TB in prisons: Containing a catastrophe
In Russia, a 16-year-old teenager arrested for getting into a fight can end up making light switches for over a year in a juvenile 'colony' (labor camp for prisoners). A woman who steals a bag of potatoes can await her sentence for months or even years, locked in the cell of a 'SIZO' (pre-trial detention center), where her living space is reduced to one square meter.
With almost one million prisoners, Russia's per capita prison population is second only to that of the USA. One out of every four adult men has been incarcerated at least once in his life. Moreover, the inhumane conditions common in Russian prisons - massive overcrowding, malnutrition, lack of hygiene, sunlight and ventilation - make them an ideal breeding ground for tuberculosis, and can turn punishment for small crimes into death penalties.
TB, a contagious, airborne disease, has long been endemic in Russian prisons, but in the early and mid 90's, the disease spun out of control and reached epidemic proportions. Given the continual release of prisoners into society, the epidemic posed a major public threat. In the region of Kemerovo, in Southwestern Siberia, the yearly incidence of TB rose to over 4,000 per 100,000 inmates - 40 times more than among the civilian population. In 'Colony 33' which was once the only prison colony in the region offering TB treatment, 400 persons out of 1,500 died in 1995.
Faced with this alarming situation and a shortage of anti-TB drugs, Dr. Natalia Vezhnina, the medical head of Colony 33, appealed for urgent help from international organizations. At the time, no NGOs had yet set foot in Russian prisons. MSF responded to the call and in mid 1996, it put the first 50 patients on treatment using a strategy recommended by the World Health Organization called 'DOTS' - 'Directly Observed Treatment Short Course'.
Working in collaboration with the Ministry of Justice and regional authorities, MSF expanded its program. To date, the program has trained close to 100 medical professionals in DOTS; cured more than 5,000 people with quality drugs; established a decentralized network of laboratories; and set up a new system of screening, diagnosing, referring, treating, and following up patients, which covers the entire penal system of Kemerovo.
The impact of MSF's intervention is now visible: according to official statistics, the incidence of TB in the penitentiary system has been cut by more than 50% over five years; MSF has clearly seen mortality decrease by seven times over the same period; and, compared to three years ago, the number of cases newly put on treatment is four times lower.
Dr. Igor Malakhov, the current medical head of Colony 33, says that pessimism, once rampant among patients and medical staff, has largely vanished. 'We first had to convince ourselves and regain our confidence in our ability to cure, and then we could pass that on to the patients. The change in mood is notable. Today the majority of the patients are optimistic. They believe in us, in our expertise, in humanitarian assistance, and they believe they will be cured. And the credit goes to all those who didn't give up - the patients, the medical personnel and MSF'.
He goes so far as to say that, in the past two years, 'the situation has stabilized' and that 'we have the control in our hands'. But one should know that Dr. Malakhov likes to present the colony he runs in a favorable light. Furthermore, he is a lieutenant colonel, and openly states himself that he is a 'military man' who 'follows orders from above' before he is a doctor. Footnote 1 Whether it reveals a Soviet habit of telling his superiors what they want to hear, or whether it is wishful thinking, Malakhov's statement is not true: the situation is still far from being under control.
Obstacles to TB control
Medical reforms alone, no matter how good, will never overcome the spread of the disease. Social assistance to ex-prisoners is needed; alternatives to imprisonment must be found; living conditions in prisons must be improved; and above all, the penal system must be overhauled. Amnesties are not sufficient - they are only a temporary solution to release overcrowding. Long-term measures must be taken to reduce the prison population.
President Putin was recently heard on national public television (NTV) saying that last year, according to the Chief Prosecutor's Office, court 'mistakes' led to the illegal imprisonment of more than 1,300 persons in Russia. No doubt the real numbers are much higher. Though a budget of about US$ 400 million has been allocated to reforming the penal system Footnote 2 between now and 2006, change is slow in coming.
And while discussions about penal reforms drag on and on, the huge flow of individuals in and out of prisons continues to pose an on-going challenge to the treatment of TB. The turnover is around 25% per year. To be effective, DOTS - which lasts 6 to 8 months and involves taking a combination of four drugs - must be complete and uninterrupted. Many prisoners are set free (either because they completed their sentence, were declared innocent after months of detention, or benefited from an amnesty) before they are cured.
A reliable TB program in civil society, with close links to the penitentiary, could ensure continuity of treatment, but such a program does not yet exist. There is also poor collaboration between the Ministry of Justice, which manages prisons, and the Ministry of Health, which manages TB structures in the civil sector.
It gets more complicated: even within the penal system, three different ministries are sometimes involved in the follow-up of a single patient. Imagine that Sasha is locked up in a SIZO, where he develops TB. He is often taken out of the SIZO and transferred to the 'IVS' (or temporary isolation unit) closest to the site where he committed his crime. He is held there while his case is under investigation. Medical professionals are rarely present at the IVS. In case of an emergency, an ambulance brings in a staff person from the closest health structure. The SIZO reports to the Ministry of Justice, the IVS to the Ministry of Internal Affairs, and the medical staff is from the Ministry of Health. There you have it.
