Nothing About us, Without us D E T E R M I N A N T I N F L U E N C E S O N T B C A R E A N D C O N T R O L

Nothing About us, Without us D E T E R M I N A N T I N F L U E N C E S O N T B C A R E A N D C O N T R O L

Inuit Nunangat s Four Regions

Context Matters Context is both historical and contemporary What is the historical context of TB in Inuit Nunangat? What is the current reality? What stands between Inuit and healthy TB free communities? How is self determination improving TB care and Control?

Context Matters. In keeping with the spirit of the Global Plan to STOP TB 2006-2015, Canada set a target to reduce the incidence rate of TB from 7.2/100,000 to 3.6/100,000 by 2015

Tuberculosis incidence rate by origin Canada: 1993-2015 40 35 30 25 Canadian-born Aboriginal 20 Foreign-born 15 10 5 0 Canadian-born non- Aboriginal 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 Year 7

Incidence per 100,000 TB incidence rate by Aboriginal origin- Canada 1994-2008 180 160 140 120 Inuit 100 80 60 40 Status Indian 20 Metis 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Public Health Agency of Canada, 2010

Rate per 100,000 population Figure 1: TB incidence rate by Aboriginal group compared with Canadian-born non-aboriginal: 2001-2010 Reporting year

Social Determinants of Health. The conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels which are themselves influenced by policy choices. (WHO, 2010). Housing Food Security Mental Wellness Access to Health Service Self Determination Tuberculosis is a social disease with a medical aspect. (Dr. William Osler, 1849-1919) )

Housing 31% of Inuit live in crowded homes ( 3% Canada) 28% of Inuit live in houses needing repair ( 8% Canada Inuit are 10 times more likely than other Canadians to live in crowded homes. Barriers to housing include: Limited economic activity Virtually non-existent private housing markets Insufficient public resources High building and heating costs due to cold climate Costly shipping and transportation of materials due to geographic remoteness (If Not Now, When? NAHO, 2010). An increase of 0.1 in the average number of persons per room in a community could Increase the risk of two or more cases of TB in the community by 40% (CTC,2007)

Food Security On World Food day, October 16 th, 2012, ITK shared some common prices of food items in Nunavut: 6 bottles of water (710 ml) $46.99 1 head of cabbage $28.54 1 package of Nutrigrain bars $16.19 1 piece of beef tenderloin (1.355 kg) $70.18 1 package of cherries (1.296 kg) $23.19 The Inuit Health Survey (2007-8): 62.6 % of households were found to be food insecure 27% of households reported some food insecurity ( 5-6 times the rate for Non-aboriginal Canadians). Malnutrition increases vulnerability to TB.

Mental Wellness Mental health issues impact on the ability to have a home, provide for a family, and make appropriate choices around health and access to service. It has impacts on treatment for those with active or latent TB infection. TB treatment is part of the colonization of Inuit. Historical factors include resettlement, residential schools creating communities struggling with multigenerational trauma Mental Health services Unhealthy coping mechanisms, gathering houses ITK has made Mental Wellness a priority for Canadian Inuit through the Alianait Action Plan.

Access to Health Service Geography is a determinant of health access to health care is also a problem not only because of distances, but because these communities struggle to attract and keep nurses, doctors and other health care providers.people must travel in order to access the service they need. This often means days or weeks away from family and social support as well as well as the additional cost of accomodation and meals. (Roy Romanow, 2002, Building on Values: The Future of Health Care in Canada.

Inuit Nunangat Medical Travel Routes Map

Self Determination Self-determination has been cited as the most important determinant of health among aboriginal peoples. (Boyer, Y. 2006, NCCAH). Self determination is the key to addressing health conditions in Inuit communities. Inuit must be engaged fully in the planning and implementation of programs that affect them. (ITK, Determinants of Inuit Health in Canada)

Nunavut Corvus Solutions.

