Quite an unhealthy environment
Tuberculosis control in prisons in countries of the former Soviet Union
Von Manfred Zahorka / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Prisoners very often originate from the most vulnerable groups of society: the poor, the mentally ill, those dependent on alcohol or drugs. These groups have an increased risk of diseases such as tuberculosis (TB) already before entering the penitentiary system. Once in prison, the risk of being infected or falling sick is amplified by poor living conditions, overcrowding, poor ventilation, poor nutritional status, physical and emotional stress, including an atmosphere of violence, humiliation and disempowerment. Since TB is transmitted by airborne spread of infectious droplets, tuberculosis thrives in prisons, where inmates share rooms with many others and overcrowding is a prominent problem. Prisons are also a locus of HIV infection, a significant risk factor for acquiring and developing TB and for dying of TB.
An estimated number of 8 to 10 million people are incarcerated on any given day world wide and their numbers are increasing. Since many are detained for short periods of time, the rates of admissions and releases are almost equivalent so that the actual number of people passing through the prison system each year is potentially four to six times higher. Prisoners are mostly male (90 to 95% worldwide) and young. Russia has the world’s highest per capita prison population with 690 prisoners per 100’000 population closely followed by the United States with approximately 630 prisoners per 100’000 inhabitants. In most low-income countries prisons are full beyond capacity, with prisoners from impoverished unhealthy backgrounds living in an even unhealthier environment.
Prison health is often forgotten or given a low priority. Prisoners are stigmatised, hidden and rendered voiceless. The public is often ambivalent about providing quality care to those accused or convicted of wrongs against society, particularly where national resources are scarce due to the economic decline during the post soviet period. Thus, prison health services generally have serious shortcomings. Under-funding and demoralisation are common. In many transition countries, rates of active tuberculosis amongst prisoners are known to be up to 50 times higher than the rates in the civilian population. It is estimated that Russia has approximately 75,000 new TB cases annually for a civilian population of 150 million, whereas in the Russian penitentiary system 40,000 new TB cases are registered annually for a population of only 1 million. Approximately 10% of the one million detainees in Russia have active TB.
In most cases health care in prisons is under the responsibility of the ministry in charge of prisons, usually the Ministries of Justice, and not of the Ministry of Health. This results in different authorities being responsible for the health of an individual arrested, detained and eventually released, with little co-ordination between them. The number of TB cases in prisons is often not included in the data of the ministries of health, even though in many countries prisoners with TB form a considerable proportion of the overall number of cases.
Tuberculosis is a major cause of sickness and death in prisons. Directly or indirectly, these threats apply not only to prisoners, but also to all who come into contact with prisons and ultimately the community as a whole. Prison gates may be closed for prisoners. However, they cannot stop infectious droplets to penetrate into the outside world. Prisons act as a reservoir for TB, pumping the disease into the civilian community through health personnel, staff, visitors, and inadequately treated released inmates. Too often prisoners and former inmates fall through the gaps in the provision of health care. For instance, in Russia approximately 13,000 prisoners under treatment for TB are released every year. But only 7,000 to 8,000 of them seek treatment once in freedom. In many cases, released prisoners cannot afford to pay for drugs and services, which officially are still given out free, but for which in reality unofficial user fees have been introduced. Stopping TB treatment before the completion of the full course often results in the development of drug-resistant tuberculosis, which needs even more complex treatment protocols at prohibitive cost.
With so many TB cases in prison and with such a high rate of imprisonment, it is not surprising that tuberculosis has become the single leading contributor to increased mortality among young Russian men. TB has spread rapidly in Russia and the former Soviet States over the past decade. In Russia, for example, TB incidence - the number of new cases in a previously healthy population in a given time period - is climbing by 10% every year.
