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Struggling to control tuberculosis in Kyrgyzstan’s prisons In Kyrgyzstan, the impoverished, land-locked state of the former Soviet Union, the incidence of tuberculosis (TB) in the creaking penitentiary system is currently about 25 times higher than in the civilian population (2,700 per 100,000).
At the end of 2005, in collaboration with the Ministry of Justice and Ministry of Health in the country, Medecins Sans Frontieres (MSF) began work in three penal institutions in and near the capital, Bishkek: two pre-detention centres (SIZOs 1 and 50), and one of the penal colonies (Colony 31) that is officially designated for TB-infected inmates. “Conditions in the prisons, especially the SIZO pre-detention centres, are very difficult,’’ explains Dr Dominique Lafontaine, MSF Head of Mission. “Cells that are 10 metres square are usually home to eight men, with an open toilet in the corner. Very little light penetrates the cells. The ventilation is also poor, helping to create the dark, stuffy conditions in which TB bacteria survives.’’ MSF is attempting to tackle the alarming rates of TB in the three selected
Kyrgyz penal institutions on a number of levels: Second, MSF has focused on the early detection of TB patients. This involves not only improving the facilities for laboratory analysis of prisoner sputum to check for TB infection, but also training medical staff to recognize the signs and symptoms of TB earlier, and working with the Ministry of Justice and other NGOs to make sure that prisoners in the country’s 35 penal institutions are identified quickly and sent to Colony 31 as soon as possible. The third component of MSF’s strategy has been to improve the living conditions in the prison, and especially to rehabilitate the areas of the prison in which TB patients stay as inpatients during the intensive phase of their treatment. Heating and ventilation systems have been revamped, and cells have been repaired and redecorated. Within the hospital a complicated system of prisoner separation has had to be put in place, as it is very important that patients who are actively contagious are not living alongside, and therefore possibly re-infecting, patients who are at a later stage of their treatment. “We do what we can to ensure that contagious patients are not infecting other inmates,” says Alexandre Lesage, Field Coordinator, “but it is a struggle. One of the problems that we face is that conditions in the hospital are seen by some as better than in the normal cells, and so some patients may actively try to get infected in order to move to the TB area. There are even rumours of a black market in sputum, with contagious TB patients selling their sputum to other patients before they go to be tested for TB.” “Another issue is the caste system that operates in all Kyrgyz prisons. The strict prisoner hierarchy, with a chief at the top and the low caste, or ‘untouchable’, prisoners at the bottom, has to be taken into account in everything that we do. For example, under the rules of this system, the low caste prisoners live in worse conditions and cannot be in the same cell, or eat with, other prisoners. We even have to organize a separate time of day for them to come and take their drugs so they do not come into contact with those from a higher caste.’’ In addition to the core activities of treatment, detection and renovation, MSF supplies high energy milk to improve the nutritional status of TB patients and increase their chances of responding to treatment, and also offers the prisoners health education. Health educators explain to prisoners how TB is transmitted, and how the treatment works. The MSF team believes that this education has been an important factor in reducing the suspicion that some patients initially felt about the treatment, and in ensuring that patients take their medication daily. The MSF team says that lots of challenges remain. Today, 752 treatments with basic drugs have been provided, but amongst the patients treated, 101 are in urgent need of more complex drugs, for drug-resistant TB which are still not available in the prisons. Thus in 2007, MSF is tackling, with the Ministry of Justice and the International Committee of the Red Cross, the management of drug resistant TB (DR-TB). MSF is concerned that the level of resistance to the basic anti-tuberculosis drugs is very high, and a significant percentage of the patients are therefore in need of more complex drugs. As well as ensuring that these drugs get to the patients that need them MSF plans to establish a system to quickly diagnose resistant prisoners and tailor their treatment in accordance with the results. In addition, in collaboration with the civilian medical sector, and other NGOs, MSF plans to strengthen the support and treatment given to prisoners who are released from the prison before their TB treatment ends. At the moment, many prisoners who are released mid-way through their treatment course do not attend civilian medical facilities to finish their treatment, which increases the risk that their TB will mutate into the drug resistant form. “Our relationships with the prison administration are very productive,” says Dominique. “MSF is committed to this program until 2010, but we always emphasise that our aim is to support the Ministry of Justice in its own planned penal reforms and the Ministry of Health in its tuberculosis program, and not to create a new, parallel system. That way, when MSF finally leaves, the improvements that we will have made together in the treatment of TB in Kyrgyzstan’s prisons, will be sustained into the future.” Read other articles on Tuberculosis
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