Nunavik Corvus Solutions

Inuvialuit Settlement Region Corvus Solutions

Nunatsiavut Corvus Solutions

Governance Inuit Tapiriit Kanatami (ITK) formed in 1971 is the national voice of Canadian Inuit living in Nunangat. ITK Board includes: President, Makivik Corporation President, Nunatsiavut Government President, Nunavut Tunngavik Inc. President, Inuivialuit regional Corp. The National Inuit Committee on Health (NICoH) works directly with ITK s Department of Health and Environment as a decision making body that identifies Health issues affecting Inuit, provides guidance and advice on policy issues and makes Recommendations to the ITK Board on health matters. Committee includes representatives from the four Inuit Land Claim Organizations.

Who has control over TB? TB is a communicable disease, within the mandate of Public Health Public Health is the responsibility of the provinces and territories. Nunavut: The government of Nunavut Nunavik: The government of Quebec Inuvialuit: The government of the North West Territories Nunatsiavut: The government of Newfoundland and Labrador Throughout Inuit Nunangat, there is significant concern around the amount of Latent TB given the high rate of infectious disease. Inuit need to be part of the solutions.

Inuit Specific Tuberculosis Strategy Led by the Inuit Public Health Task Group ( sub group of ITK) Medical Officer of Health Nunavut Medical Officer of Health Labrador Grenfell Health Medical Officer of Health North West Territories Director of Public Health Nunavik PHAC FNIHB ITK staff leads on Public Health Makkivik Corp. Nunavut Tunngavik Inc. Nunatsiavut Government Inuvialuit regional Corp. Final document will go to NICoH, then to the communities for consultation Action Plan will be formulated with the committee and community input.

Inuit Specific Tuberculosis Strategy WHY: The purpose of the strategy is to outline a way forward towards the eventual elimination of TB as a public health concern in Inuit Nunangat. WHO: Inuit, territorial and provincial governments, PHAC, Health Canada, public health systems for Inuit. HOW: Innovative, sustainable, culturally safe and epidemiologically appropriate solutions, found by working together, and by learning from and sharing with others who face similar challenges. (Inuit-specific Tuberculosis Strategy, 2013, DRAFT) The power is when people come together and work as one towards a common goal (Mary Simon)

Bringing Chest x-ray to the people In 2009, the rate of TB in Nain, Nunatsiavut was the highest in the country. A review of files showed that hundreds of residents required chest x-ray as follow up to TB and Latent TB Infection. Residents had to fly to Goose Bay for x-ray and be gone a minimum of three days****. Compliance to travel was low. A strong lobby effort was mounted by the Nunatsiavut Government and public health nursing department for a digital chest x-ray clinic in Nain Overcoming opposition, and with a year of collaborative planning, the first x-ray clinic took place, Sept. 2010, the second, November 2011.

Success Outcomes: 300 chest x-rays were taken in Nain!!!!!! Human: The service came to the people. Ground support came from the community, interpreters, drivers, local media The backlog in TB follow up was cleared allowing a go-forward approach to TB control Financial: No lost time from work Savings to NIHB No need for replacement for health care staff affected Cultural sensitivity: The staff from Labrador Grenfell Health who travelled to Nain for the first time left with a better understanding of the people and their realities.

Nanilavut TB treatment has left an emotional scar that still aches across generations. (The State of Tuberculosis in Inuit Nunangat, 2011). Inuit had to go south for treatment Some did not return Inuit Graves Project Nanilavut a multi-stakeholder working group to seek information on where the Inuit who went away for TB treatment and did not return are buried. ITK and the land claim organizations.

You may not know you have TB get tested and get treatment before you get sick! TAIMA TB means STOP TB in Inuktitut

Taima TB Endorsed by Inuit ITK, Inuit Public Health Task Group ITK, National Inuit Committee on Health Nunavut Tunngavik Incorporated. Embodies the elements in the Inuit-specific Tuberculosis Strategy Innovative Sustainable Culturally Safe.