Supporting TB Care in Inuit Communities

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.

Jessica Helwig: Hello everyone. Thank you 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. My name is Jessica Helwig and I am a senior policy analyst at the public health agency of Canada.

I'll be moderating today's session and I'm speaking to you from the unceded unsurrendered Anishinaabe Algonquin territory. At the outset, I'd like to acknowledge that we had planned to open today's webinar with words of guidance from an elder, but unfortunately they were unable to join us. While this absent is felt, we feel it remains important to be intentional about how we spend our time together today.

Thus, I'd like to invite each of you in whatever way feels most appropriate to take a brief moment to set your own intention for today's session. I would also like to share my own thoughts and personal reflections to begin. Over time, I've had the opportunity to learn, often imperfectly and sometimes unfortunately through my mistakes, about the depth, resilience, and diversity of indigenous cultures, knowledge systems, and worldviews.

These teachings continue to encourage me to think differently about my relationships to land, to community, and to one another. I am especially grateful to the individual members of my own community who have generously shared their time, knowledge, and energy with me, often without obligation and always with great patience. Their willingness to teach, to correct, and to engage in honest and sometimes difficult conversation has had a real impact on my understanding.

And while I am thankful for those lessons, I know my appreciation on its own is not enough. I carry a responsibility to keep learning and ensure this learning shows up each day in my work, in my relationships, and the spaces I shape. With that in mind, my intention for today's webinar is to show gratitude for the knowledge shared by carrying it forwards, applying what I've been gifted here in a thoughtful and tangible way after we leave this space.

Today's webinar, along with part one of this webinar series, which focused on First Nations communities, provides a platform to explore the social realities of TB and the importance of culturally responsive approaches to TB care. Both webinars have been planned with the guidance of an advisory committee of First Nations and Inuit health professionals and community members. We are grateful for their continued expertise and leadership throughout the webinar series.

I do have a few housekeeping items before we get started. Today's webinar does include external speakers which may not reflect the views of the agency or NCCID. A recording of the webinar along with a short feedback form will be sent to you following today's session.

Today's session will be conducted in English, but if you'd like to listen in French, you can access simultaneous interpretation by selecting the interpretation button at the bottom of your screen. To help reduce background noise, your audio has been muted and participant video has been disabled. If you experience any technical issues, please reach out in the chat function.

You're welcome to communicate in either English or French. If you do have a question for our speakers, please submit the question in the Q&A function and we'll look to answer them 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 Inuit communities.

Participants are encouraged to take care as they engage with this content, step away when needed, and after the webinar connect with a trusted support person or engage in self-care if needed. I'm now excited to welcome our speakers for today's webinar. I will ask them to turn on their videos now if they haven't done so already.

Mishael Gordon is Inuk, born and raised in Nunavut. Her hometown is Kangiq’niq or Rankin Inlet, but she later relocated to Iqaluit when she begin at the Nunavut Arctic College Bachelor of Science in Nursing program. Mishael grew to love the community of Iqaluit, and stayed to work, then eventually raised her young family there. Mishael’s career has largely focused on Inuit health administration, health equity, and self-determination. She now resides in Ottawa and still has strong roots in Nunavut. She is the Policy Advancement Manager at Inuit Tapiriit Kanatami or ITK, working alongside a passionate team advancing health policy equity for Inuit.

Raymond Obed is from Nain, Nunatsiavut. He holds a Bachelor of Arts in Psychology, Bachelor of Nursing, and a Master of Nursing degree. Raymond became more involved in systemic issues during a summer job working with the Nunatsiavut Government on food security in the region. Through that experience he became more familiar with what different barriers mean for the overall health of Inuit. At ITK, Raymond works as a senior policy advisor on the Public Health and Tuberculosis File in the Policy Advancement Department.

And with that, I will turn things over to Raymond and Mishael to get us started. Thank you.

Mishael Gordon: Hello everyone. My name is Mishael. I currently manage the health policy team specifically here at ITK.

Therefore, under health, tuberculosis elimination is a file that you continue to make a priority. TB is a fairly large and active file at our organization, one that our team regularly briefs our leadership about current TB trends, program updates, research, and data. In order to discuss the presentation, it is very important to understand the context of the topic in more detail before we share why TB is must be understood socially.

