Tuberculosis in prisons in countries with high prevalence
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7232.440 (Published 12 February 2000) Cite this as: BMJ 2000;320:440
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Dear BMJ,
In response to my friend Dr Michael Levy's comment to the article in
question, of which I am co-author, I would like to make the following
comments.
If my colleagues and I promoted the concepts of tuberculosis control
leading to improved prison health care(1), it is because we have seen it
first hand in some places where the prevalence is indeed high. Most
recently in Estonia, during an evaluation of the TB program in the prisons
of that country, I was able to see an example of on-going collaboration
between the Prison Authorities, the health Ministry and the National TB
Programme, all working together to provide the best care possible, and to
include the prison population in the overall goal of tackling the issue of
drug-resistant TB.
In Kazakhstan, where Penal Reform International, with experts from
ICPS (International Council for Prison Studies) and the KNCV have had a TB
program in the prisons of Pavlodar, very encouraging results have been
obtained, not only in improving the treatment of TB but also - and most
important - in implementing prison reform. These two cases are
illustrations of what we mean when we say that a prison based tuberculosis
programme may lead to an effective national programme.
It is certainly true that in other countries, prisoners facing
starvation and complete lack of medical attention may have greater
difficulties attaining these goals. However, to say that in prison systems
in general, the prospects of a tuberculosis program even being established
are remote, is surely unfair to those countries that with great
difficulties are attempting to do their level best.
Robust health systems are unfortunately scarce on the market in the
countries where TB prevalence is high. It should be our goal to push and
prod so that the treatment of tuberculosis in prisons is not forgotten in
the establishment of such systems.
While basically in agreement with Dr Levy's three principles, I must
say I would prefer the basis of "equivalence", rather than equity, for
prison health care. Equity is unfortunately not attainable due to the
inherent realities and demands of a prison system. Otherwise, I entirely
agree that the use of imprisonment should be used as a "last
resort". At the very least, this would reduce the apalling
conditions of overcrowding that are a key element in the propagation of TB
in the prisons.
Hernan Reyes MD
visiting research scholar
Society & Medicine, Columbia Univeristy, New York
(1) Coninx R, Maher D, Reyes H, Grzemska M. Tuberculosis in prisons in countries with high prevalence. Br Med J 2000; 320: 440-442
Competing interests: No competing interests
The article by Coninx et al (1) brings to the attention of the
greater health community,
the World Health Organization's Guidelines for the Control of
tuberculosis in prisons.(2)
Both the article and the guidelines from which it derives promote
concepts such as:
· "tuberculosis control leading to improved prison health care", and
· "a prison based tuberculosis programme may lead to the
establishment of an effective national programme". With prisoners around the world face overcrowding, and worse -
starvation
(Malawi), complete lack of medical attention (Papua New Guinea), and
administrative neglect (China) to single out just some abuses. Read
the report by Dr
Vasseur on conditions in French prisons (3), and you realise that the
prospects of a
tuberculosis program even being established are remote.
I believe that in the absence of an established tuberculosis program
as a component of a robust health system, tuberculosis control in prisons will,
regrettably, have to wait. To promote otherwise, in the absence of any supporting evidence
is a cruel taunt.
Three principles guide my work in tuberculosis control, and in fact
the provision of all
health care to prison inmates:
1. Health services should recognise the disproportionate health need
of inmates, and
be provided on the basis of equity
2. Engagement of community services in prisoner health care, ensures
continuity of care - whether it be an inmate who transfers to another prison,
returns to the
community, or is a worker or visitor that moves between the two, and
3. Health is not a commodity to be traded in the prison yard - no one
should be penalised, nor gain benefit, from health or illness.
In all circumstances the use of imprisonment ("loss of liberty") must
be a last resort. This is a health, as well as a human rights imperative. This simple
statement is missing
from the WHO guidelines and the article. Yet, tuberculosis control
possibly provides
the starkest example of why this must be so.
Michael Levy,
Director,
Population Health, Corrections Health Service, PO Box 150, Matraville
2036
Australia.
