Webinar: Supporting TB care in First Nations communitie ...

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Signy Baragar: Hello everyone and thank you so much for joining the communicable diseases and infection control webinar series which is being presented in partnership between the public health agency of Canada and the national collaborating center for infectious diseases or NCCID. My name is Signy Baragar. I'm a project lead for tuberculosis at NCCID and I will be today's moderator. 

Today's webinar is the first in a two-part series organized and planned with the guidance of an excellent advisory committee of First Nations and Inuit health professionals and community leaders. And we are so so grateful for all of their support and expertise in developing this webinar. As we're gathering virtually today, I want to start off by acknowledging the different lands that we each find ourselves upon. 

NCCID and I are situated on Treaty 1 Territory on the ancestral lands of the Anishnabeeg, Anishniniwak, Dakota Oyate, Denesuline and Nehethowak/Inninwak Nations. It is also in the heart of the homeland of the Métis Nation. As a fourth-generation European settler, I am thankful for these lands that I am able to live and work upon and I recognize the responsibilities that I have inherited for its protection.  

As an organization, we are committed to advancing reconciliation and action on the Truth and Reconciliation Commission’s Calls to Action and Missing and Murdered Indigenous Women and Girls Calls for Justice. The content shared by our speakers today will relate to the Calls to Action 18, 19, 20, 43, and 57, and Calls for Justice 2.1, 4.1, 4.6, 7.6, and 15.7. 

Today's webinar includes external speakers which may not reflect the views of the public health agency or NCC and a recording of the webinar along with a short feedback form will be sent to you after the webinar. The session will be conducted in English. However, if you'd like to listen in French, you can access simultaneous interpretation by selecting the interpretation B button at the bottom of your screen. 

And to help reduce background noise, your audio has been muted and participant video has been disabled. But if you experience any technical issues, please reach out using the chat function. and you're welcome to communicate in the chat in either English or French. 

If you have a question for the speakers, please submit them using the Q&A function and we'll look to answer as many as we can at the end of the webinar. I would also like to note that this webinar will discuss the legacy of colonialism and the devastating and lasting impacts TB has had on First Nations communities. So, I encourage participants to please take care as they engage with this content. 

step away when needed and after the webinar, connect with a trusted support person in your life or engage in some self-care if needed. Now, to start us off, I have the pleasure of introducing Elder Pashe to open today's conversations in a good way.  

Elder Pashe: Good morning, everybody. 

I'm very honored to be asked to be doing this this morning for a very important purpose.  I'm not going to keep you too long. I just have a few things to say and give everybody some hopefully some good thoughts for the for today. 

Okay. So, I would like to start by saying though that how important this group and work is not only to my people but to all people as a whole. And knowing that there are groups out here that are watching out for our health and wellness brings happiness to us all and you are appreciated. 

Okay. So, Creator, please watch over us all so we can improve our lifestyle and bring us together. Bring togetherness to everybody, especially at times like this. 

Help us to use the tools that we were given such as listening, patience, and respect to bring everyone together so we can control our health and happiness without using fear and anger. give a bad strength to everybody in this webinar in order to open their eyes and to see more clearly and to help with the pandemic. [unclear], thank you very much. 

Signy: Thank you so much Elder Pashe for your generous welcome and for sharing your words, wisdom and guidance with us today to open this session in a good way. I'm now excited to welcome our panelists for today's webinar. I'll ask them to turn on their videos now so that we can see your faces while I introduce you. 

Tina Campbell is the TB Advisor for the Northern Inter-Tribal Health Authority, a First Nations organization supporting 33 on-reserve communities across northern Saskatchewan. She also contributes to Stop TB Canada and Lung Sask, where she advocates for equitable access to TB care for Indigenous communities, drawing on both her professional expertise and personal experience with TB. 

Marilee Nowgesic is currently the CEO at the Canadian Indigenous Nurses Association and located in the national capital region, Ottawa.  She is also the co-chair to the design of the national Standards for Cultural Safety and Humility with the Health Standards Organization. Her work with the Public Health Agency includes a seat at the National Advisory Committee on Immunization table, and the Agency’s Indigenous Health Working Group as part of a 2-year pilot to include Indigenous healthcare providers engagement and expertise. 

