Latin America?s rise in tuberculosis linked to imprisonment rates
High incarceration rates in Latin America ? the region with the world?s fastest-growing prison population ? are exacerbating tuberculosis in a region that is bucking the global trend for falling incidents of the disease, experts have warned.
A study published in The Lancet Public Health journal has estimated that, contrary to previous assumptions, HIV/Aids is not the primary risk factor for tuberculosis in the region ? as it remains in Africa, for example ? but rather imprisonments.
While the global incidence of tuberculosis decreased by 8.7% between 2015 and 2022, it rose by 19% in Latin America. Using mathematical modelling, researchers concluded that this increase was linked to the exponential rise in imprisonment in the region, surpassing other traditional risk factors such as HIV/Aids, smoking, drug use and malnutrition.
The work is centred on six countries ? Brazil, Colombia, Mexico, Argentina, Peru and El Salvador ? that, combined, account for 79.7% of the region?s tuberculosis notifications and 82.4% of its prison population. Between 1990 and 2019, the prison population in these countries increased from 260,363 to 1,322,355 people.
?Our main conclusion is that, in these countries, about a third of all tuberculosis cases since 1990 were associated with incarceration,? said the infectious disease specialist Dr Julio Croda, from the Oswaldo Cruz Foundation (Fiocruz) in Brazil, one of the institutions involved in the study.
View image in fullscreen A women?s prison in Bogot?, Colombia. Tuberculosis rates are said to be 26 times higher among people deprived of liberty than in the general population. Photograph: John Vizca?no/Reuters
The worst scenario is in El Salvador, where the study estimated that 44% of the country?s tuberculosis cases in 2019 occurred in its prisons.
At the time, El Salvador already had the highest imprisonment rate per 100,000 inhabitants among the six countries. After the president, Nayib Bukele, implemented his controversial state of emergency to combat gangs in 2022, mass incarceration increased even further ? which, according to the study, ?is projected to have catastrophic consequences for tuberculosis?.
?The environment in these prisons is highly conducive to transmission,? said Croda, citing tuberculosis rates 26 times higher among people deprived of liberty than in the general population. ?Prisons are overcrowded spaces, lacking light and proper ventilation, with a population that already has individual hazard factors for the disease, such as smoking or malnutrition.?
Juan Pappier, Human Rights Watch?s deputy director for the Americas, said the ?dramatic increase in imprisonments? in Latin America stemmed from a combination of excessive pretrial detention ? particularly in the context of the so-called ?war on drugs?, which has led to the imprisonment of thousands of low-level offenders ? and longer sentencing durations.
?And these are all the result of pretty populist responses to crime that ? have not achieved any significant results in reducing the very worrisome homicide and extortion rates in the region,? Pappier said. On the contrary, he noted that mass incarceration had strengthened criminal organisations born within prisons, such as Brazil?s PCC and Venezuela?s Tren de Aragua.
View image in fullscreen Cells are searched during an operation at the Pampas of Sanaguillo prison in Tarapoto, Peru. ?Prisons are overcrowded spaces, lacking light and proper ventilation,? said the infectious disease specialist Dr Julio Croda. Photograph: INPE/AFP/Getty Images
Julita Lemgruber, a sociologist who headed Rio de Janeiro?s prison system between 1991 and 1994, highlighted that people in Latin America still believed ?punishment only counts if someone is put behind bars?.
?But society forgets that, in countries like Brazil, for example, there is no death penalty ? so those who are imprisoned will eventually be released and, after being exposed to the disease within the penitentiary system, can become a vector for spreading tuberculosis outside,? she said.
The study on tuberculosis projected that if imprisonment rates had remained stable since 1990, the six countries would have had at least 34,393 fewer cases in 2019 alone, which accounted for 27.2% of the total cases that year.
It projected that, if there were a gradual 50% reduction in prisoner intake and sentence lengths by 2034, the incidence of tuberculosis among the population would fall by 10% in most countries.
In El Salvador?s case, even if the country were to halt the state of emergency immediately, it would only return to pre-Bukele levels of the disease by 2034. Then, it would also need to work on a decarceration policy to ?recover, at least in part, a decade of lost opportunity for tuberculosis progress?.
Pappier said one way to achieve this would be for security forces to focus on a more strategic approach targeting the leaders of criminal factions, and for lawmakers and the judiciary to work on alternative sentencing for those not involved in violent crimes.
Croda also believes reducing the number of incarcerated people is one of the solutions. But in the meantime, he said, providing ?more humane and less degrading conditions? in prison facilities was also necessary.
He said that, in general, cases of tuberculosis were underreported within penitentiaries because diagnostic tests were rarely conducted. ?Health services simply do not reach these populations,? he said.
