CASE OF GLADKIY v. RUSSIA
Remainder inadmissible;Violations of Art. 3 (substantive aspect);No violation of Art. 6-1;Non-pecuniary damage - award
Anatoly Kovler;Christos Rozakis;Elisabeth Steiner;George Nicolaou;Giorgio Malinverni;Khanlar Hajiyev
6. The applicant was born in 1966 and lived before his arrest in Kaliningrad, Kaliningrad Region. 7. On 13 December 1999 the applicant was arrested and two days later he was placed in detention facility no. IZ-39/1 in Kaliningrad. On his admission to the facility he received a fluorography examination which revealed no signs of tuberculosis. On 20 June 2000 the applicant underwent another fluorography test which also showed no symptoms of the illness. 8. On 16 January 2001 the applicant was once again subjected to a fluorography examination which detected tuberculosis changes in his left lung. On the basis of that examination the applicant was diagnosed with infiltrative tuberculosis (“TB”) of the upper lobe of the left lung and transferred to the pulmonary tuberculosis ward of the medical department of the detention facility, where he remained until 28 January 2002. 9. Despite the Court's request for them to produce the applicant's complete medical record, the Government only submitted medical documents drawn up after 28 January 2002. Relying on a certificate issued by the head of the medical department of the Kaliningrad Regional Department of Execution of Sentences, the Government argued that in facility no. IZ-39/1 the applicant had undergone an intensive course of anti-tuberculosis chemotherapy comprising two unidentified drugs. As follows from that certificate, in May 2001 a positive dynamic in the treatment of the illness was registered. However, on 5 August 2001 the applicant's state of health seriously deteriorated. A medical examination by a tuberculosis specialist on 16 August 2001 led to the applicant being diagnosed with acute viral respiratory infection. He was prescribed “symptomatic treatment”. A fluorography examination performed on 3 September 2001 revealed a negative dynamic of the tuberculosis process showing an increase in the number of disintegration cavities. The doctor's diagnosis was “infiltrative tuberculosis of the upper lobe of the left lung in the disintegration phase, [presence of mycobacterium tuberculosis (“MBT”)], progress of the tuberculosis process and 1-2 stage hypotrophy”. According to the same certificate, the regimen of anti-tuberculosis treatment received by the applicant was amended to take the deterioration of his health into account. The applicant was prescribed “infusion chemotherapy”, including a number of drugs (izoniazid, ethambutol, and rifampicin) and detoxication therapy. 10. An extract from the applicant's medical record drawn up on 26 June 2003 shows that the deterioration of the applicant's health in August 2001 was linked to “irregular medication”. 11. On 28 January 2002 the applicant was discharged from the medical department of the detention facility with a final diagnosis of infiltrative tuberculosis of the upper lobe of the left lung in the disintegration phase, and sent for subsequent treatment to tuberculosis hospital no. 5 in Kaliningrad. On the applicant's admission to the hospital the attending doctor made an entry in his medical record noting that the applicant was calm and collected, exhibiting strong determination to continue anti-tuberculosis treatment. The applicant did not make any complaints about the quality of the treatment provided to him in the tuberculosis hospital. 12. On 11 November 2002, following a series of examinations by a forensic medical commission, the applicant was assigned second degree disability status because of his tuberculosis. In July 2004 he underwent stabilising thoracoplasty followed by an intensive course of anti-tuberculosis chemotherapy. The applicant was recommended further surgery following his release from detention. 13. From 15 December 1999 to 28 January 2002 the applicant was detained in facility no. IZ-39/1. According to the applicant, that detention facility was built in 1929 and no renovation work has been done on the cells since. 14. According to certificates issued on 12 July 2007 by the director of the facility and produced by the Government, the applicant was kept in nine different cells which measured 7.8, 16.7, 17.4, 18.4 and 21 square metres. The smaller cells had two sleeping places, the three larger cells were equipped with four bunks and the largest cell had five sleeping places. The Government submitted that the information on the exact number of inmates detained together with the applicant was not available. They further noted that at all times the applicant had had an individual bunk and bedding. 15. Relying on the information provided by the director of the facility, the Government further argued that the sanitary conditions in the cells were satisfactory. In particular, the Government submitted that the cells received natural light and ventilation through a window measuring 1.2 square metres. The cells had no artificial ventilation. Each cell was equipped with a lavatory pan, a sink, a tap with running water, wooden benches and a table. Inmates were allowed to take a shower once every seven to ten days for no less than fifteen minutes. Clean bedding was also provided once a week. The cells were disinfected. Inmates were afforded an hour of outdoor recreation per day in twelve-square-metre yards equipped with wooden benches and covered by a shed roof against rain and snow. The Government, relying on the information provided by the director of the facility, further stated that the applicant was given food “in accordance with the established norms”. 