Morbid and Mortal Inequities Among Indigenous People in Canada and the United States during the COVID-19 Pandemic: Rapid Review of Relative Risks and Protections

Background and Purpose

The COVID-19 pandemic focused the world’s attention on gross racialized health inequities. Evidence of the widespread and harmful impacts of the COVID-19 pandemic across the diverse populations of Canada and the United States of America (USA) is voluminous (Clarke et al., 2021; Mateen et al., 2020; Wendt et al., 2021; Wu et al., 2020). While the pandemic has revealed much greater relative health risks experienced by racialized/ethnic people, primary and synthetic evidence thus far has focused on the most prevalently recognized racialized/ethnic groups: Latinx and Black people (Mackey et al., 2021). There has been a relative lack of primary study and a complete absence of synthetic study of the relative morbid and mortal COVID-19-related risks experienced by Indigenous peoples in Canada and the USA (Douglas et al., 2021; Waldner et al., 2021). However, early pandemic evidence has suggested that Indigenous peoples, while clearly facing prevalent structural violence (Alberton, 2020), also experience certain cultural protections (Waldner et al., 2021).

To fill this gap in knowledge, four hypotheses were advanced:

(1) Compared to non-Indigenous people, Indigenous peoples are at greater relative risk of being infected with COVID-19, and when infected, of being very seriously ill, and ultimately dying because of their infections.

(2) Indigenous relative mortal risks are significantly greater than their relative morbid risks.

(3) Indigenous vaccination uptake is significantly greater than non-Indigenous uptake. And,

(4) Indigenous COVID-19-related relative risks are greater in the USA than in Canada.

Methods

To test the four hypotheses, we conducted a rapid review and random-effects, sample-weighted observational synthesis of the published and gray literature on four COVID-19-relevant outcomes in Canada and the USA: vaccination, infection, severe infection, and death rates.

Results

Twenty-nine Indigenous-non-Indigenous comparative surveys or cohorts that observed 33, typically age-standardized, incidence or mortality rates or their proxies were included. Consistent with structural violence theory, we found that Indigenous peoples were significantly more likely to be infected, to experience severe COVID-19 illness, or to die because of their illness, Indigenous mortal risks (RR = 2.45) being significantly greater than Indigenous morbid risks (RR = 1.40). Consistent with cultural strengths theory, vaccinations seemed equitably distributed (RR = 1.02) with a suggestion of greater vaccine willingness among Indigenous peoples in some places. There was insufficient statistical power to test the fourth hypothesis.

Conclusions and Implications

Consistent with their lifetime exposures to discrimination and structural violence, Indigenous peoples seemed clearly to be at relatively grave risk of having the most serious and deadly COVID-19 infections. However, consistent with cultural strengths theory, COVID-19 infection occurrences and vaccination uptake seemed much more equitably distributed with certain Indigenous people in some places. Clearly, much work remains to be done to Indigenize research and ultimately practices and policies in North America. Moreover, in the era of truth and reconciliation more comprehensive and meaningful efforts must be made by Canadian and American governments to work with Indigenous communities to collect and use their data in the most truthful and powerful ways (Stukes & Wu, 2020).