Inside Story

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It was my first prison visit. As a privileged white man raised in the eastern suburbs of Sydney, it was a first in many ways.

“This is where we see patients.” The nurse motions to a small, cluttered room with a cramped medical bed, narrow table, and posters on the walls decrying unsafe sex. “We keep the door open just in case, and they get taken back out as soon as the consult is over.”

A guard hovers outside as we talk. “We do a daily clinic and our doctor comes once a week… if she’s not too busy,” the nurse explains.

In the corridor, a gate slams. Distantly, irregularly, there are screams. No one feels the need to explain them. To the staff at this NSW prison, they are as unremarkable as the bars on the window.

Walking through a prison for the first time is a completely foreign experience for someone like me, a public health professional with little personal contact with the justice system. It brings a feeling of despair and discord, the sense that things aren’t quite right.

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It’s often said that no one cares about prisoners. Maybe it’s because the people in prisons are out of sight and thus out of mind; or maybe because they are disadvantaged and don’t have the power to advocate for a better deal.

Maybe it’s because so many people, especially the shock jocks who have so much power over public narratives about “law and order,” don’t appreciate that the story of incarceration is more complicated than whether someone is “good” or “bad,” or does “good” or “bad.”

The circumstances of your birth — where you live and how — affect your chances of going to prison later in life. I grew up in a wealthy Sydney suburb, and despite the constant presence of drugs and alcohol in the lives of most students in my year at school, virtually no one was arrested. The few who were never went to prison. I remember one schoolmate telling me she had punched a police officer after being caught with cocaine, for which she received a slap on the wrist.

By comparison, a quarter of young Aboriginal men in Australia are imprisoned each year, according to research published in the MJA, and almost all of them will experience the inside of a prison cell during their lives. A report commissioned by the Victorian Aboriginal Community Controlled Health Organisation in 2009 found that more than half of Aboriginal men released from prison will return there within two years.

At the root of these problems is sentencing. A NSW government report found that Aboriginal and Torres Strait Islander people were given disproportionately harsh sentences compared with non-Indigenous people who committed the same crimes, and the rate at which Indigenous people are refused bail is double that of non-Indigenous people who have committed similar offences.

Regardless, this is more than a story about despair and how systems and structures collude to perpetuate cycles of imprisonment and disadvantage. It is also a story about the steps we can all take to redeem ourselves as a society: the things we can do to even the balance that has been weighted in favour of the few for so very long. The actions needed become more and more clear the more you investigate our prison problems. As a public health professional exploring these issues for the first time, I was amazed by how easy it would be to enact major change; as a human being, I found it impossible not to wonder why we haven’t done so sooner.

Go straight to jail

As of June last year there were 41,202 prisoners in Australia. This number has roughly doubled, both in raw figures and proportionally, since the early 2000s, and it’s still increasing: from 2016 to 2017 the rate of incarceration went from 208 prisoners per 100,000 people to 216 across the country. This is far less than the truly horrifying 800+ rate in the United States, but still one of the highest in the developed world.

It gets worse. These figures are just daily averages of people imprisoned. Once judged and jailed, people are recorded, time-stamped and entered into the system. But the raw figures don’t reveal what we call the “flow” population: there may be 41,202 prisoners inside on the average day, but we actually imprison far, far more each year, and for them the system has particular problems.

According to the Community Restorative Centre, 18,000 people are released from prison each year in New South Wales alone. This is almost 50 per cent higher than the daily prison population, which is 13,000. The remand population — people who have been jailed awaiting sentencing — has been growing across the country as we enact harsh, unbending laws forcing judges to ignore the humanity of the people they sentence in favour of locking them up regardless of circumstance. In just five years between 2012 and 2017, the number of people held on remand in Australia almost doubled — in the last year alone, the figure grew from 12,000 to 13,000.

And it may come as no surprise that the people on remand experience some of the worst health problems of anyone in the country. Prisoners face endless disadvantage, but people who are held on remand can’t even access basic services.

But before we talk about healthcare in prisons, we have to look at why people are in prison at all. The first rule of public health is that individual decisions are only a small part of the picture — society, in all its complexity, plays a far greater role in the choices we make than most people realise. We talk about the social determinants of health: the cultural, social and environmental causes that affect everything from your chance of getting diabetes to the likelihood that you’ll be hit by a car.

