/ 18 December 2014

Public versus prison healthcare: What are the facts?

Africa Check investigates the real state of health care in South Africa prisons after claims made my the Deputy Minister of Correctional Services Thabang Makwetla.
Africa Check investigates the real state of health care in South Africa prisons after claims made my the Deputy Minister of Correctional Services Thabang Makwetla.

Prisoners in South Africa have access to better healthcare services than the general public, the Deputy Minister of Correctional Services, Thabang Makwetla, recently claimed.

“You find that there is (sic) better medical facilities given from government in prison than out there,” he told reporters at a World Aids Day event, after visiting six of the country’s 240-odd correctional facilities in the preceding days.

When asked for clarification, Makwetla’s spokesperson, Ntime Skhosana, said the statement referred, specifically, to the public perception that prisons were hothouses of disease and that healthcare provision was inadequate. On this point, the deputy minister had said: “It is actually the opposite. I was amazed at the intensity of healthcare given at correctional centres.”

Constitutional Court forced improvements

South Africa’s Deputy Minister of Correctional Services, Thabang Makwetla. (Delwyn Verasamy, M&G)

The department says it has improved healthcare in prisons. This follows a 2012 Constitutional Court ruling.

The court upheld a decision from the high court in the Western Cape that the department was responsible for an inmate, Dudley Lee, contracting tuberculosis (TB) while in detention, likely through overcrowding in cells and prisoner transport; a lack of adequate screening for TB; poorly ventilated cells and poor nutrition.

In support of the deputy minister’s statement, the Department of Correctional Services (DCS) claimed:

  • On July 31 2014, there were 1 469 healthcare professionals employed by the department, in addition to contract workers (equating to roughly one healthcare professional for every 105 prisoners);
  • All inmates undergo a general health assessment on admission;
  • Awareness sessions, training for officials and isolation facilities are in place to manage and prevent the spread of communicable diseases;
  • Inmates are provided with nutritionally balanced meals, and therapeutic diets are available for those who require them; 
  • The number of natural deaths in detention dropped 65% between 2004 and the 2013/14 financial year: from 0.9% of the prison population to 0.37%; and
  • There have been improvements in the management of HIV/Aids and TB – two of the biggest killers in prison.

Eight of 48 available doctors’ posts filled
In its 2011/2012 annual report, the Judicial Inspectorate for Correctional Services (JICS) found that, in contravention of department policy, 38% of inmates were not examined within 24 hours of admission to a correctional services facility and 54% did not receive immediate medical treatment when required. 

The inspectorate’s 2012/2013 report noted that the department had yet to take its findings and recommendations in this regard into account, while the 2013/2014 report found cases where the policy continued to be breached.

A shortage of staff in the DCS hinders healthcare provision. After reviewing 186 of the country’s correctional services, the JICS concluded in its 2011/2012 annual report that half of all correctional centres received a doctor’s visit once or less each week; 9% of those surveyed had not been visited by a doctor in the previous three months.

In the June 2014 National Strategic Plan Review, the director of health in the DCS, Maria Mabena, was quoted as saying that the department had filled only eight of 48 available doctors’ posts to serve roughly 160 000 inmates. Private doctors were contracted to meet the shortfall.

Poor conditions facilitate spread of disease
According to Emily Keehn, then a policy and development advocacy specialist at Sonke Gender Justice, a shortage in correctional services guarding personnel is also problematic as a prison warder must accompany all inmates on visits to a nurse or doctor, but warders are not always available. 

Staff shortages also mean inmates may be kept in overcrowded remand centres for extended hours – up to 23 hours a day in some cases – which creates favourable conditions for the spread of communicable diseases.

In a letter to Western Cape Correctional Services Regional Commissioner, Delekile Klaas, dated November 6 2014, both Sonke Gender Justice and the Treatment Action Campaign (TAC) raised issues around healthcare provision in Pollsmoor correctional centre. The organisations – together with the Visitors Committee for Pollsmoor, Lawyers for Human Rights and the Bonteheuwel Support Group for ex-offenders – had been tracking inmate complaints emanating from the centre since June.

The Sonke/TAC submission noted that prisoners in Pollsmoor had little access to healthcare professionals. In the overcrowded prison, a doctor was only available for consultations one day each week; and prisoners had not had access to a dentist for six weeks.

Poor prison conditions facilitate the spread of disease. The group found “abysmal conditions” at the prison. According to Keehn, 200 inmates in two units were sleeping on the floor without mattresses, one of those units had a leaking roof. 

Detainees had also not had access to hot water since April. The letter stated that “conditions such as these are a breeding ground for infectious diseases, such as tuberculosis and pneumonia”.

Overcrowding in prisons also increases the likelihood of the transmission of infectious diseases. According to the 2013/2014 JICS annual report, communal cells are overcrowded and in some centres, inmates are “doubled up or even tripled-up” in single cells. According to Health-e News, there is 200% occupancy of some communal cells at Pollsmoor.

John Stephens of Section 27, a public interest law centre, said the National Task Team on TB in prisons is currently conducting donor-funded baseline assessments to determine levels of infection control and healthcare services at prisons. When complete, these will provide a more detailed overview of the situation in South African prisons. However, an initial pilot at the Pretoria Local Correctional Centre produced “abysmal results,” showing infection control and healthcare provision to be “dangerously inadequate”.

