The shell and the circle: Indigenous health equity across the Pacific

“Is that a shell in your bag?” asks the security guard at the Central District Court on Liverpool Street in Sydney. Her head is cocked to one side as she looks at the X-ray screen. “It is,” I say while collecting my belongings from the tray rolling towards me. “That’s a first.” “It’s a gift. For the Walama Elders.”

I’ve arrived at the Court building to meet up with Uncle Charlie, an Elder who sits on the Walama List, an alternative sentencing procedure for Aboriginal and Torres Strait Islander people who have criminal matters in the District Court in the Greater Sydney Area. The pilot—which borrows heavily from the idea of ‘circle sentencing’—began in February 2022 and was designed primarily to reduce recidivism. In the Dharug language, the word ‘Walama’ means ‘come back’ or ‘return’, and in the context of this innovative and therapeutic judicial process, it signifies a return to culture, community and identity.

Inside my maple leaf tote bag is a large opalescent smudging shell with a thick bundle of sage given to me by a woman named Elder Mary Fayant during my research trip to British Columbia. Along with several hand-crafted items and two shawls, I have been minding these gifts for over a year, waiting to present them to the Walama Elders as a gesture of kinship, from Elder to Elder, across the Pacific.

In October 2023, under the auspices of the Law Society’s John Hennessy Legal Scholarship, I travelled to British Columbia (BC) to undertake research on the Indigenous Patient Navigator (IPN) program inside BC Corrections. My project parameters were to examine the IPN program and investigate the role of post-release rehabilitation services for Indigenous people in the community.

As a Legal Aid lawyer, I have worked on prisoner health issues for more than a decade in NSW, representing clients and undertaking various forms of strategic advocacy. BC serves as a useful jurisdictional comparator for several reasons. To begin with, it shares important similarities with NSW, in that both are geographically large territories with diverse metropolitan and regional populations. Both share a common colonial history which continues to impact upon Indigenous access to health care in the community and custody; and both have prison populations in which Indigenous people are grossly over-represented. In NSW, according to the latest Bureau of Crime Statistics and Research figures, the imprisonment rate is 10 times higher than for non-Indigenous people, or about 32 per cent compared to 3.4 per cent of the general adult population. In BC, Indigenous people represent roughly 5.9 per cent of the total adult population but, in prison, they account for 35 per cent of admissions—a similarly alarming disparity.

Another reason is that the IPN program is part of a broader Reconciliation strategy in BC which responds to underlying social and historical determinants of offending. In Canada, laws like the Indian Act, SC 1876, and the policies of segregation (which created the Indian Residential Schools and Indian hospitals) are recognised as foundational causes of health inequities born of colonisation. One cannot underestimate the role racism plays in exacerbating such disparities today. Research suggests racial discrimination causes stress-related health issues, contributes to social exclusion and reduces feelings of self-esteem. It can also contribute to lack of employment, education and housing opportunities.

The IPN program was originally implemented across BC’s provincial health system in response to a report in 2020, In Plain Sight. The report identified evidence of systemic and widespread Indigenous-specific racism within the BC health system. It followed calls by the Truth and Reconciliation Commission of Canada in 2015 to reduce health inequities by providing access to Indigenous healing approaches and ensuring healthcare providers were trained in intercultural competency and human rights. Consequently, in 2021, the BC government extended funding for six full-time navigators to the provincial prison system.

The idea of using ‘linkers’ or ‘navigators’ to support people holistically is nothing new. As a 2023 report by the Paul Ramsay Foundation acknowledged, it has a long history in youth work, community development and Aboriginal community-controlled organisations, helping clients and patients to navigate relevant systems and connecting services to respond more effectively to their needs. Herein lies another reason to spotlight BC: the navigator initiative offers a model for Closing the Gap on health in NSW prisons.

To date, the achievements of successive governments under Closing the Gap policies have fallen well short of their targets. Over a decade of research and data confirms that Aboriginal prisoners continue to exhibit greater levels of ill-health than their non-Aboriginal counterparts; chronic health conditions remain more prevalent and they leave prison to face poorer health outcomes and life expectancies. As people flow continuously in and out of custody, the prison gates become a kind of delta where the rivers of communal and custodial health issues converge. Navigator roles present an opportunity to create culturally safe continuity of care, thereby helping patients move towards self-determination.

