A man leaves an Ontario cemetery in May 2020. A new report claims the number of Canadians who died of COVID-19 could be twice as high as reported.

COVID 19 deaths could be twice as high as reported

By Moira Wyton, The Tyee, Local Journalism Initiative Reporter

The number of Canadians who died of COVID-19 could be twice as high as reported, according to a new preliminary report.

6,000 unattributed COVID 19 deaths

At least 6,000 COVID deaths  in the community before last November likely weren’t attributed to the  virus, meaning about two-thirds of deaths outside long-term care and  hospital settings were missed, the peer-reviewed report estimates.

And if unattributed COVID-19 deaths  continued at the same pace since November, Canada’s pandemic death toll  could be closer to 52,000 people, double the 26,000 plus deaths recorded  so far.

The peer-reviewed report from the Royal  Society of Canada indicates that Canada fared much worse in the pandemic  than previously thought, even before the disastrous second and third  waves set in.

Poor cause-of-death data  and limited access to testing for isolated seniors and their caregivers  and low-income and racialized communities likely meant many deaths were  not recognized or recorded as COVID-19, particularly in the early days  of the pandemic, the report said.

Was BC’s death rate extraordinary?

And while British Columbia  touted its successful handling of the pandemic, with a per-capita death  rate that was 15 per cent lower than the national average during the  first wave, the new report estimates that nearly four times as many  people over 45 died of COVID-19 before December than previously  reported.

That means that while B.C. had reported 435 deaths before November, the death toll could have been over 1,700.

B.C. has officially recorded 1,749 deaths  due to COVID-19, an outcome Premier John Horgan called “extraordinary”  on Tuesday in light of higher mortality rates in other Canadian  jurisdictions.

But infectious diseases expert and report  co-author Dr. Tara Moriarty told The Tyee the province’s actual per  capita mortality rate is likely closer to the Canadian average.

“B.C. definitely did quite a bit worse than the perception,” said Moriarty. 

Bonnie Henry does not agree

When asked about the report, which also  found that data reporting issues in B.C. are “particularly acute,”  provincial health officer Dr. Bonnie Henry said it should be taken “with  a grain of salt.”

“I don’t agree with what that report has  come out with. I think there are variations, that they have made  assumptions between what happened in Ontario, for example, and what  happened here,” Henry said Tuesday. “Undoubtedly, there are some deaths  that we missed early on. It’s just a function of the testing capacity.”

In response to Henry’s comments, Moriarty  said data and trends from Ontario weren’t used to make assumptions about  what happened in B.C., and that limited up-to-date cause of death data  in the province makes it difficult to assess how many COVID-19 deaths  may have been misattributed to other causes.

What the report surveyed

The report surveyed excess death reports  from across Canada, trends in reported pandemic deaths, cremation data  to track increasing at-home death numbers and antibody surveillance  testing to estimate missed infections and deaths in the community.

It aimed to pinpoint the number of direct  COVID-19 deaths. It excluded deaths related to the surge in toxic drugs  and those caused by pandemic prevention measures that closed services by  using age-adjusted mortality data from the last several years.

The report’s estimate of thousands more  community deaths would mean that deaths in long-term care likely  accounted for 45 per cent of deaths, not 80 per cent as previously  thought, bringing Canada closer in line with other OECD countries.

Underreported deaths

Deaths in long-term care  are likely still underreported, but not nearly as much as deaths in the  community, where events and symptoms leading to death are not as closely  monitored, particularly for isolated seniors, said co-author and  geriatrician Dr. Janet McElhaney.

Many of the uncounted deaths were likely  adults over 45 living in dense, low-income and racialized  neighbourhoods, the report found, and they were likely obscured and  missed by poor death reporting practices, difficult access to testing  and atypical or hard to recognize COVID-19 symptoms. 

Limiting tests to health-care workers or  close contacts of known cases, as B.C. did in its early days, meant that  many deaths went uncounted in the pandemic’s toll, the report found.  Many people may have feared the exposure risk of going to get tested or  not recognized their symptoms as COVID-19 and died before being  diagnosed with the disease.

Canada’s per capita testing rate for COVID-19 is about 75 per cent less than other comparable countries.

