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Putting the spotlight on lethal gaps in health services for a remote community and prison

Introduction by Croakey: An investigation of the health issues for people imprisoned in a remote Western Australian community has identified wide-ranging concerns, from gaps in services to an urgent need to address the dangers of rising temperatures.

In this final #LongRead in Croakey’s #RuralHealthJustice series, journalist Nicole MacKee profiles the health risks for people in prison and the wider community in Ieramagadu/Roebourne, a small community in the State’s north-west.

Ieramagadu/Roebourne played a tragic part in the establishment of the Royal Commission into Aboriginal Deaths in Custody, which 30 years ago handed down its recommendations, many still unimplemented according to a recent report by the Australian National University .

Since then, it is estimated that 474 Aboriginal and Torres Strait Islander people have died in custody. In WA in 2020, there were three deaths in custody, including a 47-year-old man who was found dead in his cell in Ieramagadu/Roebourne. A coronial inquest is pending on this case.

Dr Tess Ryan, an Indigenous woman of Biripai country in Taree, New South Wales, and a contributing editor at Croakey, will lead a Twitter conversation on #RuralHealthJustice and #RCIADIC30Years as part of this series. Please keep a watch on Twitter and Croakey for more details.


Nicole MacKee writes:

When Dr Seema Basil started work as a GP at Mawarnkarra Health Service in the remote Western Australian town of Roebourne (Ieramagadu, in the local Ngarluma language) just over seven years ago, there was an effective support system in place for former inmates of the local prison.

Two staff members at Mawarnkarra, an Aboriginal Community Controlled Health Organisation (ACCHO), were dedicated to supporting people who had been released from Roebourne Regional Prison, which is on the outskirts of the small town, more than 1,500 kilometres north of Perth.

The program was funded by the WA Country Health Service under the Footprints to Better Health Program.

“It was really useful because when you got a discharge summary, you could engage the team to go and reach out to this person once they were released,” Basil told Croakey.

Arrangements could be made for former prisoners to attend Mawarnkarra, Basil said, “so there wasn’t suddenly a drop in in engagement with services”.

Fast forward to 2021 and these positions are no longer funded. The funding was discontinued in 2015 after the Holman Report, an external review of WA’s State-funded Aboriginal Health Programs.

“The reality now is that we get a discharge summary, but it’s really hard to find the resources to keep that person supported,” Basil said.

For the tiny rural community of Ieramagadu/Roebourne, this lack of support seems particularly unjust, with more than 75 percent of people in Roebourne Regional Prison, located on the traditional lands of the Ngarluma people, identifying as Aboriginal.

And it was here, in 1983, that a 16-year-old Yindjibarndi boy, John Pat, died, sparking the Royal Commission into Aboriginal Deaths in Custody (RCIADIC), which handed down its findings 30 years ago.

One of the Commission’s critical recommendations was that Aboriginal Health Services be included in health planning decisions in prisons.

Ongoing calls for justice on deaths in custody, including the 1983 death of John Pat in Ieramagadu (Roebourne). Photo from a Melbourne #RCIADIC30Years rally by Marie McInerney

Barriers to support

In a 2019 research paper published in the Australian and New Zealand Journal of Public Health, Aboriginal researcher Dr Jocelyn Jones and colleagues highlighted the advantages to improving the connections between Aboriginal Medical Services and prisons.

They concluded that a “holistic model of care underpinned by a reliable funding model (including access to certain Medicare items) and consistent access to prisoners could strengthen ACCHOs’ role in primary health care delivery to people inside or leaving prison”.

It’s a model that has worked in the ACT, according to the Winnunga Nimmityjah Aboriginal Health and Community Services.

“Continuity of care is a huge issue,” said Jones, a Senior Research Fellow and Program Leader at Curtin University’s National Drug Research Institute in Perth and an expert in Aboriginal health and social wellbeing and justice health.

Jones, a Whadjuk Noongar woman, said the health status of Aboriginal people who frequently move between the community and prison was “very poor” because of lack of continuity of care, creating multiple issues with complying with and storage of medications, access to specialist services, and other complications.

She said transitional care was a significant challenge, particularly for people on remand, who are held in custody while awaiting trial or sentencing.

“Roebourne [Prison] holds a lot of remandees – 41 percent in 2019 – so you don’t know when they are going to be released or sent somewhere else,” Jones said.

“Someone might go to court that day and they won’t have any medication on them or only a day’s supply. They are often not linked to any health service.”

Jones, who has worked for the Office of the Inspector of Custodial Services (OICS) in WA and been a part of its inspection teams to the prison, said there was no simple answer to this issue. “We still don’t have that system running effectively.”

Disconnected systems

One of the main barriers to ACCHOs playing a more prominent role in prison services is that, nationally, prisoners are excluded from Medicare services and Pharmaceutical Benefits Scheme (PBS) subsided medications. This exclusion is justified as a measure to prevent ‘double-dipping’ by state- and territory-funded prisons into federally-funded health services.

However, it essentially locks ACCHOs out of delivering health care in prisons, says Associate Professor Megan Williams, Research Lead and Assistant Director at the University of Sydney’s National Centre for Cultural Competence and co-author with Jones on the Journal of Public Health paper.

“A change has repeatedly been sought, but has not occurred,” Williams wrote in The Conversation in May, calling for a nationally coordinated scheme to fund prisons to work with Aboriginal and Torres Strait Islander community-controlled health services.

Williams this week told Croakey that policy reform should also avoid promoting the idea that access to services is the solution, when it’s also about prison workforce training to address racism within prison health services.

“There is a need for cultural safety plans and anti-racism training among staff; an identified gap in prison health services,” she said.

Craig Cumming, Researcher at the University of WA’s School of Population and Global Health, has also repeatedly called for the Medicare exclusion for prisoners to be lifted.

Cumming told Croakey that continuity of care was the biggest casualty of this exclusion, and the impacts were amplified for people who “cycled in and out of prison”.

“Their whole life is disrupted on a regular basis,” Cumming said. “They just can’t get stability and continuity of care amongst their doctors, any counselling or psychiatric therapy, it gets interrupted so it’s impossible to get a therapeutic relationship going.”

He added that the state prison services did not have the capacity to properly manage the vast mental health needs of people in prison.

“A large proportion of prisoners need support for either mental illness or drug use, with 40 percent reporting being diagnosed with mental illness at some stage in their lifetime, and 65 percent reporting using illicit drugs in the year before they were incarcerated,” he said, citing Australian Institute of Health and Welfare data.

Cumming pointed to the 2019-20 annual report from OICS, the main body with oversight of prisons in WA, that highlighted inadequate mental health services and support for people in prison as an ongoing  issue in the state.

“Prison mental health and counselling services, despite best efforts of staff, often have little capacity for anything beyond acute crisis counselling,” the report noted.

Lifting the Medicare exclusion, Cumming said, would enable people in prison to access psychological services under the Commonwealth-funded Better Access initiative, improving mental health care.

Photo of the old prison, turned into a museum: Melissa Sweet (2016)