CAPE TOWN, South Africa - After police arrested Dudley Lee in a night raid, the peddler of fake perfume landed in Pollsmoor Prison, surrounded by inmates who threatened to kill him - with their coughing.
Prisons world-wide are tuberculosis hotbeds, and Pollsmoor typifies the dangers reaching well beyond the razor wire and into society at large. Mr. Lee arrived in 1999 and stayed more than four years, awaiting trial on accusations of money laundering and trafficking counterfeit passports and dollars. Ultimately, he was acquitted.
But in the meantime, the prisoners around him coughed, sneezed, spit and sweated. In so doing, they infected Mr. Lee with tuberculosis, South Africa's biggest single killer.
"These guys were coughing like dogs, practically sitting on top of me," says Mr. Lee, 67 years old. "I was busy dying in there."
He believes he infected many other people. "How many?" he says. "God knows."
A boxer and Hells Angel in his younger days, Mr. Lee fought back. In 2004, after his acquittal, he sued the prison system for giving him TB.
After a long battle, he won his case in December - forcing South Africa this year to intensify its fight against a disease that has breached jail cells, defied international borders, and grown increasingly drug resistant.
Mr. Lee's account of survival offers a stark lesson in how prisons can become deadly incubators. He held a few cards in his favor: For one thing, Mr. Lee could read, unlike many prisoners, which helped him fully grasp the danger. He built relationships with prison doctors and nurses, whose counsel kept him alive. And, importantly, he says, he had enough money outside prison that he could bribe guards to help guarantee food, a steady medicine supply and slightly more space in his triple-bunk cell.
"You feel like you're going to croak," Mr. Lee says of his time with tuberculosis. "I paid them not to put people in there."
Others weren't so fortunate.
In its latest annual report, South Africa's prison watchdog, the Judicial Inspectorate for Correctional Services, attributed 110 out of 804 natural deaths to tuberculosis in the year starting April 2011. While the rate has subsided from a decade-earlier peak, the report warned that dense populations still undermine the fight against prison TB.
"Tuberculosis is highly treatable," it said. "However, it is extremely difficult to manage in situations of overcrowding."
Following Mr. Lee's legal victory, "We sat down to see what we needed to do to address the situation," says Delekile Klaas, who oversees Pollsmoor and other prisons for the Department of Correctional Services. "We take the threat quite seriously."
Two decades after the United Nations declared tuberculosis a global health emergency, the disease is taking on dangerous new forms.
In India, doctors in Mumbai are searching for treatments against new strains that are considered all but incurable. In China, 10% of tuberculosis patients have "multidrug-resistant," or MDR, strains, which defy treatment from the two most powerful drugs.
Shortages of some TB medications are worsening drug resistance because patients sometimes run out of drugs, allowing the disease to mutate and become resistant. In the U.S., cases of MDR tuberculosis are still rare, but rose to 127 in 2011 from 109 the year before, according to the Centers for Disease Control and Prevention.
Here in South Africa, unlike most other countries, tuberculosis has increased in the past 20 years, fueled by the HIV-AIDS epidemic. The nation now has the third-largest population of TB patients, after China and India, according to the latest World Health Organization figures, even though South Africa's total population of some 50 million is dwarfed by the two Asian giants.
South Africa also has one of the world's largest populations of TB patients who are multidrug-resistant.
Prisons have long bred and spread tuberculosis. The WHO estimates that globally one quarter of a country's tuberculosis burden may come from inside prisons.
Poor monitoring abets these epidemics. Drug-resistant strains develop when patients stop taking their drugs, allowing the disease to mutate, says Max O'Donnell of New York's Albert Einstein College of Medicine.
"There's a huge public-health risk of it spiraling out of control," Dr. O'Donnell says. In his research, he has come across a prison warden in South Africa's KwaZulu-Natal province infected with extensively drug-resistant, or XDR-TB - a type that defies treatment by most available drugs.
Located at the tree-lined edge of a Cape Town suburb, Pollsmoor welcomes visitors with a sign on green gates that proclaims: "A Place of New Beginnings."
In 1982, Nelson Mandela arrived here from a blustery Robben Island off the coast, where he spent most of his 27 years in prison. The nation's first black president, who is 95 and in fragile health, has suffered lung infections that some medical experts suspect resulted from his own battle with tuberculosis in prison.
"Pollsmoor had a modern face but a primitive heart," Mr. Mandela wrote in his autobiography, "Long Walk to Freedom."
Mr. Lee entered Pollsmoor in the middle of intersecting prison crises - overcrowding and lax TB oversight.
Like others in the awaiting-trial section, he spent 23 hours a day locked in a cell with a dirty mattress. He inhaled the smoke of burning wads of twisted toilet paper, a tactic of gang members to mask the scent of marijuana.
Mr. Lee sums up his time in Pollsmoor by saying, "God, it stinks."
At the time of his arrest, Mr. Lee says he was selling dish towels, sunglasses and knockoffs of "White Lace" perfume. "Good stuff," he said. "Women would buy it like hell."
Mr. Lee, who says he retired from the Hells Angels and another biker gang, the Gypsy Jokers, after tiring of the brawls, had previous brushes with the law. In 1981, he says, he was released from a Pretoria prison after serving several years for illegally moving money out of the country to Greece, Portugal and Israel.
Soon after entering Pollsmoor, Mr. Lee met with a prison doctor, Stephen A. Craven, who advised him to stop smoking, according to documents filed in the High Court of South Africa in Cape Town. He also put Mr. Lee on half rations; medical records described him as "well obese."
