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.
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.
Earlier intervention
Ieramagadu/Roebourne is home to strong and vibrant community initiatives such as 6718 Yandi for Change (formerly the 6718 Advantage Plan), which uses a collective impact approach to help to close the gap in health inequity on a local level.
The New Roebourne project, an intergenerational arts and social change program, is also striving to enhance community wellbeing.
But, given the continuing challenge of high rates of chronic disease in the town, early intervention and continuity of care couldn’t be more important.
“Maybe about a third of our adults have type two diabetes, or some form of chronic disease,” Basil told Croakey. “The most commonly presenting conditions that we see are heart disease, type two diabetes, kidney disease, and lung disease amongst the adult population.”
Basil said Mawarnkarra’s intense focus on chronic disease management over recent years was starting to pay off in the local adult population, and the service was now redirecting energy and resources to prevention in children, “trying to intervene before a chronic disease manifests itself”.
Its efforts could be thwarted, however, if a patient was incarcerated and cut off from access to Medicare-funded services provided by Mawarnkarra.
“When people are in prison, they don’t have access to intense and holistic health care,” Basil said.
“They don’t really have access to a diabetes educator or a dietitian, and [adequate] mental health support.” This is despite the United Nations Nelson Mandela Rules on the minimum treatment of people in prison stating equivalent care in prison as in the community should be available.
Basil said Mawarnkarra provided some healthcare in the prison, such as access to a dental service and to women’s sexual health screening, with the latter unfunded.
“[The prison has] reached out to us for some of the things that their nurse has not been able to do, like Pap smears. And we’ve agreed to do them, even though we can’t claim it from Medicare.”
Basil said that she had recently approached the prison to discuss the possibility of Mawarnkarra being more involved in the provision of health services to the prison, “perhaps providing a GP to the prison once a month or a similar arrangement,” she said.
Croakey followed up with the WA Department of Justice, and a spokesperson said that the department was not aware of this approach.
The spokesperson told Croakey that Roebourne Regional Prison has access to a GP via telehealth five days per fortnight. “The consulting GP providing this service has done so for 12 months,” they said.
“The health service operated by the prison’s nursing team operates seven days a week. When hospital treatment is required, prisoners are taken to Roebourne or Karratha hospitals. Prisoners can access specialist services by appointment in Karratha or Perth.”
Health gains at risk
Basil told Croakey that while health and wellbeing among people in prison could be adversely impacted by a lack of access to “integrative, holistic” healthcare, there could also be some improvements in chronic health conditions during periods of incarceration.
“What I do find is that people’s diabetes improves when they’re in prison because there isn’t access to alcohol, or the same type of food that may be accessible outside of prison,” she said.
“There are prompts to take their medication whereas when, at home they may forget, so in some ways you get some better health outcomes in prison.”
Such gains, however, were quickly lost if the transition from prison to community care was managed ineffectively, Basil said.
“Any health advances the person may have gained from prison get reversed,” she said. “You lose the momentum.”
In a remote Aboriginal and Torres Strait Islander community like Ieramagadu, healthcare “is really different to mainstream health and one of the major ways to help the community get better, is by creating trust”, Basil said.
“That trust comes from simple things like having consistent presence,” she said.
“You have to know the community and understand the community’s very specific health needs, cultural needs and what services are available,” she said.
“That’s often a big problem if you are not from here, you are a doctor just doing a locum for a month. By the time you figure out what all the services are in town, your stint is over.”
Jones said prisons’ core focus was management and security, and while health was an important part of prison business, it remained “the poor cousin”.
She noted that calls for the transfer of the responsibility for prison health care from the Department of Justice to the WA Department of Health went back decades, including a 2005 OICS recommendation for such a change.
“If the health services were handled by state health, it would be so much better – it would be resourced appropriately, prisoners would have better access to specialist services such as women’s health, mental health and dental health services and would improve continuity of care,” Jones said.
Funding for Mawarnkarra to provide a GP service to the prison would make a “huge difference” to the care provided, she said.
“If Mawarnkarra are offering to do a service, I would be jumping on that straight away.”
Extreme heat concerns
Roebourne Regional Prison hit the headlines last year after an OICS inspection highlighted the risks of rising temperatures, noting that, on one day in March 2019, the thermometer in Roebourne reached 48.1 degrees Celsius.
“The midnight temperature on those sorts of days would be 30 degrees,” OICS Inspector Eamon Ryan told Croakey.
“If you were living [outside the prison] and it was a 30-degree night, you would drag your mattress out onto the veranda and sleep under the stars. You could get up through the night, wash your face, or make a cup of tea,” he said. “Well, you can’t do any of those things if you are in a prison cell.”
“The prison needs to provide a minimum level of care, and when you are getting 45-46 degree days and there is no cooling, that would definitely be a concern.”
It’s been a growing concern in the context of climate change, highlighted by OICS in a 2015 report on thermal conditions in prison cells that warned that people in prison were an at-risk group for temperature-related illness due, in part, to high rates of chronic illness.
“Some older Departmental facilities are ill-equipped to tolerate the temperature conditions of today and are unlikely to cope with any increase in temperature extremes due to climate change,” the report said, pointing to Roebourne as one such facility.
Last year’s OICS report on Roebourne, its seventh, noted that it had “expressed grave concern at the lack of climate control in mainstream prisoner accommodation at Roebourne and in other aspects of prison life, over many years”.
