Improving American Health, One State at a Time.

If we considered them as separate countries, the per capita COVID-19 cases in North Dakota would make the state one of the two countries in the world with the highest number of COVID-19 cases;by contrast, Hawaii's case rate positions it in the range of about 85th on the global list of countries with COVID-19.2 These differences will, and undoubtedly should, occasion substantial consideration of the factors, both preexisting and concurrent with the pandemic, that brought about these differences. HEALTH HETEROGENEITY By way of example, in a review of trends in the US burden of disease across states between 1990 and 2016, Mokdad et al. found, consistent with previous analyses, substantial variability across states in a range of health indicators.3 There was a 6.6-year difference in life expectancy at birth in 2016 between the state with the highest (Hawaii) versus the lowest (Mississippi) life expectancy. [...]focusing on five leading causes of death, the Centers for Disease Control and Prevention showed that improving all states to the levels of the healthiest states could annually prevent more than 90 000 cases of premature heart disease, 84000 cases of cancer, 28000 cases of chronic lower respiratory disease, 16 000 cases of stroke, and 36000 cases of unintentional injury deaths.6 A concrete example of how interstate variability in the forces that generate health operate is offered in the article by Baugher et al. in the April issue of AJPH.7 The authors focused on the HIV epidemic and on the factors that may be associated with reduced uptake of preexposure prophylaxis, which can protect against HIV.