge difference, and a fact that probably does not surprise anyone who’s watched sprawl development throughout the central part of Maryland over the last 30 years.

So, while California is a giant state with more cities than Maryland, the statistical density difference could account for why we have a higher rate of coronavirus infection.

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According to the sources I used — primarily, the Centers for Disease Control and Prevention, but also other statistical aggregators — California has a case rate of 174 per capita (per 100,000 of population) while Maryland’s case rate stands at 567. As of Wednesday, when I examined data, Maryland had four times the death rate (29.2 per capita) as California (7.1 per capita).

“When we look at density,” says Nuzzo, “we have to look at commonality of exposure, community transmission. It’s the reason New York got hit so hard, with greater population density. But also the commonality of exposure, people using common spaces, like subways. When you look at California, you’re looking at cities that are car-dependent, right?”

That’s something I hadn’t thought of: The amount of mass transit on the East Coast, including Baltimore, compared to California. People traveling in automobiles are simply not as vulnerable as people standing shoulder-to-shoulder in subway cars or sitting side-by-side on buses.

Next up: The prevalence of underlying health conditions that heighten the risk of death. California has an edge over Maryland in this category, too.

Using primarily CDC data, I compared the states in seven categories — statewide rates of chronic obstructive pulmonary disease (COPD), asthma, cancer, high blood pressure, heart disease, obesity and diabetes. In all but one category, California came out ahead. (Both states have about the same prevalence of heart disease.)

Another factor: Nursing homes have been widely reported as hot spots for the disease in Maryland and other states. On Wednesday, the state reported that nearly 1,000 people in Maryland nursing facilities, assisted living centers and retirement communities had died from COVID-19. That’s nearly 60% of the state’s death toll. In California, about half of the state’s reported deaths from COVID-19 have occurred in nursing facilities, but, according to published reports, health experts suspect an undercount and expect the number to grow.

At Johns Hopkins, Nuzzo has been looking at testing, critical to calculating the overall threat the novel virus poses in any population. This is an area where California has a significant edge over Maryland.

The World Health Organization says countries that have done extensive testing for the virus recorded positive results in the three-to-12% range. If positivity runs higher than that, it could mean that health professionals are primarily testing the sickest patients and missing people with milder symptoms or none at all.

According to daily tracking by Hopkins, Maryland’s average rate of positive tests was 21% over the past week — five times as high as California’s.

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What does that suggest to Nuzzo?

“This suggests we [in Maryland] aren’t testing enough,” she says, “and that many infected people are going undiagnosed and remain able to transmit if they aren’t being isolated.”

As the governor lifts his stay-at-home order, that sounds ominous.

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