tag:theconversation.com,2011:/global/topics/prisoner-health-16334/articlesPrisoner health – The Conversation2024-01-31T23:19:39Ztag:theconversation.com,2011:article/2221572024-01-31T23:19:39Z2024-01-31T23:19:39ZMost prisoners never receive visitors, and this puts them at a higher risk of reoffending<figure><img src="https://images.theconversation.com/files/572078/original/file-20240130-17-whpdmt.jpg?ixlib=rb-1.1.0&rect=30%2C22%2C5026%2C3684&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
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<p>It was like walking through the gates of hell. </p>
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<p>That’s what one visitor to a prison told us about their experience. It can be a traumatic and stressful event. Family members of first-time prisoners are most often left in a state of uncertainty about what happens next. This is coupled with the feelings of loss, devastation, and disbelief, as explained by one participant in <a href="https://dx.doi.org/10.1080/13218719.2023.2272910">our research</a>: </p>
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<p>It was a smack in the face. I was not expecting it at all […] I was pretty devastated and felt pretty alone and vulnerable. I had no idea what went wrong.</p>
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<p>We found misinformation and limited information of visitation rules and processes help create such negative experiences for visitors. Some stopped going altogether.</p>
<p>This is important to address because visitation is a crucial factor in helping prevent reoffending, but also to maintaining good mental health for those behind bars. </p>
<h2>Visits crucial for prisoners</h2>
<p>In 2021 and 2022, our research team conducted in-depth interviews with 21 participants from across Australia about the barriers to prison visitation and what their visiting experiences were like.</p>
<p>We wanted to investigate this because of the high rates of recidivism among Australian prisoners. Visitation has been shown to help with this.</p>
<p><a href="https://www.sentencingcouncil.vic.gov.au/sentencing-statistics/released-prisoners-returning-to-prison">42.7% of prisoners</a> in Australia are reincarcerated within two years.</p>
<p>We also know that prison visitation has been found to <a href="https://doi.org/10.1016/j.jcrimjus.2016.07.006">reduce prisoners’ risk</a> of reincarceration by 26%. Despite this, <a href="https://dx.doi.org/10.1080/13218719.2023.2272910">most prisoners</a> never get any visitors. </p>
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<a href="https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A phone on a metal cord on one side of a glass visitor booth in a prison" src="https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572088/original/file-20240130-16-cofmi2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many prisoners never get visitors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/visiting-boothspenitentiary-area-maximum-security-detainees-1095129356">Shutterstock</a></span>
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<p>Having visitors while in jail has other benefits too. For one, it helps prisoners to <a href="https://doi.org/10.1080/07418825.2010.498383">conform to prison life</a>. </p>
<p>It also reduces <a href="https://doi.org/10.1080/%2007418825.2018.1508606">prison violence</a>, <a href="https://doi.org/10.1177/107834580301000310">mental health problems</a>, <a href="https://doi.org/10.1086/449299">suicidal tendencies</a> and <a href="https://doi.org/10.1177/0022427808317574">misbehaviour</a>. </p>
<p>Additionally, visitation helps prisoners <a href="https://doi.org/10.1016/j.jcrimjus.2013.05.001">maintain prosocial roles</a> (like being a parent) and <a href="https://doi.org/10.1016/j.jcrimjus.2012.06.007">build optimism</a> for life once they’re released. </p>
<p>We wanted to understand why prison visits might be prevented or delayed. As such, we looked at how people new to prison visitation learn to navigate the system. </p>
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Read more:
<a href="https://theconversation.com/new-report-reveals-shocking-state-of-prisoner-health-heres-what-needs-to-be-done-217558">New report reveals shocking state of prisoner health. Here's what needs to be done</a>
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<h2>Information confusing and hard to find</h2>
<p><a href="https://dx.doi.org/10.1080/13218719.2023.2272910">We found</a> visitation rules and procedures can differ between jurisdictions and within jurisdictions. They can also be different between low, medium, and maximum prisons, and even between public and private prisons. </p>
<p>Furthermore, prisoners are transferred between prisons an average of three times during their sentence. Therefore, visitors may need to learn new rules each transfer. </p>
<p>Being new to the visitation process, most participants expressed feeling lost, overwhelmed, mentally fatigued, helpless and alone, desperate for any information. One participant told us: </p>
<blockquote>
<p>I’ve never had anything to do with any of this before [he] went to prison. I knew nothing about police, courts, prisons or anything. When [he] went in I was a mess because no one told me anything […] I think it was maybe day three or four of him being in there and I had the worst nightmare I’ve ever had about stuff, you know, happening to him in there and him being killed. Yeah, after that it was a downward spiral for me pretty fast […]</p>
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<p>Even before visitors needed to learn the rules and procedures, participants suffered stress from social isolation, financial hardship, the loss of their loved one and media coverage due to the court case. </p>
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Read more:
<a href="https://theconversation.com/they-werent-there-when-i-needed-them-we-asked-former-prisoners-what-happens-when-support-services-fail-208949">‘They weren’t there when I needed them’: we asked former prisoners what happens when support services fail</a>
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<p>Chronic stress can lead to structural changes in the part of the brain responsible for memory and decision making. Additionally, chronic stress can impair a person’s cognitive flexibility, hindering their ability to adapt to change and find information. This is a normal response when people find themselves in uncertain situations.</p>
<p>Furthermore, chronic stress can precipitate or exacerbate <a href="https://dx.doi.org/10.1080/13218719.2023.2272910">mental health problems</a>, as well as increase feelings of helplessness and/or hopelessness. This can negatively impact a person’s ability to concentrate and learn new information.</p>
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<a href="https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A hallway of barred prison cells in a prison" src="https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572090/original/file-20240130-27-s97h2z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A large portion of prisoners in Australia reoffend after being released.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/san-francisco-california-united-states-august-630056831">Shutterstock</a></span>
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<p>Most participants described their efforts to get the right information as confusing. Important details that had a direct impact on whether their visit was approved, cancellations, or traumatic visitation experience were omitted from the website or the phone conversations they had with corrections officers. A participant said:</p>
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<p>There was no information about him needing to put me on the approved visitor list and that I would not be approved until he did this.</p>
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<p>Another was deterred from visiting altogether:</p>
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<p>I quickly learned not to bother […] you get in trouble when you go visit because you don’t have something you need, or you have worn inappropriate clothing because you got wrong information from them.</p>
</blockquote>
<p>Almost all participants expressed distrust in the available information from prisons due to their negative experiences. Instead, they rely on advice provided by strangers on social media support groups specifically set-up for families of prisoners. </p>
<h2>Small changes for a big difference</h2>
<p>To improve prison visitors’ access to reliable and correct information, and ensure they are adequately supported during this stressful period, our participants made these recommendations:</p>
<ul>
<li><p>a visitation liaison person in the court to provide advice and support after sentencing</p></li>
<li><p>a visitation information support pack that can be provided to family members immediately after sentencing (if in court) or by post</p></li>
<li><p>a short demonstration video of the visitation procedure online</p></li>
<li><p>corrections/prisons to share information with the online support groups to allow them to quickly communicate changes to visitation rules and procedures, as well as any unplanned changes to visitation hours. </p></li>
</ul>
<p>These recommendations have merit and could help to increase the number and frequency of prisoners being visited, as well as help to reduce stress among visitors. </p>
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Read more:
<a href="https://theconversation.com/giving-ex-prisoners-public-housing-cuts-crime-and-re-incarceration-and-saves-money-180027">Giving ex-prisoners public housing cuts crime and re-incarceration – and saves money</a>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Receiving visitors while behind bars was a raft of benefits, but people have reported many barriers. It must be made easier to help drive down recidivism rates.Nicole Ryan, Associate Lecturer of Criminology, La Trobe UniversityNathan Ryan, Doctor of Criminology, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2175582023-11-14T19:07:15Z2023-11-14T19:07:15ZNew report reveals shocking state of prisoner health. Here’s what needs to be done<p>A new Australian Institute of Health and Welfare <a href="https://www.aihw.gov.au/reports/prisoners/the-health-of-people-in-australias-prisons-2022/contents/about">report</a> on the health of people in Australian prisons makes for sobering reading.</p>
<p>It reveals that compared to the general population, people in prison have higher rates of mental health conditions, chronic disease, communicable disease, and acquired brain injury. This is despite the fact the prison population is <a href="https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release">relatively young</a>. </p>
<p>This is a problem for everyone. <a href="https://link.springer.com/article/10.1007/s00127-020-01873-1">Research</a> shows mental health intervention and engagement helps <a href="https://pubmed.ncbi.nlm.nih.gov/32667664/">reduce offending</a> among offenders with serious mental illness. </p>
<p>Good health care in prisons, with continuity of community health care upon release, not only helps the person being treated. It also helps the community through reduced levels of offending.</p>
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Read more:
<a href="https://theconversation.com/good-mental-health-care-in-prisons-must-begin-and-end-in-the-community-40011">Good mental health care in prisons must begin and end in the community</a>
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<h2>The new report</h2>
<p>Data were collected in 2022 from 371 people entering prison during a given two-week period, and 431 who were due to be released during the data collection period or in the following four weeks. The report includes information drawn from 73 of 87 prisons across Australia (excluding Victoria, which didn’t participate in the survey this year).</p>
<p>The researchers also collected data from 4,500 people who visited the prison health clinic and another 7,100 people who received medications while in prison.</p>
<p>According to the data, around one in two prison entrants reported a chronic physical health condition.</p>
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<p>One in two prison entrants reported having been told they had a mental health condition, with almost one in five currently taking mental health related medication.</p>
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<p>Around one in five prison entrants reported a history of self-harm.</p>
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<p>Self-reported levels of distress were high:</p>
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<p>The report also revealed:</p>
<ul>
<li><p>two-thirds of prison entrants reported they had previously been in prison</p></li>
<li><p>around two in five younger prison entrants reported a family history of incarceration</p></li>
<li><p>around two in five prison entrants reported having dependent children in the community</p></li>
<li><p>nearly one in three prison entrants reported their highest level of schooling as year nine or under</p></li>
<li><p>nearly one in two prison dischargees expected they would be homeless on release</p></li>
<li><p>almost one in three prison entrants reported consuming at least seven standard drinks of alcohol in a typical day of drinking</p></li>
<li><p>almost three in four prison entrants reported being current smokers.</p></li>
</ul>
<h2>Shocking, though unsurprising</h2>
<p>As someone who has worked in prisons and researched prisoner health for more than three decades, I was sadly unsurprised by these grim findings. The results are largely consistent with <a href="https://www.aihw.gov.au/reports/prisoners/the-health-of-people-in-australias-prisons-2022/report-editions">previous reports</a> and confirm people in custody have particularly high health needs. </p>
<p>It’s easy for us to lose sight of the health needs of people in prison while they are locked away.</p>
<p>A high percentage of people in prison are on remand pending trial and once sentenced most are back in the community relatively soon. </p>
<p>Once sentenced, most spend a <a href="https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release">relatively short time</a> in prison, particularly those who commit low or medium-risk offences. </p>
<p>A high proportion of people cycle back into prison after release. There is very little continuity of care between health care in prison and in the community. The failures in the system help replicate disadvantage and leave the whole community worse off.</p>
<h2>Why is the prisoner population generally in such poor health?</h2>
<p>Many prison entrants are poorly educated, impoverished, come from families with an incarceration history, and experience homelessness.</p>
<p>They are also more likely than others in the community to have poor employment skills and histories, and to have experienced child abuse. </p>
<p>A <a href="https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release#aboriginal-and-torres-strait-islander-prisoners">disproportionate number</a> of people in prison are Aboriginal or Torres Strait Islanders, a group that generally experiences significantly poorer health than the general community. </p>
<p>Recent <a href="https://link.springer.com/article/10.1186/s12889-023-16464-3">evidence</a> also shows many people in prison have poorer levels of health literacy than people in the general community. In other words, they may struggle to obtain, understand, and use information to make appropriate health decisions. </p>
