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Reports of increased tuberculosis (TB) infections in Malawi prisons call for urgent systemic and policy action to improve living conditions in prisons across the country. Six cases of multidrug resistance TB (MDR-TB) have been reported, posing a high risk of a surge in MDR-TB cases in Malawi.

On December 7^th, the Facilitators of Community Transformation (FACT) hosted a stakeholder interface meeting regarding a rise in tuberculosis (TB) in Malawian prisons. The event was attended by various stakeholders, including the Parliamentary Caucus on TB, the National TB Control Programme, the Director of Clinical Services in Prison, and the Centre for Human Rights, Education and Assistance (CHREA). Stakeholder presentations shed light on the concerning increase in TB cases in Malawian prisons, including several recent cases of multi-drug resistant TB (MDR-TB).

According to Dr. Chiwaula, Chief Medical Officer at the Malawi Prison Service, TB is like many infectious diseases »”closely linked to poverty and therefore disproportionately afflicting low and middle-income countries. This is because TB thrives in environments with poor hygiene and sanitation, malnutrition, congestion and little ventilation. Unfortunately, Malawian prisons exhibit all such conditions to an extreme.

At the stakeholder’s interface, Dr. Chiwaula painted a worrying picture of prisoners’ living conditions. They do not have access to basic amenities, including beds, resulting in prisoners sleeping on the floor in close quarters. In addition, the prison buildings have few windows and major overcrowding, exacerbating already poor ventilation. In fact, the prison facilities are a staggering 234% overcapacity, making Malawian prisons the twelfth most overcrowded in the world. Typically, prisoners receive only one meal a day, the nutritional value of which is unknown. Dr. Chikondi Chijozi, Deputy Executive Director at CHREA, noted that the situation is made worse as sick prisoners do not receive any nutritional supplements, compromising their immune systems’ ability to fight off illness.

The unfortunate reality is that Malawian prisons do not have the capacity or resources to address the TB outbreak and its underlying causes. The prisons are severely underfunded, understaffed and generally under-prioritised. Such negligence is exemplified by the fact that Malawi’s Prison Act has not been amended since its adoption in 1966. Among the 30 prisons in Malawi, hosting a total of 15,000 prisoners, there is only one qualified health professional, as explained by Dr Chiwaula. Moreover, the prisons lack in-house health clinics »”forcing inmates to be transferred to outside hospitals. According to Dr Chijozi, the prisons do not have isolated areas where inmates with infectious diseases, like TB (and especially MDR-TB) can be treated without risk of spreading the disease.

Given such statistics, the recent TB outbreak is no surprise. There is neither the infrastructure nor the human resources to screen for, treat, and prevent TB in Malawi’s prisons. The arrival of MDR-TB in the prisons is a threatening consequence of such poor conditions. Acquired either by transmission from an individual with MDR-TB or mismanagement of TB treatment, Dr Chijozi warns that the MDR-TB is a major public health concern. She noted that standard treatment for MDR-TB is notoriously brutal. It lasts 24 months, over twice as long as treatment for TB, and requires that the patient be completely isolated to avoid transmission to others. Currently, six cases of MDR-TB have been identified across Malawi’s prisons, but without the capacity to treat the existing cases, Malawi is at high risk of a surge in MDR-TB cases. Not only is this a public health emergency within prisons, but it is also a threat to all of Malawi as infected prisoners are released from prison into society.

Globally, prisoners are considered vulnerable populations »”having little power over their own circumstances and lives. That is, ultimately, what prisons [and the justice system] are designed to do: to punish individuals convicted of overstepping their civic rights by stripping them of their civil rights. As a result, however, prisoners are often victims of human rights violations. The rise in TB and MDR-TB cases among Malawian prisoners demonstrates negligence and abuse of prisoners’ human rights. Prisoners are being exposed to substandard living conditions that are detrimental to their health. That is surely not part of their sentences. Making matters worse, many of the convicted prisoners are there for petty crimes, born out of poverty and desperation. According to Dr Chijozi, about 30% of prisoners cannot afford lawyers »”a testament to their socio-economic status. In addition, many of the individuals in prisons are there on remand »”in other words, they are waiting for trial. This means that people are forced into terrible living conditions, where their lives are at risk, before they are even found guilty for an alleged crime.

The stakeholder interface meeting was critical in bringing awareness to increasing TB rates in Malawi’s prisons and bridging gaps between Parliamentarians’ mandate and civil society organisations’ (CSOs) work. Stakeholders present agreed that action must be taken »”both at the national and community level. Members of Parliament stated their political will to act and improve living conditions for the prisoners and called upon CSOs to bring them more evidence, more policy recommendations, and more reason for action. As noted by Thokozile Phiri-Nkhoma, the Executive Director of FACT, « Today it is MDR-TB, who knows tomorrow could be Ebola, we need policy dialogues to change the discourse of our approaches on health by bringing in policymakers. It is high time we intensively engaged our politicians on matters that will transform our response to broader health rights issues. » As we take a break from our work and spend time with our loved ones over the holidays, may we remember those who do not have that freedom. And as we set New Year’s resolutions, let us not forget those who are so often forgotten. May we make 2019 the year where justice and human rights are upheld for all.

Emma Heneine and Claire Jensen are researchers with the African Institute for Development Policy (AFIDEP). Views, thoughts and opinions expressed in the article are solely those of the authors and do not necessarily reflect the official position of AFIDEP.