key: cord-0882768-ub5s7pdl authors: Tripp, Lianne title: Overlooking the Canadian Indigenous demographic data: a response to Mallard et al's call for data on COVID-19 and Indigenous populations date: 2022-03-24 journal: BMJ Glob Health DOI: 10.1136/bmjgh-2022-008847 sha: 3a1d91a1c5950f53b28433fe137852537a8d1ecb doc_id: 882768 cord_uid: ub5s7pdl nan Mallard et al's 1 commentary brings into sharp focus the dire need to collect data on COVID-19 in Indigenous populations around the world. They argue that because Indigenous populations have a history of suffering more severe outcomes relative to non-Indigenous populations during pandemics in the past, it is pertinent to document the Indigenous experience during the current COVID-19 pandemic. Furthermore, the data collation process should be standardised. Ironically, the authors found that rates of COVID-19 were higher in non-Indigenous populations compared with Indigenous in six of the nine countries included in the study. They attributed this phenomenon to countries having a better handle on disease control. 1 In the case of Canada, complete and accurate COVID-19 data facilitated the early implementation of Indigenous focus preparedness and response plans, as well as having the added benefit of Indigenous involvement in the development of these plans that were tailored to the needs of their communities. 1 Another reason for the lower rates, especially for confirmed cases, may be an artefact of low COVID-19 notification rates among the First Nations (FN) population; at the time of publication it was stated that notification was 3.2 times less than the rest of Canada. The authors' calculations and interpretation of the COVID-19 experience in FN in the Canadian context, unfortunately, are flawed for three reasons: (1) the population size estimates for FN population and Canada are incorrect, and without citations, readers cannot tell the provenience and the intended year of estimate; (2) actual counts for the COVID-19 cases and deaths were not provided; and (3) 1 ). Using the same estimated population size for FN on reserves, the corrected death rate is 8.39 per 100 000; with this corrected rate, the original finding that NFN (corrected) death rate (90.77 per 100 000) is higher than that of the FN population is still maintained. Because COVID-19 rates can fluctuate over time, a simple exploration of the FN and NFN COVID-19 monthly numbers and rates (end of month) until 14 January is provided in table 1. For the month of November, NFN COVID-19 rates were higher than the FN rates; by at least 31 December 2020, the COVID-19 prevalence rate for FN was higher than that of NFN (1730.11 vs 1548.73 per 100 000), and that trend persists to the present day (see table 1 and online supplemental figure 1 ). As for COVID-19 mortality rates, during the month of April 2021, FN death rates surpassed those of the rest of the country and remain higher throughout the pandemic (see online supplemental figure 2). As Mallard et al propose, the COVID-19 counts are grossly under-reported in FN, as such the disparities in prevalence rates are most likely even greater. The apparent 'good control of COVID-19' in Canada did not benefit the reserves in terms of COVID-19 prevalence rates, but it mitigated deaths early in the pandemic. As the second largest country in the world, with an area of nearly 10 million km 2 , undoubtedly there has been geographical variation in COVID-19 rates in the population at large and for FN populations as well. Regional variation in Canada was alluded to in Mallard et al, as they discussed the possibility of significant disparities between NFN and FN in isolated and/or remote areas such as in Saskatchewan. 1 A current examination of the variation in confirmed cases at the provincial level compared with FN (living on reserves) for each province highlights the diversity in the COVID-19 experience. The highest rates for FN are found in Alberta (20 164.60 per 100 000), and the lowest for FN are in Ontario at 6174.79 per 100 000 (see table 2 ). In general, the FN prevalence rate for each province was higher than the overall provincial rate; the only two exceptions were Ontario and Quebec. The prevalence rates were highest in the western provinces (British Columbia, Alberta, Saskatchewan and Manitoba), where more than half of FN reside, and declined in an eastwardly fashion. This finding would have most likely been observed at the the time of publication of Mallard et al's commentary 1 ; from the end of 2020 until at least June 2021, prevalence rates in the FN western provinces surpassed those of their respective provinces, 7 and FN populations experienced more severe outcomes because they represented half of hospitalisation in some provinces. 8 Reasons for elevated prevalence rates in western FN populations include the following: overcrowded living environments; social gatherings; relaxed protective measures; food insecurity; underlying morbidities; limited access to healthcare; and travelling in and out the community for work and commodities. 7 8 The epigenetic impact (alteration of how genes creates proteins) from intergenerational trauma associated with colonialism stressors, such as the residential school system and displacement, is also a major player in FN vulnerability to COVID-19. 7 The assessment of any population, let alone Indigenous populations, and COVID-19 data must be done with an appreciation of data context: the start and duration of the pandemic, and the type of data available (FNs on reserves vs. all FNs). Researchers not familiar with the demographic data of a country should scrutinise the data and as it is best practice in academia to endeavour to be transparent by providing the sources of the data. In Canada, the first case of COVID-19 was on 25 January 2020, 6 and the first cases in FN appear around 14 March 2020 6 ; with so few deaths in the FN population beginning in early May 2020 and remaining below 10 deaths until mid-September, there is no question that the first wave of the pandemic did not affect FN populations as hard as it did NFN. A single point in time for assessing the COVID-19 impact on Indigenous populations around the world is not sufficient to capture the overall and regional COVID-19 situations; by November 2020, in Canada, it was simply too early in the pandemic for SARS-CoV-2 to enact its toll on the more isolated FN communities. Unfortunately, Canada's COVID-19 data on the Indigenous populations are far from ideal, not only does it exclude many FNs not living on reserves, but FN populations and Inuit residing in the three territories (this is most likely because there are not any Indian reserves in the Yukon, only two in the Northwest Territories, and none in Nunavut). 9 Métis are excluded from the counts as well. Further, the websites for FN organisations, from the provinces, which are purported to contain both on and off reserve COVID-19 data are not up to date (the only exception being Manitoba). 10 Despite these limitations, if scholars do not take the time to carefully analyse the data available, we will run the risk of creating misleading conclusions that is perpetuated over time. Contributors LT has completed all contributions of the work including data collection and writing the manuscript. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Not required. Ethics approval Not applicable. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available in a public, open access repository. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. 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