British Columbia’s excess mortality rate dwarfed all other provinces in Canada during the first year of the COVID-19 pandemic, a new study says.
The peer-reviewed report, published in the Canadian Medical Association Journal Monday, used public data to look at how many excess deaths occurred in each of Canada’s provinces from March 2020, at the start of the pandemic, to October 2021, over a year and a half later.
Excess mortality measures how many deaths actually occurred compared to what was expected under normal circumstances. It’s one way researchers have been able to figure out the true number of lives lost due to COVID-19. But what emerged from the research was a huge gap in the number of unexpected deaths each province recorded in the period just before the Omicron variant hit.
“I think we all know that there have been deaths related to COVID. But to see the differences, at least in these estimates? ...It was surprising,” said the study’s author, Kimberlyn McGrail, a professor at the University of British Columbia’s School of Population and Public Health.
In her analysis, McGrail used Statistics Canada data to track the observed number of deaths. She then compared those numbers with a model that estimated how many deaths would have occurred if the pandemic never happened.
She found that during the first year of the COVID-19 pandemic, Canada saw a roughly five per cent increase in excess mortality. That’s higher than many countries but fewer than the United Kingdom, which recorded an 18 per cent increase in excess deaths, or the United States, which saw excess mortality climb to 22 per cent into early 2021.
In Canada, McGrail calculated the mortality rates on a per 100,000 population basis. That way, she could directly compare provinces with different populations. The researcher avoided analyzing excess deaths in Canada's three territories because of the small number of pre-Omicron COVID-19 cases reported there.
In the end, McGrail found excess mortality was lowest in Canada’s eastern provinces — even dropping below what was expected in Prince Edward Island and Nova Scotia.
Quebec had the highest reported COVID-19 mortality rate in Canada. But while there were moments during the pandemic where excess deaths outpaced reported deaths, at other times, there were “substantial periods during which mortality rates were lower than expected,” even dropping below zero.
Ontario appeared to have the smallest gap between reported COVID-19 deaths and excess mortality, something that suggested the province was the best at tracking pandemic deaths.
With a 4.5-fold gap between reported COVID-19 deaths and excess mortality, B.C. outstripped all other provinces in the number of excess deaths that went unreported. Only Alberta and Saskatchewan came close to Canada's westernmost province.
Determining how people have died throughout the pandemic has challenged health officials and vital statistics agencies globally. To date, nearly 6.3 million people have officially died from COVID-19 across the world. But some have estimated the real COVID-19 death toll could be three times higher.
As the gap in B.C. makes clear, the virus wasn't the only factor pushing up death rates to unexpected highs.
Heat dome drives highest weekly excess mortality rates in Canada
During the 2021 heat dome in late June, excess deaths per 100,000 people in B.C. literally spike off the chart, climbing to 90 deaths per 100,000 people. That’s higher than the weekly excess death rate anywhere in Canada at any time during the pandemic.
“Alberta, B.C. and Saskatchewan stand out for having had excess mortality rates nearly double (or more) those of other provinces,” wrote McGrail.
McGrail says the “remarkably diverse” mortality patterns across Canada likely have a number of explanations. She notes limited testing capacity, deaths occurring in the community rather than a hospital and different public health reporting practices all likely played a role in deciding whether or not to classify a cause of death as COVID-19-related.
“These provincial variations suggest to me that the very first thing to understand is how the different approaches to testing, contact tracing and encoding — identifying COVID-related deaths — might vary across the provinces,” she said.
Another wildcard factor that could have impacted how many people died in the first year of the pandemic: delayed or cancelled surgeries, diagnostic tests or doctor appointments.
To get a better understanding of which province actually had a “COVID-19 problem,” McGrail says differences in public health reporting practices need to be ruled out as a cause first.
In places and times where mortality rates dipped below what was expected, McGrail points to a pandemic decline in car accidents due to fewer people on the road, and a reduction in influenza-related deaths. The Statistics Canada data, she said, currently doesn’t count avoided deaths as a result of COVID-19 measures.
Other factors that need to be looked at include how pandemic policies and border shutdowns impacted an unsafe drug supply, leading to more people using and overdosing on opioids alone, said McGrail in her report.
A surge in unexpected deaths in B.C.
B.C. reported 9,496 excess deaths by October 2021, more than double that of Quebec and nearly as many as Ontario, a province with a much larger population.
Of those deaths, only 2,109 — or 22 per cent — were attributed to COVID-19. It’s not clear to what degree the opioid crisis and June 2021 heat wave drove the other nearly 7,400 unexpected deaths. But over that same period, the BC Coroners Service reported 3,416 people died overdosing on illicit drugs — more than suicides, murder and motor vehicle accidents combined. The heat wave is thought to have killed just shy of 600 people.
Even if those two causes of death were taken away, that still leaves roughly 3,000 deaths unaccounted for under normal conditions.
Pointing to the collision of the SARS-CoV-2 virus, public policy and climate change, McGrail noted a potential cascading effect leading to the most vulnerable facing a double or even triple crisis.
McGrail cited a Human Rights Watch report released in October 2021 that concluded an inadequate response from B.C. authorities made heat-related deaths worse in the province. But because those deaths were “highly associated with social and material deprivation,” COVID-19 and the poverty that came with it may well have set the stage for the most vulnerable to suffer the worst effects from extreme heat.
“If you think about the implications of COVID, they would have had some impact on the heat dome deaths because it would have affected the policy response,” McGrail said, pointing to public health measures that pushed people, in particular older British Columbians, to isolate.
McGrail called for all provinces and territories to come together and conduct a forensic analysis of how mortality has played out over the pandemic. To that end, she has shared her work with federal and B.C. government health authorities and plans to reach out to more now that her work is public.
Reforming the system tracking deaths could not come too soon. One international analysis from The Economist found that Canada is three to four months behind its peers in reporting deaths.
“Even the basic recording of mortality, we’re very slow in Canada. That surely could and should be fixed,” said McGrail.
But it's not just the government she is trying to convince.
On a second front, McGrail says more work needs to be done to involve the public in responding to public health crises.
“When we have another one of these events... part of our response is going to be being able to rally community organizations, community groups and the public at large very quickly,” she said.
“And that requires information. That requires trust.”