Zuphe Ngwada’s eyes follow the movement of his shoes as they sway back and forth beneath him. Sitting on a bench, hands firmly gripping the metal frame on either side of his lap, Ngwada (21) stares at his sneakers as they disappear underneath the wooden planks only to jut out in front of him seconds later.

A sound or thought distracts the young man, causing his legs to stiffen in front of him and then relax to rest on the concrete floor. Hands still clasped at his sides, he looks up at the blue sky framed by barbed wire lining the high walls.

Ngwada’s eyes dart around the enclosure curiously – but without suspicion.

Lost in his thoughts, his facial expression is strikingly innocent. If it wasn’t for the bright yellow overalls identifying him as an inmate from Cape Town’s Pollsmoor Correctional Centre, he could be mistaken for an average teenager.

Ngwada sits on one of the neatly arranged benches in the inner courtyard of the prison’s medical ward, intended to serve the health needs of the 8 000-odd men and women jailed there. Wood-panelled and steel framed, the benches mimic those popular in public sector clinic and hospital waiting areas.

But, unlike the situation in most public facilities, when Ngwada arrived last August, he was screened, tested and placed on tuberculosis treatment in 24 hours at no financial cost to him.

The national benchmark for the time from testing to treatment is 48 hours, according to the health department’s deputy director general for HIV, TB and maternal health, Yogan Pillay. But he says that, in reality, “the results can take up to three or four days to return from labs to facilities”.

Convenience
Norbert Ndjeka, who is in charge of drug-resistant TB and TB-HIV programmes at the national health department, told journalists last year that TB treatment at public health facilities is free but that take-up can be compromised when patients “have to fund transport costs” to often remote clinics and hospitals.

Neither Ngwada nor his family could afford the few hundred rands required for bail last year. But, he says, at least there was no “taxi fee to get to the prison clinic”.

He may have been more comfortable in his usual civilian jeans and T-shirt, but Ngwada’s bright yellow overalls have translated into six months of successful TB treatment – which, he says, “isn’t that easy to get back home” in the nearby township of Nyanga. Ngwada says he avoids his local clinic as far as possible because of the long queues that “can waste a whole day”.

On the outside, where he likely would have delayed seeking treatment, Ngwada may have spent the past year spreading TB in his community – research has shown that every untreated TB patient can infect between 15 and 20 other people in his or her community in a year.

But on this September afternoon, Ngwada is healthy. The drugs he received from the prison have cured him and likely prevented his cellmates from becoming infected. Ndjeka says that after two weeks of successful treatment patients are no longer infectious.

Controversial claims
Deputy Correctional Services Minister Thabang Makwetla was widely criticised after making an ironic statement at a World Aids Day event at a Johannesburg prison last year, when he told members of the media that healthcare in prisons was better than it was “on the outside”.

Responding to claims that correctional facilities are plagued by disease and inadequate access to health services, he said he was “amazed”, after visiting six of the country’s dozens of prisons, to find “actually the opposite”: that there were “better medical facilities” in correctional facilities than in many South African communities.

A report published by the fact-checking organisation Africa Check quickly refuted his claims, citing shortages of staff and resources as well as the generally “poor” conditions experienced in many correctional facilities as a “serious cause for concern”.

A 2011 study showed that the risk of being infected with the tuberculosis bacterium after a year at Pollsmoor could decrease from 90% to 50% if overcrowding, ventilation and improved case finding were addressed. In the research, published in the South African Medical Journal, the authors note that the prison was then at 230% capacity but, should it decrease its occupancy rate to 100%, the risk of infection would drop to 30%.

Only about 10% of people who inhale the bacterium and become infected actually develop active and infectious TB. Adverse prison conditions, however, often lead to an increase in this percentage (see “Inmates’ HIV and poor diet trigger latent TB”).

Although Makwetla’s claims “dangerously” understate the problem, according to Africa Check, Ngwada and other inmates at Pollsmoor have reason to agree with the deputy minister, when it comes to the testing, diagnosis and treatment of TB.

TB interventions show results
Despite Pollsmoor’s “deplorable living conditions”, described in an April investigation led by Justice Edwin Cameron, TB control interventions have started to show signs of success.

During a prison tour in September, Health Minister Aaron Motsoaledi told Bhekisisa the time from testing to initiating treatment for TB at Pollsmoor has been cut from a week to just over a day. For drug-resistant forms of the disease, the wait has been cut from almost a month several years ago to under a week currently.

