In a prison hospital compound built for 750 patients in the small town of Mariinsk in the Kemerova region of Siberia, 1,500 men and boys behind the wire quietly endure the lurking menace of tuberculosis.
Mariinsk is situated just three hours' drive, through picturesque forest and farming scenery, from the regional capital, Kemerova. The relative prosperity of Moscow is four hours away by air, but it could be decades away.
This is the Kuzbass region of Russia, where huge deposits of coal have been mined for generations, the winters are long and harsh, temperatures plunging as low as minus 40C, and the population is hardy and heavy-drinking.
The prison system is a big employer in the Kuzbass, with 10,000 people working in jails that hold 30,000 inmates, in an area the size of Belgium. Historically it was a region of exile for dissidents under the tsars and in Soviet times. Millions of prisoners perished in the zone, as the Russians call it, because of inhumane treatment and atrocious living conditions.
But that was then and this is now. Now most of the inmates in the region's 33 prisons and colonies are from the surrounding area, meaning one in 10 of Kemerova's population are incarcerated. Tuberculosis has always been a big killer in the zone, but the deterioration of services and shortage of money since the break-up of the Soviet Union have made matters much worse.
Dr Natalya Vezhnina, a colonel in the military and medical chief for the Ministry of Justice in the region, described a very difficult time in hospital colony No 33. "After the crisis [by which he means the break-up of the Soviet Union], it became very difficult to feed the patients, and to maintain normal conditions in the colony. We had practically run out of medicine, and more and more men were being transferred here from other colonies. One-quarter of the TB patients admitted to the hospital died from the disease. We were burying 80 men a month. It was our darkest hour."
The international non-profit medical organisation, Medecins Sans Frontieres, identified the colony as suitable for the introduction of a project which would follow World Health Organisation recommendations for the treatments of TB. After the MSF programme was introduced in 1996, the death rate from TB decreased 20-fold in two years.
THE colony in Mariinsk is a quiet place. The inmates have nothing to do but hang around, follow the prison and medical routines and put up with their disease. Most of them are well enough to spend time outside each day, now that the weather allows it. The men suffer from persistent coughing, difficulty in breathing, general weakness and usually weight loss. As they are existing on 75 per cent of the recommended daily intake of calories they are unhealthy-looking and lack energy.
Apart from poor conditions, another major part of the TB problem is that the Russian system of treatment is not streamlined, and many outmoded methods such as surgery and inhalation therapy are still being used.
In 1993 the World Health Organisation produced a strategy against TB in response to an alarming growth in the disease and particularly the emergence of a new strain of multi-drug-resistant TB worldwide. The strategy centres on the International Union Against TB and Lung Disease programme.
The programme combines speedy, microscope-based diagnosis, with the directly observed and monitored system of administering a combination of drugs daily. The other aspects of the programme are support and funding from the local government and a co-ordinated follow-up of the cases until they are declared clear.
This is what MSF is putting into practice in Colony No 33 in Mariinsk, and it is getting impressive results. The only worrying stumbling block is the steady hold of the drug-resistant strain.
The TB rate is twice epidemic level now in Russia, with 100 new cases per 100,000 population, according to Prof Nena Gvetadze of the Central TB Research Institute of the Russian Academy of Medical Science. The rate in the prisons is 50 times higher again.
A combination of factors has exacerbated the problem in the jails and made it almost impossible to contain. First and foremost is the overcrowding, especially in remand centres, where there is standing room only and prisoners in many cases have to sleep in shifts.
There is no bail in Russia. Once charged with an offence, the accused is held in a pre-trial detention centre until the case comes up. This generally takes a minimum of 18 months, even for a relatively minor charge. Some 23 hours a day are spent in overcrowded, poorly ventilated cells, existing on an inadequate diet and almost certainly alongside contagious cases of tuberculosis.
On a recent visit to a pre-trial detention centre Butyrka in Moscow, the United Nations High Commissioner for Human Rights, Mrs Mary Robinson, said the conditions she witnessed there amounted to torture.
Added to these factors is the poor record and method of TB treatment for prisoners in recent years. The diagnosis procedure has been slow and outdated, relying chiefly on Xrays. Very often, prisoners do not complete their course of medication, either because the drugs run out or the prisoner sees TB as a ticket out of the strict regime colonies and deceives medical staff when given the medicine. This erratic treatment has fostered the growth of new strains of deadly multi-drug-resistant TB.
In normal circumstances, a patient with TB can be treated successfully with a combination of up to five drugs over the course of six to nine months. The TB clears up, the patient recovers and is no longer contagious. But with MDR the TB is not being cured, and the patient is likely to become chronically ill or die. Over 15 per cent of the TB patients in Colony No 33 have MDR, and the doctors are alarmed at these results. In the general prison TB population the estimated rate is 25 per cent.
MDR treatment costs 150 to 300 times more than the treatment of drug-sensitive TB.
"The prisoners are now a threat not only to the local community but also outside Russia," Dr Laura Lobera, MSF doctor in Mariinsk, warned. "These men will be released sooner or later and will be in contact with civil society. The MDR strain is being transmitted wider and wider and will travel with people." One infectious TB case can contaminate up to 30 other people a year.
The issue of amnesty is a further complication in tackling TB. The State Duma or lower house of parliament last month voted to approve an amnesty intended to release 94,000 prisoners (just under one in 10 of the prison population), among them TB-infected prisoners. The release of 12,000 remand prisoners will come first and then the other amnesty may produce more injustice and suffering: if housing and medical care cannot be provided on the outside, the amnesty could be a recipe for disaster.
From the point of view of non-governmental organisations working in the field, they may be faced with a serious dilemma. "If we start treatment we have to be sure the patient will be there [in the prison] for the full course. We cannot contribute to the creation of more MDR TB", Dr Vinciane Sizaire, chief co-ordinator for MSF in the Kemerove region, said. Even without the amnesty, there are already 30,000 prisoners with active TB being released into the community each year.
Dr Sizaire believes what is being done in Mariinsk should urgently be taken as a model for the rest of the penitentiary system because the consequences of further neglect of the infected prison population are too dire to contemplate.
THE Irish Government donated £50,000 towards the programme in Mariinsk in December 1997. The money has helped fight the battle against TB, but unfortunately this was only the beginning, and the funding commitment is not there from the Russian government.
As Dr Igor Malakov, head of the Mariinsk hospital, put it: "TB is the leading cause of death in our prisons, and our problem lies in the lack of money. MDR TB will spread to the rest of Europe in less than five years. The danger is real and it is here."
Dr Malakov also has to contend with colleagues and friends from outside the colony calling him and asking for drugs for their patients in civilian hospitals. His hands are tied.
One of his patients, 17-year-old Oleg from Novokuznetsk, is small for his age. He has TB for the second time, and this time it looks like the incurable MDR strain. Oleg received a six-year sentence in 1995 at the age of 14 for stealing cases of vodka from a shop with two other boys. His parents and sister keep in touch and he receives a food parcel from home every month.
When asked if he is angry about his situation, he shrugs his shoulders, casts a look at the guard and says: "it's my own fault."
