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From the Winnipeg Free Press

Poverty the real disease - Millions spent fighting TB may be missing mark, some experts argue

By: Jen Skerritt - 11/12/2010

BERLIN, Germany -- Over the past year, Canada contributed close to $140 million to global efforts to fight tuberculosis and other diseases in developing countries such as Sudan, Ethiopia and the Philippines.

But at home, where the silent killer has remained a scourge in remote First Nations communities for more than a century, the government will fork over a mere $10.8 million between 2010 and 2011 to combat the disease.

Some medical experts and aboriginal leaders say Canada's international image masks the fact some Canadians still live in conditions often described as Third World, with residents of isolated reserves living in overcrowded homes rotten with black mould and with limited access to running water.

Last year, a Free Press series revealed some Manitoba communities have some of the highest TB rates in the world -- up to 100 times that of the Canadian average.

While experts say it is shocking that TB exists in wealthy nations, Canada is in the same bind as nations across the globe: no one has figured out exactly how to treat TB and simultaneously address the underlying social conditions that help the airborne disease spread.

Gaps in access to treatment and effective outreach programs are as problematic in remote First Nations communities as they are in some of the poorest parts of Africa, and rates of TB continue to rise in pockets of poverty in nations across the globe, including Canada.

At a recent world TB conference in Berlin, global experts discussed why a preventable, curable disease killed 1.7 million people last year. Some believe new drugs and state-of-the-art diagnostics are the way of the future and that a faster method to track, treat and cure the airborne infection will make it easier for patients to adhere to a strict treatment regimen.

Others think that's putting the cart before the horse, and medical leaders from all nations need to start pushing governments to examine the real reason TB still exists: poverty.

"Maybe all the effort in treating TB is not enough. Maybe we need to do something about social determinants (of health)," Dr. Anne Fanning, former Alberta TB control director and WHO medical officer, told a crowd of medical colleagues in Berlin. "We've accepted (disparities) but ceased to address them."

Worldwide TB rates peaked in 2004 and began to decline, according to World Health Organization's (WHO) evaluation co-ordinator Katherine Floyd, who said the slow drop comes on the heels of an intense 15-year push to halve TB rates by 2015.

Between 1995 and 2009, a total of 41 million TB patients were successfully treated in programs in countries around the world. WHO estimates up to six million lives were saved because of programs that used health workers or trusted family or community members to administer TB drugs to patients every day until they were cured.

While more TB patients are able to access quality treatment, problems with adherence to treatment and followup are still fairly widespread. More than one-third of TB patients do not complete treatment. Ninety per cent of drug-resistant TB cases are not diagnosed and treated according to international guidelines.

African countries such as Swaziland are among those hardest hit, where about 80 per cent of TB patients are also infected with HIV. Access to quality laboratory diagnostics is often unavailable, and proper health education and support is spotty at best.

Below are the stories of four countries' struggles with TB treatment.

SOME RAYS OF HOPE IN CANADA

CANADA’S overall TB rates are among the lowest in the world, but the disease has made a quiet comeback in First Nations communities since the late 1990s.

The rate of tuberculosis among aboriginals in Manitoba is 51 times that of the non-aboriginal population, and a new study by Dr. Anne Fanning, former Alberta TB control director and WHO medical officer, shows the disparity between aboriginals and non-aboriginals is most pronounced in Manitoba and Saskatchewan.

Fanning, one of the speakers at the Union World Conference on Lung Health, lectured about the burden of TB in Canadian indigenous communities. Higher TB rates are found among other indigenous populations around the world.

Last year, a Free Press series revealed some Manitoba communities had among the highest TB rates in the world. After the series ran, then Winnipeg MP and NDP health critic Judy Wasylycia-Leis brought TB to the attention of the federal health committee, which held hearings into the state of TB treatment among the nation’s aboriginal population.

The health committee recommended Health Canada step up its fight against TB and be more accountable about how it tracks, treats and monitors TB cases. The government later issued a lukewarm response, saying it will take those ideas into consideration as it renews its national TB strategy.

Experts called the response superficial and Manitoba aboriginal leaders were disappointed the strategy did not address a critical housing shortage that has helped TB spread.

Some medical experts say Canada lacks the political will to fight TB and that is why the nation continues to see rising rates of the disease.

Aboriginals have shorter life expectancies, lower overall incomes and less education compared to the rest of the Canadian population. Fanning said Canada "wins" the disparity contest between aboriginal and non-aboriginal when compared to other wealthy nations such as the U.S. and Australia.

Many northern reserves in Manitoba don’t have access to a community-based doctor, and anyone who is seriously ill must fly hundreds of kilometres south to Winnipeg. Public health nurses try to build relationships with patients to help them finish their rigorous nine months of drug treatment, but some patients still slip through the cracks and do not complete treatment.

Former Manitoba TB control director Dr. Earl Hershfield said Canada doesn’t need to borrow ideas or components of TB control from other nations. It just needs to commit to solving the problem. "There are a lot of things you could do, but there’s zero political will to do anything," Hershfield said.

Health Canada declined to speak with the Free Press for this article, and said it may "revisit this request" once its renewal strategy is complete.

In an email statement, Christelle Legault, a government spokeswoman, said Canada has reviewed what other countries are doing to fight TB to determine whether some components would be useful in preventing and controlling the disease in First Nations communities.