How HIV/AIDS is managed in correctional centres 

South Africa’s Department of Health launched a new single dose antiretroviral pill last year to treat HIV-positive patients with in public health facilities. (Reuters)

In the 2012-2016 National Strategic Plan on HIV, Sexually Transmitted Illnesses (STI) and TB, prisoners are identified as a “key population”, as individuals are at higher risk of HIV exposure and transmission. As a result, the DCS is required to “ensure the provision of appropriate prevention and treatment services, including HIV, STI and TB screening, prompt treatment of all inmates and correctional services staff, ensuring a continuum of care through proper referrals”.

According to the DCS, 107 415 inmates had been tested for HIV in 2013/2014, with 6.35% of those testing positive. This was up from the 76 202 inmates tested in 2012/2013, where the positivity rate was 8.76%. However, statistics on HIV prevalence in prisons are difficult to come by, says Keehn.

Though the DCS noted a 95.7% ARV uptake among inmates, an HIV support group in Boksburg Correctional Centre in 2013 complained that access to ARVs was disrupted for weeks at a time and that inmates had periodically been unable to access ARVs over a number of years.

In a submission to former correctional services minister Sibusiso Ndebele on behalf of Sonke Gender Justice and the Siyanakekela Support Group, Section 27 noted that a prisoners were not given ARVs unless accompanied by a prison guard, and that a lack of guards meant they did not receive treatment.

Several inmates reported that they were not regularly provided with the special dietary requirements that had been prescribed for them. They also complained of not having their HIV status adequately monitored.

According to Sonke’s Keehn, the organisation also received complaints around ARV provision from Modderbee Correctional Centre and correctional centres in the Western Cape. In some cases, disrupted ARV treatment is a result of inmates being transferred between centres, or spending short periods in correctional centres as remand detainees.

Furthermore, the 2013/2014 JICS annual report notes inmate complaints around HIV- and TB-related treatment and “failure to provide medical treatment”.

Containing TB in prisons 
As with HIV, prisoners have been identified in the National Strategic Plan on HIV, STIs and TB as a “key population” when it comes to managing TB.

According to the DCS, prisoners undergo TB screening on admission, twice a year, on release and each time they see a nurse. According to its statement, 79.84% of inmates were screened on admission in 2013/2014, with 91.26% screened between April and September 2014. Roughly 60% of inmates had been screened on release in 2013/2014, with about 81% screened between April and September this year. It also noted that the turn-around for laboratory results has increased significantly.

However, Section 27’s Stephens says available studies suggest a worsening threat: prevalence in prisons is thought to be roughly seven times higher than in the general population and 10% of new cases were diagnosed as multi-drug-resistant TB. 

A modelling analysis of Pollsmoor concluded that a person in prison for one year had a 90% chance of becoming infected with TB, while a study conducted in Johannesburg Prison concluded a high (3.5%) undiagnosed TB prevalence rate.

The DCS has started using a new test, known as the Xpert MTB/RIF test, which has a more rapid turnaround on diagnosis and greater accuracy than current screening procedures, and which picks up drug resistant strains. However, Stephens says only a few prisons have thus far had access to the technology.

According to Stephens, one of the problems is a lack of information about the management of the disease in prisons. He says the DCS has, over a number of years, “not complied with legal obligations related to record keeping”.

While prisons are required to keep an electronic TB register, there is little evidence of this being the case. Civil society organisations have had little success in their requests for summaries of, or access to these registers, leaving them with little knowledge of the type of healthcare being provided.

An opinion piece by the TAC’s Lieve Vanleeuw notes the impact staff shortages have on TB treatment: there is a shortage of doctors on hand to treat the illness and, while nurses in some correctional centres are able to prescribe the medication, pharmacists won’t release it without a doctor’s signature. When security staff are unavailable to escort prisoners to healthcare professionals, inmates go untreated.

Vanleeuw quotes Dr Sweetness Siwendu, who treats multi-drug-resistant TB patients from Pollsmoor and Goodwood correctional centres: “Different categories of prisoners cannot be transported together. If three patients come from three different sections it means that three separate vehicles are needed to transport them. This results in patients coming at different times or not at all.”

Vanleeuw also notes the structural conditions that facilitate the spread of TB – a sentiment echoed in a Wits Justice Project submission to the Portfolio Committee on Justice and Correctional Services in October 2014: “Over-crowding of cells, poor structural conditions (such as ventilation in cells) and inadequate environment for taking medication (including the lack of access to appropriate foods to accompany medication) will continue to stymie progress.”

This poses a significant public health threat, says Nooshin Erfani-Ghadimi, project co-ordinator of the Wits Justice Project. “We’ve heard from a lot of TB experts that the whole country faces the consequences of unchecked TB in prisons, to say nothing of HIV. There are many inmates who come into prison for a couple of months and then leave again, acting as carriers for undiagnosed and drug-resistant strains of TB.” 

“Until we can get a handle on the situation on the inside, we won’t be able to manage the crisis on the outside.” the project co-ordinator said

Conclusion: The claim is exaggerated
While the DCS appears to be taking a more aggressive stance towards healthcare provision in correctional centres following the Constitutional Court finding in the Dudley Lee matter, studies by civil society organisations show that under-staffing, overcrowding and inconsistent treatment of disease in prisons remain a serious cause for concern. 

Many prisons remain hothouses of disease.

It is difficult to draw direct comparisons between prison healthcare and healthcare facilities available to the general public but, given the evidence of the lack of consistent and adequate health care in many prisons, the deputy minister’s claims are exaggerated and dangerously understate the problem.

  • Edited by Julian Rademeyer and Anim van Wyk.

This article was written by Africa Check, a nonprofit fact-checking organisation. Follow Africa Check on Twitter: @AfricaCheck.