Why does TB have such a hold on the Inuit communities of the Canadian Arctic?

The ancient and deadly disease of tuberculosis has an unlikely grip on the Canadian Arctic.

In a country where the rate of TB is among the world's lowest – 4.8 active cases per 100,000 people – the territory of Nunavut is an extraordinary outlier.

About 1 in 500 people had active TB in 2021 in Nunavut, which is home to about 40,000 people, most of them Inuit.

The most recent wave of TB infections in Nunavut began in January 2021 in the community of Pangnirtung. Two years later, Pond Inlet began reporting cases. A few months after that, it had spread to Naujaat.

Since the outbreaks began, 82 people have been diagnosed with active TB, and 502 others have been diagnosed with latent TB – they're infected but don't have symptoms or spread it to others. That's from reports issued by the government of Nunavut in mid-April.

So far, five people have died.

This new outbreak comes in the aftermath of a 2018 vow by Canada to eliminate TB, a bacterial infection that is the second-deadliest infectious disease after COVID-19, among the Inuit by 2030.

And it's not as if TB is an impossible foe. "TB can be treated. It's curable," says Paul Irngaut, the vice president of Nunavut Tunngavik Inc, a group representing the Inuit in Nunavut. "TB is not scary, as it used to be."

So why does tuberculosis continue to strike in this icy, remote part of the country?

100-plus years of TB ups and downs

Outside traders introduced tuberculosis to the Inuit around 1919, and it soon swept through the Arctic Indigenous peoples as it did the rest of Canada. By 1997, though, aggressive tracking and treatment brought the rate of people with TB in Nunavut down to 1 in 3,200.

But it has since multiplied due to persistent issues that lead to greater spread: inadequate housing, poverty, food insecurity and stigma against TB testing and treatment.

Among the Inuit, that stigma stems from memories of previous campaigns to diagnose and treat the disease. Families and communities were wrenched apart during the Canadian government's efforts in the mid-20th century to control TB.

When Joanasie Illauq, a 75-year-old hunter living in Clyde River, reflects on how Inuit life has changed in a few short decades, his TB evacuation in the 1960s is the first memory to come to mind.

Illauq was 14 when a ship came to Clyde, a community about 100 miles from where he lived in a sod house with a handful of other nomadic Inuit.

All residents of Nunavut were required to go to the ship for a census – and while they were aboard, they were tested for TB. If they tested positive, they were kept on the ship with no chance to say goodbye to family or gather any belongings.

Illauq had no idea what the doctors were saying as they shuffled charts and x-rays. "I never talked English, never, nothing," he says.

He was taken a thousand miles south to a TB sanatorium in Hamilton, Ontario, where the teen boy – used to roaming land and sea to hunt ptarmigan, seals and narwhal – was confined to a bed, not allowed to get up and walk. "Never. For one whole year."

Patients who died were buried in unmarked mass graves.

Now, Illauq resists leaving Clyde River when he gets sick, even though there aren't enough health workers there to take care of serious issues.

Many challenges in the fight against TB

Convincing people to get tested is just one of the challenges to eradicating tuberculosis in Nunavut.

Another is housing: It's expensive to ship construction materials to Nunavut, so houses are chronically overcrowded.

"There are four-bedroom houses with 18 people living in them," says Dr. Kevin Patterson, a physician who works in Kivalliq, a region in Nunavut. "Most of the houses are still all heated with heating oil — the most expensive imaginable way to heat a house — and people are poor, so they seal up the cracks."

Because houses are not only overcrowded but may have poor ventilation, respiratory illnesses spread like wildfire.

Needing to fly "down south" for medical treatment is another barrier. Residents in many remote communities in Nunavut don't have regular access to doctors. For serious illnesses, residents have to be medically evacuated by plane to Iqaluit, the territory's capital, or to Ottawa or other cities in southern Canada.

As for the government promise to wipe out TB in the region, it soon fizzled as attention shifted away from the North during the COVID pandemic.

Pop-up solutions

Now pop-up clinics are being deployed to Nunavut to test and treat as many people as possible.

Last fall, Pangnirtung launched a pop-up clinic in its community hall when the local health center became overwhelmed with people needing TB tests and treatments. Testing was voluntary, but officials offered gift cards to increase participation. More than 1,100 residents out of about 1,600 were screened. The 10-week clinic, which cost about $2 million in U.S. dollars to run, discovered 6 active and 55 latent cases this way.

Now local government offices in Naujaat have been transformed into a clinic, where a doctor, four nurses, an epidemiologist, a radiology technician and laboratory technician hope to screen at least 1,000 of the 1,230 residents.

The new, temporary clinic opened on April 15 and will run until the end of May. The screening includes a questionnaire, a TB skin test and chest X-ray. Depending on what those results show, the next step can be a blood test or a phlegm sample.

"We can do the actual tests right there in one of the offices, so we can detect TB right away," Irngaut said. His organization, NTI, is partnering with the health department to run the clinic.

Most infants in Nunavut receive the Bacille Calmette-Guérin (BCG) vaccine, which protects against meningitis and TB infection in parts of the body other than the lungs but does not prevent infection in the lungs or onward transmission. It can't be given to babies with immune issues, such as HIV.

On average, one person with active TB will infect 23 other people.

While people with latent infections aren't contagious, they have about a 5% chance of developing active tuberculosis in the next five years and an additional 5% chance of developing active TB over the rest of their lives.

"Its ability to remain dormant and then reemerge subsequently has made it hard to eradicate," Patterson said. "But we've succeeded elsewhere in Canada."

Patients with active TB take antibiotics for at least six to nine months. People with latent TB take the medication for at least three months. "You don't have to go down south unless you get very, very, very sick," Irngaut said.

The idea of delivering as much TB care within the community as possible – including by health workers and non-physicians, if necessary — is similar to Paul Farmer's pioneering work in community health care, especially in low-resource settings, said Patterson.

"The attempt should always be made to finish the treatment in the local communities and avoid evacuation, because the second you start evacuating people, you create a disincentive for people to seek care," he said.

Irngaut says the long-term goal is still to eliminate TB in Nunavut. "And the only way we can do it is if we get help from everybody. It's very hard because everybody has to get screened. It's an uphill battle," he said.

Delving into wastewater

But there's another way to know when an outbreak is in its earliest days – wastewater sampling. In January, Nunavut announced a five-year plan to track tuberculosis in the wastewater.

With wastewater testing, "you don't have people go in and get clinically tested — and because of that, you can really get a perspective of what's happening in the whole community," says Robert Delatolla, a professor of civil engineering at the University of Ottawa. He has been tracking deadly illnesses like COVID and RSV in wastewater in Nunavik, an area in northern Quebec that is part of the Inuit homeland.

"Instead of testing person to person to person, it could be for five people in a home, it could be for 50 people in a cluster of homes, it could be for a thousand" people in a community, Delatolla said. It's also easier to identify outbreaks in the earliest stages and more economical than spending millions on campaigns to respond to spiraling outbreaks later on, he believes.

But while wastewater sampling and pop-up clinics like the one in Naujaat are important, Patterson said, TB will never be extinguished fully without addressing the stigma of past trauma and eradicating "the profound poverty and crowding that characterizes northern communities."

Melody Schreiber is a journalist and the editor of What We Didn't Expect: Personal Stories About Premature Birth.

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