What are the social determinants of prison?

Do not pass GO

Social determinants are almost always about power. Members of low-status groups, who experience social and cultural disadvantage, are also prey to worse health. So, to take an example from my own work in diabetes epidemiology, people who are admitted to western Sydney hospitals speaking a language other than English are sicker in hospital, stay longer, are more likely to go into intensive care, and are worse off generally. This effect gets even more stark when they have chronic diseases like diabetes.

What may come as a surprise is that prisons are very similar to hospitals.

Some of the similarities are obvious. Race is a huge influence, with people of Indigenous, African and southeast Asian descent disproportionately represented in prisoner populations and in statistics on poor health. Having one or more parents incarcerated is one of the biggest predictors that you will be imprisoned yourself. More than 70 per cent of prisoners surveyed by NSW Health had one or both parents who had been incarcerated at some point, often while the respondents were still children. It is not surprising, then, that being raised in care is also a major factor in whether you will be put in prison, with prisoners four times as likely to have been raised in care than the general population.

Basically, your parents’ disadvantage rubs off. Louis Peachey, a GP and advocate for prisoner healthcare, tells me that it can be hard not to see ill-health and imprisonment as “destined” to happen.

There is more. The federal government estimates that almost 65 per cent of prisoners are either unemployed immediately prior to imprisonment or are permanently unable to work. That’s roughly ten times the unemployment rate, which hovers around 5.6 per cent of the total Australian population. People are likely to go to prison many times, with 60 per cent of prisoners having been incarcerated previously. Prisoners are twelve times as likely to be homeless than the average person, with a large proportion of the remainder being in a “transient living situation” — sleeping on couches — prior to being put behind bars.

Disadvantage also multiplies. Aboriginal and Torres Strait Islander people are disproportionately represented in prisons, making up about a quarter of all prisoners in Australia but only 3 per cent of the overall population, but Indigenous women experience even greater disadvantage. In New South Wales, which houses the largest prison population of any state, Indigenous women make up more than half of all female prisoners — less than 2 per cent of the population, but more than 50 per cent of prisoners.

In Australia, being tough on crime has become a byword for vote-winning. Virtually every state government in the country, while talking about issues like transport and schooling, has also sold the terror of bad people skulking in the night.

Victoria’s Labor government, in many ways the most progressive state government in the country, has enacted harsh new sentencing laws that deny judges the ability to use their judgement in sentencing. This is despite the lack of evidence that such measures work, and indeed the general downward trend of crime.

Your chance of being murdered in Australia today is less than half what it was in the 1980s. The main driver behind our increased prison population is drugs, and even then the high incarceration rate is largely due to a “tough on crime” approach, in wilful disregard of the evidence that it doesn’t work. Harsher sentences, by and large, merely push social issues like welfare and equity from the streets, where we can see them, to the prison, where we cannot.

A recent Guardian Australia investigation threw harsh light on the impacts of disadvantage. “Deaths Inside” is a harrowing account of how we have ignored and silenced some of the most vulnerable people in our society. More than 130 Aboriginal people have died in custody in Australia since 2008; more than half of those deaths are directly attributable to a lack of medical care.

The stories in this series are a horrifying wake-up call: in one, a man, forgotten in his cell, dies for want of his heart medication. More than 40 per cent of the time, basic police procedures that might have prevented Indigenous deaths in custody were not followed.

With the average sentence length hovering around two years, it’s important to remember that virtually everyone who goes behind bars will eventually come out. With an increasing number of prisoners held on remand, and likely to serve shorter sentences, it’s even more vital to provide effective care to people who may otherwise swing from service to service, without ever seeing improvements in their lives.

Which is why healthcare for prisoners is so important.

Do not collect $200

Reading reports into prison health is an almost surreal experience. There are lots of them, for a start. Each state does its own, and the federal government puts them all together into one mega-report once every few years.

It’s surreal because the numbers are so difficult to comprehend. Looking at the statistics, you start to imagine Third World countries, war zones where adequate healthcare is unimaginably distant, refugee camps where the government has imprisoned people for years.