Liza Sam is Dakelh-un from Nak’azdli, “The place where the little people’s arrows flow out of the lake”. After working over 21 years at Nak’azdli Health, Liza joined the First Nations Health Authority Northern Nursing team, providing a range of nursing services to many First Nations communities across Northern BC. Today, Liza works with nurses across BC as a TB Clinical Nurse Educator.   

And with that, I'll now turn things over to our first speaker, Tina, to get us started.  

Tina Campbell: Good afternoon, everybody. Thank you for the beautiful introduction. 

a special thank you to our elder for opening the session in such a beautiful way. I am grateful for the opportunity to be part of this important webinar series. Thank you for taking the time to join today. 

My presentation is called Understanding the Realities of Tuberculosis in First Nations Communities. In the next 15 minutes, I'll provide a brief overview of the current tuberculosis situation in Canada and share some insights into TB and First Nations communities. I also want to acknowledge that my understanding of TB is shaped not only by my professional roles working in various Indigenous communities in Canada, but also by my personal and familial experiences with TB. 

I will touch on how the legacy of colonization, ongoing social inequities, and stigma continue to impact TB outcomes today and why it's important that we recognize and address these realities. I recognize that 15 minutes is only a short time to speak on such a complex issue and what we've covered today will provide a foundation.  but the learning must continue. 

To build on that, let's start with a closer look at what tuberculosis looks like in the Canadian context. TB is not a new disease. It has been known for thousands of years and was once called consumption because of how it slowly weakened the body. 

It affected people across the world and was once one of the most feared diseases. Before modern medicine, it spread easily and caused significant illness and death, especially in places where people were living in crowded conditions with limited access to food and health care. In Canada, TB was introduced through early European contact and and spread as settlers moved across the country. 

Indigenous populations, including First Nations and Inuit communities, were particularly impacted as they had not previously been exposed to the disease and had little natural immunity. Rates of TB dropped significantly in the mid-1900s with the introduction of treatment and better diagnostics. While Canada currently has one of the lowest overall rates of TB in the world, the disease has not disappeared despite being a preventable and treatable illness. 

The Public Health Agency of Canada reported that in 2024 there were 258 cases of active TB reported throughout the country. TB in Canada is also not experienced equally. In fact, we continue to see disproportionately higher rates among Indigenous peoples, particularly Inuit and First Nations communities in addition to those born outside of the country. 

In this graph, PHAC compares TB incidence rates among three Indigenous groups with Canadian-born non-Indigenous individuals and those born outside of Canada. Inuit populations have the highest incidence of TB per 100,000 people. First Nations rates are also elevated, higher than Métis and Canadian born non-Indigenous populations and slightly lower than those born outside of Canada. 

This graph presents data from the public health agency of Canada showing TB incidence rates by province and territory in 2024. The highest rates are seen in Nunavut followed by the Northwest Territories, Manitoba and then Saskatchewan. This reflects ongoing systemic and structural inequities. 

And before we look more closely at First Nations communities, it is important to ground ourselves in this reality that TB in Canada is not just a medical issue. It's a social, historical, and structural one. Let's take a closer look at northern Saskatchewan where I currently work as the tuberculosis adviser with the Northern Intertribal Health Authority. 

Our organization serves 33 First Nations on reserve communities, representing approximately 47.9% of the total on reserve population within Saskatchewan. However, we only make up about 3.2% of the province's total population. When we look at the data, however, we see that TB rates within these communities are significantly higher than those seen across the rest of Saskatchewan and Canada. 

And this next graph helps illustrate that disparity. This graph reflects TB rates from 2016 to 2025. We saw some of our highest numbers between 2021 and 2023 following the onset of COVID-19 pandemic. 