<h2>Why is this a problem for all of us?</h2>
<p>Prisons are very much part of our community and most people are incarcerated temporarily. By enhancing the health care of people in prison and ensuring continuity of care to the community, we can reduce the costs associated with health care more generally. Investing early to improve the health of prisoners can save a lot of taxpayer money down the track.</p>
<p>And as some types of mental health conditions are related to a higher risk for offending, better health care can help enhance public safety.</p>
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Read more:
<a href="https://theconversation.com/victorias-prison-health-care-system-should-match-community-health-care-180558">Victoria’s prison health care system should match community health care</a>
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<h2>What needs to be done?</h2>
<p>We need to reassess how we think of prisons and those detained in them.</p>
<p>We have an opportunity to target people entering prisons to increase their health care and health literacy. Health care, and particularly mental health care, are critical ingredients in enhancing prisoners’ wellbeing, their health literacy and their continuity of care upon release. </p>
<p>All states screen detainees upon admission for health issues. And, encouragingly, the new report on prisoner health reveals almost three-quarters of prison dischargees rated the health care they received in the prison clinic as good or excellent. </p>
<p>But as good as they are, correctional health services cannot effectively overcome systems issues. Health care in prison is not enough to address health literacy, prevention of health problems, and continuity of care upon release.</p>
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Read more:
<a href="https://theconversation.com/raising-the-age-of-criminal-responsibility-is-only-a-first-step-first-nations-kids-need-cultural-solutions-186201">Raising the age of criminal responsibility is only a first step. First Nations kids need cultural solutions</a>
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<p>The health and mental health care service system in Australia is fundamentally flawed. </p>
<p>Prison health services are funded by state governments without federal funding enjoyed by all other Australians through the <a href="https://www.researchgate.net/profile/Ann-Claire-Larsen/publication/328250377_In_Sickness_and_in_Prison_The_Case_for_Removing_the_Medicare_Exclusion_for_Australian_Prisoners/links/5bc92b1aa6fdcc03c7939cfb/In-Sickness-and-in-Prison-The-Case-for-Removing-the-Medicare-Exclusion-for-Australian-Prisoners.pdf">Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS)</a>.</p>
<p>This funding inequity and systemic issues contribute to the overall disadvantage in health care for people in prison.</p>
<p>And in some states, the responsibility for prisoner health care rests with the department of justice rather than the department of health. </p>
<p>This contributes to a breakdown in integrated service planning and delivery, which should include prisoner health care, health care upon release, and continuing care while in the community. </p>
<p>Boosting health literacy among people detained in prisons can help. Health literacy includes health-related critical thinking, communication, and problem-solving. </p>
<p>It means equipping people with the skills they need to actively participate in their own health and wellbeing.</p>
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Read more:
<a href="https://theconversation.com/they-werent-there-when-i-needed-them-we-asked-former-prisoners-what-happens-when-support-services-fail-208949">‘They weren’t there when I needed them’: we asked former prisoners what happens when support services fail</a>
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<p class="fine-print"><em><span>James Ogloff has received funding from the Australian Research Council and is a Strategic Advisor for the Victorian Institute of Forensic Mental Health (Forensicare). Forensicare provides mental health services in prisons in Victoria. </span></em></p>This is a problem for everyone. Research shows mental health intervention and engagement helps reduce offending among people with serious mental illness who commit offences.James Ogloff, University Distinguished Professor of Forensic Behavioural Science & Dean, School of Health Sciences, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1805582022-05-09T00:54:31Z2022-05-09T00:54:31ZVictoria’s prison health care system should match community health care<p><em>Aboriginal and/or Torres Strait Islander readers are advised that names of deceased people are included in this article.</em></p>
<p><em>The Victorian Aboriginal Legal Service is representing family members of Veronica Nelson, Ms Calgaret, and Michael Suckling in coronial investigations/inquests into their deaths in custody.</em></p>
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<p>When someone is placed in prison, they are entirely dependent on prison officers and prison health-care providers. Incarcerated people do not get to choose when they see a doctor or mental health practitioner, when they take medicine, or what type of care they receive. They cannot call 000 and be taken to a hospital if they are dangerously ill. </p>
<p>In Victoria, if a person in prison is Aboriginal and/or Torres Strait Islander, they do not get access to culturally competent care through Aboriginal community-controlled health organisations. In Victoria, prison health care is provided by for-profit <a href="https://www.corrections.vic.gov.au/justice-health">private companies</a> contracted by the state government.</p>
<p>Imprisoned peoples’ physical health and/or social and emotional well-being is at the mercy of prison officers and prison health-care providers. </p>
<p>Through our practice at the Victorian Aboriginal Legal Service, we have seen the differences between how people are treated in the community and how they are treated in prisons and youth prisons. </p>
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Read more:
<a href="https://theconversation.com/does-the-pre-election-budget-address-ways-to-realistically-close-the-gap-for-indigenous-people-180312">Does the pre-election budget address ways to realistically 'close the gap' for Indigenous people?</a>
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<h2>The right to health care continues when people are incarcerated</h2>
<p>International law <a href="https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf">requires</a> “prisoners should enjoy the same standards of health care that are available in the community”. This health care should be “free of charge” and “without discrimination”. It also makes clear <a href="https://www.ohchr.org/en/instruments-mechanisms/instruments/international-covenant-economic-social-and-cultural-rights">everyone</a> has the right to the “highest attainable standard of physical and mental health”.</p>
<p>The Victorian Charter of Human Rights and Responsibilities <a href="https://content.legislation.vic.gov.au/sites/default/files/2020-04/06-43aa014%20authorised.pdf">requires</a> that persons deprived of liberty (such as people in prison or police custody) be treated with humanity and respect.</p>
<p>The <a href="https://www.coronerscourt.vic.gov.au/sites/default/files/2020-04/Finding%20-%20Tanya%20Day-%20COR%202017%206424%20-%20AMENDED%2017042020.pdf">Coronial Inquest</a> into the death of Yorta Yorta woman, Aunty Tanya Day, found that police and prison staff must ensure access to medical care for detained people. <a href="https://content.legislation.vic.gov.au/sites/default/files/2022-04/86-117aa159%20authorised.pdf">Under law</a>, incarcerated people in Victoria have the “right to have access to reasonable medical care and treatment necessary for the preservation of health”.</p>
<p>Yet incarcerated people in Australia are excluded from access to funding under Medicare and the Pharmaceutical Benefits Scheme. This impacts not only <a href="https://www.inspectorcustodial.nsw.gov.au/inspector-of-custodial-services/reports-and-publications/inspection-reports/adult-reports/health-services-in-nsw-correctional-facilities.html">health care</a> in prisons by Aboriginal health services, but also the ability to provide continuity of care to incarcerated Aboriginal people as they enter and exit prison.</p>
<p>In Victoria, health care in prisons is the <a href="https://www.corrections.vic.gov.au/justice-health">responsibility</a> of the Department of Justice and Community Safety, not the Department of Health. Health care is provided by a subcontracted and fragmented system of multiple, private health-care <a href="https://www.vals.org.au/wp-content/uploads/2022/02/139._VALS_Eastern_Australian_Aboriginal_Justice_Services_Ltd_Redacted.pdf">providers</a>. This contributes to inconsistent health care across the prison system.</p>
<p>From our clients in prison, we hear about limited access to health care for critical conditions such as cancer, diabetes and heart problems. What’s more, people in prison are often prescribed medication without a thorough health check. <a href="https://www.theage.com.au/national/victoria/self-harm-incidents-among-victorian-aboriginal-prisoners-jump-by-more-than-50-per-cent-20220216-p59wyj.html">Self-harm incidents</a> among Aboriginal people in Victorian prisons have risen by more than 50%. Despite this, we still hear of lack of access to counselling, psychiatric care, trauma and grief support.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-the-kidnapping-of-a-first-nations-man-on-new-years-eve-in-1788-may-have-led-to-a-smallpox-epidemic-173732">How the kidnapping of a First Nations man on New Year's Eve in 1788 may have led to a smallpox epidemic</a>
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<h2>Imprisonment should not be a death sentence</h2>
<p>There have been <a href="https://nirs.org.au/news/31-years-since-royal-commission-into-aboriginal-deaths-in-custody/">more than 500</a> Aboriginal and/or Torres Strait Islander deaths in custody since 1991. Last year, a Guardian <a href="https://www.theguardian.com/australia-news/2021/apr/09/the-facts-about-australias-rising-toll-of-indigenous-deaths-in-custody">analysis</a> on the 30th anniversary of the <a href="http://www.austlii.edu.au/au/other/IndigLRes/rciadic/">report</a> of the Royal Commission into Aboriginal Deaths in Custody found:</p>
<blockquote>
<p>For both Aboriginal and Torres Strait Islander people and non-Indigenous people, the most common cause of death was medical problems, followed by self-harm.</p>
</blockquote>
<p>However, the Guardian also found Indigenous people who died in custody were three times more likely not to receive all necessary medical care, compared with non-Indigenous people. For Indigenous women, the result was even worse – fewer than half received all required medical care prior to death. </p>
<p>This conclusion is chilling, given that incarcerated people, particularly Aboriginal people, have <a href="https://www.aihw.gov.au/getmedia/2e92f007-453d-48a1-9c6b-4c9531cf0371/aihw-phe-246.pdf.aspx?inline=true">higher rates</a> of underlying health conditions than the general population.</p>
<p>The Royal Commission into Aboriginal Deaths in Custody recommended prison health care be culturally safe and “be of an equivalent standard to that available to the general public”. This recommendation still has not been implemented.</p>
<p>Multiple upcoming coronial inquests will examine deaths in custody in Victoria’s prisons, and the adequacy of prison health care. Aboriginal man, <a href="https://www.theage.com.au/national/victoria/aboriginal-man-gained-140kg-during-three-years-in-custody-prior-to-death-in-jail-20210409-p57hrq.html">Michael Suckling</a>, died of a suspected stroke at Ravenhall Correctional Centre. His death will be examined in a coronial inquest later this year.</p>
<p>Veronica Nelson, a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, died at Victoria’s main women’s prison, Dame Phyllis Frost Centre. A <a href="https://www.theguardian.com/australia-news/2022/apr/26/veronica-nelson-made-repeated-calls-for-help-before-her-death-in-custody-inquest-hears?utm_term=Autofeed&CMP=soc_568&utm_medium=Social&utm_source=Twitter#Echobox=1650964553">coronial inquest</a> into her death began last week. The inquest will examine matters including the <a href="https://www.vals.org.au/veronica-marie-nelson-inquest-begins-today/">adequacy of the health care</a> Veronica was provided in prison, and whether her Aboriginality affected the treatment she received.</p>
<p><a href="https://www.vals.org.au/ms-calgarets-story-must-be-told/">Ms Calgaret</a>, a proud Yamatji, Noongar, Wongi and Pitjantjatjara woman, died at Sunshine Hospital after being transferred from Dame Phyllis Frost Centre in a critical condition in November 2021. The <a href="https://www.news.com.au/national/victoria/courts-law/coroner-to-probe-newborn-babys-tragic-death-in-melbourne-prison/news-story/0679b4ba482860ecf392dc6d3ce5ac3a">death</a> of a newborn baby at the same prison is also being examined in an upcoming coronial inquest. Despite these deaths and widespread calls for the Victorian Government to invest in community not prisons, the government is <a href="https://homesnotprisons.com.au/">proposing</a> to expand Dame Phyllis Frost Centre.</p>
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Read more:
<a href="https://theconversation.com/racism-is-a-public-health-crisis-but-black-death-tolls-arent-the-answer-176453">Racism is a public health crisis – but Black death tolls aren't the answer</a>
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<h2>Culturally safe health care for Aboriginal people</h2>
<p>The Australian Health Practitioner Regulation Authority has <a href="https://www.ahpra.gov.au/About-Ahpra/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/health-and-cultural-safety-strategy.aspx">defined</a> cultural safety as follows:</p>
<blockquote>
<p>Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practise is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive health care free of racism.</p>
</blockquote>
<p>The <a href="https://www.naccho.org.au/acchos">first Aboriginal community controlled health organisation was founded in Redfern in 1971</a>, “in response to experiences of racism in mainstream health services and an unmet need for culturally safe and accessible primary health care.” Aboriginal-led health organisations are essential to ensuring culturally safe health services are provided to Aboriginal people, and are a manifestation of Aboriginal self-determination.</p>
<p>In the <a href="https://www.abc.net.au/news/2020-10-19/don-dale-medicare-health-services-rejected-by-greg-hunt/12776808">Northern Territory</a> and the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13007">ACT</a>, Aboriginal community controlled health organisations have begun coming in to prisons to deliver primary health services in adult and youth prisons. </p>
<p>This is a crucial first step to providing culturally safe health care to incarcerated Aboriginal people. This will improve access to health care for those who are imprisoned, and provide support and consistency upon release. This is vital when many of our community members cycle in and out of prison at frequent intervals, due to failures of the justice system. </p>
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<h2>Time to action the lessons learned</h2>
