A public health catastrophe looms: The Australian and New Zealand prison crisis

In the past decade, the prison population of both Australia and New Zealand has increased by more than 30%. The proportion of the population who are in prison is well above the Organisation for Economic Co-operation and Development average in both countries, with 2018 data showing New Zealand and Australia at 220 and 167 per 100,000, respectively. This increase has accelerated since 2013, outstripping the ability of prison health services to adapt and cope. The situation is even worse than it appears, because remand prisoners account for much of the increase, and their health and social needs are typically more acute than those of sentenced prisoners.

The increasing prison population is not explained by changing patterns of recorded crime in either country. The causes of the increase likely vary between jurisdictions, but changes in justice processes including bail, sentencing and parole are most relevant. Since 2013, changes to bail legislation have occurred in New Zealand and most Australian states and territories. In all of these cases, the legal amendments have placed more burden of responsibility on defendants to show they do not pose a risk while on bail. Defendants who have access to stable housing are more likely to be granted bail in general. However, affordable housing is increasingly out of reach for those of low socio-economic status and with chronic mental and physical illnesses. Therefore, many more in these vulnerable groups are now likely to be remanded to prison.

These procedural changes reflect decreasing societal tolerance for risk, and the influence of politicians and lobbyists. Hackneyed statements about getting ‘tough on crime’ are commonly voiced by politicians at all points on the political spectrum. Few public officials are elected on a platform of offenders’ rights. Politicians’ exaggerated statements about crime are also echoed by public perception that crime is increasing even when it is not (Gluckman, 2018). Recently, governments’ response to crime therefore has followed a populist agenda rather than being based on balanced moral or scientific arguments. Interestingly, the current New Zealand Government accepts that the prison population is unacceptably high and without intervention, it will continue to climb. The government has pointed to untreated mental disorders as one of the reasons for this ongoing growth. It has set itself a goal to decrease the prison population by 30% over the next 15 years, but this is unlikely to occur without improved access to treatment for defendants and prisoners with mental disorders and addictions.

Unsurprisingly, rates of mental disorders and substance use disorders are greatly increased among prisoners compared to the general population (Indig et al., 2016). Substance problems in particular contribute to the high mortality among prisoners, which peaks immediately after release from prison and remains elevated for at least 12 months afterwards. Providing high-quality mental health and addiction treatment both in prison and after release is therefore vital. As highlighted in a recent article in this journal, effective treatment for prisoners with a psychotic disorder is particularly crucial because of their poorer offending outcomes (Nielssen et al., 2018).

The current prison crisis is of great relevance and urgency to mental health services. Providing high-quality mental healthcare to prisoners is tough even under ideal conditions. It requires both enough resources and good cooperation between health and correctional systems. The rapid expansion in prison populations has placed both sets of organisations under extreme pressure, to the detriment of mental healthcare. The finite pool of resources is being spread ever wider. For forensic mental health services, this means directing resources to only the most severely ill people. In some jurisdictions (notably Victoria, where the media has focused on the problem), prisoners requiring hospital treatment are waiting unacceptably long in prison. In many cases, these prisoners are unfit to stand trial or have a defence of insanity, and prolonged detention in prison violates their human rights.

As a group, prisoners are not often fondly viewed by the general public. In many cases, this is for understandable reasons. Yet most offenders who are imprisoned have faced severe setbacks early in life, including parental mental illness (Valuri et al., 2017), abuse, poverty and extreme family discord. Prisoners therefore are vulnerable and need support to preserve their human rights, including the right to good health. Indigenous prisoners are a particularly important group in this regard. In New Zealand, Māori make up about half of the prison population despite being only about 15% of the total population. In Australia, the figures are even more pronounced: Aboriginal and Torres Strait Islanders make up about one quarter of the prisoner population despite being only 3% of Australians. Health and social disparities between indigenous and non-indigenous people have been widely studied and reported. Broadly speaking, they can be attributed to the downstream effects of two centuries of colonisation (Shepherd and Phillips, 2016). The prison statistics for indigenous people in Australia and New Zealand are no exception. They are an indictment on both countries and they warrant more shame and public outrage than has been seen so far. While the solutions no doubt are complex, providing indigenous people with greater power and control over justice processes (particularly for less serious offending) seems an essential starting point. In New Zealand at least, provisions of the Treaty of Waitangi provide a powerful mandate for this.

Political processes created this prison crisis, and political solutions to it are required. In the meantime, the health and social services sectors need to move fast to deploy existing resources more effectively, while lobbying for increased resources to cope with the expansion in prisoner numbers. To draw the attention of politicians, there needs to be visible, robust public debate about the role of prisons in a civilised society. Politicians who seek public support for a stance that is ‘tough on crime’ need to be forced to provide evidence for their views. In the meantime, mental health clinicians must remind politicians and lawmakers that prisoners have an equal right to healthcare as the rest of the population.

None of these arguments should detract from the empathy and support which victims deserve. There remains a place for imprisonment alongside other outcomes for offenders, but a culture of retributive rather than restorative justice should not be allowed to be the dominant one. The voice of victims needs to be at the forefront of justice policy, but at the same time the fact that many imprisoned offenders have themselves been victims should not be missed.

In summary, there is great cause for alarm. The prison crisis in Australia and New Zealand is an urgent public health problem which is highly relevant to mental health clinicians including psychiatrists. For forensic mental health services, a watchful waiting approach is not an option. Many of these services are already working well beyond capacity, and the situation is likely to get worse. It is time for mental health clinicians in leadership roles to leap into the debate and help avert a public health catastrophe.