HomeTB among Inuit is a public health crisis. In 2019, the rate of active TB reported among Inuit living within Inuit Nunangat was 40 times the rate for Canada as a whole (189/100,00 vs 4.7/100,000) and more than 400 times the rate for the Canadian-born, non-Indigenous population (189/100,000 vs 0.4/100,000) (see Chapter 1: Epidemiology of Tuberculosis in Canada). There are 65,000 Inuit in Canada, the majority of whom live in four regions that comprise Inuit Nunangat (the Inuit homelands): the Inuvialuit Settlement Region (in the Northwest Territories), Nunavut, Nunavik (in northern Quebec) and Nunatsiavut (in northern Labrador). It includes 51 communities and encompasses roughly 35% of Canada’s landmass and 50% of its coastline. Regular, reliable airline and seasonal supply ship services are critical, as access to most communities is by air and water in summer and by air only in other seasons. All communities have a health center, the majority of which are staffed by registered nurses with advanced training. Referrals out of community to a regional hospital or to care facilities in southern urban centers are frequently required. Emergency medical evacuation services are available,51 although geography and weather conditions can affect response times.
Historical traumas from earlier efforts by the Canadian government to address TB epidemics among Inuit continue to have an impact on the current context of TB in Inuit communities.52–55 As the Canadian Arctic was colonized in the first half of the 1900s, it became a time of rapid social changes and disease epidemics for Inuit. Before effective TB drugs became available, TB death rates among Inuit were high.18 Many were sent to TB hospitals in southern Canada during the 1940s-1960s.56,57 Families were not informed of where loved ones were taken or where those who died were buried.58 Inuit who returned, particularly children, faced new challenges, including reduced physical capacities related to their illness or treatment, and the loss of language, family attachments and other aspects of Inuit culture. In 2019, the Prime Minister delivered an apology on behalf of the Canadian government for the treatment of Inuit with TB during this time,59 and the Nanilavut Initiative began helping Inuit locate, visit and mark the graves of family members who did not return home.58,60–62
In 2019, the incidence rate of TB disease varied across Inuit regions, from 0 in the Inuvialuit Settlement Region to 139/100,000 in Nunavut, 517/100,000 in Nunavik, and 112/100,000 in Nunatsiavut.63 TB rates also vary dramatically within regions, with some communities experiencing recurrent TB outbreaks. There is also a large pool of latent TB infection across all regions in Inuit Nunangat that creates a high risk for future outbreaks. The BCG vaccine is given to neonates in all regions except Nunatsiavut. While the BCG vaccine is important for preventing disseminated TB among children, it may have a confounding effect on screening programs for latent TB infection among young children (see Chapter 9: Pediatric Tuberculosis).
High rates of TB among Inuit are a symptom of the health disparities they experienced. Social and economic inequities faced by many include: poverty; crowded and inadequate housing;64 food insecurity;65 low academic achievement; and high rates of unemployment.63 These inequities assert themselves beyond TB; collectively, the 4 Inuit regions have rates of suicide that range from 5 to 25 times the rate of suicide for Canada as a whole and are among the highest rates in the world.66 There is also high overall prevalence of other respiratory illnesses, including asthma, chronic obstructive pulmonary disease, lung cancer67,68 and respiratory syncytial virus (RSV), as well as smoking and use of harmful substances that cause or exacerbate these diseases.
Inuit experience challenges in accessing health services that most Canadians do not face.69 Historical experiences continue to affect how individuals, families and communities perceive the potential consequences of being diagnosed with TB. Many diagnostic services are not available in Inuit communities, requiring extensive travel for simple tests and procedures. Inadequate telecommunications services limit access to virtual care. Frequent turnover of health care providers,70 particularly in smaller and more remote communities, and language and cultural differences between clients and providers are recognized as important ongoing obstacles to health services for Inuit.71 These barriers may cause delays in TB diagnosis and treatment. Delays can increase the severity of illness, perpetuate ongoing transmission and amplify the prevalence of latent TB infection in Inuit communities.
In 2018, Inuit leadership and the Government of Canada jointly committed to eliminating TB from Inuit communities by 2030.72 Inuit Tapiriit Kanatami (ITK), the national organization representing Inuit, released the Inuit Tuberculosis Elimination Framework in December of 2018 to guide this work.63 Priority areas for action and investment highlighted in the framework include: enhancements to TB care and prevention programming; reductions in poverty; improvements in social determinants of health; creation of social equity; empowerment and mobilization of communities; strengthening of TB care and prevention capacity; developing and implementing Inuit-specific solutions; and ensuring accountability for TB elimination. Each Inuit region has developed its own TB elimination action plan. The TB elimination action plans are tailored to the needs and strengths of each region to ensure investments and activities are informed by local TB epidemiology and health systems. Meaningful involvement of Inuit and Inuit communities in TB programming and planning is the foundation of eliminating TB from Inuit Nunangat.
Respect for Inuit values, language, knowledge, culture and the historical context of TB across Inuit Nunangat is integral to providing TB care in Inuit communities. TB care is a partnership between the healthcare provider and the patient, their family and their community. The goal of building strong and sustainable TB care programs and eliminating TB is not managing illness; it is achieving and protecting wellness.
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