Inside the Filipino jails struggling to contain an ancient killer
Locked inside a sparse cell at the end of an isolated corridor, 18 inmates share five hard bunks, one toilet stall and a grim diagnosis: tuberculosis.
The ancient disease is “endemic” in the Philippines’ overcrowded prisons, and these emaciated men are only the most recent victims.
“There were approximately 300 [others in my cell], and about 40 others were diagnosed at that time,” said Marco, another inmate at Quezon City Jail, northeast of the capital Manila.
The 35-year-old – who spoke on condition of anonymity and who’s name has been changed – contracted tuberculosis last October, before the facility moved to a new, more spacious yet still fairly bleak, facility in May.
“When I was first diagnosed I couldn’t accept it,” said Marcos, who has been behind bars for nine years, having been charged with robbery and firearms possession.
“I didn’t want to take the medications, it wasn’t until my body totally disintegrated that I took the drugs,” he told journalists, speaking quietly in an echoey meeting room. “Initially I was scared.”
Both his parents had previously contracted TB, a killer that remains rampant across the Philippines. Cases have been increasing across the vast archipelago since 2007 and, with 740,000 patients, the country has the fourth worst epidemic in the world.
The highly infectious bacteria has found an especially fertile breeding ground inside the country’s hot, congested prison network, where occupancy rates have soared to as high as 400 per cent since former president Rodrigo Duterte launched his controversial war on drugs.
In the first three months of this year, just over 39,000 new and relapsed TB cases were reported in penal institutions, according to figures the Department of Health’s Epidemiology Bureau shared with the Telegraph – up from roughly 32,500 over the same period in 2023.
“Our jail system is a petri dish for every infectious disease,” said Fides Lim, a spokeswoman for Kapatid, a group campaigning for political prisoners – including her husband Vincente Ladlad. The asthmatic 75-year-old, who has been in jail for six years while awaiting trial, was diagnosed with TB last April.
“The prison health system has been very, very poor, there is not sufficient medical care,” she told The Telegraph. “Really, anyone is lucky to make it out of jail with their health intact. It’s a death trap.”
Prisons and pathogens have long been closely linked. In the 1770s, prison reformer John Howard warned that more people in British jails were killed by typhus, then dubbed “gaol fever”, than by executions. A century later, a third of convicts sent to the Andaman Islands penal colony in the Indian Ocean died of dysentery and diarrhoea within 18 months, according to colonial jail records.
More recently, a 2019 investigation found almost half of people incarcerated in New Mexico had hepatitis C, while the ‘Kent variant’ of Covid-19 tore through a prison on the Isle of Sheppey in 2021 – infecting some 75 per cent of staff – and the World Health Organization is currently helping Nigeria stem a cholera outbreak at a Lagos prison.
Dr Leonardo Martinez, an assistant professor of epidemiology at Boston University, said infectious pathogens are “much more common in prisons” than outside, driven by factors including overcrowding, undernutrition and a lack of adequate healthcare.
But he added that these issues are “especially relevant” for TB. The highly contagious bacteria remains one of the world’s deadliest diseases, infecting 10.6 million people and killing 1.5m in 2022. On average, 2.5 patients die every minute.
Prisoners are on the frontline of this pandemic: according to a 2021 study published in the Lancet, rates among incarcerated individuals are, on average, ten times higher than in surrounding communities.
“If one person contracts TB in an overcrowded setting, it can spread like wildfire,” said Dr Martinez, a co-author of the report. “But these aren’t sporadic outbreaks, in many countries it’s endemic – there’s a sustained epidemic.
“Although the rates are much higher inside prisons than outside, often people are leaving prison with TB and spreading it to social networks,” he added. “In some settings, 20-30 per cent [of cases in the community] are directly related to someone who used to be in prison.”
Another Lancet paper last year, also co-authored by Dr Martinez, warned progress has stagnated globally, with transmission skyrocketing in regions with mounting mass incarceration, such as the Philippines. Only three countries – Brazil, Russia and China – have more infections in prisons, according to the paper.
“There’s only so much a TB control programme can do if the environment just gets more and more crowded,” said Dr Martinez. “But I think the real reason [rates stagnated] is that historically, and even now, this is an under-prioritised population. Most countries I work in don’t even have large-scale interventions to decrease incidence in prisons.”