<p>In prisons, officers and prison health staff make life and death decisions <a href="https://www.vals.org.au/wp-content/uploads/2022/05/VALS-Submission-on-RACGP-Draft-Standards.pdf">every day</a>. When they are negligent, there must be accountability, space for truth, and justice. </p>
<p>The Victorian and Federal governments do not need any more “examples” of what can happen when health care is not equivalent to that in the community, and is not culturally safe. Aboriginal people are dying in custody, becoming disabled, or living with the preventable development or exacerbation of mental or physical health conditions as a result of negligent practices. </p>
<p>The writing is on the prison wall. </p>
<p>It is time for governments to care, it is time for them to act. </p>
<hr>
<p><em>This article was written with permission from Apryl Day to write about Aunty Tanya Day, and the family members, whom VALS represents, of Veronica Nelson, Ms Calgaret, and Michael Suckling.</em></p><img src="https://counter.theconversation.com/content/180558/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andreea Lachsz is the Head of Policy, Communications and Strategy at the Victorian Aboriginal Legal Service. VALS is representing the family members of Ms Veronica Nelson, Ms Calgaret, and Michael Suckling in coronial investigations/inquests into their deaths in custody.</span></em></p><p class="fine-print"><em><span>Nerita Waight runs the Victorian Aboriginal Legal Service which receives funding from Department of Justice and Community Safety and Corrections Victoria . Nerita is currently a member of the Victorian Women’s Correctional Services Committee. </span></em></p><p class="fine-print"><em><span>Sarah Schwartz is a Senior Lawyer / Advocate at the Victorian Aboriginal Legal Service and acts for family members of Veronica Nelson, Ms Calgaret and Michael Suckling in coronial proceedings into their deaths in custody.</span></em></p>Victorian prisons provide limited access to adequate health care, particularly for Aboriginal and Torres Strait Islander people. Coronial inquests into deaths in custody show something must be done.Andreea Lachsz, PhD Candidate, University of Technology SydneyNerita Waight, Chief Executive Officer - Victorian Aboriginal Legal Service, Indigenous KnowledgeSarah Schwartz, Lecturer, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1581312021-05-20T04:38:36Z2021-05-20T04:38:36ZComprehensive Indigenous health care in prisons requires federal funding of community-controlled services<figure><img src="https://images.theconversation.com/files/398225/original/file-20210502-21-ltaw9c.jpg?ixlib=rb-1.1.0&rect=71%2C369%2C9333%2C5947&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Prisons need to improve services for chronic conditions, mental health, and palliative care.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/">Andrew Mercer/ Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><a href="https://apo.org.au/node/30017">The Royal Commission into Aboriginal Deaths in Custody Report</a> made over 200 directives about improving the health of people in prisons in its 339 recommendations in 1991. One of these recommendations included additional funding to provide better health services for Aboriginal and Torres Strait Islander people in prison. </p>
<p>Aboriginal and Torres Strait Islander people are over-represented in prisons. They are <a href="https://www.abs.gov.au/statistics/people/crime-and-justice/prisoners-australia/latest-release">15.6 times more likely to be incarcerated than non-Indigenous Australians</a>.</p>
<p>Yet, there are virtually <a href="https://www.racgp.org.au/running-a-practice/practice-standards/standards-for-other-health-care-settings/health-services-in-australian-prisons">no staff skilled in engaging with cultural protocols</a> in health services in prisons. And current policies and procedures do little to extend cultural care to families when the death of an Aboriginal or Torres Strait Islander person in prison has occurred. </p>
<p>The royal commission and the United Nations recommend people in prisons have access to health care equivalent to what is available in the community. However, the system is still strained, as the multiple deaths of Aboriginal people in custody in recent months, <a href="https://indigenousx.com.au/daily-reporting-wayne-fella-morrison-inquest/">inquests</a> revealing gaps in health care, and a <a href="https://www.parliament.nsw.gov.au/la/papers/Pages/tabled-paper-details.aspx?pk=79426">health report tabled to NSW Parliament</a> make clear. </p>
<p><a href="https://apo.org.au/node/311817">A critique of the royal commission’s implementation of recommendations</a> also highlights several areas for urgent attention.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-the-planned-ndis-reforms-discriminate-against-aboriginal-and-torres-strait-islander-people-160183">Here's why the planned NDIS reforms discriminate against Aboriginal and Torres Strait Islander people</a>
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<h2>National frameworks silent on prisoner health</h2>
<p>The restructure of prisoner health care from state correctional services to state health departments in the last two decades in most Australian jurisdictions has been touted as one positive reform after the royal commission. </p>
<p>But it failed to recognise that state health departments make miniscule allocations to health care for Aboriginal and Torres Strait Islander people – the commonwealth largely has responsibility for this.</p>
<p>And because prisons fall under state and territory responsibility, prison health is also rarely mentioned in national frameworks. <a href="https://www.health.gov.au/resources/publications/national-strategic-framework-for-chronic-conditions">The National Strategic Framework for Chronic Conditions</a> makes no mention of prisons, despite people in prison disproportionately experiencing chronic conditions.</p>
<p>The <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/natsih-plan">National Aboriginal and Torres Strait Islander Health Plan</a> acknowledges the over-representation of Aboriginal and Torres Strait Islander people in prison and their greater risk of suicide and drug overdose after being released, but it offers no leadership on state and territory action.</p>
<p>The recent inclusion of a justice target in the <a href="https://apo.org.au/node/311463">Closing the Gap framework</a> is likewise not focused on improving health services in prisons. It only aims to reduce Indigenous adult prison numbers by 15% and youth detention by 30%. </p>
<p>Currently, over 140 Aboriginal and Torres Strait Islander community-controlled health organisations operate across Australia, with membership to the <a href="https://www.naccho.org.au/">National Aboriginal Community Controlled Health Organisation</a>. </p>
<p>Data indicate Aboriginal and Torres Strait Islander people have low levels of access to mainstream government services compared to community-controlled health services. These health services are also allocated <a href="https://www.researchgate.net/publication/283728861_Indigenous_health_expenditure_deficits_obscured_in_Closing_the_Gap_reports">disproportionately less funding</a> than mainstream services.</p>
<p>And since the royal commission, there have been few funding schemes to support these health services to work in or with prisons. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-families-of-indigenous-people-who-die-in-custody-need-a-say-in-what-happens-next-159127">The families of Indigenous people who die in custody need a say in what happens next</a>
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</em>
</p>
<hr>
<h2>Indigenous health care barriers in prisons</h2>
<p>There are other barriers to Aboriginal and Torres Strait Islander people receiving adequate health care in prison settings.</p>
<p>Prison health organisations <a href="https://www.researchgate.net/publication/349283966_Strengthening_Indigenous_Australian_Perspectives_in_Allied_Health_Education_A_Critical_Reflection">rarely meet Aboriginal and Torres Strait Islander staff targets</a>, or retain them in leadership roles. Members of the prison workforce have often acknowledged they “need cultural competence training”. </p>
<p>It is little wonder Aboriginal and Torres Strait Islander people <a href="https://vimeo.com/431642089">report frequent experiences of racism in mainstream services</a>.</p>
<p>Aboriginal and Torres Strait Islander health services also rely on fee-for-service income via payments from Medicare. But prisoners do not have access to Medicare. </p>
<p>As Professor Peter O’Mara, the chair of the Royal Australasian College of General Practitioners Aboriginal and Torres Strait Islander Health Council, <a href="https://www1.racgp.org.au/newsgp/clinical/expert-backs-racgp-calls-for-access-to-specific-me">explains</a>, </p>
<blockquote>
<p>If you’re a prisoner, you lose your right to Medicare. That means if an Aboriginal health service wants to provide support, they can’t bill Medicare.</p>
</blockquote>
<p>This essentially locks Aboriginal and Torres Strait Islander community-controlled health services out of delivering health care in prisons. A change has repeatedly been sought, but has not occurred.</p>
<p>In addition, prisons face new challenges due to Australia’s ageing prisoner population. Research highlights a <a href="https://journals.sagepub.com/doi/10.1177/1039856219891525">long-term shortage of mental health clinicians in prisons</a>. Palliative care specialists and nurses with palliative care training are <a href="https://www.caresearch.com.au/caresearch/TabId/3781/ArtMID/6000/ArticleID/1686/National-Palliative-Care-in-Prison-PiP-Project.aspx">almost entirely missing</a>.</p>
<h2>Aboriginal community-controlled organisations in prisons</h2>
<p>Reducing the over-representation of Aboriginal and Torres Strait Islander people in prisons is one part of addressing health inequity. </p>
<p>Another is improving people’s overall health and wellbeing in the community, which could potentially reduce their contact with the criminal justice system. Recommendation 188 of the royal commission said the self-determination of Aboriginal and Torres Strait Islander people is key to this.</p>
<p>The royal commission also outlined how Aboriginal health services could deliver self-determined improvements in prison health services. </p>
<p>It recommended governments invite Aboriginal health services to deliver care in areas where they already operate, or where Indigenous people are particularly over-represented in the prison population. That hasn’t happened.</p>
<p>The royal commission also recommended Aboriginal health services be included in health planning decisions, including:</p>
<ul>
<li><p>recommendations 127 and 252: examining delivery of medical services to people in police custody and hospitals</p></li>
<li><p>recommendation 152: assisting with reviews and guiding prison health standards, including on cultural matters</p></li>
<li><p>recommendations 154 and 133: training prison health staff and police</p></li>
<li><p>recommendation 265: integrating Aboriginal health care with mental health and psychiatry</p></li>
<li><p>recommendation 283: operating early intervention programs to reduce the numbers of Indigenous people incarcerated</p></li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A person applying pressure to their arm where blood was taken." src="https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=335&fit=crop&dpr=1 600w, https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=335&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=335&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=421&fit=crop&dpr=1 754w, https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=421&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/400888/original/file-20210516-23-o8n0q9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=421&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The National Strategic Framework for Chronic Conditions makes no mention of prisons, despite people in prison disproportionately experiencing chronic conditions.</span>
<span class="attribution"><a class="source" href="http://www.unsplash.com/">nguy n hi p ufwC cmbaaI unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>Prisons need culturally safe care</h2>
<p>I’ve come to know an Aboriginal family whose loved one was diagnosed with a terminal illness in prison. The process for his release was under way, but there were gaps in communications and decisions between prison officials and his family. </p>
<p>He was so immobile and frail it was hard to believe he was still ultimately seen as a threat to community safety. He died alone in prison, despite his family having community-based end-of-life care arrangements approved on the traditional Country of his ancestors, according to their protocols. </p>
<p>His case notes were minimal, and there was no evidence of cultural care. The autopsy report still causes major confusion and trauma for his family, and they have had no support. </p>
<p>The family has lost all trust for governments, who they believe <a href="https://www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-framework/contents/background-material">betrayed their own policies</a> about culturally safe care.</p>
<p>This case illustrates why Aboriginal people with health issues should be diverted from police custody into health services where possible. This is vital because so many deaths in custody have been as a result of preventable health issues. </p>
<p>A nationally coordinated scheme is also required that funds prisons to work with Aboriginal and Torres Strait Islander community-controlled health services. These services could also provide relevant data in health planning for prisons. </p>
<p>The federal government must lead change; it is not interference in state and territory criminal justice systems when the focus is on Aboriginal and Torres Strait Islander people’s health and wellbeing.</p><img src="https://counter.theconversation.com/content/158131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Williams receives funding from the Medical Research Futures Fund, the National Health and Medical Research Council, the NSW Aboriginal Land Council, Cancer Australia and Commonwealth Health. She is affiliated with Croakey.org and Deadly Connections. </span></em></p>Despite the disproportionate numbers of Aboriginal people in prisons, there are near to no cultural protocols in place, and chronic illness is often not addressed.Megan Williams, Associate Professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1341062020-03-20T14:06:01Z2020-03-20T14:06:01ZCoronavirus: why prison conditions can be a perfect storm for spreading disease<p>The coronavirus pandemic presents one of most pressing public health challenges in a generation. <a href="https://theconversation.com/coronavirus-the-uk-approach-explained-133672">The UK government approach</a> is to limit the number of people who have the virus at any one time and protect the most vulnerable by decreasing the rate of transmission through hand washing and social distancing. But what happens when it is just about impossible to socially distance and you’re in a highly vulnerable group?</p>
<p>Prison environments can create a perfect storm for spreading disease. Inmates often live in unsanitary, <a href="https://howardleague.org/prisons-information/prison-watch/">overcrowded</a> conditions with <a href="https://www.theguardian.com/society/2018/oct/27/prisoners-dying-poor-care-services-prisons-mental-health-care-quality-commission-report">limited access to healthcare</a>.
In all countries, it is people from the <a href="http://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf">poorest and most marginalised</a> sections of the population who make up the bulk of those serving prison sentences. And many of them <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30466-4/fulltext">have diseases</a> such as tuberculosis, sexually transmitted infections and HIV/AIDS. </p>
<p>Incidence of these diseases in prisons is much higher than in the general population. And older prisoners over 60 are the <a href="http://www.prisonreformtrust.org.uk/Portals/0/Documents/Bromley%20Briefings/Winter%202019%20Factfile%20web.pdf">fastest growing group in prisons</a>. This is particularly concerning since death rates from the coronavirus disease (COVID-19) are highest in this group.</p>
<p>At the time of writing, <a href="https://www.theguardian.com/world/2020/mar/18/first-uk-prisoner-with-covid-19-confirmed-at-strangeways-manchester">the first case of COVID-19 in a British prisoner</a> has been confirmed at Strangeways prison in Manchester. A member of <a href="https://www.independent.co.uk/news/uk/home-news/coronavirus-prison-officer-highdown-hmp-surrey-test-positive-a9404931.html">prison staff has also tested positive</a> for COVID-19 in another prison. Other staff and prisoners have been placed in isolation as a precaution. </p>
<h2>‘Hard to keep clean’</h2>
<p>Clearly concerns of a wider outbreak of COVID-19 in prisons are valid, particularly given that prisoners enter custodial settings with a range of complex health needs. But prisons also expose them to further risks. <a href="https://www.sciencedirect.com/science/article/abs/pii/S1353829218303514">Our research</a> in a prison for young people shows the herculean task placed on prisoners to maintain their physical and mental health in overcrowded, unhygienic and confining conditions. </p>
<p>Even prior to the pandemic, young men in prison told us about the difficulties they faced in maintaining their personal hygiene and accessing appropriate materials and equipment to keep themselves and their environment clean. They said there was a lack of accessible health information. And much of what existed was in written format, despite many prisoner experiencing <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/36000/12-p168-2011-skills-for-life-survey.pdf">difficulties with literacy</a>. Overall, 72% of prisoners in our wider prison survey reported difficulties gaining access to information and services to help them maintain good health while in prison. </p>
<p>Our participants also spoke about the long periods of time locked away in their cell – sometimes shared with other prisoners – with some locked away for up to 22 hours a day. Our research found that this boredom often leads to stress and anger, as well as heightened health fears relating to contracting illnesses and the fear of dying alone in a prison cell. </p>
<p>We also found that access to emotional support was severely limited with restricted times available to contact friends and family. With heightened mistrust among prisoners, for many there was no one to turn to about concerns. While some might expect this of prison conditions, such social disconnection could, during a pandemic, increase stress and anxiety in ways that significantly damage prisoners’ health.</p>
<h2>Protecting prisoners</h2>
<p>Much of the difficulties seem to be down to broader structural constraints placed on prisoners. By the nature of their imprisonment, prisoners cannot plan or make decisions for themselves yet remain at most risk of infections and poorer health. </p>
<p>The Howard League for Penal Reform, a leading UK prison charity, has <a href="https://howardleague.org/blog/covid-19-measures-that-could-be-considered/">written</a> to the Ministry of Justice demanding precautions are taken to protect people in prison –- and thereby the wider population – from COVID-19. </p>
<p>In <a href="https://www.gov.uk/government/news/coronavirus-covid-19-prison-preparedness-lucy-frazer-statement">response</a>, prisons minister Lucy Frazer stated that good practice is being promoted on posters and that handwashing facilitates are available to all prisoners. Frazer also said that guidance has been issued about visits to prisons and that contingency plans are in place to protect staff and prisoners alike. </p>
<h2>Urgent action needed</h2>
<p>But it’s clear that urgent action is required to support and alleviate the concerns of prisoners and their families. Concerns around COVID-19 are even more stark considering that three Chinese provinces registered <a href="https://www.businessinsider.com/500-coronavirus-cases-reported-in-jails-in-china-2020-2?r=US&IR=T">more than 500 cases</a> in prisons. In Italy, <a href="https://www.independent.co.uk/news/world/europe/coronavirus-italy-prison-riots-death-toll-modena-foggia-alfonso-bonafede-a9396311.html">riots are reported</a> to have occurred in at least two dozen prisons after visits were stopped. In one prison at least 12 inmates died after they broke into a healthcare unit and overdosed on methadone. </p>
<p>We need a comprehensive plan from government and health authorities. This must include the ability to quickly detect and isolate cases and the introduction of improved hand washing facilities, stepped up cleaning regimes and personal hygiene protocols. </p>
<p>There should also be a clear and transparent flow of information to manage heightened anxieties. And particular focus on continued contact with family and friends outside of prison using virtual approaches, increasing credit on phone cards and better access to telephones. </p>
<p>Prisoners must also be encouraged to manage their wellbeing through cell based activities such as workouts, education opportunities and access to entertainment and hobbies. There may also be a case for reducing the prison population, which currently stands at around 84,000. </p>
<p>Releasing low category prisoners would free up capacity in what might be a period of staff shortages and increased cases. Iran has already taken this step to <a href="https://www.businessinsider.com/coronavirus-covid-19-iran-releases-eighty-five-thousand-prisoners-2020-3?r=US&IR=T">temporarily free about 85,000 prisoners</a> in an effort to combat the spread of COVID-19. </p>
<p>Prisons must not be forgotten during this epidemic. It’s also important to remember that staff come and go from these establishments and that most prisoners will be released at some point and will come back into society. Prisoner health and wellbeing cannot be seen as separate from our own.</p><img src="https://counter.theconversation.com/content/134106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anita Mehay has received funding from the Economic and Social Research Council.</span></em></p><p class="fine-print"><em><span>Jane Ogden has received funding from the Economic and Social Research Council.</span></em></p><p class="fine-print"><em><span>Rosie Meek has received funding from the Economic and Social Research Council.</span></em></p>Prisons are already a hotbed of disease, and without action COVID-19 could have catastrophic consequences behind bars.Anita Mehay, Research Fellow and Health Psychologist, UCLJane Ogden, Professor of Health Psychology, University of SurreyRosie Meek, Professor of Criminology & Psychology, Royal Holloway University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1307792020-03-04T21:13:21Z2020-03-04T21:13:21ZFuelling a crisis: Lack of treatment for opioid use in Canada’s prisons and jails<figure><img src="https://images.theconversation.com/files/318731/original/file-20200304-66106-13763lm.jpg?ixlib=rb-1.1.0&rect=287%2C8%2C5703%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Incarcerated people are often denied access to treatment for opioid use disorder. This October 2016 file photo shows corrections officer opening the door to a cell in the segregation unit at the Fraser Valley Institution for Women in Abbotsford, B.C. during a media tour.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>The opioid overdose crisis has <a href="https://health-infobase.canada.ca/sutance-related-harms/opioids">killed almost 14,000 Canadians since 2016</a>. </p>
<p>One flashpoint of this crisis is Canada’s correctional facilities. <a href="https://www.csc-scc.gc.ca/research/sr-18-02-en.shtml">Opioid-related deaths are increasing</a> among incarcerated people. Post-release, their prospects are even worse: in the two weeks after release, a prisoner’s risk of overdose is <a href="https://doi.org/10.9778/cmajo.20150098">more than 50 times higher</a> than in the general population. <a href="https://doi.org/10.1371/journal.pone.0157512">One in 10 of all overdose deaths</a> is a prisoner released in the past year. </p>
<p>Despite this, our prisons and jails often delay or deny access to evidence-based treatments for opioid use disorder and fail to ensure appropriate supports on release.</p>
<h2>Opioid agonist therapy</h2>
<p>Governments have brought <a href="https://www.cbc.ca/news/canada/toronto/ontario-opioid-class-action-suit-1.5394066">class-action lawsuits against pharmaceutical companies</a> and <a href="https://www.justice.gov/opa/pr/second-appalachian-region-prescription-opioid-strikeforce-takedown-results-charges-against-13">prosecuted overprescribing doctors</a>. Canada’s federal government is <a href="https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis.html">taking action on opioids</a>. </p>
<p>But our divergent experiences as a physician, a legal academic and a formerly incarcerated harm reduction activist have taught us that much of the responsibility lies with government itself — specifically, its failure to provide prisoners with timely access to opioid agonist therapy (OAT) and ensure post-release continuity of treatment.</p>
<p>People incarcerated in Canada’s federal prisons and provincial-territorial jails are highly likely to have experienced <a href="https://doi.org/10.2105/AJPH.2018.304855">childhood trauma</a>, poverty and the corrosive effects of <a href="https://www.oci-bec.gc.ca/cnt/rpt/annrpt/annrpt20162017-eng.aspx#s6">racism</a> and <a href="https://www.oci-bec.gc.ca/cnt/comm/press/press20200121-eng.aspx">colonialism</a>. They are highly likely to struggle with <a href="https://doi.org/10.1111/add.13877">addictions</a> and <a href="https://www.cfp.ca/content/62/3/215">mental illness</a>. Incarcerated people, like many on the outside, use drugs as a form of coping.</p>
<p>OAT provides a medication (usually buprenorphine/naloxone or methadone) to prevent drug cravings and withdrawal symptoms. It is the <a href="https://doi.org/10.1503/cmaj.170958">first-line treatment for opioid use disorder</a> and the standard of community-based care across Canada. <a href="https://doi.org/10.1371/journal.pmed.1003002">OAT saves lives</a>, <a href="https://doi.org/10.1016/S0140-6736(16)30769-3">reduces HIV and hepatitis C transmission</a>, improves a host of social and psychological outcomes and is associated with a decreased risk of <a href="https://doi.org/10.1111/add.14059">future criminal charges</a> and <a href="https://www.csc-scc.gc.ca/research/005008-0322-eng.shtml">imprisonment</a>.</p>
<h2>Legal standards for health care</h2>
<p><a href="https://laws-lois.justice.gc.ca/eng/acts/C-44.6/index.html">Canadian</a> and <a href="https://undocs.org/A/RES/70/175">international</a> law obliges prisons to provide incarcerated people with health care at community standards. But <a href="https://doi.org/10.1016/j.drugalcdep.2018.09.003">research</a>, <a href="https://www.mcscs.jus.gov.on.ca/english/Deathinvestigations/Inquests/Verdictsandrecommendations/OCCInquestHWDC.html">coroners’ inquests</a> and <a href="https://cp-ep.org/wp-content/uploads/2019/09/JAIL-Hotline_Q1-Report_Final.pdf">prisoners’ rights groups</a> all tell a similar story: too often, people are not provided addictions treatment on admission, whether or not they were being treated in the community. This means they go into acute withdrawal and are at increased risk of use, relapse and overdose. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cells at the Central Nova Scotia Correctional Facility in Halifax in May 2018. File photo.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
</figcaption>
</figure>
<p>The result? Missed opportunities to provide care to people who desperately need it, and deaths with little oversight or accountability. While we pursue progressive solutions like <a href="https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Decriminalization-Controlled-Substances-Policy-Brief-2018-en.pdf">decriminalization</a> and <a href="http://capud.ca/sites/default/files/2019-03/CAPUD%20safe%20supply%20English%20March%203%202019.pdf">safe supply</a>, we must urgently make OAT available to everyone incarcerated who would benefit.</p>