It is very important to understand this in order to provide culturally appropriate TB care. Currently, there are about 70,000 Inuit in Canada with the majority living across the 51 communities in the four regions of Inuit Nunangat, an area compromising 40% of Canada's land area and 72% of its coastline. Inuit communities are remote and most are not linked by roads to urban centers.

In this part of my presentation, the slide represents the history of my people, their relationship with the government, and the movement towards self-determination. The slide is a model presented is referred to as the Nunavik pedagogial approach. We'll call it the NS curve for short.

It was designed to help Inuit youth understand their place in the world and how the present came to be. It contains regional perspective but its function of highlighting how the colonizers created a dependence on them. We'll use it as a tool to show how Inuit lost control of their lives.

It applies across Nunangat. The timeline is an overview. There will always be outliers who arrived first but were focusing on when big changes which were taking place.

The NS curve showed us how Inuit have progressively lost power and how Inuit are progressively claim reclaiming it. The slide shows how the NS curve introduces the long history of colonialism in Inuit communities enabling TB to flourish. We'll begin with the arrival of the settlers in roughly the 1600s.

Started with the whalers, explorers, traders, and missionaries. And then in the 1900s, we move into the government era. You'll see a vast variety of changes that happened in a fairly short time frame that spanned from the early 1900s into the 1950s.

And then we move on to the rebound when Inuit political movement became when oil and gas exploration meant Inuit were reclaiming their homelands and enabling the modern-day land claim agreements that we see today. Here we see some statistics related to the social determinance of Inuit Health. Although the details here may be dated, this is an example of the huge socioeconomic disparities between Inuit and non-Inuit in Canada that we still see today.

We need to express how Inuit are marginalized from the rest of Canada in order to explain how we can work together to address these disparities. Inuit are extremely resilient and want Canadians to know what we contribute and how we can contribute. The social and cultural challenges that exist today can be undone in large part through self-determined policies that support and empower Inuit families and communities.

These realities contribute to the current rates of tuberculosis and many infectious diseases that Inuit are affected by. Here you will see a recent campaign ITK developed with our partners in Inuit Nunangatto encompass the message across to Canada. The very real urgency to address tuberculosis although this may be a busy slide you can find this resource on our website at itk.ca.

But it is important for us to share the statistics and the incidence rates of TB in Nunangat. The World Health Organization states the social determinance of health are the conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at a global, national and local levels which are themselves influenced by policy choices.

Although the ITK social determinants of Inuit health report had identified 11 interconnected social determinants of Inuit health. Together they help explain how social conditions influence TB exposure progression and recovery. Several highlighted social determinants include housing, the overcrowding, ventilation and housing quality, food security being nutrition, affordability and access to preferred foods as well mental wellness, stress, trauma, substance use, and community support. The availability of health services is also important to ensure timely diagnosis, the continuity of care, and the access to transportation. These factors do not operate alone.

They accumulate and reinforce TB risk. This framing helps connect public health, clinical care, and social conditions. What we know is that these factors impact the social conditions sharing the TB pathway exposure.

So, as we saw in slide four where I shared the statistics, some of the statistics, the issue with housing is a major concern in Inuang. There aren't enough of them and those that are available are often grossly inadequate in size and quality with overcrowding, poor ventilation and close contact conditions increase the chance of spread. activation of TB related to poor nutrition, stress, substance use, and other health conditions can increase vulnerability.

And then when we talk about healing and recovery, the delayed diagnosis, barriers to culturally safe care, and unstable living conditions can make recovery harder. Now, in order to provide culturally safe and responsive care, relationships with individuals and communities focus on these driving factors. Center care in a culturally safe way with humility and respect.

Recognizing inite knowledge, priorities, and community leadership. reducing TB stigma through careful, contextually safe communication, and then being innovative with service design and delivery. Coordinating TB care with housing, food, and social supports, removing barriers related to travel, scheduling, and followup.

