A Silent Death Penalty? Tuberculosis in Southeast Asian Prisons
Considering the already unequal distribution of health resources globally, it is perhaps unsurprising that criminals are not a high-priority target population for high-quality healthcare delivery. But imagine a young prisoner, charged with a crime as minor as petty theft, contracting and dying of tuberculosis in an overcrowded prison, long before he is even brought to trial. The above scenario is by no means out of the ordinary, particularly among prisons in low-resource settings. Inadequate nutrition and unsanitary living conditions conducive to TB transmission can turn a period of incarceration into a death sentence, especially when there is inadequate access to treatment.
Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is responsible for 2 to 3 million deaths annually worldwide. The disease is a particular concern among the most vulnerable: immune-compromised patients such as those with HIV/AIDS, and those living in densely populated settings such as prisons, or areas with inadequate sanitation facilities [1]. The emergence of multi-drug resistant tuberculosis (MDR-TB) is a further concern with regards to TB management, as the second-line multidrug therapies required to effectively treat TB are significantly more expensive than standard first-line regimens, thus making the treatment of MDR-TB particularly difficult in prisons facing budgetary constraints on health care [2].
Tuberculosis and incarceration:
The very high TB prevalence rates in Russian prisons have been well documented. Proportionately higher prevalence rates of TB in the incarcerated compared to in the general population are also seen in other parts of the world. In Africa for example, while some countries such as Tanzania have very high TB prevalence rates among their imprisoned population [3], other countries such as Malawi have much lower prevalence rates. Even in regions with low prevalence rates,many have high rates of concomitant HIV cases [4], which exacerbates the difficulties associated with detecting TB in HIV-positive patients and effectively treating TB-HIV co-infections [5].
Although fewer studies are available regarding the prevalence of TB in South Asian prisons, it is also estimated to be high [6]. A study in Thailand, for example, reported that the prevalence of cases of TB that were resistant to at least one of the drugs in TB multidrug therapy ranged from 43 to 54% among three prisons [7]. These realities highlight the concerning aspects of the TB-HIV dual epidemic and suggest that measures to address TB in prisons, particularly in a Southeast Asian context, should occur concurrently with measures to address HIV.
Considering the high prevalence rates of TB among prisoners, health interventions that address both biological and socioeconomic influences on transmission within prisons are urgently needed. Such efforts should be supplemented with public health policies and management procedures that address the process of re-integrating TB-infected prisoners into the civilian public health system, and appropriately monitoring their treatment. What remains a crucial barrier to this more effective management of TB are barriers to rapid diagnosis in low-resource settings, which hinder both need-based treatment and evidence-based policy.
Diagnostic, Treatment and Policy Challenges
The accurate and early diagnosis of TB is challenging due to the slow growth of the causative bacterium, and rapid diagnostic tools are therefore urgently needed in order to allow the earlier detection of the disease and consequently more favourable treatment outcomes and the minimization of the emergence of resistant strains [8, 9]. A significant concern is the fact that the clinical presentation of TB is less evident in HIV-positive individuals. This results in many HIV-concomitant TB infections remaining undiagnosed, which delays treatment and can result in in poorer patient outcomes, further underlining the need for more effective diagnostics that appropriately take into account patient histories, co-infections and co-morbidities [10].
HIV-TB co-infection and the diagnostic difficulties associated with it also produce significant policy challenges with regard to TB treatment at the population level. Although TB remains the leading cause of AIDS-related death, public health policy has largely neglected to address the growing population of HIV-TB co-infected individuals in developing countries and in vulnerable communities such as prisons [5].
For example, in many low-income countries where TB treatment regimens are scarce, the difficulty of treating HIV-positive patients with TB lies in the fact that the provision of treatment for TB to patients is only endorsed by health ministries in cases where patients test positive for TB. However, the widely used diagnostic test, which is based on the detection of the causative bacterium in patient sputum, leaves many HIV-associated cases of TB undetected, as patients with HIV do not normally have a high bacterial load in their sputum, even when they do have TB [5].
Such discrepancies between health need and health policy must be revised to allow need-oriented policy. In particular, to appropriately address TB and MDR-TB in incarcerated populations in Southeast Asia, where HIV prevalence rates are high, a comprehensive approach at the socioeconomic, clinical and public health policy levels is required.
The Political Landscape of Prisoner’s Rights:
“If access to healthcare is considered a human right,
who is considered human enough to have that right?”
~ Dr. Paul Farmer, Pathologies of Power
Recognizing the public health challenges present in prisons, it is critical to consider the broader political-legal dynamics in which these poor conditions arise, and the systems that legitimate these conditions. Firstly, the International Covenant on Civil and Political Rights (ICCPR, enacted in 1976) contains several clauses pertaining to prisoners’ rights. However, it mainly articulates the need for the separation of juvenile offenders from adults, as well as the differential treatment of pre-trial prisoners compared to the convicted. 11 The Covenant contains no specific guidelines on the standards that should be upheld in prisons with regard to living conditions and health, and only generally states that prisoners should be treated in a manner that is conducive to their “reformation and social rehabilitation” [11].
A second document dealing with prisoner’s rights at the international level is the United Nation’s Standard Minimum Rules for the Treatment of Prisoners. Although this document addresses issues such as hygiene, sanitation, and nutrition in prisons, the standards outlined function only as guidelines and are in no way legally binding [12]. Therefore, there are few legal provisions, apart from what can be derived from existing human rights law, for accountability on the part of the state regarding the safeguarding of prisoners’ health.