16. The applicant did not dispute the cell measurements. However, relying on submissions by his former fellow inmates whose complaints about the conditions of detention in facility no. IZ-39/1 had already been examined by the Court (see, among other authorities, Artyomov v. Russia, no. 14146/02, §§ 123-133, 27 May 2010, and Shilbergs v. Russia, no. 20075/03, §§ 89-99, 17 December 2009), he alleged that the cell which measured 21 square metres had had eight sleeping places and had usually housed 24 inmates. The smallest cells, which measured 7.8 square metres, had either four or six sleeping places and accommodated from 8 to 12 detainees. The remaining three cells were equipped with eight sleeping places and housed 16 inmates. Given the lack of beds, inmates had slept in shifts. They were not provided with bedding. 17. The applicant further submitted that the sanitary conditions had been appalling. The cells were infested with insects but the management did not provide any insecticide. The walls in the cells were covered with a thick layer of mould. Pieces of plaster were falling from the walls. The applicant submitted that the windows were covered with metal blinds which blocked access to natural light and air. It was not before 25 November 2002, that is long after his transfer to another detention facility, that the metal blinds were removed in compliance with the recommendations of the Russian Ministry of Justice. It was impossible to take a shower as inmates were given only fifteen minutes and two to three men had to use one shower head at the same time. That situation was further aggravated by the fact that inmates could only take a shower once every two weeks. Inmates had to wash and dry their laundry indoors, creating excessive humidity in the cells. They were also allowed to smoke in the cells. The toilet was a filthy hole in the floor, separated from the living area by a small partition, and spread an unpleasant odour in the cell. At no time did inmates have complete privacy. Anything they happened to be doing – using the toilet, sleeping – was in view of the guard or fellow inmates. No toiletries were provided. The food was of poor quality and in scarce supply. 18. The applicant complained to various Russian authorities, including the Kaliningrad Regional Ombudsman, about the poor conditions of his detention. On 28 June 2001 the applicant received a letter from the Ombudsman which, in so far as relevant, read as follows: “An inspection, performed by the Kaliningrad Regional Ombudsman on 25 April 2001 in the detention facility established that [each inmate] has less than one square metre of personal space while the required norm is 4 square metres for each detainee, thus the constitutional rights of detained individuals are being violated. Other violations of sanitary norms and [norms] related to medical assistance were discovered and the Ombudsman recommended the head of detention facility no. IZ39/1 to eliminate [those violations].” 19. On 12 July 2001 the applicant lodged an action against detention facility no. IZ-39/1 and the Ministry of Finance seeking compensation for damage caused to his health because he had contracted tuberculosis in detention, had been denied access to adequate medical services and had been detained in appalling conditions for almost two years after his arrest. 20. On 19 November 2001 the Tsentralniy District Court of Kaliningrad dismissed the action, reasoning that as the applicant had been medically examined on his admission to facility no. IZ-39/1, had remained under constant medical supervision and had shared cells with healthy inmates, there was no evidence of fault on the part of the facility administration for the damage caused to his health. In addressing the applicant's complaint about the poor conditions of his detention and a possible link between the detention conditions and his having been infected with tuberculosis, the District Court found as follows: “[The applicant's] arguments that sanitary requirements were not complied with in the detention facility are unsubstantiated, as the representative of the detention facility refuted those arguments ... despite the fact that the facility premises need reconstruction, all sanitary measures are taken in the facility; tuberculosis patients take showers separately from healthy inmates, then the premises are disinfected. There are separate premises for outdoor walks for tuberculosis patients. Those premises are also disinfected. It was established in the course of the hearing that [the applicant] had not had tuberculosis before or been registered as a tuberculosis patient, and that his tuberculosis had been detected for the first time in the detention facility. However, that circumstance cannot serve as a ground for upholding the plaintiff's claims, because the cause of the illness was not established and the prison authorities were not at fault; furthermore, there was no action/inaction on the part of the prison administration which could have created the conditions for the development of the plaintiff's illness. The overcrowding in the cells of the detention facility is an objective circumstance which was not caused by the facility administration and, moreover, the court did not establish a direct causal link between the overcrowding in the cells where [the applicant] was detained and his illness.” The applicant participated in the hearings before the District Court. 21. The applicant appealed, and sought leave to attend the appeal hearing. 22. On 27 February 2002, in the absence of the applicant, who had not been notified of the hearing, the Kaliningrad Regional Court upheld the judgment of 19 November 2001. The Regional Court concluded that the fact that the applicant had contracted tuberculosis in the detention facility “could not serve as evidence of the defendant's fault in having caused the illness” because the cause of the tuberculosis had not been and could not be established. 