And of course, building trust through continuity, listening, and partnership. On this slide, you'll see our regional counterparts and community members actively involved in TB education and awareness, food security initiatives, as well advocating for housing improvements. Some recommendations for healthcare providers when you're treating in with TB making link for them for their TB care with housing food and social supports reducing barriers to diagnosis treatment and followup planning for follow-up care around travel family responsibilities and continuity of care and of course work with inite partners to ensure cultural ally safe and community informed care.

And to conclude our presentation that in 2018 when ITK began drafting the Inuit TB elimination framework, it was vital that the Inuit treaty organizations were able to develop and implement their own TB elimination regional action plans. as each of our four Inuit Nunangat regions had and continues to have a different relationship with TB. Since then, ITK has held a role in advocating to Canada by utilizing the Inuit governance process of engaging the ITK's regional priorities to ensure that INuit are actively gaining momentby leading initiatives and activities.

Here you will see some of our TB managers meeting with President Obed last fall 2025. Thank you. Thank you everyone.

Raymond Oed: And that should be up. so hello everyone. my name is Raymond Oed.

I am a senior policy advisor with within ITK. My focus is on public health and TB and has been for the last about a year now. where I support the Inuit public health task group and the regional TB managers.

and so just for my portion of the webinar, I will be talking more about the providing culturally appropriate care for in communities as a whole. so going into it we have definitions just a few definitions that or key terms that have been used in in the landscape of cultural safety and other aspects. So these are terms that you've likely heard before.

So I'll quickly work through them. So the first is cultural awareness. And it's as it sounds, being aware of cultural differences that exist.

Cultural sensitivity moves beyond awareness, meaning to respect cultural differences. Cultural competency moves further again to effectively meaning to effectively provide quality care to those of different cultures. And some definitions do include that the practitioner themsel are self-reflecting to provide care as well.

Cultural safety has the foremost focus on the person receiving care, including to build an environment that is safe for a client or patient. And a healthcare provider should be reflecting on their role and the power play power balances in play. And cultural humility is a supporting factor of cultural safety, meaning to recognize the necessity for self-reflection and to always learn from the people who are receiving our care.

In the chapter 12 of the Canadian TB Standards 8th edition, there's an introduction to TB care to improve cultural competence for those healthcare providers servicing indigenous peoples of Canada. In this case, there's a section on Inuit that briefly covers the historical context of TB health disparities and access to health services. To quote a line from the chapter, respect for Inuit values, language, knowledge, culture, and the historical context of TB across Inuit Nunangat is integral to providing TB care in Inuit communities.

Mishael had covered portions of health of health disparities and access to health services and I will similarly provide a brief introduction to culturally appropriate care. To provide culturally appropriate care and to help us combat TB, it is important to understand the context of the TB challenges facing our communities as well the solutions we are putting in place to address them. TB was brought to Inuit Nunangat by early European explorers and whalers.

The epidemic was compounded by movement off the land into fixed settlements. In the first half of the 1900s, rates of TB among inuit were staggeringly high. Approximately 1,500 to two to 2,000 cases per 100,000 population.

Extreme public health strategies to combat this epidemic involved abrupt separation of TB patients from their families, often for years. Inuit traveled vast distances through various means of transportation such as the now infamous CD Howe and many survivors recall experiencing seasickness as well fear and anxiety for being disconnected from their families. Many never returned back home.

Trauma related to TB evacuations as well as related loss of language and culture continues to have lasting impacts on inweek families today. In March 2019, former Prime Minister Trudeau publicly apologized and launched the Nanilavut Initiative. And the Nanilavut Initiative was formally launched in 2018 to help family members who lost loved ones in southern sanatoriums find their graves and mark them properly.

Ine treaty organizations have been tasked to connect families with their loved ones and have been able to do so over the past three years holding memorials in Edmonton, Hamilton, Quebec City, and in parts of Labrador. As Mishael shared earlier, the Inuit tuberculosis elimination framework is an example of innuite self-determination, setting out to allow ittos and regional partners plan out tuberculosis elimination activities. The framework places the clinical focus on TB control within the broader context of the social determinants of health that are the roots of the disease.

I do always want to highlight when sharing the framework that ITK has also released the innovate housing strategy and the food security strategy outlining how we intend to these issues which are vital to the elimination of TB from our communities and there there is a poverty reduction strategy that is that should be released as well. So next are the priority actions in the framework. I won't go too in depth with the priority actions but share the actions themselves.