During this time, much of the healthcare workforce was focused on COVID-19 response and TB screening and early detection were often delayed. As a result, we began to see more advanced disease at the time of diagnosis, including severe and life-threatening forms of TB affecting the spine and brain with some long-term impacts. Between 2021 and 2023, we responded to four community TB outbreaks, all of which since have been rescinded. 

However, we currently are managing one other outbreak that was declared in January of 2025 and remains ongoing. Throughout this time, our program faced significant challenges and barriers in delivering TB services. This brings us to an important question. 

Why are these impacts being felt more heavily in First Nations communities? To understand that, we need to look beyond the data and explore the broader social, historical, and systemic factors that continue to shape these outcomes. So, why are rates higher among First Nations communities? 

We are still seeing the impacts of overcrowded housing, food insecurity, limited access to health care and stigma and mistrust because of the historical treatment of Indigenous peoples. These are not just background factors. They are drivers of transmission, delayed diagnosis and challenges with treatment. 

TB in many ways becomes more than a disease. It becomes an indicator of inequity. Now into the final section of this session. 

Let's talk about the legacy of colonization stigma and the social inequities that affect current health outcomes. To understand TB and Indigenous communities, we must acknowledge the history behind it. The spread of TB was not accidental. 

It was shaped by policies of forced relocation that separated families from their lands, livelihoods, and ways of life. Reserve systems and institutions created to segregate Indigenous peoples. And these led disrupt to disruptions of sorry these disruptions led to hunger, overcrowded housing, and conditions where TB could spread rapidly. 

In institutions such as residential schools, many children became ill and far too many never returned home. Later, individuals diagnosed with TB were sent to Southern Sanitoriums often for years, separated from their families, language, and support systems. Again, facing the same uncertainty of whether or not they would return home. 

These experiences left deep emotional, physical, and spiritual scars that continue across generations. That history is still carried today. It shapes how communities experience TB and how they engage with care. 

I just want to take a moment to point out these photos on the slide. On the left are photos of the Fort Capel Sanatorium southern Saskatchewan. And on the right that is my grandmother, Melanie Deschambeault, outside Fort Capel Sanatorium the 1950s where she was sent twice. 

At one point during one of her stays, one of her young children under the age of 10, my aunt was there at the exact same time, but they were not allowed to interact. And you can imagine what that must have felt like a mother for a mother and for a child in a place that was unfamiliar, isolating, and frightening. These experiences didn't just end when they left those buildings. 

They shaped how people viewed healthcare, trust, and safety moving forward. We also have to remember it wasn't only those who were sent away who were affected. It was families, family members and communities left behind. 

My grandmother also left her husband and some young children. And one of my aunts that was left behind as a young child shared that she struggled to trust after that experience cuz she was told that her mother wouldn't come back, that her mother was dead. And when I reflect on this, I think about the strength and the perseverance it took for my grandmother to survive that experience. 

And it's powerful and honestly humbling to realize that if it weren't for her strength, I wouldn't be sitting here presenting to you today. When we look at TB today, we continue to see the impact of social determinants of health in very re real ways. In many remote and northern communities, housing remains overcrowded. 

Units are in need of repairs and units are poorly ventilated. These conditions allow TB to spread more easily and in many ways mirror the environments where TB thrived historically. Nutrition is another key factor. 

Access to fresh, healthy food is often limited due to cost and transportation barriers, while processed foods are more affordable and have a longer shelf life. This contributes to poorer health outcomes and increases the risk of other illnesses like diabetes and heart disease, further impacting a person's ability to fight infection. As well as being diagnosed with certain illnesses, this can increase your risk of becoming infected with TB. 

Access to health care also remains a significant challenge. Many communities are remote or fly in only with hospitals and specialists located far away. High turnover among healthcare staff makes it difficult to provide consistent ongoing care. 

All of this can delay diagnosis. And with TB, delays matter. In some cases, individuals may avoid screening altogether, especially when TB is viewed negatively. 

And that leads us into an important part of this conversation. TB is not just an illness. It is shaped by history, experience, and how our communities carry it. 

