Aboriginal incarceration: health and social impacts

Incarceration has major health implications. There is increasing evidence that many people in prison are there as a direct consequence of the shortfall in appropriate community-based health and social services, most notably in the areas of housing, mental health and wellbeing, substance use, disability, and family violence.1-3 The most comprehensive study of prisoner health in Australia to date, the New South Wales Inmate Health Survey, identified that two-thirds of inmates had substance use concerns and more than 74% had mental health issues in the preceding 12 months.2,3 Currently, Aboriginal prisoners represent 22% of the total Australian prisoner population, the highest proportion in 10 years.4

One of the key themes of the Royal Commission into Aboriginal Deaths in Custody was that imprisonment should be a sanction of last resort.5 Although this principle is enshrined in legislation in most states, it is highly questionable whether it is followed in practice. Aboriginal people continue to be incarcerated at truly alarming rates. On any one day, 6% of Australia’s young Aboriginal men (aged 25–30 years) are in prison.4 It has been estimated that each year up to a quarter of all young Aboriginal men have direct involvement with correctional services.4,6

Although Australian incarceration rates overall are similar to rates in other industrialised nations, averaging 163 per 100 000 adult population in 2005, national age-standardised rates for Aboriginal prisoners of 1561 per 100 000 are at an unacceptable level and rising (Box 1).4,7,8

For most prisoners, imprisonment involves repeated short-term incarcerations. In South Australia, prison stays are less than 3 months at a time for 80% of remand prisoners and less than 6 months for 90% (Business and Performance Services, Department for Correctional Services, unpublished report, 2004). There is a constant flux through the system, described by Mick Dodson in 1996 in his role as Social Justice Commissioner:

Internationally, there is no evidence that countries with higher rates of incarceration are safer than others.7

This compounding of social disadvantage through excessive incarceration is a fundamental injustice against Australia’s Aboriginal population.

Although the above comments focus predominantly on Aboriginal men, the situation for Aboriginal women is also grave. Aboriginal women, who currently comprise around 8% of the Aboriginal population in prison, experience higher rates of substance use and mental health issues than their male peers, many having long histories of childhood and adult sexual or physical abuse.10,11 Their specific needs warrant separate and detailed attention beyond the scope of this article.

Most studies of prisoner health have focused on improving the delivery of health services to people in prison. Unless the effect of the constant churn of prisoners in and out of prison is adequately acknowledged, programs will be largely ineffectual at engaging clients and achieving lasting health gains.

The post-release consequences of incarceration are only just beginning to be articulated. Literature in this area is sparse. However, it is becoming evident that the first 6–12 months following release from prison is a high-risk time. Recent studies in Western Australia showed that released Aboriginal prisoners have an almost 10 times greater risk of death than the general WA population and an almost three times greater risk of death compared with their Aboriginal peers in the community. The main causes of death are suicide, drug and alcohol related events, and motor vehicle accidents.12

Attempts to offer continuity of health services from prison to the community, where they exist, are frequently thwarted by former prisoners’ inability to meet their most basic needs, such as housing, transport and Centrelink welfare payments. Nationally, Centrelink has determined that former prisoners are entitled to receive the equivalent of 1 week’s Centrelink payment to carry them through their first 2 weeks after release.13 Policies of this kind place an additional burden on already disadvantaged Aboriginal families to provide financial support for newly released family members. Additionally, former prisoners frequently lack the identification documents required to access Centrelink payments, open bank accounts and complete housing application processes.

Arguably most problematic of all is the lack of access to suitable housing. One of the few studies conducted on housing after release found that former prisoners who are re-incarcerated report that a lack of suitable housing is a key factor in their unsuccessful transition to outside life.14

To begin to explore these issues in South Australia, we recently conducted a short survey at Adelaide Remand Centre of all Aboriginal prisoners. Of 45 Aboriginal male inmates, 41 were interviewed. The findings are summarised in Box 2.

The finding that 73% of Aboriginal prisoners expected to have no or insecure housing on release corresponded with our clinical experience. On community follow-up, most had left prison without accommodation in place and with few options available to them. Public housing stocks in SA are diminishing and private rental for Aboriginal men without references is rarely achievable.15 Consequently, it becomes almost impossible to provide continuity of health care to these clients, many of whom have major health needs, particularly for mental health and substance use support.

When basic needs such as shelter and a secure source of income are out of reach, the incentive and capacity to attend ongoing medical and counselling appointments, maintain medication regimens and adopt healthy lifestyle practices are severely compromised.

The need for better service integration can be further illustrated by considering hepatitis C treatment. In SA, close to 60% of metropolitan Aboriginal prisoners are positive for hepatitis C virus (HCV) antibodies.16

As part of the National Hepatitis C Strategy, there is an identified priority to increase HCV treatment rates. Custodial settings are seen as one of the key sites to address HCV management.17 However, as treatment programs take 6–12 months to complete and most prison stays are less than 6 months, most prisoners are effectively excluded from access to treatment because of their short prison stays and the inherent difficulties of post-release follow-up.

It would seem reasonable to suspect that this rapidly cycling population comprises the people whose destabilised lives put them at increased exposure to and risk of unsafe practices, such as needle sharing and further transmission of HCV in the community. There is a clear need to better understand the experiences of this population and to establish programs that can provide continuity from within prison through to post-release support. Acknowledgement of the interrelationship between social factors, justice decisions and models of health care is critical here.

Solutions for the excessive incarceration of Aboriginal people throughout Australia must be sought and enacted in the community — not in prisons — and must address the underlying determinants of incarceration and recidivism. If we adopt models that integrate social health perspectives as fundamental components of our service delivery, then there is every reason to believe that we have the capacity to make real health gains.

Dedicated services are required. Mainstreaming cannot possibly address the complexity of needs for Aboriginal families. Nor is it the domain of correctional services to be the primary providers of community-based mental health, drug and alcohol or primary care services. In SA, more than 80% of prisoners are discharged without parole conditions (Business and Performance Services, Department for Correctional Services, unpublished report 2004), with the responsibility for care frequently falling back on the health and human services sectors.

Legal solutions such as court diversions, circle-sentencing, and other community-based alternatives to court processing of offenders can only be effective if health and human services take a lead role in developing carefully planned and integrated community-based programs to support them.

A culturally responsive health perspective allows us to hear what Aboriginal people have been telling us for a long time — that patterns of criminal behaviour are often an expression of the deep wells of pain, anger and grief experienced by Aboriginal people on a daily basis as a consequence of their long history of dispossession in this country.18,19 Forced separation through incarceration intensifies this, creating a further marginalised and destabilised young Aboriginal population and placing added burdens, both financial and social, on the individuals and on Aboriginal women and children.

If we are serious about breaking the cycle of disadvantage and incarceration, we must honestly address the stigmatising and discriminatory practices occurring across all service sectors, from targeted policing and unachievable bail requirements, to the difficulties of access to health services for people with a history of correctional involvement.

Any discussions about Aboriginal men’s health must address incarceration. We cannot hope to achieve major improvements in wellbeing, quality of life and arguably in life expectancy, while continuing to pursue manifestly unacceptable incarceration practices.

A recent study in NSW showed that nearly half of all the young people in juvenile justice custody, 42% of whom are Aboriginal, have a history of a parent in prison. Eleven per cent have a parent currently in custody.20 For the sake of this and future generations, we must break the cycle.

1 Indigenous and non-Indigenous prisoners, rate per 100 000 adults, 1992–2004

Reproduced with permission from Australian crime facts and figures 2005, Figure 91.6