Episode: "Cool Hand Luc"

LA MACA PRISON : IVORY COAST

Country Background

After gaining independence from France in 1960, Ivory Coast was a beacon of political and economic stability in West Africa for almost four decades, presided over for most of this period by President Felix Houphouet-Boigny. In 1999, a military coup led by Robert Guei toppled Henri Bedie, Houphouet-Boigny’s successor, and the nation began a steady decline into political volatility and aggressively nationalist sentiment.

A second military coup in September 2002 preceded several months of fierce conflict and the decimation of a relatively effective public health system, especially in rebel-held northern areas. Although a power-sharing agreement has been reached between the rival groups, the nation’s health facilities continue to suffer a lack of resources and trained personnel.

A Long, Hard Battle: Health Care and Advocacy for a Neglected Prison Population

La MACA (Maison d’Arrêt et de Correction d’Abidjan) is the largest prison in Ivory Coast – a horribly overcrowded government detention center in the coastal city of Abidjan. Historically, the Ivoirian government has placed a relatively low priority on administration and health care in the nation’s prisons, resulting in a captive population at La MACA subject to inhumane living conditions, poor sanitation, malnutrition, and the constant threat of an infectious disease outbreak.

In an effort to improve the situation on all of these fronts, MSF has run a project in La MACA since 1997, when local prison authorities invited MSF to intervene on behalf of the facility’s inmates.

MSF’s La MACA project is somewhat atypical. MSF maintains several other long-term projects in prisons, but often medical care focuses on a specific problem like infectious disease. In Siberia, for example, MSF was invited into the government prison to conduct a tuberculosis intervention. With a finite mandate and a firm understanding with the Russian government, MSF’s TB intervention in Siberia should act as a successful pilot project that will be handed over to the prison health authorities after a specified period.

At La MACA, MSF has taken a different role, in which tenacious advocacy has necessarily accompanied medical services. Since a prison official invited MSF into the facility to improve health care, MSF’s volunteer doctors and nurses have fought alongside local Ministry of Health personnel and prison administrators on behalf of the inmates, calling for more humane detention procedures, larger food rations, and medical resources from the national government.

It’s been a long, hard battle. In June 2001, MSF denounced the detention conditions in a juvenile observation unit in La MACA prison, submitting a report showing that 60% of the health problems experienced by the under-age detainees were due to excessive confinement. In response, the prison authorities ended constant cell confinement for minors and reduced the number of minors detained (down from an average of 150 to 60 in six months). MSF has also initiated a social work program to re-establish family links for some minors as a further way to reduce detention times.

For adult detainees, MSF maintains a nutritional program, which benefits some 300 people with no food resources other than the inadequate prison rations. In the hope of increasing the food supply for La MACA’s prisoners, MSF submitted a report on misappropriated food aid to the authorities in late 2001.

Project update

Since this episode was filmed in mid-2002, MSF’s project in La MACA has had to contend with waves of cholera and beri beri inside the prison and an influx of new prisoners. Beriberi, a vitamin deficiency disease resulting in cardiac and nervous system dysfunction, was detected among La MACA’s prisoners in December. By March of this year, MSF volunteers and Ivoirian medical personnel managed to contain the outbreak, treating 712 cases primarily with a vitamin-rich nutritional supplement.

Starting in September, 2002 fighting between rebelling military factions and the Ivoirian government has produced an enormous increase in the number of detainees at the already overcrowded prison. To make matters more difficult, the prison authorities have put a moratorium on paroles. Currently, the prison’s population hovers at close to 5,500, from under 5,000 when episode 2 was shot in the summer of 2002 (the prison was built to hold 1,500). Insecurity and chaos throughout the country have also hindered inmates’ families and friends from visiting the prison with much-needed food, money and supplies for the prisoners. As a result, malnutrition has increased and sanitation has decreased. In response, MSF has escalated water and sanitation logistics as well as nutritional aid and medical care in the correctional facility.

Read the diary of an MSF surgeon who worked during the conflict of 2002