Name: Teghan CollingwoodStudent Number: N8549109Tutor: Colleen Niland
"Desires Out of Wires"

Illicit Substance Use, Incarceration and Poor Health in Australia

A social and cultural analysis of the health impacts of illicit substance use and consequent incarceration in Australia.

Desires Out of Wires
"Desires Out of Wires" by Suzanne M, 2008

“Desires Out of Wires” by Suzanne M 2008
(Prison Fellowship Australia, 2008)
‘Art from Inside’ is an annual competition and exhibition of artwork by current and former prison inmates in Australia. The purpose is to provide art-therapy for individuals, and promote creative expression to reduce the destructive and negative effects of the prison environment (PFA, 2008). Artwork exhibitions are centred around themes of hope, love, reparation, justice, forgiveness, reconciliation, fear and alienation.The above artwork was drawn by artist Suzanne M in 2008. The artwork is a reflection on her experience of incarceration, firstly in response to fear:

“The barb wire border represents being locked in. The handcuffs and hands behind bars are also my representation of incarceration. The pills and syringe are my problems with drug abuse [which] ultimately led to my incarceration”.

Then in response to hope:

“The key is to unlock my fears and to stay clean in the future. The bird in the heart [represents] love for my family and friends. The rose [represents] growth in my future and the religious figure being hope in my life”.

The artwork received a ‘commended’ in the exhibition in 2008.

The Public Health Issue

The use of illicit drugs in Australia is detrimental to population health. The health risks of illicit substance consumption and abuse are myriad, including poor physical, mental and psychosocial health, with mental illness and addiction possible outcomes (Department of Health and Ageing, 2011). However, the health risks are not merely confined to consumption; drug use is a prevalent risk factor for criminal activity and incarceration (Australian Institute of Health and Welfare, 2010a; Butler et al., 2003; Collins & Lapsley, 2002). Despite a supposed rehabilitative purpose, the Australian incarceration system largely exacerbates health inequalities and generates poor health outcomes for those with a history of illicit substance use.

What is the Current Literature Saying?

Drug Use is a Risk Factor for Incarceration
Drug use is a risk factor for incarceration.
Drug use is a risk factor for incarceration.

In Australia, illicit drug use is a key risk factor for crime involvement and incarceration (AIHW, 2010a). Firstly, the possession and supply of prohibited substances incurs a criminal penalty (AIHW, 2011, p. 135). Furthermore, a large proportion of crime is drug-related, particularly property and violent offences (AIHW, 2011, p. 135; Payne & Gaffney, 2012, p. 1). The most recent report by the Australian Institute of Criminology revealed sixty-six percent of police detainees tested positive to illicit drug use (Gaffney et al., 2010). This percentage is reflected similarly in the incarcerated population, with sixty-six percent of prisoner entrants being under the influence of illicit drugs at the time of offending (Payne & Gaffney, 2012, p. 1). Additionally, arrest and imprisonment statistics often conceal systematic patterns of drug use, abuse and its criminal correlates, as these do not account for self-attribution crimes (Johnson, 2006). Regardless, compared with rates of fifteen percent in the general population, illicit substance use is significantly more prevalent among those involved in crime (AIHW, 2010b, p.11; Payne & Gaffney, 2012, p. 1).

Crime and Incarceration are Determined by Drug Use
Qualitative research provides insight to the nature of the drug-crime relationship. Payne and Gaffney (2012) conducted a study which found thirty-three percent of police detainees attributed their arrest to illicit substance use. Similarly, a report by Collins and Lapsley (2002) estimated up to fifty-two percent of prisoners attributed personal drug use to subsequent criminal behaviour. These trends are exacerbated depending on the type of drug used and nature of the crime. For example, offenders who were regular users of heroin or stimulants were five times more likely to engage in criminal activity than those without a history of regular drug use (Payne & Gaffney, 2012, p. 1). Those with an addiction, namely heroin users, reported the highest rate of involvement in property crimes, often as a means of economic support (Payne & Gaffney, 2012). Furthermore, Makkai and Payne (2005, p. 159) found higher rates of crime involvement and repeat offending amongst prisoners who used multiple drugs more frequently. These statistics further highlight the complex and prevalent association of drug use a predictor of crime and incarceration in Australia.

