Issue 14 / 20 April 2015

ONE of the most memorable articles I shepherded to publication in the MJA was an essay submitted for the Dr Ross Ingram Memorial Competition in 2011.
Aboriginal academic and educator Lindy Moffatt wrote about her son’s rapid cascade from illicit drug use to risk-taking, crime, the criminal justice system and prison.

Once in prison, her son developed a psychiatric illness that would see him hospitalised on a forensic order for more than a decade.

While told without embellishment, the story was evocative and has stayed with me all the more because I had the privilege of meeting the author and her son some months later when the essay won the competition.

A case report in the current issue of the MJA, which is the basis of an MJA InSight news story, reminded me of the winning essay, and of the vicious cycle of young people with mental illness being at increased risk of incarceration, with their mental and physical health under further threat when they are in custody.

Strikingly, the MJA report also highlights the risk of lifelong consequences to physical health if mental health problems are not carefully managed in the prison environment.

The risks are particularly acute for young Aboriginal and Torres Strait Islander people, who are currently incarcerated at a 24 times the rate for non-Indigenous youth and make up more than half of all young people in juvenile detention.

Among those in prison, the rates of mental illness such as anxiety, depression, substance misuse and psychosis, are very high: 73% overall for Indigenous men and 86% for women according to a 2008 estimate from Queensland.

Last week’s leaked (then hastily released) Report of the National Review of Mental Health Programmes and Services acknowledges that the system has failed Indigenous people with mental illness.

“Of critical concern is the dire status of the mental health and wellbeing of Aboriginal and Torres Strait Islander people”, the report says. “Indigenous people have significantly higher rates of mental distress, trauma, suicide and intentional self-harm, as well as exposure to risk factors such as stressful life events, family breakdown, discrimination, imprisonment, crime victimisation and alcohol and substance misuse. Service and system responses to these poor outcomes are inadequate, and have generally not been designed with the particular needs of Aboriginal and Torres Strait Islander people in mind.”

The report devotes a section to how this might be addressed, including adding mental health to the Closing the Gap targets, use of mental health and social and emotional wellbeing teams in primary care, and making mainstream services more culturally safe.

Aboriginal and Torres Strait Islander leaders have argued for the past few years that incarceration rates should also be added to the Closing the Gap targets because of the link between incarceration and ill health.

Earlier this month, health news blog site, Croakey, launched a crowdsourcing campaign, #JustJustice, to assemble and publish a body of knowledge about the problems of, and solutions to, the high rates of incarceration in Indigenous people.

In launching the campaign, Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda called the over-incarceration of Indigenous Australians a “public health catastrophe” and encouraged health professionals to engage with this issue by bringing their knowledge and research; their successes and failures to the public debate.

While the pathways to prison are complex, we can no longer view over-incarceration as simply a social issue.

The health sector must be involved in this contested but vitally important area of endeavour if we want change.


Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

6 thoughts on “Ruth Armstrong: Compounding problems

  1. Paul Dessauer says:

    Chris, you also wrote; “Otherwise Aborigines are consigned to perpetual ill health despite the devotion of limitless resources and endless goodwill”. The Aboriginal people I work with do not describe being treated with “endless goodwill”. Rather, they face prejudice and discrimination every day. Nor does our government devote “limitless resources” to them. Our current federal and state governments are cutting funding, and in WA threatening to withdraw funding from 150 remote communities. If this “cost cutting” measure takes place, we will see a return to the fringe dweller and long grass camps of 40 years ago.

    Without attention to the social and economic determinants of health, we are doomed to repeat this intergenerational tragedy again and again. We need to close the gap, not close communities…

  2. Paul Dessauer says:

    In Australia, an Aboriginal adult is 14 x more likely to be incarcerated than a non-Aboriginal person convicted of the same offence(s).

    In WA they are 20 x more likely to be incarcerated.

    Juveniles in WA are 48 x more likely to be imprisoned than their non-Aboriginal peers.

    Many of these people are imprisoned for petty, non-violent property offences or for disorderly conduct, and in WA many are imprisoned for unpaid fines.