There are many obstacles to effective treatment of TB in prisons. An unofficial internal hierarchy exists frequently within the prison population. The rules and laws within this system have direct implications for the control of TB. Unfair selection of patients for treatment and trafficking of medicines can occur. Patients in the lower strata of the hierarchy may be pressurised by their bosses to hand over their TB drugs. Other patients may sell their drugs to the guards, give them to their relatives during family visits or use them as currency for gambling or for paying their debts. Poorly paid prison health staff may tolerate exchanges of sputum, taking bribes from wealthy prisoners. Some prisoners may avoid diagnosis because they are afraid their release may be held up until they complete treatment. Other inmates may try to get on TB programmes even if they do not have the disease or may deliberately expose themselves to infection, because of the perceived - and in some cases quite real - benefits of better care in a hospital. Education of patients is difficult in prisons. Prisoners have more immediate worries than the allusive dangers of not receiving a full course of treatment.
Communication between prison health services and civil TB programmes is lacking. Together with the stigma of coming from a prison, this lack of communication makes it difficult to ensure that released inmates can continue treatment when released. There also is a lack of information to prisoners about availability of TB services in the civil society. Additionally, adequate treatment is not always available or financially accessible. Amnesties, such as the release of nearly 350,000 Russian prisoners in March 2001, may pose a huge burden on the public health system due to the sheer number of people suddenly in need for TB treatment and make collaboration between the prison and the civilian TB programmes even more important.
Tuberculosis control in prisons is a public health urgency. Governments have an obligation to provide minimum levels of health care, accommodation and food for every prisoner. Health service providers should recognise the disproportionate health needs of prisoners, and services should be provided on the basis of equity or at least equivalence. TB treatment in prisons should follow the widely recognized WHO standards (Directly observed treatment, short course; DOTS). However, considering the special prison conditions some additional precautions have to be taken.
TB control in prisons demands firm political support, strong leadership, and adequate financial resources. International resources and expertise is needed in support to overcome the serious problem of TB in prisons. In terms of case detection, the usual case finding through self-referral should be complemented by active case finding (cases are actively sought by TB services) and screening on entry to prison. Giving of sputum should be directly observed so that trade with sputum samples does not occur.
Many TB patients find adherence to treatment difficult. This is even more the case in prisons, where generally the environment is not supportive and problems such as alcohol/drug abuse and psychiatric diseases are more common. TB education should be part of an integrated package of health education and health promotion for prisoners. Issues such as HIV/AIDS prevention, prevention of drug abuse, alcoholism and violence need to be included. It is crucial that not only prisoners with TB, but also healthy prisoners, staff, visitors and policy makers are well informed about the disease and the necessity of early detection and complete treatment. Peer educators can play an important role in educating patients. Cured TB patients or their relatives can often be more convincing and committed than health personnel.
*Manfred Zahorka is a family practitioner, public health expert and epidemiologist by training. He has been working for more than 15 years in public health and health systems development in developing and transitional countries in Eastern Europe, Central Asia and Africa. Currently, he is working with the Swiss Centre of International Health within the Swiss Tropical Institute in Basel. Contact: Manfred.Zahorka@unibas.ch
Information sources and further readings
Tuberculosis control in prisons - A manual for programme managers. World Health Organisation and International Committee of the Red Cross. WHO/CDS/TB/2000.281. Geneva, Switzerland.
Christian Auer, Claudia Kessler Bodiang, SENTENCED TO DIE? Tuberculosis control in prisons with a focus on the Republics of the former Soviet Union, A commissioned paper established by the Swiss Tropical Institute in the context of the mandate t.751-14 of the Swiss Agency for Development and Co-operation (SDC), February 2002, Bern, Switzerland.
Farmer Paul, Cruel and unusual: drug resistant tuberculosis as punishment, chapter in: Sentenced to die? The Problem of TB in Prisons in East Europe and Central Asia. London: Prison Reform International; 1999:70-88.
Reyes H and Coninx R, Pitfalls of tuberculosis programmes in prisons.
BMJ 1997 Nov 29; 315:1447-50.
Perelman MI, Tuberculosis in Russia. International Journal of Tuberculosis and Lung Disease 2000; 4(12): 1097-1103.
Pille Lindkvist, Tuberculosis among prisoners - Interdisciplinary expert meeting on prevention and control; report from an international meeting in Singunta, Sweden, October 4th to 6th, 2000.