If you can name a health condition, prisoners are probably more likely to have it than the average person on the street. A quarter enter prison with a chronic health condition. Half have a diagnosed mental illness. A third are disabled. Adjusted for age, rates of asthma, diabetes, cardiovascular disease and arthritis are all significantly higher than in the general population.

Most prison health workers will tell you that they try their best, but that mammoth bureaucracies stand in the way of even the most basic treatment. Jeremy Resnick, a prison psychiatrist working in Sydney, says that even talking to patients is almost impossible at times: “You have to have four guards in the room, in case they are physically violent. If there aren’t guards available… you have to talk to the guy through a door.”

These are people who have been diagnosed with a mental illness severe enough to be seen in a prison psychiatric hospital. Even the highest level of care that corrective services can afford comes with bars and callous disregard.

Worse, we have so neglected mental health facilities in NSW prisons that people who have been declared innocent by reason of mental illness are routinely housed with other prisoners because of a lack of dedicated mental health beds. These are people who have been diagnosed as so mentally unwell that it is not safe for themselves or others for them to be out in public, and yet we commonly throw them into one of the worst environments possible for mental health.

While prisoners can get fairly quick access to the nurses who are employed in the prison itself, seeing a specialist is a painful routine that can take months to organise. One man in the prison where Louis Peachey works was on the waitlist for a specialist to take a look at his ears to see if he was eligible for an implant. He is largely deaf — a by-product of childhood infection — and when the long-awaited call came, he didn’t hear it. When the prison guards called his name, he didn’t respond. No one cared enough to check, and he missed his specialist appointment. It was months of waiting down the drain, all for the lack of basic coordinated care and respect.

Penny Abbott, a GP who works in women’s prisons and has done considerable research into prison health, has identified major issues that face women specifically. In prison, they face perennial problems that have been plaguing women in the prison system for decades, such as access to sanitary pads and tampons, and care during pregnancy. But then once released, they often contend with medical homelessness — the inability to find care in a single place, or have a regular doctor of any kind — and transiency, and end up with no identified health providers like GPs or specialist care. Abbott’s research has demonstrated that not only are women at greater risk of health issues on release from prison, but they are also likely to experience severe stigma from doctors in the outside world.

All of this is compounded when you look at the flow population. Where prisoners on long sentences are at least able to access basic care — it may take months to set up a specialist appointment, but at least you have one — people on remand, or staying for only a few weeks, don’t have even this luxury.

This painful transition is clear from the stories of women entering and leaving prison. They are filled with the desire to be treated “like a normal person,” and the unending slog of trying to prove that they aren’t lying about their healthcare issues.

All too often, there is a single cause of their plight. One issue overshadows almost everything about prison health and how we see the people we lock away and then ignore. I’m talking, of course, about drugs.

Whatever you do, don’t get sick

It’s strange. We can talk about how not all prisoners are bad people. We can have a conversation about how societal issues might be behind the degradation of so many of our fellow Australians. It’s not hard to see how people down on their luck might make a few bad choices and end up in trouble.

That all falls apart when it comes to drugs. According to the Australian Institute for Health and Wellbeing, more than 80 per cent of prisoners report using illicit drugs in their lifetime, with 67 per cent using in the twelve months prior to coming to prison. A staggering 37 per cent report having used drugs during their current sentence, a figure that is almost certainly lower than reality when you consider that people might hesitate to admit they have broken the rules behind bars.

In other words, it’s a massive problem.

But we prefer to blame and stigmatise drug users rather than enact effective policies to reduce the associated harms of drug use. Where other countries have implemented harm-reduction methods such as needle exchanges, safe injecting spaces, and opioid addiction treatment for people in prisons, Australia has a haphazard approach to addiction services that varies widely from state to state. Want to see an addiction counsellor? Better hope you’ve been sentenced in a state that offers the service. There are even variations from prison to prison.

And that isn’t even the worst part. There is strong evidence that improving the health of prisoners makes them less likely to reoffend. That has been demonstrated time and again. Prisoners who are treated for their blood-borne diseases (think HIV and hepatitis) do better on release than those who languish without care.