Getting all the concerned parties in Kemerovo to sit around a table for the best interest of Sasha and some 30,000 other prisoners has been one of MSF's main efforts. The organization has helped to create a 'Coordination Committee' and to devise a region-wide common strategy to control TB, which supports the regional government as the final decision-maker. Currently, MSF is pushing for the regional TB program to be approved at the federal level, and hopes such a program could serve as a model for other regions and for the nation as a whole.
Convincing authorities that DOTS is a cost-effective anti-TB strategy also remains on the agenda. 'The common attitude is: 'if we only had more money, we could work well,'' says Dr. Natalia Vezhnina, who has recently taken her 20-year struggle against TB out of Colony 33 and into the civil sector with the Memorial Gorgas Institute. 'But WHO standards have proven efficient in a context where resources are limited and there is an epidemic.'
The public health approach of WHO gives priority to the rapid detection, isolation, and treatment of infectious patients over those who are not infectious. Prioritizing is considered a medical imperative in an epidemic context. This approach differs from the more individualized and resource-intensive treatment methods of Russian professionals. There are other discrepancies: for example, Russians traditionally use more surgery, and they use mass fluorography (X-rays) to detect suspected TB cases, rather than the cheaper and more reliable method of collecting sputum.
When the public health structure was highly centralized and relatively robust under the Soviet Union, TB was managed impressively well. However, with the arrival of perestroika and the economic crisis, the system broke down. And the breakdown created a man-made disaster: multi-drug resistant tuberculosis, or 'MDR-TB'.
This highly dangerous form of tuberculosis emerges when the TB strain has mutated and become resistant to drugs (specifically, to Rifampicine and Isionaside, the two most powerful antibiotics against 'simple' TB). MDR-TB is caused by treatment that is incomplete or erratic, or by poor quality drugs. It is also contagious: a person can be directly infected with the resistant strain.
DOTS , the treatment for MDR-TB, lasts up to two years, produces numerous side effects, is only about 60% effective, and is costly. Without treatment, about one quarter of those infected will get better, three quarters will die. It is estimated that 1 out of 10 prisoners has TB, and among those with TB, about 1 of every 5 has MDR-TB. The high prevalence of multi-drug resistance among prisoners is the biggest obstacle to raising the cure rate above its current 70% mark, in order to cut the chain of transmission. Moreover, the HIV/AIDS epidemic that looms ahead could boost MDR-TB's killing rate. Footnote 3
The human tragedy of MDR-TB is hidden in Colony 33, in the small town of Mariinsk. Slowly but steadily, the number of chronic patients coming from different penal institutions in Kemerovo and sent to Mariinsk has increased over the years. There are now 600 of them, most with MDR-TB, hanging on to their lives.
MSF is firmly committed and morally engaged to treat as many of these patients as it can. But it will probably have access to second line drugs at a preferential price of US$ 3,000 per person for only 150 persons. And the start of DOTS is being delayed by a long series of hurdles. These range from getting final, official authorization to import these drugs to guaranteeing that DOTS can be continued in the civil sector whenever patients are released from the colony.
The stakes are high. 'The so-called 'second-line drugs' used to treat MDR-TB are a last resort' explains Dr. Dominique Lafontaine, MSF's field coordinator in Kemerovo. 'If you start DOTS , and the DOTS system is poor, you can create an epidemic of 'super-resistant MDR-TB'. And then you can do absolutely nothing.'
'But how can a nurse even begin to explain all of this to the patients she faces every day?' asks an MSF doctor in Mariinsk, Lianne Vos. 'What does she tell the young patient who asks: 'why can't I phone my parents so they can buy and bring the medicines that will cure me?' The local medical staff looked at the situation and said 'something has to be done''.
What they are doing is offering palliative care: giving the patients first-line drugs that will not cure them, but in some cases, may decrease their load of bacilli and thus ease their suffering. The patients also do physical exercise, eat high nutrition meals, and can receive psychological counseling.
'We promote a healthy, active way of life, to motivate the patients,' says the head nurse of one of the MDR-TB wards. She adds, 'Because hope should be the last thing to die'.
1 With the exception of a number of civil servants, all the personnel employed in Russia's correctional institutions are military: until recently, these institutions were run by the Ministry of Interior Affairs. In 1998, responsibility was handed over to the Ministry of Justice.
2/ One of the key, proposed amendments is the restoration of jury trials (they existed in tsarist Russia). This system is already running (as an 'experiment') in 9 regions of Russia. Valery Abramkin, a renowned human rights activist, says the 'experiment' shows that juries of 12 'common people' give out non-guilty verdicts in about 20% of all cases, versus the current system of legal experts, which acquits only 1%.
3/ Usually, 10% of persons carrying the TB bacillus will develop an active form of the disease. But due to decreased immunity, persons with HIV have 30 times more chances of developing TB. Drug users, the major HIV/AIDS risk group in Russia, are well represented among the prison population.