23. On 22 April 2002 the President of the Kaliningrad Regional Court lodged an application for supervisory review of the judgment of 27 February 2002, arguing as follows: “In violation of the requirements of Article 299 of the RSFSR Code of Civil Procedure the [Regional] Court examined the case upon [the applicant's] action although there was no evidence that the plaintiff had been notified of the date and place of the court hearing. [The applicant] is in detention and was not brought to the court, however, he has the right to submit his arguments, [or] participate in the proceedings through his representative ... and, thus, he has to be promptly notified of the day of the examination of the case.” 24. On 16 May 2002 the Presidium of the Kaliningrad Regional Court accepted the application for supervisory review, quashed the judgment of 27 February 2002, having endorsed the arguments of the Regional Court President, and sent the case for fresh examination by the appeal court. 25. In March 2002 the applicant lodged an additional statement of appeal, informing the Regional Court that he had appointed two lawyers to represent him during the appeal proceedings. He also noted that in the event of the lawyers' failure to appear, the Regional Court should issue the judgment in their absence. No request for leave for the applicant to appear before the Regional Court was filed. 26. By a letter of 27 May 2002 the Regional Court informed the applicant's lawyers and the applicant that a hearing had been scheduled for 19 June 2002. 27. On 19 June 2002 the Kaliningrad Regional Court, having examined the case on the basis of the parties' written submissions as the applicant's representatives and the respondent party failed to appear, upheld the judgment of 19 November 2001. The Regional Court confirmed the District Court's findings that the applicant had been healthy before his placement in custody, and that tuberculosis had only been detected more than a year after his admission to the detention facility. It further endorsed the District Court's conclusion that it was impossible to establish the cause of the illness and that there was no fault on the part of the facility administration in the deterioration of the applicant's health. Without providing any details, the Regional Court further stressed that the applicant had been subjected to regular medical check-ups during his detention and that he had received the necessary medical assistance. It also noted that the fact that the cells in the detention facility had housed 1.5 times more detainees than they had been designed to accommodate could not be the cause of the applicant's illness. 28. The applicant was served with a copy of the judgment on 16 August 2002. “1. Provision of anti-tuberculosis aid to individuals suffering from tuberculosis is guaranteed by the State and is performed on the basis of the principles of legality, compliance with the rights of the individual and citizen, [and] general accessibility in the amount determined by the Programme of State guarantees for provision of medical assistance to citizens of the Russian Federation, free of charge. 2. Anti-tuberculosis aid shall be provided to citizens when they voluntarily apply [for such aid] or when they consent [to such aid], save for cases indicated in Sections 9 and 10 of the present Federal law and other federal laws ...” “1. Individuals suffering from tuberculosis who are in need of anti-tuberculosis aid shall receive such aid in medical anti-tuberculosis facilities licensed to provide [it]. 2. Individuals who are or have been in contact with an individual suffering from tuberculosis shall undergo an examination for the detection of tuberculosis in compliance with the laws of the Russian Federation...” 1. Regular medical examinations of persons suffering from tuberculosis shall be performed in compliance with the procedure laid down by a competent federal executive body ... 2. Regular medical examinations of persons suffering from tuberculosis shall be performed irrespective of the patients' or their representatives' consent. 3. A medical commission appointed by the head of a medical anti-tuberculosis facility ... shall take decisions authorising regular medical examinations or terminating them and record such decisions in medical documents ...; an individual in respect of whom such a decision has been issued, shall be informed in writing about the decision taken.” “2. Individuals suffering from contagious forms of tuberculosis who... intentionally avoid medical examinations aimed at detecting tuberculosis, or avoid treating it, shall be admitted, by court decision, to specialised medical anti-tuberculosis establishments for mandatory examinations and treatment.” “2. Individuals admitted to medical anti-tuberculosis facilities for examinations and (or) treatment, shall have a right to: receive information from the administration of the medical anti-tuberculosis facilities on the progress of treatment, examinations... have meetings with lawyers and clergy in private; take part in religious ceremonies, if they do not have a damaging impact on the state of their health; continue their education... 3. Individuals ... suffering from tuberculosis shall have other rights provided for by the laws of the Russian Federation on health care ...” “Individuals ... suffering from tuberculosis shall; submit to medical procedures authorised by medical personnel; comply with the internal regulations of medical anti-tuberculosis facilities when they stay at those facilities; comply with sanitary and hygiene conditions established for public places when persons not suffering from tuberculosis [visit them].” “4. Individuals... suffering from tuberculosis shall be provided with medication free of charge for out-patient treatment of tuberculosis by federal specialised medical facilities in compliance with the procedure established by the Government of the Russian Federation...” 29. Russian law gives detailed guidelines for the provision of medical assistance to detained individuals. These guidelines, found in joint Decree no. 640/190 of the Ministry of Health and Social Development and the Ministry of Justice, on Organisation of Medical Assistance to Individuals Serving Sentences or Detained (“the Regulation”), enacted on 17 October 2005, are applicable to all detainees without exception. In particular, section III of the Regulation sets out the procedure for initial steps to be taken by medical personnel of a detention facility on admission of a detainee. On arrival at a temporary detention facility all detainees must be subjected to preliminary medical examination before they are placed in cells shared by other inmates. The examination is performed with the aim of identifying individuals suffering from contagious diseases or in need of urgent medical assistance. Particular attention must be paid to individuals suffering from contagious conditions. No later than three days after the detainee's arrival at the detention facility, he should receive an in-depth medical examination, including fluorography. During the in-depth examination a prison doctor should record the detainee's complaints, study his medical and personal history, record injuries if present, and recent tattoos, and schedule additional medical procedures if necessary. A prison doctor should also authorise laboratory analyses to identify sexually transmitted diseases, HIV, tuberculosis and other illnesses. 30. Subsequent medical examinations of detainees are performed at least twice a year or at detainees' request. If a detainee's state of health has deteriorated, medical examinations and assistance should be provided by medical personnel of the detention facility. In such cases a medical examination should include a general medical check-up and additional methods of testing, if necessary, with the participation of particular medical specialists. The results of the examinations should be recorded in the detainee's medical history. The detainee should be fully informed of the results of the medical examinations. 31. Section III of the Regulation also sets the procedure for cases of refusals by detainees to undergo medical examination or treatment. In each case of refusal, a corresponding entry should be made in the detainees' medical record. A prison doctor should fully explain to the detainee the consequences of his refusal to undergo the medical procedure. 32. Detainees take prescribed medicines in the presence of a doctor. In a limited number of cases the head of the medical department of the detention facility may authorise his medical personnel to hand over a daily dose of medicines to the detainee for unobserved intake. 33. Section X of the Regulation regulates medical examinations, monitoring and treatment of detainees suffering from tuberculosis. It lays down a detailed account of medical procedures to be employed, establishes their frequency, and regulates courses of treatment for new tuberculosis patients and previously treated ones (relapsing or defaulting detainees). In particular, it provides that when a detainee exhibits signs of a relapse of tuberculosis, he or she should immediately be removed to designated premises (infectious unit of the medical department of the facility) and should be sent for treatment to an anti-tuberculosis establishment. The prophylactic and anti-relapse treatment of tuberculosis patients should be performed by a tuberculosis specialist. Rigorous checking of the intake of anti-tuberculosis drugs by the detainee should be put in place. Each dose should be recorded in the detainee's medical history. A refusal to take anti-tuberculosis medicine should also be noted in the medical record. A discussion of the negative effects of the refusal should follow. Detainees suffering from tuberculosis should also be put on a special dietary ration. 34. On 21 March 2003 the Ministry of Health adopted Decree no. 109 on Improvement of Anti-Tuberculosis Measures in the Russian Federation (“the Anti-Tuberculosis Decree” or “Decree”). Having acknowledged a difficult epidemic situation in the Russian Federation in connection with a drastic increase in the number of individuals suffering from tuberculosis, particularly among children and detainees, and a substantial rise in the number of tuberculosis-related deaths, the Decree laid down guidelines and recommendations for country-wide prevention, detection and therapy of tuberculosis which conform to international standards, identifying forms and types of tuberculosis and categories of patients suffering from them, establishing types of necessary medical examinations, analyses and testing to be performed in each case and giving extremely detailed instructions on their performance and assessment; it also laid down rules on vaccination, determined courses and regimens of therapy for particular categories of patients, and so on. 35. In particular, Addendum 6 to the Decree contains an Instruction on chemotherapy for tuberculosis patients. The aims of treatment, essential anti-tuberculosis drugs and their dose combinations, as well as standard regimens of chemotherapy laid down by the Instruction for Russian tuberculosis patients conformed to those recommended by the World Health Organisation in Treatment of Tuberculosis: Guidelines for National Programs (see below). 