Stigma is a social process where individuals are devalued, judged, or treated differently because of a condition like tuberculosis. In many communities, TB is still surrounded by fear and misunderstanding. And because of that, people may hesitate to get tested or seek care. 

They may worry about how they will be seen, how they will be treated, or what others will say. I see stigma in real time. When outbreaks are declared, there are times when communities choose not to publicly acknowledge them out of fear of discrimination or being treated differently by neighboring communities. 

We've had individuals travel to other communities for care and experience discrimination simply because of where they are from. I've heard people say things like, "They have TB, stay away from there." Or, "If they if you're from that community, don't come visit." And these words, they carry weight. They reinforce fear and they deepen stigma. 

We often hear that TB is a disease of poverty, but in reality, it's a disease of inequity. Like I keep saying, it thrives in conditions like overcrowded housing, food insecurity, and limited access to health care, not because of individual choices, but because of systemic barriers. When TB becomes linked to poverty, it can also become linked to judgment. 

And that's where stigma grows. People may feel shame. They may delay getting tested. 

They may hide their diagnosis. And that delay can have serious consequences because early diagnosis and treatment are critical. And the reality is treatment is not easy. 

TB treatment can require multiple antibiotics taken every day for months. Often this is done through direct observe therapy or DOT where a trained worker administers and watches each dose being taken. While DOT is the safest approach, especially with medications that can have serious side effects, it can also make treatment feel very visible and for some that can add to the stigma. 

At the same time, especially in remote communities, DOT is more than just treatment. It's direct link to care. It ensures people are supported, monitored, and quickly assessed if concerns arise. 

Stigma doesn't just affect health. It affects daily life. Relationships can change. 

People may feel isolated. It can even impact someone's role in their community and their ability to work. And in our community, stigma is not new. 

It's rooted in history, in past experiences, and trauma, and in mistrust that still exists today. So, while inequity creates conditions for TB to spread, stigma creates the silence that allows it to continue. As we move forward, it's not enough to address TB medically. 

We must also create safe, supportive environments where people feel respected, supported, and not judged for coming forward. At NITHA, our approach is rooted in walking alongside our communities, not leading ahead, but moving forward together. We strengthen community-based TB programs by supporting the people on the ground, our TB workers and nurses who are doing this work every day, often in their own communities with care and commitment. 

We expand screening and early detection so that TB is found earlier before it has a chance to impact families and spread within households. But just as important, we focus on building trust. We know that trust takes time and it comes from relationships from showing up and from providing care in the way that feels safe and respectful. 

We continue to raise awareness and reduce stigma because no one should feel alone, ashamed, or judged for going through that TB treatment. This work is not quick and it's not easy, but it's steady and is grounded in community. And together, step by step, we are walking towards TB elimination. 

Oh. So, in closing, I just wanted to acknowledge this poster that you've seen throughout my presentation. It was created by my son, which makes it especially meaningful to me. 

At the center, you'll see lungs filled with floral designs inspired by bead work with green representing life, breath, and our connection to the land. The medicine wheel surrounds it reminds us of balance and wholeness. On one side, it reflects the past stories being shared between generations, including experiences of loved ones who were taken to TB sanatoriums. 

These stories are still carried with us today. On the other side, it shows knowledge being shared and what TB care can look like moving forward. grounded in awareness, understanding, and community. 

For me, this piece is really powerful because it shows our next generation is watching. They see the work being done. They see how hard we work to bring care to the most vulnerable. 

And more importantly, it shows what they can learn, what they carry forward and choose to share in their own meaningful ways, just like this poster.  

Signy: Thank you so much, Tina. I'll now move it on to Marilee. 

Marilee Nowgesic: Hi, everyone. And so I'm going to try to do this quickly because I'd rather you hear from again from the nurses.  

I am the chief executive officer with the Canadian Indigenous Nurses Association. I'm very grateful to PHAC for hosting this webinar today as tomorrow is World Tuberculosis Day as we recognize this around the globe. CINA is the advocacy, research, education and policy health sector in regards to the Canadian Indigenous nurses. 

