For months, Indonesian drugs convict Yohannes Ruli Karamoy watched his body wasting away, unaware that he had contracted tuberculosis.
“I would wake up at night, sweating and coughing non-stop,” 57-year-old Karamoy said as he waited to be examined by a doctor in a dimly lit clinic inside Jakarta’s fortress-like Cipinang prison.
“My chest felt heavy and I became very weak,” he said in a faint voice from behind a surgical mask.
The disease has left Karamoy frail and emaciated, weighing only 43 kilograms. His condition has improved since he began treatment in October, to the point where he can now walk two laps around the prison lawn.
Karamoy is far from alone in Indonesia in suffering from TB, a contagious bacterial infection that attacks the lungs.
The nation of 250 million people had the second-largest number of TB cases last year, at 10 per cent of the global total, behind only India, according to the World Health Organization.
An estimated 100,000 Indonesians in the general population die from TB each year, WHO statistics say, not including the many others who die after contracting HIV and TB.
Official figures show the rate of TB deaths in prisons is roughly the same, at around 40 per 100,000 people. In 2015, at least 70 inmates out of a prison population of about 180,000 died from the disease.
However, those fighting the spread of the infection in prisons believe these figures are significant underestimates.
“TB detection is low in prisons in the regions,” said Yulius Sumarli, a doctor at the Cipinang clinic. Many prisons do not have TB programmes in place at all, he said.
“It’s a challenge for prison authorities at the local level, given scant resources,” he said.
Severe overcrowding, a shortage of medical staff, and poor facilities are complicating government efforts to curb the disease.
Indonesia’s 477 prisons hold more than 181,000 inmates, even though they were designed for 118,000, according to the Justice Ministry.
Overcrowding is worse in prisons in major cities. The Cipinang prison in the capital, designed for 1,100 people, now has 3,300 inmates.
“That is why it is very important for us to detect as many cases as possible so they can be treated promptly and stop the disease from spreading further,” Sumarli said.
The government’s “war on drugs” has worsened overcrowding, with drug offenders like Karamoy accounting for about 80 per cent of inmates in many prisons, said Ummu Salamah, health chief at the country’s correctional department.
“We don’t agree that drug users should spend time in prisons, because this has put a lot of pressure on our resources,” Salamah said.
“The war on drugs sometimes contradicts rehabilitation policies,” she said.
Because many prisons lack isolation rooms, TB inmates often mix with healthy ones, said Yakub Gunawan, a programme manager at Red Institute, an organization which works with authorities to help inmates follow their TB and HIV/AIDS therapies.
“Imagine if in a 12-square-metre room with 20 people there’s one person with TB, how many people will get infected?” Gunawan said.
A TB person with active TB will stop infecting other people after two weeks of drug treatment, but many facilities in less-developed areas, mainly in eastern Indonesia, have no health staff at all.
“In remote places, we have agreements with local government health offices to send nurses and doctors from community clinics to prisons from time to time,” Salamah said.
On the Cipinang prison lawn, suspected TB cases arrive on a regular basis. Inmates wearing blue vests lined up in front of a table set up to register those who have TB symptoms.
“I’ve had a cough for about a week,” said 24-year-old Abladi, who is awaiting trial for drugs possession, his mouth covered with a white mask.
“Maybe it’s just the flu,” he said.
TB patient Karamoy said he would be released from prison in two months, after serving more than four years, but he has to finish his course of treatment.
“I want to be cured, so I’m making the best of my time here to get treatment because it’s free,” he said.