36. Section 22 of the Detention of Suspects Act (Federal Law no. 103FZ of 15 July 1995) provides that detainees should be given free food sufficient to maintain them in good health according to standards established by the Government of the Russian Federation. Section 23 provides that detainees should be kept in conditions which satisfy health and hygiene requirements. They should be provided with an individual sleeping place and given bedding, tableware and toiletries. Each inmate should have no less than four square metres of personal space in his or her cell. 37. In 2002, following the inspection in 2001 of penitentiary facilities in the Kaliningrad Region, the Regional Ombudsman published his report which, in so far as relevant, read as follows: “One of the most acute problems continues to be the problem of medical and sanitary assistance [provided to] detainees. The medical [and] sanitary assistance provided in the prison system does not ensure the preservation and improvement of [detainees'] health, and the financial resources available are insufficient to meet the detainees' needs in terms of medical and sanitary assistance. In fact, penitentiary institutions and temporary detention facilities are frequently left without any financial resources to purchase medical equipment or medicines, in serious violation of the right to health and medical assistance guaranteed by the Constitution of the Russian Federation. A particular concern is the contraction of tuberculosis in those institutions ... In 2001 [the Kaliningrad Regional Department of the Russian Ministry of Justice] received 849 complaints (including 32 collective complaints) from detainees, 382 of which concerned medical assistance ... According to information supplied by [the Kaliningrad Regional Department of the Russian Ministry of Justice], 1,386 persons are detained in [facility no. IZ-39/1] ... The Kaliningrad Regional Ombudsman received 75 complaints from persons detained in facility no. IZ-39/1 ... In 2001 the Ombudsman visited the detention facility. During the visit the Ombudsman identified the following violations: overpopulation [of the facility] (more than three instances); shortage of bedding; absence of radio in certain cells; complete absence of TV sets or refrigerators; limitation of the time for outside walks ...; insufficient medical assistance. ... [Facility no. IZ-39/1] was built before the war; it requires complete reconstruction. During the last seven years the detention facility has always been overpopulated, housing three times more inmates than it should; management are therefore unable to comply with the minimum space requirement per inmate. While the rule is 4 square metres of living space per inmate, inmates in the detention facility have less than one square metre each. Persons whose guilt [in having committed crimes] has not yet been established by a court are detained in conditions which diminish their human dignity and frequently cause harm to their health.” 38. Article 1064 § 1 of the Civil Code of the Russian Federation provides that damage caused to the person or property of a citizen shall be compensated in full by the tortfeasor. Pursuant to Article 1069, State agencies and State officials are liable for damage caused to an individual by their unlawful actions or failure to act. Such damage is to be compensated at the expense of the federal or regional treasury. Articles 151 and 1099-1101 of the Civil Code provide for compensation for non-pecuniary damage. Article 1099 states, in particular, that non-pecuniary damage shall be compensated irrespective of any award for pecuniary damage. 39. The Code of Civil Procedure of the Russian Federation provides that individuals may appear before a court in person or act through a representative (Article 48 § 1). The court may appoint an advocate to represent a defendant whose place of residence is not known (Article 50). The Advocates Act (Law no. 63-FZ of 31 May 2002) provides that free legal assistance may be provided to indigent plaintiffs in civil disputes concerning alimony or pension payments or claims concerning damage to health (section 26 § 1). 40. The Penitentiary Code provides that convicted persons may be transferred from a correctional colony to an investigative unit if their participation is required as witnesses, victims or suspects in connection with certain investigative measures (Article 77 § 1). The Code does not mention any possibility for a convicted person to take part in civil proceedings, whether as a plaintiff or a defendant. 41. On several occasions the Constitutional Court has examined complaints by convicted persons whose requests for leave to appear in civil proceedings were refused by the courts. It has consistently declared the complaints inadmissible, finding that the impugned provisions of the Code of Civil Procedure and the Penitentiary Code did not, as such, restrict the convicted person's access to court. It has emphasised, nonetheless, that the convicted person should be able to make submissions to the civil court, either through a representative or in any other way provided for by law. If necessary, the hearing may be held at the location where the convicted person is serving his or her sentence, or the court hearing the case may instruct the court with territorial jurisdiction over the correctional colony to obtain the applicant's submissions or carry out any other procedural steps (decisions no. 478-O of 16 October 2003, no. 335-O of 14 October 2004 and no. 94-O of 21 February 2008). 42. By virtue of Articles 58 and 184 of the Code of Civil Procedure, a court may hold a session outside the courthouse if, for instance, it is necessary to examine evidence which cannot be brought to the courthouse. 43. The European Prison Rules provide a framework of guiding principles for health services. The relevant extracts from the Rules read as follows: “Health care 39. Prison authorities shall safeguard the health of all prisoners in their care. Organisation of prison health care 40.1 Medical services in prison shall be organised in close relation with the general health administration of the community or nation. 40.2 Health policy in prisons shall be integrated into, and compatible with, national health policy. 40.3 Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation. 40.4 Medical services in prison shall seek to detect and treat physical or mental illnesses or defects from which prisoners may suffer. 40.5 All necessary medical, surgical and psychiatric services including those available in the community shall be provided to the prisoner for that purpose. Medical and health care personnel 41.1 Every prison shall have the services of at least one qualified general medical practitioner. 