"Canada is seen as a wealthy country," said Chief Wilton Littlechild, a lawyer and advocate from Ermineskin Cree Nation in Alberta. "That perception masks the real situation in indigenous communities. People think all communities are healthy and wealthy, but that’s not true."

Littlechild, a rare voice of optimism, said he thinks the fact that the nation finally ratified the United Nations Declaration on the Rights of Indigenous People is a sign the government is ready to co-operate on TB and other pressing health issues. He is convinced the federal government and First Nations leaders can hammer out real solutions and effect change in communities that still live in poverty.

"I think what’s important to note is Canada is making great strides in trying to help us, trying to help us solve the situation," he said.

"It’s better to light a candle than to curse at the dark."

REMOTE COMMUNITIES GIVEN STAKE IN TREATING DISEASE

In the absence of better tools to detect and treat TB, some nations have taken an aggressive approach to treating sick people and building up outreach in affected communities.

Brazil declared TB a national priority in 2004.

The country is among the 22 worst-affected nations. The government beefed up funding for TB by expanding treatment and early detection programs and training more health workers.

Like Canada, Brazil’s indigenous population is particularly affected, and rates of TB in poor, remote villages scattered across the country are more than double the average. More than 40 million indigenous people live in South and Central America, most in Brazil and Peru.

Dr. Mirtha Del Granado, head of Bolivia’s TB program and regional advisor for TB in the Americas for the Pan American Health Organization, says the government’s commitment had a particularly good impact in remote indigenous communities.

Residents process TB tests in local labs, and people from the community administer TB drugs to people who were infected. Indigenous leaders meet with health officials to periodically discuss and evaluate the program and make suggestions.

Del Granado said training local residents to have a stake in the TB programs ensured rural areas would have a stable workforce and not be plagued by a high turnover of outside workers.

The country has seen an overall decline in TB incidence, with the largest drop in its native population.

"The incidence in indigenous (communities) is going down eight per cent per year," Del Granado said.

Del Granado said Brazil is now hoping to move away from hospitalization toward home-based TB care for sick patients and ways to incorporate traditional healing into treatment.

Despite progress, the overall health of the communities is impeded by overcrowded homes, lack of sanitation and poor nutrition. Del Granado said it’s difficult to manage the side effects of TB medication due to lack of adequate food. Even some patients say more priority should be given to obtaining better housing and access to fresh water.

"In some ways, they say the (TB) drugs were not what they needed," she said.

QUICK MOVE EASES CRISIS IN ZAMBIA

OPENNESS to change is key, but it’s often difficult to get decision makers on board, say human rights advocates.

In some instances, however, government response is swift.

In Zambia, a Human Rights Watch study of prisons found TB was spreading in cells that were so overcrowded, 60 people were sometimes crammed into spaces designed for 10. It’s estimated one-third of prisoners had TB and the number of people co-infected with HIV was 10 times that of the general population.

Joseph Amon, an associate professor at Bloomberg School of Public Health at Johns Hopkins University and lecturer at Princeton University, said many prisoners reported lack of adequate food, sexual violence and people sleeping in shifts due to intense crowding.

The Zambian government responded immediately by ordering the closure of inhumane punishment units and funding TB testing and treatment for prisons.

Amon said the quick move effectively stopped some of the gross human rights violations within prisons that helped TB spread.

Health ministries and governments often recognize their investment in TB is not paying off because of broader social issues — such as poor housing, instability and substance abuse — that don’t fall within the scope of TB control but help the disease spread, Amon said.

Health departments, social services and governments must be on the same page. Countries need to treat TB and simultaneously improve living conditions. This in turn will make patients more likely to adhere to treatment and avoid re-infection, he said.

"You can put in place effective programs and treat people effectively so they don’t become re-infected," Amon said.

There "isn’t a reason to sort of shrug your shoulders and say, ‘Well, TB just exists’ or ‘TB is inevitable’ because it’s not inevitable."

PRISON REFORMS SHOW PROMISE

SOME countries have piloted nonmedical programs to reduce TB rates.

The former Soviet state of Moldova, sandwiched between Ukraine and Romania, launched a prison reform program in 1999 to tackle a rapid rise in drug-resistant TB among the country’s inmates.

Annabel Baddeley, a World Health Organization TB consultant based in France, said Moldova took the drastic step of decriminalizing drug use and introduced alternatives to prison sentences such as probation and community services. These measures decreased the prison population at a time when the rate of TB in prisons was nearly 20 times that of the rest of the population.

Baddeley said the measures, combined with pre-release TB education programs and $100 incentives to encourage prisoners to complete their drug treatment, have resulted in some progress.

"It wasn’t an example that was completely without flaws, but there was real progress that was made by taking a step back and saying, ‘You know, what’s our objective here and does it serve anyone’s interest to put minor offenders in prison when they’re non-violent and what they really need is drug-dependency treatment?’ " said Joseph Amon, director of health and human rights at Human Rights Watch, an independent advocacy group.

Baddeley said progress has been stunted by a "perverse" incentive that’s pushed some prisoners to refuse TB treatment and become sicker.

The Moldovan government allows some prisoners to be placed in more comfortable isolation units or be released into the community as part of a "humane release" program if their TB worsens.

"The government is open to change," Baddeley said, and is currently reviewing several policies.