Not all of the reported global inequalities in COVID-19 results may be attributed to differences in the distribution of individual-level clinical risk factors between regions. Researchers set out to investigate the connections between environmental and social factors and country-level variations in COVID-19-attributed mortality among rheumatic illness patients worldwide. From the COVID-19 Global Rheumatology Alliance (GRA) registry extracted individual-level data on persons (aged 18-99 years) with rheumatic disease and a confirmed status of their highest COVID-19 severity level between March 12, 2020, and August 27, 2021, for this observational study. All data on the environment and society was collected from open sources. Mortality due to COVID-19 was the major outcome measure. After accounting for individual-level risk factors, scientists utilized multivariable logistic regression to assess the independent correlations between environmental and societal factors and mortality. To determine if differences in death rates between countries could be adequately explained by environmental and social factors, they employed a series of nested mixed-effects models. Investigators analyzed data from 14,042 patients in 23 countries. The average age was 54.4 years (standard deviation: 15.6), with 72.5% of the population being female and 27.5% being male. Air pollution (odds ratio 1.10 per 10 μg/m3 [95% CI 1.01–1.17]; P=0·0105), proportion of the population aged 65 years or older (1.19 per 1% increase [1.10–1.30]; P<0·0001), and population mobility (1.03 per 1% increase in number of visits to grocery and pharmacy stores [1.02–1.05]; P<0·0001 and 1.02 per 1% increase in number of visits to workplaces [1.00–1.03]; P=0·032) were independently associated with higher odds of mortality.  Increases in hospital beds (0.94 per 1-unit increase per 1,000 people [0.88-1.00]; P=0.046), human development index (0.65 per 01-unit increase [0.44-0.96]; P=0.032), government response stringency (0.83 per 10-unit increase in containment index [0.74-0.93]; P=0.0018), and follow-up time (0.78 per month [0.69-0.88]; P<0.000 The intraclass correlation coefficient was 12% (0.1-9.5; P=0,14), indicating that these factors adequately explained cross-national differences in deaths attributed to COVID-19. In view of the observed regional variations in COVID-19 outcomes among people with rheumatic disease, these findings highlighted the importance of environmental and societal factors as potential reasons and established the framework for a new research agenda to address these inequalities.