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Dr Ross Ingram Memorial Essay Competition

Antecedents of chronic kidney disease in Aboriginal offenders in New South Wales prisons

Beverley F Spiers
Med J Aust 2009; 190 (10): 524-526.

In 2006, with outstanding cooperation from Department of Corrective Services staff at Cessnock Correctional Centre, two Justice Health staff made a huge step in walking together in the constant fight for Aboriginal health. In a mere six and a half hours, 88 Aboriginal offenders — 100% of the Aboriginal population in that centre — were screened for markers of kidney disease.

We had been fighting for years to get renal screening into the jails. Finally it happened! A special renal screening research project funded by the Hunter New England Area Health Service was to be carried out in three facilities in the Hunter Valley and northern New South Wales: Cessnock, St Heliers (Muswellbrook) and Tamworth.

We were offered five days to do three jails. If anyone could pull it off, I reckoned I could. I’ve been an Aboriginal Health Worker in the system since 1985, longer than most of the “lifers” — but they let me out from time to time, I like to remind everyone.

I did some serious thinking and strategic planning on just how to pull this off at the Cessnock site. I had 66 Aboriginal patients spread over five wings and various other locations, and no nurse or place to do the screening.

A well-meaning officer jokingly said to me on hearing about it, “How many you wanting to do?”

“Sixty-six, officer — the lot”, I answered.

He laughed and retorted, “Impossible, you’ll never do it . . . I’d say 30, tops . . . and three days. It’s a bet”. They were fighting words.

“You’re on.”

That was how this story started.

What I first needed was a nurse and a place to do it. I fronted the clinic and did some passionate Aboriginal-kidney-health-at-an-all-time-low talking to the Justice Health Nursing Unit Manager. She was already four nurses down that day, but after some drastic roster raping and creative roster placing, I got my Aboriginal male nurse for the project.

We needed a toilet for collection of specimens. Urine testing is not the easiest thing to do in a hurry.

Next we needed to give the patients-to-be an incentive.

I headed into the prison-yards — “Calling all Kooris!” I’d kick that Koori grapevine into gear fast to get the word out. The bait was a Koori-coloured red, yellow and black water bottle. One each. It wasn’t much, but then most of these guys have almost nothing.

To make sure everyone knew what was happening and how important it was to get 66 permission forms signed beforehand, we arranged afternoon tea for the next day. Hot buttered damper with syrup and billy tea were promised. That hit the spot. Full turn-up next day and 66 names and forms were signed and collected, with spares kept at the ready for any new arrivals.

The officer’s challenge was taken by all offenders with wry grins and much laughing as hot buttered damper with syrup was consumed with lots of lip-smacking and licking of fingers and enthusiastic agreement as we planned D-Day down to the minute. The jobs of rounding everyone up and getting them from point A to point B were allocated. Twelve patients at a time was agreed — ready to roll out, bladders brimming, as others returned. They were ready — all they needed was complete cooperation from all officers concerned on the day.

D-Day arrived. By 7.30 am I was already in the yards as the wings were emptying for breakfast. We rallied the Kooris to win the bet as soon as methadone parade was over. We had 66 for sure, and others signing on, as the transports arrived with more offenders. It was shaping up well. By mid morning, the Aboriginal Delegate (the community leader of all Aboriginal offenders of the centre) had 22 more signed permissions: 100% of the Aboriginal population in the Cessnock facility, now 88 in total. All in.

“Bring it on Aunt, we’re ready for them!” The war cry went up. Something was about to break the boredom that day. Everybody knew it and was ready to play a part — not just the Kooris.

The operation was fully planned for speed. As each patient arrived in the allotted clinic area, I would give him a specimen cup to write his name and ID number on; record his height and weight; then send him on to the nurse to have his specimen tested and blood pressure taken. Each patient was warned — any abnormality and he would be listed to see the doctor.

After receiving their water bottles, each group returned to the yards to spread the word of encouragement and help rally the rest. When the queue got down to five, the Aboriginal Delegate and I would take off down the “avenue” to gather the next 12.

