Researchers are calling for a coordinated, whole-of-government response

More than 30 million people pass through prisons worldwide every year, including almost 70,000 in Australia.

Studies in many countries have shown that people who spend time in prison tend to have worse physical and mental health than people who have never been to prison.

This includes higher rates of infectious diseases, cognitive disabilities, mental illness, substance use problemschronic and non-communicable diseases, and self-harm and suicide attempts. Importantly, these complex and co-occurring health problems often play out against a backdrop of trauma, abuse and disadvantage.

These same people are present dramatically increased risk of preventable death after release from prison.

In our recent studypublished in The Lancetwe combined prison data with death data for more than 1.4 million people released from prisons in eight countries (Australia, Brazil, Canada, New Zealand, Norway, Scotland, Sweden and the US) between 1980 and 2018.

In the first few weeks after release, we found that overdoses from alcohol and other drugs were the leading cause of death in all countries except Brazil, where deaths from interpersonal violence predominated.

As the length of time between release from prison and death increased, the burden shifted to suicide, accidental injuries, and non-communicable diseases, including cardiovascular disease and cancer. Infectious diseases such as HIV were responsible for only 3.5% of all deaths.

Prison creates a ‘perfect storm’ of marginalization and exclusion

There are several factors that contribute to the high mortality rate after release from prison. First, incarceration functions as a filter for poor health and marginalization—a concept also called “the sedimentation of diseases“with people who spend time in prison typically having much poorer health than those who don’t.

Second, most prisons do not provide adequate physical and mental health care, despite United Nations measures. Nelson Mandela Rules that require a standard of care equivalent to that of the community.

Third, investments in transition care to ensure that people released from prison are connected to health and social care providers in the community are woefully inadequate in many countries, including Australia.

Fourth, the stigma of incarceration, combined with interruptions to health care, housing, relationships, employment, and other forms of social capital, creates a “perfect storm” of marginalization and exclusion for these vulnerable individuals.

A healthier transition back to the community

So, what should be done? In accordance with international standardsPrison healthcare providers can take three important steps to prevent these deaths.

First, they can routinely assess each person’s health status and comprehensively identify health care needs as they enter prison. Second, they can provide – free of charge and without discrimination based on legal status – a standard of health care that is at least equivalent to that available in the community.

Third, they can support a healthier transition to the community by conducting a comprehensive needs assessment prior to release and coordinating transitional health care around the time of release.

While correctional health care providers play a key role, reducing preventable deaths after incarceration will require a coordinated response from across government. The World Health Organization (WHO) recognized this and recommended it in 2019 prisons must be included in all public health strategies, policies and planning under the banner: “prison health in all policies.”

For example, community health care providers can proactively engage with people before they are released to facilitate continuity of care and prevent relapse to poor health and health risk behaviors.

This is especially important in Victoria and Western Australia, two states that continue to fly in the face WHO guidance by financing prison health care through a Ministry of Justice rather than a Ministry of Health.

Current measures are insufficient to reduce preventable deaths

There are a few promising examples of Aboriginal Community Controlled Health Organizations (ACCHOs) providing this type of outreach, but while the Australian Government continues to excluding people in custody from Medicare subsidiesthese models are not scalable.

Housing and homelessness services are also critical to improving health outcomes and preventing post-release deaths, given the very high rates of post-incarceration homelessness and the unsurprising situation link between homelessness and poor health and mortality in this population.

While Australia’s commitment to reducing incarceration among Indigenous people is commendable, this will not be enough to reduce preventable deaths among this population. This is because incarceration is largely a sign of pre-existing risk. For the most part, the increased mortality rate after incarceration is not causal.

The best available international evidence suggests that incarceration has little impact on health, either negatively or positively. Incarceration is therefore too often a missed opportunity to improve health outcomes, including reducing preventable deaths among those most at risk.

It is often said that ‘what gets counted, gets done’, and in Australia (and internationally) deaths after incarceration are not routinely counted. Informed by previous work in our groupthe Australian Institute of Health and Welfare (AIHW) now offers a estimate of deaths after incarceration every three years, based on an analysis of Centrelink data.

However, this approach underestimates the number of deaths and, crucially, does not provide information on the causes of death, which is essential for prevention.

An equal opportunity to survive and thrive

Australia shows off exceptional infrastructure for routine linking of administrative data, with the capacity to routinely monitor post-incarceration deaths by linking correctional and death data. The main obstacle to such a system is political will.

This is by no means a uniquely Australian problem, and more research in low- and middle-income countries – true Most of the world’s prison population is incarcerated– is urgently needed.

This is important because our findings largely reflect high-income Western countries and it is likely that the causes of death – and therefore the opportunities for prevention – will be very different in the context of different countries.

The WHO has done so in the European region developed a mechanism for routine reporting on prison health, but due to a lack of data, this system does not currently record post-incarceration deaths.

Routine monitoring of post-incarceration deaths and coordinated government-wide responses to prevent them are urgently needed.

The high mortality rate after release from prison, in Australia and internationally, is tragic and avoidable. We can and must do more to ensure that people released from prison have equal opportunities not just to survive, but to thrive.