Hepatitis C and prisons

Public Health Association of AustraliaMichael Moore CEO

Ngunnawal people have always lived here. In this place we sang and danced and laughed. Young men became wise men. The sky and the earth gave us food and water. Then others came

The Public Health Association of Australia

• Equity The prime driver Social determinants of health

• Prevention Clean water Sanitation Immunisation Health promotion Health Protection

John Snow1854 cholera

The Broad Street Pump

Snow saw a problem and became an advocate for governments to take actionNo success until 1858 – the great stink

Identify the problem + advocacy

• Hepatitis C - 2006 Estimates & Projections• General Community

• The total number of people who have been exposed to hepatitis C in Australia is 264,000

• It is estimated there are 197,000 people with chronic hepatitis C infection• Up to 39,000 people may be unaware they have hepatitis • 65% of those with hepatitis C are aged 20 to 39

years & 35% of total notifications are in women• National rates of hepatitis C in prison entrants

is 34% for males and 50 to 70 percent for females

Social Determinants of Health

• Sir Michael Marmott - WHO Report on Social Determinants of Health - inequity is on a social gradient

• There are an estimated 22,000 Aboriginal and Torres Strait Islander people with hepatitis C

• In 1991, the Royal Commission into Aboriginal Deaths in Custody – Looked at such issues of organisation, culture and policy,

security issues, access to health care, domestic politics and the system in the communities to which people return after incarceration

– Now twenty years since the start of the Commission– More aboriginal people in custody– Health threats from hepatitis C and from HIV/AIDS

Royal Commission into Aboriginal Deaths in Custody

Royal Commission – a success?• The Royal Commission

provided a road map – but ...

• Aboriginal and Torres Strait Islander peoples now make up 24% of the total prison population– an increase from 14% in

1992• They make up only 2.5% of

the total Australian population

Memorial for John Pat in front of the prison walls of the decommissioned Fremantle Prison. It was erected in September 1994 "in memory of all Aboriginal people who have died in custody in Australia"

Indigenous versus non-Indigenous Incarceration in Australia*

0.0

500.0

1,000.0

1,500.0

2,000.0

2,500.0

3,000.0

NSW Vic. Qld SA WA Tas. NT ACT

Rate/100,000

Indigenous Non-Indigenous rate

A/Prof Ted Wilkes NDRI

Indigenous people are 13 times more likely to be incarcerated than non-Indigenous people

Aboriginal

(%)

Non-Aboriginal

(%)

Drug use 40 41

Traumatic event 9 12

Sad 2+ weeks 16 11

Drinking 12 7

Nature/personality 7 5

Top 5 health concerns of prisoners

Source: 2001 NSW Inmate Health survey

A/Prof Ted Wilkes NDRI

Substance misuse in prisons• Substance misuse

– Alcohol: more than a third of women and half of men drink in harmful range

– Tobacco: 83% of women and 78% of men smoke tobacco

– Illicit drugs: 80% of total have used during lifetime

• Chronic illness (e.g. diabetes, mental health, cardiovascular) – 95% women and 78% men have one or more

chronic health condition

• 64% of men and 40% of women have been exposed to hepatitis C virus – Compared to 2% of in general community

PHAA: Justice Health Conference Resolutions

• Advocacy and research– Respect Australia’s local, international and human rights obligations to

prisoners• Issues for Indigenous Australians

– Adopt an Indigenous holistic health focus particularly for Indigenous prisoners

• Health services and planning– Promote the concept of nationally binding targets for the states and

territories for reducing incarceration rates– Recognise and respect the role and contribution of all staff throughout

the justice system• Blood borne viruses, tobacco, other drugs and lifestyle diseases

– Adopt a national harm minimisation framework for prisons• Mental health and co-morbidity issues

– Develop a National Prisoner Mental Health approach

Blood borne viruses, other drugs and lifestyle diseases

• This includes:– The use of opioid replacement therapies (including a pilot

study of a heroin trial) – The adoption of needle and syringe programs (NSPs) in

prisons to initially be trialled in a small number of prisons– National guidelines for bloodborne virus screening with

periodic follow up within the corrections system – The ongoing national surveillance of BBV and STIs

including the National Prison Entrants Bloodborne Virus Survey

– Ensuring national availability of condoms, dams, lubricants in both adult and juvenile correctional facilities

• Adopt all harm minimisation strategies and programs available in the community with demonstrated efficacy

Community – ‘prisoner health is community health’

• Average length of time of incarceration– 7 months

• Revolving door• Indigenous impact

– The Indigenous population is relatively young, with a median age of 21 years compared with 37 years for the non-Indigenous population.

– This is largely the product of higher rates of fertility and deaths occurring at younger ages among the Indigenous population (ABS 2004c).

– At 30 June 2006, people aged 65 years and over comprised just 3% of the Indigenous population, compared with 13% of the non-Indigenous population.

– In comparison, 37% of Indigenous people were under 15 years of age compared with 19% of non-Indigenous people

• Ted Wilkes speaks of ‘normalisation of incarceration’ – as a ‘right of passage’

ABS and AIHW 2008A/Prof Ted Wilkes NDRI

New Prison in ACT Alexander Maconochie Centre

• 19th century prison reformer and reforming Norfolk Island commandant

• Provides hope for the new prison

• Ironically, forward thinking prisons of today work by implementing the Maconochie systems after nearly two centuries

International• The United Nations 1990 General Assembly Resolution on the

Basic Principles for the Treatment of Prisoners (Article 9) states:– “Prisoners shall have access to the health services available in the

country without discrimination on the grounds of their legal situation”.

• World Health Organization view– “All prisoners have the right to receive health care, including

preventive measures, equivalent to that available in the community without discrimination” WHO 1993

• Being denied an international right is a denial to justice

International Incarceration Rates

Aboriginal Australians

ACT LegislationACT Human Rights Act, 2004Sections 19 (1)

– “Anyone deprived of liberty must be treated with humanity and with respect for the inherent dignity of the human person.”

• Human Rights Commissioner Dr Helen Watchirs– Audit of Prisons ACT Correctional Facilities Aug 2007

• Over 100 recommendations including a Needle and Syringe Program

• Being denied right under Human Rights Act is a denial to justice

Countries with Prisons with NSPs (2006)

Switzerland 1992 7Germany 1996 1 (6 closed following political decision)Spain 1997 38Moldova 1999 7Kyrgyz Rep. 2002 11Belarus 2003 1 (as of 2004)Luxembourg 2005 1Isl. Rep. of Iran 2005 1 to 6Armenia 2004 3Ukraine 2007 2 pilot projects due start September 2007UK (Scotland) 2007 pilot study approved to start in 2007Portugal 2007 implementation by 2008

SURELY IT IS POSSIBLE IN THE ACT

Wodak 2008

Who is stopping this access to justice and to just health care?

• Prison officers – we need to engage– Claim it is because of fear of needles as weapons

• This has been managed in Spain and Switzerland

– Truth• It is moral issue for prison warders• In some prisons they are part of the supply chain

• Politicians – we need to engage– Either law and order themselves or concerned

about law and order campaigns

Ottawa Charter -Template for Action

• Health promotion – puts health on the agenda of policy-makers

• Uses diverse but complementary approaches– legislation – fiscal measures, taxation– organisational change

• Identification of obstacles to healthy policies – Then ways of removing them – The aim must be to make the healthier choice the easier

choice for • Policy-makers • People