Health Inequalities in Australian Prisons

Despite an ideal environment to target health inequalities, myriad reasons contribute to a decrease in health status for prison inmates in Australia (Butler et al., 2004). Prisoners experience disproportionate levels of physical, mental and social health disadvantage prior to incarceration; characterised by poverty, abuse, lower rates of primary care and increased engagement in risk-taking behaviours (AIHW, 2010a; AIHW, 2010b; Gillies et al., 2008, p. 549; Moller et al., 2007). Furthermore, the prison setting has been found to foster criminal culture, stress and the transmission of communicable diseases (Moller et al., 2007, p. 7). Although mental health, drug dependence and communicable diseases are target health areas for prison services; social division and boredom are confounding factors for health promotion (Moller et al., 2007). Prisoners also experience increased risk of violence, sexual assault, suicide, substance abuse and smoking (Butler et al., 2003; Eckstein et al., 2007; Moller et al., 2007). The AIHW (2010a) reported an access rate of forty-two percent for inmates to prison health services, which did not reflect the health burden in Australian prisons. Eckstein et al. (2007) and Gillies et al. (2008, p. 549) found prison health services as inefficient in addressing health inequalities; attributable to the magnitude of the prisoner health burden and inadequate resources. Further, these outcome are likely to be much poorer for those with a history of illicit drug use (Butler et al., 2003).

Health Inequalities Experienced by Those Who Engage in Illicit Substance Use

Prisoners with a history of illicit drug use are likely to continue drug use whilst incarcerated (Butler et al., 2003, p. 89). Butler et al. (2003, p. 92) conducted a cross-sectional study of prisoners, which found forty-three percent used illicit substances in jail; predominately heroin and cannabis. Furthermore, approximately half of this figure had injected drugs whilst in prison, with sixty-eight percent sharing injecting equipment (Butler et al., 2003, p. 92). Prisoners who engage in intravenous drug use experience great health risks, including contracting blood-borne diseases such as HIV, hepatitis C and acute infections; confounded by the high prevalence of these diseases within the prison population and sharing of injecting equipment (AIHW, 2010, p. 60; Butler et al., 2003, p. 92; Crofts et al., 1995). Drug use is also correlated to increased risk of mental health problems (Butler et al., 2011; Henderson, 2007; Johnson, 2006). The AIHW (2010b, p. 11) states eighty-six percent of prisoners experiencing ‘very high psychological distress’ used illicit substances. Similarly, Johnson (2006) found the prevalence of co-morbid substance use disorder and mental illness in forty-six percent of women, and twenty-nine percent of male inmates. Although these studies do not consider the cause-effect relationship, they provide scope to the prevalence of mental health morbidity in drug-using inmates.

Drug detection squad in an Australian prison

Drugs confiscated in an Australian prison.
Drugs confiscated in an Australian prison.

Prisoner Post-Release Experiences and Drug Use
Released prisoners have substantially higher risks of mortality and morbidity than the general population, at rates up to twelve-fold compared with the Australian community (Hobbs, et al., 2006). Confounding factors include financial stresses, profound isolation, shame and stigmatisation, homelessness, difficulty accessing primary health services and problems re-integrating into the family structure (Baldry et al., 2006; Hobbs et al., 2006; Kinner, 2009; Kariminia, et al., 2007; Stewart et al., 2004). Illicit drug use is a key risk factor for mortality within this population, and Kinner (2006) reported more than fifty percent of prisoners intended to use drugs upon release (Hobbs, et al., 2006). Similarly, Kinner (2009) reported sixty-four percent of post-released prisoners used illicit drugs within thirty-four days of release. Hobbs et al. (2006) further noted mortality related to illicit substance use occurred eleven times more frequently than other deaths. This is attributable to increased risk of overdose, suicide and chronic health conditions associated with substance misuse (Kariminia, et al., 2007, p. 422). Furthermore, prisoners with a history of illicit substance use experience high rates of recidivism, and those with an injecting history are three times more likely to be re-incarcerated than their non-injecting peers (Payne & Gaffney, 2012, p. 1). Similarly, meta-analyses have identified substance misuse as a significant determinant of recidivism (Dowden & Brown, 2002; Gendreau, Little, & Goggin, 1996; Kinner, 2009). Collectively these factors perpetuate the drug-crime cycle, and poor health outcomes amongst this population.