Under the under each priority actions, there are key elements that add definitions on what implementation can look like across inapp. The priority actions are to enhance TB care and prevention programming, reduce poverty, improve social determinance of health and create social equity, empower and mobilize communities, strengthen TB care and prevention capacity, develop and implement in specific solutions, and ensure accountability for TB elimination. I have highlighted priority actions 1, four and five as being directly related to the topic of supporting TB care.

Priority action one meaning healthcare healthc care providers are competent in TB care. Priority action four represents the health human resources training required and priority action five ensuring that the TB system follows what is in spec what are Inuit specific solutions and recently at the beginning of the month research out of Nunavik shows the relevance of the framework to the local context in communities and why it is important to have initiate specific solutions. There are seven calls to action in the article.

One of which is implementing Inuitled cultural safety training for healthcare workers. And what I have here is a video from Tunga Inuit and Inuit organization in Ottawa that provides community supports and other programming. They have developed various videos related to programming to the programming that they have.

This video covers Inuit cultural safety in the medical system with a focus on Inuit coming south for medical travel. We'll play a short portion of the video before continuing the presentation. And I do need to note that at the very beginning there's loud music, but then it the sound equalizes to something that's more manageable.

It's important for doctors to build trust with the inweek patients because they are leaving home. They're getting on an airplane and traveling for about 3 hours and going into a foreign place. They may not understand the English language very well.

Everything's a new experience and it's a very different setting for them and it could be a daunting experience for them. Inuit have a history of feeling mistreated with the relocation. They were moved away from their survival places.

Children were sent to residential schools and there was medical patients that were sent for tuberculosis treatment and never came back. These experiences have created a culture of skepticism whenever it comes to medical travel or anything to do with medical. So some ways a doctor could build trust with the ine patient is to talk slowly and to use simple language.

Don't confuse silence or little eye contact as non-engagement. Pay attention to non-verbal communication. They might raise their eyebrows to give a yes answer or squinch their nose for a no and shrug their shoulders for I don't know or they don't understand.

You want to ask questions because you want to get a straight answer of a yes or a no. So if they understand, then you know they got the message. Try not to ask repetitive questions.

You might try to learn the language. A little goes a long way. Even if you learn to say can we ask them how are you?

So we'll stop there. It is an 8 minute video. So it's not something we want to cover during this entire webinar, but it is available on on YouTube for others to watch if they're interested in continuing.

So the rest of this is more so highlights that you know are applicable that can be used across the different settings you know in areas of Inuit Nuning and in the south as well. and so you know starting off with building trust you know something that you want to do as a healthcare provider with any with any patients and in particular with Inuit is to build trust with them to be able to have that conducive therapeutic relationship. There's also the environment.

So in the definition of cultural safety I shared included the environment that the environment should be safe for Inuit inmate patients as well to recognize the history of mistreatment that has existed with TB but also all of the medical system as well. so recognizing that and being aware of how that influences the relationship that that you will have with with a patient or client. There's also to talk slowly and with simple language in English is may not be the first language for Inuit in patients.

So being able to work with that understanding as well the use of body language. This this has been a big piece of of communication with within clients is body language. In the video, it does highlight, you know, yes and no or I don't know.

So, yes being the raising of the eyebrows, no being the scrunching of the nose, and then I don't know if you if you shrug your shoulders. Um, those are things to look out for when working with Inuit clients. And also as a healthcare provider, it works well to ask questions that have a yes or no answer as well and to be able to work with those work through those questions as well with yes or nos.

It's also beneficial to be specific with with what is required after the meeting so that that it's very clear on when timelines are are expected to be followed and and next steps that are required for the medical system but also with with the client themselves and simple initute does go a long way. you know Mishael started with in in the dialect it's unla which is good day or good afternoon. So simple things like that can go a long way and then what's I'd say more so important for the south but broadly across is the importance of country food.

So if programming in the south does have country food, it it does, you know, bring a lot of wellness to inite clients as well. So these next two slides are directly relevant to those providing care to initiate in the south. Medical travel is a reality with limited access to health care services in init.

