Fighting TB with prisoners' rights

By Annabel Raw

Today is World Tuberculosis Day, commemorating the discovery of the cause of the disease in 1882. Tuberculosis (TB) is an ancient disease with traces in human remains being recorded since antiquity. Despite advances in public health and treatment, today TB continues to claim over one and a half million lives every year, the majority of fatalities being in Africa.

While reflecting on its impact in southern Africa, I want to propose that one of the most important things we can do to combat TB is something which might come as a surprise: to realise the human rights of prisoners by improving prison conditions. I want to argue that if not for the human empathy we should preserve for prisoners as subjects of human rights, we should also be concerned about the treatment of prisoners in the region as a public health issue.

By some estimates, 90% of persons exposed to TB never manifest symptoms or become infectious. However, TB thrives in conditions where ventilation is poor, in conditions of overcrowding and poor sanitation, and among persons whose immune systems are weak — persons with HIV, or those who are undernourished and who receive little attention to their health needs. The grim reality is that these are the dominant characteristics of prisons in the region.

First, many prisons in southern Africa are desperately overcrowded. For example, in 2009 the Malawi High Court declared overcrowding in Malawi prisons a violation of prisoners’ human rights, amounting to torture. Six years later, the prison population continues to climb with the current occupancy levels at about triple the prisons’ capacity. So dire is the congestion, that in most prisons, inmates can spend their entire sentence sleeping in a sitting position commonly referred to as shambas.

Second, inmates are housed in conditions of appalling sanitation, ventilation and light. A 2011 study found that South Africa’s Pollsmoor Prison was so damp, overcrowded, poorly ventilated and inmates so inadequately screened and treated that incoming prisoners faced a TB transmission risk of 90%. In 2012, the Constitutional Court affirmed the barbarity of these conditions in holding prison authorities liable for an inmate claimant’s infection with TB. Conditions do not look to have improved much since then.

Third, prisoners in southern Africa have high rates of HIV infection, and are often undernourished. The Mwanza case in Zambia has highlighted the extent to which malnutrition leads to HIV-positive prisoners not being able to use their antiretroviral (ARV) treatment effectively, making them more prone to infection with opportunistic infections like TB, and more infectious to others. In a further example, recent fatal riots in Zimbabwean prisons have been dismissed by officials as prisoners merely wanting nicer relish with their meals: a poorly-attempted subversion of the fact that prisoners receive minimal nutrition, where likely conservative official estimates indicate over 100 prisoners die from malnutrition alone in Zimbabwe each year.

Fourth, access to medical treatment is vastly inadequate. In Botswana, the Tapela case brought to attention that the government deliberately withholds ARV treatment and refuses to provide viral load testing for HIV-positive prisoners who are foreign. In Zambia, some prisons have no on-sight medical facilities or staff, and prisons face frequent drug stockouts, preventing timely and consistent access to medicines to curb drug resistance.

These problems are ubiquitous in the region, making prisons hotbeds for the spread of disease, particularly TB. But it doesn’t end there.

The majority of prisoners will be released from incarceration at some point, returning to their communities and families with the illnesses they contract in prison. Prisoners have daily contact with prison staff too, whose health, and in turn the health of their families and communities, are at risk of exposure to TB and other communicable diseases. Prisoners are part of our communities.

If the mere fact of being human is not enough to incite outrage on behalf of these prisoners, it is worthwhile to keep in mind that these conditions are faced not only by convicted adult criminals but by unconvicted remand detainees, by child detainees housed in adult facilities, and by small children who are in some countries housed together with their incarcerated mothers.

It is clear then that no effective response to TB in southern Africa can neglect the state of prisons: the violation of prisoners’ rights is a public health concern for all. For as long as we continue to imprison people in such medieval conditions, archaic diseases like TB will fester as public health crises despite modern advances in treatment.

Annabel Raw is a health rights lawyer at the Southern Africa Litigation Centre.