TB behind bars

“There is no greater error than to imagine that tuberculosis in prisons because of the isolation of the institutions does not constitute a great danger to society at large” Dr JB Ransom, 1911.

The burden of tuberculosis (TB) in prisons in most countries is considerably higher than in the general population, and often makes a large contribution to the country’s burden, according to the World Health Organization (WHO). The WHO also reports that TB in prisons has been reported to be up to 100 times higher than that of the civilian population and cases of TB in prisons may account for up to 25% of a country’s burden of TB.

Failure to control TB in prisons not only causes suffering and death among inmates but also fuels the TB epidemic in society at large. “Prior incarceration is second only to HIV-infection as a risk factor for TB disease in township populations,” says Professor Robin Wood from the Desmond Tutu HIV Centre. “Prisons should be recognised as a TB hotspot with an at risk population more than twice the size of the gold mining workforce.”

With more than half a million new cases of TB every year, of which approximately 15 000 are drug resistant, neither the South African government nor the general public can take this public health threat lightly. The case of Dudley Lee versus the Minister of Correctional Services got a considerable amount of attention and urged the National Department of Health (NDOH) to step into correctional services territory.

Awaiting-trial prisoner Dudley Lee sued the Department of Correctional Services (DCS) for causing him to get infected with TB while at Pollsmoor Prison. The Constitutional Court agreed and advised the DCS to implement proper infection control measures to prevent more inmates from getting sick (and suing the department). Dudley Lee sadly died on 21 May this year in the Victoria Hospital, Cape Town.

Following the Dudley Lee case, the Department of Health stepped in and initiated a mass screening campaign in correctional centres nationwide. Screening on entry, twice a year and on exit should lead to more cases being detected, which should, in turn, help curb the spread of TB. Or at least in theory. In reality, the screening campaign comes with its own challenges. While screening represents a first and important step towards recovery, it needs to be followed by treatment. Without providing effective access to TB and HIV treatment, mass screening is not only an expensive exercise but also presents a serious ethical issue.

Since the Westville case in 2006, in which the Durban High Court ordered the Department of Correctional Services to provide ARV treatment to all inmates at the prison that required treatment, the Treatment Action Campaign (TAC) has been monitoring prisons in several provinces. A recent investigation by the TAC in correctional centres in the Western Cape, KwaZulu-Natal and Gauteng, however, revealed several systemic failures on the side of correctional services management that affect the uptake of treatment by inmates.

Maria Mabena, Director for Health at the DCS has confirmed in an interview with NSP Review, that they employ only eight doctors nationwide to look after close to 160 000 inmates that are incarcerated annually at any one time (360 000 people move through correctional services in a year). Mabena admitted that the department has only filled eight of the 48 doctors’ posts.

To fill the gap, she says, DCS has agreements with the health department at provincial level to contract private doctors on a sessional basis. Most centres that the TAC visited in the Western Cape, Gauteng and KwaZulu-Natal reported to have a doctor for half a day or a day per week.

As in the general public health system, healthcare services are nurse driven but nurses in correctional centres cannot initiate antiretroviral therapy (ART). Complaints have been received from inmates that wait more than three months for ART to be initiated. Investigations by NSP Review has confirmed that in some correctional centres, nurses can prescribe TB treatment but the pharmacy will not dispense without a doctor’s signature.

Many inmates interviewed by the Treatment Action Campaign claimed that even when the doctor is available and present, the department requires that inmates are accompanied by a security official to go to the prison hospital. This requirement often prevents inmates from
accessing care because security staff are frequently unavailable to accompany them. A number of inmates also said lockdown, which in most correctional centres is from anytime between 2pm to 4pm and 6am to 7am, means that the centre operates on minimum staff and cells are not even opened in emergencies.

Dr Sweetness Siwendu sees MDR-TB patients from Pollsmoor and Goodwood correctional centres every second Wednesday. MDR-TB treatment takes up to two years to treat and requires monthly check-ups to monitor for side effects and adjust medication if necessary. Yet MDR-TB patients in Pollsmoor often miss their appointments with Dr Siwendu. “Different categories of prisoners cannot be transported together. If three patients come from three different sections it means that three separate vehicles are needed to transport them. This results in patients coming at different times or not at all” says Siwendu.

But inmates also come and go and in remand detention this happens on a daily basis. “Inmates come and go as they are released or transferred. Sometimes they leave prison for the courts and do not return if released. They then go home without medication or referral to the clinic and they are lost to follow up”, says Siwendu. “This presents a huge problem,” says Siwendu because “[this patient] is definitely going to be sick again and he’s going to infect a lot of people wherever he goes until he’s sick enough to go to the clinic again.”

Over and above ensuring screening and access to treatment, the most ignored fact in the government’s response is the fact that they are still not preventing inmates from getting infected. Overcrowding, a lack of ventilation and long lockdown times have repeatedly been proven to increase the risk of infection with TB. A high prevalence of HIV, poor nutrition and interrupted access to ART make the progression to disease all the more likely.

The NDOH and DCS recently formed a National Task Team (NTT) to operationalise the mass screening campaign and implement additional measures to reduce the TB epidemic in prisons. Chaired by the NDOH, the NTT acknowledges the factors that are causing transmission of TB but hasn’t come forward with adequate solutions. The DCS, which supposedly co-chairs the NTT and holds the key to an urgent public health issue, washes its hands of the task by blaming old infrastructure and points the finger at the Department of Public Works.

A special edition of the NSP Review, focusing on TB in Prisons will be published early August.