Culturally safe healthcare behind bars

The sky is sapphire blue as I pull up in a taxi to Prince George Regional Correctional Centre. I’m here to tour the prison and interview two staff members about the IPN program. The day before, on a gusty and cold October afternoon, I white-knuckled my way through a two-hour flight from Calgary, praying to the gods of budget itineraries that we wouldn’t all end up as a smokestack on regional news. An hour later, I stepped out of my hotel to find somewhere to eat in town. The sunset was all mauve and peach syrup, and the city was quiet apart from the low drone of steroidal pickup trucks passing down Highway 97. Prince George is Cariboo country as much as it is oil ‘n’ gas, a place many in the province call ‘the capital of Northern BC’. More accurately, it’s central BC—the last major city en route to the rugged, expansive north. Archaeological evidence confirms the Lheidli T’enneh people have lived in the area for 9,000 years, connected to land which spans prairies, tundra, jagged mountains and coastal rainforest. Today, Indigenous people comprise approximately 15 per cent of the population, one of the largest ratios of any city in the province.

“Hi, I’m Richard. You must be Anthony.” “Pleasure to meet you.”

Richard Berger is the Health Services Manager for BC Mental Health & Substance Use Services at Prince George RCC, an adult male facility which is home to up to 175 prisoners. He greets me in the reception area before we head through a secure door into a wing of the prison. The first things I notice are the many murals along the corridors painted in the iconic Northwest Coast Indigenous style. It’s a visual language which uses ‘formlines’—bold flowing lines and geometrical elements used to depict figures, animals and oral histories, all of which are interconnected. The layered, curvilinear patterns, often in red and black, give the impression of three dimensions, such that the outline of an eagle pulses with life. And that is the sensation I have as I walk down the hall to meet former navigator, Chris Tyler.

The role of the IPN program is to facilitate culturally safe access to health services and improve continuity of care for Indigenous people in custody and sometimes beyond. Navigators like Chris adopt a no-wrong-door philosophy. The only criterion for assistance is that a person identifies as Indigenous. In practice, however, they will help any prisoner who asks, to avoid creating a hierarchy of health care. The work itself is varied but they focus primarily on attending GP appointments and connecting with patients outside the clinic. Chris describes the work as being akin to an interpreting function. Clients will often attend an appointment but, as he puts it, “they don’t want to appear to be unintelligent in front of the doctor. So, they just say ‘Yeah, yeah, yeah’. Then they leave and they tell me they didn’t understand.” Scholars and practitioners call this phenomenon ‘gratuitous concurrence’ and it occurs as much in intercultural healthcare settings as it does in legal ones. When it does, navigators do much more than simply reframe information; they also advocate for patients by speaking with healthcare professionals directly and relaying further guidance. Often this influences medical behaviour by encouraging doctors to use less jargon or give a patient more time to address their concerns.

Connecting with culture is another key strategy in overcoming barriers to equitable healthcare. By creating dedicated spaces in the prison for cultural practice, BC Corrections have expanded the opportunities to engage people about their health needs. Richard and Chris take me down to a room called the Indigenous Cultural and Spiritual Support Centre. It’s a space where inmates come together, often led by an Elder, to connect with culture and tradition through activities such as drumming, carving, weaving and ceremony. Compared with the guarded, hierarchical and sometimes violent atmosphere on the unit, Chris describes it as a “disarming place” where inmates would talk about anything. He recalls one experience when participants were making moccasins. As he made his way around the circle of tables to admire their work, an inmate asked: “Hey Chris, can you check into this [with] that doctor for me?”

Richard has also seen the benefits of participating in spiritual services firsthand. He spoke about the contrast between seeing a patient in a medical setting compared with being in a circle where they could build a connection. “Just being in a space where they feel safe to talk, you find out information from them that you wouldn’t know and … it would help with that rapport later on.” As much as the navigator improves a person’s contact with practitioners, it is their engagement beyond the clinic which has proven to be invaluable to each patient’s healthcare journey. For health staff like Richard, it’s been a game-changer: “It’s like you take the nursing hat off.”

A vibrant cultural ecosystem

One feature which differentiates the BC correctional system from NSW is the sophisticated ecosystem of identified staff who collaborate to support people inside. When I meet with Lori Pruce, a Métis woman and the Strategic Director of Indigenous Programs at BC Corrections, she explains to me that navigators don’t operate alone; they work closely with the Transitions Team, Indigenous Cultural Liaisons (ICLs) and Indigenous Justice Program (IJP) workers contracted to BC Corrections. Together, these workers offer a holistic model of care which aims to improve a person’s social and emotional wellbeing. It’s also evidence-based. Researchers like Professor Marie Claire Van Hout at Liverpool John Moores University argue that throughcare services are optimal when they are programmed across the continuum of care inside and outside prison. It therefore implements international best practice in delivering effective throughcare in detention: integrated multi-agency partnerships designed to address the complex, interrelated challenges faced by prisoners during their rehabilitation. Another navigator, Blake*, tells me “it’s all basically health-related stuff when you get the bigger picture of things.”

