April 27, 2010

Background

The Prisons of Zambia                                                  

Despite international and national legal commitments to prisoner health, observers have noted in recent years that conditions in Zambia’s prisons are grossly inadequate.[2] Zambia’s prisons were built prior to 1964 to accommodate 5,500 prisoners.[3] In October 2009, they housed 15,300—nearly three times official capacity.[4] In 2005, when the total national prison population was 14,427, nearly 35 percent of those were remand prisoners awaiting trial (including 230 remanded juveniles).[5] Women constitute 2.6 percent of the total convicted prison population in Zambia.[6]

Zambia has a total of 86 prisons throughout the country, 53 of them standard prisons and 33 open air/farm prisons. One of these facilities is dedicated exclusively to juveniles, and one exclusively to women, though juveniles are incarcerated with the adult population at other facilities throughout the country, and women live in separate sections of additional facilities throughout the country.

Zambia’s Prison Population [7]

2005 Total Population: 14,427

Adult Convicts: 8,658

Adult Remandees: 4,938

Immigration Detainees: 294

Condemned Prisoners: 273

Remandee Juveniles: 230

Convicted Juveniles: 79

Mentally Ill Prisoners: 25

Source: Zambia Human Rights Commission, “Annual Report: 2005”

By law, the Zambia Prisons Service is established for the management and control of prisons and the prisoners they hold.[8] International law requires that penitentiary systems’ “essential aim” is prisoners’ “reformation and social rehabilitation,”[9] and Zambia’s system espouses the goals of both order and reform.[10]

Zambian law establishes minimum standards for medical care, and requires that the officer in charge of each prison maintain a properly secured hospital, clinic, or sick bay within the prison.[11] A serious gap exists between these legal requirements and practice, with little or no medical care available at most of Zambia’s 86 prisons. Only 15 of Zambia’s prisons include health clinics or sick bays, and many of these clinics have little capacity beyond distributing paracetemol.[12] In February 2010, the Zambia Prisons Service employed only 14 trained health staff—one physician, an administrative rather than a clinical role, one health environmental technician, nine nurses, and three clinical officers[13]—with 11 prospective staff still in training.[14] “The ratio is out of this world,” Dr. Chisela Chileshe, the physician in charge of the prison medical directorate, concluded, referring to the ratio of medical staff to the inmates under their care.[15]

While there are some Ministry of Health medical staff seconded to work in the prisons, they are often present there only a few days a week, and there is only one Ministry of Health physician who visits the prisons.[16]Coordination between prison health officials and Ministry of Health officials has been minimal. The National Health Strategic Plan 2006-2010, designed to lay out how to achieve national health priorities through goals for government, health workers, cooperating partners, and other key stakeholders, includes no mention of prisons.[17]

Donors have actively supported health initiatives in Zambia, though relatively little of this assistance has gone to government or NGO-based prison health initiatives thus far. For HIV/AIDS alone, in 2009 the United States contributed over US$262 million and the Global Fund contributed over $137 million to Zambia, with other major HIV/AIDS donors including the European Union, Sweden, Denmark, Norway, the Netherlands, and the United Kingdom.[18] In 2008, the National HIV/AIDS/STI/TB Council analyzed HIV/AIDS spending in Zambia. That assessment listed no amount for aid to prisoners in 2005 and $76,300 in 2006.[19] Some NGOs have received grants for prison-based health work—for example, in 2006 the Prisons Fellowship of Zambia in Lusaka and Ndola each received $10,506 as Global Fund Sub-Recipients,[20] the Go Centre/CHRESO Ministries, which provides HIV testing and treatment at several prisons, is funded by the US President’s Emergency Plan for AIDS Relief,[21] and USAID funds an HIV prevention, treatment, care and support (“SHARe”) program which operates in some prisons.[22] Funding problems for both Prisons Service and Ministry of Health services will be compounded by the fact that, as a result of a corruption scandal at the Ministry of Health, Global Fund funding to Zambia has been halted pending an audit.[23]

Funding to improve the prisons generally is inadequate.[24] In 2010, the Zambian national budget was over 16 trillion Zambian kwacha ($3,376,810,000), 14.5 percent of which was financed through partners.[25] The Zambia Prisons Service 2010 budget was 52 billion Zambian kwacha ($10,974,600).[26] The Prisons Service has never been funded by the Ministry of Finance to its requested amount.[27] NGOs note that every year, the Prisons Service is the least funded of the services under the Ministry of Home Affairs.[28]