<p>In Nova Scotia, the provincial health authority is responsible for delivering health care in the province’s jails, rather than Correctional Services, as is common in other provinces. Nova Scotia’s jails have a blanket policy of<a href="https://www.cbc.ca/news/canada/nova-scotia/jail-medication-mental-health-methadone-withheld-1.3708938">not providing prisoners with OAT unless they are already on it when they arrive</a>. Those who are not on therapy suffer through withdrawal or find ways to keep using illicitly inside. This is a clear violation of the government’s legal obligation to provide equivalent health care in detention. </p>
<p>Provinces like Ontario, which have celebrated Nova Scotia’s wisdom in making correctional health care the responsibility of the Department of Health and Wellness instead of corrections, should take note: simply shifting responsibility is not enough to ensure sound policy.</p>
<h2>Feeding a crisis by limiting OAT</h2>
<p>As people who have lived or worked in prisons and with people who have been incarcerated, we have seen first-hand how limiting OAT in prison feeds the opioid crisis inside. It increases the demand for illicit drugs to be smuggled in or diverted. </p>
<p>In some institutions, those receiving OAT are subjected to a <a href="https://impactethics.ca/2019/11/19/methadone-access-in-prisons-stop-strip-searching/">daily strip search: a degrading and re-traumatizing practice</a>. Others who want the medication to prevent their own withdrawal symptoms target prisoners receiving OAT. People soon start diverting their medication, for instance by vomiting it up and straining it through a sock for someone else to use. If someone says no to a demand to divert their OAT, they may be subject to violence. </p>
<p><a href="https://www.cbc.ca/news/canada/nova-scotia/methadone-nova-scotia-jail-burnside-clayton-cromwell-1.3836706">If someone is caught diverting, their OAT is discontinued</a>, placing them at high risk of overdose. If treatment were not so intensely restricted, these adverse events could be reduced or eliminated.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=651&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=651&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=651&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=818&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=818&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=818&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Denying access to opioid agonist treatment using medications such as methadone (above) feeds the opioid crisis in prisons and jails.</span>
<span class="attribution"><span class="source">AP Photo/The Evening News, Chuck Branham</span></span>
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</figure>
<p>There are a few glimmers of hope. Rhode Island implemented a statewide correctional OAT program and saw a <a href="https://doi.org/10.1001/jamapsychiatry.2017.4614">60.5 per cent reduction in one-year overdose mortality after release</a>. In 2016, people incarcerated in British Columbia launched a <a href="https://www.theglobeandmail.com/news/british-columbia/bc-prisoners-get-addiction-therapy-after-settlement-in-charter-challenge/article29648890/">Charter challenge over policies limiting access to OAT in B.C. jails</a>; while that lawsuit settled, it contributed to increased access to the treatment. Access expanded further when the B.C. Ministry of Health took over provincial correctional health services in 2017. </p>
<p>But elsewhere, <a href="https://www.csc-scc.gc.ca/health/002006-2007-en.shtml">access to OAT in federal prisons</a> or provincial jails continues to be denied or unreasonably delayed. This has led B.C.’s Prisoners’ Legal Services to launch a <a href="https://prisonjustice.org/wp-content/uploads/2018/12/OST-rep-complaint-to-CHRC-20180604-narrative-1.pdf">representative human rights complaint on behalf of federal prisoners with opioid use disorder</a>, focused on access to OAT.</p>
<p>Federal, provincial and territorial governments need to step up and tackle the opioid epidemic at its flashpoint: our prisons and jails. Timely access to OAT for every incarcerated person who could benefit is required to turn the tide of death and ill health. Until we make these changes, Canada’s most vulnerable will continue to endure extraordinary suffering at the hands of our government and the body count will continue to rise.</p><img src="https://counter.theconversation.com/content/130779/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Bodkin receives funding from the Canadian Research Initiative in Substance Misuse and is an employee of Hamilton Health Sciences. She is affiliated with the Prison Health Member Interest Group at the College of Family Physicians of Canada. Her views represent only her own opinions.</span></em></p><p class="fine-print"><em><span>Matthew Bonn is an employee of Mainline Needle Exchange as a Frontline Harm Reduction Support Worker. He is the Lead Peer in Peers Assisting & Lending Support (PALS) which is a Harm Reduction Prison Outreach Program funded by PHAC. He is also a Research Assistant with Dalhousie & SMU. Currently receives funding from Gilead & AbbVie for Hepatitis C Elimination. </span></em></p><p class="fine-print"><em><span>Sheila Wildeman is a Vice-Chair of East Coast Prison Justice Society and a member of Dalhousie's Health Law Institute. </span></em></p>Urgently needed treatment for opioid use disorder is often denied to incarcerated people, feeding the crisis in prisons and jails.Claire Bodkin, Resident Physician, Department of Family Medicine, McMaster UniversityMatthew Bonn, Frontline Harm Reduction Worker & Health Promotion Research Assistant, Dalhousie UniversitySheila Wildeman, Associate professor, Schulich School of Law, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/741642017-05-23T20:22:51Z2017-05-23T20:22:51ZHow do we choose who gets the flu vaccine in a pandemic – paramedics, prisoners or the public?<figure><img src="https://images.theconversation.com/files/169628/original/file-20170516-11959-g48mkm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When resources are scarce, deciding who should be front of the queue for the flu vaccine is an ethical minefield.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/542841772?src=klO8E652QSlCv0lK2AJk8A-1-68&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Ideally, everyone who needs to be immunised against influenza has access to the flu vaccine. But in a <a href="http://www.who.int/csr/disease/swineflu/frequently_asked_questions/pandemic/en/">pandemic</a>, initially there will be more people needing protection than there are doses.</p>
<p>So how do authorities decide who to vaccinate first? Is it based on who’s most vulnerable? Who would benefit most? Or are other factors at play?</p>
<h2>The next global pandemic</h2>
<p>The World Health Organisation <a href="http://apps.who.int/iris/handle/10665/20355">has urged nations</a> to plan for future pandemics, which it predicts <em>will</em> happen when a highly contagious and deadly disease emerges and spreads around the world rapidly. </p>
<p>The potential impact of a pandemic is, however, difficult to predict. The last severe pandemic, estimated to have claimed about 50 million lives, was <a href="https://wwwnc.cdc.gov/eid/article/12/1/pdfs/05-0979.pdf">Spanish flu</a> (1918). The <a href="https://www.cdc.gov/sars/about/fs-sars.html">severe acute respiratory syndrome or SARS outbreak</a> (2003) and <a href="http://www.who.int/csr/disease/swineflu/frequently_asked_questions/about_disease/en/">swine flu</a> (H1N1) pandemic (2009) were mild by comparison.</p>
<p>In a pandemic, vaccines may not be available immediately and could take <a href="http://www.who.int/immunization/newsroom/PI_QAs/en/">four to six months</a> to produce. Once available, difficult distribution decisions arise. </p>
<p>Assuming Australia can manufacture a stockpile, the issue may not be so much scarcity, but who to protect first. Decisions need to be explained to the public, and some may be controversial or unpopular. </p>
<h2>Health workers first</h2>
<p>A lot will depend on the severity of the outbreak. A highly infectious and deadly disease that can kill anyone regardless of factors affecting immunity, such as existing ill health, will make medical needs roughly equal. This would be the case in a severe pandemic. An outbreak like H1N1, where some people are less likely to recover if infected, can be called a mild pandemic.</p>
<p>In either case, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/519F9392797E2DDCCA257D47001B9948/$File/AHMPPI.pdf">national plans</a> stress the importance of protecting health workers first, including doctors, nurses, paramedics and other front-line medical personnel. This would limit absenteeism, prevent health workers from transmitting disease and ensure treatment was available to those in need.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170251/original/file-20170522-12254-yaagjz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The public is likely to support priority vaccination for health care workers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/430440025?src=x1A7SWzETMXxScAEY1wZ9Q-1-18&size=medium_jpg">from www.shutterstock.com</a></span>
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</figure>
<p>Although <a href="http://www.who.int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf">several ethical principles</a> support prioritising health workers, there may be conflict. </p>
<p>The ethical principle of <a href="http://www.iep.utm.edu/util-a-r/">utilitarianism</a> would have us protect people who promote the greatest good, in this case treating the most patients. So, if we follow this principle, it may make sense to prioritise those who are socially valuable, like doctors.</p>
<p>However, a principle of fairness and non-discrimination would constrain us from giving the flu vaccine to everyone who was perceived to be socially valuable, like poets, philosophers or footballers. So, we’d still need to define who was socially valuable.</p>
<p>A more general egalitarian principle might be that prioritising health workers increases the chances that <em>everyone</em>, including the worst off, receives treatment. </p>
<p>Whichever ethical principle you apply, the community would likely support priority protection for those who risk their lives for others, such as front-line health workers.</p>
<h2>Vulnerable groups next, but not always</h2>
<p>In a mild pandemic, compromised immunity makes some people more vulnerable. Children, for example, were <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/519F9392797E2DDCCA257D47001B9948/$File/Impact.pdf">more likely to be hospitalised</a> during the H1N1 pandemic and are likely to be vulnerable in terms of infection, complication and mortality in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504394/">future pandemics</a>. </p>
<p>So, it is likely to be uncontroversial to prioritise people facing a greater risk of dying from infection, including the very young, pregnant women, those with existing ill health and the elderly. </p>
<p>However, we still need to weigh up vulnerabilities and the benefits or fairness of possible vaccine allocations. </p>
<p>For example, would age-based rationing be fair? According to the <a href="https://bmcmedethics.biomedcentral.com/articles/10.1186/1472-6939-1-1">fair innings argument</a>, a child, who is yet to enjoy a “<em>fair</em> share of life”, would have a stronger claim to a scarce and vital resource than an elderly person. This position does not, however, specify what would be a fair share of life and thus what would be a cut-off point for <a href="http://www.who.int/csr/resources/publications/cds_flu_ethics_5web.pdf">prioritisation</a>.</p>
<p>Alternatively, utilitarianism and promoting the greatest good might guide us to prioritise children because of life years gained, or protecting those needed for the future (maximising good outcomes). This would mean prioritising youth ahead of, for example, the terminally ill.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170252/original/file-20170522-12226-1mykxzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">According to the ‘fair innings’ argument, vaccines need to be prioritised for children so they can have a ‘fair share of life’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/241370368?src=RjRr4LqDxHDVN_fHNvrO_g-5-7&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Although the community would likely support prioritising children, they may be less keen on measures that deny or delay lifesaving resources for the medically vulnerable. And terminally ill patients and those over a certain age may support prioritising the young.</p>
<p>The best general principle may be that when there is no relevant difference between two patients, each should have an equal chance of protection. But then we need to decide whether age or life-years gained are relevant differences. </p>
<p>When there is no difference, a vaccine lottery may be fairest, where everyone has the same chance of receiving help.</p>
<h2>Poor and disadvantaged need protection</h2>
