Stop TB Partnership

Opinion piece: TB in Prisons

Written by Lieve Vanleeuw

26 June - South Africa - Tuberculosis (TB) has been the leading cause of death in South Africa since 1997. The World Health Organization (WHO) Global TB Report 2013 estimates that more than 500,000 people in South Africa develop TB each year which amounts to 1% of the population. While the Department of Correctional Services has no official data on the incidence of TB in its centres, it is estimated to be considerably higher than in the general population. In an effort to stop the spread of TB, the Department of Health has initiated a massive screening campaign in all 246 correctional centres in South Africa.

In the past four months, field workers from the Treatment Action Campaign (TAC) visited several correctional centres in the Western Cape, KZN and Gauteng, and conducted interviews with inmates, warders, healthcare practitioners and researchers in the field of TB. These interviews revealed a number of systemic failures on the side of correctional services management that affects the uptake of treatment by inmates.

Failure to control tuberculosis 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."1

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)2 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).

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.

The DCS employs only eight doctors nationwide to look after 360 000 people annually.3 As in the general public health system, healthcare services are nurse driven but nurses in correctional centres cannot initiate antiretroviral therapy (ART)4. Complaints have been received from inmates that wait more than three months for ART to be initiated. In some correctional centres, nurses can prescribe TB treatment but the pharmacy will not dispense without a doctor’s signature.

But 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.

Dr Sweetness Siwendu sees multi-drug resistant (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 lock-up 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 full report is due to be published in August by the Treatment Action Campaign.

1Wood R., Tuberculosis in South African Prisons: Cruel and Usual. Published in NSPReview 11, TAC/SECTION27, August 2014.

2Following the May national elections in South Africa, the Department of Correctional Services and the Department of Justice have since merged into the Department of Justice and Correctional Services (DJCS). Minister Michael Masutha is heading the new Department.

3Interview with Maria Mabena, Director for Health, Department of Correctional Services (DCS). March 10, 2014, Pretoria.

4Interview wit nurses and Independent Correctional Centre Visitors (ICCV) at several correctional centres in KZN, Gauteng and Western Cape