In fact, BC Corrections have gone to great lengths to create spaces where inmates can either learn about or practice cultural rites as part of their rehabilitation. During my visit to another prison, Kamloops Regional Correctional Centre, the ICL showed me the foundations of what they are calling an ‘Indigenous Village’. Once constructed, the layout will include a longhouse—a communal space to experience Indigenous ways of knowing—and a sweat lodge to perform purification rites.

However, practising culture isn’t necessarily a straightforward proposition for everyone in custody. That same ICL describes many inmates as being in “the newborn stage” of cultural practice. Due to the ongoing impacts of colonisation, the residential school system and intergenerational trauma, many have never participated in their own cultural rites. Both he and Blake believe it is their job to find out which inmates want to learn and give them resources and opportunities to do so—even if they belong to a community with different traditions.

I wanted to understand the division of responsibilities between these various roles, so I asked each staff member to explain how they work together. Universally, the answer was the same. “It takes a village to help a client reintegrate into a community,” says Chris matter-of-factly, adapting a timeworn adage of early parenting. And he’s right. Criminological research suggests a prisoner’s health is a keystone variable affecting their reintegration. Positive health interventions in prison are crucial to an individual’s prospects of rehabilitation. By maintaining a patient-centred approach and communicating informally (Chris quite likes sticky-notes), the network of Indigenous navigators, liaisons and contractors ensure clients’ needs are identified and addressed by whomever has capacity.

But what happens when people are released from prison and no longer have access to the same network of staff? Return to the community from prison is a period of considerable stress, typically characterised by social stigma, adaptation issues and difficulty accessing stable housing, social security and employment. Reoffending during this time is also strongly associated with poor engagement with health services and impoverished community connections. In NSW, Justice Health has a Community Transitions Team and a suite of policies addressing release planning for different categories of prisoners with various health conditions, including complex or chronic conditions, disabilities, communicable diseases or those at risk of self-harm. Yet there is no dedicated patient navigator for those first few weeks of freedom. 

Under the BC model, navigators can work with patients post-release although once they walk out through the prison gates, their participation becomes voluntary. For sentenced individuals, discharge planning begins about one to two weeks before release and typically involves connecting with community services. Up to three months after release, a navigator might take a client to the doctor, help them obtain status and ID cards, and perform regular check-ins. As Lori puts it, “the most effective navigators aren’t the ones working in the office, they’re the ones working from their car.” Meanwhile, the ICL makes similar efforts to reconnect an individual to the community. Lori suggests the range of connections they facilitate can include everything from Elders and knowledge keepers to social workers and counsellors. A fundamental part of their role is to build relationships.

What makes Prince George RCC particularly special is that clients who connect with the ICL are automatically connected to the Indigenous Justice Program in the community too. That has nothing to do with BC Corrections and everything to do with the Prince George Urban Aboriginal Justice Society which has the contract for both the prison and the community program. Although there are no guarantees about who succeeds in securing government tenders, it struck me that, in contrast to NSW, the design of BC’s health infrastructure—born in a culture of human rights and led by community—made it possible for a sophisticated cultural ecosystem to develop and flourish.

The challenges

Innovation always entails challenges and the IPN program is no exception. For a start, with just six navigators working across ten prisons, there simply aren’t enough to meet the needs of the 1,800 people inside. As the only navigator for five prisons, Blake’s caseload is up to 50 clients. On any given day, he might see 15 men. The women’s prison, a 188-bed facility called Alouette, has no navigator at all. That puts pressure on navigators to prioritise who they see. Best practice would dictate that every facility has its own navigator (although Chris recommends two), but that requires more funding from the BC government. Further, the issue of staff to client ratios is compounded in areas which do not have an IJP. Despite the evolution of an ecosystem, systemic gaps persist.

Timing is another major challenge for achieving continuity of care. A program manager I speak to says “the broader system of care is broken” and describes the IPN program as “a bridging service.” Nevertheless, even if people are ready to access supports in the community like drug treatment, those services don’t always have capacity. No bed? No treatment.

Just as in NSW, unplanned releases from custody also have logistical implications for linkers and transition teams alike. For the fully remanded populations of two Pretrial Centres, North Fraser and Surrey, the vicissitudes of judicial timetables and outcomes mean that a proportion of prisoners are released directly from court. That phenomenon is identical to what occurs in NSW. It is therefore essential for custodial health services and operators to ensure there are contingencies in place to prepare relevant consents, medical records, medications and linkups for prisoners prior to attending court to facilitate an effective transition to community providers. (One BC Corrections employee I spoke to gave the example of “scrambling” to work out, on the morning of a release, where to send a patient’s prescription for opioid agonist treatment.)