These, he says, are the results of implementing TB control guidelines for prisons, which his department published in March 2013. They stipulate that offenders should be screened for the disease when they enter the prison, twice during their incarceration and then again when they are discharged.

Prison medical staff, in collaboration with provincial health department personnel, are encouraged to contact the families of inmates who have TB on entry – to refer possibly exposed relatives to be tested at their local clinic.

There has also been a “massive” increase in diagnostic capabilities at some bigger prisons: seven of these, including Pollsmoor, house a machine, called the GeneXpert, that can detect drug-resistant TB in two hours – without which a diagnosis can take up to three months in South Africa, according to health department figures.

Pollsmoor area commissioner Clifford Mketshane says that, through the programme, 100% of inmates have been screened for TB. The prison now also cures 75% of patients, compared with just over half last year.

Medical acumen: Health Minister Aaron Motsoaledi visited Pollsmoor prison in September, to learn more about the TB prevention and treatment programme there (above), as well as its diagnostic technology and general conditions (below).

TB common in prisons
Historically, prisons are a hotbed for TB, with rates of the disease in these institutions ranging from 11 to 81 times higher than in the general population, according to guidelines for controlling TB in correctional facilities published by the World Health Organisation (WHO).

The scourge of TB in prisons persists because inmates are likely to come from populations already at a higher risk of the disease, such as poor people and reoffenders.

But the WHO notes that prison settings themselves significantly facilitate the transmission of the airborne epidemic because of overcrowding, inadequate ventilation, malnutrition and the high number of people passing through these facilities.

Prisoners, of which there are roughly 160 000 in South Africa, form one of three key groups the health department is targeting in its renewed TB control efforts. Motsoaledi says miners and peri-mining communities are also receiving attention because of the high prevalence of the disease in these populations.

An average of 7% of miners who are tested are found to have TB compared with 5.8% of prisoners, according to Motsoaledi.

But Pollsmoor’s rate is above average, mirroring the mining sector at 7%, says Mketshane. He blames this on high TB rates in the general community as well as prison conditions such as overcrowding, staff shortages and dilapidated infrastructure.

Although overcrowding has been reduced since Cameron’s investigation in April, shifting from 230% of total capacity to 196%, the situation is “extreme” and is the most severe problem facing the prison, according to the judicial report.

TB in prisons puts everyone at risk
Controlling TB in prisons does not benefit the correctional facility alone: the WHO says there is a surplus of evidence suggesting that transmission dynamics between inmates and broader society “play a key role in driving overall population incidence, prevalence and mortality rates of TB”.

According to Cameron, one of the most important issues underlying Pollsmoor’s TB epidemic is the “filthy and cramped” conditions in which prisoners are expected to spend up to 23 hours of their day – which can’t be addressed solely by diagnostic equipment or access to drugs.

With an average of 65 inmates per cell, the report notes that overcrowding is “practically and undoubtedly degrading and hazardous for every detainee subjected to it”.

One such detainee, Theodore Armot (24), leans against the heavy metal doors through which prisoners are led from the medical ward to their cells.

As a beige-uniformed correctional officer walks past, he takes his hat off and holds it loosely in one hand. A large, faded tattoo covers his forehead: “26”, symbolising his membership of the notorious prison gang of the same name.

“I took my treatment every day,” he says flatly. Diagnosed during a prison-wide screening drive earlier this year, he’s completed the required six months of treatment and is cured of TB. He’s also a month away from being released from prison.

But he doesn’t look excited about either of these facts.

“I’ve just got to focus while I’m here,” he says, while his eyes survey the other people in the concrete courtyard with suspicion.

When prompted for an explanation, he shrugs and looks to the side – exposing another tattoo: two shakily drawn words: “more money”.

A correctional officer starts walking in his direction. He stands upright, glances at the room where he used to pick up his daily pack of pills and whispers: “But there’s no way I’m coming back here – TB or no TB.”

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State under fire

August 2012 marked the court ruling described by activists as “ground-breaking” and a victory for the rights of inmates affected by tuberculosis – a disease endemic in the country’s correctional facilities and exacerbated by overcrowded and unsanitary conditions. 

After spending five years in Pollsmoor Correctional Facility awaiting trial and charged with a number of financial crimes, Dudley Lee was finally acquitted and released in 2004. But during his incarceration he developed TB, which he claimed was owed to the poor conditions and inadequate medical care available at the facility. 

Although he was treated and cured at Pollsmoor, he sued the state and, after a protracted legal battle, he won the case. According to court documents, he received damages totalling R270 000 from the department of correctional services in late 2013, only months before he died from cancer at the age of 68. 

After the successful court ruling, the Democratic Nursing Organisation of South Africa said in a media release that the “landmark” judgement proved “the responsibility of the state to maintain and safeguard the constitutional rights of detainees”. 

But a few years later, civil society group Detention Justice Forum has reported that prisoners’ attempts to hold the state accountable for the conditions in which they developed TB have proved fruitless. Affiliated to groups such as Section27 and Lawyers for Human Rights, the forum claims that, instead of the state acknowledging its responsibility to protect the health of inmates, as was hoped by activists, the department is “wastefully” defending all civil claims. 

These claims, similar in substance to those of Lee’s, should be settled based on his precedent, they say. 

In an April submission to the department, the forum claims this is a “waste of limited public money that could be better spent protecting the public and addressing the conditions that led to the claims in the first place”. 

The latest annual report from the department shows that nearly R1-million was spent in the 2013-2014 financial year on “contingent liabilities”, under which legal fees incurred defending civil claims fall. The forum claims that, if resources were redirected to improving overcrowding and poor ventilation in prisons in particular, the spread of TB would decline by 30% – which could prevent many future civil claims. 

They note the health department’s involvement in increasing diagnostic and treatment services in prisons but point out that, without the government investing more “in strategies that ensure its respect for inmates’ human rights”, it will not reduce the risk of TB in prisons – or “its own risk of continuing to be sued in similar cases”.

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Inmates’ HIV and poor diet trigger latent TB

A third of the global population is infected with the tuberculosis (TB) bacterium, according to the World Health Organisation (WHO) – but this “latent” form of the disease only progresses to active TB in about 10% of cases. In most people, the bacterium remains dormant for life.

But, in South Africa – one of the WHO’s 22 high-burden countries – up to 80% of the population has latent TB, according to Yogan Pillay, deputy director general for HIV and TB at the health department. 

But when a person’s immune system is compromised, it affects the body’s ability to contain the bacterium, which then begins to multiply, resulting in illness, says the WHO. 

When this happens, a patient develops symptoms and becomes infectious – and can infect between 10 and 15 people in the space of a year. Health Minister Aaron Motsoaledi, during a tour of the Pollsmoor prison near Cape Town in September, said latent TB serves as a “reservoir” that threatens all the improvements that have been made in TB control to date. This “reservoir” is activated by a number of factors – many of which are endemic to South Africa and its correctional facilities where, among others, HIV infection and malnutrition are significant factors holding back efforts to control TB. Pollsmoor is no different. 

HIV and diabetes 
People with HIV have a reduced ability to fight the airborne bacterium that contains TB. Although previously estimated at 30%, the WHO’s 2015 Global TB Report, published in October, notes that one’s risk for developing TB increases 26 times if one is infected with HIV. 

South Africa has one of the highest comorbidity rates in the world for both diseases: Pillay says up to 70% of the TB population is HIV positive. According to Pollsmoor’s area commissioner, Clifford Mketshane, between March 2013 and August 2015 only 18% of inmates who tested positive for HIV were started on treatment. He says this is largely owing to “high turnover of detainees in the remand centre and the changing of identities”. Pillay says patients on HIV treatment are less likely to develop TB and more likely to survive should they develop TB. 

In comparison, during the same period, Mketshane says that 97% of prisoners who tested positive for TB received treatment. 

Research has shown that people with diabetes are three times more likely to develop active TB. South Africa has one of the highest diabetes rates in the world. 

Malnutrition 
Being underweight and having micronutrient deficiencies also raise the risk that latent TB will become active. A 2005 study in the British Medical Journal estimated that patients who are underweight – with a body mass index below 18.5 – are at a fourfold increased risk of developing symptomatic TB than normal or overweight patients. 

An April investigation into the conditions at Pollsmoor, conducted by Justice Edwin Cameron, noted the “emaciated physical appearance of prisoners” and reported many inmates complaining of not being given enough food. The investigation found that prisoners are often required to stay in dark and poorly ventilated cells for 23 hours a day. 

Another risk factor for TB disease progression is a lack of the micronutrient vitamin D, according to a 2011 British Medical Journal study, which notes that the vitamin is naturally synthesised by the body if exposed to the ultraviolet rays in sunlight.