Prison medical services particularly suffer from lack of funding. Despite a comprehensive strategic plan on HIV/AIDS/STI/TB, according to the Ministry of Home Affairs HIV/AIDS focal point person Gezepi Chakulunta, “we haven’t done much on the strategic plan because of lack of funding.”[29] Dr. Chileshe explained that plans to expand prison health services were likewise hampered by lack of funding. He has plans for a directorate which will include a head office and prison-based services, a physician in each of the country’s nine regions, a referral hospital for prisoners, and clinics in all the prisons, but funding for such a system remains uncertain.[30]

Prison-based medical care under the medical directorate (aside from seconded Ministry of Health employees and medications) comes out of the prison budget (under the Ministry of Home Affairs), rather than the Ministry of Health budget. In 2009, a budget for prison medical services did not exist.[31] For 2010, Dr. Chileshe  reported that “my budget will be 200 million kwacha [$42,210] per year ... about 16.6 million per month [$3,503] excluding salaries....I do not have enough to do all that we want.”[32] By contrast, to have a clinical officer and clinic at each of the 53 standard prisons (still leaving 33 open air prisons without a Prisons Service clinic), he said, would cost about 26 billion kwacha ($5,487,320).[33]

HIV and TB in Zambia and the Prison System

While HIV prevalence among Zambian adults is 15 percent,[34] available evidence suggests that HIV prevalence in Zambian prisons is significantly higher. A study conducted in 1998-99 in three Zambian prisons found a male HIV prevalence of 27 percent, and a prevalence of 33 percent among female inmates.[35] Based on these data, prevalence has until recently been routinely estimated at 27 percent of the overall prison population.[36] HIV/AIDS has had deadly consequences in the prison population, among officers and inmates: Between 1995 and 2000, an estimated 2,397 inmates and 263 prison staff died from AIDS-related illnesses.[37]

In the general population, in 2004, the Zambian government introduced free access to anti-retroviral therapy (ART) in the public health sector. In June 2005, the government declared the ART service package (including counseling, x-rays, and CD4 testing[38]) free of charge.[39] The Zambian National HIV/AIDS Policy includes prisoners and commits to providing HIV prevention information, voluntary counseling and testing upon admission to custody, and detection and treatment programs to prisoners.[40]

Since its commitment to free treatment in the public health sector, Zambia has been making progress in treating its HIV-positive population. Between 2004 and 2007, the number of people on ART jumped from 20,000 to 151,000, an increase from seven percent coverage of those requiring it to 46 percent.[41] The estimated percentage of women living with HIV who received ART to prevent mother-to-child transmission increased from 18 percent in 2004 to 47 percent in 2007.[42] However, Zambian HIV/AIDS NGO representatives report that access to ART in rural areas is significantly more limited than that in urban areas, and there is also a sizable difference between medical infrastructure and personnel availability between urban and rural areas.[43] Access or further expansion is uncertain with the suspension of Global Fund grants, pending corruption investigations.

Such a high HIV prevalence, coupled with poor prison conditions, raises a significant risk of tuberculosis (TB) infection. As well as being the most common opportunistic infection among people living with HIV in Africa, TB is pervasive in southern African prisons because of overcrowding, poor ventilation, and lack of prevention practices such as prompt identification and treatment of persons with active TB.[44]A 2000-2001 study in 13 Zambian prisons for pulmonary TB among inmates concluded that a high rate of pulmonary TB exists in Zambian prisons, speculating that true prevalence rates may approach 15-20 percent, with significant rates of drug resistance and multi-drug resistant TB[45] (MDR-TB).[46]Indeed, with mortality rates as high as 24 percent, tuberculosis is among the main causes of death in prisons in developing countries.[47]Worldwide, TB is the “leading infectious killer for people living with HIV”, responsible for an estimated 13 percent of AIDS deaths.[48]  

In the general population, Zambia bears a heavy burden of TB, with a prevalence of 387 cases of all forms of TB per 100,000 members of the population in 2007 and 115 TB-related deaths per 100,000 members of the population in that year.[49] In 2009, there were 50,000 cases of TB throughout the country.[50] MDR-TB comprised 1.8 percent of all new TB cases in 2007. Yet Zambia has also been making progress in treating TB in the general population: Between 2000 and 2006, the coverage of Directly Observed Treatment, Short-course (DOTS) expanded significantly.[51] For new sputum smear-positive cases, between 1999 and 2007, the treatment cure rate rose from 50 percent to 78 percent; the treatment success rate rose from 69 percent to 85 percent.[52] However, difficulties in screening, diagnosing and treating various forms of TB—particularly extra-pulmonary TB—continue to contribute to difficulties in establishing an effective response to the disease nationwide.[53]

