Sporadic cases of TB almost certainly occurred in the Americas before European contact, but significant exposure and the introduction of possibly more virulent strains of Mycobacterium tuberculosis (M. tuberculosis) occurred post-contact,24–26 with dispersal following trade routes and encroaching settlements.9 The gradient of TB in First Nations can reflect the serial stages of European colonization, with the lowest rates in the Atlantic region and the highest rates reported in the North, consequently mirroring the earliest and latest encounters.27,28 Since the mid-20th century, when Health and Welfare Canada began implementing serious TB prevention and care measures among the First Nations of Canada, and when the first effective anti-TB drugs were discovered, rates of TB in Indigenous Canadians have been slowly falling.29 The rate of decline, however, has been slower than the rate of decline in the Canadian-born, non-Indigenous population, such that the relative rate (Indigenous/non-Indigenous rate) has been increasing,29,30 highlighting a continuous inequity in health indicators for First Nations.
In 2015, the last year in which all provinces and territories reported disaggregated data, there were 155 Registered Indian cases (Registered Indians or Status Indians are persons who are eligible to be registered as an “Indian” under the Indian Act, and who therefore are able to use services and benefits that are offered by federal departments) reported in Canada; all were reported in the provinces west of Quebec and in the territories. The prairie provinces alone reported 127 (81.9%) cases. Most cases (101, or 65.2%) were living on-reserve at the time of diagnosis.31 The on- and off-reserve crude rates of disease were 19.3 and 10.7 per 100,000 persons, using population estimates from Aboriginal Affairs and Northern Development Canada (AANDC)/Indigenous Services Canada (ISC). On the prairies in 2004-2008, again using AANDC/ISC population estimates, the age- and sex-adjusted rates in Registered Indians were 52.6 (95% confidence interval 49.2-56.0) per 100,000 person-years (37.6 times the rate in Canadian-born “others”), with rates on- and off-reserve being 62.2 (57.3-67.0) and 40.0 (35.4-44.6) per 100,000 person-years, respectively.32 Rates on the Prairies increased incrementally with age, with males having higher rates in each age group.32 In 2007-2008, the distribution of pulmonary TB cases according to community-of-residence on the prairies was highly focal; only 47 (23.6%) of 199 reserve communities reported a case and most of these communities were in the northern latitudes. In Alberta, where near-universal opt-out human immunodeficiency virus (HIV) testing of TB patients has been performed since 2003, being Indigenous was an independent risk factor for HIV seropositivity.33
After European exposure, multiple diseases decimated the First Nations population, which negatively affected communities’ social and economic infrastructures.34 The rise of TB that occurred in the latter half of the 19th century resulted from events related to the decline of the fur trade and the destruction of the bison-based economy. These changes jeopardized many First Nations’ political and economic autonomy, thus forcing many to ratify treaties with the Canadian government. The treaty terms and the eventual introduction of the Indian Act (the Act) of 1876, led to mandatory relocations onto reserves, loss of liberties and land claims, even though the initial agreements were based on shared land management principles, in exchange for crucial living essentials needed to survive.35,36 Despite the allocation of food rations and basic living infrastructures, the rations were subpar and used as a means of coercion, leading to malnutrition and impoverished living conditions in many communities34,35 and culminating in TB outbreaks on reserves.37
Prairie First Nations faced extraordinarily high TB death rates, which peaked shortly after they were placed on reserves, with 9,000 deaths per 100,000 persons in 1886; that rate fell to approximately 800 deaths per 100,000 persons in 1926.38 Off-reserve, TB outbreaks were appearing in Indian residential schools across the prairie provinces, with up to one-quarter of students dying from TB.39,40 Residential schools were an assimilation tactic to incorporate Indigenous children into Canadian society, starting in the 1880s, and with the last school closing in 1996. In the early days of Indian Residential Schools, the common themes of poor ventilation, poor construction design, overcrowding, lack of basic medical treatment and malnutrition contributed to the propagation of TB, unseen in the general public.37 The epidemic of TB on reserves concerned non-Indigenous Canadians; due to public outcry, the Canadian government funded sanatoria treatment for First Nations Peoples, beginning in the late 1930s.37,41 In general, sanatoria were established on the idea that treatments of “open air,” bed rest and a balanced diet would cure TB. However, designated First Nations sanatoria were racially segregated, underfunded, understaffed and First Nations patients often found the forced treatments distressing and isolating.41–44
Recorded TB incidence declined considerably during the 1940s to 1960s, due to the expansion of medical interventions to combat the disease,45 including Bacille Calmette-Guérin (BCG) vaccinations, mass radiography, tuberculin surveys and anti-TB drugs.46 However, many of the interventions were coerced on nonconsensual First Nations children and adults.41 These negative experiences have been harbored and passed on to each generation, creating even further resentment, suspicion and distrust toward the government and the medical system in general.
Regardless of these medical advances, there are numerous structural barriers that impede TB elimination in remote First Nations populations. First, isolated clinics provide inadequate healthcare, due to understaffing, insufficient supplies of practical diagnostic equipment (digital chest radiography, interferon-gamma release assays and sputum testing), the inconvenience of transporting samples to external laboratories and limited local human resources to ensure patients’ adherence to treatment and unsatisfactory documentation of HIV rates, prevalence of TB drug resistance and BCG vaccination within the community. When these clinics cannot provide the necessities, the inconvenient transportation of patients to a larger health facility, thousands of kilometers away, is the subsequent step. Additionally, widespread discrimination and implicit bias from health care providers means patients become reluctant to seek, or travel for, care.47 Too often, Indigenous Peoples’ medical cases are mismanaged, overlooked and misdiagnosed. Inconsistent access to culturally safe health services is a modern and prominent structural barrier. Furthermore, living conditions on reserves continue to mirror the past. The low socioeconomic situation for many communities continues to be reflected in substandard conditions. Overcrowded, multigenerational homes, lack of access to clean water, high rates of unemployment and food insecurity contribute to the continuity of TB transmission.48,49
Although TB rates have significantly decreased since the unprecedented highs in the late 1800s and early 1900s, the disease is by no means close to being eliminated. In fact, these unacceptable rates remain high in relative terms and have been so for the past decade. The practical steps to ameliorate the current situation must involve the federal government resuming annual TB reports that would acknowledge the present inequitable health status, implement measurable goals and establish accountability. The Truth and Reconciliation Commission provided eight recommendations specific to health (#18-24, 55), outlining realistic targets to lessen disparities in health outcomes our people face across Turtle Island (a First Nation term to denote the North American continent). To date, active TB incidence rates are thirty-two times higher for First Nations Peoples than the general non-Indigenous, Canadian-born population.50 It is evident that the devastating rates of TB were historically parallel with the height of Canada’s racist legislation against First Nations Peoples. Yet, as efforts slowly begin to recognize reconciliation for First Nations, TB persistently remains an indicator of colonialism.
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