Jail is not good for your health. Communicable diseases like hepatitis, HIV and tuberculosis are more prevalent. About forty percent of the prison population has mental health issues and to make matters worse, delivering good care in prisons is a challenge. It seems clear to me that we need to keep people out of jail as much as we can – but that’s not always happening.
Summer May Finlay is a Yorta Yorta woman. She considers herself privileged: “My mother was an Aboriginal woman and absolutely determined and driven to make sure that her children would get the best.”
Summer started her career as a youth worker and now has a master in public health. She works in Aboriginal health and is undertaking a PhD in Aboriginal health at the University of SA.
“I have the capacity and education to have a voice for those who don’t, and that’s one of the reasons I want to raise over-incarceration of Aboriginal and Torres Strait Islander people,” says Summer.
Although the majority of Aboriginal and Torres Strait Islander people do not come into contact with the law, they are over-represented in Australian prisons. This is concerning as we know there is a health and life-expectancy gap compared to the non-Indigenous population.
I spoke to Summer about over-incarceration and what should be done about it.
Why is over-incarceration happening?
“That’s a good question isn’t it,” says Summer. “There is a range of factors, such as the links between over-incarceration and low-education, poverty and dispossession. There are also historical issues including our western justice system, which in some cases may not take cultural issues into consideration. It’s complex and that’s the reason we want to look at a solution and not so much the problem.”
“Our western justice system may not take cultural issues into consideration
“There is an inherent, unconscious bias which I also call institutionalised racism. We know that the police system and the court system are looking to address this. For example, a lot of Aboriginal people are incarcerated for short periods of time because they don’t turn up to court. They may be in a remote setting or transient, but if the court refuses to take this into account, they may blame it on the individual.”
A potential health catastrophe
“Incarceration affects the ability to get or keep a job, which creates financial restraints and subsequently a range of health and mental health issues. It could be that people don’t have the money to manage their diabetes. The Hepatitis C prevalence is higher in jail so therefore people incarcerated are more likely to become infected.”
“Fifty percent of juveniles that are incarcerated are Aboriginal and we only make up three percent of the population. They are removed from an education setting, and put in a justice system. They experience many difficulties after they are released.”
“People don’t become hardened criminals overnight. It usually starts off with petty crimes and non-violent crimes. That should be diverted before they reach a point where they are incarcerated for serious crimes. People also go to jail for fines. There are community service options but they aren’t used enough as they’re not always available, for example in remote areas. Funding for these programs may be ad-hoc or insufficient, and sometimes it comes down to political will.”
Do the crime, do the time?
“We have an Australian mentality that if you do the crime you do the time. A criminal system is meant to be a deterrent but clearly it’s not working as such with some Aboriginal and Torres Strait Islander people. Seventy percent of people that are incarcerated have been in jail before. So the system has failed miserably.”
“We have tried the paternalistic approach for over 200 years now, so let’s try our approach for a change
“We know what the problem is, we know the statistics, but we need to be looking at what happens when someone is in jail and after their release. We should also be looking at some of the solutions within the community. Over-incarceration isn’t going to change overnight so we need long-term funding that transcends political terms.”
“One of the key things for me is that we need to have better informed conversations about Aboriginal over-incarceration. We need to be focusing on mobile and community, Aboriginal-driven solutions. If you don’t have a solution that is driven by the people who are involved in it, than quite frankly, it is never going to work. We have tried the paternalistic approach for over 200 years now, so let’s try our approach for a change.”
In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Melissa Sweet suggested the topic of this post: ‘Social determinants of health’. She tweeted: “Interested in your take on SDOH & how they play out locally.” Thankfully, to make the task easier, Melissa suggested some background reading: 436 articles from the Croakey archives.
Note: ‘Social determinants of health’ are economic and social conditions that influence the health of people and communities.
“Doc, that’s not going to work.” The health worker was standing behind me. She had overheard my consultation with the elderly man. I thought I was doing a great job, as I had taken the time to explain what diabetes was all about – in layman’s terms – and how he should inject the insulin.
The indigenous health worker continued: “He lives mostly outside and keeps his medications under a tree.” I couldn’t believe what she had just said. When the penny dropped I realised she was, of course, right: the insulin wouldn’t last in the excessive heat of the Kimberley.
It was clear that I had no idea of my patients’ living circumstances. I felt like a fool.
The home visit
Another time, another place. I was doing a home visit in a Cape York indigenous community as part of a team consisting of two nurses, a social worker, a health worker, a police officer and a local government representative.
The verandah was covered with rubbish and furniture. It was hot inside. The room was empty, apart from a few mattresses. The concrete floor and walls were dirty. “How many people live here?” I asked. “Between 8-20, depending on when you visit,” said the social worker.
The patient was lying on a mattress – she clearly only had a short time to live. There was not much I could do apart from some small medication changes. Afterwards, we had a long chat on the verandah about fixing the air-conditioning and the tap, and making her last days as comfortable as possible.
All tip and no iceberg
The contribution of doctors and other health care professionals to our wellbeing is relatively small: Depending on what source you read, healthcare contributes for about 25 percent to our health. On the other hand, an estimated 50 percent of our health is determined by economic and social conditions (see image).
One of Australia’s leading researchers on the economic and social determinants of health is Professor of Public Health Fran Baum. “Typically,” she writes in this editorial, “responses to diseases and health problems are knee jerk and concerned with ameliorating immediate and visible concerns.”
Professor Baum calls this the ‘all tip and no iceberg’ approach. Instead of focussing on disease and unhealthy behaviours we should improve the conditions of everyday life.
To combat the chronic disease and obesity epidemic for example, we should not just be advising lifestyle changes and initiating medical treatment. These are tip-of-the-iceberg solutions.
Instead, says Baum, let’s look below the surface at things like urban planning, the availability of unhealthy food, our sedentary lifestyles at home and at work, and equal opportunities for all.
In my work the influence of economic and social factors is apparent. Some examples:
The 26-year old single mother who cannot afford medications for her children
The 38-year old machine operator who gained 10 kg of weight since he started a fly-in-fly-out job in a remote mining community
The 50-year old chief executive who makes 14-hour days in a high-pressure environment, and develops anxiety symptoms.
My role as a GP in these scenarios is modest. Ok, ‘all tip and no iceberg’ may be too harsh – apart from the fact that it sounds like ‘all icing and no cake’…
But Professor Baum has an important message: We must not close our eyes to what really makes us ill and, more importantly, change it.
“It is socially unacceptable to say you’re a heavy drinker, but it is actually socially acceptable to be a heavy drinker.” This interesting quote from a GP came out of a research project by Dr Michael Tam, GP at the School of Public Health and Community Medicine in Sydney. It may explain why GPs feel reluctant to discuss alcohol intake with their patients…
Dr Tam tried to find out why doctors are avoiding the topic. He found the following 3 barriers:
Many GPs didn’t want to be seen as moralising or didn’t want to label people with an alcohol problem
There was doubt about effective screening tools; what people say may not always reflect their true alcohol intake, so why bother asking
GPs were concerned that discussing the topic would affect the relationship with their patients
Dr Tan concluded that routine alcohol screening questionnaires by GPs may not be helpful to detect at-risk drinking.
What do you think needs to happen? Fill out the poll below or leave a comment.