It referred to a 2014 review that found the average night time temperature in non-air-conditioned cells at Roebourne then was 33 degrees, and typically over 35 degrees in the hours before midnight.
“Such temperatures were found to be not just uncomfortable but posed a significant risk to prisoner health,” it said, adding that “repeated recommendations by this office for installation of effective climate control systems over many years were doggedly rejected by the Department”.
While many of the 2020 OICS report’s 12 recommendations were supported by the WA Department of Justice, the department did not support the report’s calls to implement effective climate control in all cells. In its response, the Department pointed instead to initiatives such access to an air-conditioned recreation hall, the installation of ice machines, and shade structures.
A WA Department of Justice spokesperson told Croakey that it was undertaking a feasibility study in 2021-22 to “determine what is possible for cell temperature management at Roebourne Regional Prison”.
The OICS report stated that “for many years we were concerned that poor conditions were being tolerated for regional Aboriginal prisoners which would never have been allowed for a mixed population metropolitan prison”, but there had been marked improvements during the most recent inspection.
Mental health and healing
The OICS report also called for a mental health/addictions nurse position to be re-established at Roebourne.
Ryan told Croakey the incidence of mental health for people who are in prison “is very high” and the provision of effective care in this setting was vital.
“It’s vital not only from the perspective of managing people who are at self-harm risk, but just for people’s general health and wellbeing. Undiagnosed, or under-treated mental health can have enormous impact on the health of the individual, but also on the welfare of everyone around them.”
The Department supported this recommendation, and a spokesperson told Croakey that, as at May 2021, the mental health services provided at Roebourne Regional Prison are:
- a senior Mental Health Alcohol and Other Drugs nurse provides a telehealth clinic once a week
- a Consultant Psychiatrist consults via telehealth weekly and attends the prison once every eight weeks
- a senior Social Worker and a Prison Support Officer are based at Roebourne full time.
The spokesperson further noted that prisoners with mental health symptoms who cannot be provided adequate care at Roebourne may be transferred to another prison with appropriate services.
Dr Jocelyn Jones has contributed to a soon-to-be published book, Indigenous Knowledge and Mental Health: A global perspective, and says Traditional Healers could also play an important role in managing mental health issues among prisoners, complementary to the role to Western psychiatrists.
“All Aboriginal people should have access to Healers who come from and understand their own country and culture,” she and her co-authors write in the book, noting that Aboriginal people with mental health problems reported positive outcomes where Traditional Healers were involved.
The involvement of Traditional Healers in care also improved the trust and rapport with conventional mental health services, they wrote.
Cultural support
The OICs report recommended that the prison enhance its cultural effectiveness by “attracting Aboriginal staff, developing cultural competence of all staff, and further engaging local Aboriginal elders and service providers”.
The WA Justice Department spokesperson said the Martu Visitors Program had been introduced in response to this recommendation.
That sees community Elders and leaders deliver educational and aspirational sessions in Martu languages for 30 to 40 men and women at the prison on a bi-monthly basis and “helps prisoners make a successful transition back to family and community,” the spokesperson said, adding that Pilbara Community Services also provides reintegration and support services.
But still missing from Roebourne is an Aboriginal Visitors Scheme, with the Department blaming difficulties in recruitment and retention of suitable candidates for the failure to consistently deliver on what was a recommendation of the RCIADIC.
Jones said the AVS plays a “critical role” in encouraging cultural understanding and connection in a prison environment, providing “a link between the family and the community and the prisoner”.
That was also the message in 2016, as part of Croakey’s #JustJustice project, from Phyllis Simmons, who for many years was an Aboriginal visitor at the Roebourne prison and said prisoners with health concerns needed to have treatment “from the people who know the people”.
Sounds of healing
Five years on, that’s a concern also for Roebourne resident and Senior Banjima man Angus Smith, who worries that programs to maintain connection between the prison and the community seemed to have dwindled in recent years.
“There used to be more programs to deal with the needs of prisoners,” said Smith, who worked with the Department of Corrective Services for six years until 2001. “In a lot of ways, they seem to have gone backwards.”
Now, Smith’s only involvement in the prison is through the Songs for Peace project.
Once a year, Smith packs up his guitar and heads to the prison to write and perform songs with people with prison. Workshops and performances are held in the prison and in the community.
In the 2020 project, the Roebourne community residents sang: “People say it’s long ago, to me it’s yesterday.”
“We use music to try and get people to express themselves,” Smith told Croakey. “They can’t always do this by talking to someone, but through music they can speak out and it helps them to deal with their problems.”
Smith, who was a school friend of John Pat, said music and other forms of art could provide an important relief for inmates.
“It’s a way to vent your emotions,” he said. “I like it because it helps me, and it helps others too.”
But it’s not enough, Smith said. “There are the same guys going in and out of prison every year and no one really has any programs to deal with it. They are not doing enough, I believe.”
Watch the 2018 Songs for Peace community program via YouTube.
The Commonwealth, Department of Infrastructure, Transport, Regional Development and Communications has provided funding for the Croakey Health Media #RuralHealthJustice series through the Public Interest News Gathering Program (PING) grant program.
The PING Program was set up in 2020 to support regional broadcasters and publishers to maintain or increase their production and distribution of public interest journalism in regional Australia during the COVID-19 pandemic.