What we're going to try to focus on in this particular segment is the critical concepts that we want to be able to address regarding TB and that is through cultural safety which Tina has brought forward very eloquently through the Saskatchewan lens, cultural competence and cultural humility. But please remember that cultural safety and cultural competence are different and need to be addressed differently when we are looking at our health care providers providing the information, the treatment and or a plan for our people at the community level. We must recognize and I'm thankful that many of you have had an opportunity to look at the chapter 12 regarding the Indigenous portion from the Canadian Journal of Respiratory Critical Care and Sleep Medicine. 

This will give you some key points on how we're looking at addressing TB and its eradication around the globe. The one thing that has now changed significantly is that the United Nations Declaration on the Rights of Indigenous People is now part of Canadian legislation. So this makes it accountable. 

The accountability factor is key now and it is one that we will help work with our community people, our health care professionals, our health care providers in addressing what is missing from your lens. We want to be able to look at knowing that our Indigenous nurses through their ways of knowing are the first point of contact regardless of where you live in addressing and targeting a plan for better health outcomes for our people. While the government of Canada in 2018 committed to eliminating TB by 2030, they also targeted the Inuit population within that elimination timeline. 

2035 is targeted for the entire Canadian population. But in the past decade, we know that we've seen a rise in the diagnosis of tuberculosis and that while only in while our Indigenous population is 10% of the Canadian population, we know that at least a quarter of the TB cases are Indigenous people. Canada faces many challenges in looking at TB medicines and the formulations that patients require. 

But health care providers have reported that access barriers result in treatment issues, increased hospitalizations, evacuation from the community, poor patient health outcomes, and patient hesitancy to take drugs that are not approved by Health Canada. While all of these are important to our important and impact our people, it diminishes the aims of our non-Indigenous and Indigenous partners in being able to target TRC outcomes like those mentioned by Tina in the previous presentation. We need to consider all of the social determinants of health as we try to address these so that we can align them with the regional needs and for our healthcare providers. 

Thank you for your time and best wishes to everyone.  

Liza Sam: Sorry. Well, there we go. 

so I just like to acknowledge the tradition lands an ancestral and unceded lands of which we are all calling in from today. we honor the past and present stewardship of these lands throughout generations. [unclear] or Nak’azdli. 

my name is Liza Sam and I belong to the frog clan and I come from the place where the little people's arrows flow out of the lake, otherwise known as Nak’azdli or colonially known as Fort St. James. I'm very honored to be joining you today and I'd like to thank Elder Pashe for her opening words and blessings and just starting us off in a good way. 

before I start, I'd like to just provide a little context for our work in British Columbia. This map is a representation of the First Nations Health Authority service delivery area throughout British Columbia. In BC, there are over 200 First Nations communities, each with their own histories and experiences with tuberculosis. 

And our team works directly with nurses from across BC who are working with clients living on reserve. Connection is so central to our work. Connection between clients, family, community, nurses, providers, and partners. 

Establishing and maintaining relationships to ensure good work can be done in partnership with client community and family. Who can you build relationships within the community? other health staff leaders. 

And this is not always elected leaders, but also community champions, community partners such as lab, pharmacy, looking at hours, shipping times, who do we go to and how do things run in each new community you come to? Learn what are the strengths of the community you are in. And remember, you are a guest to each new community. 

Find out what is the protocol and what works for your current community. Never assume what works here.  what works in your current community will work into your next community. 

In our minds, this is the diagnosis and this is what we need to do to get to our end goal.  but many times this is what we may be faced with and hoping to get someone to their end journey or their end goal. And a lot of us experience this. 

in TB care we often see people with the same diagnosis and the same goals but the way we get there can be completely different. You are the medical expert and the community and its members the persons you are working with are the experts in their lives. There together you and the client can bring together each of your expertise to the journey of healing. 

They are the one constant in their own life work and they know what will work for them. Involve them to be a part of the solution. Here, sorry. 

Here is an example of what wraparound services may include. These are situations we all work with. How do we manage TB while thinking outside of the box to achieve and protect the wellness of the client and community? 

