I want to thank the committee for inviting me. I speak as an individual rather than on behalf of any organization.
I have four recommendations.
One, there must be one single unified TB program in each province for both aboriginal and non-aboriginal people. The program must be accountable to and the responsibility of the chief provincial officer of health. The current system of two TB programs, one administered by FNIHB, the other by the provincial department of health, is not only inefficient but counter-productive. TB does not respect boundaries and cannot be controlled by fragmented methods. The responsibility and accountability are opaque in the current system. Cooperation and communication should not depend on personality but should be mandated. People may argue about whether two public health systems, federal and provincial, work for other diseases such as hepatitis, but it clearly does not work for tuberculosis.
Two, there must be clearly articulated objectives, performance targets, and yearly evaluations. These must meet national and international standards. The data must be openly available and shared. This is required in order to expose what is being done and what is not being done in aboriginal TB programs in Canada. Meaningful data are not currently uniformly available. Patients are often blamed, but programs need to take a hard look in the mirror. Confidentiality is often used as an excuse for secrecy; however, it is possible to share information while ensuring patient and community confidentiality. If we had information we would see that some programs succeed and some fail. We see late diagnoses, misdiagnoses, inadequate treatment, failure to contact trace, and failure to employ prevention therapy. The causes of failure include lack of fiscal human resources, insufficient knowledge, insufficient skilled or consistent staff, failure to endorse or follow accepted guidelines, and failure to engage communities. Aboriginal people need to be part of this process. Programs must be accountable to the health authorities but also to aboriginal people.
Three, TB programs must support, nurture, and form a true partnership with those in each community who have capacity. This promotes community ownership of problems and the solutions. TB programs are often so focused on the disease, they fail to use local people. The Navaho have a successful program run by local Navaho people. They are responsible to the Indian Health Service, but their community feels ownership because they see their own faces working the program.
Four, the social determinants of TB, including poor housing and poor nutrition, must be addressed seriously and credibly. There is an unfortunate tendency of TB programs to blame these social determinants for the failure to control TB. However, we have to remember that the fastest decline ever recorded for TB occurred in and among the Inuit from 1960 to 1980, and it was achieved primarily through the medical program.