Stephen Lewis: PM Trudeau, the UN, Nunavut and Tuberculosis
Excerpt from AIDS-Free World Co-Director Stephen Lewis’ speech delivered at the University of Alberta’s Alumni Weekend
Edmonton, Alberta, 12:00 PM, September 23, 2017: At the United Nations, the Prime Minister unequivocally declared his intention to repair relations with Indigenous communities across Canada, to attempt to compensate for the hundred and fifty years of colonial oppression, humiliation and pain.
He spoke with pride of the creation of two separate ministries to address First Nations, the Métis Nation and Inuit peoples in Canada. I’d like to propose a test of his intentions.
The devastating TB epidemic in Nunavut Inuit communities is curable, capable of elimination. When I recently returned from a fact-finding tour of TB in Nunavut, I promised, amongst other undertakings, to convey what I had learned about a straightforward formula that could lead to the elimination of tuberculosis.
Herewith the formula. But first let me emphasize that I pretend to no medical expertise. I am persuaded, after listening carefully, that what I’m about to set out is rooted in and embraced by the Inuit community in Nunavut. That is what gives it credibility.
Back in 2007, Natan Obed, now the President of Inuit Tapiriit Kanatami (ITK), and Dr. Gonzalo Alvarez, a leading respirologist, founded a group of research projects called “Taima TB.” It began with a remarkable community-led awareness campaign that dramatically increased the number of people who came forward for testing … discovering and treating many new active and latent TB cases in the process. It gained the approval of the public health officials in the Ministry of Health.
There emerged a Taima TB ‘toolbox’ that consists of five components. As I understand it, when taken together, and implemented, these are the components that can move towards the elimination of TB. It has the support of both ITK and Nunavut Tunngavik Incorporated (NTI).
First, digital chest X-rays to detect active TB disease. The digital X-rays, using the internet, can be read by radiologists in Ottawa. As things currently stand, the X-rays from some communities are of such poor quality that children have to be sent to Ottawa, at enormous expense, to have an X-ray taken.
Second, what is called Sputum Induction, also to detect active TB disease. It’s the introduction of a saline solution to induce a cough so that a sputum sample can be taken. Where X-rays may not catch TB, Sputum Induction can. It’s the standard of care in Iqaluit, and with some training can become the standard of care in all communities.
Third, Gene Xpert is a modern point-of-care rapid test, used more and more widely around the world (especially South Africa), to detect active TB. It is the best current laboratory technology. The results can be known the next day rather than waiting weeks or months. Lay people can be trained in its use. It means that treatment for TB can begin almost immediately, resulting in a much higher standard of care. The Government of Nunavut wants to roll out Gene Xpert across the territory: they are stopped by lack of funds.
Fourth, 3HP to provide a shorter treatment regimen for latent tuberculosis. The present regimen extends over nine months; 3HP combination would require taking one pill a week for twelve weeks. The Minister of Indigenous Services, Dr. Jane Philpott, authorized the use of 3HP as part of an ongoing study in Ottawa and Nunavut to prove efficacy. There is little doubt that it should be implemented.
Finally, IGRA, Interferon-Gamma Release Assays, a simple blood test to diagnose latent TB infection. It’s a major improvement on the normal skin test because the skin test can cause a ‘false positive’ if the individual has taken the BCG vaccine (a vaccine used in high-risk TB jurisdictions and Nunavut is one of those jurisdictions).
The critical fact about Taima-TB is that it provides a framework for government action. If the Government of Nunavut is provided with the necessary human and financial resources, Taima TB can be further embedded in the Inuit communities. It would make a huge difference, but the role of the Nunavut government is crucial: the Federal Government must therefore deliver.
This plan to institute prevention and treatment of TB must obviously be accompanied by a herculean effort to address the social determinants of health. It’s crucial that the Federal Government also deal with poverty, housing, food prices, training of health professionals (there is a desperate need for nurses), and above all, always above all, language and culture. But this five-point plan is a strong start to create the momentum necessary to lead to elimination.
To put it simply, but starkly, TB in Nunavut is a test of the Federal Government’s integrity. Will the Inuit peoples live forever with rhetorical blandishments, or will the torrent of words, disgorged from the podium of the UN General Assembly, convert to action? Will the government make Nunavut a model for ending TB?
In that regard, there was one aspect of the Prime Minister’s UN address that is confusing, even disturbing. He made a point of aligning Canadian policies with the Sustainable Development Goals … thus, he spoke of clean water, Goal #6; he spoke of education, Goal #4; he spoke of decent work, Goal #8; he spoke of housing, Goal #11, he spoke of women and girls, Goal #5.
What was the one goal conspicuously absent? Goal #3: the right to health. That worries me. This was a very carefully calibrated speech. Why is health missing?
What might it mean for TB in Nunavut? After all, the amount of money involved is a relative pittance. To maintain the continuing research requires half a million a year for five years. The resources needed to operationalize the plan throughout the communities of Nunavut should be seen as a fraction of the budget of the Ministry of Indigenous Services.
We’re talking of 35,000 Inuit citizens, citizens of Canada. The decades of discrimination have taken a dreadful toll. The incidence of TB, even now, is between fifty and two hundred times the rate of TB in non-Indigenous Canada.
But the words of the Prime Minister are loud and clear: “… Canadians get it. They see the inequities. They’re fed up with the excuses. And that impatience gives us a rare and precious opportunity to act.”
This was said before the world. The world heard, and the world will be waiting. So will Canada.
* Mr. Lewis read the first third and last third of the speech verbatim, and summarized the five-point plan in the middle.