When Nash Dhalla was seven-years-old she had to flee her home country of Uganda and Idi Amin’s political regime, which saw thousands of others like her displaced.
Nash and her family landed in Vancouver, Canada, which took in a number of Ugandan refugees thanks to a long term friendship between then Prime Minister of Canada, Pierre Elliott Trudeau, and The Aga Khan IV (Prince Shah Karim Al Hussaini).
Asked if being a refugee influenced the path she would take in later life as a TB nurse she weighs this thought up carefully as though it had never crossed her mind before.
“I am super lucky to have been given the opportunities I have been given, to live in Canada and to be educated in Canada - I don’t know if that would have been my lot in life had we stayed in Africa. I think being a refugee has made me sensitive to and aware of international and global issues, TB is one of them and certainly in my lifetime HIV has been one of them. It seemed logical this is where I would end up. I think leaving Uganda influenced what I choose to do for a living, absolutely.”
Being born in a developing country initially gave Nash an interest in working in community healthcare overseas. She worked in various countries, including Zimbabwe and India, before returning to Canada and spotting a vacancy for a TB outreach worker in Vancouver’s Downtown Eastside and inner city.
Ten years later she became a TB nurse working mainly with marginalised groups including those with addictions and/or mental health issues. More recently she has had ‘the honour’ of working with first nation communities and aboriginal people both in the inner city and on the 203 First Nations Community Reserves of British Columbia.
Describing Nash as fiercely passionate about her work is an understatement. Having Nash on your side working tirelessly to care for patients, but also shouting as loud as she can about the scourge of TB to anyone who will listen (and perhaps those who won’t or don’t care to) can only be likened to having a championship boxer fighting your corner. Can her work be frustrating at times? Yes. Can it can be incredibly sad and heartbreaking at times? Most definitely. Does she face overwhelming challenges every day? Goes without saying. But this only serves to ignite her commitment.
Working in a developed, resource-rich country such as Canada one might think that life as a TB nurse is less of a struggle than in the high burden TB countries Nash has previously worked in. How are they different? This is, in fact, the wrong question to ask, says Nash. What we should be asking is how they are the same.
Issues such as accessibility to drugs and drug shortages, social and economic difficulties facing patients, stigma around TB, how to reach and treat patients who live in remote communities and - perhaps the issue that fuels Nash more than anything – a lack of political will are as relevant to her working with TB in the West as they were when she was overseas.
She pulls no punches. “In Western countries a lot of resources have been mobilised for HIV and AIDS, there’s a lot of political will. Although it is still a major health issue, HIV is now a chronically manageable disease. I did not think I would see that in my life time and it is amazing. But how TB differs is that it doesn’t have the political will behind it. In North America if you say you work with TB, they ask ‘why’? They think it is a disease of the past, of the developing world, but in British Colombia we have an average of 300 cases of active TB each year.”
The biggest shift Nash has seen with TB day to day is the rise of multi-drug resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB). Of course this is a global problem too but Nash sees and – feels – the consequences at a very local level.
She says: “If you look at the history of drugs available to treat TB it is woefully inadequate. If someone has a resistant profile it is horrible. I am currently working with a young person under ten who has MDR and it is heartbreaking because the medications are so toxic they have lots of side effects. She has extensive hearing loss, neuropathy and trouble walking. There is stress on the family, they now only have one income as her mum has quit her job to take care of the daughter.”
And the similarities between high burden countries and the West don’t end there. Nash explains: “It is quite frustrating because if you try to model TB care within the HIV realm you quickly realise that they have many more medications at their disposal and we don’t. We have to go through Health Canada and special access to get the medications we need. We have drugs shortages in the West and you would think ‘really’? But the political will and the cooperation that crosses borders with HIV and AIDS just does not happen with TB. We have the pretext that we are living in the West and that people have access to housing and appropriate healthcare and this isn’t always the case.”
The stigma of TB, however, is one that does cross national boundaries. “It is a disease that brings a lot of fear and stigma in Canada. In the past we had sanatoriums and people were taken away from their families and we didn’t do as good a job as we could of explaining the disease process, so we have that historical context too”.
So what can be done?
For Nash it is simple. Raise the profile of TB, shout loud, be an advocate and get the stark messages out there. “I think it is outrageous that we have TB deaths in British Columbia, that we have deaths of TB all over the world and it should be a chronically managed disease but it’s not. It’s not just a disease of poverty; it’s a disease that can affect anybody”.
And Nash is using every opportunity available to her to do this. She is a member at large for the North American Region of The Union, working with the organising committee on the North America Region TB conference in Vancouver and the US each alternate year. For the last two years she has attended The Union World Conference on Lung Health and is a member of The Union’s Nursing and Allied Professionals Committee (NAPS). She is also part of the Stop TB Canada Advocacy group.
“I think what the HIV world has done really well is to unify and to speak with a voice and, for me, it’s all about that advocacy working, but on an international, national and local level to make sure that the voice of TB programming and patients are heard.”
Nash says that The Union has been instrumental in helping her to do this, guiding her to get involved in the fight against TB on an international scale. She regularly emails Dr Jane Carter, President of The Union, who has ‘been amazing’ and appreciates the access she gets via The Union to a ‘small, family network of TB workers’ at a global level.
For Nash it is all about achieving one goal – better vaccines, better medications. Eradication. She has designed a t-shirt ‘Spread TB knowledge not TB disease’ and says her future is destined to continue in the field of TB. In other words she isn’t ever going to give up. “I’m quite a loud and obnoxious woman that can use humour to get messages out there but sometimes other people just don’t have that access.
“I think right now people in the West are so removed from it they don’t see it as disease that affects them or infects them, but one third of the world’s population has the TB germ – we should let people know so that it gets the response, the backing and the economic funding that it really needs.”
If anyone can help to galvanise people it is Nash Dhalla who speaks with such passion and eloquence about TB, all grounded in 20 years of solid experience.