by Alexandra Boothroyd – BA History, University of Sussex
Public health is shaped by history, as demonstrated by crises such as the explosion of HIV/AIDS among South Africans in the 2000s: a product of poverty tied to decades of apartheid and governmental refusal to support life-saving anti-retroviral therapy. The enduring threat of tuberculosis in Indigenous communities in Canada is also a deeply historical issue, inextricably linked to the nation’s colonial past.
March 24th marks World Tuberculosis Day. For the better part of a century, tuberculosis (TB) was the leading cause of death worldwide, and though the number of cases has fallen steadily since the late 1940s, it remains the most common cause of death by infectious disease. TB is a curable and preventable disease, and thus its continued presence speaks of a crisis of public health.
Caused by Mycobacterium Tuberculosis, TB is spread through droplets in the air when those infected with its active form cough, sneeze or speak. Up to a third of the world’s population is infected with latent TB infection, yet less than 10% of cases will become active. The active disease can affect any part of the body, however pulmonary cases are the most common, causing chronic cough, fever, night sweats and weight loss. Today the prognosis for active TB is relatively good if caught early on, and a combination of antibiotics (rifampicin, isoniazid, ethambutol and pyrazinamide, among others) administered over many months will cure most cases. Yet uneven access to treatment and the threat of Multi-Drug-Resistant TB (MDR-TB) – frequently tied to historical injustices — mean that the burden of this potentially fatal disease remains heavy.
To many in the UK, TB conjures Victorian associations. Its spread was indeed facilitated by much of what characterised the 19th century; intense industrialisation and urbanisation came hand in hand with cramped living conditions, poor sanitation and ventilation. TB thus became inseparable from class; though it transcended class boundaries, “the consumption,” as it came to be known, affected above all the urban poor.
In other industrialized countries, TB holds similar associations, and has been all but forgotten by much of the population. In Canada, however, the disease continues to thrive in certain indigenous communities; and though indigenous people (including aboriginal First Nations, Inuit and Métis people) make up only 5% of the Canadian population, they account for 17% of all cases. Canadian residents who were born abroad account for the vast majority of the remaining 83% of cases. This discrepancy speaks of the stark contrast between living conditions for indigenous and non-indigenous Canadians; a contemporary problem deeply rooted in colonial history.
TB was first brought to Canada by European settlers around 1700, and spread west with the establishment of the Canadian Pacific Railway in the late 19th century. An epidemic tore through Inuit communities during the 1950s and 60s, infecting over a third of the population. Due to the inadequate provision of health care in these communities, many were sent south for treatment in sanatoriums. The average stay was upwards of two and half years, and authorities often failed to notify the families of those who died in these facilities.
Today, much of Canada’s indigenous population live on reserves in remote parts of the country. High household occupancy density, poly-substance-use and delay in seeking treatment all contribute to the high instances of TB in these communities, in some cases up to 38 times the national average. Yet TB isn’t the only health problem affecting indigenous communities disproportionately; obesity and poor mental health contribute to an average life-expectancy 5-10 years less than that of the general population. Access to medical treatment is patchy at best; maternal and paediatric health care is not universally available, palliative care and rehabilitation therapies receive no government funding, mental-health services and addiction treatment fall short of demand. This is above all representative of systematic governmental neglect of Indigenous peoples, yet the issue also has a geographical angle. Covering roughly 10 million km2, Canada is the world’s second largest country. While roughly 90% of the population is concentrated along the southern border, many Indigenous reserves are extremely remote, hundreds of miles from the next settlement. Getting doctors to these communities is thus difficult, and coupled with a severe lack of government funding, health care remains inadequate.
More broadly, there exists a dramatic socio-economic gap between Indigenous and non-Indigenous peoples, directly linked to the systematic oppression and neglect of indigenous population. Following European settlement, church-run and government funded Residential Schools were set up, bringing the involuntary removal of Inuit, Métis and First Nations children from their families in the name of “aggressive assimilation.” Forced to convert to Christianity, speak English and abandon traditional ways of life, these children suffered physical, sexual and psychological traumas that have shaped consecutive generations.
Canada is among the world’s wealthiest countries and most of its citizens enjoy access to excellent public health care. Yet like other former colonies, there exists a discrepancy between living standards and privileges afforded to the indigenous and non-indigenous populations. Most observers agree that the problem of TB in Indigenous communities is largely a colonial legacy, perpetuated by the socio-economic development gap and continued lack of adequate health care and health education.
“Many of our social conditions, many of our specific health status indicators, are in line with developing countries and are not in line with the greater Canadian population, says Natan Obed, president of Inuit Tapiriit Kanatami, a governing body representing Inuit peoples. Obed frames the issue of living conditions in Indigenous communities in the context of development, and highlights it as one of Canada’s most pressing issues. “If we want Canada to be able to live up to its moral high-ground then we need to start working on the social determinants,” he says.
The Truth and Reconciliation Commission (TRC) was set up in 2008 to address the legacies of Canada’s colonial past, modeled on a South African scheme that dealt with the history of apartheid. Reconciliation will need to be the first step towards health equity, and while the TRC has made steps on this direction, there remains a lot to be done.