By Jo Baker
LONDON, Jan 7 2016 (IPS)

It is a grim fact that prisoners in most countries suffer from poorer health than non-prisoners, and that their right to health is not always protected. But for certain groups these rights can be even more elusive. Such is the case for women.

Jo Baker

For me, this was starkly illustrated during a visit to the clinic of a large women’s jail in the southern Philippines. Here, a very thin woman lay curled and still on a narrow wooden bench. Her hands were cradling her taut, bloated stomach, her eyes tightly closed. The nurse explained that she was an addict, arrested while heavily pregnant for drug possession (a sentence that keeps the country’s women’s jails lamentably stocked), and that her baby had died days earlier in a government hospital because of a condition related to her drug use, after a complicated labour. Being understaffed and short on medicine and beds in the prison, the best treatment she could offer the woman on her return, as she faced her withdrawal, post-labour pain, grief, separation from family, and possible years awaiting trial, were paracetamol, kind words and a bench. Hers would be a particular and gendered kind of purgatory.

In speaking with imprisoned women and healthcare practitioners across five countries, our research team commonly found harmful responses and barriers to healthcare that existed because the inmates were women. These included women who were imprisoned in Jordan while recovering from brutal gender-based violence (including honour crimes and rape), without adequate treatment or rehabilitation; women who prepared for and recovered from childbirth in dirty rooms with little more than substandard prison rations, water and soap; and women who were isolated and punished because of attempts to self-harm or commit suicide. “One girl used the edge of a seafood shell on her wrists,” recounted an inmate in the Philippines. “They scolded her. If you want to die, go ahead, do it now!”

These responses are of course unlikely to be particular only to these countries.

International standards (including the Bangkok Rules) now recognize that because women commonly face certain risk factors and backgrounds, they require a gender-specific framework for healthcare. More women than men suffer from particular diseases, including HIV, hepatitis and some cancers. They have differing sexual and reproductive health (SRH) needs, including those relating for example, to birth, abortion and the menopause. They are more susceptible to particular mental health problems. Studies have found self-harm in prison to be up to ten times higher among women than among men, and suicide to also be proportionally higher. This list goes on.

Women (especially those in conflict with the law) are also, crucially, more likely to have been victims of sustained gender-based violence and sexual abuse. Yet prisons, which are increasingly taking in women, are rarely equipped to respond to these forms of trauma. As I was told quietly by one prison healthcare worker, gesturing to a courtyard of around 20 women. “Almost all the women here are mothers, and a lot have maltreatment and molestation in their histories. I can look around and count more than ten women who have been raped. Some have been prostituted by their families. Then drug use comes in and makes it a vicious cycle.”

These and other cultural factors lead to a different sense of shame, which can also work as a barrier to healthcare. For example inmates in Jordan, Zambia and the Philippines told me that they often avoided reporting urinary tract infections and SRH problems to male health staff. Yet some prisons for women don’t employ female doctors, and these issues remain unrecognized, and sometimes debilitating.

My research findings with DIGNITY (see our comparative study here) therefore stress the urgent need for every prison and place of detention to follow a framework for healthcare that is gender-responsive and trauma-informed – one that treats women’s specific health needs, and trains staff accordingly. In just a few facilities did we find gestures towards this.

But not all gender-sensitive health responses are medical. The traditional prison model – designed as a harsh criminal justice response to violent men – remains the basis for many institutions detaining groups that are neither violent, nor male. In the facilities where women told me of harsh disciplinary structures, negative relationships between staff and inmates, and their isolation from caring relationships, they tended to report very low morale, forms of depression, and other signs of serious struggle, such as self harm and hunger strike. This was markedly different in facilities (such the one described here in Albania) that connected the women with the outside community – particularly their children – and gave them tools to cope, learn, communicate and prepare for the future.

Meanwhile, exercise is known to be important to health and morale, and is a right of prisoners under international law (see the Mandela Rules). Yet only in one of five countries, the Philippines, were detained women encouraged and able to exercise every day. In the other countries, exercise and sports facilities of some kind were common only in prisons for men.

Many of our findings on health fell in line with those observed by the former UN Special Rapporteur on Violence Against Women in her 2013 report on women’s incarceration, and they indicated clear and harmful examples of discrimination. Yet in reviewing issues raised by UN treaty body reports, we found women’s health to largely be a gap: UN experts are not giving this area consideration.

The human rights of these women entitle them to better, and must be championed, internationally and in their own countries. As once said by Dostoevsky, society must be judged by the way that it treats its prisoners. Or rather, and as told to me by one mother and survivor of domestic violence, sentenced to life in a Zambian prison: “If you’ve offended, certain things you must accept. But I don’t deserve to pass through some of these things. I came to prison healthy. I’m not intending to leave sick.”

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Excerpt:

Egyptian HCV carriers will soon have cost-effective alternatives to interferon therapy. Credit: Cam McGrath/IPS.

By Cam McGrath
CAIRO, Apr 9 2014 (IPS)

Mohamed Ibrahim first learned he had hepatitis C when he tried to donate blood. Weeks later he received a letter from the blood clinic telling him he carried antibodies of the hepatitis C virus (HCV). He most likely acquired the disease from a blood transfusion he received during surgery when he was a child.

“I needed a lot of blood, and this was at a time before they screened it,” Ibrahim recalls.Even with new drugs showing promise in reversing cirrhosis, it may already be too late for late-stage HCV patients.

