Pearls and Irritations

Every day people are imprisoned for drug-related crimes in line with ‘tough on drugs’ policies. It’s time to face the futility and unsustainability of this approach to drug use.  

Prisons are a growth industry. In the 2016/17 Budget the NSW Government announced a $3.8 billion infrastructure plan for the state’s prison system to address current and future needs; and between 2006 and 2016 Victoria’s prison population increased by 67%.

A quick look at National Prisoner Census data reveals that on 30 June 2017 over 40,000 adults were in Australian corrective custody. They were mostly male, frequently serving a sentence for a drug-related crime and were disproportionately Aboriginal and/or Torres Strait Islanders.  Half had injected drugs before, and one-third disclosed injecting while in prison.

Studies show that injecting drug use decreases in prison, while syringe sharing increases posing a high risk for hepatitis C transmission. Around one-third of all prisoners in Australia are living with chronic hepatitis C, a potential life-threatening liver disease. Little wonder esteemed infectious diseases physician and prison blood borne virus (BBV) expert Professor Andrew Lloyd AM said “ prisons act as incubators of hepatitis C, driving the epidemic both within the prison system and in the community at large.”

How do we turn this around?

Drug law reform is part of the solution to the burgeoning prison population resulting in fewer convictions. Addressing the postcode lottery of inequalities and strengthening disadvantaged communities through prevention and early intervention are also critically important – particularly for young Aboriginal and Torres Strait Islander people. Based on the twin goals of safer communities and reduced incarceration, the Justice Reinvestment approach is a standout in this regard and is unequivocally a better option than punitive custodial environments and the unsustainable cost of building more prisons.

As we wait for a new, more logical, evidence-based, and humane approach to drug use to be constructed in Australia, we must acknowledge that no prison is ‘drug free’ and therefore we must adopt measures to reduce the harms associated with prisons and drug use.

Take provision of opioid substitution therapy (OST) as an example. The World Health Organization (WHO) recommends OST for prisoners and the United Nations Office on Drugs and Crime (UNODC) describes it as an “essential”. Australian studies have found OST is protective against acquisition of hepatitis C and HIV, and that mortality in opioid-dependent prisoners was significantly lower while in receipt of OST. Why then is access to OST restricted rather than mandated in Australian prisons?

Need and syringe programs

Bleach, used to clean injecting equipment, is only available to prisoners in three Australian jurisdictions. It is in any case a sub-optimal choice compared to Prison Needle and Syringe Programs (PNSP), as to avoid detection injecting is often rushed and groups of prisoners are sharing one ‘loaded’ syringe. The UNODC says “it is unethical to propose bleach when a more efficient means of prevention, such as PNSP, is available”.

By not providing PNSP in Australia, every day we are contravening the:  International Covenant on Economic, Social and Cultural Rights Article 12; the Universal Declaration of Human Rights, Article 25; and the human rights principle “equivalence of care” (resolution 45/111 of the United Nations Organization (“Basic principles for the treatment of prisoners”) whereby prisoners should have health care equivalent to that in the community.

The published evidence supporting PNSP is irrefutable. The Australian Prime Minister’s advisory body, Australian National Council on Drugs, reviewed the evidence and recommended an Australian trial in 2002. In endorsing the 2010-2013 National Hepatitis C Strategy, all Australian Health Ministers endorsed trialling PSNP. Since then, the Australian Capital Territory (ACT) Government under the leadership of Katy Gallagher as Chief Minister, committed to introduce a regulated PNSP at the ACT’s prison. The commitment stalled however when she left the ACT government for a career in federal politics and it was eventually ‘put to bed’ by a deed of agreement gifting power of veto over PSNP to the ACT prison union.

This provides a cautionary tale about abdicating power over public health measures to prison unions on the one-hand and over-reliance on a single strong and effective leader to stare down the rhetoric and opposition from those unions on the other. Sustained political will to implement PNSP has, for the most part, been missing in Australia.

More recently, the South Australian Government committed to investigate the feasibility of implementing “the full suite of harm reduction strategies available to the wider South Australian community in prison settings”. We remain hopeful.

In the absence of sustained political will, legal action may turn out to be the catalyst for exchanging the current unregulated needle and syringe supply programs run by prisoners throughout Australia for much safer and effective systems of regulated PNSP. Most recently legal action by Canadian advocacy groups resulted in Correctional Services Canada announcing a phased plan to implement a PNSP which subsequently commenced in mid-2018.

Treatment as prevention

For now, ‘treatment as prevention’ is the primary strategy being used to control hepatitis C in Australian prisons. This has produced remarkable results in a handful of prisons and has clear benefits for individual prisoners, society as a whole, and potentially for the elimination of hepatitis C in Australia. Acknowledging that the full range of harm reduction strategies in the community is not available inside prisons, the jury is still out on whether hepatitis C reinfections will undermine prison-based ‘treatment as prevention’ programs.

Hepatitis C treatment is expensive and OST and PNSP are cheap by comparison. Public health experts are in agreement that combining both treatment and harm reduction produces the best results. So why don’t we just give it a go in prisons?

Unfortunately, too many of those able to instigate changes put evidence-based harm reduction in prisons in the ‘too hard basket’ – along with drug law reform.

It is difficult – and the right thing to do.

Helen Tyrrell is the CEO of Hepatitis Australia and a Harm Reduction Australia advocate.

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