EDITORIAL

Tuberculosis control in Brazilian prisons: new approaches to an old problem

Alexandra Roma Sánchez^I; Vilma Diuana^II; Bernard Larouzé^III

^IPrograma de Controle da Tuberculose, Coordenação de Gestão em Saúde Penitenciária, Secretaria de Estado de Administração Penitenciária do Rio de Janeiro, Rio de Janeiro, Brasil; Technical Advisor to the Projeto Fundo Global TB-Brasil
^IIPrograma de Controle da Tuberculose, Coordenação de Gestão em Saúde Penitenciária, Secretaria de Estado de Administração Penitenciária do Rio de Janeiro, Rio de Janeiro, Brasil
^IIIDepartamento de Epidemiologia e Métodos Quantitativos em Saúde, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil

Numerous factors explain why tuberculosis (TB) is an urgent problem among persons deprived of liberty (PDL) in Brazil: severe overcrowding, increasing prision occupation rates (150% of planned capacity, and up to 300% in some prisons), poorly ventilated cells with no sunlight, high HIV prevalence... In some States of the country, the TB incidence rate among PDL is 35 times that of the general population!

To fight this curse and to insure PDL their right to health, the number of health professionals working in the prison system is insufficient. They are underpaid, subject to precarious work contracts and have high turnover. TB and HIV/AIDS control programs, when they exist, are frequently vertical and prescriptive, to the detriment of a more comprehensive health approach. Further, these programs are poorly integrated to the extra mural health network which, in some places, set quotas for the prison system, thus limiting the access to AFB microscopy. Integration between health and justice at the various levels of government and their relationships with civil society organizations are still insufficient. Social control of prison health services is deficient.

Nevertheless, some positive developments have appeared under the aegis of the Ministry of Health (MoH) - National TB Control Program, National AIDS Program, Technical Division for Health in the Prison System -, the Ministry of Justice (MoJ), and the Global Fund (GF). Structured TB control activities are being developed in prisons, including reinforcement for passive detection, implementation of active detection (especially among incoming PDL), better treatment supervision, and awareness-raising for PDL, their families and for prison staff. In various states, TB diagnostic capacity has been reinforced by creating intramural laboratories under the technical control of reference laboratories in order to respond to the high demand for AFB microscopy. The sustainability of these laboratories is being assured by State or municipal TB programs which, in some instances, provide technicians on a part time basis. For the first time, the MoH's technical manual has dedicated a specific chapter to TB control in prisons. A course on health in the prison system is being prepared for health administrators and professionals to better adjust their practices to the specificities of the prison setting. Research projects are currently developed in order to provide scientific and technical basis for decision makers. Such initiatives include a program initiated by the GF in partnership with the Prison System Department of the MoJ and the National TB Program, seeking to establish guidelines for prison construction and renovation that take health needs into account. Finally, prison overcrowding is now considered as a problem that demands urgent solutions. As for TB and HIV/AIDS, recent regional meetings led by the MoH, MoJ, GF and UNODC should allow better organization for controlling these endemics in Brazilian prisons and including them in the public policy agenda. These activities are linked to the current revision of the National Health Plan for the Prison System. However, the minimum needs of PDL are still far from being met. Major human and financial investments are needed to insure access to health for Brazil's 473,000 PDL, not as a privilege or charity, but as a Constitutional right.