At the center, we have a person starting out with TB preventative medications or very sick a very sick person diagnosed with TB disease. How can we gain the trust of the client to participate actively in their care plan at the same time reducing stigma, protecting privacy and helping community members to trust the system? How do we manage and involve the many participants in the holistic care of the client and community? 

Start by building relationships with clients and the teams involved. provide by providing by starting surrounding the individuals and communities with safe and supportive environments. Some of examples of working outside the TB box. 

Ask who else can help? Are there community support workers or caregivers we can have access to that can help us do the work that we need to do? have culturally safe TB educational resources and communications. 

If you go to our FNHA.ca and look up our TB services, you'll find some of our resources that we have at First Nations Health Authority. and just one example, when I was working in community as a nurse, we always I always tell nurses to look for what is their word for sputum their language. and our word was quest in our language. 

So we always had a poster up that said got quests come see the nurse. And so I always encourage nurses to like find out the word for sputum your community and make that a part to reach for the elders because sometimes you would talk to them and say I need a sputum and they'd have a confused look on their face and then you'd say you got I need your quest and they'd say oh okay and so it just helped by bringing that simple word into our work to just help us get forward in what we needed to do. we reduce to reduce barriers we worked with a medical health officer we worked with a medical health officer sorry who made lab and chest x-rays as a walk-in appointments for us. 

And this was especially important when we were working with hard-to-reach clients. And so when we had someone that in our in our presence, we could just whip them off and take them over to lab and x-ray and get it out of the way for them really quickly rather than for them booking appointments or waiting when we might not see them again. we would bring contact tracing to the people we worked with where they felt safe and we would go to them and bring snacks and treats with us. 

we would find creative incentives such as favorite foods, traditional foods, or gift cards to help us do our work.  mental health can be easy as connecting them to a counselor or providing a listening ear while you're transporting clients.  we always help clients to seek out community programs to fill their calendars and agendas,  fill up their days,  to help them get to the end of their treatment journey. 

and we would sign them up for grief and loss workshops or job readiness programs, anything that was happening in the community, and sign them up to take the take their courses and fill up their schedules while they recover.  in contact tracing,  we asked who else are you worried about? We would say our our our script of who's contact, who, what timelines did you get sick? 

And I go through our whole script, but we had someone in all I the simple words were just  who else are you worried about? And he was really worried about these other people and who were who didn't even come on our list at all. So just involving him and asking who else are you worried about just brought more people in and brought him as part of the journey and the solution in his situation. 

Who else can help us with DOT? We partnered with sometimes we can partner with pharmacists to offer TB meds when and one time we had we partnered with a pharmacist to do the DOT when the person was coming in for their daily OAT treatments. and so we partnered it up and it worked well for that for the client at that time. 

communicate client's history to the 20 nurses after you you've moved on so the client doesn't have to go through unneeded procedures or testing or telling their story over and over. Find a way to really flag client files and that you need to make sure that you're communicating that history so all the nurses coming after you after you've moved on can find it easily and help move that client's journey quicker. help the client and community to understand and know their TB status so that they may advocate for themselves or their family when the new staff come in after you. 

Remember they are the one constant in their journey long after healthcare providers have moved on. I just want to say thank you and Signy for inviting me today for the honor of speaking with you all today and just help continue work to help reduce stigma and fear and mistrust by teaching about the new story of TB. the story where we have better treatments, we have better outcomes and Indigenous people are more a part of their their own journeys and a part of the solution and that I just want to say thank you for having me here today with you. 

Signy: thank you so much Liza and Tina and Marillee for your wonderful presentations today.  at this time we have about 15 minutes or so to open it up to questions from the audience. So, please submit your questions using the Q&A function found at the bottom of your Zoom screen. 

we do have one question already. this question is about based off the pre-reading the suggested pre-reading which was chapter 12 of the tuberculosis standards and this person has said that in the reading it says there was evidence that TB occurred sporadically among Canadian Indigenous populations prior to European contact but it was further dispersed after European contact and they're just wondering if they could get a little bit more information about if one of you could speak a bit about how the European contact and colonization contributed to the large-scale TB epidemics historically and that are still ongoing today.  so either of you that might want to this this question might relate most to Tina your presentation at the start but if you if either of you want to take a take a go. 

