Deaths in custody rightly receive significant attention in the media, but the far higher rate of deaths among ex-prisoners during their first year after release from prison is not widely reported. A high risk of death after release from custody seems counterintuitive, but the phenomenon has been reported in overseas literature. In this issue of the Journal (Kinner), we present the first Australian evidence.
Kinner and colleagues found that, in 2007–08, more than 400 ex-prisoners died in their first year after release — up to 30% of these in the first month. While their analysis had methodological limitations, it is likely that their estimates understate the mortality rate.
The Australian prison population is about 30 000, a figure that had increased by 39% over the decade to 2009. Approximately 50 000 prisoners are released each year, and there are about 385 000 ex-prisoners living in the community (http://www.aihw.gov.au/publication-detail/?id=6442468371). This represents 1.8% of the Australian population, so ex-prisoner health has significant repercussions, and the load on our health services is likely to increase. It is now clear that this population is extremely vulnerable.
Almost half of all deaths were drug-related, involving mostly non-Indigenous ex-prisoners. While Indigenous Australians comprise more than a quarter of the total prisoner population, they are less likely to be injecting drug users. As Kinner et al discuss, there are evidence-based programs available that may reduce drug-related deaths, yet they are not being widely implemented. Reducing deaths from non-drug-related causes is more complex. Interventions that target mental illness, chronic disease and injury prevention will be required as part of the solution.
Sadly, a United States man with chronic health problems recently resorted to stealing $1 from his bank with the aim of being arrested to gain access to prison health services. If we are to look for answers overseas, there is probably more to be learnt from the German penal system, which aims to resocialise and rehabilitate prisoners. It endeavours to “normalise” living conditions so that they resemble life in the community (http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhaff/193/19304.htm). Presumably, this makes the transition to freedom less stressful.
The Australian penal system, with a 2-year recidivism rate of about 40%, and about half of prisoners having been previously imprisoned, is failing. Prisoner health must be seen to encompass both inmates and those recently released. It should be seen to include justice issues that influence health: is the quantum of punishment appropriate; are there alternatives to incarceration; are rehabilitation and education programs available? Programs that smooth the reintegration of prisoners into society are urgently required.
Better data are needed to understand what is happening to prisoners after release, but the results of the study by Kinner et al leave no doubt that the health care system must flag ex-prisoners as a high-risk group, and move to meet its needs.