Without these programmes, many sick inmates languish behind bars. According to the 2023 paper, only 53 per cent of incarcerated people with TB gain a diagnosis, giving the bacteria space to spread – and kill.
“This suggests there’s a lot of TB that’s not being screened, not being even looked for, if half of TB cases in prisons are undiagnosed,” said Dr Martinez. “There aren’t enough interventions in prisons, that’s really the primary reason we haven’t seen progress.”
At Quezon City Jail, where we met Marco, officials are insistent that TB is being dealt with properly.
The 4,000 inmates are only able to leave their cells for 30 minutes a day, but it’s a rare example of a Filipino prison which isn’t over capacity.
“The ability of this jail to identify TB is exceptional, as compared to other jails,” said Dr Henrick Fabro, chief medical officer for Capital Region Health Service, which covers 15 jails including Quezon City. “We have systems in place so it is very much under control.”
All inmates must have an x-ray before they enter the jail. If the images show signs of TB, or if a new arrival has symptoms, samples are taken and tested. The quiet lab on the first floor screens up to 20 samples each day. Where results are positive, inmates are immediately isolated and treated.
Yet gaps remain, as the 18 weary men in isolation demonstrate. When asked how many caught the bacteria while already behind bars, all raised their hands.
Now, they’re each taking TB drugs with notoriously nasty side effects without so much as a mattress or pillow.
Nutritious food isn’t exactly plentiful, either – the daily budget stretches to just 70 pesos (90 pence) per person per day – and there are sporadic water shortages. Poorly ventilated cells are also prone to overheat; humid outside temperatures often surge well above 30 degrees, while the heat index hit a punishing 53 earlier this year.
But one of the biggest constraints in identifying infections, said prison nurse Malcolm Daryl Tabuzo, is the lack of their own x-ray machine.
“New inmates have their x-rays at the police station, but we don’t always know how long they’ve been there – sometimes x-rays are months out of date,” he said. “We try to make sure everyone has an x-ray annually, but it’s a logistical challenge to organise at health centres.”
Which is why, in a scorching courtyard surrounded by forbidding prison trucks, a small team of nurses are working their way through a long list of handcuffed patients in yellow t-shirts emblazoned with the slogan “person deprived of liberty”.
“Inhale, exhale, inhale, then hold,” said Rosselle Anne Flora, as an inmate stands against an x-ray machine in the specially designed medical van. “And relax”, she added seconds later, before a black and white scan of the man’s lungs appeared on the computer screen. Soon, an AI tool confirms that – unlike two others this morning – there are no signs of TB.
This mobile van, operated by Philippine Business for Social Progress, travels across the country to offer healthcare to remote communities and incarcerated populations. It comes to Quezon City annually.
“Quezon City Jail has one of the better TB programmes,” said Dr Raymund Narag, an associate professor of criminology at Southern Illinois University in the US. “But it’s a mixed bag nationwide – and if even the best programmes still have active TB cases, you can imagine what it’s like in the worst.”
According to the Department for Health’s latest annual briefing, published in May for 2022, the TB infection rate still stands at 1,777 per 100,000 people in prisons, compared to 599 outside. Yet the agency conceded this is likely “an underestimation of the true prevalence of TB in jails/prisons due to gaps in reporting and notification”.
Dr Narag understands this threat better than most. When he was finally acquitted of false murder charges in 2002, having spent six years, nine months and four days in a cramped Filipino jail cell, he emerged with his freedom – plus TB.
Long recovered, he is now pushing the government to improve standards and reduce congestion across the board. Not everyone is willing to engage.
“It depends on the authorities, it’s a mixed bag,” he told the Telegraph. “Some people are very open to working with us, others have what we call bureaucratic inertia… I think the situation is better than it was in my time, but it is not very consistent.
“It’s a struggle for us because there’s a lack of facilities, a lack of health personnel, a lack of resources, a lack of medical equipment and so on,” Dr Narag added. “The budget is just very tight. There’s a lack of appreciation of the plight of people behind bars.”
Back in the first floor meeting room, Marcos – who finally tested negative for TB in April, after six months of a treatment that made him dizzy and turned his urine an unsettling deep brown – is dreaming about his future.
“It’s very simple,” he said, when asked what he would do first when he eventually leaves. “I just want to sleep in a soft bed.”
The Global Fund, which finances some TB projects in the Philippines, contributed to travel costs for this reporting trip.
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