The tuberculosis epidemic breaks through prison walls
Tuberculosis is a disease associated with poverty. Prisons, where the number of people suffering from tuberculosis is particularly high, have very limited means available to fight the disease. Interview with Dr. Francisco Duda, coordinator of the ICRC’s work on disease control in prisons.
It is the extremely high number of cases of tuberculosis in places of detention. The number of detainees with tuberculosis can be up to 100 times higher than the number of cases in the rest of society! In some countries, 25% of those with the disease are in prisons.
Why are there so many cases of tuberculosis in places of detention?In many countries, the prison budget is not sufficient to ensure that detention conditions are acceptable. Overcrowding and poor ventilation favour the transmission of the disease. The shortage of food makes the detainees weak and more likely to contract the disease. The prison health services, which are generally in a state of neglect and less efficient than those in society, are unable to provide early diagnosis or effective treatment.
The high incidence of tuberculosis in prisons is also due to the specific nature of the prison population. AIDS and tuberculosis are closely related (see the interview with E. Burnier). There also happens to be a very large number of people with the HIV/AIDS virus in prisons and many detainees are users of intravenous drugs, one of the main groups of people at risk of contracting HIV/AIDS; in some countries they constitute the majority of the detainees. Sexual relations between men is another HIV/AIDS risk factor, is also more prevalent in prison than in the rest of society.
Finally, it should be stressed that AIDS increases not only the risk of contracting tuberculosis but also that of dying from it.
What effects do these high tuberculosis rates in prison have on the rest of the community?
To succeed in controlling tuberculosis in society, it is vital for the fight against tuberculosis in prison to be included in the programme. In fact, there are a great many possible transmission vectors between prison and the community. It is estimated that worldwide there is an average of between eight and ten million prisoners on any one day. Because of the frequent movement in and out of places of detention, four to six times more people pass through there in the course of a year. Moreover, non-detainees – particularly those who work there and the detainees’ families – have regular contact with the prison.
These exchanges between prison and the rest of society help to pass on the tuberculosis bacillus, and it is pointless to try to combat the disease without taking account of places of detention.
What can you tell us about resistance to tuberculosis treatment?
Tuberculosis is generally treated with four medicines over a period of between six to nine months. In some cases, resistance to a particular medicine develops, either because treatment has been broken off or is inadequate, or because of direct transmission by someone who has built up a resistance to the disease. The usual treatment is then no longer effective.
Two of the medicines are considered as forming the “backbone” of the treatment because they kill the bacteria. When resistance to these two medicines occurs, we talk about multi-drug resistant (MDR) tuberculosis. MDR tuberculosis can be treated but treatment is lengthy, complex and costly.
However, what is more disturbing is that since March 2006, the World Health Organization (WHO) has been reporting the first cases of extreme drug resistant (XDR) tuberculosis, which is characterized by resistance to the three main categories of medicines used to treat MDR tuberculosis and is associated with a very high mortality rate.
The ICRC is working in some countries – the southern Caucasus, Peru, Kyrgyzstan. What are the criteria for taking action in one country rather than another?
First of all, we only take action in the context of detainee protection work, that is in countries in which the ICRC visits persons deprived of their freedom and evaluates the detention conditions with a view to bringing about their improvement.
Then we only step in when the prison authorities do not have the capacity or the means to deal with the problem. The treatment also has to be followed up once the detainee being treated has been released.
Depending on what is needed, the ICRC may provide technical or financial support or take full charge of the situation when there is no other solution.
Does the ICRC work with other organizations to combat tuberculosis in prison?
Yes, the ICRC does work with other organizations. The problem of tuberculosis is not merely a health problem; it is related to poverty, social problems and detention conditions. Non-medical players may therefore take action to improve the prison infrastructure, for example. Many organizations have resources available to respond to the particular problems in prisons. We try to mobilize all the resources in a country and to work in partnerships while maintaining our independence.
Similarly, various partners may take part in the programmes to combat tuberculosis. In the tuberculosis prevention programme in Kyrgyzstan, for example, we are working with the Ministers of Health and Justice, the National Red Crescent Society, Doctors Without Borders, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and WHO.