TUBERCULOSIS: TB once again stalking the Canadian Arctic

PATRICK WHITE 2010-December 13-Toronto Globe and Mail

Six decades ago, a malady known as consumption stormed across the Arctic, snuffing hundreds of lives, tearing apart thousands of families, and seeding a deep distrust in a bungling public health-care system.
Now, the pernicious disease written so indelibly upon Inuit history and psychology is making an unwelcome return to the North. This week, Nunavut recorded its 98th case of tuberculosis in 2010, the most logged in the territory’s 11-year history.
The increase is particularly stark compared with the rest of the country: Nunavut’s infection rate is now 62 times the national average, adding to the territory’s standing as one of the world’s worst places for respiratory health.
The outbreak has alarmed health officials, who chalk it up to abysmal living conditions, the strange nature of the disease and fading expertise in an illness whose fiercest days were considered to be long gone.
“Tuberculosis doesn’t require any fancy machines for treatment, it just requires skilled, dedicated people,” said Pamela Orr, a professor of medicine and microbiology at the University of Manitoba and a leading researcher of infectious diseases in aboriginal populations. “We don’t have many in Canada because TB is a bit of a forgotten sheep in the medical field here.”
The resurgence comes with grim historical echoes. By 1956, the federal government had snatched one in every seven Inuit from their homes and placed them in southern sanitoriums, where it was thought a combination of rest, good nutrition and good hygiene would cure the illness.
Many never returned. Their families rarely found out how they died.
“There remains a lot of residual negativity against the health-care system because of that,” said Isaac Sobol, Nunavut’s chief medical officer of health. “There was a lot of grief and trauma associated with the disease.”
While TB has retreated since then, poor living conditions in Nunavut have not. The territory has the socio-economic indicators to rival developing nations: Half of all homes are overcrowded or in serious need of repair; 70 per cent of kindergarten pupils go to school hungry; half of the residents qualify for some form of social assistance; about 70 per cent of Nunavummiut smoke.
Those conditions alone don’t generate the disease. Nunavut also has a high percentage of middle-aged and older residents who carry a dormant version of tuberculosis from exposure to a past epidemic that may have been inadequately treated.
“This prevalence of latent infection is the tinder for the forest fire, and the social conditions provide the spark,” Dr. Orr said.
The medical establishment is debating how best to tackle the rising tuberculosis rates. One faction insists that the only cure is for governments to confront socio-economic conditions head on. Others argue in favour of a ramped-up treatment method. They cite Stefan Grzybowski, a doctor and researcher who launched an aggressive northern program of tracking and treating tuberculosis at home with a slew of new antibiotics. The approach led to the largest decrease in tuberculosis infections ever published.
“It was an almost military-style campaign,” said Dr. Orr, who says a partial return to the Grzybowski days may be needed.
There are significant hurdles to any tactic.
While tuberculosis is curable, the antibiotic regimen is long – six months or more. Already, the government of Nunavut is resorting to incentives such as a free hamburger and fries to persuade TB patients to take their medication.
Health Canada, which largely leaves TB up to the provinces and territories, has spent $9.6-million fighting the disease in the past year, even chipping in a comic book showing young Inuit in parkas demonstrating the benefits of taking TB medication.
But such contributions can seem paltry in a territory where the health system is already stretched.
“Staffing is always an issue,” Dr. Sobol said. “Within a limited budget, to have enough people to fly to a community and trace the source of an outbreak is a challenge. ... For a long time now, I’ve thought that TB does not get the recognition it should be getting.”
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