In the prison population, suspected prevalence rates are very high, though reliable data do not exist.[54] The physician in charge of the prison medical directorate reported that TB is the leading cause of death in the prisons;[55] he acknowledged that “the prisons are a breeding ground for TB/HIV” and has recognized the impact of prison conditions on the spread of TB.[56] The Zambia Prisons Service has reported a case infection rate for TB of 5,285 cases per 100,000 inmates per year.[57]

At Mumbwa prison, a prison officer reported that with a prison population of 354, only four prisoners had been tested for TB in the previous year—and all four were found to be positive.[58] High HIV prevalence compounds the dangers posed by TB: As the HIV/AIDS coordinator at Lusaka Central prison aptly noted, “People with compromised immune systems are vulnerable to TB. Ventilation is very poor at the prison. People with HIV catch TB easily.”[59]

[2]In 2003, the Zambia Human Rights Commission reported that its “inspections revealed serious situations of congestion, filth, disease, inadequate food and poor water and sanitation facilities. Generally inmates lacked decent sleeping facilities and uniforms….Health and medical services were almost non-existent or poor in the majority of the prisons. The major diseases included tuberculosis, diarrhea and scabies….Inmates complained of torture, delayed justice, poor living conditions, inadequate food and poor medical attention.” Zambia Human Rights Commission, “Annual Report: 2003,” 2003, pp. 1 and 12. In 2005, the UN Committee on Economic, Social and Cultural Rights expressed concern about the “living conditions of prisoners and detainees, especially with regard to access to health-care facilities, adequate food and safe drinking water.” UN Committee on Economic, Social and Cultural Rights, “Consideration of Reports Submitted by States Parties under Articles 16 and 17 of the Covenant: Concluding Observations of the Committee on Economic, Social and Cultural Rights: Zambia,” Thirty-fourth session, 25 April-13 May 2006, E/C.12/1/Add.106, June 23, 2005, para. 28, http://www.unhchr.ch/tbs/doc.nsf/c12563e7005d936d4125611e00445ea9/04e80cf87aa13784c125700500465779/$FILE/G0542576.pdf (accessed February 22, 2010).

[3] US Department of State Bureau of Democracy, Human Rights, and Labor, “2009 Human Rights Report: Zambia,” March 11, 2010, http://www.state.gov/g/drl/rls/hrrpt/2009/af/135983.htm (accessed March 18, 2010).

[4]PRISCCA, ARASA, and Human Rights Watch telephone interview with Zambia Prisons Service headquarters, November 23, 2009.

[5]Zambia Human Rights Commission, “Annual Report: 2005,” 2005, http://www.hrc.org.zm/media/2005_annual_report.pdf (accessed March 1, 2010).

[6]Lisa Vetten, “The Imprisonment of Women in Africa,” in Jeremy Sarkin, ed., Human Rights in African Prisons, (Cape Town: HSRC Press, 2008), p. 136 (based on data provided by the International Centre for Prison Studies).

[7] While the prison population was significantly higher—15,300—in 2009, 2005 disaggregated statistics for the entire prison system by prisoner type were the most recent available.

[8]Prisons Act, Laws of Zambia, vol. 7, chapter 97, 1996, http://www.parliament.gov.zm/index.php?option=com_content&task=view&id=21&Itemid=49 (accessed February 22, 2010), sec. 8.

[9] International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 59, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, acceded to by Zambia on April 10, 1984, art. 10(3).

[10]Zambia Prisons Service, “HIV & AIDS/STI/TB Workplace Policy of the Zambia Prisons Service,” July 2006, p. 14.

[11]The Prisons Rules, Laws of Zambia, vol. 7, 1996, http://www.parliament.gov.zm/index.php?option=com_content&task=view&id=21&Itemid=49 (accessed February 22, 2010), sec. 24(1).

[12]In 2003, the Zambia Human Rights Commission reported that “[h]ealth and medical services were almost non-existent or extremely poor in the majority of the prisons. Prison clinics have either closed down due to lack of personnel, drugs and other basic essentials…or they exist without any personnel or essential drugs.” Zambia Human Rights Commission, “Annual Report 2003,” p. 15.

[13] In Zambia, clinical officers typically have three years of post-secondary school training and the capacity to prescribe medications. PRISCCA, ARASA and Human Rights Watch interview with Dr. Chisela Chileshe, director, Zambia Prisons Service Medical Directorate, Lusaka, February 6, 2010.

[14] Ibid.

