Pitfalls of tuberculosis programmes in prisons

Introduction

Among its other activities, the International Committee of the Red Cross visits prisoners in countries all over the world, essentially in countries at war or affected by conflict. As part of its work aimed at ensuring that prisoners receive adequate care, it has had to deal with the issue of tuberculosis.

Recent experience in countries of the former Soviet Union has given us an insight into how complicated the treatment of tuberculosis can be in prisons. There are pitfalls that must be avoided if the disease is to be treated in accordance with the directly observed treatment, short course (DOTS) strategy drawn up by the World Health Organisation and the International Union against Tuberculosis and Lung Disease.1

Directly observed therapy is designed to ensure, by means of direct observation, that patients actually take their full course of treatment. Prisons are, however, particularly difficult environments for applying such a strategy. Prevalencies five to ten times the national average are not uncommon and can be up to 50 times the reported national average.2 3 Tuberculosis may be a, or even the, major cause of death in prisons in developing countries, with mortality rates as high as 24%.4 In the case of tuberculosis, it is better to do nothing than to do something badly—and failure to complete courses of treatment can have disastrous results, leading to the development of multidrug resistant strains of Mycobacterium tuberculosis.

The problems described here apply essentially to countries where problems of low income are accompanied by a high prevalence of the disease. Prisons are full beyond capacity, with prisoners from impoverished unhealthy backgrounds living in an even unhealthier environment. Prison health services suffer serious shortcomings, and the internal violence of prisons also has its influence. The setting is perfect for tuberculosis to develop and …