<p>Overcrowded living and poor sanitation promote the spread of disease. And contagion in a disadvantaged, or impoverished community, can spread rapidly. So a pandemic may disproportionately impact the less well off.</p>
<p>So, the greater likelihood of becoming infected and suffering economic and social losses should entitle disadvantaged groups to special protection. This is because of the wider social benefits of interrupting disease spread, limiting vulnerability to harm and preventing stigmatisation of groups who, through no fault of their own, spread disease.</p>
<p>Due to overcrowding, lack of infrastructure and lack of health and education services, Australia’s <a href="https://www.mja.com.au/journal/2005/182/5/immunisation-reducing-health-inequality-indigenous-australians?=ip_login_no_cache%3D322415a6ae54ce1b77aedd0cecadcc88">Indigenous population</a> is especially vulnerable to infectious diseases. So part of a just pandemic response must include limiting this burden.</p>
<h2>Prisoners and obese people at risk too</h2>
<p>Not all vulnerable groups are equal in the eyes of the public. So prioritising vaccination for some groups – like <a href="https://academic.oup.com/phe/article-abstract/5/3/283/1437450/Prioritizing-Vaccine-Access-for-Vulnerable-but">prisoners or people who are severely obese</a> as happened in several Canadian jurisdictions in 2009 – can be unpopular if the public blames these vulnerabilities on poor life choices.</p>
<p>With prisoners, close living and regular person-to-person contact means a highly contagious disease could spread quickly. Infected people returning to the community could pose a health risk to others. In Canada, public disapproval caused some decision makers to <a href="http://montreal.ctvnews.ca/health-minister-says-vaccination-of-inmates-unacceptable-1.450402">retreat from the proposal</a>. If adopted, authorities would likely secure public support by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685700/">communicating the benefits</a> to community health.</p>
<p>Obese people have a <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(06)70523-0/fulltext?rss=yes">greater risk of becoming sick and dying</a> from infectious diseases. So, protecting this group is consistent with a principle of non-discrimination and prioritising the vulnerable, regardless of any possible perception that vulnerability is the fault of the individual. </p>
<h2>Tough decisions will test us all</h2>
<p>Just because allocating vaccines to particular groups can be unpopular is no reason to stop authorities from doing so.</p>
<p>Whether unpopular measures turn into some form of <a href="https://academic.oup.com/phe/article-abstract/5/3/283/1437450/Prioritizing-Vaccine-Access-for-Vulnerable-but">social unrest or dissent</a> will likely turn on how effectively authorities communicate their ethical decision-making to the public and secure support before and during the pandemic. </p>
<p>In some cases of vulnerability, there may not be the requisite political will to make just, yet unpopular, decisions. The next pandemic may not only claim many lives it will also test our character and that of our institutions.</p><img src="https://counter.theconversation.com/content/74164/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Connal Lee does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australia needs to think about who gets the flu vaccine first before the next pandemic strikes and supplies run low.Connal Lee, Associate Lecturer, Philosophy, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/739122017-03-13T19:20:00Z2017-03-13T19:20:00ZPrisoners are excluded from the NDIS – here’s why it matters<figure><img src="https://images.theconversation.com/files/159875/original/image-20170308-14951-ofomdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The NDIS is designed to provide personalised support to all Australians with a disability.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The National Disability Insurance Scheme (NDIS) is <a href="https://www.google.com.au/search?q=Australian+Government.+National+Disability+Insurance+Scheme+Act+2013.+Canberra%3A+Austalian+Government%2C+2013&oq=Australian+Government.+National+Disability+Insurance+Scheme+Act+2013.+Canberra%3A+Austalian+Government%2C+2013&aqs=chrome..69i57.606j0j4&sourceid=chrome&ie=UTF-8">designed to provide access</a> to personalised supports and services for all Australians with a disability. However, the NDIS specifically <a href="https://www.legislation.gov.au/Details/F2013L01063">excludes prisoners</a>. </p>
<p>Inadequate disability-specific services in prison make this exclusion inconsistent with conditions in the <a href="https://cdn.penalreform.org/wp-content/uploads/1957/06/ENG.pdf">United Nations’ “Mandela Rules”</a>. These set out minimum requirements for the treatment of prisoners. They state health care in prison must be equivalent to that in the community. </p>
<p>Excluding prisoners from the NDIS is also inconsistent with Articles 12 and 13 of the <a href="http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf">UN Convention on the Rights of Persons with Disabilities</a>. These state that people with disabilities must have equal legal capacity with others in all aspects of life. This includes equal access to, and within, the justice system.</p>
<p><a href="https://www.alrc.gov.au/sites/default/files/pdfs/publications/alrc_124_whole_pdf_file.pdf">Australia ratified</a> the UN convention in 2008 and the optional protocol in 2009. In December 2015, Australia and all other members of the UN General Assembly <a href="http://www.un.org/en/ga/search/view_doc.asp?symbol=A/70/PV.80">unanimously adopted</a> the Mandela Rules.</p>
<p>This means the federal government, by excluding prisoners from the NDIS, is discriminating against prisoners with a disability in direct contravention of our international human rights obligations. </p>
<p>People with disability are more at risk of incarceration and, without adequate support, of re-offending. Interrupting care also puts those with a disability at risk of further incarceration. </p>
<p>Further, denying services to prisoners with a disability doubly disadvantages Indigenous prisoners and potentially widens the gap of Indigenous disadvantage.</p>
<h2>Disability increases incarceration risk</h2>
<p>Disability often restricts workplace, school and social participation. People with a disability are at increased risk of poverty and social exclusion. They often have complex health and social needs, and experience barriers to accessing health and social services. </p>
<p>Without appropriate support, <a href="https://assets.justice.vic.gov.au/corrections/resources/0423a0c6-958e-4847-904a-61032a59a7d9/intellectual_disability_in_the_victorian_prison_system.pdf">disability can increase the risk</a> of incarceration. Nearly all forms of disability are more common among prisoners than the general population. A study of inmates across Queensland estimated <a href="https://www.ncbi.nlm.nih.gov/pubmed/23723292">one in ten prisoners</a> had an intellectual disability – although inclusion of <a href="https://www.adhc.nsw.gov.au/__data/assets/file/0003/264054/Intellectual_and_cognitive_disability_in_criminal_justice_system.pdf">cognitive and psychiatric impairment</a> dramatically increases the proportion with disability.</p>
<p>People with a disability are <a href="http://www.tandfonline.com/doi/full/10.3402/vgi.v3i0.14834">particularly vulnerable</a> to manipulation or assault in prison. They also experience <a href="https://www.ncbi.nlm.nih.gov/labs/articles/28054417/">decreased access</a> to prison services and activities. </p>
<h2>Indigenous prisoners with disability</h2>
<p>The rate of Indigenous incarceration is around <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4517.0%7E2016%7EMain%20Features%7EPrisoner%20characteristics,%20Australia%7E4">13 times greater</a> than that of non-Indigenous prisoners. This inequality gap <a href="http://www.disabilityjustice.edu.au/wp-content/uploads/2015/10/The-Booming-Industry-continued-Australian-Prisons-2017-.pdf">increased by 50%</a> between 2001 and 2016. </p>
<p>The <a href="https://theconversation.com/our-3b-a-year-system-is-flying-blind-in-supporting-ex-prisoners-39999">true magnitude of the inequality is actually even greater</a>. That’s because estimates are based on a daily snapshot of the prison population and Indigenous people churn through this system at a faster rate than non-Indigenous people. </p>
<p>Although Indigenous prisoners are <a href="https://www.ncbi.nlm.nih.gov/labs/articles/28054417/">more likely</a> than non-Indigenous prisoners to experience a disability, their disabilities are <a href="https://www.ncbi.nlm.nih.gov/pubmed/28090702">less likely to be identified</a>. And among prisoners with a disability, those who identify as Indigenous are <a href="https://www.adhc.nsw.gov.au/__data/assets/file/0003/264054/Intellectual_and_cognitive_disability_in_criminal_justice_system.pdf">less likely</a> to have received disability services before incarceration. This means Indigenous people with a disability can find the experience of incarceration particularly harrowing. </p>
<p>A lack of consistent care likely perpetuates the inequalities that Indigenous people experience prior to incarceration.</p>
<h2>More likely to return to custody</h2>
<p>Transition to the community requires people with a disability to <a href="http://www.aic.gov.au/media_library/publications/tandi_pdf/tandi528.pdf">adapt rapidly to new circumstances</a> and interact with a complex service environment. </p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1111/jir.12349/full">Our recent research</a> found the majority of prisoners with intellectual disability likely remain unidentified and unsupported when they return to the community. They often <a href="https://www.ncbi.nlm.nih.gov/pubmed/28090702">lack the capacity</a> to look after their health, including through access to health services. </p>
<p>Not surprisingly, intellectual disability is a <a href="https://assets.justice.vic.gov.au/corrections/resources/0423a0c6-958e-4847-904a-61032a59a7d9/intellectual_disability_in_the_victorian_prison_system.pdf">risk factor</a> for return to custody. Ex-prisoners with generally poorer health are <a href="http://www.emeraldinsight.com/doi/abs/10.1108/IJPH-09-2014-0027?mobileUi=0&journalCode=ijph">more likely</a> to return to custody. </p>
<p>The federal government has repeatedly refused to reconsider a clause in the <a href="https://www.legislation.gov.au/Details/C2016C01004">Health Insurance Act (1973)</a> that excludes prisoners from Medicare and PBS subsidies. A <a href="https://theconversation.com/inmates-are-excluded-from-medicaid-heres-why-it-makes-sense-to-change-that-71976">similar exclusion</a> exists in the much-maligned US prison system. </p>
<p>This inequity persists despite calls from the <a href="https://ama.com.au/position-statement/health-and-criminal-justice-system-2012">Australian Medical Association</a>, <a href="https://www.phaa.net.au/documents/item/239">Public Health Association of Australia</a> and others for reform. </p>
<p>The NDIS exclusion is yet another substantial barrier between disability service providers and prisoners. By implementing this exclusion, the government is flying in the face of compelling evidence that interruptions in care for people with a disability increase the risk of poor health and re-offending.</p>
<p>Effectively meeting the health, social and cultural needs of Indigenous people with a disability in custody is central to ending the cycle of incarceration and closing the gap. The government’s decision to actively exclude prisoners from the NDIS will exacerbate an already unsettling track record of contravening the <a href="http://gh.bmj.com/content/1/1/e000018">human rights</a> of Indigenous Australians.</p><img src="https://counter.theconversation.com/content/73912/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jesse Young is supported by a Melbourne International Research Scholarship. Our research studies mentioned here received funding support from the National Health and Medical Research Council and the Australian Institute of Criminology. </span></em></p><p class="fine-print"><em><span>Stuart Kinner receives funding from the National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC). He is affiliated with the Public Health Association of Australia, National Prisoner health Information Committee, National Youth Justice Health Advisory Group, and Academic Consortium on Criminal Justice Health. </span></em></p>By excluding prisoners from the NDIS, the federal government is discriminating against prisoners with a disability in direct contravention of our international human rights obligations.Jesse Young, Research Fellow and PhD Candidate, The University of MelbourneStuart Kinner, Professor, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/492932015-11-05T19:04:35Z2015-11-05T19:04:35ZHere’s how we can stop putting Aboriginal people with disabilities in prison<p><a href="https://www.mhdcd.unsw.edu.au/">Our research</a> shows how Australia imprisons thousands of Aboriginal people with mental and cognitive disabilities each year because of a lack of understanding, and a dearth of community-based services and support. </p>