This is where the story gets humorous. Some of the old laggers who were taking it easy, sitting in the sun on the walls along the avenue and generally bored silly with the monotonous routine of their surroundings, started to take a keen interest in the comings and goings and the unusual enthusiasm of the Koori lads that morning. At this point they decided to get in on the act too. As they spied them striding fast (you don’t run inside jails) towards the avenue gates, the laggers would call out, “Come on you Koori lads, Aunt is coming for you, boots and all”. Fact is, Kooris never hurry for anyone or anything, it’s kind of a principle — but when they heard that call, “there was movement in the yards, for the word had passed around, that Aunt was coming fast and the boots were gaining ground”, they were gathering and forming up already in lines.

The old laggers sitting on the walls were well into the game by now and sent out a new call to the avenue rover: “Hey chief, they’re on their way back now . . . big bunch of ’em coming up fast”. This alerted the rover to open up each of the three security gates promptly for us to pass through. On the third trip down, the old laggers called out in jovial fashion, “Go Aunt, go! We’re taking book on this, you know”.

That called for some laughter and cheering as the patients passed each time. The applause and calls of encouragement from the crowd, which had now swelled considerably, added a definite flavour to the day. Our project had become a talking point. Some officers remarked later that the Aboriginal health exercise lifted morale that week for the whole jail. It had been all good.

By lunchtime, we were out of resources. Hunter Area Health had only sent 50 packs. We’d ordered more, but were still waiting for them. I phoned again — they were on their way. We still had two wings and the work crews to get through. Cuppa was in order, but then word came — “The parcels are here and on their way down!” Yes! The officers were met halfway. They had two big bags of water bottles and the testing gear. Cheers rang out from the avenue throng and the officers were heroes for a minute or so.

Because of the tight security in the next areas (Maximum), it took a little longer, but we finished by 2.30 pm, still with time to catch the Aboriginal lads returning from work in their assigned prison duties for the day. Because of prison staff shortages, early lockdown in Maximum meant they had to be escorted individually down two flights of stairs to take part. With great officer cooperation, it happened. We needed to complete the project before total jail lockdown at 4.00 pm, and we did. Hoping we’d managed to test everyone, the pair of us wearily trudged back through the long jail yards past all five wings to the clinic. Our step lightened as we heard the inmates calling to us, “Good on you fellas, did you get them all? . . . Deadly job you two, a great day!”

Everyone wanted to know if they had reached the goal, headed by the officer who’d bet we couldn’t do it. With a grin on his face he asked if we’d done all 66 prisoners, looking very confident we hadn’t. I was happy to bring him up to date. Count done: 100% of current Aboriginal offenders had participated and all had been tested. By the clock, we had done 88 patients in six and a half hours!

The officer was astounded: “That was some feat you two pulled off . . . I can’t believe it . . . glad I didn’t put money on it!”

The serious side of the screening research project showed itself in the results. Of the 88 Aboriginal offenders, 14 screened positive for microalbuminuria and many more were positive for other high-risk chronic illnesses such as hypertension and diabetes.

The next two jails visited were St Heliers and Tamworth. At St Heliers, all 37 Aboriginal offenders were screened. Of these, 13 tested positive, and again many were referred for other high-risk illnesses. At Tamworth, 42 Aboriginal people were screened (one refusing), with 14 being positive and one dangerously positive.

In all, over the three sites, 167 renal screenings were carried out, resulting in 42 abnormal kidney readings.

As a result of this successful renal screening project, one new Aboriginal position has been created for the area: the Coordinator Aboriginal Renal/Health Promotion will be working with the Aboriginal Health team for two years within the existing 16 Aboriginal Chronic Care Program sites. The Program gives us vital information on the cardiovascular health of Aboriginal offenders well in advance of onset of cardiovascular disease. The renal health component is a nice addition to the Program.

Aboriginal people normally don’t access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the centres any more due to a lack of staff and funding. This is why we need Aboriginal Health Workers in every jail, especially in those with a high percentage of identified Aboriginal offenders.

Change — stalled a decade ago — is slowly starting to happen again. Twenty per cent of the male client base and 31% of the female client base in NSW prisons are Aboriginal people, with levels as high as 50% in younger offenders. Despite the Royal Commission into Aboriginal Deaths in Custody1 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justice Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders. It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW.

