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Since summer, Mass. has had more deaths per capita than nearby states. Why?

Some of the COVID-19 dead were remembered in April at the Holyoke Soldiers’ Home, sight of the worst outbreak at a long-term-care facility in Massachusetts.
Some of the COVID-19 dead were remembered in April at the Holyoke Soldiers’ Home, sight of the worst outbreak at a long-term-care facility in Massachusetts.Barry Chin/Globe Staff/The Boston Globe

Months after COVID-19 began to ravage the Northeast, leaving thousands dead and countless communities in mourning, the disease began to loosen its deadly grip: Fatalities in the hardest-hit states declined sharply, and by the start of summer, it seemed that the region could let out a sigh of relief.

But while the death rates in other Northeastern states continued to decline rapidly throughout the summer, almost in lockstep, progress in Massachusetts slowed. In September, COVID-19 claimed 392 lives here — more than were reported in New York and New Jersey combined.

States count and report COVID-19 deaths differently, making direct comparisons difficult. But epidemiologists said the numbers paint a bleak picture of the pandemic’s hold on Massachusetts. As statistics suggest the virus is again on the rise, specialists appear at something of a loss to explain why the state’s death toll remains so stubbornly high.

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“I would think if anything, many of the hospitals in Massachusetts have learned how to better manage patients with COVID-19, and we should be seeing less mortality,” said Dr. David Hamer, an infectious disease expert at Boston University School of Public Health and physician at Boston Medical Center. “I just can’t easily explain why that figure in particular is much higher [than in nearby states].”

Other specialists shared Hamer’s surprise. The state’s world class hospitals, high rates of insurance coverage, and relatively low rates of COVID-19 transmission over the past few months all provide strong defenses. Some speculated that the heavy death toll at long-term-care facilities, where 270 of last month’s fatalities originated, could provide part of the explanation. Others pointed to quirks of timing, or random chance. But fundamentally, the relatively high loss of life here is difficult to explain when compared to New Jersey, Connecticut, and New York, nearby states that have followed otherwise similar paths through the pandemic.

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States' methods for counting and publicly reporting COVID-19 deaths vary, a point Massachusetts officials highlighted.

“While we are continuing to monitor our data, looking for trends over several weeks, it is important to note that states have varying policies for determining COVID-19 deaths, which can create discrepancies when comparing across different states like New York and New Jersey,” Tory Mazzola, a Massachusetts COVID-19 Command Center spokesperson, said by e-mail on Friday.

Generally, states follow national criteria that classify some COVID-related deaths as “confirmed” and others as “probable” — a designation that means some combination of a person’s symptoms, previous testing, exposure to the virus, or death certificate notes lead public health researchers to conclude that they likely died at least in part from COVID-19.

New York does not report probable COVID-19 deaths, while the other three states compared here do. However, Johns Hopkins University data used in the Globe’s analysis include probable cases reported by New York City, the region that accounts for the majority of that state’s cases and deaths. Additionally, deaths in confirmed cases account for more than 97 percent of Massachusetts' total reported deaths, and even accounting for potential discrepancies in reporting, the gap between deaths here and elsewhere in the region are stark.

Massachusetts — like New York, New Jersey, and Connecticut — saw reported cases peak in April, followed soon by peaks in daily death counts. The states also seemed to begin recovering from their deadly first waves at roughly the same time: Total deaths in the four states dropped 69 percent from June to July, according to data collected by Johns Hopkins and analyzed by the Globe.

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From there, though, Massachusetts made only halting progress while the other three raced ahead. Death rates in those states fell below 2 per 100,000 in August, and despite some fluctuation, remained low in September.

While September deaths in Massachusetts were down 60 percent from June, the death rate remained higher than in 26 other states, including several that experienced waves of infections and hospitalizations over the summer.

Comparing death rates across states can still be difficult for a number of reasons, said Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security. Even small differences in the timing of new cases or reporting methods can translate into larger, seemingly indecipherable disparities in deaths and death rates, she said.

“But in terms of predictors of deaths, it’s been pretty consistent. Age is probably the most important factor," Nuzzo said. "Generally speaking, if you’re noticing big trends, it’s probably due to the timing of when the cases started ticking up and how long it takes to get to the more vulnerable groups.”

When presented data showing Massachusetts’ death rate relative to other Northeastern states, several specialists speculated that one weakness in the state’s early pandemic response could still be hampering its efforts at recovery: Long-term-care facilities, home to the majority of Massachusetts residents who have died of COVID-19, remain vulnerable.

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“The numbers definitely seem concerning,” said Helen Jenkins, a Boston University epidemiologist. “My question would be, is Massachusetts still doing a poor job on the [long-term-care] front?"

Of the more than 9,000 probable and confirmed COVID-19 deaths Massachusetts has reported over the course of the pandemic, nearly two-thirds have emerged from long-term-care facilities. By comparison, about 40 percent of COVID-19 deaths nationally have been linked to such settings, although some states attribute deaths differently than Massachusetts does. New York, for example, does not link COVID-19 deaths to a nursing home if a resident dies in a hospital, rather than the nursing facility itself.

“The death rate per thousand in nursing homes in Massachusetts is out of whack, for lack of a better term, with the death rate in the broader [state] population,” said Alex Brill, a fellow at the American Enterprise Institute, a think tank based in Washington, D.C. Brill and fellow researcher Benedic Ippolito found that Massachusetts was one of just four states that had “particularly bad outcomes within nursing homes," a June report said. Connecticut and New Jersey also fell within this category, although they deviated less from the national norm.

A Globe Spotlight team investigation found that Massachusetts’ early pandemic response largely overlooked the needs of nursing homes and other long-term-care facilities, focusing instead on hospitals. State officials have since made moves to correct its early missteps, but advocates said they have further to go, with hundreds in elderly care facilities still dying of COVID-19 each month.

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“This isn’t over for elders,” said Al Norman, a longtime advocate for seniors. Norman said that elders he works with are afraid of entering group care settings but often feel they have nowhere else to go. “We’re not really doing right with older people right now in terms of providing them options,” he said.

“Count up every nursing home death, and that touches 10 or 11 staffers,” said Elizabeth Dugan, an associate professor of gerontology at the University of Massachusetts Boston. While COVID-19 concerns might have faded over the summer for many Massachusetts residents, a pervasive sense of grief and fear has lingered in long-term-care communities, she said.

“We have world-leading medical care, but there was no attention to elder care. We don’t think of nursing homes as part of the health care system,” she said. “We could have done better. We should have done better.”

Mazzola, a spokesman for the state’s COVID-19 Command Center, said “the Baker-Polito administration has taken substantial action since March to protect our most vulnerable seniors and continued action as necessary throughout this ongoing pandemic, including additional protections for older adults, standards of care and infection disease controls."

“COVID-positive cases in long-term care facilities have declined by about 97 percent and deaths by more than 90 percent since the height of the pandemic, and we continue to closely monitor the impact the virus has on these facilities.”

Mazzola also highlighted the state’s efforts at increasing public health enforcement and awareness in “persistently high-risk communities,” such as Chelsea, Everett, Lawrence, and Framingham.

But Jenkins, the BU epidemiologist, said there is at least one thing the state’s approach is lacking: time for officials to determine exactly where deaths are coming from and why, in recent weeks, case counts and other key indicators have been ticking up.

“A lot is in flux in Massachusetts at the moment,” Jenkins said. “This seems like it’s not a time to move ahead. It is a time to pause, to reflect.”


Dasia Moore can be reached at dasia.moore@globe.com. Follow her on Twitter @daijmoore.