A/HRC/38/36 prisons as tuberculosis incubators, with as few as 18 per cent of prisons in high-burden tuberculosis countries having access to such tools. 74 91. Excessive hospitalization, in some cases in prison-like hospital conditions for multidrug-resistant (MDR) and extensively-drug resistant (XDR) tuberculosis, is also an issue of concern. Many countries default to isolation, particularly in the context of such drug-resistant strains of tuberculosis. This results in fear and mistrust in public-health systems and inadequately supports the realization of the right to health of people with tuberculosis. Prolonged isolation, used for lengthy treatment of such drug-resistant tuberculosis, has also shown to induce feelings of fear, anger, self-blame, depression and suicide; there have been similar findings among incarcerated individuals. 75 This is unsurprising, as persons with the disease perceive prolonged isolation as imprisonment. B. Community-based care and tuberculosis 92. WHO recognizes that community-based care can achieve results comparable to those of hospitalization and may result in decreased nosocomial spread of tuberculosis, and emphasizes that community-based care should always be considered before isolation. 76 Forced isolation is unethical and is not in conformity with the right to health. 93. Despite the evidence, and ethical and rights-based considerations, some criminal laws provide for confinement and punitive practices as part of national responses to tuberculosis. While these may be perceived as “public-health” measures to stem the spread of the disease, they entail significant human rights violations and further harm public health, undermining efforts to effectively address the disease. Rather than relying heavily on confinement, a rights-based approach calls for the development of well-resourced community health-care options, ensuring that persons with tuberculosis have adequate information, nutritional support and income and other support while undergoing treatment and/or if tuberculosis results in a loss of employment. While underresourced, small-scale, innovative, community-based treatment models have proven extremely effective, with high treatment completion and cure rates.77 94. Confinement as a response to tuberculosis increases stigmatization of people with the disease, driving those most at risk underground and away from health care. Confining people with tuberculosis not only puts them at risk by placing them in settings often characterized by inadequate access to treatment and support, but also fuels the spread of the disease within these settings. As a particularly stark example, incarceration has been utilized to isolate persons with tuberculosis, punishing them for not adhering to the treatment, even though violations of the right to health led to their non-adherence in the first place. Confinement inappropriately places the burden of tuberculosis treatment and care on the person, effectively isolating and criminalizing those who are sick instead of providing the health care and support needed to complete treatment. These practices must be brought to an end. VII. Conclusions and recommendations 95. Deprivation of liberty and confinement, when they are used as widespread forms of addressing various social, and often non-criminal, issues, create an environment that is detrimental to the enjoyment of the right to physical and mental 74 75 76 77 Banuru Muralidhara Prasad and others, “Status of tuberculosis services in Indian prisons”, International Journal of Infectious Diseases, vol. 56 (2017). Kingsley Lezor Bieh, Ralf Weigel and Helen Smith, “Hospitalized care for MDR-TB in Port Harcourt, Nigeria: a qualitative study”, BMC Infectious Diseases (2017). WHO, Guidelines on Ethics of Tuberculosis Prevention, Care and Control (2010), pp. 11–12. See, for example, WHO, Regional Office for Europe, Good Practices in Strengthening Health Systems for the Prevention and Care of Tuberculosis and Drug-resistant Tuberculosis (Copenhagen, 2016). Available from www.euro.who.int/__data/assets/pdf_file/0010/298198/Good-practicesstrengthening-HS-prevention-care-TBC-and-drug-resistant-TBC.pdf. 19