<p>It also shows what can be done about this shameful breach of human rights.</p>
<p>We have data on hundreds of Aboriginal people with mental and cognitive disabilities that tells the story of their early and regular contact with police, courts and custody. And Aboriginal researchers in our team have spoken with Aboriginal people with disabilities, their families, communities and service providers in New South Wales and the Northern Territory so we can better understand their experiences. </p>
<h2>What will make a difference</h2>
<p>Based on that research, we are recommending these principles and strategies to underpin policy reform:</p>
<p><strong>1. Self-determination</strong></p>
<p>Self-determination is key to improving the human rights and well-being of Aboriginal people with mental and cognitive disabilities. This means an <a href="https://www.humanrights.gov.au/right-self-determination">ongoing process of choice</a> on matters affecting them, their families and communities.</p>
<p>Community-led knowledge, solutions and services to respond to the over-representation of Aboriginal people with mental and cognitive disabilities in prison should be properly supported and resourced. And we must ensure the input of Aboriginal women on their needs and aspirations given their particular disadvantage and vulnerability in the criminal justice system. We also need better services for Aboriginal people in regional and remote areas. </p>
<p>Education and cultural competency for non-Aboriginal organisations and people working in this area is crucial.</p>
<p><strong>2: Person-centred support</strong></p>
<p>Person-centred support that puts Aboriginal people with mental and cognitive disabilities at the centre of their care and that’s appropriate to their culture and context is essential. People should be supported to make decisions about their own needs and recovery. </p>
<p>Disability services and the National Disability Insurance Scheme (NDIS) need an overt strategy to support Aboriginal people with disabilities in the criminal justice system. This initiative should also cover the needs of people with borderline intellectual disability and fetal alcohol syndrome disorder (FASD), who may not be recognised as having a disability but who often need targeted support so they don’t end up in prison.</p>
<p>Specialised housing, services and treatment options should be available in the community to prevent incarceration and improve well-being.</p>
<p><strong>3. A holistic and flexible approach</strong></p>
<p>A determined holistic and flexible approach to services for Aboriginal people with mental and cognitive disabilities is needed from a young age to avoid contact with the criminal justice system. Early recognition by maternal and infant health services, early childhood and school education, community health services and police is important. </p>
<p>Governments should provide positive and preventive support that allows Aboriginal children and young people with disability to develop and flourish. We need supported housing and case management options for people with cognitive impairment to help keen them out of the the criminal justice system. The <a href="https://www.portal.facs.nsw.gov.au/Guidelines/SourceDocuments/cjp_tailored_support_packages.pdf">NSW Community Justice Program</a> is a good example. It provides specialised intensive 24-hour supported accommodation to drop in support for people with an intellectual disability who have been in the criminal justice system. </p>
<p><strong>4. Integrated services</strong></p>
<p>Government and non-government services need to work in a more integrated way to improve referral, information sharing and case management, and to better support Aboriginal people with mental and cognitive disabilities.</p>
<p>Justice, Corrections and Human Services departments and non-government services should take a collaborative approach to program pathways for Aboriginal people with disabilities who need support across their sectors. All prisoners with a cognitive impairment should be referred to the public advocate of the state or territory they are in.</p>
<h2>Better practice and prevention</h2>
<p>It’s vital that Aboriginal understandings of “disability” and “impairment” underpin support for Aboriginal people with mental and cognitive disabilities in the criminal justice system. The particular experiences and perspectives of Aboriginal women should be central.</p>
<p>Better education and information on Aboriginal people with disabilities is needed for police, teachers, education support workers, lawyers, magistrates, health, corrections, disability and community service providers to help them understand and work with Aboriginal people with cognitive impairment, mental health disorders and complex support needs. </p>
<p>More resources are also needed for Aboriginal communities, families and carers so they can better support people with mental and cognitive disabilities.</p>
<p>Our data tracks the pathways of Aboriginal people with mental and cognitive disabilities into early contact with police, courts and custody largely due to a lack of appropriate health, education, disability and community services. We heard about the racism and stigma faced by Aboriginal people with disabilities that drives the cycle of over-policing, under-servicing and incarceration.</p>
<p>This predictable path is preventable. Early intervention and diversion into holistic, therapeutic, culturally responsive, local community-based services are essential. These will enable Aboriginal people with mental and cognitive disabilities to live with dignity and support in their communities.</p>
<hr>
<p><em>This is the fifth in a series of articles by this research team. Click <a href="https://theconversation.com/au/topics/aboriginal-people-with-mental-and-cognitive-disability-43089">here</a> to read more on the Indigenous Australians with Mental Health Disorders and Cognitive Disability in the Criminal Justice System (IAMHDCD) Project.</em></p>
<hr>
<p><em>Ruth will be on hand for an Author Q&A between 10 and 11am AEDT on Friday November 6, 2015. Post your questions in the comments section below.</em></p><img src="https://counter.theconversation.com/content/49293/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth McEntyre was the Australian Postgraduate Award Industry recipient for the IAMHDCD Project.</span></em></p><p class="fine-print"><em><span>Eileen Baldry receives funding from The Australian Research Council, FaCS NSW, Dept of Justice NSW. She is affiliated with PIAC & CRC. </span></em></p><p class="fine-print"><em><span>Ruth McCausland is Vice-President of the Board of the Community Restorative Centre.</span></em></p>The predictable path into prison for Aboriginal people with disabilities is preventable. Here are some solutions.Elizabeth McEntyre, PhD Candidate in Social Work and Criminology, UNSW SydneyEileen Baldry, Professor of Criminology, UNSW SydneyRuth McCausland, Research Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/486592015-10-13T02:25:46Z2015-10-13T02:25:46ZYoung offenders must be screened for fetal alcohol spectrum disorders before sentencing<figure><img src="https://images.theconversation.com/files/98153/original/image-20151012-17853-8cvs0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's vital to ensure youth put behind bars have been properly assessed before sentencing.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Australia’s prison population is growing at <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4517.0%7E2014%7EMedia%20Release%7EAustralian%20prisoner%20numbers%20climb%20to%20ten%20year%20high%20(Media%20Release)%7E10023">unprecedented rates</a>. In some states Indigenous prisoners far outnumber their non-Indigenous counterparts. </p>
<p>Last year in the <a href="https://theconversation.com/state-of-imprisonment-if-locking-em-up-is-the-goal-nts-a-success-39185">Northern Territory</a>, 86% of those in prison and 96% of those in juvenile detention were Indigenous. <a href="https://theconversation.com/state-of-imprisonment-lopsided-incarceration-rates-blight-west-38986">In Western Australia</a>, Indigenous people account for only 3% of the population, but 40% of prisoners. </p>
<p>It is unacceptable to ignore the intellectual capacity of a person facing the court and it’s vital to ensure that youth put behind bars have been properly assessed before sentencing. This is particularly important for Australians affected by fetal alcohol spectrum disorders (FASD). These occur throughout society and in high levels in some Indigenous communities.</p>
<p>The capacity to <a href="http://www.ncbi.nlm.nih.gov/pubmed/26338492">screen for prenatal alcohol exposure</a> – as well as to diagnose FASD – must urgently be increased. This echoes <a href="http://www.theaustralian.com.au/business/legal-affairs/test-kids-before-courts-for-fetal-alcohol-syndrome-magistrate/story-e6frg97x-1227546353318">recent calls by Perth Children’s Court magistrate</a> Catherine Crawford for clinicians to assess children and youth before sentencing, so the court understands their cognitive limitations. </p>
<h2>Cognitive limitations</h2>
<p>Fetal alcohol spectrum disorders are a <a href="http://www.ncbi.nlm.nih.gov/pubmed/25848734">group of preventable conditions</a> resulting from exposure to alcohol in the womb. Alcohol readily crosses the mother’s placenta, entering the circulation of the developing fetus with devastating effects. </p>
<p>Significantly, it can disrupt brain development and that of other organs, causing lifelong problems. These include developmental delay, intellectual and memory impairment, as well as a range of behavioural, emotional and mental health disorders. </p>
<p>People with FASD can suffer from attention-deficit hyperactivity disorders (ADHD), communication disorders, poor impulse control, disobedience and hostility issues, and learning difficulties. </p>
<p>They often struggle to distinguish right from wrong and fail to learn from mistakes. Few with FASD will live and work independently. Many have mental health and substance misuse problems. </p>
<p>It is no surprise that <a href="http://www.ncbi.nlm.nih.gov/pubmed/15308923">many also come in contact with the law</a>. An adolescent living with a FASD in Canada or the United States, for instance, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22032097">is estimated to have</a> a 19 times higher risk of incarceration than someone without a FASD.</p>
<p>Despite this, the condition remains poorly recognised and few obtain a diagnosis prior to offending. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20888044">Offenders with FASD</a> are often poor witnesses and fail to understand why they have been detained. Unable to negotiate the justice system, they are adversely influenced by others and often enter a cycle of re-offending.</p>
<h2>FASD and the justice system</h2>
<p><a href="http://www.theguardian.com/commentisfree/2014/mar/14/jailed-without-conviction-send-rosie-anne-fulton-home">Rosie Fulton</a>, a 21-year-old Aboriginal woman with FASD and significant intellectual impairment, was arrested last year after stealing and crashing a car. Declared unfit to stand trial, Rosie was sent to Western Australia’s Kalgoorlie Prison for lack of alternative accommodation. </p>
<p>She stayed in jail for 21 months with no trial or conviction. Only after her story broke, mounting pressure on the health ministers of Western Australia and the Northern Territory led to Rosie being <a href="http://www.abc.net.au/news/2014-06-25/aboriginal-woman-in-jail-without-conviction-to-be-freed/5550790">transferred</a> to supervised community accommodation close to her family in Alice Springs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98155/original/image-20151013-17809-10fddn7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young people with a FASD often have learning difficulties.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/francisco_osorio/8425548570/in/photolist-dQx93N-fwr2cP-dYzGoR-dQx5qh-dQwVB1-dQwTi9-dQrk7x-8v4TQ-tFR8Jw-BLfMq-dQwQsw-dQxavq-dQrwZH-BM4DM-pdYzyy-rbD36X-ruXheR-aYtadR-dQwRxL-cdmjho-dQrhXV-dQriPF-p3N7f7-dQx8D7-dQwTxj-ebGSib-dQwSi9-ehTt4H-eeW2XT-dQxaYy-dQrheM-wEzWQQ-dQxcTf-dQrECB-6TJzFk-dQrEaM-ebBe6z-dQrF8P-dQwR1b-dQru36-dQrv3r-dQxbx3-eeW1NR-dQrkCr-aYtadZ-6fnd68-azyH5Z-aYtae2-dQxbL5-dQrqZn">Francisco Osorio/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>In Australia, we don’t know how many people deemed “unfit to plead” are in prison and how many have cognitive impairment, as we lack recent data regarding rates of FASD in prisons. US studies suggest up to 60% of young people with FASD will at <a href="http://www.ncbi.nlm.nih.gov/pubmed/15308923">some time enter the juvenile justice system</a>. </p>
