Tom Maguire from the campaigns team at RESULTS spent two weeks during December in Romania creating a short video and photo-story on drug-resistant tuberculosis (TB). In this blog post he discusses some of the innovative measures that have been introduced in Romania’s prisons to reduce TB rates.
Despite having one of the highest rates of TB and multi-drug resistant TB (MDR-TB) in Eastern Europe (30,000 people currently have TB in Romania and 1,500 people die from it every year), Romania’s TB rates in prisons are remarkably low. Historically, TB rates have been drastically higher in prisons than in the general population for two reasons. Firstly, prisoners are usually more likely to come from communities where TB rates are high. Secondly, once a person enters the prison system, prison conditions – including overcrowding, poor ventilation and poor nutrition – help the disease to spread. This isn’t just a problem in low- and middle-income countries; case rates of TB in prisons are among the highest recorded in any population globally, including here in the UK.
In 2002, TB in Romanian prisons was 20-times higher than rates in the general population. Recognising the scale of the problem, the National TB Program in Romania applied for a Global Fund grant in 2003 to improve conditions and facilities in the TB prison hospitals. By 2005, all of the 44 prisons in Romania had introduced airborne infection isolation wards and special sputum collection rooms to help improve diagnoses.
Four years later, a Global Fund grant allowed for the roll out of a programme to help educate prisoners about the risks of TB and the simple measures they can take to help stop the disease from spreading.
A decade on and TB rates in Romania in prisons are down by 75%; impressive given the high rates of TB in the general population and the government’s low public expenditure on health.
Importantly, these reductions in rates of TB in prisons shouldn’t be attributed solely to improvements and activities supported by Global Fund money. According to Lucica Mihailescu , the head of the TB Program in Romania’s prisons: “wider institutional changes including the proper integration of the country’s National TB program in the prison system and a concerted effort to reduce overcrowding have been key to getting rates down”.
Throughout my time in Romania, I was given the opportunity to see some of the Global Fund-supported activities in action in three high security prisons, two in Bucharest and one in Targa Ocna in the north of the country. Below is a short summary of my visits.
Jilhava Prison
My day at Jilhava began by attending a group educational session about TB, conducted by a trained prison guard. Training prison staff to be able to deliver educational workshops is a key element of the Global Fund programme. With a familiar face conducting the training, it was evident that participants were able to interact more freely and have a more honest and open discussion with the facilitator.
Rahova Prison
The following day, I visited Rahova prison, 20 miles north of Bucharest, which houses all the country’s prisoners before they are formally convicted. Here I was given the opportunity to witness a man participate in a two-hour e-learning platform designed to help educate inmates about what TB is and how you can catch it through a series of interactive quizzes, games, and questions. There was even a Mario-style game, where participants had to navigate themselves through a maze, avoiding infected patients to complete the game – a novel, if not slightly patronising, way to highlight just how contagious TB can be.
After completing his session on the platform, I spoke with the participant to see what he learnt and whether he thought the session was useful. His response was positive: “Yes, I enjoyed the platform and liked the interactive element. I knew nothing about TB before today but I now know a lot”. Most of the prisoners I spoke with who had completed the programme also highlighted that they had enjoyed the sessions as it gave them the opportunity to learn something new in an environment that was otherwise mundane and unchanging.
Targa Ocna
In Targa Ocna, , I was given the opportunity to spend a good period of time with some of the inmates in the TB hospital, including a memorable encounter with a young guy called Marius. Marius had contracted regular TB twice in the last six years before being diagnosed with MDR-TB in 2012. Recalling his first diagnosis and its impact on his life, Marius spoke to me about some of the stigma associated with the disease:
“When I got sick for the first time, I lost my girlfriend. We were together for five years and I lost her because her family didn’t agree. When I was hospitalised I lost my friends; at least three-quarters of them. When I went back to school, the children would shout “Tebecistule” at me [this translates as ‘handicapped’]. I was 18 years old and in the ninth grade and hadn’t been in high school long. Everyone avoided me … boys, girls, especially girls … I didn’t have any relationships for two years because of TB”.
Marius’s story isn’t unique. TB is a disease that continues to be a source of shame and social exclusion both in Romania and elsewhere. Finding ways to tackle this stigma is an on-going challenge, and something that must be addressed if we are ever going to be able to prevent people like Marius suffering from a similar fate.
Collaboration between the National TB Program and the Global Fund in Romania’s prisons is a success story amidst a backdrop of on-going challenges to get the epidemic under control. Scaling up and rolling out this model to prisons in other countries, such as Moldova where prevalence of TB in prisons is alarming high, would help reduce rates throughout the region and should be prioritised by national governments.