Morbid and Mortal Inequities among Indigenous Peoples during the COVID-19 Pandemic: Research Synthesis

Overview: Findings from this study, based on structural violence and cultural strengths theories, revealed that Indigenous peoples are more likely to be infected with, experience severe illness related to, or die because of COVID-19. However, consistent with cultural strengths theory, some Indigenous peoples demonstrated greater vaccine willingness than non-Indigenous peoples.Proposal text: The COVID-19 pandemic has illuminated gross racialized health inequities and injustices (Mackey et al., 2021). Evidence of the widespread and harmful impacts of the COVID-19 pandemic across diverse populations in Canada and the United States of America (USA) is voluminous (Clark et al., 2021; Mateen et al., 2020; Wendt et al., 2021). While the pandemic has revealed the much greater relative health risks experienced by racialized/ethnic people, the primary and synthetic evidence thus far has focused primarily on Latinx and Black people (Mackey et al., 2021). To date, 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 (Douglas et al., 2021; Waldner et al., 2021). However, some of the early pandemic evidence suggested that Indigenous peoples, while clearly the victims of prevalent structural violence, also experience certain cultural protections.

Aiming to begin to clarify their relative risks and protections, we conducted a rapid review and sample-weighted synthesis of published and gray literature on four COVID-19-relevant outcomes in Canada and the USA between January 1, 2020 and August 1, 2021: vaccination, infection, severe infection, and death rates. Twenty-nine Indigenous-non-Indigenous comparative surveys or cohorts that observed 33 incidence or mortality rates or their proxies were included.

This rapid review, the first synthetic study of Indigneny-COVID-19 inequities in North America, hypothesized certain Indigenous protections based upon Indigenous cultural strengths and certain risks based upon Indigenous peoples’ long histories of structural violence in North America. Our three hypotheses were largely supported and the fourth, insufficiently powerful to test. First, the pooled relative risk of COVID-19 among Indigenous peoples compared with otherwise similar non-Indigenous people was statistically and practically significant, indicating that Indigenous peoples were two-thirds more likely to be infected or die with COVID-19 as the primary or contributing cause of death (RR = 1.65). Second, Indigenous peoples’ risk of death (RR = 2.45) was significantly greater than their risk of infection (RR = 1.40), Indigenous peoples being about one and a half times as like to become ill with COVID-19 and two and a half times as likely to die as a result. Pre-existing, chronic health conditions secondary to lifetime structural violence exposures were likely responsible for the much worse mortal outcomes among Indigenous peoples. Third, despite long histories of oppression, providing Indigenous peoples with every reason to mistrust governments, their vaccination uptake rate was on par with that of non-Indigenous people, who were primarily non-Hispanic White people (RR = 1.02).

This rapid review provided evidence that inequalities exist among Indigenous and non-Indigenous people on COVID-19 related outcomes. Consistent with their lifetime exposures to discrimination and structural violence (Alberton, 2020), 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 even demonstrating significant protective advantages over non-Hispanic White people.