The United States has one of the world's highest rates of COVID deaths per million despite massive spending, several phases of lockdowns, mask mandates, and a moonshot initiative to develop vaccines.

Confirmed deaths per million in the U.S. have hit roughly 2,470 on Wednesday since March 2020, ranking 22nd in the world for highest death totals. By comparison, Australia, which has had aggressive lockdowns, tightly sealed borders, and a 91% vaccination rate among adults, has seen just 86 deaths per million.

Experts say numerous factors go into the bottom-line results of each country's COVID response, but most cite early efforts, vaccination rates, and buy-in for safety measures. The dismal effort in the U.S. got off to a terrible start, according to Dr. Amesh Adalja, senior scholar at the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health.

“The first 100,000 [deaths in the U.S.] were probably not stoppable," Adalja said. "And after that, I think there was clearly bungling."

That bungling included New York, New Jersey, Pennsylvania, and other states putting infected senior citizens in nursing homes where the virus spread like wildfire to the most vulnerable people.

"We knew that elderly people were hyper-susceptible to COVID-19," Adalja said. "But we let nursing homes get overrun.”

The countries worse off than the U.S. include Peru, Bulgaria, Croatia, and Brazil, according to tracking maintained by Our World in Data from the University of Oxford.

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Now, the deaths due to COVID-19 are largely preventable thanks to highly effective vaccines, yet roughly 34% of those eligible have not gotten the shots.

“What's happening now is COVID has become a vaccine-preventable death. And it so happens that in many parts of the country, there are too many high-risk people that are not vaccinated, and that's what's driving deaths,” Adalja said.

Meanwhile, several other countries’ relatively low total deaths per million reflect high vaccine uptake, as well as stringent rounds of lockdowns and restrictions on movement that are not dissimilar from those in the U.S.

Denmark, for instance, has had about 558 deaths per million since March 2020.

A Danish COVID-19 behavior analysis from the Washington Post found that people’s high trust in public health officials helped the country reach high vaccination levels this year. More than 90% of Danes trust in their public health system to give honest takes on the state of the pandemic and are willing to go along with the government’s strategy to paint regular testing as a moral obligation. Danes were also compliant with restrictions from early on, positioning the country to lift those restrictions without doing an about-face.

Vaccines were also widely accepted in Denmark, with nearly 82% of people 5 and older receiving at least one dose of the COVID-19 vaccine.

To date, about 66% of Americans 5 and older have been fully vaccinated and roughly one-third of adults have gotten booster shots, according to federal data.

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The U.S. has endured several COVID-19 waves since the onset of the pandemic nearly two years ago. During the first two surges in the first half of 2020, the U.S. underwent phases of lockdown and masking mandates that varied based on the state. Much of 2020 was marked by sweeping business closures and restrictions on gatherings. While several states maintained indoor masking rules and limits on gathering sizes into the late spring of 2021, other states such as Texas nixed all remaining mitigation measures far earlier in March of this year.

By fall 2020, when social distancing measures had been relatively relaxed, a wave of new severe cases engulfed the midwest, rippling outward to affect the South and both coasts. Only a couple of months later did vaccines from Pfizer-BioNTech and Moderna become available in record time due to the Trump administration’s vaccine and treatment development initiative, Operation Warp Speed. Still, deaths kept climbing and reached a peak of more than 3,300 per day in early January.

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The advent of vaccinations in 2021, on top of existing mask and social distancing mandates in much of the country, was credited with flattening case and death curves by late spring. But the delta variant stymied progress toward the diminution of cases.

The delta outbreak reached its apex in late summer this year, with most southern states hitting record cases or deaths. Effects of the delta variant were especially severe in pockets of low vaccination coverage. Hospitals in the Northeast and Midwest are still reeling from the delta wave, which continues to circulate fastest in communities with relatively low vaccination rates.