David McDonald
Consultant in Social Research & Evaluation
Fellow, National Centre for Epidemiology & Population Health
The Australian National University
Community Coalition on Corrections’ Public Forum,
Canberra, 14 March 2008
HOW FEAR AND STIGMA INHIBIT
SOUND PUBLIC HEALTH POLICY
1
Overview
 Stigma and discrimination
 Imprisonment and prison health
 Blood-borne virus (BBV) transmission and prisons
 Stigma, fear and discrimination: their links to BBV
transmission
 The public health approach
 Impediments and facilitators of rational policy re BBVs
and the AMC
 Discussion
2
Two worlds …
‘The vilest of deeds like poison-weeds
Bloom well in prison-air:
It is only what is good in Man
That wastes and withers there:
Pale Anguish keeps the heavy gate
And the Warder is Despair.’
The Health Promoting
Prison movement
(Oscar Wilde, ‘The Ballard of Reading Gaol’,
1896)
(based on the 1986 Ottawa Charter for
Health Promotion)
3
Stigma …
Erving Goffmann: Stigma: notes on the
management of spoiled identity (1964)
 Stigma is the gap between ‘virtual social identity’
and ‘actual social identity’
 Three types:
 ‘abominations of the body’
 ‘blemishes of individual character’
 ‘the tribal stigma of race, nation, and religion’
4
Stigma
 A mark made upon the skin by burning with a
hot iron…as a token of infamy or subjection;
a brand (OED)
 Stigmatize: to set a stigma upon;
to mark with a sign of disgrace or infamy;
to characterize by a term implying severe
censorship or condemnation (OED)
5
Thief being
branded,
engraving,
ca. 1638
(Source:
www.bowdoin.edu/news/archi
ves/images/brand2.jpg)
6
Stigma is a social process,
linked to discrimination
Illness is constructed as preventable or controllable
2. ‘Immoral’ behaviours causing illness are identified
3. These behaviours are associated with ‘carriers’ of the
illness in other groups…
4. Certain people are thus blamed for their own infection
and
5. Status loss is projected onto the ‘other’, which may (or
may not) result in disadvantage to them: discrimination
1.
(Deacon 2006)
This is dependent upon unequal power relationships
7
Who are the stigmatized?
Category or label
Choices/behaviour/ situation
 Drug use
 Heroin or shiraz?
 Sexual partner(s)
 Gay lesbian bisexual
 What illness one is living
transgender or straight?
 Hepatitis C, HIV/AIDS or
high blood pressure?
with
8
Why do we imprison people?
“Men are sent to prison as a
punishment, not for punishment”
(Sir Alexander Patterson, UK 1930s)
 Functions of sentencing & imprisonment:
 punish
 deter
 incapacitate
 rehabilitate
9
Blood-borne viruses and
prison
 Prison populations and imprisonment rates are rising
 Hepatitis C, hepatitis B & HIV/AIDS transmission in
prisons are key health and management concerns
 Risk factors include:
 High prevalence of HCV and HBV among prisoners
 High-risk injecting
 High risk sexual behaviour
 Lack of resources for prevention
 Stigma and discrimination
10
Blood-borne viruses and
prison
 HCV & HBV transmission occurs in Australian
prisons: ‘Individuals entering an Australian prison
HCV negative have a 10% per annum chance of
becoming infected with the virus’ (Batey 2007)
 Leading risk factors
 Injecting: contaminated injecting environments and
contaminated injecting equipment (Butler et al. 2004)
 Among non-injectors: contaminated tattooing environments and
contaminated tattooing equipment (Butler et al. 2004)
 Correctional Services’ and Governments’ policies reflecting and
creating stigma and discrimination
11
Stigma, fear and discrimination in
the community
Anti-Discrimination Board of NSW 2001: C-change: the
report of the enquiry into hepatitis C related discrimination
 The evidence to this Enquiry clearly demonstrates that
hepatitis C is a highly stigmatised condition and that
discrimination against people with hepatitis C is rife.
 Such discrimination is often driven by irrational fears
about hepatitis C infection, due to an inadequate
understanding of how hepatitis C is transmitted.
 However, a perhaps more powerful driving force for
discrimination than ignorance about hepatitis C
transmission, is that infection is inextricably linked with
illicit drug use, a highly stigmatised behaviour.
12
…and particularly in health
settings
 ‘Discrimination was reported by 22% of the 237 IDUs who
reported being HCV-positive, with 17% reporting that the
discrimination occurred in the preceding 12 months.
 …half [the incidents] were perceived to be due to their
drug user status, 15% of these incidents were due to HCV
status and 25% due to a combination of both.
 Twenty-five incidents occurred in a health-care setting,
of which 13 resulted in the service being withheld.’
(Day et al. 2003)
13
The Public Health Approach
host
agent
environment
14
The Public Health Approach
 The core of health promotion: making
healthy choices easy choices
 Change the person
 Change the agent
 Change the environment/system
15
Preventing the BBV epidemic in prisons
 Primary prevention: prevent the onset of the condition
 Eliminating the organism (BBVs and stigma)
 Environmental protection
 Interrupting the chain of transmission
 Reducing susceptibility in the host
 Health education and community participation
 Secondary prevention: arrest the progression of an
established condition
 Screening
 Investigation of the causes, transmission pathways and risk
factors, and develop interventions
 Tertiary prevention: limiting the adverse consequences
of an established condition
 Treatment
(O’Brien 2006)
16
Dealing with stigma and discrimination
and BBV transmission in the AMC
 ACT Human Rights Commission’s Human Rights Audit on
the Operation of the ACT Correctional Facilities 2007
 auditing prisoner health records and conducting an
epidemiological survey
 strategies for the prevention of BBV transmission
 ‘Consistent with the ethos of a healthy prison, the
emphasis must continue to shift from a culture that
privileges control and security over detainees’ needs.
