Equity-focused public health practice as a strategy to tackle TB
Photo: Richard Revel
It’s no secret to anyone working in tuberculosis (TB) programs in public health that the social determinants of health (SDH) have a major influence on who is at risk for contracting TB. More specifically, a person who is at risk for contracting TB is often facing other risk factors such as compromised immunity, malnutrition, smoking, diabetes, alcohol abuse, inadequate housing and indoor air pollution, which are all influenced by the SDH. Many current TB programs prioritize treatment over addressing the SDH and, as a result, often do not address the cause that determines a person’s vulnerability to contracting TB in the first place. As I have been learning more about the relationship between health equity and TB, I have come across a few SDH-oriented TB strategies that put equity at the forefront and have the potential to address a broader set of health inequities as well.
Applying a health equity lens
One approach is to look at TB programs currently operating within public health and apply a health equity lens. A joint publication from the NCCDH and the National Collaborating Centre for Infectious Disease (NCCID) explores public health strategies for reducing inequities in infectious disease and how TB programs can address the SDH. Elizabeth Rea, the associate medical officer of health at Toronto Public Health and one of the contributors to this document, describes TB is the “poster-child” for addressing equity. For her, there is a “layering” of equity issues when it comes to TB because “the determinants of health are also the determinants of TB.” Toronto Public Health applied a health equity impact assessment (HEIA) process to their TB program and, consequently, has hired a social worker to work directly with TB clients. When a TB case is identified as having barriers associated with the SDH, the social worker will work with that client to directly address those barriers, such as facilitating the client’s access to income and housing supports, in addition to access to treatment for TB.
Offering financial aid
Another example of adressing the SDH in order to address TB can be found at the Denver Metro TB Program in Denver, Colorado. This program tries to eliminate TB disparities through a patient assistance fund to help when a TB diagnosis may cause loss of income, making it difficult to afford housing and food. Michelle Haas, an infectious disease physician with the Denver program, describes SDH that make up the “package of inequity” of TB. As she explains, the SDH related to life expectancy broadly across a population are the same ones that increase the risk of TB, which include poverty, inadequate housing and lack of access to healthcare. While TB may not be a leading cause of death in some areas, it often leads to having multiple negative health and life consequences, which have a greater impact for marginalized populations. The Denver program wants to “think beyond TB to address TB,” focusing instead on addressing health equity as a strategy towards TB elimination.
Mandating equity training
The role of bias and racism in how TB programs are delivered also needs attention. In the city of Madison, Wisconsin, all public health and municipal staff are required to attend implicit bias training sessions given by the Racial Equity and Social Justice (RESJ) committee. Jenny Lujan, a public health nurse with their TB program, explains that over half the TB program's staff sit on the RESJ committee, and the knowledge they have gained has led to the development of a TB program charter, logic model and other planning documents that put the elimination of racial inequities at the center of their work. The thought is that communicating about racial inequity and its relationship to TB will help staff with two things: addressing implicit biases they may not be aware of and developing goals that include addressing racism and other equity issues beyond just treating disease.
Prioritizing Indigenous self-determination
Indigenous populations who live in remote locations have increased risk of contracting TB due to SDH such as income inequity, food insecurity and inadequate housing. If Indigenous communities are close to major construction, mining or other large infrastructure projects, communities may have additional TB risk due to the environmental impacts, including air pollution. The First Nations Health Authority (FNHA) in British Columbia serves a number of areas that are affected by TB. Isa Wolf, a public health nurse with the FNHA, has reinforced the importance of involving community members in the planning process to address the SDH and equity aspects of TB. This encourages moving beyond a medicalized model when it comes to approaching the environmental aspects of the disease, instead proposing an equity-slanted intervention to addressing TB risk.
Together, these examples offer different ways to address TB and contribute to its elimination. What they represent — public health approaches to addressing health equity at a population level through attention to the SDH — could also help address other critical health inequities facing marginalized populations.