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Toronto's silence on tuberculosis reinforces the mantra that silence equals death

Cover of report, "TB or not TB? There is no question" Image from Toronto Disaster Relief Committee archives

On the day that the Coroner's Inquest into the death of Grant Faulkner, who was homeless, ended with jury recommendations that I had planned to write about in this blog, I received a disturbing email.

Here is an excerpt:

Dear Service Providers,

Toronto Public Health (TPH) is investigating a person diagnosed with active Tuberculosis (TB) in the homeless community. This individual was admitted to hospital and has passed away.

As we normally do in these events, TPH is now working to identify contacts of this individual and offer screening for TB.

This person was accessing community services during the infectious period prior to hospitalization. TPH is working in collaboration with this community agency to conduct screening of all identified contacts.

I've heard this story before.

Maybe I've just been doing this too long. I have been doing this too long; but I still question why history is repeating itself.

As Canadian activist Dr. Norman Bethune, who experienced tuberculosis himself, once said, "There is a rich man's tuberculosis and a poor man's tuberculosis. The rich man recovers. The poor man dies."

We know this story too well.

There is a long and unpleasant history of how TPH dealt with a tuberculosis (TB) outbreak in the early 2000s. Fifteen men and one shelter worker developed active TB, three homeless men died. Many others, including agency staff, were found to have latent TB (not active). The seriousness of the outbreak was not released by TPH for many months. It was essentially kept secret from the shelters, the drop-ins, from the street nurses and other agency workers.

The community was mad as hell and mobilized. The Tuberculosis Action Group (TBAG) was formed. We held a public inquiry entitled "TB or not TB? There is no question." We then forced a Coroner's Inquest in 2004 that actually led to heightened funding for TPH for directly observed prophylactic therapy treatment.

However, the City of Toronto has done little to diminish the conditions that worsen TB occurrence and spread. Consider the now 32 year of forced nightly migration in the Out of the Cold program, the lack of cleaning or other standards developed for the Out of the Cold program or respite sites, and the constant overcrowding in the shelter system. Consider inadequate ventilation systems, people malnourished, low social assistance rates. These are the makings of a public health crisis.

Once again, a person in the "homeless community" with active TB has died. TPH is refusing to identify the location, as they "do not want to stigmatize specific locations." I do acknowledge that they are doing some form of follow-up, but I am outraged that they are repeating the history because, well, silence equals death.

Homeless people have a right to know where there has been active TB. Frontline workers and healthcare workers need to know so they can be on the lookout for symptoms. TPH has to realize that no one goes to just one place and sits there forever. Homelessness=forced movement - - always.

This population is highly at risk: they have a heavy burden of ill health, reduced access to health care, are forced to live or stay in congregate type overcrowded settings, and if they are substance-using their health is further compromised.

Who is creating the stigma? A case of measles in a school becomes public knowledge with TPH media releases and officials clarifying information and offering advice. Same for any infectious disease identified in a passenger on a plane. Same for potential Hepatitis A exposure in restaurants.

The stigma here is on TPH's part by not disclosing risks to the poor.

Image from Toronto Disaster Relief Committee archives

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