Tuberculosis: Canadian Arctic tragedy, growing global threat

By Jack Miller
16 February 2011

The startling incidence of tuberculosis among the native population of Canada, one of the world’s most affluent countries, is the product of a long and continuing history of injustice.

According to a pre-release, internet edition of the Public Health Agency of Canada’s Tuberculosis in Canada 2009, the overall incidence of TB remains extremely low in Canada. During 2009, an average of 4.7 out of every 100,000 people in Canada was diagnosed with active TB. However, the ratio was significantly higher among the country’s aboriginal or native population—with 27.8 TB cases per 100,000 inhabitants.

The disparity became even more striking among the Inuit of Arctic Canada. The incidence of TB in the federal territory of Nunavut, where the Inuit population is concentrated, was nearly forty times the national average. And the disease continues to ravage the Inuit of Nunavut. In 2010 about a hundred new TB cases were diagnosed in a jurisdiction with a population of some 33,000, making Nunavut, as a recent Globe and Mail article noted, “one of the world’s worst places for respiratory health.”

Such articles are few and far between. The deplorable conditions to which Canadian capitalism has condemned the country’s native population are generally treated as an embarrassment best not talked about; although there are increasingly strident voices on the right—some of them with the ear of the Conservative government—that complain that the government lavishes too much money on Canada’s impoverished native population.

The TB epidemic in Canada’s far north is part of a global resurgence of the disease that is being fuelled by the vast and growing gap between rich and poor around the world. But this resurgence has not made much of a dent in Canada’s corporate media. Compared to AIDS, or newsworthy illnesses such as Ebola, West Nile Virus or Avian Flu, tuberculosis has apparently lost the power to strike fear, at least in affluent countries. Yet a World Health Organization scientist, quoted in New Scientist back in 2001, described the rapidly emerging strains of drug-resistant tuberculosis as “Ebola with wings.”

A poor people’s disease

When a person suffering from active tuberculosis coughs or sneezes, TB-causing bacteria are released into the air inside tiny droplets of water. In badly-ventilated environments, these droplets remain suspended in the air. In cramped living conditions it is more than likely that someone will inhale the bacteria and become infected in turn.

The human immune system finds it difficult to combat TB. The most likely outcome of infection is that the immune system will destroy some but not all of the attacking bacteria. The disease will remain inactive but it will not be eliminated. In this latent state TB is not contagious.

If the immune system is weakened, however, the bacteria can overwhelm the body’s defences. In about one case out of ten, the latent disease becomes active, leading to coughing fits, blood-stained sputum, fever, pallor, persistent weight loss and death. Poor diet, stress, substance abuse, fatigue—anything that puts pressure on the immune system—can contribute to the activation of the illness.

Given the way it is transmitted and activated, it is not surprising that TB is considered primarily a disease of the poor.

A 2004 report prepared by the Aboriginal Peoples’ Roundtable pointed out the negative impact of the decision by the (Liberal) federal government in 1993 to end almost all federal funding of public social housing, on which the majority of the Inuit relied. Statistics Canada estimated that 7 percent of Canadians lived in overcrowded conditions. Among the Inuit the average rose to 53 percent, revealing one of the key causes of the Arctic health crisis.

Today, more than half-a-decade later, half of all homes in Nunavut are deemed overcrowded or in need of serious repair.

The history of aboriginal contact with Europeans also continues to cast a shadow over the present. The statistics provided by the Public Health Agency of Canada show clear regional differences in infection rates. Rates for aboriginals in Eastern Canada are slightly higher than the national average. Rates for aboriginals in British Columbia are significantly higher, while rates in Manitoba and Saskatchewan show a dramatic difference.

Dr. Stefan Grzybowski, a leading Canadian expert on TB, noted that rates were highest where contact with Europeans was most recent. In a 1999 article for the Canadian Medical Association Journal he commented, “The high mortality rates that afflicted aboriginal people from the Prairies toward the end of the 19th century reflected their lack of ancestral exposure to TB combined with the opportunity for transmission within the reserve system.”

