By David Bryden
Dozens of men crammed into a small, dark, window-less prison cell, peering out from the barred doorway, pleading looks on their sweaty faces. In a week-long research trip to Haiti in 2016, a colleague and I toured the largest prison in Port-au-Prince, and this is the image I cannot forget.
The National Penitentiary in Port-au-Prince was built for 800 prisoners but is now housing 4600, and the rate of tuberculosis (TB) exceeds that of the general population of the country 17-fold. TB patients have no prison hospital in which they could be appropriately isolated and treated. The prisoners are poorly fed, with only one or two meals a day and little or no protein, making TB — an airborne bacterium — even more likely. These conditions in Haitian prisons are far from unique.
In fact, many prisons around the world are essentially factories for production of TB, including drug-resistant TB, now the single biggest infectious disease killer in the world. Unless the world tackles prison conditions, ending this disease will remain just a distant dream. A male detainee in Zambia told a researcher,
“There are delays in getting to the clinic. It depends on the officials, if they want to take you there or not. Sometimes you can go as long as a month waiting to go to the clinic...They don’t open the door in the cell at night for anything. There are no windows, no air. Someone who was 28 years old died at night in my cell, and they didn’t open the door until the morning.”
The scale of the problem is staggering. In 2016, the Lancet published a study by Dr. Kate Dolan of the University of New South Wales and colleagues, estimating that, of the global 10.2 million incarcerated population, 2.8 percent, or 286,000, have active TB. A further 3.8 percent, or 389,000, also have HIV.
According to the Stop TB Partnership, the risk of TB in prison, on average, is 23 times higher than in the general population. “Isolation of infectious prisoners is rare; many prisoners who are isolated might not receive treatment, and conditions are frequently appalling,” state Dolan et al. “Tuberculosis treatment completion rates in prisoners are often low, exacerbated by their movement within and in and out of the prison system,” they note.
A study of conditions in a Colombian prison ironically called “La Esperanza,” or “Hope,” presented at last year’s Union World Conference on Lung Health found a TB rate 37 percent higher among prisoners than in the general population. A study on TB among prisoners in Indonesia found 5 percent with multi-drug resistant TB (MDR-TB), nearly double the rate in the general population.
The high rate of HIV in prisons — many times higher than adults in the community — is exacerbated by a lack of prevention options, as well as sexual violence. Even prisoners living with HIV who can overcome barriers to HIV treatment face a much greater risk of TB. Data from sub-Saharan Africa show a prevalence of HIV infection among prisoners from 2.3 to 34.9 percent and, of TB, from 0.4 to 16.3 percent.
Overcrowding seems to be the single biggest root cause. Dolan et al lay the blame on the practice of mass incarceration of people who inject drugs, and they urge decriminalization, alternatives to incarceration, and access to opioid agonist therapy. Pre-trial detention and the slow process of adjudication also drives overcrowding; in fact, many people are held for years without being formally charged. There is also an overuse of incarceration for other non-violent offenses.
Some countries have directly addressed the issue. Mongolia, for instance, reported a two-thirds reduction between 2001 and 2010 of TB among prisoners through active TB case finding and upgrading health services and living conditions. Reducing prison populations and improved nutrition was important to this success.
At the penitentiary in Port-au-Prince, I saw the dedicated work of an NGO, Health Through Walls, to provide TB and HIV services despite adverse conditions. With USAID and Global Fund support, they provide accurate HIV and TB diagnoses, including using the latest methods, as well as treatment and nutritional supplementation in 11 prisons in Haiti. With a tiny budget, they are saving many lives.
Global prison populations, now at 10.2 million people, have grown since 2000 for both men and women, and it is estimated that every year four to six times this number pass through the world’s prisons, with most returning to the community.
The world cannot hope to end TB unless we face the crisis in prisons. When heads of state gather for the UN High-Level Meeting on Tuberculosis this September, they must make strong commitments, including funding, to improve conditions and achieve rapid reductions in TB, HIV, and other diseases in prisons — and we must hold them to their promises.
David Bryden, is the TB advocacy officer at RESULTS, where he coordinates U.S. advocacy on TB and co-chairs the TB Roundtable.
Photo: Prisoners at the National Penitentiary, Port-au-Prince. Credit: RESULTS Educational Fund/David Bryden
 Telisinghe, Lilanganee et al. "HIV and tuberculosis in prisons in sub-Saharan Africa," The Lancet, Volume 388, Issue 10050, 1215 - 1227. Accessed: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30578-5/fulltext.
 Dolan, Kate et al. "Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees", The Lancet, Volume 388, Issue 10049 , 1089 - 1102. Accessed: https://www.thelancet.com/action/showCitFormats?pii=S0140-6736%2816%2930466-4&doi=10.1016%2FS0140-6736%2816%2930466-4.
 Yanjindulam P1, et al. "Reduction of tuberculosis burden among prisoners in Mongolia: review of case notification, 2001-2010", The international journal of tuberculosis and lung disease, 2012;16(3):327-9. Accessed: https://www.ncbi.nlm.nih.gov/pubmed/22640445