Philippines: inmates and prison staff work together to stop TB

     As early as 7:30 in the morning, a line of inmates snakes around the maximum security compound of the New Bilibid Prison in Muntinlupa City. More than 70 prisoners are waiting for their turn to enter a small hut, each clutching a mineral water bottle or jug in his hand.

" How are you? " asks the nurse as she hands three tablets to a prisoner. " I'm fine, " he replies with a toothy grin before gulping the pills down. Behind him, another outpatient prisoner takes his turn at " Tutok Gamutan " – a monitored, six-month drug treatment programme for TB patients inside the Philippines’ national penitentiary.

" Our strategy is to ensure that they are taking their medicine and not selling it, " says Dr Ma. Cecilia Villanueva, the TB coordinator at New Bilibid Prison hospital.

Although it is a curable disease, TB has been one of the top three reasons prisoners have been admitted to the hospital and one of the principle causes of death among inmates for the past six years.

" Many inmates are still getting sick, " says Dr Villanueva. Around 300 prisoners underwent treatment for TB between April and December last year alone. The Directly Observed Treatment Short Course (DOTS) strategy for treating TB patients was implemented at the detention facility back in 2003.

 Helping hands  

On the prison’s DOTS ward, more than 40 inmates are suffering from complications of TB. The disease affects people and prisoners of all ages, including younger inmates like 24-year-old Mark* and Joseph*, who is 32 .

     Joseph was detained in 2005. He was diagnosed with TB and started treatment just last December. He says his weight originally dropped to 53 kilos due to his loss of appetite.

" My system really went down. I easily got tired from walking short distances, " he explains.

Prisons provide a perfect place for airborne illnesses, like TB, to thrive because of the cramped and poorly ventilated living quarters. A lack of access to sunlight, good nutrition and medical care can also play a role in its spread.

Now visibly healthier at 75 kilos, Joseph is officially cured and volunteers to help other TB sufferers. " This sickness is really difficult because you don't know what will happen to you, " he says.

Mark, on the other hand, believes he already had TB when he was transferred to the national penitentiary in 2006.

" It got worse here, " says the young man, who underwent treatment in 2007. " I used to cough up blood often. I almost died. "

Like Joseph, today, Mark is doing better and helps his fellow inmates cope with the debilitating disease. " I'm cured now. I don't cough anymore. I'm doing this because I want to be of help. I collect sputum samples and assist whenever the patients cough up blood or need to be taken to the doctor, " he adds.

 Targeted framework  

Much has yet to be done but Dr. Villanueva says a " Call for Action " process, launched by the ICRC in collaboration with national agencies, paved the way for a specific framework to effectively address TB in Philippine jails and prisons.

" Before, there were no operational guidelines. We just followed the DOTS program of the Department of Health, but it was designed more for TB in communities, not jails. After the ‘Call for Action’ was launched, operational guidelines were implemented. The ICRC also helped in training our staff, while communication with the Bureau of Jail Management and Penology was improved, " the doctor explains.

These guidelines are now implemented in seven pilot jails and prisons throughout the country, ensuring full access to the National TB Programme for 30,000 inmates.

According to prison health officials, the framework also ensures that new detainees are properly screened and that released prisoners get the follow-up they need.

     " Previously, we did not know that some inmates already had TB. Now when they are committed, they go through a simple TB screening checklist. When they are eventually released from prison, a referral system is in place so they can continue their medicine through health centres, " she said.

" For there to be effective TB control, it is important that steps to diagnose and manage TB are implemented during each stage of an inmate's incarceration… that means when they’re first jailed, throughout their detention and after their release, " says Dr Sarji Muldong, who manages the ICRC’s TB-related activities in Philippine prisons. " The presence of dedicated health staff is also crucial.”

In 2009, the ICRC sponsored the training of over 160 detention staff from 22 jails and prison facilities in the country on proper TB management.

The authorities also plan to build a DOTS clinic, with help from the ICRC, outside the hospital annex where sputum exams are done, to enable more sophisticated testing and serve as a venue for consultations.

Ironically, Dr Villaneuva says efforts to stop prisoners from catching TB cases may lead to an initial increase in the number of declared cases due to improved screening. But ultimately, the doctor predicts that by boosting the system’s diagnosis and care capacity, the incidence of the illness among inmates will decline in the long-run.

" We want to reduce infections but with the improved DOTS strategy, the numbers will probably go up over the next two to four years because we will find more TB cases. Then it may go down, " he says.

Information campaigns are also being mounted on how the disease is transmitted and how to prevent it from spreading. A " health aide inmate " in each ward keeps an eye out for fellow prisoners who have a persist ent cough for more than two weeks – a basic symptom of TB.

" Prisons are generally a captive population group, where a good TB control programme, if implemented properly, will have a significant, positive impact on the entire community. With the strong collaboration of agencies like the New Bilibid Prison, this killer can be prevented from striking behind bars, " says Dr Muldong.

* Names have been changed at the request of the inmates.