[15] Ibid.

[16] Ibid.

[17] Republic of Zambia, Ministry of Health, “National Health Strategic Plan 2006-2010,” November 2005, http://www.who.int/nha/country/zmb/Zambia_NH_Strategic_plan,2006-2010%20.pdf (accessed March 2, 2010).

[18] World Bank, "Implementation, Completion and Results Report on a Grant in the Amount of SDR 33.7 million to the Republic of Zambia for the Zambia National Response to HIV/AIDS (Zanara) Project in Support of the Second Phase of the Multi-Country Aids Program for Africa," February 27, 2009, http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2009/04/01/000333038_20090401005842/Rendered/PDF/ICR9220ZM0P00310Disclosed0031301091.pdf (accessed March 1, 2010), pp. 67-68.

[19] Ministry of Health and National HIV/AIDS/STI/TB Council, "Zambia: National AIDS Spending Assessment for 2005 and 2006: Final Draft Technical Report," July 2008, http://data.unaids.org/pub/Report/2008/nasa_zambia_0506_20080721_en.pdf (accessed March 2, 2010), p. 82.

[20] Ibid., p. 112.

[21] PRISCCA, ARASA, and Human Rights Watch interview with Helmut Reutter, Go Centre/CHRESO Ministries, Lusaka, October 14, 2009.

[22] PRISCCA, ARASA, and Human Rights Watch interview with Simon Mutonyi, SHARe, October 16, 2009.

[23]PRISCCA, ARASA, and Human Rights Watch interview with Sharon Nyambe, national coordinator, HIV/AIDS in prison settings, UNODC, Lusaka, October 16, 2009.

[24]PRISCCA, ARASA, and Human Rights Watch interview with Robby Shabwanga, projects officer, Legal Resources Foundation, October 14, 2009. In 2010, a Ministry of Home Affairs official characterized funding as “nothing”. PRISCCA, ARASA and Human Rights Watch interview with Gezepi Chakulunta, HIV/AIDS focal point person, Ministry of Home Affairs, Lusaka, February 4, 2010.

[25] “2010 Budget Address by Dr. Situmbeko Musokotwane, MP, Honourable Minister of Finance and National Planning Delivered to the National Assembly on Friday 9th October, 2009,” http://www.mofnp.gov.zm/ (accessed March 18, 2010), p. 12.

[26] Email communication from Dr. Chisela Chileshe, director, Zambia Prisons Service Medical Directorate, March 15, 2010.

[27] PRISCCA, ARASA, and Human Rights Watch interview with Frederick Chilukutu, deputy commissioner of prisons, Zambia Prisons Service, October 12, 2009.

[28]PRISCCA, ARASA, and Human Rights Watch interview with Robby Shabwanga, projects officer, Legal Resources Foundation, October 14, 2009.

[29] PRISCCA, ARASA, and Human Rights Watch interview with Gezepi Chakulunta, HIV/AIDS focal point person, Ministry of Home Affairs, February 4, 2010.

[30]PRISCCA, ARASA, and Human Rights Watch telephone interview with Dr. Chisela Chileshe, director, Zambia Prisons Service Medical Directorate, Lusaka, October 13, 2009; PRISCCA, ARASA and Human Rights Watch interview with Dr. Chisela Chileshe, director, Zambia Prisons Service Medical Directorate, Lusaka, February 6, 2010.

[31] Email communication from Dr. Chisela Chileshe, director, Zambia Prisons Service Medical Directorate, March 15, 2010.

[32] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Chisela Chileshe, February 6, 2010.

[33] Ibid.

[34] World Health Organization, UNAIDS and UNICEF, “Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response: 2008 Update: Zambia,” October 2008, p. 4.

[35] Oscar O. Simooya et al., “‘Behind Walls’: A Study of HIV Risk Behaviors and Seroprevalence in Prisons in Zambia,” AIDS, vol. 15(13), 2001, pp. 1741-44.

[36] US Department of State Bureau of Democracy, Human Rights, and Labor, “2008 Human Rights Report: Zambia,” February 25, 2009, http://www.state.gov/g/drl/rls/hrrpt/2008/af/119031.htm (accessed March 2, 2010); US Department of State, “2009 Human Rights Report: Zambia.”

[37] Zambia Prisons Service, “Draft Operational Plan,” 2008, p. 9.