It is important to know when an interpreter is needed through understanding if you as the health care provider and the client are on the same page. And so if that may not be the case, you would want to make sure an interpreter is available. So interpreters help healthcare providers with improving communication.

so that it's not just one particular way of talking that that is taking place but other ways that can help make everyone on the same page. Being able to translate the interpreter is able to translate medical terminology and they also can act as comfort for the client through culture and language. And another area of highlight is our patient escorts.

So those are individuals that travel with a client who is receiving medical care in the cell. It is not always the family that travels with the patient. So you need to be mindful of that as well not to assume that is the case.

So patient escorts support patients as they are working through the medical system and navigating the south where they may not be used to you know large cities as a whole. Just one one one large aspect. They also are meant to receive information from the healthcare providers as well.

They're they're passing on the knowledge and helping the patient with decision making at the same time. And if it's required, they will be working with the family as well with making with with supporting the patient to make decisions on on next steps and and those types of things. So this is a very I'd say brief introduction to some cultural safety, some cultural culturally appropriate care for init.

I do have here highlighted two additional resources that might be useful to navigate for understandings more of the more of the Inuit culture. So the first is the Inuit wave published by Pauktuutit women of Canada. this has this was released a few years ago but it does cover a few different a lot of the aspects of culture for or use as well.

And then there's another Inuit YouTube video that's mostly on the history of the medical system in in so that's another video but that is 20 minutes long. Additionally, what was shared recently is the position statement from the Canadian Pediatric Society on cultural safety and practice providing quality health care for first nations Inuit and Metis children and youth. They highlight the learn self-reflect act framework for behavior change.

The learn self-reflect act framework is one model for self-reflection and any others you receive through your training may work as well. Separately, the ITK best practice webinar for March covered some of the same material on the social determinants of of health, but also TB stigma that was not directly covered in the material today. Um, the webinar was co-presented by. And I would say that understanding TB stigma would be a beneficial aspect of beneficial aspect of to understand when wanting to provide care to initiate.

it is a very big topic hence why it was not covered today and I cannot stress this enough. What I have provided is an introduction. So for in-depth cultural safety training, you really should connect with the four enemy treaty organizations for region specific training as there are differences across the regions.

There are some similarities that I have covered, but there will still be distinctions that would be best covered by the four Inuit treaty or organizations. So for example, if you're going to the Inuit Valley settlement region, you'd want to connect with the Inuit Valley Regional Corporation or you know going west Nunavut you'd want to connect with Nunavut Incorporated sorry and so eliminating TB from inmate communities does require work across all levels. So, as frontline healthcare providers, there could be many roles, but I do want to emphasize providing culturally appropriate TB care and being advocates for in you've heard from Mishael and myself, but also what you hear from your patients for positive change.

Um, not not to just, you know, be there be there providing care, but also advocating for positive change in in the healthcare system as well. Thank you, Nakamik.

Jessica: Thank you to Mishael and Raymond for the insightful presentations today.

Uh, at this time, we'd now like to open it up to questions from our audience. So, please submit your questions using the Q&A function found at the bottom of your Zoom screen. Uh, we do have some questions already rolling in.

so I will get started and say when we talk about the association between TB and substance use is the increased risk of TB mainly due to the type of substance so the the chemical effect on the body or the immune system or is it more about how the drug is used especially thinking about how smoking and inhalation can directly damage the lungs. Is there evidence or research further explaining that association?

Mishael: So, I'll start and Raymond might want to expand further.

So, I will say it is both and so in Inuit Nunangat there are high rates of tobacco use amongst the population of Inuit. And so this is often a mechanism for dealing with stress amongst other addictions amongst the population. But as it also is seen as a social activity that also would contribute to both of those aspects in in this targeting of TB policies.

So, it it's so smoking tobacco use is has got some pretty high rates across each of the Inuit regions. I can't say specifically right now what those rates are, but it is pretty high amongst you know internet. Great.

Jessica: Thank you, Mishael. you highlighted the Inuit tuberculosis elimination framework as a strong example of Inuit self-determination. from your perspective, what have been the biggest challenges in translating this framework into day-to-day clinical or public health practice?