From a Social, Cultural and Philosophical Perspective

Key Social Groups at Risk and Cultural Influences

From a public health perspective, it is essential to recognise which social groups are most at risk of drug use and consequent incarceration, so that intervention, support and prevention programs are appropriately targeted. Firstly, Indigenous Australians are grossly over-represented in the incarceration system, and sixty-eight percent have a history of illicit drug use (AIHW, 2010a). Undermined by a history of dispossession, many Indigenous Australians experience social disadvantage, thus engage in drug use and subsequent criminal activity (Gillies et al., 2008). Female prisoners are also a key risk group; they are more likely to present with addiction problems and injecting behaviour, attributed to histories of physical and emotional abuse (Easteal, 2001; Forsythe & Adams, 2009). The rates of female incarceration, particularly drug-related offences, are also increasing, further highlighting this group as vulnerable to the drug-crime cycle (ABS, 2011). Australian youth and young adults are also a key risk group. Exposed to a growing drug culture, juvenile offenders with a history of social, familial and personal instability are over-represented in the incarceration system, and this is likely to transgress to repeat offending as a young adult (ABS, 2011; Blackman, 2010; Degenhardt, Lynskey, & Hall, 2000). Finally, injecting drug users also experience disproportionate risk, as they experience higher rates of risk taking behaviours, recidivism, and mortality (Payne & Gaffney, 2012). Targeting these social groups and culture trends are imperative in reducing the health burden posed by illicit drug use and its criminal correlates; however, without appropriate policy, the effectiveness of such strategies is debatable (Australia21, 2011; AIHW, 2010a; AIHW, 2011).

At risk: Indigenous Australians
At risk: Indigenous Australians
At risk: Juveniles
At risk: Juveniles
At risk: Women
At risk: Women
At risk: Intravenous drug users
At risk: Intravenous drug users

Morality and Drug Policy in Australia

Recent literature highlights the decriminalisation of drugs as a key strategy for improving the health of illicit drug-users in Australia (Australia21, 2011). Current drug policy in Australia involves a prohibition approach, in that specific substances are categorised as illicit; and the possession, use or supply may result in criminal charges (Makkai, 2000). Concurrently, The National Drug Strategy, focuses on reducing the supply, demand and harm related to drug consumption in the population (DoHA, 2011). Literature argues that prohibition is destructive to health in myriad aspects (Australia21, 2011; Global Commission on Drug Policy, 2011; Makkai, 2000). Fore-mostly, as evidenced in the literature review, the culture of illicit-drug use in Australia is viewed as a criminal matter, not a public health issue, thus a risk factor for incarceration. Once incarcerated, inmates experience decreased access to harm minimisation strategies such as needle exchanges, which are key protective factors for physical and mental health problems, including contracting blood-borne viruses (Rodas, Bode, & Dolan, 2012; DoHA, 2011). Further, the consequent outcomes of imprisonment are likely to perpetuate the drug-crime cycle (Kariminia, et al., 2007).

"Forty percent of inmates in Canberra's jail tested positive for hepatitis C"
"Twenty-five percent of the prison population injects drugs in prison"

Duff (2004) applied Foucault’s philosophical theory to the practice of drug use in contemporary society, and suggests drug policies need to extend beyond concepts of harm minimisation. Current drug policy has forced the practice into a private conduct, whereby intervention, prevention and treatment strategies have little impact (Duff, 2004). Duff (2004) further states drug use should be viewed as a personal experience, as it seeks to fulfil an individual desire and purpose; a ‘practice of the self’. Consequently, Foucault’s philosophy suggests policy should be concerned with fostering a culture of limits, moderation and responsible consumption for those engage in drug use; thus, an effective means of harm reduction (Duff, 2004). Altering the perception, policy and culture of drug use will aim to alter the morals of society whilst reducing the harms and criminal activity associated with drug use (Duff, 2004).

