Pandemic Mortality Rate Much Lower in Canada Than in the US. Why?

In broad strokes, Canada and the United States have a fair amount in common: same language, shared land mass, well off relatively to the rest of the world.

Davis Fisman

But when it comes to COVID-19 deaths from COVID-19, they parted company. In a commentary published yesterday in the Proceedings of the National Academy of Sciences (PNAS), David Fisman, M.D., M.P.H., an epidemiologist at the Dalla Lana School of Public Health at the University of Toronto, said that a recent analysis after statistical standardization to make the populations of the two countries comparable, Canada has experienced 100,000 fewer cumulative deaths from COVID-19 than the U.S. and that 28% of those deaths occurred in people younger than 65.

So why the difference? Fisman goes through several possible explanations. Is Canada perhaps underreporting deaths from COVID-19, in effect “hiding” the true mortality? He says there is underreporting in Canada but there is also underreporting in the U.S. and that research published in Lancet showed that underreporting in the two countries are similar.

Canada has universal health insurance whereas health insurance in the U.S. is a jumble of public (Medicare, Medicaid, the VA) and private payers. Alison Galvani, Ph.D., a Yale epidemiologist, and her colleagues reported the results of an analysis in PNAS in June that showed that, by their calculations, a single-payer system in the U.S. would have saved 212,000 lives in 2020, a large fraction of them but not all related to COVID-19. Galvani offers possible explanations for why a the U.S. patchwork of insurance coverage would translate into a higher death rate: higher rates of poorly controlled chronic conditions, such as hypertension and diabetes, that increase the risk of a COVID-19 case being severe, delays in care because people worry about medical bills, lower vaccination rates because many Americans don’t have strong relationships with a primary care physician. 

But Fisman says he is unsure whether the differences in healthcare insurance is the real explanation. He discusses some of the shortcoming in COVID-19 healthcare in Canada (rural healthcare facilities are underresourced and lack of the use of monoclonal antibodies to keep people out of the hospital) notes that the infection fatality ratio for COVID-19 is similar in the U.S., Canada and several other countries. “The threefold difference in deaths must be explained, at least in part, by difference in the rates of infection rather than differences in infection outcome or case mix.”

Fisman settles on Canadians having a more communitarian outlook as the overall explanation for the mortality difference, notwithstanding the Freedom Convoy protests in Ottawa.

“Acceptance of sacrifice of individual needs or convenience for purposes of disease control has likely been easier to achieve in Canada than in the United States as Canadian Society is more communitarian and less individualistic than U.S. society,” Fisman writes. Communitarian ideas may help sustain the country’s single-payer system, he notes, although there is some fraying tat the edges with increasing push for privatization in some part of Canada. Social capital is sliding in the U.S. but is stable or even increasing in Canada, Fisman says.

Fisman makes an interesting distinction between healthcare, which he describes as being designed to restore people to good health and public health, which is supposed to work to keep people healthy in the first place by preventing disease. But public health depends on trust in government agencies, particularly healthcare agencies and Fisman says such trust is in short supply in the U.S., relative to Canada.

But lest Canadians get too self satisfied, Fisman notes that Australia has mortality stats that are better than Canada’s by about the same amount as Canadian-U.S. difference. Both Canada and the U.S. have much to learn from Australia, he says.

“Australia worked hard to eliminate local transmission of SARS-CoV-2 for as long as that strategy could be sustained,” he writes.

So what should be made of these country comparisons? “It is difficult to legislate cultural change, even if that were desired,” Fisman writes. Perhaps, though, if Canadians were more aware of their country’s mortality advantage over the U.S. the dissatisfaction about the Canadian policies would be tempered. He said it might be naïve to hope that the “large numbers of Americans will reflect on how much less impactful the pandemic could have been and how many lives might have been spared had it emulated some of its global peers.”