But for people who abuse drugs, the evidence is that not only do rehabilitation programs in prison make them less likely to reoffend — when taking heroin is illegal, getting people off it makes crime reduction a foregone conclusion — they also make them less likely to die. Much less likely. A recent review of a drug program in the United States found that one life could be saved for every eleven people treated in this kind of program.

For comparison, you need to treat 104 people with statins, a commonly prescribed heart medication, to prevent a single heart attack. That number goes up enormously to prevent a single death. If this drug program were for anyone other than prisoners, we’d be implementing it everywhere we could.

Back to the real world

There’s a painful truth that you learn when you start looking at public health: as a society, our morals are completely backward. We will happily deny lifesaving treatment to disadvantaged teen mothers because we’ve judged them and found them wanting, and instead fund enormously expensive transplants for those who’ve led less fraught lives. Not that transplant patients don’t deserve to be healthy too, but the point is that the services we offer people all too often depend on what we have arbitrarily decided is morally attractive behaviour. You see it in hospitals, where drug and alcohol services are a low priority, you see it in LGBT+ care, where PrEP therapy has taken years to be funded despite abundant evidence of its success.

Most of all, you see it in prisons, where we take away people’s health because they are criminals.

Peachy describes this as “extrajudicial punishment.” Sentences are extremely specific — judges have to specify things like the distance you are allowed to go from your house, or the people that you are and aren’t allowed to interact with. But one thing that can’t be specified is that sentenced people should lose their access to health services. Yet we do it anyway.

The saddest thing is that many prisoners believe they get decent healthcare in prison. More than 80 per cent of them rate the healthcare that they receive in prison as better than what they get on the outside. There’s likely some bias there — asking people questions about how great prison was on the day they’re released isn’t ideal — but the theme holds remarkably true. Most people don’t think that what they get in prison is all that bad, compared to the awful care they see when they are living in the community.

Which is a tragedy. As I’ve outlined, prison healthcare is sporadic and filled with problems. Imagine how lacking the care must be that is available to these people outside prisons.

The bottom line is that prison is not just a dank, dark hole of pain and suffering. It also represents a real hope. It is the ideal place to intervene — people have time to improve themselves. But they can’t improve if there’s nothing there to support them. It’s hard to climb out of a hole without a bit of help from the outside.

So what can we do?

Steps towards change

We will not fix this overnight. There are no simple solutions to complex problems.

One possibility is to give prisoners access to Medicare. The standard response when confronted with this suggestion is a blank stare. You see, most people don’t realise that currently we don’t give prisoners access to Medicare. But it’s true: a quirk in the Health Insurance Act 1975 bars the provision of services by both the state and the Commonwealth, so prisoners are excluded from accessing Medicare-funded services. These include everything from standard GP visits to a whole range of diagnostic tests. Instead, they have to rely on a labyrinthine process of state-funded services that rarely manages to deliver what’s needed.

Two of the largest professional medical bodies in the country, the Royal Australian College of General Practitioners and the Australian Medical Association, support changing Medicare. The RACGP has recently proposed to the federal government that a number of specific Medicare services be made available to prisoners, an idea well worth pursuing.

There are other ways in which we can help. According to an official prison visitor in New South Wales, Ilan Buchman, there are small changes that we can all advocate for and even make ourselves. Giving to charities like the Community Restorative Centre, or local Aboriginal community organisations that provide support to families affected by imprisonment is a fantastic first step. These organisations can make a real and immediate difference in the lives of people who otherwise are given little help by society as a whole.

We can also reduce stigma in our everyday lives. Stop using prison as a judgement, and crime as a joke. Stop telling governments, with our fears and with our votes, that harsh sentencing is something that will keep them in power.

It is also vital that we advocate for change. On the back of the Guardian Australia investigation into deaths in custody, dozens of organisations have stepped up to demand change in the way our legal services treat Indigenous Australians. You can add your voice to theirs, or join forces with one of the many other advocacy organisations that are trying to make the lives of prisoners less dangerous and fraught with pain.

There are small, everyday things that we each can do. Charity, advocacy, support. In many ways, the least that we can do.

The only things that stand in our way are hollow moralisations. Mass-produced labels that tell us that someone is either “good” or “bad.”

Ensuring that people who are interned in criminal facilities have access to good healthcare isn’t just good for society: it’s a basic moral responsibility. •