Reference : V-P-AZ-E-00361
Date : 18/02/2010
Country/Region : AZERBAIJAN
Caption : Baku, rundown treatment facility for TB patients, including ex-detainees. These two men met in the prison hospital and have remained close friends since being released. Both continue to need treatment for multi-drug resistant TB.
Photographer : AHAD, Zalmaï
Confidentiality level : public
Publication restrictions : publication without restrictions
Copyright : ICRC
Description : Azerbaijan: preventing tuberculosis from becoming a death sentence for criminals

In Azerbaijan, a jail term for a petty crime can turn into a death sentence if a prisoner catches tuberculosis from fellow detainees. The ICRC's Anna Nelson and renowned Afghan/Swiss photographer, Zalmaï, went behind bars in Baku to discover what's being done to help tuberculosis-infected inmates.

On the outskirts of Azerbaijan's capital, Baku, not far from the city's rich petroleum fields, the authorities are racing against time to stop a silent killer.

For the past 15 years, the country's prison officials have been working to stem the spread of tuberculosis (TB)- a deadly disease that infects roughly 9.5 million people worldwide each year. Globally, around 4,500 people die from it on a daily basis - that's about one person every 20 seconds.

"A man can kill another man with his bare hands… but he can kill hundreds of people with TB," says Nahmat Rahmanov, the lead physician at Baku's Special Treatment Institution (STI), which houses around 1,000 infected inmates from across Azerbaijan's penal colonies.

Rahmanov isn't exaggerating. Drug-resistant forms of the airborne illness are spreading at an alarming rate across the globe. To catch any form of the disease - drug resistant or not - all you have to do is breathe in the presence of someone who is actively infected with it. Contrary to what a lot of people might think, childhood vaccines don't protect adults against TB.

Rampant disease

At first glance, STI looks much like any other prison - high walls topped by curls of barbed wire, armed guards in watchtowers and heavy iron gates separate the thieves, swindlers, drug dealers, murderers and other assorted criminals from the outside world. But once inside, the facility feels distinctly more like a hospital than a jail.

The years following the collapse of the Soviet Union saw a sharp increase in the spread of infectious diseases. When the ICRC started visiting Azerbaijan's prisons in 1995, delegates discovered that TB was the main cause of death among inmates.

Since then, the authorities and the ICRC have slowly but surely managed to drastically reduce the number of TB cases in detention centres by improving screening, prevention, treatment and follow-up.

"In 1999, we had 285 prisoners die from TB. By 2009, we managed to get the number of deaths down to 20," says STI Director, Nizami Guliyev, an austere-looking man, who is visibly very proud of his sprawling facility.

He shows off the elaborate ventilation system that has been put in place to provide a maximum of fresh air in the cells and communal sleeping areas - typically a breeding ground for TB. Posters on the wall explain through drawings that the disease thrives in dark, confined spaces. In a new wing, modern surgical equipment will soon be installed, while the prison already boasts an on-site diagnostics laboratory and pharmacy.

Human dignity

Talking to the inmates - from the petty criminals to those serving life sentences -
one thing becomes clear: beyond the tablets, x-rays and white coats, what really makes a difference to their recovery is the fact that they are treated with dignity and consideration.

Over the years, the wardens have learned that a healthy environment can have a big impact on a patient's adherence to treatment and its outcome.

"The main goal of the Ministry of Justice is to cure these patients and we do everything we can to provide them with treatment and good living conditions so they can go back to society healthy and not infect others. We want them to become citizens who can contribute to society," explains one prison guard.

At STI, the cells and communal rooms are bright and clean, relatives are allowed to bring food for their incarcerated loved ones and there is even a small library, where books are meticulously divvied up into sections for highly and less contagious readers. Telephone booths labeled as "positive" and "negative" indicate which phones infectious or non-infectious detainees can use to call home.

Life on the inside essentially revolves around TB and that suits prisoners like Salman and Ilham just fine. The pair shares a room on the severely contagious ward, which is walled off from other sections of the prison.

"I'm feeling much, much better. Here, we get everything we need. There is food, heating and decent bathrooms. I can take a shower whenever I want to. It's quiet and comfortable," says Salman.

Their days are spent playing backgammon, tending a small but flourishing collection of spider plants, watching TV, doing laundry and waiting in line to take their medicine under the watchful eye of a prison doctor.

Salman has been suffering from TB more than six years. He's already been treated twice for drug-sensitive TB and is now undergoing treatment for the multi-drug resistant kind, known as MDR-TB. The medication can have severe side effects, including liver failure and extreme nausea. Patients need to stay on it for around two years and it can take more than two months just to find the right combination of medicine for each individual.

"Each of us knows what the other is going through, which helps a lot. We keep each other going," says Salman of his roommate.

Dilapidated dacha

Not far from the well-appointed prison hospital, closer to the Caspian Sea, lies the former summer dacha of the Nobel brothers, who got rich off the country's oil derricks back in the 1870s.

Today, it is home to a radically different set of "brothers" - Iramal and Ilgar, who met as prisoners at the TB treatment centre and, like Salman and Ilham, have formed a close bond. They were transferred to the dilapidated dispensary after being released in 2009. It is the only care facility in the country that is willing to take ex-convicts.

"We make sure they get three meals a day and regular checks by the doctors. The medical staff ensures they don't skip their medicine," says the director of the facility, Ismayilov Habil. "Last month, three patients died. They had no family, so I used my own money to bury them in a nearby cemetery. My philosophy is that everyone deserves to be treated with compassion, so I do what I can."

The ICRC provides food and hygiene items for the former detainees and collects their blood and sputum samples for regular analysis. The organization also offers a modest financial incentive to the nurses, who are responsible for directly observing patients' treatment.

No doubt the Nobel brothers would scarcely recognize their country home if they were alive today. Hollow-cheeked patients sleep five or six to a room and there is little to do while waiting to get better but nap on metal cots and watch an endless stream of grainy images on the small black and white TV. Ilgar and Iramal may no longer be behind bars, but in many ways, they are still imprisoned by their disease.

Ilgar, a repeat narcotics offender, suspects he caught TB during his first stint in jail back in 2001. He recently completed another 18-month sentence for drug use and now has nowhere else to go.

"I am alone in this world and homeless," he says in a hushed, breathy voice. "I don't know what I would do if this place didn't exist. No one has ever come to see me but luckily, I have Iramal. We lived through some very hard days together in prison. We will never forget those days and we will remain friends all our lives."

Uncertain future

Unfortunately for Iramal, the future remains very uncertain. At 28, he's been on MDR-TB medication for more than two and a half years. He has tried a host of treatments and still there's a chance he won't live to see 30.

He was put behind bars for hooliganism and is now fighting off a virtual death sentence because of TB.

"I stopped drinking and doing drugs and I've started praying," says Iramal, whose striking, blue-green eyes match the peeling paint on the walls. "I haven't seen my family since I got out of prison because I don't want to risk infecting them. All I want is to get better and turn my life around."

He and Ilgar tuck their hands inside their sleeves as they step outside for a breath of air. The two "brothers" bend their arms across their chests and bow their heads against the bitter, salty wind.

No one can predict how their journey will end or whether they will live long enough to see their friendship last. For now, they are living, powerful reminders of the importance of stopping TB from destroying even more lives, both inside prisons and out.

Original material : digital
Resolution : 4000x2666
Orientation : landscape
Colour/B&W : black and white