However, social theory suggests change in drug policy would be impaired by ‘moral panic’:

“a condition, episode, person or group of persons [that] emerges to become defined as a threat to societal values and interests; its nature is presented in a stylised and stereotypical fashion by the mass media” (Cohen, 2002 in Anleu, 2007, p. 321).
Labelling theory denotes that current social norms in Australia confer derogatory labels and heavy social stigma on those convicted of drug use and consequent criminal behaviour, and on a wider scale, ‘moral panic’ (Anleu, 2007; Plummer, n.d). This is a form of social control, and has been found to influence political intervention, resulting in changes to legislation to regulate offensive behaviour (Anleu, 2007). Therefore, decriminalisation of drugs aims to facilitate a paradigm shift, in which those who consume drugs experience greater health support, and are not soley viewed as criminal offenders in relation to social morals.

Foucault on Crime and Punishment
Philosopher Michael Foucault

The concept of punishment and prisons are rooted in history (Oliver, 2010). Philosopher Foucault explored the nature of punishment from the eighteenth century, and noted it was characterised by physical punishment, namely torture; facilitating public entertainment, justice and sovereign power (Oliver, 2010). Foucault noted a disparity in the temporal intentions of punishment, with a shift from physical to psychological inflictions, concurrent with a transgression in social morals (Oliver, 2010). Social values transgressed to understanding criminals in a psychological sense, and intentions evolved for offenders to be rehabilitated to contribute to the economy; thus the prison (Oliver, 2010). However, the literature review reveals the social morals which define contemporary incarceration as being more ‘civilised’ and ‘humane’, are far from fulfilled (Makkai, 2000). Further,the literature highlights the current prison system is exacerbating the burden on the economy, as many offenders, particularly those who use illicit substances, are not only subject to the physical ‘torture’ of the eighteenth century, but also psychological ‘torture’. That is, those who are incarcerated in Australia experience significantly higher rates of morbidity and mortality, characterised by poor physical and psychological health (AIHW, 2010a). The high rates of recidivism further highlight the inability of the prison to fulfil these social morals, as the majority of prisoners are not rehabilitated, creating further burden on the economy (ABS, 2011; AIHW, 2010a; AIHW, 2010b; Oliver, 2010; Payne & Gaffney, 2012). Therefore, the barriers exist in educating society of complex these complex health issues, and the ineffectiveness of the Australian punishment system, to restore social justice.

Personal Reflections
Completing this assessment piece has allowed me to develop a deeper understanding of the social and cultural forces which underpin public health issues in our society. ‘Desires out of Wires’ not only represents the artist’s personal experience of incarceration, but the story of many inmates across Australia. For many prisoners, incarceration is determined by a history of social disadvantage and consequent drug use. This artefact represents the health inequalities of this population, which current policy in Australia fails to address. On a deeper level, it represents the challenge our society is faced with to re-invent the social morals which surround the consumption of illicit substances in Australia, and the ‘torturous’ punishment many of Australia’s prisoners are subject to. Personally, I was saddened to realise the artist of the artefact is highly likely to never integrate back into society. Without addressing these disparities, the true intentions of prisons to ‘rehabilitate’ individuals as active citizens who are willing and able to positively contribute to our social world will be unfulfilled.

As a result of the extensive research involved in this assignment, I feel less certain, and I have far more questions unanswered. One particularly interesting aspect from my research was the extensive literature which supports decriminalisation and harm reduction strategies for those who use drugs on a national and international scale, particularly in reducing the spread of HIV/AIDS and other blood-borne diseases, in society and in prison. I am confounded that Australian prison inmates do not have access to needle exchange programs, as this is a public health right in the wider community. In fact, I am surprised this information is not proposed to the public in a more active way; and I am sure this anomaly would apply to many, if not all, other public health issues. Perhaps, this inconsistency aligns with Foucault’s philosophy of ‘torture’ for those who deviate from social norms and are consequently incarcerated. In the future, I will continue to question the social fabric of my world, and as a Health and Home Economics teacher I will value the opportunity to help my students do the same; as I believe this is key to a healthy society for future generations.

I would encourage the readers of this wiki to view this short film from the British Medical Journal, on the rising HIV epidemic on an international scale, and the role the incarceration system has to play:

Additional materials

Australia21 report on current drug policy and health in Australia
Australia21 report on current drug policy and health in Australia

Report by the AIHW: The Health of Australia's Prisoners 2010
Report by the AIHW: The Health of Australia's Prisoners 2010

Learning Reflections

Reference List

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