    A young woman died whilst in police custody for unpaid fines. It costs between $200,000 and $300,000 per year to incarcerate someone. Dealing with non-violent offenders who have mental health or alcohol and other drug problems, let alone people who are guilty of nothing more than unpaid traffic or parking fines, in this way is a ridiculous and countreproductive waste of taxpayers money.

  3. Paul Dessauer says:

    Hi Ruth, Thanks for drawing attention to this important issue. It’s a pity our “Prime Minister for Aboriginal Affairs” appears incapable of delivering anything but simplistic slogans. He did promise to spend a week a year in an Aboriginal Community as PM. As it turns out he spent 3 days in a remote community a year after he was elected, and by all accounts he didn’t spend any time listening to the local people, he just hung out with the truancy officer.

    Hi Chris, I do agree that health problems amongst Aboriginal Australians are not isolated from broader issues. However I must disagree when you write that there is no reason  “Aborigines can’t join and be full members of this society”.

    Aboriginal people are struggling with generations of economic educational and social disadvantage, and with the effects of intergenerational trauma. There are very significant  reasons why so many young Aboriginal people feel helpless and isoalted from main stream society. One of these reasons is the massive overrepresentation of Aboriginal people in our prison system. I work in WA, where Aboriginal people make up <3% of the population, but more than 45% of the prison population.

  4. tom gavranic says:

    I have spent  the first half of my long medical career journeying, in varying capacities, throughout Aboriginal Australia. Yet never  was I taught anything meaningful about Aboriginal spirituality or their social structure; nor anything useful about alcohol, one of our country’s major health problems, including being a major reason for Aboriginal incarceration. I am sure that this applies to the legal and policing departments

    Later in  my career, I was introduced to AA by an Aboriginal alcoholic who had recovered his sobriety. By attending meetings regularly I began to get a much deeper understanding of alcoholism and actually began to treat alcoholics successfully! This was a great improvement on my previous 0% success rate. One of the major impediments to treating alcoholism successfully is the misdiagnosing of it as anxiety, depression, and even as criminal behaviour. Another is to denigrate AA as a “religious” approach, with all the negative connotations this can have in Aboriginal communities.

    There are major impediments to using AA as a treatment modality and even more so in Aboriginal communities and in gaols, as is evident from our footballers, who are diagnosed with various forms of “drug addiction” or “depression, bipolar” etc but never, ever, do any of them suffer from “alcoholism”. It is the same in Aboriginal communities. When prisoners are released on probation under circuit sentencing, the adjudicating panels tend not to see how important it is for the released person to attend AA regularly, even if he is adhering to all other requirements.


  5. Chris Strakosch says:

    As I have written before, the health of the Australian Indigenous peoples cannot be considered in isolation. The relative good health enjoyed by non indigenous Australians is part of the fabric of twenty first century society. Aborigines will never have the same levels of physical and mental health as the rest of us unless they become full members of this advanced technological way of life. This is not a “white society” from which non whites are excluded by some racial bias. At a recent graduation ceremony I attended, 17 of the 36 PhDs awarded were to non Caucasian scholars. There is no reason Aborigines can’t join and be full members of this society while still maintaining a proud heritage. As Noel Pearson pointed out, the Jews can match anyone for a history of discrimination but have made huge contributions to the advancement of the human race while still maintaining their rich cultural heritage. Otherwise Aborigines are consigned to perpetual ill health despite the devotion of limitless resources and endless goodwill.

  6. David Noble says:

    This is a very thought promoting article.  I wonder if members of the medical profession consider the potential exacerbation of physical and psychiatric conditions when our patients are “detained/restrained” against their will.  

    The concept of incarceration should not be limited to jail detention.  As a profession we use chemical and physical restrains.  We also place patients in “lock up” wards- often because they express an opinion that we do not agree with.  

    I recall a great quote by Rob Siltanan, and made famous by Apple as a marketing campaign… “The ones who are crazy enough to think they can change the world are the ones who do”.  Empowerment is an approach that worked for Apple.  Perhaps we should consider this also as we try to get some traction following the release of the Report of the National Review of Mental Health Programmes and Services.

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