[38]The number of CD4 cells (T-helper lymphocytes with CD4 cell surface marker) used to assess immune status, susceptibility to opportunistic infections, and a patient’s need for ART; CD4 count is the most important lab result for untreated HIV patients. Joel E. Gallant and Christoper Hoffmann, Johns Hopkins Point-of-Care Information Technology, “HIV Guide: CD4 Cell Count,” March 18, 2009, http://www.hopkins-aids.edu/management/laboratory_testing/cd4_cell_count.html?contentInstanceId=8279 (accessed March 2, 2010). 

[39] World Health Organization, UNAIDS and UNICEF, “Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response: 2008 Update: Zambia.”

[40] Republic of Zambia, Ministry of Health, “National HIV/AIDS/STI/TB Policy,” January 2005, p. 34.

[41] World Health Organization, UNAIDS and UNICEF, “Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response: 2008 Update: Zambia,” pp. 12-13.

[42] Ibid., p. 16.

[43] PRISCCA, ARASA, and Human Rights Watch PRISCCA, ARASA, and Human Rights Watch interview with Felix Mwanza, national coordinator, Treatment Advocacy and Literacy Campaign, Lusaka, October 15, 2009.

[44]UNODC, UNAIDS and World Bank, “HIV and Prisons in Sub-Saharan Africa: Opportunities for Action,” p. 2.  E. Rutta et al., “Tuberculosis in a Prison Population in Mwanza, Tanzania (1994-1997),” The International Journal of Tuberculosis and Lung Disease, vol. 5(8), 2001, pp. 703-06.

[45] According to the World Health Organization, multi-drug resistant TB is “is a specific form of drug-resistant TB due to a bacillus resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.” Drug resistance “arises due to the improper use of antibiotics in chemotherapy of drug-susceptible TB patients. This improper use is a result of a number of actions, including administration of improper treatment regimens by health care workers and failure to ensure that patients complete the whole course of treatment. Essentially, drug-resistance arises in areas with poor TB control programmes.” World Health Organization, “Drug- and Multi-Drug Resistant Tuberculosis (MDR-TB)—Frequently Asked Questions,” undated, http://www.who.int/tb/challenges/mdr/faqs/en/index.html (accessed March 1, 2010).

[46]C. Habeenzu et al., “Tuberculosis and Multidrug Resistance in Zambian Prisons, 2000-2001,” TheInternational Journal of Tuberculosis and Lung Disease, vol. 11(11), 2007, pp. 1216-1220.

[47]R. Coninx et al., “Tuberculosis in Prisons,” The Lancet, vol. 346, November 1995, pp. 1238-39.  Studies have found a high rate of pulmonary tuberculosis in prisons, which suggests active transmission.  See, e.g., D.S. Nyangulu et al., “Tuberculosis in a Prison Population in Malawi,” The Lancet, vol. 350(9087), November 1997, pp. 1284-87. 

[48] UNAIDS, “Tuberculosis and HIV,” undated, http://www.unaids.org/en/PolicyAndPractice/HIVTreatment/Coinfection/TB/default.asp (accessed February 12, 2010).

[49] World Health Organization, “Zambia: TB Country Profile: Surveillance and Epidemiology,” 2007, http://apps.who.int/globalatlas/predefinedReports/TB/PDF_Files/zmb.pdf (accessed March 2, 2010).

[50] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Nathan Kapata, director of the national tuberculosis program, Ministry of Health, Lusaka, February 8, 2010.

[51] World Health Organization, “Zambia: TB Country Profile.”

[52] World Health Organization, “Treatment Outcomes, New Smear Positive Cases, 1995-2007,” 2009, http://www.who.int/tb/publications/global_report/2009/update/a-5_afr.pdf (accessed March 2, 2010), p. 8.

[53] PRISCCA, ARASA, and Human Rights Watch interview with Felix Mwanza, national coordinator, TALC, October 15, 2009.

[54] PRISCCA, ARASA, and Human Rights Watch interview with Dr. Helen Ayles, project coordinator, ZAMBART, Lusaka, February 9, 2010.

[55] PRISCCA, ARASA, and Human Rights Watch telephone interview with Chisela Chileshe, October 13, 2009.

[56] Chisela Chileshe, “The Role of a Prison Manager in TB/HIV/AIDS Prevention and Management,” powerpoint presentation, undated, presentation on file with Human Rights Watch.

[57] Zambia Prisons Service, “Draft Operational Plan,” 2008, p. 9.

[58] PRISCCA, ARASA, and Human Rights Watch interview with Sergeant Kabukabu, prison officer, Mumbwa Prison, October 5, 2009.

[59] PRISCCA, ARASA, and Human Rights interview with Annie Sabuni, HIV/AIDS coordinator, Lusaka Central Prison, October 3, 2009.