Tina: Signy could you repeat the question? 

Signy: Absolutely. Yes. so the question was saying in the in the TB standards chapter 12 it was saying that there has been some evidence that the TB was occurring sporadically among Canadian Indigenous populations prior to Canada European contact but that it was genomic analysis found that it was further dispersed after European contact. 

And so they're wondering if someone could speak a bit about how the European contact and colonization contributed to the largescale TB epidemics that that we've seen since then and continue to see today. 

Tina: From the things that I've read about in terms of contact of TB with Indigenous peoples in Canada. it was brought when you know when they were doing things like doing the railway across Canada brought to various remote communities that way and then obviously to the north with the Hudson Bay trading the Northwest Company. so we had people going to the northern parts and that's how TB was brought to various regions. 

and of course you know Indigenous peoples were isolated into remote communities like in the Arctic they were taken from where they were brought up to hunt and live and you know and have their community. So they were forced relocation is what I had mentioned in my in my PowerPoint. so of course they were taken away from their normal means of hunting and gathering into places that didn't have the the that to sustain their their livelihoods and their health and their well-being. 

so a lot their health struggled a lot and then obviously disease it just makes people more easily susceptible to illness. and that's how the numbers rose. And then on in First Nations communities on reserves a lot of people were not allowed to leave reserves certain periods of times. 

And if when they left reserves they were specifically gone to residential schools, Indian hospitals and those institutions where they say as well that during that time frame that you know things that were readily available for non-Indigenous Canadians treatment wise medication wise even when it was introduced Indigenous people still weren't given the same access. So TB continued to thrive in those environments and within our communities and we still see we still see high rates of TB on reserve.  

Signy: Thanks so much, Tina. 

We have another question here.  this one might be best directed to Liza. they're saying they're asking what should non-Indigenous health workers be most mindful of when visiting a First Nations community and providing TB care. 

Liza: I think the most important thing I always talk to nurses about is building relationships with the community. But also more important is to build those relationships. You need to go into a community as a guest and remember you are a guest in the community. 

and what would you do if you went to somebody's house and would you just take over and start cooking or going in? Right. So you are coming in as a guest to somebody's home and always remember that you are a guest and be mindful of that and be respectful when you come to the communities and don't have a cookie cutter approach of if you're an expert nurse and have gone and worked in 20 communities, don't come to the new community and bring all of that work and say this is how we're going to do it here. 

you're going to ask what works for you in your community. what kind of communication do you do? Where do you meet people? 

How do you do your appointments? and really come to the community as a guest and figure out what works for that community, I believe, is a huge thing that you can do. And remember the people that you're working with, they're the one constant in their journey. 

They know what works well for themselves. They know what they've tried in the past and what works and what doesn't work for them. And really every person that you come to has a different story. 

So remember we can have the same diagnosis for many many people with the same end goal, but the way that they're going to get there is going to be very different for every person. And we need to remember that that each person has their own story. And we need to not take that story out of them or force that story out of them, but be with them as they're sharing that story with you. 

And remember, it's a honor and a privilege what you're doing helping the people on their journeys. I hope that answered.  

Thanks. 

Signy: I have another question.  Tina, did you want to speak on the question that I question two or expand? 

Tina: I just had one I just had one comment and just to be mindful of Indigenous peoples in Canada specifically too have so many different groups within the Indigenous umbrella. 

like for example in northern Saskatchewan we have Cree, we have Metis, we have Dene peoples and each community you know they may be dene speaking in this these four communities but each community is still different in the way they govern in their practices. So it's just really really important to be mindful of that. And I always do encourage people, you know, going to different communities or working with different cultures,  to just really just do some research into the area and the land and the people that you're going in to serve. 

