The United States has lost more than 1.1 million people to COVID-19, but Maryland’s health decisions during the pandemic helped keep deaths in the state at a national low.

Maryland had the fifth fewest deaths in the country per 100,000 residents, with 285 people per 100,000 succumbing to the disease, according to a new study published in the medical journal The Lancet.

By contrast, states like Mississippi and Arizona saw nearly double the rate of deaths.

“Our results show that SARS-CoV-2 infections and COVID-19 deaths disproportionately clustered in states with lower mean years of education, higher poverty rates, limited access to quality health care, and less interpersonal trust,” the study states.

Dr. David Marcozzi, the chief clinical officer at the University of Maryland Medical Center, said Maryland’s evolving strategy paired with an effort to care for disenfranchised populations helped keep the death rates down.

“When we knew more about the disease we pivoted and we provided guidance to ensure our citizens were protected, that folks knew how to get masks and when to wear masks, that folks had countermeasures like monoclonals or Paxlovid,” Marcozzi said.

Paxlovid is an antiviral drug that reduces the risk of hospitalization and death from COVID.

Maryland also adapted its resources by turning facilities into extra bed areas for hospitals and then changing those buildings into vaccination centers and clinics when needed.

Marcozzi said Maryland’s policies can help the future of disease response.

“The gauntlet of leadership depends on learning from where we failed, and getting better the next time,” he said. “A paper like this, published in The Lancet, helps shape that behavior.”

The federal government is ending the national emergency on COVID in May. There are, however, still nearly 300 people dying per day from the disease.

Maryland and the city ofBaltimore will continue some services that will sunset under that decree like vaccinations and free tests.