Older people are also more likely to  present atypical or asymptomatic COVID-19. For example, a  community-based senior in their 80s may have had nausea and fatigue, not  recognized it as COVID-19, and not been tested before their death,  which makes it more likely to be classified as a natural death.

“B.C. death reporting really lags behind  the pandemic, in terms of recognizing and reporting that these deaths  were happening,” said McElhaney, noting all-cause death data in B.C. is  up to date only until February 2020.

Province working with Coroners Service

The province has worked with the BC  Coroners Service to ensure all sudden and unexpected deaths in the  community are tested for COVID-19, Henry said, and has reported on  mortality data during the pandemic as well.

“The vast majority of deaths that we saw  were related to COVID in older age groups and related to the overdose  crisis in younger age groups,” she added. 

There is also evidence that some sudden  deaths in the community were due to people not seeking care for acute  and chronic health conditions due to fear of the virus, Henry noted.  “This is absolutely something that we are continuing to monitor and  change and to try and understand.”

Quebec tested all deaths for COVID-19 infection.

‘Systemic ignorance’

The report suggests that approximately 80  per cent of estimated excess deaths occurred either weeks before or  between major spikes in reported cases, particularly during summer 2020.

This information, just like missing disaggregated race-based data,  would have been crucial to understanding where and how the virus was  spreading, and how to protect communities early on in the pandemic’s  course.

“We missed, actually, the fact that this  pandemic was on us, the second wave was here earlier, and the chance to  start developing measures where we can see what the impact is of the  pandemic before we started to see more deaths in long-term care,” said  McElhaney.

Deaths in minoritized communities

Similar to poor death reporting, a lack of  disaggregated race-based data for COVID-19 cases and deaths means B.C.  and many other Canadian jurisdictions didn’t have a handle on the  pandemic’s trajectory after decades of ignoring and underfunding  racialized communities.

“It speaks to our systemic ignorance,” said  study co-author Eemaan Kaur Thind. “We’re likely missing so many  deaths, especially in minoritized communities.”

The effects of systematic racism mean that a  disproportionate number of racialized people are low-income, work in  frontline, minimum wage jobs,and often face language and financial  barriers to health care that leave them with chronic health issues, said  Thind.

This means racialized people are both more  likely to contract the virus at work or in their communities and are  also at higher risk of serious illness and death.

Deaths due to COVID-19 were on average twice as high  per capita in neighbourhoods where there is a large proportion of  visible minorities, according to a previous study. In B.C., that rate  was more than 11 times as high.

“It’s not that having higher melanin in  your skin means you’re more likely to get sick or die from COVID-19,”  said Thind. “It’s basically systemic racism and other social  determinants of health at play.” 

Listening to communities to understand what  they need is essential, Thind said, but the public health system should  not need the people bearing the brunt of the pandemic to advocate in  order to protect them.

But the fact the Canadian health system  runs on advocacy is nothing new, Moriarty said, and needs to be reformed  to prevent a future pandemic wreaking the same devastation again.

“It’s almost coming to light too late,”  said Moriarty. “We need every province reporting those deaths in a  timely manner, we need to know if deaths are abnormally high, and if so,  why?”

There are likely many more people, particularly seniors in the community, whose function and qualities of life have declined. 

“All these people died, but there are a  whole bunch of people who we missed who are that much closer to not  being able to be independent in the community,” said McElhaney.

Overhaul Canada’s  death-reporting system

The report recommends overhauling Canada’s  death-reporting system to report preliminary death rates weekly and  monthly, adopting the United States’ Centers for Disease Control’s  methods for estimating excess mortality in Canada, mandating a national  task force on COVID-19 mortality and testing everyone who dies whether  in hospital or in the community for COVID-19.

But the report also raises disturbing  questions, with implications not just for future pandemics but how a  siloed system fails and marginalizes racialized, elderly and disabled  people.

“We also need to grapple with, morally and ethically, how we missed so many deaths,” said Moriaty. “Why didn’t we see them?” 

“I’m afraid they were people others didn’t notice, and their deaths weren’t really remarked upon.”

Links of Interest:

Top photo credit: A man leaves an Ontario cemetery in May 2020. A new report claims the number of Canadians who died of COVID-19 could be twice as high as reported.Photo by Nathan Denette, the Canadian Press

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