Signy: Thank you so much to both of you. a question a third question can be directed to Tina or Liza or Marilee. how do you challenge TB stigma within your daily interactions and how can we normalize these conversations? 

Marilee: Hi Signy I'll give that a try. first of all just wanted to say that the way that we're trying to normalize is first of all getting that getting that fear away and to in order to normalize that we're work we CENA are working with many other partners and healthcare organizations in looking at the immunization strategy what does that strategy require specific to Indigenous people much like what Tina and Liza both were talking about it has its regional and needs to have its geographic location considerations. We need to be cognizant of the fact that remote isolated communities are a different target audience because who is doing the monitoring, who is doing the tracking? 

We also need to look at the governance and the sovereignity of the data collection that is being done with our frontline workers and how it is that that stewardship is being shared. Because when we're looking at that, we also have to consider the various age levels. We know that housing conditions, like Tina pointed out, is one of the many factors in looking at the spread of TB, but we also want to be able to address what is being collected, how is that being shared with the health care providers. 

And then it also triggers another level and that is the the fiscal or the financial responsibility because that is a federal, provincial and territorial jurisdiction plan or treatment on how they're going to look at this and how they're going to be able to treat TB elimination. Thanks.  

Signy: Thanks so much, Marilee. 

We probably have time for one or two more questions.  I have a question that's might be a bit of a followup on that last one. They're saying with directly observed therapy or DOT a number of clients have been finding the experience challenging and it seems like it can sometimes add stigma to TB. 

So, do you have suggestions for reducing stigma while people are receiving TB treatment via DOT or directly observed therapy? 

Liza: I can add I just I think really giving education to the community as a whole to understand TB and what TB infection and TB treatment and the people that are going through TB treatment are really doing a service to their community and making sure that they're protecting and so they need to be honored and respect for the work that they're doing on themselves to get them through their TB treatment to help protect more of their community members, but also for the person going through TB the TB journey with treatment to help them have the words to build them up their confidence and let them know that they are doing good work. they are doing a part to help their community and protect their community. 

And in all of that education with the client, giving them the words and confidence to be able answer questions to people. I think there's a lot of fear out there, but they have fear of being stigmatized too. but giving them the confidence that they are doing good work by taking the TB treatments and help them to working with people and just giving them words and letting them introduce who you are and the work that we're doing together and helping them to bring out words to share their stories maybe. 

But really a lot of education in the community on both sides of the community members and the person going through treatment will help reduce that stigma, help them have confidence and also the messages that we always give to community is all the TB work that you're doing in community is helping us to have some control where we didn't have in the past but we have today we have more control as Indigenous persons as and as individuals in a part of that TB journey today so that we have more part in and more success well when we're involved as Indigenous persons to stop TB from reaching a new generation where we didn't have control in the past but today we have way more control and way more part in that story.  

Signy: Thank you so much. well we do have lots more questions. 

We're unfortunately coming up to the end of the webinar, so I want to make a few just closing remarks.  and on behalf of NCCID and my colleagues at the Public Health Agency, I'd like to extend my sincere gratitude to you three, Tina, Liza, and Marilee for sharing your expertise with us today, as well as our wonderful advisory committee members for their guidance and contributions to this this session. And just a reminder that this is a two-part webinar series and so the next webinar will be called supporting TB care in Inuit communities and that will take place next month and we'll send out the registration link as soon as it's ready. 

So please keep an eye on your inbox and as you can see in the background of Marilee and Liza's screen, tomorrow is World TB Day. so we encourage you to check out some other webinars that are occurring. there is one next week by Indigenous Services Canada on March 31st. 

It's titled TB Talks: Building Trust and Supporting Tuberculosis Treatment Adherence in Contexts Shaped by historical harm. And it's intended for all professionals involved in supporting or providing TB care to First Nations, Inuit or Metis peoples. And so a link has been shared in your chat for that. 

And to end the webinar, please share your thoughts with us in our feedback form that will be shared with you right after this webinar ends. Thank you again so so much. We hope you enjoyed today's webinar and I wish you all a great rest of your day. 

Thank you.