ICRC (press release), Switzerland
International Committee of the Red Cross
March 24 2006
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.
©ICRC
Eric Burnier, the ICRC doctor responsible communicable-disease
control programmes
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
How serious is the problem of TB in prisons?
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?
How DOTS has worked
– 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
How DOTS has worked
– 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.
From: Emil Lazarian | Ararat NewsPress