<p>Another study, conducted in a forensic mental health facility in Canada, showed <a href="http://www.ncbi.nlm.nih.gov/pubmed/10533996">23% of resident youth</a> had one type of FASD. This figure <a href="http://www.ncbi.nlm.nih.gov/pubmed/25693629">may be higher in vulnerable Australian populations</a>, particularly in some remote regions where alcohol use in pregnancy is prevalent. </p>
<p>The economic impact of incarcerating people with FASD is huge. In Canada, <a href="http://www.ncbi.nlm.nih.gov/pubmed/25846557">the direct cost to the correctional system</a> between 2011 and 2012 was CAD$17.5 million for youth and CAD$356.2 million for adults. </p>
<h2>Screening for FASD</h2>
<p>Diagnosing FASD is a challenge because as children get older, a firm history of prenatal alcohol exposure may be elusive. With age, the characteristic facial features (small eye openings, a thin upper lip and flat philtrum, the area between the upper lip and base of the nose) of fetal alcohol syndrome – a subset of FASD – diminish, and growth deficits correct.</p>
<p>Thorough assessment by a physician, a psychologist and, if necessary, allied health professionals, can identify impairments required for a FASD diagnosis, whether fetal alcohol syndrome or a neuro-developmental disorder associated with prenatal alcohol exposure. Such impairments can be in IQ, communication, memory, motor and executive function, and other areas.</p>
<p>In Canada, youth probation officers are using a <a href="http://www.asantecentre.org/">tool for screening young offenders for FASD</a>, and identifying the need for referral and assessment. </p>
<p>Another tool for health professionals with accompanying guidelines for assessing and diagnosing people with FASD is <a href="http://www.ncbi.nlm.nih.gov/pubmed/24083778">being developed in Australia</a>. This will standardise the diagnostic approach.</p>
<p>Tools such as these are necessary to increase screening and diagnostic capacity in the justice and health systems. If a diagnosis is known, the associated behavioural and cognitive deficits can be taken into account when considering the reliability of evidence given by an offender, the supervision required in detention, and the sentence. </p>
<h2>Appropriate care</h2>
<p>There has been a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20888044">call for better legal support</a> for people with vulnerabilities in their journey through the criminal justice system. Consideration should be given to the <a href="http://www.ncbi.nlm.nih.gov/pubmed/23228502">defence of diminished responsibility</a> in conditions such as FASD. </p>
<p>And alternative models of care need to be found to avoid imprisonment of those unable to plead. As identified in the case of Rosie Fulton, this poses a significant challenge, particularly in remote Australia where alternative accommodation is not readily available and would be costly to establish. </p>
<p>But prison is far more costly. In Canada, the justice system accounts for <a href="http://www.ncbi.nlm.nih.gov/pubmed/26072470">40% of the total costs of FASD</a> (including health and education). And Australia’s <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Legal_and_Constitutional_Affairs/Completed_inquiries/2010-13/justicereinvestment/report/index">Senate inquiry on justice reinvestment</a> heard that the estimated cost of detaining a juvenile offender in New South Wales in 2010–11 was much higher ($A652 per day) than the cost of supervision in the community ($A16.73 per day).</p>
<p>To end the cycle of re-offending, we urgently need evidence-based strategies to ensure offenders with FASD are recognised early and receive the care they deserve.</p><img src="https://counter.theconversation.com/content/48659/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Elliott receives funding from the National Health and Medical Research Council of Australia and the Australian Government for research into Fetal Alcohol Spectrum Disorders.
She is a Member of the Board of charities Cure Kids Australia and the Institute for Creative Health and a member of the Medical Advisory Committee of the Steve Waugh Foundation. </span></em></p>Many young people in jail suffer fetal alcohol spectrum disorders. Diagnosing these before sentencing will establish the most appropriate path for these vulnerable offenders, which often isn’t jail.Elizabeth Elliott, Professor of Paediatrics & Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/399992015-04-26T19:30:50Z2015-04-26T19:30:50ZOur $3b-a-year system is flying blind in supporting ex-prisoners<p><em>This article is one of several following up The Conversation’s series, <a href="https://theconversation.com/au/topics/state-of-imprisonment">State of Imprisonment</a>, which provides snapshots of imprisonment trends in each state and territory.</em></p>
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<p>Nobody knows how many people get out of prison in Australia each year. This fact is so striking that it bears repetition. Despite recurring investment of more than <a href="http://www.pc.gov.au/research/recurring/report-on-government-services/2015/justice/corrective-services">$3 billion a year in our correctional systems</a>, we simply cannot determine how many people move through those systems each year.</p>
<p>It’s not that this information is difficult to find, or that it’s not publicly available. We simply don’t know.</p>
<h2>Understanding throughput is important</h2>
<p>For other large, state-based and publicly funded systems, such as hospitals and schools, information on throughput is readily available, and rightly so. These systems are funded by the taxpayer, for the taxpayer, and routine public reporting is critical to ensuring transparency and accountability. </p>
<p>Information on throughput is also critical to service planning: if we don’t know how many people use the service, or what these people look like, how can we possibly ensure that the service is appropriate in scale and character?</p>
<p>Yet we can only estimate how many people move through our prisons each year. We don’t have even a basic demographic description of these people. This information is important because almost everyone who goes to prison comes back out again, and effective support during the transition from prison to community is critical to preventing re-offending. </p>
<p>Effective transitional support can also reduce the risk of other poor outcomes that disproportionately affect ex-prisoners, such as preventable death, the spread of infectious disease and expensive, avoidable hospitalisation. </p>
<p>Effective support for people coming out of prison is therefore critical to public safety, public health and the public purse. But we don’t know how many people in Australia need this sort of transitional support.</p>
<h2>What <em>do</em> we know?</h2>
<p>It’s not that we don’t know anything about the people we incarcerate: for well over a decade the Australian Bureau of Statistics (ABS) has produced a <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4512.0">quarterly publication</a> that reports how many people were in prison on an average day, broken down by basic demographic characteristics. For example, we know that Indigenous Australians are over-represented in our prisons by an age-adjusted factor of 13. The ABS also produces an <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4517.0">annual publication</a> reporting on the number and characteristics of people in prison on June 30 of each year.</p>
<p>Notwithstanding the redundancy in these two publications, so far so good. The problem is, people being released from prison look different to those in prison, and there are a lot more of them. How can this be?</p>
<p>For the purposes of illustration, let’s consider our hospitals. According to the <a href="http://www.aihw.gov.au/publication-detail/?id=60129546922">Australian Institute of Health and Welfare (AIHW)</a>, in 2012-13 there were about 86,300 hospital beds in Australia and for the 42% of patients who stayed in hospital overnight, the average length of stay was just 5.6 days. Because of this staggering throughput, there were almost 9.4 million hospital separations – when someone is discharged from hospital – in the 2012-13 financial year. This is more than 100 times the number of hospital beds, which is a pretty good proxy for the number of people in hospital on the average day.</p>
<p>Now let’s consider our prisons. Across the country we have almost 34,000 people in prison on the average day and we’re spending billions building more prison beds, at a rate well in excess of population growth. Prisons are, by definition, a growth industry. </p>
<p>The average expected length of stay for sentenced prisoners is 1.8 years, but for those on remand – around one in four prisoners – the average length of stay is just three months. Almost two in five of those released from prison return within two years, most of them within the first year. Those with unresolved substance use and mental health problems are more likely to return to custody.</p>
<p>So how many “prison separations” do we have each year in Australia? How many people does this represent? We don’t know.</p>
<p>In 2012, the AIHW asked the states and territories to provide this information, for inclusion in a report on the <a href="http://www.aihw.gov.au/publication-detail/?id=60129543948">health of Australia’s prisoners</a>. On June 30 of that year there were 29,236 prisoners in Australia. Based on the information it received, the AIHW estimated that 33,751 individuals – 15% greater than the average daily number in prison – were released during the 2011-12 financial year.</p>
<p>Unfortunately, this estimate was hobbled by the fact that one jurisdiction was unable to provide a count of either receptions or releases, while another provided a count of separations rather than individuals.</p>
<h2>What did our research find?</h2>
<p>More recently, we attempted to <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12346/abstract">estimate this figure</a> by extrapolating from detailed throughput data provided by the NSW Bureau of Crime Statistics and Research. After accounting for demographic differences between the jurisdictions, we estimated that the number of people released from prison each year in Australia is around 25% greater than the daily number in prison. Applied to the most recent ABS statistics, this equates to an estimated 42,239 persons released from prison in 2013-14 – 8,448 more than the “number of prisoners” reported by the ABS.</p>
<p>Perhaps more importantly, we found that the characteristics of people being released from prison differ meaningfully from those in prison. Those being released were disproportionately young, Indigenous and female. For every young Indigenous woman in prison on the average day, we estimated that about 3.7 young Indigenous women were being released from prison each year.</p>
<p>Is this dramatic over-representation of particularly vulnerable people taken into account in the planning and funding of transitional programs for prisoners in Australia? It seems unlikely.</p>
<h2>Fix the data to fix the system</h2>
<p>So what needs to be done? First, an appropriate national body, probably the ABS, needs to commit to annual reporting of prison throughput in Australia. This should include at least the basic demographic characteristics of those released. It’s not rocket science, and would for the first time provide a platform for considering whether transitional programs for prisoners are appropriate in scale and character. </p>
<p>Then comes the hard bit: bringing evidence-based transitional programs to scale and ensuring that they are appropriate to the target population. With a rapidly increasing incarceration rate, enormous capital and recurring expenditure on the prison system, and predictably poor health, economic and offending outcomes for those released from prison, it’s about time we stopped flying blind in service planning for ex-prisoners.</p>
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<p><em>Alex Avery was a co-author of <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12346/full">the research paper</a> published in the Australian and New Zealand Journal of Public Health, on which this article is based.</em> </p>
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<p><em>You can read the other articles in the State of Imprisonment series <a href="https://theconversation.com/au/topics/state-of-imprisonment">here</a>.</em></p><img src="https://counter.theconversation.com/content/39999/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stuart Kinner is an NHMRC Senior Research Fellow. He receives funding from the National Health and Medical Research Council and the Australian Research Council, and co-convenes the Justice Health Special Interest Group in the Public Health Association of Australia.</span></em></p>We simply don’t know how many prisoners are released each year, nor their demographic characteristics. As a result, we cannot tailor services that would reduce ex-prisoners’ risks of re-offending.Stuart Kinner, Professor, Griffith Criminology Institute, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.