Tuberculosis is one of the most widely known and publicised diseases in the world due to its lethality and the massive problem it poses in many areas around the world, especially in its drug-resistant form. Long periods of latency that precede tuberculosis manifestation make it extremely difficult to detect the disease in patients until it is activated by another factor. This is usually a weakening of the immune system by another illness. Co-infection with the human immunodeficiency virus (HIV) is particularly dangerous. The opportunistic nature of tuberculosis and the speed with which the bacteria can eat away the organs of its host further raise the difficulty of treatment. The conditions associated with areas of high tuberculosis burden include unsanitary environments, cramped living quarters, and a high degree of lawlessness. To many people, the places that the above description calls to mind are individual countries, but there are also numerous hidden areas where the issues are equally serious and insufficiently addressed.
Under the above criteria, prisons are ideal breeding grounds for tuberculosis—poor and cramped living conditions as well as little access to clean food, water and healthcare create the perfect opportunity for the disease to become active. For example, in the early 21st century, tuberculosis grew to near epidemic levels among inmates in Russian penitentiaries. The growth was further exacerbated by the prisons’ notoriously harsh conditions; in combination with HIV, mortality levels skyrocketed from post-Soviet rates. WHO intervention attempted to lower the incidence of disease in the form of the Directly Observed Treatment Short-course (DOTS) program. The program consisted of five key components: development of strong government commitment to tuberculosis control, quick detection by sputum smear microscopy, application of a standardised treatment regimen of select drugs for 6-8 months, standardisation of the recording reporting system, and provision of an uninterrupted supply of all essential tuberculosis drugs. DOTS usage spread over the world after initial success in Tanzania. Unfortunately, the evolution of tuberculosis quickly outstripped that of the program and such a regular drug regimen found itself challenged by the emergence of multidrug-resistant tuberculosis. Thus, the WHO intervention in Russia was ineffective in lowering the incidence of tuberculosis. However, that does not mean that there have been no success stories.
Partners in Health (PIH) - a nonprofit health care organization - and their project in Haiti is an example of an intervention that was truly effective in tuberculosis treatment. A major driving force behind their success is the effectiveness of their approaches in every project. From Cange, Haiti to Carabayllo, Peru, PIH employed a variety of unconventional methods such as making long-distance trips to individual patients and extending services even when resources were tight. Although these methods drew some criticism centering around the unsustainability of these efforts, the results of PIH were remarkable. What differentiated them from the other projects was exactly the “extra mile” that their treatments took to ensure that interventions improved not only the patients’ health, but their living conditions as well. The effectiveness of these efforts serves as evidence for the importance of a biosocial approach to tuberculosis treatment that covers both the physical and human needs of the patient.
Criticisms for PIH generally centre around the unsustainability of such a broad-based approach, yet similarly successful programs have been implemented in the Soviet Union. Hallmarks of the Soviet approach to tuberculosis were the wide range of social benefits that came with medicine. Treatment standards included increased space for each patient, improved food quality, money for medications, and social support in the form of ten months of disability support as well as job protection for 12 months. Interestingly, during this time, Soviet phthisiatrist Alexander Rabukhin suggested a chemotherapy regimen that held marked similarity to the modern-day DOTS program with the additional clause for the provision of support against negative social stigma. Like the efforts of PIH, these efforts were successful in reducing the incidence of tuberculosis within the country, decreasing the mortality of the disease from 200/100,000 to approximately 7.9/100,000. In comparison to WHO approaches, the key similarity that PIH and Soviet interventions share is the inclusion of consideration for social factors and determinants of the disease in the design of the treatment program. If these approaches were to be combined with the current updated technologies and resources available to WHO, current programs would be much more effective, especially in maintaining health in the long term. In the context of prisoners, this would include both better conditions and care while incarcerated as well as once released.
Ideally, inmates would have a chance to live a frugal yet dignified life after release that would not require a return to their previous lifestyle but give them a true chance for self-improvement. After all, it is difficult to avoid a reversion to crime if there does not appear to be any other readily available option. The inclusion of additional services and benefits, at least during treatment and for a short duration after, would facilitate the patients’ reintegration into society and add a net positive value to their health. The establishment of such a system would also be a net positive for the government and the country in the long run in the form of lowered recidivism rates and costs of treating tuberculosis, but only if they can be implemented in the first place.
Many obstacles exist before the implementation of a broad-based approach to tuberculosis treatment is possible. For example, few governments have the same acuteness and ability to focus as an organisation like PIH or as the Soviet Union with its authoritative socialism. Nevertheless, many would benefit from considering aspects of their approaches during the development of a tuberculosis management program. Funding is often an obstacle for the creation and implementation of successful interventions. Possible solutions for this are increased partnerships and the streamlining of approaches and interventions. Both would help with raising the quality and range of care provided to patients without overt increases in the amount of resources dedicated to disease management. If resources could be pooled and concentrated and interventions with clear target objectives are implemented, it would be much easier to achieve the objective of lowering tuberculosis incidence in prisons. As an extremely powerful international organisation with the power to convene the relevant voices and a high-level platform on which policies can be made and effected, WHO would be an instrumental player in this.
Tuberculosis treatment, like that of many other diseases, is very difficult and requires the acknowledgement of needs across a wide spectrum. However, in spite of the changes that can be made, it is important to note that large strides forward have been made in tuberculosis treatment around the world. WHO’s 2015 “End TB Strategy” stresses governmental stewardship and accountability, strong connections with communities and civil society organisations, protection of human rights, and collaboration at both the global and country levels. In comparison with the original approach, the consideration of the social determinants of tuberculosis is very heartening. Indeed, such an approach, in combination with the scientific advancements in treatment, points towards the development of much more effective interventions that would address both the biomedical and social roots of the disease.