Raymond: I'll start Mishael. So the framework itself is written to be able to write regional specific action plans. So there is you know there is learning on the individual level to be able to understand like okay if if this is going to be translated into my own work that I'm doing it will take some thinking.

The idea is that with this framework, both the both the new treaty organizations and the regional partners that they work with would be working together to develop specific areas of action that can improve the TB care the TB program program within each jurisdiction. So it is not quite clear like on the day-to-day I would say the day-to-day clinical care that you would be providing. However, it is meant to actually translate to strengthening the TB program overall and and not not just the TB program but also wanting to action on social determinants of health as it relates to TB.

So making sure that we are engaging with not just the public not not just the health system but also those who can influence ch influence changes on on housing, food security, mental wellness, poverty as well. Thanks Raymond. Mishael, did you want to add anything to that?

Jessica: Okay, perfect. So the our next question diving back into this very practical application given the lasting intergenerational trauma associated with the historical TB evacuations and the sanatoriums how can healthcare providers meaningfully acknowledge this history in a clinical interaction without retraumatizing patients are there practices that you have seen work?

Mishael: Well I can start a little bit about this item Raymond you can add to if you think needs be, but there's actually a program that was initiated with ITK and the Inuit treaty organizations in 2019 after previous Prime Minister Justin Trudeau apologized to Inuit regarding the historical TB evacuations that had occurred between the 1940s and 60s.

This program is called Nanilavut. And so this has been a program that the ITO's have led within their regions to work with the federal government, the Department of Crown Indigenous Relations. And so, um, there's been some, uh, work to, uh, find some of these families that had been forcibly removed from their regions, from their home communities.

Um, many of them didn't return home. They either passed away in southern Canada and were buried there. Those that did return are now likely elderly or have since passed away, but they would have children as well descendants who would tell this story on behalf of their families.

And so this program has been an opportunity for addressing that trauma and providing closure to the these families by communicating with the Inuit organization and for those that were buried in southern Canada to visit as a lasting opportunity to say their farewells to those family members. How a clinical interaction would go about addressing without ret-raumatizing patients? I think that acknowledging some of those historical traumas is a good opportunity, but also acknowledging that is not practice any longer.

Most Inuit patients can stay in their homes or within their regions to receive care or those that have to leave to receive care will return home. when they're wealth enough to. Raymond, is there anything else you'd like to include?

Raymond: I broadly there is the practice of trauma informed care. that it it's a topic we didn't really cover either in this but it is something to consider looking into. And once again, there is the whole aspect of TB stigma as well.

How to, you know, ways to decrease TB stigma. Um, and recognizing that it it does have an impact on people seeking care as well. 

Mishael: That's a whole other TB webinar.

Raymond: I also do have to correct myself. It's TB stigma and fear. I have to correct myself.

That is something I need to remind myself to include the part. 

Jessica: Well, I think you've both really clarified the the nuance that that comes with TB. It's not just an infection, but it's it's a legacy of of all of these different factors coming in.

So, I appreciate you starting to highlight some of them, and yes, I we can only do so much in our one-hour webinar, but I appreciate you introducing these topics. the next question goes towards Raymond. It was regarding the video that you shared there are a lot of people in the chat have found it really helpful. and they're just wondering if there are any other key resources or tips that you might have to help bridge any potential communication gaps to better support patients. So perhaps maybe narrowing it down in in a way to better support patients focusing specifically on on key communications.

Raymond: So I don't have anything to share directly but I know that you know each region does have with within their within their health system some some resources that help with communication just as an example in Nunavut they have put together a sort of lexicon when it comes to you know talking about different medical aspects for personal I I guess to be able to learn more of the Inuit with some specific dialects. there's an online resource for learning as well. I can put that in the chat.

those are those are what come to mind immediately for me. but we do not have like direct resources to be able to share. Thanks Raymond.

Jessica: We will definitely collect any resources you have and be sure to share them in our follow-up email to all of our participants. So, don't worries about putting them in the chat for now. Um, shifting gears a bit from a treatment perspective when a therapeutic relationship has been established and and barriers have been reduced for the client.

We're talking about covering costs from medication and providing incentive vouchers for transportation. but the client is still not interested in taking their TB medication. How can we continue to encourage them to take treatment? Are there other methods that we can use to explain the importance of taking medication without you know again going stepping into that retraumatization concern.

