Not One Pandemic: A Multilevel Mixture Model Investigation of the Relationship Between Poverty and the Course of the COVID-19 Pandemic Death Rate in the United States.

The COVID-19 pandemic, which began in China in late 2019, and subsequently spread across the world during the first several months of 2020, has had a dramatic impact on all facets of life. At the same time, it has not manifested in the same way in every nation. Some countries experienced a large initial spike in cases and deaths, followed by a rapid decline, whereas others had relatively low rates of both outcomes throughout the first half of 2020. The United States experienced a unique pattern of the virus, with a large initial spike, followed by a moderate decline in cases, followed by second and then third spikes. In addition, research has shown that in the United States the severity of the pandemic has been associated with poverty and access to health care services. This study was designed to examine whether the course of the pandemic has been uniform across America, and if not how it differed, particularly with respect to poverty. Results of a random intercept multilevel mixture model revealed that the pandemic followed four distinct paths in the country. The least ethnically diverse (85.1% white population) and most rural (82.8% rural residents) counties had the lowest death rates (0.06/1000) and the weakest link between deaths due to COVID-19 and poverty (b = 0.03). In contrast, counties with the highest proportion of urban residents (100%), greatest ethnic diversity (48.2% nonwhite), and highest population density (751.4 people per square mile) had the highest COVID-19 death rates (0.33/1000), and strongest relationship between the COVID-19 death rate and poverty (b = 46.21). Given these findings, American policy makers need to consider developing responses to future pandemics that account for local characteristics. These responses must take special account of pandemic responses among people of color, who suffered the highest death rates in the nation.