Mr. Lee defied efforts to reduce his rations. He says he arranged small payments to prison staff for breaded pork chops and ice cream. He also says he bribed guards for cleaner blankets and a less crowded cell.
"It cost money to do time there," he says.
Several Pollsmoor officials said they weren't personally aware of the bribing of prison guards.
Months after being arrested in 1999, Mr. Lee was released on bail, but then got picked up again. This time, he was denied bail.
Pollsmoor authorities say they are obligated to house people sent to them by the courts, regardless of space. At the end of June, Pollsmoor held 7,094 inmates with only 4,336 beds, or 61% above capacity, according to the prison.
Mr. Lee developed a violent cough in 2003, diagnosed as tuberculosis. He began a standard treatment. "When they started talking about multidrug-resistant tuberculosis, I nearly had a heart attack," Mr. Lee says.
A friendly nurse sometimes gave him an extra day's dosage if she was going to be away, Mr. Lee says. "I don't want you to die," the nurse jokingly told him, he says. "You know how much paperwork that is?"
The treatment made him weak, but he stuck with it and says he bribed guards to get access to his medicine. After reading up on tuberculosis, he says he vowed to prison authorities to "sue the s - out of you people."
He wasn't the only one alarmed by the spread of tuberculosis among prisoners. His prison physician, Dr. Craven, says he separately began keeping a personal record of botched TB tests, missing paperwork and other problems. He kept a copy of his log, "Derelictions of Tuberculosis Duty," on his computer at home.
In the prison's juvenile section, Paul Theron became similarly distressed. Under South Africa's white apartheid government, prisons ran along military lines that stressed cleanliness and accountability. In the postapartheid era, the doctor says, discipline became lax.
"Like everybody who grew up in apartheid, you wanted to see change that was real," he says, and that moved toward "valuing human dignity." But some change, he says, "wasn't as real as it appeared."
In 2004, Mr. Lee was acquitted and released. The same year, he lodged his suit against South Africa's minister for the Department of Correctional Services.
Mr. Lee's lawyer, Jonathan Cohen, faced a challenge: It wasn't clear where his client had picked up the disease.
The defense argued Mr. Lee couldn't prove he contracted TB in prison. Mr. Cohen took aim at prison management, claiming their shoddy controls let the disease flourish. To buttress that argument, Dr. Craven turned over his "Derelictions of Tuberculosis Duty" logs.
A team of researchers used Dr. Craven's files to build a model showing the extent of TB risk in the overcrowded, poorly ventilated and understaffed prison. Pollsmoor prisoners had a 90% chance of contracting regular tuberculosis, and faced heightened risk of MDR-TB, too, according to a 2011 paper the team published in the South African Medical Journal.
"The appalling conditions are the perfect storm for creating drug-resistant TB," says Robin Wood, a research team member and director of the Desmond Tutu HIV Centre at the University of Cape Town.
In December, South Africa's highest court, the Constitutional Court, ruled in Mr. Lee's favor, holding the state responsible for what happened to him in detention and ordering him to be compensated. The size of the award hasn't been determined.
The ruling set a precedent for other prisoners harmed in jail, and jolted the nation's prison system. "Authorities were aware that there was an appreciable risk of infection and contagion," the judge concluded. "They had a duty to take reasonable measures to reduce the risk."
As the case wound through courts, Pollsmoor implemented new tuberculosis controls. It created an isolation ward for MDR-TB patients and appointed a dedicated nurse to track tuberculosis inside the prison. It launched "sputum blitzes" to check people regardless of whether they showed symptoms.
At the end of June, Pollsmoor had 152 prisoners with standard tuberculosis, 16 with MDR TB, and none with XDR TB, said Jabulani Shinga, Pollsmoor's health manager. He estimates the number of tuberculosis patients has come down sharply since Mr. Lee's period in prison. Patchy record keeping prevents clear comparisons.
Following Mr. Lee's victory, South Africa's government announced new guidelines for managing tuberculosis, HIV and sexually transmitted diseases in correctional centers.
¥In March, Deputy President Kgalema Motlanthe visited Pollsmoor, calling prison facilities this year's focal point for tuberculosis. He presided over the donation to prisons of new GeneXpert machines - devices that cut TB diagnosis times to less than two hours, instead of days or weeks.
Down the hall from the cell that once prevented Nelson Mandela from spreading the politics of racial equality, the most feared inmates in Pollsmoor prison today are confined to the MDR ward. Trevor Sam developed drug-resistant tuberculosis after he stopped taking his medication and starting smoking crystal methamphetamine, or "tik" as it is called in Cape Town.
In April, he was arrested and charged with stealing a woman's handbag, which he denies. After a GeneXpert machine flagged his condition, he was immediately transferred to the isolation ward. There, nurses monitor his morning injections and 18 pills a day. "When people see me, they run," says Mr. Sam, 34, speaking through a white gauze mask.
Today, Mr. Lee lives free from tuberculosis at a home for the aged in Cape Town. The dinner bell rings at 4:45 p.m. Karaoke starts soon after that. The former biker rolls his eyes and heads out for a smoke.
On a bluff overlooking Table Mountain, Mr. Lee says he has become a born-again Christian who studies the Bible via messages sent to him on his cellphone. Still, a part of him relishes a brawl, even a legal one over TB in prison.
"Hopefully, in some small way I've managed to goad, or bully, this country into doing something about it," Mr. Lee says. "I'm a fighter, always have been. You know what they say in boxing: Don't lie down."
- Betsy McKay in Atlanta contributed to this article.
Write to Peter Wonacott at firstname.lastname@example.org