Raymond: So this is very this is a very specific question and I will try my best to answer but it as someone who is not directly providing care re realistically it is the person- centered approach there's a lot more that's happening with the person than as you did in the question it does cover you know cost for medication incentives, vouchers for transportation. There could be other things that are taking place that are limiting the the individual's ability to take part in the treatment.

And so it is that person- centered approach. It is, you know, actually working through with them. What I've heard from [unclear] last year was the use of TB social workers.

that is not practice within Inuit Nunangat. but you know essentially working with individuals that are able to provide that social care for for the patient would I would say is best practice in this instance. But in in inat I would say that still falls on onto the nurse's responsibility.

Mishael: I also want to include that our organization are not service providers. We don't provide clinical care to patients. So some of these questions might not be totally part of our practice as an organization.

So compliance dealing with patients and treatment is typically led by the PTs within these regions. The space for ITK and the ITOs is advocacy and providing some of that wraparound care and support.

Jessica: Thanks Mishael and thank you for that clarification.

We also do have a fair number of public service employees on the call as well as some policy makers. so I'm curious about if you have any recommendations for embedding cultural safety when working within treaty organizations especially at the policy level. Yeah.

Mishael: So each region really like I said in my presentation each region has a different relationship with tuberculosis. So for example in the Inui settlement region for many years does not have active tuberculosis in their region. So their policy will vary when you compare it to an a region such as Nunavique with high incidents and breakouts.

So it's really a matter of building and establishing a relationship with that ITO and the partners in that region to ensure that community leaders and Inuit are being represented in in that space. Raymond, do you want to include anything there? 

Raymond: Coincidentally, this did come up in a recent conversation sort sort of not not quite the same context.

But communication is key. So very clear communication being clear on if there is a project happening, timelines of the project and when to be expecting like work with being clear on what is being expected of both sides of the of the relationship timelines and and things like that. So that's one aspect of being having clear communications.

and well actually I think that mostly covers it. It's like the and then the second part is that something actually does happen. It's not just something that is taken in as just engagement.

you know that you want to make something of the relationship as well. that there should be some there should be an outcome with that with that relationship. 

Jessica: Thank you Raymond.

I am noting the time so there's still lots of questions in our chat so but we only have time for one or two more. so I think this is is a great one to wind down on. Um, when we talk about eliminating TB in Inuit communities, um, what indicators are we looking at beyond just crude incident rates?

Are there ways that we can measure the effect of TB programs and services by showing how effective community-led and culturally appropriate care um, have been making an impact in communities? 

Raymond: I'll go ahead and start. So indicators have not been developed themselves.

However, I would say that it is understood in modeling that has happened in other areas that social determinance is would like addressing the social determinance will have a large impact on the TB rates that that exist in in Nuning. So that is already just one massive benefit to innovative health and well-being is the improvement to the social determinance of health. So social health and social equity.

The other part is would be improved the idea around the framework and around TB elimination is improving the health system as well. So one of the goals is to increase the amount of inuit that are in the health workforce that are able to provide care locally so that people are not flying for medical travel. So that's another aspect. two aside from just the Inuit in health workforce, it's also having diagnostics and other things that are local to communities or you know within like jurisdictions, things like that. So that another aspect of medical care like people are not having to fly for x-rays, not having to wait two weeks for a lab result before having to think about care, things like that. So there there's quite a lot there that is involved with TB elimination that would have a positive impact overall on inuit health and well-being.

Jessica: Thanks, Raymond. It it does seem like we're just starting to scratch the surface with today's conversation, but unfortunately we are coming up to the end of our webinar. I think as an intention, we should all take away from this webinar is that there is there is much more to be done and much more work to be applied.

But on behalf of my fact colleagues as well as my colleagues at NCCID, I would like to extend my sincere gratitude to both Mishael and Raymond for sharing their expertise with us today. as well. Once again, thanking our advisory committee members for their valuable guidance and contributions to this event.

To end this webinar, please do share your thoughts with us in our feedback form which will appear once the webinar ends. And we hope you've enjoyed today's webinar. I wish you all a great rest of your day.

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