Tuberculosis in prisons: a forgotten killer
Prisoners, especially in poor countries, are particularly vulnerable to infectious diseases such as HIV/AIDS and TB. In the following interview, Dr Eric Burnier, who runs the ICRC's communicable-disease control programmes, stresses the need to give prisoners access to the same medical care as the general population.
- Worldwide tuberculosis kills close to 5,000 people every day.
- 2 billion people carry tuberculosis bacillus
- 425,000 new cases of multi-drug resistant tuberculosis develop every year
Twenty years ago it was thought that medical advances would make it possible to eradicate TB, but the disease has persisted and remains a very serious problem throughout the world, especially in the prisons of many countries – the main reasons being overcrowding and the highly contagious nature of TB. The prevalence of TB in prisons is much higher than among the general population – in some countries as much as 100% higher – and in many of these countries TB is one of the main causes of death in prison.
Of particular concern is the fact that TB is becoming increasingly resistant to classical drugs, mainly because of inconsistent treatment or the use of poor-quality drugs.
What is the connection between TB and HIV/AIDS?
The two diseases are very closely linked, and the development of the HIV/AIDS pandemic is one of the reasons for the upsurge in TB, especially in Africa. When a person is infected with the HIV/AIDS virus, his immunity gradually decreases, which makes it easier for him to become infected with TB or for a dormant infection to become active again. As with TB, the percentage of HIV/AIDS patients is particularly high in prison, especially in countries where the disease is associated with the use of intravenous drugs, as is the case in the countries of the former USSR.
How did the ICRC become involved in combating TB in the prisons of the southern Caucasus?
The ICRC is not a medical organization per se and its mission is not to fight pandemics like HIV/AIDS or TB. Nonetheless, when 10 years ago, following the Nagorny Karabakh conflict, ICRC delegates discovered prisoners of war who were suffering and dying from TB in Azerbaijan, they couldn't simply denounce the situation and leave it at that. The disease was spreading and nothing was being done to contain it. Since the government didn't have the means to deal with the problem by itself, the ICRC launched a programme to fight, prevent and treat TB in the country's prisons. The programme was designed together with the ministry of justice and its medical staff. Over the following years similar programmes were set up in Georgia and Armenia.
Was it difficult to launch these programmes?
It wasn't easy, partly because the countries involved were still heavily reliant on detection and treatment techniques inherited from the Soviet era, which were giving increasingly poor results. To make the fight against TB more effective, we had to convince them to adopt the approach recommended by WHO: DOTS (directly observed treatment, short course).
Another difficulty stemmed from the fact that in the southern Caucasus as elsewhere in the world, health problems in prisons do not fall within the remit of health ministries. In the case of pandemic diseases like TB, it is essential that a country's ministries of justice and health work together. The ICRC has long sought to promote discussions and negotiations between these two ministries, reminding them that prisoners are citizens and that as such they must have access to the same medical care as other members of society.
What role has the ICRC played in designing TB programmes?
The ICRC works closely together with WHO and applies the DOTS strategy recommended by this organization. As part of this strategy, TB cases are detected and recorded according to strictly defined rules, drug stocks are regularly replenished to cope with demand and drugs are taken under close supervision during the entire course of treatment. Finally, cases are systematically recorded so that the situation can be constantly evaluated.
In the three countries of the southern Caucasus, the first thing the ICRC did was to persuade the authorities to adopt this strategy. Since they would have been unable to address the problem in all its complexity or meet the costs involved, the ICRC launched a programme aimed largely at substituting for them. The programme included training activities, the provision of drugs and laboratory equipment, detection services, treatment and follow-up care for prisoners with TB and the rehabilitation of prison medical facilities.
What were the results?
- In Azerbaijan:
- around 7,000 prisoners with tuberculosis have been treated
- the tuberculosis mortality rate has fallen from 14% in 1995 to 3% in 2004
- in Georgia
- more than 3,000 prisoners with tuberculosis have been treated
- the percentage of detainees suffering from tubercolisis has fallen from 6.5% in 1998 to 0.6% in 2005
Probably the most remarkable result was to have fully convinced the medical staff of the justice ministries of the three countries involved that the DOTS strategy was the right one to use, and that it was effective not only in developing countries but in other countries as well. What finally brought them round was the good results obtained by these programmes (see box).
Another very positive result is that prisoners are now screened for TB upon their admission to prison. Each prisoner is examined and if he presents TB symptoms and the TB bacillus is detected in his sputum, he is given a treatment course and placed in isolation.At present, the ICRC is gradually pulling out of these programmes and handing them over to the authorities. The existence of the Global Fund to Fight AIDS, Tuberculosis and Malaria makes it easier to do this now than it would have been 10 years ago.
How do you deal with treatment resistance?
Treatment resistance is a very serious problem since it means that we must resort to drugs that are very costly, have secondary effects that make them more complicated to use and must be taken for a much longer period of time. With the classical DOTS treatment, we can cure any TB patient not resistant to DOTS drugs in six to eight months. But when a patient is resistant, he must take second-line drugs for up to two years, which is very costly and entails considerable difficulties. In the countries of the southern Caucasus we worked together with other organizations – in particular Germany's overseas cooperation service – to find adequate solutions to the problem of treatment resistance.
How has the ICRC's role changed in recent years?
The ICRC has been playing an increasingly supportive role in the southern Caucasus, backing up the authorities in their efforts to combat TB in prisons on their own. It is also helping the governments involved to obtain the necessary funding.
In other parts of the world – Africa, in particular, where increasing use has been made of the DOTS strategy over the past 20 years – the ICRC adopted this supportive role from the very start, while at the same time reminding the authorities that prisoners, as citizens, are entitled to the same drugs, follow-up care and attention as the general population. Whatever a prisoner may have done to deserve his sentence, his punishment is to be in prison and not to become infected with a potentially fatal disease like TB.
story of a detainee in Azerbaijan and see also the
tuberculosis in prison in listen to the audio interview (in Spanish) with Sergio León, ICRC doctor, about Latin America