Instead, meeting detainees’ needs should be
acknowledged as assisting to maintain security and
order in the prison’ (Recommendation 5.2.1, p. 93, my emphasis).
17
Impediments to & facilitators of
rational policy on the AMC
 The players in the policy process:
policy makers, influencers, the public (affected
communities), media (Nutbeam 2006)
 How evidence is used: as a prop or for enlightenment?
(Nutley et al. 2007)
 Types of evidence:
 research
 knowledge & information
 ideas & interests
 politics
 economics
(Bowen & Zwi 2005)
18
Assessing & monitoring stigma &
discrimination in the AMC
 UNAIDS Protocol for the Identification of Discrimination
Against People Living with HIV (UNAIDS 2000)
 Examples of indicators; for each assess as to required by
law, required by internal protocols/regulations or simply
occurring in practice:
 Refusal to treat on grounds of BBV status
 Differential treatment on grounds of BBV status
 Testing without knowledge
 Refusal to inform a person of the results of a test
 Health controls, e.g. segregation
 Compulsory notification of BBV status to sexual partners,
relatives, etc.
 Breaches of confidentiality
19
For discussion …
 Is the concept of a ‘heath promoting prison’ realistic or just pie-in-
the-sky?
 Is it true that Correctional Services’ and Governments’ policies can
reflect and create stigma and discrimination?

and that this is a risk factor for blood-borne virus transmission?
 Fear of drug users and their HCV positive status and discrimination
against them are rife in the community, including in health care
settings. Can the AMC be better?
 Focus where: prisoners’ knowledge, attitudes & behaviour? Prison
staff? Corrections policy generally? Elsewhere?
 How can we move to a situation where ‘…meeting detainees’ needs
should be acknowledged as assisting to maintain security and order
in the prison’ (ACT Human Rights Commission 2007)?
 Should qualitative and quantitative assessments of stigma and
discrimination be part of the performance indicators for evaluating
the AMC?
20
References
International Conference on Health Promotion 1986, 'Ottawa Charter for Health Promotion,
WHO/HPR/HEP/95.1', paper presented to First International Conference on Health Promotion,
Ottawa, 17-21 November, <http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf>.
Goffman, E 1963, Stigma: notes on the management of spoiled identity, Penguin Books, Harmondsworth,
Eng.
Link, BG & Phelan, JC 2001, 'Conceptualizing stigma', Annual Review of Sociology, p. 363.
Deacon, H 2006, 'Towards a sustainable theory of health-related stigma: lessons from the HIV/AIDS
literature', Journal of Community and Applied Social Psychology, vol. 16, pp. 418-25.
Braithwaite, J 1996, Dorothy J. Killam Memorial Lecture: Restorative Justice and a Better Future,
Dalhousie University, 17 October, 1996, viewed 20 Nov. 2000
<http://www.realjustice.org/Pages/braithwaite.html>.
Batey, RG 2007, 'Controversies in and challenges to our understanding of hepatitis C', World Journal of
Gastroenterology, vol. 13, no. 31, pp. 4168-76.
Butler, T, Kariminia, A, Levy, M & Kaldor, J 2004, 'Prisoners are at risk for hepatitis C transmission',
European Journal of Epidemiology, vol. 19, no. 12, pp. 1119-22.
New South Wales, Anti-Discrimination Board 2001, C change: report of the enquiry into hepatitis C
related discrimination, The Board, [Sydney].
Day, C, Ross, J & Dolan, K 2003, 'Hepatitis C-related discrimination among heroin users in Sydney: drug
user or hepatitis C discrimination?' Drug Alcohol Rev, vol. 22, no. 3, pp. 317-21.
21
References (cont.)
O'Brien, S 2006, 'Preventing epidemics of communicable disease', in D Pencheon, C Guest, D Melzer &
JAM Gray (eds), Oxford handbook of public health practice, 2nd edn, Oxford University Press, Oxford,
pp. 206-16.
ACT Human Rights Commission 2007, Human Rights Audit on the Operation of ACT Correctional Facilities
under Corrections Legislation, Human Rights Commission, Canberra.
Nutbeam, D 2006, 'Developing healthy public policy', in D Pencheon, C Guest, D Melzer & JAM Gray
(eds), Oxford handbook of public health practice, 2nd edn, Oxford University Press, Oxford, pp. 312-8.
Nutley, SM, Walter, I & Davies, HTO 2007, Using evidence: how research can inform public services, Policy
Press, Bristol.
Bowen, S & Zwi, AB 2005, 'Pathways to "evidence-informed" policy and practice: a framework for
action', PLoS Medicine, vol. 2, no. 7, p. e166.
UNAIDS: Joint United Nations Programme on HIV/AIDS 2000, Protocol for the identification of
discrimination against people living with HIV, UNAIDS Best Practice Collection, Joint United Nations
Programme on HIV/AIDS, Geneva, http://data.unaids.org/Publications/IRC-pub01/JC295Protocol_en.pdf .
22
Presenter’s contacts
David McDonald
Director
Social Research & Evaluation Pty Ltd
PO Box 1355
Woden ACT 2606
Phone: (02) 6238 3706
Mobile: 0416 231 890
Fax:
(02) 9475 4274
Email: mail@socialresearch.com.au
Web:
www.socialresearch.com.au
==========================================
Fellow
National Centre for Epidemiology and Population Health
The Australian National University
Canberra ACT 0200
Email: david.mcdonald@anu.edu.au