41.2 Arrangements shall be made to ensure at all times that a qualified medical practitioner is available without delay in cases of urgency. ... 41.4 Every prison shall have personnel suitably trained in health care. Duties of the medical practitioner 42.1 The medical practitioner or a qualified nurse reporting to such a medical practitioner shall see every prisoner as soon as possible after admission, and shall examine them unless this is obviously unnecessary. ... 42.3 When examining a prisoner the medical practitioner or a qualified nurse reporting to such a medical practitioner shall pay particular attention to: ...; b. diagnosing physical or mental illness and taking all measures necessary for its treatment and for the continuation of existing medical treatment; ... f. isolating prisoners suspected of infectious or contagious conditions for the period of infection and providing them with proper treatment; ... 43.1 The medical practitioner shall have the care of the physical and mental health of the prisoners and shall see, under the conditions and with a frequency consistent with health care standards in the community, all sick prisoners, all who report illness or injury and any prisoner to whom attention is specially directed. ... Health care provision 46.1 Sick prisoners who require specialist treatment shall be transferred to specialised institutions or to civil hospitals when such treatment is not available in prison. 46.2 Where a prison service has its own hospital facilities, they shall be adequately staffed and equipped to provide the prisoners referred to them with appropriate care and treatment.” 44. The complexity and importance of health care services in detention facilities was discussed by the European Committee for the Prevention of Torture in its 3rd General Report (CPT/Inf (93) 12 - Publication Date: 4 June 1993). The following are the extracts from the Report: “33. When entering prison, all prisoners should without delay be seen by a member of the establishment's health care service. In its reports to date the CPT has recommended that every newly arrived prisoner be properly interviewed and, if necessary, physically examined by a medical doctor as soon as possible after his admission. It should be added that in some countries, medical screening on arrival is carried out by a fully qualified nurse, who reports to a doctor. This latter approach could be considered as a more efficient use of available resources. It is also desirable that a leaflet or booklet be handed to prisoners on their arrival, informing them of the existence and operation of the health care service and reminding them of basic measures of hygiene. 34. While in custody, prisoners should be able to have access to a doctor at any time, irrespective of their detention regime... The health care service should be so organised as to enable requests to consult a doctor to be met without undue delay ... 35. A prison's health care service should at least be able to provide regular outpatient consultations and emergency treatment (of course, in addition there may often be a hospital-type unit with beds)... Further, prison doctors should be able to call upon the services of specialists. As regards emergency treatment, a doctor should always be on call. Further, someone competent to provide first aid should always be present on prison premises, preferably someone with a recognised nursing qualification. Out-patient treatment should be supervised, as appropriate, by health care staff; in many cases it is not sufficient for the provision of follow-up care to depend upon the initiative being taken by the prisoner. 36. The direct support of a fully-equipped hospital service should be available, in either a civil or prison hospital... 38. A prison health care service should be able to provide medical treatment and nursing care, as well as appropriate diets, physiotherapy, rehabilitation or any other necessary special facility, in conditions comparable to those enjoyed by patients in the outside community. Provision in terms of medical, nursing and technical staff, as well as premises, installations and equipment, should be geared accordingly. There should be appropriate supervision of the pharmacy and of the distribution of medicines. Further, the preparation of medicines should always be entrusted to qualified staff (pharmacist/nurse, etc.). ... 39. A medical file should be compiled for each patient, containing diagnostic information as well as an ongoing record of the patient's evolution and of any special examinations he has undergone. In the event of a transfer, the file should be forwarded to the doctors in the receiving establishment. Further, daily registers should be kept by health care teams, in which particular incidents relating to the patients should be mentioned. Such registers are useful in that they provide an overall view of the health care situation in the prison, at the same time as highlighting specific problems which may arise. 40. The smooth operation of a health care service presupposes that doctors and nursing staff are able to meet regularly and to form a working team under the authority of a senior doctor in charge of the service. ... ... 54. A prison health care service should ensure that information about transmittable diseases (in particular hepatitis, AIDS, tuberculosis, dermatological infections) is regularly circulated, both to prisoners and to prison staff. Where appropriate, medical control of those with whom a particular prisoner has regular contact (fellow prisoners, prison staff, frequent visitors) should be carried out.” 45. A further elaboration of European expectations towards health care in prisons is found in the appendix to Recommendation no. R (98) 7 of the Committee of Ministers to Member States on the ethical and organisational aspects of health care in prison (adopted on 8 April 1998 at the 627th meeting of the Ministers' Deputies). Primarily restating the European Prison Rules and CPT standards, the Recommendation went beyond reiteration of the principles in some aspects to include more specific discussion of the management of certain common problems including transmissible diseases. In particular, in respect of cases of tuberculosis, the Committee of Ministers stressed that all necessary measures should be applied to prevent the propagation of this infection, in accordance with relevant legislation in this area. Therapeutic intervention should be of a standard equal to that outside prison. The medical services of the local chest physician should be requested in order to obtain the long-term advice that is required for this condition, as is practised in the community, in accordance with relevant legislation (Section 41). 