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The rate of active tuberculosis (TB) on the lands known as Canada is 1 of the lowest in the world. As “a social disease with a medical dimension,” it is well-recognized that success in eliminating TB is dependent not only upon medical treatment but upon addressing and remedying social inequalities and addressing these social determinants of health. Of the 1,796 cases of active TB reported in Canada in 2017, 72% were in people born outside of Canada and 17% were in Indigenous people. The disparities in the distribution of TB that these rates reveal must be understood in terms of structural conditions and social determinants of health, including poverty, inadequate housing and overcrowding, food insecurity, and access to health care.Stigma, as a social determinant of health, is of particular focus within TB policy and care. Underpinning TB elimination strategies in Canada is the expressed need to “[e]nd the stigma and discrimination associated with TB – the underlying social, cultural, and historical factors that lead to shame and silence around TB.” Viewing TB stigma as a social determinant of health highlights how TB stigma is “inextricably linked to an individual’s social positioning.” Within Canada, TB mostly afflicts Indigenous peoples and migrants. This highlights how other structural dimensions that shape social positioning — including colonialism, racism, and migration — are affected by and influence TB stigma.The thrust of the attention on stigma around TB is that the shame associated with TB, and the fear of being isolated, is a barrier to the uptake of screening and treatment programs. The concept of health-related stigma and its intersection with other forms of identity-based discrimination are explored further in the 2019 annual report on the state of public health in Canada. Here, in the opening address, Chief Public Health Officer of Canada, Dr. Theresa Tam, describes how: Stigma and discrimination towards persons with health conditions, such as mental illness, substance use disorders, and HIV, cannot be understood or treated separately from stigma related to other characteristics such as race, gender, sexual orientation, age, and income. These many forms of stigma, that intersect in complex ways, are very much present in our health system, driving those most in need from getting effective care and accessing services. It means that we, as health system leaders and practitioners, are contributing to negative health outcomes.(p. 5) A recent CADTH Policy Insights identified the importance of colonialism and stigma as affecting adherence to latent TB infection treatment. Stigma, which resulted in avoiding contact with health care systems and providers due to fear, was seen as part of Canada’s legacy of colonial TB policy toward Indigenous peoples, particularly in the North. From the 1940s to 1960s, Canada’s TB policy was to remove Indigenous children and adults from the north for treatment in sanatoria in the south. Many died and were never heard from again, with families still searching for their loved one’s graves. In 2019, the federal government issued an apology to the Inuit for these policies and practices, acknowledging them as colonial and as a destructive force in the lives of individuals, families, and communities, and as leaving a lasting impact to this day.For newcomers to Canada, the process of settlement is known to be highly disruptive and stressful. Migrants disproportionately work for low wages and in precarious jobs, and face additional challenges finding adequate housing — all of this in addition to language barriers and the process of acculturation. The socioeconomic position of migrants is attributable to the reactivation of latent TB infections.This CADTH Rapid Response aims to describe the ways that stigma interacts in relation to structural racism, colonialism, and migration that are particularly relevant to addressing TB in Canada. This specific focus aims not to diminish or negate other forms of discrimination and structural or social relations of power. Our aim is to further a broader understanding of how these particular forms of discrimination and systemic inequalities are shaped by and, in turn, shape stigma in TB policy and care. |
