Romanian prisons fight spread of TB, HIV

JILAVA, Romania — Communist Romania was a vast den of spies and paranoia, with thousands locked up inside one of Eastern Europe’s cruelest prison systems. Twenty years later, prisoners land behind bars for different reasons, but they still have much to fear.

Prisons are widely considered a leading source of HIV and tuberculosis (TB) infection. And Romania, which already claims the highest TB rate in the 27-member European Union, now worries that heroin injection with tainted needles is spurring an HIV crisis. (Overcrowding and lack of hygiene are leading causes of TB in the slums of Mumbai, as well.)

But thanks to the work of Veronica Broasca and others, as the world marks Tuberculosis Day today, Romania’s prisons can be held up as a success story.

Broasca, an activist with the Romanian Association Against AIDS, heads up the group’s prisons program. She and her colleagues are allowed into Romania’s prisons to provide drug-addiction services, offering inmates a chance to come forward for either clean needles or methadone treatment. Before she leaves, Broasca also unloads a batch of condoms, lubricants and HIV literature in the prison’s visitation room.

She credits prison officials for their progressive mindset, but said they’re also driven by fear of inmates’ ability to seek revenge through the courts. Recent lawsuits accuse prisons of denying them access to proper health care.

“Convicts know their rights,” said Broasca. Prison administrators “tell us they’ll be sued in one second if they don’t provide the treatment needed.”

This new respect for prisoner rights also reveals that in Romania two decades of post-communist democratization has grown roots. Romania’s campaign to join the EU obliged it to align its laws and values with club members. As further incentive, Europe dangled a carrot: cash to tackle problems such as the TB infection rate.

This adds up to a rare success: While the World Health Organization (WHO) last week lamented that Europe’s TB treatment has grown less effective, Romania has dramatically reduced its rate of incidence.

“They understood they had a problem, needed international help, and the funding was there,” said Giovanni Battista Migliori, the Italian director of the WHO Collaborative Center for TB and Lung Diseases, who has worked with Romania since 1995. “The condition was change, and they said ‘OK.’”

That change represents a remarkable about-face. Longtime Romanian dictator Nicolae Ceausescu zealously guarded state secrets from both his people and the outside world. TB was a third rail for Romanian medicine. Since it was seen as a poor man’s affliction, Ceausescu — obsessed with his regime’s image — refused to admit the problem even existed.

Mihai Apavaloaei recalls that during his medical training in the 1980s he was forbidden from writing a patient’s diagnosis as “tuberculosis.” Today, Apavaloaei speaks freely about his challenges as chief commissar of the Jilava prison hospital, Romania’s largest.

Located in a converted 19th-century fort, in a bleak village outside Bucharest, the prison’s drinking water is reportedly so contaminated inmates are left to contend with maggots.

The state welcomed whatever Western help it could find to improve prison conditions. The Global Fund to Fight AIDS, Tuberculosis and Malaria paid to build new isolation rooms in the hospital to quickly detect inmates carrying TB. It also trained prison staff in how to prevent and control the spread of TB.

Apavaloaei marvels at how far Romania has come. Romanian officials now publicly concede they can’t prevent unprotected sex or drug-smuggling in their prisons, even though both sex and drugs are barred. So prison officials throw up their hands and let in activists like Broasca.

The prison-prisoner dynamic has come even farther. Apavaloaei says any inmate who asks to speak with him can file a complaint if the hospital director fails to meet them that day.

“Democracy is a good thing,” he said, smiling through his thick moustache. “But there are situations when people can abuse democracy. Probably because we didn’t have democracy for so many years, now we over-use it.”

That doesn’t mean all is rosy with the prison system.

Sergiu Stupu, president of the Jilava prison-guard union, said that by Romanian standards prison guards are fairly well paid. Yet some guards are so desperate for extra money they jockey for roles in which they come into contact with TB- or HIV-infected patients, for which they receive a 50 percent high annual salary.

It may be Russian roulette, but Stupu said the guards like their odds.

“It’s a lottery of fate,” he said. “They take a chance: Maybe I’ll get it, maybe I won’t. They think only the unlucky ones get it.”

Indeed, despite a more effective detection and treatment system, such risky behavior raises questions about how deeply the TB and HIV messages penetrate Romanian society.

“There’s a lot of ignorance about it,” said Adrian Mocanu, the director of a state-run TB institution in Bucharest. “I even know some doctors who use their elbows to open doors.”

Meanwhile, Broasca and Apavaloaei predict that rising heroin addiction will fuel HIV rates, both inside prison and in society at large. Bucharest pharmacies are so concerned that sales of syringes draws addicts into their stores that only three pharmacies in a city of 2 million sell them. So, addicts swap dirty needles.

Despite the progress made in fighting TB, Romania still has a lot of progress to make, Migliori said. While the country is now down to about 120 TB cases per 100,000 people, a fellow EU member like his native Italy reports only 7 cases per 100,000.

Romania, while a member of the wealthy EU, is still poor enough to need foreign assistance with its infectious diseases. As eastern Europe’s new EU members have learned, donors now focus their euros farther east and south.

Romania may struggle to maintain momentum, Migliori said: “The curve is going down, but they still have high numbers. Without all the external funding, it’ll be a challenge.”