46. The fact that transmissible diseases in European prisons have become an issue of considerable concern prompted a recommendation of the Committee of Ministers to Member States concerning prison and criminological aspects of the control of transmissible diseases and related health problems in prison (adopted on 18 October 1993 at the 500th meeting of the Ministers' Deputies). The relevant extracts from the Recommendation read as follows: “2. The systematic medical examination carried out on entry into prison should include measures to detect intercurrent diseases, including treatable infectious diseases, in particular tuberculosis. The examination also gives the opportunity to provide health education and to give prisoners a greater sense of responsibility for their own health .... 15. Adequate financial and human resources should be made available within the prison health system to meet not only the problems of transmissible diseases and HIV/Aids but also all health problems affecting prisoners.” 47. An expanded coverage of the issue related to transmissible diseases in detention facilities was given by the European Committee for the Prevention of Torture in its 11th General Report (CPT/INF (2001) 16 published on 3 September 2001), a discussion prompted by findings of serious inadequacies in health provision and poor material conditions of detention which were exacerbating the transmission of the diseases. Addressing the issue, the CPT reported as follows: “31. The spread of transmissible diseases and, in particular, of tuberculosis, hepatitis and HIV/AIDS has become a major public health concern in a number of European countries. Although affecting the population at large, these diseases have emerged as a dramatic problem in certain prison systems. In this connection the CPT has, on a number of occasions, been obliged to express serious concerns about the inadequacy of the measures taken to tackle this problem. Further, material conditions under which prisoners are held have often been found to be such that they can only favour the spread of these diseases. The CPT is aware that in periods of economic difficulties - such as those encountered today in many countries visited by the CPT - sacrifices have to be made, including in penitentiary establishments. However, regardless of the difficulties faced at any given time, the act of depriving a person of his liberty always entails a duty of care which calls for effective methods of prevention, screening, and treatment. Compliance with this duty by public authorities is all the more important when it is a question of care required to treat life-threatening diseases. The use of up-to date methods for screening, the regular supply of medication and related materials, the availability of staff ensuring that prisoners take the prescribed medicines in the right doses and at the right intervals, and the provision when appropriate of special diets, constitute essential elements of an effective strategy to combat the above-mentioned diseases and to provide appropriate care to the prisoners concerned. Similarly, material conditions in accommodation for prisoners with transmissible diseases must be conducive to the improvement of their health; in addition to natural light and good ventilation, there must be satisfactory hygiene as well as an absence of overcrowding. Further, the prisoners concerned should not be segregated from the rest of the prison population unless this is strictly necessary on medical or other grounds ... In order to dispel misconceptions on these matters, it is incumbent on national authorities to ensure that there is a full educational programme about transmissible diseases for both prisoners and prison staff. Such a programme should address methods of transmission and means of protection as well as the application of adequate preventive measures. It must also be stressed that appropriate information and counselling should be provided before and - in the case of a positive result - after any screening test. Further, it is axiomatic that patient-related information should be protected by medical confidentiality. As a matter of principle, any interventions in this area should be based on the informed consent of the persons concerned. Moreover, for control of the above-mentioned diseases to be effective, all the ministries and agencies working in this field in a given country must ensure that they co-ordinate their efforts in the best possible way. In this respect the CPT wishes to stress that the continuation of treatment after release from prison must be guaranteed.” 48. The CPT report on the visit to the Russian Federation carried out from 2 to 17 December 2001 (CPT/INF (2003) 30) provides as follows: “102. The CPT is also seriously concerned by the practice of transferring back from SIZO [temporary detention facility] to IVS [temporary detention ward in police departments] facilities prisoners diagnosed to have BK+ tuberculosis (and hence highly contagious), as well as by the interruption of TB treatment while at the IVS. An interruption of the treatment also appeared to occur during transfers between penitentiary establishments. In the interest of combating the spread of tuberculosis within the law-enforcement and penitentiary system and in society in general, the CPT recommends that immediate measures be taken to put an end to the above-mentioned practice.” 49. On 23 December 2009 the World Bank published the Implementation Completion and Results Report (Report no. ICR00001281, Volume I) on a loan granted to the Russian Federation for its Tuberculosis and Aids Control Project. The relevant part of the Report read as follows: “According to the World Health Organization (WHO), Russia was one of the 22 high-burden countries for TB in the world (WHO, Global Tuberculosis control: Surveillance, Planning, Financing, Geneva, 2002). The incidence of TB increased throughout the 1990s. This was due to a combination of factors, including: (i) increased poverty, (ii) under-funding of TB services and health services in general, (iii) diagnostic and therapeutic approaches that were designed for a centralized command-and-control TB system, but were unable to cope with the social mobility and relative freedom of the post-Soviet era, and (iv) technical inadequacies and outdated equipment. Migration of populations from ex-Soviet republics with high TB burdens also increased the problem. Prevalence rates were many times higher in the prison system than in the general population. Treatment included lengthy hospitalizations, variations among clinicians and patients in the therapeutic regimen, and frequent recourse to surgery. A shrinking health budget resulted in an erratic supply of anti-TB drugs and laboratory supplies, reduced quality control in TB dispensaries and laboratories, and inadequate treatment. The social conditions favouring the spread of TB, combined with inadequate systems for diagnosis, treatment, and surveillance, as well as increased drug resistance, produced a serious public health problem. TB control in the former Union of Soviet Socialist Republics (USSR) and in most of Russia in the 1990s was heavily centralized, with separate hospitals (TB dispensaries), TB sanatoriums, TB research institutes and TB specialists. The system was designed in the 1920s to address the challenges of the TB epidemic. Case detection relied strongly on active mass screening by X-ray (fluorography). Specificity, sensitivity, and cost-effectiveness considerations were not features of this approach. Bacille Calmette-Guerin (BCG) immunization was a key feature of the TB control system... By 2000, there was more than a two-fold increase in TB incidence, and mortality from TB increased 3 times, compared with 1990. The lowered treatment effectiveness of the recent years resulted in an increase in the number of TB chronic patients, creating a permanent 'breeding ground' for the infection. At that moment, the share of pulmonary TB cases confirmed by bacterioscopy did not exceed 25%, and the share of such cases confirmed by culture testing was no more than 41% due to suboptimal effectiveness of laboratory diagnosis, which led to poor detection of smear-positive TB cases. Being a social disease, TB affected the most socially and economically marginalized populations in Russia.” 50. The following are the extracts from Treatment of Tuberculosis: Guidelines for National Programmes, World Health Organisation, 1997, pp. 27, 33 and 41: “Treatment regimens have an initial (intensive) phase lasting 2 months and a continuation phase usually lasting 4-6 months. During the initial phase, consisting usually of 4 drugs, there is rapid killing of tubercle bacilli. Infectious patients become non-infectious within about 2 weeks. Symptoms improve. The vast majority of patients with sputum smear-positive TB become smear-negative within 2 months. In the continuation phase fewer drugs are necessary but for a longer time. The sterilizing effect of the drugs eliminates remaining bacilli and prevents subsequent relapse. In patients with smear positive pulmonary TB, there is a risk of selecting resistant bacilli, since these patients harbour and excrete a large number of bacilli. Short-course chemotherapy regimens consisting of 4 drugs during the initial phase, and 2 drugs during the continuation phase, reduce this risk of selecting resistant bacilli. These regimens are practically as effective in patients with initially resistant organisms as in those with sensitive organisms. In patients with smear negative pulmonary or extra-pulmonary TB there is little risk of selecting resistant bacilli since these patients harbour fewer bacilli in their lesions. Short-course chemotherapy regimens with three drugs during the initial phase, and two drugs in the continuation phase, are of proven efficacy... Patients with sputum smear-positive pulmonary TB should be monitored by sputum smear examination. This is the only group of TB patients for whom bacteriological monitoring is possible. It is unnecessary and wasteful of resources to monitor the patient by chest radiography. For patients with sputum smear-negative pulmonary TB and extra-pulmonary TB, clinical monitoring is the usual way of assessing response to treatment. Under programme conditions in high TB incidence countries, routine monitoring by sputum culture is not feasible or recommended. Where facilities are available, culture surveys can be useful as part of quality control of diagnosis by smear microscopy... Directly observed treatment is one element of the DOTS strategy, i.e. the WHO recommended policy package for TB control. Direct observation of treatment means that a supervisor watches the patient swallowing the tablets. This ensures that a TB patient takes the right drugs, in the right doses, at the right intervals ... Many patients receiving self-administered treatment will not adhere to treatment. It is impossible to predict who will or will not comply, therefore directly observed treatment is necessary at least in the initial phase to ensure adherence. If a TB patient misses one attendance to receive treatment, it is necessary to find that patient and continue treatment.”