In the context of the unequal and profit-driven distribution of health resources globally, the lack of strict regulations regarding their rights causes even less attention to be paid to their health concerns. Within this demonstrably inadequate legal framework for prisoners’ rights, how does one conceptualize a prisoner’s right to health? Two considerations are relevant in this regard: first, the concept of the Human Right to Health, and second, the idea of imprisonment as rehabilitation as opposed to punishment, as outlined in the ICCPR [11].
Firstly, if we consider health to be a human right, then surely prisoners should not be excluded from accessing this right [2].
Secondly, if the treatment of prisoners, and the conditions within prisons, should serve the purpose of rehabilitation, it follows that more attention should be paid to facilitating that prisoners actually survive long enough to be rehabilitated, rather than falling victim to infectious diseases as an indirect result of their imprisonment.
The Neglect of Prison Settings in the WHO’s Past Efforts to Address TB:
The WHO’s Directly-Observed Therapy Short-course (DOTS) program, introduced in 1998, mandated observing patients taking their multidrug therapy in order to improve treatment adherence rates. The program faced two main shortcomings when implemented for TB management in prisons. Firstly, it took much longer for the policies mandated under the DOTS program to be successfully implemented in prisons than it did for them to be introduced into civilian public health systems around the world. 4 This shows that prison inmates represent a neglected population both in terms of their ability to access treatment and their ability to benefit from public health policies that aim to improve treatment outcomes. Considering that prisons are also an epidemiologically unique environment due to the presence of multiple co-infections in its population as well as the altered dynamics of disease transmission within such a densely-populated and confined area, their neglect in the processes of policymaking and intervention design are a particular concern.
Secondly, the DOTS program was actually ineffective at preventing the emergence and spread of MDR-TB, as a main component of the program involved the highly standardized prescription of first-line drugs to TB patients [2]. This was of particular concern in low-resource settings (including prisons) as the program did not include efforts to ascertain the drug-resistance status of cases of TB. The identification of MDR-TB and obtaining second-line drugs were considered too expensive to be a viable option among marginalized populations, thereby failing to address the potential for further spread of MDR-TB within these populations.
A second past effort to curtail the spread of TB includes the Stop TB strategy, implemented by the WHO from 2006 to 2015, which aimed to eliminate TB as a global public health problem by 2050, and, by 2015, to halve its incidence in comparison to 1990 [13]. As it is now 2016 and the deadline for this latter target has passed, it is relevant to consider the effectiveness of the Stop TB strategy, specifically in terms of its impact (or lack thereof) on the management of TB in prisons.
First of all, the Stop TB program emphasizes the need to prioritize access to diagnostics and treatment for the disease [13]. Although it specifically highlights the need for accessibility for high-risk populations such as prisoners and the poor the complete Stop TB Strategy document contains no precise description of the means by which this is to be achieved [14]. Moreover, although part of Stop TB’s mission is to reduce the socioeconomic consequences of TB in terms of the financial burden that its treatment represents for patients [15], little attention is paid in the Stop TB strategy to reduce the underlying social and politico-economic factors that make the poor and marginalized more likely to contract the disease in the first place, and less likely to experience positive treatment outcomes.
Measures for TB control in Prisons:
Recognizing the ineffectiveness of the WHO’s past one-size-fits-all approach to addressing TB, specific measures that target the transmission, treatment, and management of the disease in prisons, both at the biological and social level, are required. Firstly, at the biological level, measures to address TB in prisons include the enforcement of regulations to reduce overcrowding and improve nutrition standards within prisons, as well as the reduction of the likelihood of transmission of TB. This is exemplified through the implementation of Ultraviolet Germicidal Irradiation (UVGI) fixtures in prisons [16], and the use of more accurate diagnostic tools such as the Mycobacterium tuberculosis and Rifampin Resistance Test (Xpert MTB/RIF).
This test has been shown to have high sensitivity and specificity, even in HIV-concomitant cases, and is also capable of identifying mutations in the bacterial gene responsible for resistance to the anti-mycobacterial drug Rifampin [17], therefore representing a significant improvement over existing diagnostic tests, which determine drug resistance through the comparatively slow process of growing bacterial cultures and exposing them to a series of antibiotics.
The more rapid identification of resistance to Rifampin, as facilitated by this novel testing method, will therefore allow the earlier detection of drug resistant TB cases, opening the door to earlier treatment with the necessary second-line drugs [17]. However, as the sensitivity of a test (its capacity to detect the disease in cases where it is in fact present) is influenced in part by the prevalence of the disease in the target population, further research is needed to develop more accurate diagnostic tools for use among high-prevalence populations such as prisoners [18].
Thus, apart from the persistent challenges surrounding the improvement of diagnostic tools to suit prison settings, there remain also the broader legal, political and economic challenges that obstruct the implementation of successful TB management strategies. In addition, the currently weak legal provisions governing prisoners’ rights further impede healthcare delivery to prisoners and the improvement of their general living conditions. The strengthening of this legal framework requires substantial political will, a human rights-based approach [2], and additional emphasis on rehabilitation rather than mere punishment in the justice system. Framing prisoners’ health as a human rights issue may be one way to garner support for the development of the technological, economic, political and legal capacities to protect prisoners, and to afford them their right to health.
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