Indonesia: Overcrowding fuels TB in prisons

JAKARTA, 25 January 2010 (IRIN) - Serious overcrowding, a shortage of medical staff and a lack of funding are thwarting Indonesia's efforts to tackle tuberculosis (TB) in prisons, experts say.

Indonesia's 422 prisons hold more than 140,000 inmates, even though they were designed for 80,000, according to the Justice Ministry.

The government started a programme to control TB in prisons in 2004 by adopting the so-called Directly Observed Treatment, Short-course or DOTS, a treatment strategy for detection and cure recommended by the World Health Organization (WHO).

But so far only 122 prisons in 17 of the country's 33 provinces have benefited from the DOTS programme, which receives support from the Global Fund, said Daniel Rasjid, head of the TB control strategy at the director general of the prison system.

"The main problem is overcrowding," Rasjid told IRIN. "Overcrowding makes it easy for diseases to spread and TB spreads much more easily compared to HIV because it doesn't require physical contact." A crackdown on drugs had contributed to the overcrowding, with most inmates, particularly in major cities, convicted of drug offences, he said. 

Left untreated, each person with active TB can infect on average 10 to 15 people a year.

According to Justice Ministry data, 90 prisoners across the country died of TB in 2009, after 150 the previous year.

Indonesia, the world's fourth most populous nation of 230 million people, has the third-highest tuberculosis burden in the world, according to WHO. An estimated 140,000 Indonesians die from TB each year, according to Stop TB Partnership Indonesia, with TB the second leading cause of death after heart disease for all ages in the country, according to the Health Ministry.

And while little is known about the current prevalence of TB in Indonesian prisons, a Health Ministry study in 2005 showed that 1.7 percent of prisoners had TB, said Tjandra Yoga Aditama, the Health Ministry's director-general for disease control and environmental health.

That figure was 16 times as high as the prevalence of the disease among the general population, he said.

Aditama said in addition to overcrowding, a shortage of health specialists, poor sanitation, poor monitoring of prisoner transfers, and lack of awareness among prison officials and inmates contributed to the spread of TB.

"TB control and prevention measures cannot be carried out fully because of the poor conditions of prison buildings and infrastructure," Aditama said.

"But efforts are being made to [separate] inmates with TB from others, especially those who are vulnerable, such as people with HIV/AIDS," he said.

A prison TB surveillance system is still being developed applying the same standards used in the national TB control programme, he said.

Shortage of doctors

Rasjid said prisons in provinces such as Aceh and Papua had no permanent doctors while in places such as Maluku, East Nusa Tenggara and West Nusa Tenggara, one doctor was solely responsible for all the prisons.

Doctors working for the local health department made irregular visits to these prisons, sometimes once in two weeks, Rasjid said.

"Doctors and nurses are at the forefront of the fight against TB. But most of more than 300 doctors we have serve in Jakarta and other prisons on Java island," he said.

Ideally a major prison should be served by two doctors, one dentist, two nurses and one lab technician, he said.

Funds allocated by the government were also insufficient to allow prisons to provide decent healthcare and meals, Rasjid said. "Let's say that the capacity of a prison is 700 people. Even if there are 2,500 inmates there, the food budget will cover only 700 people."

Muhammad Hatta, a consultant for the government's TB control programme, said there had been cases of multiple drug resistance (MDR) among prisoners.

About 2 percent of newly diagnosed TB cases in Indonesia are estimated to have developed MDR, WHO said.

Hatta said Indonesia's TB fight was "failing" because it had been unable to maintain the continuity of medical supplies, with money mostly coming from foreign donors.

"Our TB programme depends heavily on foreign funds, including the provision of drugs," Hatta said. "There's been a lack of support on the part of the government as well as NGOs for TB programmes in prisons. There are hundreds of NGOs working on HIV/AIDS but very few are dealing with TB," he said.

He said the problem of overcrowding was so bad that in one instance, 50 people were cramped in a 25 sqm cell. "Inmates had to take turns lying down because there wasn't enough space for them all to lie down at the same time," he said.

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