(1) Coninx R, Maher D, Reyes H, Grzemska M. Tuberculosis in prisons
in countries with high prevalence. Br Med J 2000; 320: 440-442.
(2) Maher D, Grzemska M, Coninx R, Reyes H. Guidelines for the
control of
tuberculosis in prisons. Geneva: World Health Organisation, 1998.
(WHO/TB/98.250.)
(3) Dorozynski A. Doctor's book shames French prisons. Br Med J 2000;
320:465.
Competing interests: No competing interests
TB and legal and illegal migration: the case of Mexico-US border
Editor - Rudi Coninx et al recently stated that: "The internationally
recommended strategy for tuberculosis control relies on the detection and
cure of patients, with a priority for infectious cases."1 Tuberculosis
(TB) has proven to be a quite persistent illness, and last December 6,
1999, the American Medical Association House of Delegates, through its
Council on Scientific Affairs (CSA), was informed that during 1998 foreign-
born people caused 42% of tuberculosis cases in United States, in contrast
with 22% in 1986. The CSA has also reviewed national and international
strategies currently in practice to control TB, the objective is to assess
the possibility of practicing proof of TB screening for visitors who plan
to remain in the US longer than 120 days.2
The CSA recommended that the American Medical Association recognize that in
order to eliminate TB in US is necessary its control in foreign countries,
and to study in the US the epidemiology of TB within the foreign-born
population.
The CSA also reported that worldwide more people die of this
illness, "between 2 million to 3 million per year. In addition, one-third
of the world's population is infected, and TB is the leading killer of
women between the ages of 15 and 44. Current estimates indicate that
between now and 2020, 1 billion people will contract TB, 200 million will
become ill and 70 million will die."2
According with CSA report, the WHO explains this resurgence of TB as due
to factors like the influence of the HIV epidemic in spreading TB. The
wide movement of people between cities and countries has also favoured its
spread. But it is also important the fact that developing countries have
irregular and inefficient TB-control programs.
In accordance with the Travel Industry Association of America, 46.4
million international visitors went to the US during 1998, 13.4 from
Canada and 9.3 million from Mexico. Data from the US Immigration and
Naturalization Service (INS) says that in recent years this country has
annually admitted between 700 thousand and 800 thousand legal, permanent
residents. In contrast, during the "fiscal year 1999, the INS processed 155
thousand illegal immigrants, 126 of whom had active TB",3 about 54 percent
(83,700) from Mexico, a daily average of 230.
Mexico has a population of around 100 million, 30 million did not finish
elementary school and 25 million live in "extreme poverty" -read: misery-,
with concomitant under nutrition and low body defences. In fact, it
has
been recently emphasized that vitamin D influences immunity to TB and it
is "predicted to be the largest single infectious cause of death between
1990 and 2020."4 Therefore, regarding Mexican immigrants, hardly any of these
people have been receiving suitable medical care of their respiratory tracts.
Meanwhile, the WHO is preparing a global plan to combat TB and it
should be ready for implementation in 2001. The measure hopes to detect at
least 70% of worldwide cases of infectious TB and treating at least 85% by
31 December 2010.2
Alejandro Cuevas-Sosa
Centro de Prevención y Tratamiento de la Violencia Sexual e Intrafamiliar,
Apartado Postal 44-212, Col. Del Valle 03101, Mexico, DF
1. Coninx R, Maher D, Reyes, H, Grzemska, M. Tuberculosis in prisons
in countries with high prevalence. BMJ 2000; 320: 440-442.
2. Stapleton S (1999). Immigrants transporting TB to the US. American
Medical News, December 6.
3. Shelton D L (2000). On the front line in the battle against TB.
American Medical News, January 31.
4. Wilkinson RJ, Llewelyn M, Toossi Z, Patel P, Pasvol G, Lalvani A,
Wright D, Latif M, Davidson RN. Influence of vitamin D deficiency and
vitamin D receptor polymorphisms on tuberculosis among Gujarati Asians in
west London: a case-control study. Lancet 2000; 355: 588 - 589.
Competing interests: No competing interests