Why talking about COVID-19’s ‘comorbidities’ is so controversial

As the head of a small congregation in rural Saskatchewan, Bradley Robertson hears his fair share of community chatter about COVID-19 - from those who fear the virus, to those who say it's all blown out of proportion.

He always thought it was important to use his platform to encourage others to keep themselves and their neighbours safe from the virus. When his sister got sick with it back in Vancouver, the threat became all the more real.

There are those who are saying: Why are we placing such a big deal on this?" Robertson said. And I'm thinking, the numbers have been low, because we've been mostly responsible. Now they're on the rise again."

As leaders, we have to take responsibility."

The disagreements Robertson noticed are happening all over the country, with some escalating into widespread and emotional debates over our lives, personal responsibilities and the role of government in reigning in the pandemic.

That's what has happened in the case of Alberta's reporting on comorbidities, an issue that comes layered with the kind of nuance that can be in rare supply during an emotionally charged national conversation during a pandemic.

Comorbidities are pre-existing health conditions ranging from high blood pressure to cancer.

In Alberta, comorbidities appear to have made 98 per cent of the 575 people who have died from COVID-19 more vulnerable to the disease.

Last month, the province began listing comorbidities alongside its regularly updated death statistics.

Ontario and B.C. have not followed suit.

Experts agree this is crucial information to know, to reveal more about the toll the coronavirus pandemic is taking on society, and to help plan when it comes to things such as distributing vaccines to at-risk groups.

However, the question of comorbidities has also fuelled a narrative that has led some Canadians to question the need for severe public health measures to limit the spread of COVID-19 within the general population.

And that narrative has public health officials concerned.

The thinking, promoted by commentators and Twitter users in Alberta and across the country, goes something like this: When we look at the COVID-19 death data, the vast majority of people who have died have some kind of comorbidity. Those without comorbidities appear to be at far less risk (of death, although far less is known about the long-term effects of COVID-19). So, some of those people without comorbidities should be able to make personal choices to accept the risk of getting COVID-19, and do things like keep small businesses open, and socialize with loved ones. One commentator has repeatedly referred to only 10 otherwise healthy" people in Alberta dying of COVID-19.

Public health experts and leaders have contested this in no uncertain terms, with the federal health minister calling it a dangerous" way of thinking. Prime Minister Justin Trudeau said last week in the House of Commons that a storyline distinguishing between protecting people with comorbidities from the rest of the population downplayed" the seriousness of the pandemic's losses.

The complicating factor is that, while this narrative is concerning to public health officials, it is not based on falsehoods. Comorbidity data does, in fact, paint a picture of parts of the population that are at much greater risk of death than others.

So is it dangerous to focus on comorbidities?

Severe outcomes are not limited to just those who are at the very end of their lives, and it is a mistake to think so," Deena Hinshaw, Alberta's chief medical officer of health, said in a daily update last month.

Over half of men over 50 in Alberta have high blood pressure.

That should not be a death sentence."

A Saskatchewan-based blogger tweeted about the release of comorbidity data in Alberta, calling it a cynical effort to somehow minimize or diminish these deaths."

The tweet received support from high-profile public health experts in Alberta, including Dr. Lynora Saxinger, who co-chairs the province's scientist advisory group on COVID-19.

Patrick Saunders-Hastings, a University of Ottawa epidemiologist, said the dangers of highlighting comorbidities lie in the way the information is communicated, not the facts, themselves.

First, there's the risk of downplaying the deaths that have occurred by suggesting, even implicitly, that they were not as attributable to COVID-19 because of the accompanying risk factors.

That's not true, because it was COVID-19 that killed these people, not their comorbidities.

Then there's the issue of the message the emphasizing of comorbidities sends to those feeling apathetic about the pandemic and its restrictions.

There have been challenges around the communication of risk profiles as it relates to individual responsibility," Saunders-Hastings said.

We have seen younger and healthier population groups who have been less willing to comply with (public health orders and recommendations)."

On the extreme ends of that non-compliance are events such as the Calgary antimask rally last weekend, which saw hundreds of Albertans take to the streets, in defiance of public health orders, to protest public health restrictions. Or the now well-known case of Adam Skelly, who kept his Etobicoke barbecue restaurant open, despite public health orders, before being shut down.

Even comparatively minor flouting of the rules, such as going to visit a few friends and their house, is misguided, Saunders-Hastings said.

The risk cohorts that have been identified related to COVID-19 are so broad that, even in those younger, otherwise healthy, groups, most people would have interaction with people with those risk factors," he said.

Comorbidities for COVID-19 deaths in Canada include high blood pressure, dementia, and diabetes, all fairly common conditions.

Advanced age is also a known risk factor for severe COVID-19.

That means practically everyone in the population is in contact with someone who has a comorbidity, even if they do not have any themselves.

For many Canadians, it's a deeply personal topic.

I hear from Canadians, they call me to talk about a family member who has an underlying condition and they're concerned," said Colin Furness, a University of Toronto epidemiologist. There's emotional pain there."

When Lethbridge MP Rachael Harder shared a Toronto Sun column to her Facebook page, quoting the line about only 10 otherwise healthy" COVID-19 deaths, the backlash was swift. Almost 1,000 comments followed the article, and most appeared to be people criticizing the MP for a lack of sensitivity toward those hundreds with comorbidities who died in her province.

She edited the original post with more quotes from the column, saying it's important to protect the most vulnerable in the pandemic.

At the end of the day, I'm simply posting an article that presents to the Canadian public the stats," Harder told the Star. The stats show who the most vulnerable are."

She repeated the same thing when asked whether she thought her post promoted the view that focusing on comorbidities could encourage those not at risk to argue for fewer restrictions.

Robertson, the pastor in Eastend, Sask., is from the same area as Harder, and said he was one of the people disappointed by the thinking Harder seemed to promote with her Facebook post. He said he was glad to see her update the original post with what he thought was more compassion for those at risk.

At the time, my sister was going through treatment in a Vancouver hospital for COVID-19 and she was touch-and-go for getting intubated," Robertson said. I felt that those numbers were being dismissed. It's almost feeding the people who are saying this is all nonsense' about the pandemic."

In his small town, Robertson says he comes across people who feel differently about the measures to stop the spread of COVID-19; some are more supportive of the measures than others.

I try to encourage others who are listening to think about people who are vulnerable, so, even if you don't agree, or, even if you think you're not at risk, still wear a mask and follow the rules," he said.

Reporting on comorbidities is an important piece of the puzzle, especially as we approach a vaccination phase of the pandemic.

Understanding that we will not be able to vaccinate everyone right away ... we would need to make these prioritization decisions," said Saunders-Hastings. And that's in these at-risk groups."

That's not to dismiss the risk of younger and otherwise healthy individuals, but we have a need to allocate those resources to health workers and people at risk of transmitting to high-risk individuals," he said.

Vaccines are expected to begin arriving in Canada in early 2021, with about three million doses expected in the first three months, in a population of about 38 million people.

Alex McKeen is a Vancouver-based reporter for the Star. Follow her on Twitter: @alex_mckeen