Growing up in Canada, I always wanted to work as a physician in resource-poor parts of the world, but I never expected that would lead me to the far north of my own country. The highest documented rates of hospital admission for bronchiolitis caused by respiratory syncytial virus (RSV) can be found not only in low- and middle-income countries, but also among Inuit infants in Canada’s Nunavut territory. Nunavut has high rates of poverty, food insecurity and severe overcrowding. A study found that nearly 70% of Inuit preschool children live in food-insecure households, which translates to poor health outcomes1.
I first travelled to the area as a physician in 1995, as part of my paediatric training. The number of children with some sort of respiratory disease startled me. I later conducted a review of infant admissions to Baffin Regional Hospital in Iqaluit, Canada, in 1995, which confirmed my experience: 90% of all hospital admissions were for lower respiratory tract infections, mostly RSV. At the turn of the millennium, an antibody against RSV called palivizumab became available. Palivizumab has been shown to be 78% effective in reducing hospital admissions owing to RSV in premature babies, and because it creates passive immunity with antibodies, it should work just as well in full-term infants.
Part of Nature Outlook: Respiratory syncytial virus
But it is expensive — costing as much as US$10,000 per child per RSV season — and therefore its use is restricted to those infants perceived as being at high risk of severe RSV, for example, children born prematurely or those with chronic respiratory or cardiac disease. We should expand the list of those whom we class as ‘at risk’.
At the moment, healthy Inuit babies are not designated as high risk — and therefore will not receive this potentially life-saving preventive therapy — but they should be. Inuit infants are 4–8 times more likely to be hospitalized with RSV than those in the south who are born prematurely or have serious health concerns2. Babies who live in the remote parts of Canada are more likely to face extra risk factors, such as exposure to cigarette smoke and inadequate living conditions. The vast area of the Canadian Arctic also compounds social problems. A typical Canadian infant who develops severe bronchiolitis can access a hospital in two hours, but Inuit babies in remote communities often need to be flown to hospitals thousands of miles from home, where the language and culture will be foreign to them.
My colleagues and I have published several studies demonstrating that cost should not be a barrier. The expense of air ambulances and stays in intensive care units means that it would be cheaper to pay for every full-term Inuit baby to receive palivizumab than it would be to evacuate and treat those who develop severe disease. However, these findings have yet to be acted on by government officials. The preventive therapy was approved for use in Canada 21 years ago, and despite campaigning, with a petition of almost one-quarter of a million signatures on www.change.org/fairmedicine, the implementation of palivizumab for Inuit children continues to be blocked.
One argument against rolling out palivizumab to all Inuit infants, as expressed by the Canadian Paediatric Society3, is that improving living conditions in these communities would be even more cost-effective in the long term. Housing is indeed at a crisis point in the Canadian Arctic and must be addressed, and there is no doubt that solving this problem would alleviate RSV rates. But, these solutions are not forthcoming and until they are, it is simply cruel to withhold life-saving preventive drugs.
A new RSV antibody drug called nirsevimab, which was licensed in Canada in April and is expected to be cheaper and easier to implement than palivizumab, might offer a potential solution. RSV vaccines have also been approved this year for older adults and pregnant people. However, antibody therapies remain the best way to prevent serious RSV infections in young children. Despite all these emerging tools to fight RSV, the lack of a response from the government since the first cost analyses were published about 15 years ago tempers any optimism I might harbour. This inertia is part of a wider pattern.
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The life expectancy of First Nations people in Canada is, on average, more than 11 years shorter than that of other Canadians. And it’s getting worse; the gap was approximately eight years in the 1990s. Suicide rates in Canada’s Indigenous youth are six times higher than in non-Indigenous Canadian populations. The rate of heart disease for Indigenous people is as much as 50% higher as compared with the general Canadian population, and the death rate from strokes is twice as high.
This inequality not only persists, but also widens. We need to make sure that RSV drug access isn’t just another example on the long list of disparities between the quality of life of Indigenous and non-Indigenous Canadians.
Other countries should take note, too. Canada is sadly not the only place with a significant health gap between its Indigenous and non-Indigenous populations. Take Australia, for example, where just 28% of Indigenous adults are said to be in good health, compared with 54% of non-Indigenous adults, according to data compiled by the Australian Institute of Health and Welfare4. It’s a similar picture in the United States and New Zealand, too. When it comes to RSV and the question of remedies, the drugs are there, the data are there and people have waited long enough.
If we are truly committed to reconciliation as the Canadian government states, then things need to change. If we can make progress on this, then it shows the rest of the world that the pernicious burden of health disparity shouldered by Indigenous people is not unsolvable. We just need to act.
The author declares no competing interests.