Health horror behind bars

Last night Carte Blanche Medical highlighted a story about the horrors and dangers of tuberculosis (watch the video here). Read more about how TB is spreading like wildfire behind prison walls.

Imagine spending 10 years with little more than 2,4 sq m to yourself. The cell is badly ventilated, the food is not great, and somewhere along the line you got tuberculosis (TB) and for some reason the warder isn't bringing you your pills anymore.

Of course, this is not what the judge sentenced you to when he said "10 years". The law is very clear that you have the right to safe custody and that the deprivation of liberty is sufficient punishment for your crimes.

But the reality in prisons around the country is that they're a health horror. And the fact that you are not in jail doesn't mean you are not affected. Some have gone as far as describing prisons as "epidemiological pumps" that fuel the TB epidemic on the outside.

The shocking stats
In January 2007 there were about 166 000 people in South Africa's 237 operational prisons, says Lukas Muntingh of the Civil Society Prison Reform Initiative (CSPRI). The problem is that the actual capacity of these prisons is only 115 000 – which means they are 51 000 people (about 40%) over capacity.

An estimated 60% of prisoners are in prisons that are more than 150% full. According to Muntingh, the worst case of overcrowding is at Umtata's Med B prison which is 430% full.

In total, he says, an estimated 360 000 people circulate through the prison system every year.

One result of the overcrowding is that instead of the already limited 3,5 sq m per prisoner the system was designed for, each prisoner now only has 2,4 sq m to him or herself. As this is an average, the actual number may be even lower in some prisons. To put this in perspective, Muntingh points out that the European Committee for the Prevention of Torture considers 6 sq m to be the minimum space a prisoner should have, with 8 to 10 sq m preferable.

Heavy toll on health
Actual disease statistics underscore why South African conditions are such bad news: the World Health Organisation estimates that tuberculosis rates in prisons are up to 100 times what they are in the general population, and a recent study has estimated that about 20,5% of SA prisoners are HIV-positive.

According to Paula Akugizibwe of the Aids and Rights Alliance of Southern Africa (ARASA), the extreme overcrowding in our prisons is a key contributing factor to the TB problem. This is compounded by the increased proximity to infectious cases, prolonged duration of exposure, and poor ventilation.

Hernan Reyes of the International Committee of the Red Cross, writing in the International Journal of Prisoner Health, agrees that overcrowded prisons facilitate the spread of the airborne disease.

"Arriving prisoners are put into cells very often without even a cursory health check, thus finding themselves pooled together in unhealthy settings, putting all at risk of contagion if TB is present," says Reyes.

He also points out that prisoners often suffer from impaired immunity due to factors such as concomitant disease, a harsh and unhealthy living environment and malnutrition.

He speculates that psychological factors such as persistently high levels of stress due to the ever-present uncertainties of prison life may affect a prisoner's immune system adversely. "Prisons are also often very violent places. To these one must add the constant nervous tensions of often shaky family relationships," he writes.

If you add to this the high rate of HIV infection among the prison population (like TB, estimated at 20,5%), you have virtually ideal conditions for TB (HIV's impact on the immune system dramatically increases the risk of contracting TB).

Not a healthy group to start with
It is also worth noting that prisoners do not represent a cross-section of outside society. Prisoners are overwhelmingly male (about 98%), range in age between 15 and 45 years, and come predominantly from poorly educated and socio-economically deprived sectors , says Reyes.

He points out that offenders often belong to minority or migrant groups and many live on the very margins of society. "They enter prison with a higher risk of already being unhealthy. Offenders often have little education, and, for a variety of reasons, do not take care of their health. Often living in unwholesome settings, they are much more likely to suffer from a variety of debilitating diseases already, which includes tuberculosis. Additional health problems such as drug addiction, and of course alcoholism, can contribute to a deteriorated state of health."

A crumbling system
Apart from these basic problems, our prison system is also held back by a number of other problems, ranging from gangsterism, stigma, lack of staff, poor staff training, and bad systems for managing medical records.

Muntingh points out that many jobs in the prison service remain unfilled. The following is the percentage of filled positions by category:

  • Health-science related – 75%
  • Medical practitioners – 31%
  • Pharmacists - 62%
  • Nurses - 66%
  • Psychologists - 36%


In addition to staff shortages, staff often lack training and skills in dealing with difficult issues such as sexual violence. Add the influence of organised gangs, a culture of silence, a trade in medication, long response times to complaints, and the system starts seeming very fragile.

Another stumbling block is the lack of a proper medical records system, which often leads to breaks in treatment, which in turn can lead to drug resistance.

When being transferred from one prison to another, for example, prisoners often have to go through the whole HIV and TB screening process from the beginning. This can lead to breaks in treatment, which in turn, can lead to the development of drug resistance.

Critics point out that this kind of problem could easily be solved by letting the prisoner take his medical records with him to the new prison.

A judicial matter?
Whereas it may seem obvious that a higher crime rate would lead to fuller prisons, Muntingh points out that the size of the prison population is in fact not directly related to the number of crimes committed in the country. Muntingh was speaking at the 13th meeting of the Joint Civil Society Monitoring Forum (JCSMF), held in Cape Town last year. The JCSMF is a group of civil society organisations including the Aids Law Project, Treatment Action Campaign, Medicins Sans Frontiers, and the Public Service Accountability Monitor.

The increased prison population is thought to be a result of things such as mandatory minimum sentences legislation and the increase in sentence jurisdiction of the district and regional courts.

Muntingh points out that in 1998 only 35% of sentenced prisoners were serving terms of more than seven years. By 2006 though, this figure had risen to 62%.

The JCSMF last year urged government to undertake steps to implement sentencing reform in this regard.

(Marcus Low, Health24, updated March 2009)


Read more:
A day in prison
More prisoners to get ARVs

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