Canada’s plan to eliminate tuberculosis in Inuit communities: Will it be enough?

The new framework and what makes it different

The Inuit Tuberculosis Elimination Framework highlights six priority areas: enhancing TB care and prevention programming; reducing poverty, improving social determinants of health and creating social equity; empowering and mobilizing communities; strengthening TB care and prevention capacity; developing and implementing Inuit-specific solutions; and ensuring accountability for TB elimination.

The $27.5 million over five years that has been allocated by government will be distributed to each of the four regions which make up Inuit Nunangat: Inuvialuit Settlement Region in the Northwest Territories and Yukon, Nunavut, Nunavik in northern Quebec, and Nunatsiavut in northern Labrador.

“[Inuit] regional organizations are developing the regional action plans,” says Deborah Van Dyk, Senior Policy Advisor at ITK. These are expected to be completed by March 2019, and funding will then be dispersed by ITK to the regions, once costing for the action plans has been completed.

When asked what the framework’s priorities will look like in practice, Van Dyk explains that the framework provides an overall road map. “The specifics of enhancing TB care and prevention programming are going to be part of the regional action plans. How each region is going to look at that priority area and build up their own programs may look different.”

Regarding the government commitment of $27.5 million, Wong explains that government worked with Inuit partners to identify gaps in addressing TB (aside from social determinants of health) to determine the amount to allocate. “We have been informed specifically about the need for early diagnosis, early treatment, and supports for adherence to medications.”

Details on how each of the priorities will be achieved have not yet been released, leaving regions with flexibility. “The different Inuit regions are looking at individual needs in order to tailor the best way to have more capacity to help eliminate TB,” Wong describes. He explains that it is not only about more nurses and doctors and more advanced technology and equipment, but also about having more trained community workers and local champions to take the lead and sit down with communities to explain tuberculosis.

Will it work?

Stakeholders Healthy Debate spoke to are hopeful regarding the framework. It is considered much needed and an improvement from past TB interventions.

“[The framework] is Inuit-driven, and that’s what makes it quite different from anything that has been worked on in the past,” says Van Dyk. “[It] is shifting the focus from control to actual TB elimination. [It] is moving beyond a medical model and also looking at the social determinants of health that are driving the issue of TB in Inuit communities.”

Sylvia Doody, Director for Health Services with the Nunatsiavut Government Department of Health and Social Development, explains that the region has been doing a lot of community work and engagement in the past year as a result of an outbreak in Nain, Labrador, in 2018, which tragically left a 14-year-old dead. Lessons learned and a better understanding of the needs of the community will be used to develop their regional plan.

Doody explains that communities in Nunatsiavut are remote and isolated, fly-in only for most of the year. “We want to have TB care as close to home as possible,” she says. “Our communities do not have capabilities around equipment such as chest X-ray. Community members are often flown to the nearest site to receive those services.”

Since the outbreak last year, Nain has received a portable chest X-ray unit on loan from the Public Health Agency of Canada. “We have heard from the community since we have had the portable unit in Nain how convenient it has been for people to go to local health centres and have their chest X-ray done,” she says. “There are all those hidden costs that [people in bigger centres] don’t even think about, that [are taken] for granted because [people] can just go to the local hospital to receive services.”

Doody says the new framework “is written based on our priorities and what we see as areas for action to see elimination of TB by 2030 in our regions. It is written with a context of having the Inuit priorities at the centre and what we need to see.” She highlights addressing social determinants of health and increasing capacity—both human resource and equipment—as the Inuit-specific solutions her region is considering for TB elimination.

However, there could be some challenges to disease eradication.

Stigma and suspicion around tuberculosis interventions have been a major barrier to past interventions. Wong acknowledges that this is due to the harsh treatment and forced relocation of Inuit in the mid-20th century. “It really is a big issue. Individuals worry about ‘What will happen to me when I am diagnosed with TB? Will I be taken away from the community?’” He is hopeful that modern approaches that engage local community members will be the solution but appreciates that “for community members who are still afraid of TB, they may not actually be very clear about the current situation with TB diagnosis and TB treatment.”

Furthermore, there is consensus that the allocation of $27.5 million over five years, which Van Dyk calls “an initial contribution,” may need to be revisited in the future. Doody and Wong both agree that it’s too early to determine the need for additional funding, leaving the door open for future consideration of additional funding.

Though regions will be using the initial TB funding in part to address social determinants of health in their communities, broader funding strategies and frameworks are needed on a national level to address these issues. At present, there is uncertainty on where this necessary additional funding will come from.

Wong highlights inadequate housing, poverty and food insecurity as major barriers to tuberculosis eradication. Though he emphasizes the federal government’s announcement of $640 million dollars cumulatively over the past two budget cycles to address inadequate housing in Inuit Nunangat, he understands that government may play a role in ensuring funding to address other social determinants in the future. “We would advocate and work with our Indigenous partners to bring issues such as food insecurity to the table, or with a poverty reduction strategy.”

Van Dyk explains that in addition to the funding and framework for tuberculosis, there is a framework to be released in the coming months to complement the already announced funding for Inuit housing. She also notes that ITK is working with government to determine a strategy for food insecurity in Inuit Nunangat.

“It is imperative for [government] to support Inuit communities in their efforts to eliminate TB in Inuit Nunangat and also in addressing other factors that contribute to the spread of the disease, including inadequate housing, food insecurity, and poverty,” says Wong. “When you have efforts being led by the Inuit peoples, by the communities themselves, that is the secret to success.”