A study published today in the Medical Journal of Australia concludes that more prison inmates in Australia die in the year after they’ve been released than the annual number of deaths in custody. A disproportionate number of these died within the first four weeks of their release.
Although consistent with international findings, the report should prompt health leaders and the community to try harder to reduce the numbers of prisoner deaths following release.
This number is about ten times higher than the death rate in men and women of the same age in the general population. It is a shocking finding.
We should remember that most of the dead are relatively young people. This means many years of life expectancy are being lost among these ex-prisoners.
The number of prison inmates dying in the year following their release is about the same as the number of injecting drugs users dying in the community each year from drug overdose – or the number of Australian servicemen killed during the entire Vietnam War.
Starting on the back foot
Most of the people entering prison in Australia are appallingly disadvantaged. Many have very poor educational and employment records. Many were institutionalised as children or had parents who served prison sentences.
Severe physical and mental illness is very much more common among prisoners than in the community.
Multiple risk factors for heart disease are much more common in the prison population, and almost twice as common among Aboriginal inmates.
The authors point out that the number of prison inmates has increased by 15% in the past decade. Australia now has the third-highest rate of incarceration among rich nations (after the United States and New Zealand) and the figure is climbing.
Alternatives to prison
The English Labour politician Dennis Healey used to say, “The first law on holes is that when you’re in one, stop digging!”
So our first response to this study should be to ask ourselves how we can start reducing our high and rising incarceration rate.
Keeping people in prison is not cheap. It costs at least $80,000 to keep an inmate in prison for a year.
As a conservative politician in the UK said, “Prisons are an expensive way of making bad people worse.”
We need to make much greater use of non-custodial sentencing options and reduce the number of people awaiting trial in prison.
It is outrageous that 20 years after a Royal Commission into Aboriginal Deaths in Custody recommended reducing the rates of incarceration of Aboriginal Australians, these rates are still climbing.
The role of drugs
Drug law reform would help to reduce the number of prisoners, but we also need to focus on reducing the number of deaths related to drug use.
Drug-related deaths within the year after release accounted for about a third of deaths in Western Australia and 45% of those in New South Wales.
Although often criticised by radio shock-jocks and drug war hawks, methadone and buprenorphine treatment have been convincingly shown to be effective, safe and cost-effective. Deaths are reduced by 80%.
The study authors suggest inmates with a history of heroin dependence should be offered this treatment in prison and again before release. Any treatment in prison must be linked to treatment in the community.
Methadone and buprenorphine treatment also reduce crime substantially and probably reduce the rate of recidivism. But in many parts of Australia, such treatment is very scarce and too expensive.
The authors also recommend distribution of the antagonist drug naloxone to heroin using prisoners on release.
In theory, the benefits of this are very plausible but the evidence is still weak. A large trial is under way in the United Kingdom and Australian authorities should wait for the results of that trial before proceeding.
Physical and mental health
We should try to improve the rates of follow up of recently released prisoners in primary health care. One aim should be to reduce cardiovascular risk factors.
Smoking rates are still very high among prisoners even though the overwhelming majority want to stop. Inmates clearly need more help to stop smoking in prison and after returning to the community.
One of the most effective interventions would be to increase post-release employment.
A few years ago I visited a health clinic in Iran, which was based in the community but looked after prisoners (and their families) in the year following release.
Finally, we need a mental shift in the way we think about prisoners. People who commit serious crime are sent to prison as punishment, not for punishment.
The World Health Organisation recommends prisoners receive the same standards of prevention and treatment health services as others in the community.
This excellent study serves as a wake-up call stirring us into action. We need to act now to help one of the most marginalised groups in our society.