Overincarceration of Indigenous people: a health crisis
=======================================================

* Davinder Singh
* Sarah Prowse
* Marcia Anderson

KEY POINTS
*   Indigenous people are greatly over-represented in the incarcerated population in Canada.

*   Overincarceration of Indigenous people has both immediate and compounded long-term health effects.

*   Indigenous people lose far more years of life to time spent incarcerated than to premature death from cancer, injuries, heart disease and stroke.

*   The recommendations of decades-old and recent reports to address racism in the Canadian justice system must be implemented to properly address inequities in health between Indigenous and non-Indigenous people as a public health priority.

Indigenous people are incarcerated at a much higher rate in Canada than the general population.1 It is well known that incarceration is a negative determinant of health.2 For Indigenous Peoples, the legacy of colonialism and ongoing systemic racism, including in the Canadian justice system,3 has both immediate and far-reaching negative health impacts, and contributes to health inequities between Indigenous and non-Indigenous Peoples. The overincarceration of Indigenous people leads to an inequitable distribution of the health harms of incarceration, as well as an enormous burden of years of life lost attributable to incarceration for Indigenous Peoples.

Indigenous men lose 4–6 times more years of life to incarceration than non-Indigenous men, and Indigenous women lose 6–9 times more years of life than non-Indigenous women, across both the federal penitentiary and British Columbia provincial jail systems.1 However, Indigenous people in some provinces and territories likely have a much higher ratio of life lost to incarceration compared with non-Indigenous Canadians than those reported above. For example, in Manitoba, Indigenous adults are incarcerated 18 times more often than non-Indigenous adults, compared with a rate ratio of 4.5 in British Columbia, which suggests the ratio of years of life lost to incarceration in Manitoba is higher, perhaps much higher, than in British Columbia.1 This should not be viewed as fair punishment, as many rigorous reports over decades have shown that the inequitable incarceration rates are a result of the effects of colonialism and systemic racism.3,4

To illustrate the effect of this social determinant, it is helpful to compare years of life lost to incarceration with years of life lost to premature death from common diseases. Although being incarcerated is not the same as dying prematurely, liberty is of such fundamental importance that it is protected by section 7 of the *Canadian Charter of Rights and Freedoms*, in the same section as life and security of person. Indigenous men lose years of life to incarceration at a rate of 76 times years of life lost to cancer for First Nations men; 53 times years of life lost to heart disease and stroke; and 9 times years of life lost to injuries.5 Indigenous women spend less time incarcerated than Indigenous men, but they also lose many more years to incarceration than to common health conditions. Indigenous women lose years of life to incarceration at a rate of 8.5 times years of life lost to heart disease and stroke for First Nations women; 5 times years of life lost to cancer; and 1.6 times years of life lost to injuries in Canada.5 Yet, even these estimates of years of life lost to incarceration do not account for the years of life lost resulting from health effects of incarceration.

Incarceration has wide-ranging consequences for human health: from direct to indirect; from infections to death; and from individual-to family- and population-level effects.

After individuals are released from incarceration, their risk of death is substantially higher than the average risk of death in the community.2,6 This risk is particularly high in the first 2 weeks after release — with a reported increase of 6 times the expected number of deaths after accounting for age and sex2 — largely attributable to drug overdose (56 times the average risk in the 2 weeks after release)2 and suicide (29 times the average risk between 2 and 4 weeks after release).2 The risk of death after release from incarceration also increases the longer the person is incarcerated.6 Even after taking into account other factors like education and the reason for incarceration, every year that a person spends behind bars decreases the person’s life expectancy by 2 years.6

Incarceration has also been associated with increases in the risks of major depression,7 acute and chronic infections,2,7 and heart disease7 and its associated risk factors: hypertension and obesity.8 Furthermore, parental incarceration increases the risk for negative health effects for children throughout the life course, both directly and indirectly, via its impact on children’s social determinants of health.9

Incarceration negatively affects social determinants of health, such as employment and career prospects, relationship stability and housing status.10,11 Lack of access to these social determinants also increases risk of involvement in the criminal justice system, creating a cycle of poor health and vulnerability for criminal justice involvement.12 These issues are compounded for Indigenous Peoples, given their historic and current experiences of racism and social inequality.