Visiting Aboriginal Medical Services staff should be welcome to work with members of their community who are in jail, but clearly, Aboriginal Health Workers are needed within the system itself, trained to go into the yards with the Aboriginal Delegates to encourage the brothers to access and be tested at the Health Centre.

The hardest part of the process is moving the prisoners within the jail. Locked gates, classification, segregation, non-association, constant lockdowns, inter-jail transfers without notice, request forms denied or simply lost — all add to the burden of self-destructive thinking that offenders bring into jail with them. Even knowing of a serious medical problem, they will often give up and cease to care. Aboriginal people in general, and prisoners in particular, are also dealing (or not dealing, as the case may be) with the blight of long-term systemic racism. A popular notion (unfortunately given scientific credibility by Charles Darwin) is that they are the lowest form of human life — one step above the apes:

[H]ow little can the hard-worked wife of a degraded Australian savage, who uses hardly any abstract words and cannot count above four, exert her self-consciousness, or reflect on the nature of her own existence? [quoting Büchner]

. . . At some future period . . . the civilised races of man will almost certainly exterminate and replace throughout the world the savage races.2

I commend you instead to the words of Kevin Gilbert — a self-educated Wiradjuri man and former offender — writing 100 years later, after doing 15 years for murder:

As Aborigines began to sicken physically and psychologically, they were hit by the full blight of an alien way of thinking. They were hit by the intolerance and uncomprehending barbarism of a people intent only on progress in material terms, a people who never comprehended there could be cathedrals of the spirit as well as of stone. Their view of Aborigines as the most miserable people on earth was seared into Aboriginal thinking because they now controlled the provisions that allowed blacks to continue to exist at all. Independence from them was not possible. White people’s devaluation of Aboriginal life, religion, culture, and personality caused the thinking about self and race that I believe is the key to modern Aboriginal thinking. As Robert Kantilla said, “Suffering is that the white people class them as the lowest person on earth”.

My thesis is that Aboriginal Australia underwent a rape of the soul so profound that the blight continues in the minds of most blacks today. This psychological blight, more than anything else, causes the conditions we see in reserves and missions today and is repeated down the generations . . .

[T]hey have been patterned into that stereotype, and they do live it.3

No more is needed to explain the present and ongoing over-representation of Aboriginal people in the prison population, or their generally poor health.

And the solution? Kevin Gilbert goes on to say that it starts with your education, and I agree. But it’s a special education. It’s a pity I don’t have room to quote him more, because he just blows Charles Darwin away.

And healthwise, whether you’ve been injured by a truck or by generations of white racism, it’s the same solution, believe it or not education.

Kooris, Gooris, Murris and all Aboriginal people, your health education can start right here, with you learning these principles:

  • Recovery and ongoing maintenance of your good health starts, first and foremost, with a free decision by you to take primary personal responsibility for it. Yes, you can do it, and yes, you are worth it.

  • You need education — information, strategies, and especially role models. Find them, and stick with the strength, or else . . .

For the many Aboriginal people locked in prison — especially those also locked in their self-destructive rituals of negativity, resentment and blame — experience shows that the process of health education in prison is only likely to start when they are targeted, brought together and encouraged into the caring hands of Justice Health’s wonderful Health Centres, with their specially trained and enthusiastic Aboriginal Health Workers.

Beverley F Spiers, BEd(Aboriginal Adult Ed), GradDipAdultEd, Aboriginal Health Worker/Education Officer
Justice Health, Aboriginal Health Unit, Cessnock Correctional Centre, Cessnock, NSW.
Acknowledgements: 

I acknowledge the Aboriginal people of the Awabakal nation, the traditional owners of the land on which I work.

Reference Text: 
Johnston E, Commissioner. Royal Commission into Aboriginal Deaths in Custody. http://www.austlii.edu.au/au/other/IndigLRes/rciadic (accessed Apr 2009).
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Darwin CR. The descent of man. London: John Murray, 1871: 200-201.
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Gilbert K. Living black: blacks talk to Kevin Gilbert. London: Penguin, 1977: 3.
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