Populations most at risk of TB infection are also often those who live in conditions of poverty, social inequality and marginalization. Key populations include those living in substandard housing, in conditions of poor sanitation, overcrowding and with poor nutrition. They include people in prisons and closed settings, miners, migrants, refugees and internally displaced persons. Their socioeconomic circumstances place them at greater risk of TB infection and hinders their ability to realize their health rights to voluntarily access TB prevention, treatment, care and support services without discrimination.
Miners in southern Africa are at exceptionally high risk of TB and other lung diseases due to working in confined, humid and poorly ventilated conditions and due to prolonged exposure to silica dust. Migrant mine workers in southern Africa are dependent upon their employment for survival and have limited power to negotiate their working conditions. They often have limited access to health care services in their working environment and in their home environments, where they return once they become too ill to continue to work.
Prisoners are at high risk of HIV and TB exposure and infection. In many countries of the world, prisoners are kept in settings that violate their human rights – prisons are often overcrowded, lack hygienic sanitation and provide poor nutrition and limited access to adequate HIV and TB health care services and harm reduction measures. Prison conditions may expose prisoners to violence and sexual abuse. Weak justice systems may result in awaiting-trial prisoners spending unnecessarily long periods of time in detention, exposing them to higher risks of infection. Criminal laws prohibiting same-sex sexual activity and correctional laws prohibiting sex in prisons are often raised as barriers to providing condoms in prisons; yet the failure to provide condoms in prisons places prisoners at further risk of HIV exposure.
Rights-based TB policies and activities may seek to, for example a) review and reform criminal and correctional laws and policies to allow for the provision of condoms and harm reduction programmes to prisoners; b) strengthen access to justice to provide for measures to reduce overcrowding in prisons; and c) train prisoners on their rights and how to enforce them.
Similarly with HIV, once affected by TB, patients and their families report stigma and discrimination. In some countries, unnecessarily punitive public health policies aimed at preventing TB transmission or managing patients with drug-resistant TB, infringe human rights even further. They isolate, hospitalize and even incarcerate TB patients for lengthy periods of time, forcing them to remain away from their homes, families and community support systems for purposes of prevention or treatment.
The Stop TB Partnership recognises that TB stigma exacerbates the medical, social and economic hardships of TB and is a cross-cutting barrier to accessing quality, affordable and timely TB care and support services. It has developed the TB Stigma Assessment tool to support countries to assess the extent to which TB stigma acts as a barrier to health care and to support the development of recommendations to address TB stigma.
Many TB policies unreasonably limit rights in ways which are inconsistent with achieving public health goals and contrary to international human rights law. For example, in the 2018 Risk, Rights & Health Supplementary Report, the GCHL noted the adverse impact of punitive approaches, where “people who use drugs often remain excluded from HIV, TB, and hepatitis treatments, or are subjected to coerced or confined TB treatment. Imprisoned patients are lost to follow up.”
In Kenya, a group of TB patients were arrested and detained in prison, under the Public Health Act, for failing to comply with their TB treatment. They were kept in overcrowded prison conditions that failed to support their treatment for TB and also placed other prisoners at risk of infection.
The High Court of Kenya determined that, while isolating a person with TB who fails to take treatment may be necessary in the interests of public health, it should be for purposes of treatment rather than punishment. Isolation should also comply with ethical and human rights principles set out in international law – for example, with adequate measures to promote treatment adherence, appropriate infection control and reasonable social support. The court held that the imprisonment of the patients was unconstitutional in the circumstances. It ordered the government to develop an appropriate policy on the involuntary confinement of persons with TB and other infectious diseases.
Daniel Ng’ etich v Attorney General, Petition No. 329, 2014
Video – Kelin Kenya: TB is not a crime
Some frameworks and initiatives to protect the rights of people living with TB are described below.
On 26 September 2018, Heads of State gathered in New York at the United Nations General Assembly first-ever High-Level Meeting on TB, to accelerate efforts to end TB, resulting in an ambitious Political Declaration on the Fight Against Tuberculosis to strengthen action and investments to end TB.
The Declaration consists of 53 commitments to end TB globally by 2030, which include human rights commitments and alignment with the targets set out in the Sustainable Development Goals.
Notably, the Declaration commits Member States to:
In 2018, the Global Commission on HIV and the Law emphasised the severe impact of TB on the lives of people with HIV and vice-versa. Globally, more than 13% of people with TB tested HIV-positive and TB is the leading cause of HIV-related deaths. The Commission’s report noted human rights issues that affected people with TB, including evidence of stigma, discrimination and punitive public health responses to people with TB, as well as the lack of investment in research and development of new diagnostics and tolerable treatments for TB.
The Commission made strong recommendations for Interventions to Strengthen Human Rights to protect and promote the rights of people with TB from discrimination and to increase access to diagnostics and treatment for TB.
In 2018, the Stop TB Partnership established a TB and human rights discussion group that meets virtually each month to unpack, explore, strategize and coordinate on key issues, challenges and opportunities for advancing a human rights-based response to TB. The specific aims are:
Human rights champions are encouraged to join the discussion group.
In 2016, a working group of experts convened by the Global Fund comprehensively defined programmatic responses to address human rights and gender-related barriers to TB services. The Tuberculosis, Gender and Human Rights Technical Brief, updated in 2020, specifically recommends, in addition to the 7 key programmes promoted for HIV: