CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 5 avril 2011

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display:inline-block }     FIRST SECTION         CASE OF VASYUKOV v. RUSSIA   (Application no. 2974/05)                 JUDGMENT     STRASBOURG   5 April 2011     FINAL   15/09/2011     This judgment has become final under Article 44 § 2 (c) of the Convention. It may be subject to editorial revision. In the case of Vasyukov v. Russia , The European Court of Human Rights (First Section), sitting as a Chamber composed of:   Nina Vajić, President,   Anatoly Kovler,   Elisabeth Steiner,   Khanlar Hajiyev,   George Nicolaou,   Mirjana Lazarova Trajkovska,   Julia Laffranque, judges, and Søren Nielsen, Section Registrar, Having deliberated in private on 15 March 2011, Delivers the following judgment, which was adopted on that date: PROCEDURE 1.     The case originated in an application (no. 2974/05) against the Russian Federation lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Russian national, Mr Aleksandr Mikhaylovich Vasyukov (“the applicant”), on 28 December 2004. 2.     The applicant, who had been granted legal aid, was represented by Ms Y. Yefremova and Mr M. Rachkovskiy, lawyers practising in Moscow. The Russian Government (“the Government”) were represented by Mrs V.   Milinchuk, former Representative of the Russian Federation at the European Court of Human Rights, and subsequently by their Representative, Mr G. Matyushkin. 3.     The applicant alleged, in particular, that he had contracted tuberculosis and had been denied adequate medical assistance in detention. 4.     On 16 November 2007 the President of the First Section decided to give notice of the application to the Government. It was also decided to rule on the admissibility and merits of the application at the same time (Article 29 § 1). 5.     The Government objected to the joint examination of the admissibility and merits of the application. Having examined the Government’s objection, the Court dismissed it. THE FACTS I.     THE CIRCUMSTANCES OF THE CASE 6.     The applicant was born in 1973 and lives in the town of Oryol. A.     Criminal proceedings against the applicant 7.     On 14 February 1997 the applicant was arrested on suspicion of manslaughter. He was allegedly severely beaten up after police officers took him to a police station. 8.     On 31 October 1997 the Sovetskiy District Court of the Oryol Region found the applicant guilty of murder and sentenced him to twelve years’ imprisonment. The judgment was upheld on appeal and became final on 16   December 1997. Ten days later the applicant was sent to serve his sentence in correctional colony no. 2, Oryol Region. B.     The applicant’s state of health and the quality of the medical assistance afforded to him in detention 9 .     Relying on a copy of the applicant’s medical record and certificates issued in December 2007 by the acting head of temporary detention facility no. IZ-57/1 in Oryol (“facility no. 1”), the Government argued that on 25     February 1997, on admission to facility no. 1, the applicant had undergone   a chest fluorography examination, which revealed no signs of tuberculosis. The Government further submitted that every six months the applicant had been examined by medical specialists and had been subjected to chest fluorography examinations for the purpose of tuberculosis screening. The examinations revealed no presence of the illness. As follows from the list of X-ray examinations enclosed with the applicant’s medical record, between March 1997 and 30 October 2001 the applicant received seven fluorography examinations. The authorities had fully complied with the schedule of one exam every six months at the beginning of the applicant’s detention. However, almost a year passed between the chest fluorography examinations in 2000 and 2001. 10 .     On 29 October 1998 a tuberculosis specialist at correctional colony no. 2 made the following entry in the applicant’s medical record: “[The applicant] is assigned to the 4 th [group] of tuberculosis regular medical supervision as [he] has been in contact with inmate A. who suffers from tuberculosis... [The applicant is prescribed] izoniazid 0.6 [mg] once,... [multivitamins] [and] diet for two months.” The applicant’s medical history (record no. 3607/415) drawn up in the tuberculosis hospital of facility no. 1 identified the applicant’s detention with inmate A. in October 1998 as the cause of his tuberculosis. 11 .     According to the applicant, in September 2000 he had been detained for several days in a punishment cell with an inmate, Mr Ye., who was suffering from an active form of tuberculosis. Mr Ye. had been constantly coughing up blood. The applicant’s requests for a transfer to another cell received no response from the colony administration. Soon after release from the punishment cell the applicant had fallen ill. However, his numerous complaints to the colony medical division had been to no avail. Relying on a certificate issued by the Oryol Regional police department, the applicant further argued that in March 2001 Mr Ye. had died from tuberculosis. The Government averred that the applicant had never been detained with the late Mr Ye. However, he had been detained with a person bearing the same last name as Mr Ye. The applicant’s cellmate at the time had not been suffering from an active form of tuberculosis and therefore had not presented a danger to other detainees. 12.     On 30 October 2001 the applicant was once again subjected to a   fluorography examination, which detected tuberculosis changes in the form of dense foci and local fibrosis in his left lung. 13 .     According to the Government, on 15 November 2001 the applicant was transferred to the tuberculosis hospital in facility no. 1 for treatment. However, it appears from the applicant’s medical record and certificates issued by the acting head of facility no. 1 and the director of correctional colony no. 2, it was not until 7 December 2001 that the applicant was admitted to the facility’s tuberculosis hospital. Following a number of tests doctors diagnosed the applicant with “focal pulmonary tuberculosis, [type] 1A, [smear-negative results for] mycobacterium tuberculosis (“MBT”)”. Between 17 December 2001 and 14 February 2002 the applicant was subjected to an intensive chemotherapy regimen, comprising a number of drugs: isoniazid, rifampicin, ethambutol and tisamid. During the initial stage of the treatment the applicant adhered to a strict medication regime and received sixty doses of anti-bacteriological medicines. On 15   February 2002 the continuation phase of the therapy commenced, comprising treatment with 120 doses of isoniazid and rifampicin (“HR regimen”). The chemotherapy regimen was accompanied by pathogenetic and general health-improving therapy with a daily special dietary food ration. The intake of every dose was observed by the hospital staff. As follows from the applicant’s medical record, clinical blood and urine analyses, sputum monitoring, as well as regular chest radiography examinations, were conducted regularly during the applicant’s treatment in the hospital. 14.     On 26 June 2002 the applicant was discharged from the tuberculosis hospital with a final diagnosis of “focal tuberculosis of the left lung in the resolution phase” and recommendations to continue treatment with isoniazid and ethambutol (“HE regimen”) accompanied by a daily special dietary food ration. The doctors also indicated that the next X-ray examination should be carried out within three months and that clinical blood and urine analysis and sputum monitoring should be performed once in three months. 15.     Between 27 June and 25 October 2002 the applicant was detained in correctional colony no. 2. His medical record shows that on 28   June 2002 the colony doctor made a note that the applicant was to receive special dietary food. On 9 October 2002 the applicant was examined for the first time by a colony doctor, who once again confirmed that the applicant was suffering from focal tuberculosis of the left lung. The doctor authorised a chest X-ray exam and sputum testing. On 22   October 2002 the applicant was sent to Oryol town tuberculosis hospital to undergo prescribed examinations. 16.     On 31 October 2002, having studied the applicant’s medical records, including the results of an X-ray examination and the three sputum smear tests performed in October 2002, a medical panel comprising a number of medical specialists took into account the positive dynamic of the applicant’s treatment and issued the following diagnosis: “focal tuberculosis of the upper lobe of the left lung in the resolution and consolidation phase,... (fading of the tuberculosis process)”. On 18 November 2002 the applicant was transferred back to correctional colony no. 2 with a recommendation to continue outpatient treatment on a two-month HE regimen twice a year. 17 .     During his first medical examination in the colony on 13 January 2003 the applicant complained of fatigue and headache. A chest fluorography exam performed on 5 February 2003 revealed singular small residual patches in the upper lobe of the applicant’s left lung. In early March 2003 the applicant was prescribed prophylactic treatment with isoniazid and ethambutol. A subsequent chest fluorography exam, on 29   April 2003, showed numerous firm patches in the left lung. The colony tuberculosis specialist made an entry in the applicant’s medical record, noting no reason to amend his diagnosis. A subsequent X-ray exam, on 21 July 2003, led to the applicant being diagnosed with “local fibrosis in the upper lobe of the left lung [and] small firm patches”. A month later a colony tuberculosis specialist examined the applicant, recording the absence of complaints and authorising another course of prophylactic treatment on an HE regimen starting from 1 September 2003. Clinical blood and urine tests and a chest fluorography exam performed on completion of the treatment confirmed the diagnosis made on 21 July 2003. 18 .     In December 2003 colony medical staff developed a schedule showing future medical procedures and their frequency. In particular, the applicant was to undergo a fluorography examination once in three months and to be subjected to blood, urine and smear testing twice a year. The resumption of the prophylactic treatment on an HE regimen every six months was also recommended. That schedule was upheld on 27 February 2004 by a special tuberculosis medical panel which, having studied the applicant’s medical records, issued the following diagnosis: “clinical recovery from pulmonary tuberculosis accompanied by residual changes in the form of firm foci in the upper lobe of the left lung”. 19 .     In the beginning of March 2004 the applicant became extremely ill. A chest fluorography exam carried out on 23 March 2004 showed that he had a left-sided spontaneous pneumothorax. On 27 March 2004 the applicant was admitted to the tuberculosis hospital in facility no. 1 in Oryol. On the basis of another X-ray exam, which showed that the applicant had suffered a complete collapse of the left lung and in view of his complaints of severe chest pain and dyspnea (breathlessness) at rest, on 29   March 2004 he was transferred to the surgical department of the Oryol Regional Tuberculosis Hospital where he was immediately subjected to a chest tube drainage of the left pleural cavity. On 13 April 2004, after an X-ray confirmed the re-expansion of the left lung, the chest tube was removed and the applicant was discharged from the Regional Hospital to the tuberculosis hospital in facility no. 1. The discharge was effected with a recommendation that the applicant undergo an intensive two-month chemotherapy regimen with four drugs: isoniazid, rifampicin, pyrazinamide and ethambutol (“2 HRZE regimen”). The applicant remained in the facility tuberculosis hospital until 6 May 2004. A prescription certificate attached to the applicant’s medical record shows that he received four anti-bacteriological medicines between 14 April and 6 May 2004. 20.     On 19 May 2004 the applicant arrived in correctional colony no. 2. When he was admitted a colony doctor made the following entry in the applicant’s medical record: “arrived from [the tuberculosis hospital of facility no. 1] in Oryol with diagnosis of clinical recovery from pulmonary tuberculosis accompanied by residual changes in the form of firm foci in the upper lobe of the left lung. Prophylactic treatment [is to be carried out] twice a year for two months, [and] an X-ray examination [and] clinical blood and urine tests [are to be performed] twice a year. Diet food ration until 1 June 2005”. 21.     It appears from the applicant’s medical record that the schedule of X-ray examinations and clinical testing was fully complied with. However, in August 2004 the applicant lodged a complaint with the Prosecutor General’s office alleging inadequate medical assistance. The complaint was readdressed to the Oryol Regional Prosecutor. No response followed. 22 .     The applicant’s medical history contained a number of entries made by attending tuberculosis specialists, recording the applicant’s negative attitude towards the treatment. In particular, on 1 September 2004 the colony doctor reported the applicant’s refusal to take a two-month prophylactic course of anti-bacteriological drugs. In February 2005 the colony medical staff recorded the applicant’s refusals to submit to an X-ray examination and blood, urine and sputum tests. It was also noted that the applicant did not want to confirm his refusals in writing. Numerous further attempts in March and April 2005 by the colony medical staff to persuade the applicant to submit to medical procedures and to undergo prophylactic treatment were unsuccessful. On 28 June 2005 the applicant was summoned to the colony medical unit where, in the presence of the director of the correctional colony and representatives of the Moscow Human Rights Commission, it was once again explained to him that it was necessary to continue treatment and undergo medical examinations, and he was warned that a relapse was possible. The applicant wrote a statement that he was willing to submit to medical examinations and treatment, on condition that he was admitted to the tuberculosis hospital of facility no. 1 for examinations by independent medical specialists invited by his relatives. When two days later the applicant was made an offer to be sent to Livny Town Hospital he refused it. 23.     Early in August 2005 the applicant applied to Livny District Court seeking to be released on parole on health grounds. In particular, the applicant argued that his tuberculosis and the absence of effective treatment made him eligible for release. On 5 August 2005 the District Court stayed the proceedings so that a thorough medical examination of the applicant could be carried out. The examination was to be performed in the tuberculosis hospital in facility no. 1. 24.     Between 20 and 25 August 2005 the applicant underwent medical examinations, including an X-ray exam and clinical blood analysis, in the tuberculosis hospital in facility no. 1. He, refused however to submit to urine and sputum smear and culture testing and to undergo an electrocardiogram, citing “personal considerations”. Having observed no pathology, the hospital doctors confirmed the applicant’s previous diagnosis of clinical recovery from tuberculosis and declared that he was fit to continue serving his sentence in the correctional colony. 25.     On 9 February 2006 the District Court dismissed the applicant’s request for release, relying on the results of the applicant’s medical examination in August 2005 and finding that the applicant’s health did not preclude him from serving the sentence. The applicant did not appeal. 26 .     All entries made by attending doctors in the applicant’s medical history between 1 September 2005 and February 2007 recorded that he was refusing to undergo seasonal tuberculosis treatment and/or to submit to medical observations and testing. For instance, on 14 April 2006 the applicant was visited by a representative of the Medical Department of the Oryol Regional Service for Execution of Sentences. The visit was carried out in response to a complaint from the applicant’s mother about the authorities’ alleged failure to provide the applicant with effective medical assistance. The applicant firmly refused to talk to the representative and protested that he did not wish to have any such contact in the future. In May 2006 the head of the medical department of the correctional colony, assisted by a physician from the Human Rights Committee, examined the applicant. The latter complained of shortness of breath, fatigue, dizziness and excessive perspiration. An X-ray examination did not reveal any changes in the lungs. The applicant refused a request that he submit to additional clinical examinations. His refusals were attested to by written statements of at least two members of the colony medical staff. 27.     In August 2007 the director of correctional colony no. 2 lodged an application with the Livny District Court of the Oryol Region requesting that the applicant be compulsorily admitted to Special Medical Tuberculosis Establishment no. 3 in the Tula Region for an in-depth medical examination and prophylactic treatment for tuberculosis. The colony director argued that since August 2004 the applicant had on a number of occasions refused to submit to prophylactic and clinical examinations, which violated sanitary and anti-epidemic regulations. The applicant’s refusals made it impossible for the colony medical personnel to observe the dynamic development of the illness and to effectively control and treat it if necessary. The colony director insisted that the applicant’s behaviour presented a danger to a large number of detainees and colony staff members who were in contact with the applicant. 28.     The applicant and his representatives objected, arguing that the District Court lacked jurisdiction to authorise the applicant’s admission to a hospital against his will, as he did not suffer from the contagious form of tuberculosis. In any event, the applicant was ready to submit to medical observations if they were to be carried out by specialists from medical establishments other than those in correctional colony no. 2 or detention facility no. 1. He insisted that the medical assistance afforded to him in those two facilities had been inadequate and ineffective. 29.     On 14 August 2007 the District Court adjourned the proceedings, having authorised a forensic medical examination of the applicant by specialists from the Oryol Regional Forensic Medical Expert Bureau to determine the form of tuberculosis from which the applicant suffered. The District Court held, in so far as relevant, as follows: “By virtue of Article 10 § 2 of the Russian law “On Prevention of Dissemination of Tuberculosis in the Russian Federation” 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. By virtue of Article 18 § 3 of the Russian Penitentiary Code individuals sentenced to imprisonment who are suffering from contagious forms of tuberculosis shall be admitted for mandatory treatment by the detention facility administration following a decision by a medical panel. The case file materials do not contain any information on the form of tuberculosis from which [the applicant] is suffering... The colony representative also did not provide such information in court hearings. The court therefore considers that special knowledge in the field of medicine is required for the correct decision in the present case, and that it is necessary to perform a complex forensic medical examination to determine the state of [the applicant’s] health”. 30.     On 11 September 2007 the applicant was transferred to facility no. 1 to receive the expert examination. He was sent back to the correctional colony on 19 October 2007. On 25 September 2007 the Expert Bureau issued a report, noting that it was impossible to determine the form of tuberculosis from which the applicant was suffering because of the latter’s refusal to submit to medical examinations, and given the absence of any recent information in the applicant’s medical record describing the state of his health. On 20 December 2007 the Livny District Court, finding that in 2006 and 2007 the applicant had repeatedly refused to undergo medical examinations, testing and seasonal prophylactic treatment and that the possibility of a relapse could thus not be excluded, ordered the applicant’s placement in Special Medical Tuberculosis Establishment no. 3 in the Tula Region. That decision was upheld on appeal by the Oryol Regional Court on 13 February 2008. 31.     The applicant’s medical record shows that while detained in the correctional colony between 19 October and 28 December 2007 the applicant continued refusing to submit to medical examination, X-ray exams, clinical testing and seasonal prophylactic treatment. Each time, in response to the applicant’s refusal, colony staff members drew up reports recording the refusal and describing the applicant’s behaviour. 32.     The most recent medical certificate, dated 28 December 2007, issued in correctional colony no. 2 and submitted to the Court by the Government, reads as follows: “[The applicant’s skin and visible mucous membrane are clean. Normosthenic [athletic] type; satisfactory nutrition; the osteoarticular skeleton is without deformations; movements are entirely preserved. [The applicant] refused to submit to an objective examination (palpation, percussion, auscultation, anthropometric measuring). [He] has no complaints; the state of his health is satisfactory. At present [his] diagnosis is: clinical recovery from pulmonary tuberculosis, [Supervision Group Type] 3 until February 2007; the tuberculosis control was not cancelled as [he] is refusing to undergo medical examinations and treatment.” 33.     In the meantime, in 2007 the applicant lodged an action against the Russian Ministry of Justice, the Oryol Regional Service for Execution of Sentences and correctional colony no. 2, seeking, inter alia , compensation for damage caused to his health as a result of his having contracted tuberculosis in detention and inability to receive effective medical assistance. 34.     On 3 June 2008 the Livny District Court dismissed the applicant’s claim for damages, finding no evidence of fault in the authorities’ actions and no causal link between their actions and the damage caused to the applicant’s health as a result of his having contracted tuberculosis. While issuing the judgment, the District Court rejected as unreliable statements by a number of applicant’s former inmates, who had argued in open court that inmates suffering from contagious forms of tuberculosis had frequently been detained with healthy inmates in correctional colony no. 2 and that many of them had contracted tuberculosis during their detention in that facility. The District Court’s judgment became final on 17 September 2008 when the Oryol Regional Court upheld it on appeal. 35.     The applicant was released in 2009, having served his entire sentence. II.     RELEVANT DOMESTIC LAW Health care of detainees 1.   Federal Law of 18 June 2001 no. 77-FZ “On Prevention of Dissemination of Tuberculosis in the Russian Federation” Section 7. Organisation of anti-tuberculosis aid “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...” Section 8. Provision of anti-tuberculosis aid “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...” Section 9. Regular medical examinations “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.” Section 10. Mandatory examinations and treatment of persons suffering from tuberculosis “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.” Section 12. Rights of individuals.... suffering from tuberculosis “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...” Section 13. Obligations of individuals... suffering from tuberculosis “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].” Section 14. Social support for individuals... suffering from tuberculosis “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...” Regulation on Medical Assistance to Detainees 36.     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. 37.     Subsequent medical examinations of detainees are performed at least twice a year or at a detainee’s 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. 38.     Section III of the Regulation also sets out the procedure for cases of refusal by detainees to undergo medical examination or treatment. In each case of refusal, a corresponding entry should be made in the detainee’s medical record. A prison doctor should fully explain to the detainee the consequences of his refusal to undergo the medical procedure. 39.     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. 40.     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. Prophylactic and anti-relapse treatment of tuberculosis patients should be carried out 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. Anti-Tuberculosis Decree 41 .     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 “the 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 in respect of tuberculosis, in conformity with 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, etc. 42 .     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). III.     RELEVANT INTERNATIONAL REPORTS AND DOCUMENTS A.     General health care issues 1.     Recommendation Rec(2006)2 of the Committee of Ministers to   member states on the European Prison Rules, adopted on 11   January 2006 at the 952nd meeting of the Ministers’ Deputies (“the European Prison Rules”) 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.” 2.     3 rd General Report of the European Committee for the Prevention of Torture (“the CPT Report”) 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 3 rd 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 out-patient 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 appr