Some may not agree that years of life lost from incarceration are comparable with those lost from premature death. However, years of incarceration cause more negative impacts to *minobimaadiziwin* (Anishinaabe term roughly translating to “living a good life” and often used to describe health) than many other causes of premature death. In teachings from several Knowledge Keepers, including Margaret Lavallee and David Courchene Jr., to one of the authors (Anderson) about *mino-bimaadiziwin*, critical aspects of living the good life involve being with family and community, living in harmony with the land, and fulfilling one’s personal purpose through service to others. The overincarceration of Indigenous people, driven largely by systemic racism in the justice system is, at a population level, a substantial barrier to the highest possible attainment of *mino-bimaadiziwin* for Indigenous Peoples.

As noted by the Aboriginal Justice Inquiry of Manitoba in 1991, “Many opportunities for subjective decision-making exist within the justice system and there are few checks on the subjective criteria being used to make those decisions … Aboriginal people … do not “benefit” from discretionary decision-making, and … even the well-intentioned exercise of discretion can lead to inappropriate results because of cultural or value differences.”3 Yet the issue of systemic racism extends beyond the justice system and affects health.13 To move forward to address racism in the justice system, public health should partner with the Department of Justice to refine understandings of the mechanisms by which systemic racism operates to increase the rates of incarceration of Indigenous Peoples. This has been previously detailed in both decades-old and recent reports; there is a need to examine why the recommendations of these reports were not implemented.3,4 In future, it is imperative that we carefully monitor and report on both the overincarceration of Indigenous people and its effects on health (see number 19 of the *Truth and Reconciliation Commission Calls to Action*).4

Governments have pledged to address inequities in Indigenous Peoples’ health as part of the effort of reconciliation. However, if we do not address the public health crisis of overincarceration, we will not succeed in this endeavour.

## Footnotes

*   *CMAJ* Podcasts: author interview at [https://soundcloud.com/cmajpodcasts/181437-com](https://soundcloud.com/cmajpodcasts/181437-com)

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** All authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

## References

1.  Owusu-Bempah A, Kanters S, Druyts E, et al. Years of life lost to incarceration: inequities between Aboriginal and non-Aboriginal Canadians. BMC Public Health 2014;14:585.
    
    

2.  Kouyoumdjian FG, Kiefer L, Wobeser W, et al. Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study. CMAJ Open 2016;4:E153–61.
    
    

3.  Report of the Aboriginal Justice Inquiry. Winnipeg: Aboriginal Justice Inquiry Commission; 1991.
    
    

4.  Honouring the truth, reconciling for the future: summary of the final report of the Truth and Reconciliation Commission of Canada. Ottawa: Truth and Reconciliation Commission of Canada; 2015.
    
    

5.  A statistical profile on the Health of First Nations in Canada: vital statistics for Atlantic and Western Canada 2003–2007. Ottawa: Health Canada; 2014.
    
    

6.  Patterson EJ. The dose-response of time served in prison on mortality: New York State, 1989–2003. Am J Public Health 2013;103:523–8.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.2105/AJPH.2012.301148&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=23327272&link_type=MED&atom=%2Fcmaj%2F191%2F18%2FE487.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000330762600039&link_type=ISI) 

7.  Massoglia M. Incarceration as exposure: the prison, infectious disease, and other stress-related illnesses. J Health Soc Behav 2008;49:56–71.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1177/002214650804900105&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=18418985&link_type=MED&atom=%2Fcmaj%2F191%2F18%2FE487.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000256633200004&link_type=ISI) 

8.  Houle B. The effect of incarceration on adult male BMI trajectories, United States, 1981–2006. J Racial Ethn Health Disparities 2014;1:21–8.
    
    

9.  Wildeman C. Imprisonment and infant mortality. Soc Probl 2012;59:228–57.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1525/sp.2012.59.2.228&link_type=DOI) 

10. Pager D, Western B, Sugie N. Sequencing disadvantage: barriers to employment facing young black and white men with criminal records. Ann Am Acad Pol Soc Sci 2009;623:195–213.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1177/0002716208330793&link_type=DOI) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000265207100015&link_type=ISI) 

11. Massoglia M, Remster B, King RD. Stigma or separation? Understanding the incarceration–divorce relationship. Soc Forces 2011;90:133–55.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1093/sf/90.1.133&link_type=DOI) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000294035800007&link_type=ISI) 

12. Kendall P. Health, crime, and doing time: potential impacts of the *Safe Streets and Communities Act* (former Bill C-10) on the health and well-being of Aboriginal People in BC. Vancouver: Office of the Provincial Health Officer; 2013.
    
    

13. Policy and position statements: racism and Public Health. Ottawa: Canadian Public Health Association; 2018. Available: [www.cpha.ca/racism-and-public-health](http://www.cpha.ca/racism-and-public-health) (accessed 2019 Feb. 20).