Now, at 24, Ibrahim is living with the blood-borne virus, knowing it is slowly eroding his liver. Unless treated, by the time he reaches his forties the disease will likely advance to cirrhosis or liver cancer.

While Ibrahim has been undergoing treatment since he first learned of his infection, the medication is costly and yet ineffective.

“Nothing has worked, and the side effects of the medicine are as bad as the disease,” he says. “I can’t work in [other places such as) Dubai or Saudi Arabia, because they require a clean blood test before issuing a work permit.”

Ibrahim is one of an estimated eight to 10 million Egyptians living with hepatitis C.

Egypt is said officially to have the highest prevalence of hepatitis C in the world, with 10 to 14 percent of its 85 million people infected, and about two million in dire need of treatment. HCV-related liver failure is one of the country’s leading causes of death, taking over 40,000 lives a year.

But Egyptians infected with HCV now have fresh hope in novel treatments.

The Egyptian government recently struck a deal with U.S. pharmaceutical firm Gilead Sciences to purchase its new hepatitis C pill Sovaldi at a fraction of its American price.

Under the agreement, Gilead will supply a 12-week regimen of Sovaldi to Egypt for 900 dollars, instead of the 84,000 dollars the medicine costs in the United States. Egypt’s health ministry is expected to make the drug available at specialised government clinics in the second half of 2014, once local drug registration procedures are completed.

Studies have shown that Sovaldi is up to 97 percent effective in curing HCV type-4, the most common strain of hepatitis C among Egyptians. The pill is seen as a significant improvement over the traditional HCV treatment in Egypt, which is a 48-week course of the anti-viral drug interferon taken in combination with ribavirin tablets.

The existing treatment costs up to 7,000 dollars using pegylated interferon supplied by multinational pharmaceutical firms Roche and Merck, and is only about 60 percent effective. Many patients also report severe side effects such as anaemia and chronic depression.

Interferon is available without a prescription at pharmacies in Egypt, but at 150 dollars per weekly injection, the 48-week regimen is well beyond the reach of most Egyptians. Reiferon Retard, a locally manufactured interferon, costs a third of that price, but critics claim it is less than 50 percent effective.

Since 2006, the Egyptian government has treated more than 250,000 HCV patients at specialised units affiliated to the National Committee for the Control of Viral Hepatitis, a government body formed to tackle the disease. Interferon injections are provided at reduced cost or free to uninsured Egyptians, but as many as half of the patients treated suffer a relapse within six months.

A 2010 study by the U.S.-based National Academy of Sciences estimates that more than 500,000 new cases of HCV infection occur in Egypt each year. Researchers attributed the spread of the disease to the high background prevalence of HCV in Egypt – about 20 times higher than the global average – and to poor medical hygiene practices, including the use of unsterilised medical equipment and unscreened blood.

Egypt’s government claims the figures are highly exaggerated, and that the high prevalence is the clinical outcome of infections decades earlier.

Many HCV carriers were infected during a national campaign in the 1960s and 1970s to stamp out the water-borne disease schistosomiasis, also known as bilharzia. Health authorities administered repeated injections of the bilharzia treatment to Egyptians in rural areas using unsterilised needles, inadvertently spreading hepatitis C among the population.

“Doctors at that time were unaware of HCV, which was only identified in 1987, and were using glass syringes instead of the plastic disposable syringes that is current practice,” explains Dr. Refaat Kamel, a surgeon and specialist in tropical diseases. “Once a needle got infected, the disease spread quickly.”

Kamel says a better understanding of the structure and reproductive mechanism of HCV has allowed scientists to devise more effective treatments.

Gilead’s Sovaldi received the approval of the U.S. Food and Drug Administration (FDA) in December 2013 after clinical trials demonstrated its effectiveness in curing HCV without significant adverse effects. The drug, one of a new line of direct-acting antiviral agents, combats the disease by targeting infected liver cells and inhibiting the enzymes that allow the virus to replicate.

The FDA has also approved Janssen Therapeutics’ Olysio, a direct-acting antiviral agent that is about 25 percent cheaper than Gilead’s pill. Pharmaceutical firms AbbVie, Bristol-Myers Squibb, Merck and others are all hustling to develop their own oral therapies.

Sovaldi’s effectiveness on HCV type-4 is proven only when used with interferon and ribavirin. Further testing will establish whether the drug can be taken without weekly interferon injections, or as a combined therapy with other direct-acting antiviral agents.

“Trials here of six months of Sovaldi without interferon but with ribavirin showed similar success rates, higher than 96 percent (cured),” says Dr. Mohamed Abdel Hamid, director of the government-run Viral Hepatitis Research Lab (VHRL). “The drug might also be effective taken for three months without interferon. We just don’t know yet.”

He says that apart from the reduced cost and greater efficacy of Sovaldi, oral medication could reduce the manifold problems associated with long-term intravenous interferon therapy.

“Obviously, over 48 weeks there is a lot more that can go wrong,” Abdel Hamid tells IPS. “Adherence is a problem as patients must visit the treatment centre at the same time every week to receive the injection. There are also problems keeping the interferon cold, and the medication has many side effects.”

But he cautions that even with new drugs showing promise in reversing cirrhosis, it may already be too late for late-stage HCV patients. With a limited healthcare budget, Egypt is expected to prioritise treatment for those in whom the disease has not yet manifested.