A persistent barrier which arguably cuts across all the others is racism. Staff were careful to point out that the existence of the IPN program doesn’t mean systemic and structural racism has been eliminated. When I returned to BC in 2024, I spent time interviewing people with lived experience of being in prison. One 30-year-old woman of Cree and Métis background told me she had never even heard about the IPN program during her time at Alouette. Instead, after disclosing she was Indigenous, she felt “pushed aside,” adding “all the white girls got to see the doctor.” Another interviewee with diagnosed depression said she didn’t feel comfortable with custodial health care: “Typically, I wouldn’t go to the doctor. I’d just leave it.” Listening to their stories, I was reminded of experiences relayed to me by my own clients in custody. I found myself wondering: what would it take to progress more steadily towards health equity in NSW?

Working with Elders

All the men call her ‘grandma’. Men twice her size, men with tattoos snaking up around their necks. Ex-gang members with scars, only some of them visible. They smile and listen as she asks how they’re doing, whether they’re staying straight. “Yes, grandma,” they say, nodding deferentially.

Standing just under five feet tall, Elder Mary exudes authority and wisdom. She is a Cree Elder and what is called an All-Nations teacher. I’m sitting with her and Elder Caroline in the courtyard of Tim’s Manor, home to an Indigenous-focused Community Residential Facility program called Miyáqˈelhá:wetawt in Abbotsford, BC. The residence is managed by a nonprofit organisation named Connective which runs housing, outreach, employment and community-based programs across BC. With 16 beds, the program offers safe, secure housing  and wraparound support to men released from federal prisons with residency conditions.

My visit related to the second phase of my project, examining the role of post-release rehabilitation programs for Indigenous people. While there are Elders who work with inmates and navigators inside the provincial prisons, I wanted to understand how community programs employ Elders to help people reconnect with culture and spirituality. At Tim’s Manor, an Elder is on site twice a week to provide one-on-one support and lead residents in sacred ceremonies. Residents cook traditional meals, eat together and participate in beading, carving, painting and drumming.

When I sit down with Elder Mary, she tells me she has spent most of her career working in prisons. She is a font of stories—about roughnecks reduced to tears and prison guards who hung their uniforms at the door to join circles of connection with inmates. When she’s working with the men, she says, “there’s a grandma part, and there’s an Elder part.” Her approach is simple: a little bit of kindness and love—and no judgment.

For many Indigenous people, Western medicine is alternative medicine. Elder Mary says “the beading and drum-making is therapy for us.” It’s an ethos reflected in Article 24 of the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) which affirms that Indigenous people have the right to Indigenous medicines and health practices. It’s also a perspective shared by Lori, who emphasised that Elders possess a rare knowledge and skill which is not understood due to the impacts of colonisation. As well as working in one of the most difficult environments imaginable, they take on layers of racism and systemic discrimination every day, and yet “they dedicate their lives … to help wounded people find a path to healing.” It’s possible to imagine how much faster that healing might be if we could only peel that layer away.

Maybe it’s because we are on Elder Time, but the hours pass like minutes, and I feel there is so much more to learn. Before I leave, Elder Mary takes me around the Manor, collecting items handcrafted by the residents. A few are for my family but most are for the Elders at the Walama List, which I have explained to her is a holistic, Indigenous-led therapeutic reintegration strategy. Among the gifts is the seashell from the territory of the Coast Salish people and a bundle of Buffalo sage from
St:lō lands for smudging. The practice of burning sage in the shell symbolises the elements of fire, water and earth, and allows the smoke to do its powerful healing work.

After two visits to BC and hours of interviews, the shell also represents something much larger. It affirms an insight which Lori shared when we first met in 2023. “Our cultural programs are medicine,” she said. “They’re so powerful that non-Indigenous clients seek them out.” One can only hope that some day soon, the winds of reform will carry a similar message down the corridors of the facilities responsible for people in custody in NSW.

Anthony Levin is the Manager and Senior Solicitor in Legal Aid NSW’s Human Rights Team. He was twice awarded the John Hennessy Legal Scholarship, enabling him to undertake a research project on legal systems in another jurisdiction. Anthony’s research led him to discover a new initiative used in prisons in British Columbia, Canada.

Header image: The author with Uncle Charlie Mundine and Catherine Lomas, Walama List Lead, DCJ. All photo: Henry Ea, LSJ Online