There is a slow, indirect violence in South African prisons that is killing inmates in droves. Last year alone, 652 inmates died in what were categorised as "natural deaths" by the Judicial Inspectorate for Correctional Services. Most of these deaths were likely related to tuberculosis and HIV and Aids.
A recent case where HIV-positive inmates defaulted on treatment in Boksburg Correctional Centre reveals some of the challenges and failures of healthcare delivery in the prison system. In this David and Goliath battle, a small HIV support group faced the machinery of the department of correctional services.
Last year, in my role as Sonke Gender Justice's policy and development advocacy specialist managing prisons programmes, I received a complaint from inmates who were members of an HIV support group at the Boksburg Correctional Centre.
The chairperson of this group, Themba*, though HIV negative, was seeking urgent help for fellow inmates who were HIV positive. Their access to antiretroviral medicines had been interrupted throughout the year, putting them at risk of defaulting on treatment.
"People have gone for two weeks without treatment," Themba said. "And it seems like, as a support group, we just watch and do nothing about it."
Two weeks may sound brief and, indeed, this is not an issue of wholesale denial of treatment. According to its current annual report, the correctional services department has greatly improved on testing and initiating HIV treatment for inmates.
Potentially fatal side effects
The problem is that HIV treatment is inconsistent: a few weeks on, a few weeks off. But even these brief interruptions can put patients at risk of defaulting. And defaulting from HIV treatment has potentially fatal side effects for patients as it leads to drug resistance, which in turn can lead to illness and death.
Inmates must be tested for resistance and, if resistance has developed, a second-line drug cocktail must be prescribed that is very costly for the government and is harsh on the patient's body.
Support groups have long been part of the successful model for treatment, offering HIV-positive people psychological support and helping members to access their constitutional right to health. Groups can band together to insist on treatment when it is denied, and share information with each other about prevention and treatment. The benefits of a support group are multiplied in prisons, where even basic medical care is often difficult to access.
In Boksburg, the inmates' support group comprised committed individuals – both HIV positive and HIV negative – determined to ensure proper treatment, despite the risk of backlash from the correctional services department. Their most important objective was to make sure no one died from lack of medical care.
Consider that prisons are hypermasculine and incredibly violent places, where individuals are warehoused and invisible to the public. Inmates' daily movements are controlled, and many are kept in their cells for up to 23 hours a day, released only to fetch their food. There are gangs, sexual violence and corruption, which the correctional services department fails to control adequately because its ranks are stretched thin and are insufficiently trained to handle these issues.
Almost no public sympathy exists for these despised inmates. We forget that inmates carry the lingering effects of all this abuse back into our communities when they are released. No wonder prison officials got away with torturing inmates in Mangaung for so long (the abuse was revealed by the Wits Justice Project in 2013, published in the Mail & Guardian, and confirmed by a 2010 high-level department of correctional services report). How much easier it must be to let some HIV-positive inmates miss treatments.
David and Goliath
The inmates' support group at the Boksburg Correctional Centre stood up to the Goliath correctional services department, and did so remarkably. Their internal complaints resulted in nothing except an official reply saying that the inmates were lying; and that after the Judicial Inspectorate of Correctional Services apathetically failed even to verify the complaints.
We assisted the support group in securing legal representation, leading to a standoff with the department of correctional services. One day before filing papers in court, the inmates were given a full month's supply of medication.
Subsequent negotiations between Sonke Gender Justice, Section27 and the correctional services department came to an impasse. The systems that caused the periodic defaulting remain unidentified and unchanged.
The department doggedly focused on protocol and on trying to uncover how Sonke and Section27 came to learn of the complaint, instead of examining how to address and ensure access to medicines.
In focusing on identifying the whistle-blowers, the department homed in on the support group, asserted the members were criminals not to be trusted, and called them an "illicit pressure group".
Today, the department has disbanded the support group, a counterproductive manoeuvre in line with its strategy to deny and avoid the problem. The inmates no longer benefit from the solidarity and encouragement of the support group. At least the inmates continue to receive their medicines – a thin silver lining in this frustrating ordeal – and a fragile and vulnerable lining at that. If their treatment is again interrupted, there is no support group to speak out.
Since this case in Boksburg, I have received complaints from inmates elsewhere. It is not surprising to receive them. HIV prevalence rates remain critically high: about a quarter of South Africa's inmate population was HIV positive as of March 2013, according to reports.
I just hope that there are support groups in these others centres, and that they have the same conviction to confront the risks and accusations to ensure their rights and access to treatment. The department of correctional services should also be reminded of South Africa's Constitution, which states that "everyone who is detained, including every sentenced prisoner, has the right to conditions of detention that are consistent with human dignity, including … adequate medical treatment".
*Not his real name
Emily Keehn was a policy and development advocacy specialist at Sonke Gender Justice at the time of writing this article
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