WHERE IS TB IN CANADA’S 2022 BUDGET?
Prime Minister Justin Trudeau and the Liberals have time and again signaled the importance of achieving the United Nations Sustainable Development Goals (UN SDGs) by 2030. The commitment was evident with the recent announcement of Prime Minister Trudeau as the new co-chair of the UN SDG Advocates Group. Against this backdrop, it is in the spirit of advocacy and accountability that STOP TB Canada has reviewed the 2022 Budget. Tuberculosis (TB) is an important marker of success in achieving the SDGs, with a 90% reduction in TB mortality being an SDG target for all countries around the world, including Canada. Although International Development Minister Harjit Sajjan announced on World TB Day, 2022, a financial contribution of 11 million to TB REACH – an initiative that supports the most vulnerable populations in TB endemic countries – a domestic agenda to combat TB remains absent from the priorities of the budget.
TB is the biological expression of social inequity, requiring biosocial solutions to effect elimination. In that sense, health in general, and TB more specifically, should appear in all policies, and draw significant investments from other sectors. TB is a disease that greatly impacts the most underserved members of society and is influenced by actions taken to address the broader social determinants of health, such as availability of nutritious foods, safe housing, and access to health care. As of 2020, Canada has a low overall rate of TB (4.7/100,000 population), but very high population-specific rates among immigrant/newcomer groups, First Nations, and Inuit. With a new budget focused on improving life for all Canadians, the absence of an agenda for TB signals an apathy towards achieving health and well-being that is truly for all and within grasp.
Here we analyze Canada’s 2022 Federal Budget, with an eye for where investments in TB are missing and should be captured.
Chapter 6.3: Strengthening Canada’s Ability to detect and Respond to Public Health Events and Emergencies
The government commits to strengthening Canada’s ability to detect and respond to public health events and emergencies, and highlights the need for “reliable, comparable data”. COVID-19 is presented as an example for the burden it places on Canada’s public health infrastructure. While COVID-19 has certainly tested the country’s health systems, some of the best assets in the fight against TB have been leveraged to combat COVID-19. TB investment put in place over the years gave Canada and other countries a leg up in the fight against the new pandemic. Given that responding to the needs of TB affected persons birthed this system and continues to demonstrate its strengths and weaknesses, the TB stakeholder community in Canada has been making calls for reliable, timely, and high-quality data for years. These forms of data are a cornerstone for the development of solutions to meet the needs of clinically and socio-economically vulnerable people and communities served by frontline providers. It is our hope that the additional funding to the Public Health Agency of Canada (PHAC) for improved surveillance ($436.2 million over 5 years) be partially directed towards its responsibilities to analyze and report timely TB data that are appropriately disaggregated to meet the needs of TB service providers and those at risk of disease. Crucially now, as policies and resources diverge from COVID-19, data will be key to understanding how far efforts have been set back and where we need to go to achieve elimination together.
Chapter 6.3: Maintaining the National Emergency Strategic Stockpile
The budget goes on to address the National Emergency Strategic Stockpile (NESS). TB drugs are at risk of shortages and even standard of care treatments found on the World Health Organization’s Model List of Essential Medicines, such as rifapentine for latent TB and cycloserine and bedaquiline for drug-resistant TB, are not formally marketed in Canada. The NESS might not be the best program to address TB drug shortages, but it does highlight that the budget is specific and that TB was overlooked. Programs such as the Critical Drug Reserve during COVID-19, where drugs key to COVID-19 treatment are managed to prevent shortages, could be easily adapted to address TB drugs and help create a stable supply. There is a responsibility to include TB drugs in strategic stockpiles/reserves to prevent TB and treat all cases to completion with the safest and most efficacious regimens available.
Chapter 7.2: Improving Health Outcomes in Indigenous Communities
The budget outlines commitments to move forward on reconciliation and to support strong and healthy Indigenous communities. Money is provisioned for “high quality health care” with no stipulation on spending ($268 million). Allocating money this way respects Indigenous sovereignty and the right to determine community priorities. There is, however, a specific allocation to mitigate ongoing impacts of COVID-19 ($190.5 million). There are commonalities in the transmission of SARS-CoV-2 and Mycobacterium tuberculosis (M.tb) – both are airborne and their spread are mitigated vis-à-vis non-pharmacological interventions that include testing, masking, isolation of infectious cases and contact tracing. As a result, remote Indigenous communities with high incidence rates of TB and/or COVID-19 may see dual benefits if the domestic threat of TB is recognized. For example, GeneXpert machines deployed to these communities can be used for concomitant TB/COVID-19 screening leading to improved individual and public health outcomes through timely detection. We hope to see specific allocations that address the historic impacts of TB in Indigenous communities. These include reported abuses in a segregated hospital system and related dislocation efforts (from family, community and culture); a failure to acknowledge and heal from these traumas continues to sustain contemporary TB epidemics.
Chapter 1.1: Affordable Housing in the North
On a positive note, the budget provides a specific line item for affordable housing in the North ($150 million over two years). Insufficient housing leading to crowding and poor ventilation contribute to the spread of TB. Additional housing is greatly needed. Yet, a specific mention of health outcomes linked to housing is absent in the current budget, and the tremendous preventive healthcare benefits that save lives and cut costs.
Chapter 5: Providing International Assistance
In today's globalized world, an outbreak anywhere is a potential pandemic everywhere. Viruses like SARS-CoV-2 and mycobacteria like M.tb, which spread through air, are not stopped by borders. Investments in the Access to COVID-19 Tools-Accelerator (ACT-A) and further sharing of COVID-19 vaccines are not only a morally just investment, but also offer direct health protection for Canadians.
The current budget, however, does not indicate the learnings from the pandemic to break down silos and leverage any health responses in an integrated manner. As has been demonstrated, massive disruptions in services and diversions of staff in the wake of COVID-19 have set back TB elimination efforts around the world. This erosion of the healthcare system needs to be prevented by investing in all public health programs. The budget does not mention the importance of the Global Fund to fight HIV, TB, and Malaria, despite its great need for ambitious investment and the 7th replenishment coming up this year in September. By only investing in a single disease response to COVID-19, we are missing out on an opportunity to be a global health leader in our implementation of the entire SDG agenda.
Closing Remarks
The budget outlines an inspiring number of areas that are all fundamental to the health and wellbeing of Canadians. Whether the emphasis is on housing, climate change (‘healthy air is healthy lungs’), catering to the needs of Indigenous communities or building safe and inclusive communities, many chapters in the 2022 Federal Budget are directly relevant to our mission of ending TB at home and abroad.
TB is not a disease of history – it is present, it is here in Canada and around the world. We urge Prime Minister Trudeau to take up the challenge of TB elimination and not rest on the laurels of Canada’s progress to date – a consistent TB incidence rate of four and five per 100,000 population for 15 years now, without any reduction. The convergence of the COVID-19 pandemic, war in Ukraine, and climate crisis mean that because of Canada’s inaction over years past, the resurgence of TB in our lands is becoming a growing and real risk.
- With inputs from Robin Love, Adam R. Houston, Petra Heitkamp, Courtney Heffernan, Lena Faust, Robyn Waite, and Ekatha Ann John