The Europeans who came to the Americas had developed a certain level of immunity to the diseases they brought with them. The indigenous peoples with whom they came into contact would only begin to develop immunity after several decades of devastating epidemics. At the same time, the native peoples were forced into conditions of poverty under which diseases like TB were guaranteed to flourish. Long after the original wave of epidemics, latent infections persisted among the survivors, posing an ever-present risk to future generations.

Living in one of the most inhospitable of Earth’s inhabited regions, the Inuit of the far north were the last of Canada’s aboriginal peoples to come into sustained contact with Europeans. By the middle of the twentieth century, the TB infection rate for the Inuit had reached crisis proportions and was ranked among the highest in the world. Despite the efforts of outspoken individuals, the plight of Canada’s native peoples was ignored by successive governments, in flagrant disregard of treaty commitments and constitutional obligations to safeguard aboriginal health.

Attitudes began to change in the 1950s. With the discovery of antibiotics, diseases like tuberculosis became treatable, preventable and curable. Through the application of rational scientific thought and practice, and by an effort of collective will, tuberculosis ceased to be a significant health hazard in the affluent regions of the Earth. This must be accounted a major achievement for humanity.

The fact that TB persists outside (and within) the affluent nations, and is poised to return in virulent new forms as a global mass killer, is a damning indictment of the prevailing social and political system.

Ottawa and the Inuit in the 1950s

In the 1950s, federal governments began to take a renewed interest in the Canadian north and its peoples. While proclaiming humanitarian goals, government efforts were frequently coloured by racist attitudes and purposes unrelated to the welfare of native communities.

A particularly egregious example was the forced relocation of 19 Inuit families from northern Quebec. It was becoming increasingly difficult for the Inuit of Inukjuak to survive by following their traditional hunting way of life, so the government promised to relocate them to a more favourable location. Instead they were moved 1200 kilometres north to Resolute Bay and Grise Fiord and left to fend for themselves in a barren cold environment. In August 2010, the federal government apologized to the survivors for the years of hardship and misery that they endured. The official statement of regret made no reference to the fact that that the Inuit had been relocated to assert Canadian sovereignty in the Arctic, during the Cold War—a cause that is, if anything, of even greater interest to Canada’s elite today when climate change and better technology are opening up the resources of the far north to more systematic exploitation.

Government attempts to deal with the TB crisis in the 1950s exhibited the same inability to treat the Inuit as fully human. Coastguard vessels would dock at a community and summon all the inhabitants for compulsory X-ray screening. Those found to be infected were not allowed to leave the ship to gather belongings or take their leave of family and friends. They were seized and taken south to sanatoria, often for several years of treatment. Those who died were buried in paupers’ graves, with no notification to their families. Those who returned, especially the young, came back as disoriented strangers.

Nonetheless the next 30 years saw a progressive and dramatic reduction in TB infection rates among all aboriginal peoples and among the Inuit in particular. Despite numerous missteps, government efforts began to have an impact on the overall health of the Arctic population. Meanwhile, governments placed pressure, often coercive in nature, on the Inuit to abandon their traditional way of life. The prospect of medical care for themselves and their children was undoubtedly a significant factor for many in opting for “civilized” existence in larger, more settled communities.

In the boom conditions of the 1950s and early 1960s, such decisions did not seem unreasonable. Employment opportunities, such as the Rankin Inlet nickel mine, were opening up and offering alternatives to the precarious hunting and fishing way of life. In a self-perpetuating cycle, a more settled life led to improvements in health which led to a rapid growth in population, as infant mortality fell. In turn, the traditional way of life became increasingly less viable as a way of supporting a rapidly growing population. Faced with competition from expensively mechanized hunting and fur-trapping operations, most Inuit allowed their traditional skills to fall into disuse.

The end of the post-war boom first made itself felt on the economic and geographic periphery. Having largely abandoned their traditional way of life, the Inuit saw the employment opportunities of the boom years vanish. By the 1970s, outside a small stratum of police and government employees, welfare had become a significant factor in the basic survival of the Inuit population.

The resurgence of TB among the Inuit

Optimism about the prospects for eliminating TB among the Inuit persisted into the 1980s, as infection rates continued to decline. By the beginning of the 1990s it had to be acknowledged that rates were no longer declining but had stalled at a level well above the national average. Rates remained stable for several years but from 2004 onwards infection rates among the Inuit have begun to rise again, nearly doubling by 2009.

This epidemic is a product of pervasive poverty and the spread of antibiotic resistant strains of TB. While the creation of Nunavut in 1999 as an Inuit-majority territory was promoted by the federal government and Canadian elite as proof of Canada’s embrace of the aspirations of the Inuit, little has been done to promote socio-economic development. Half of the territory’s population receives social assistance. Almost three-quarters of kindergarten children go to school without breakfast.

Confronted with antibiotics, TB bacteria have shown a resilient capability to evolve drug resistant varieties. Successful treatment of active TB requires several months of medication with more than one type of antibiotic. If treatment is interrupted before all bacteria have been eliminated, there is a danger that highly resistant bacteria may infect others and continue to evolve. Twenty percent of current infections worldwide involve Multi-Drug-Resistant Tuberculosis (MDR-TB), which is resistant to the commonly used first-line antibiotics. Two percent involve Extensively-Drug-Resistant Tuberculosis (XDR-TB), which is resistant to most second-line antibiotics as well.

To prevent the emergence of drug-resistant strains, the World Health Organization recommends that TB treatments should be conducted following a strategy known as a Directly Observed Treatment Short-Course (DOTS). The essence of DOTS is regular supervision by a health-care worker for the duration of the treatment, together with a guaranteed supply of drugs until the treatment is completed.

Failure to follow a DOTS-like approach places patients and communities at seriously heightened risk of TB. A dramatic surge in MDR-TB in Eastern Europe in the late 1990s was attributed to the limited and inadequate treatment given to TB sufferers in Russia’s overcrowded and insanitary prison system.

DOTS is effective but expensive. Over and above the cost of the drugs is the cost of maintaining health workers in the field, particularly in the isolated and challenging conditions of the far north. To be effective DOTS workers must not only possess the appropriate medical skills, but they must also be able to gain the trust of the communities within which they work—a potentially uphill task among people who still remember the aggressive tactics of the TB-screening coastguard vessels of the 1950s.

The lack of sufficient effective health care workers is compounded by the social ills attendant on chronic unemployment. Alcoholism and drug abuse are rampant, accompanied by resigned indifference to the sustained pursuit of long-term goals. There is a high probability that courses of treatment lasting half a year or more will not be completed, with a consequent escalation of risk to oneself and others.

Demands for funding and programs to recruit and train healthcare workers, including workers recruited from the Arctic communities themselves, should be raised and unequivocally supported. But it is hard to avoid the conclusion that the upward turn in Inuit TB rates is a symptom of a much broader despair.

Since the brief Arctic summer of optimism at the height of the post-war boom, an entire generation has grown up knowing nothing but poverty and permanent unemployment. It is blatantly clear that there will be no fundamental change in their situation under the current political and economic system.

The working class must come to the defence of the Inuit and all Canada’s First Nations peoples as part of its struggle to develop an independent political movement—uniting native, French and English-speaking, and immigrant workers—against Canadian capitalism and for the socialist reorganization of society. Only by replacing a social order that has private profit as its animating principle with a society focused on fulfilling human needs will it be possible to overcome the centuries-old oppression of Canada’s aboriginal peoples.

This author also recommends:

Canada’s “Northern Strategy” and the militarization of the Arctic
[10 September 2010]