Citizenship, democracy and the political determinants of indigenous health
Indigenous health receives significant public expenditure, yet remains a matter of profound public policy failure. Solutions presuppose a philosophical reconsideration of the meaning of Indigenous citizenship and opportunities for substantive Indigenous policy deliberation.
The Indigenous median age of death is around 20 years less than the national median. Indigenous health receives significant public expenditure. Yet premature Indigenous deaths are largely preventable and the health differential is one that affects just 2% of the national population. Indigenous health is a site of profound and sustained public policy failure.
Relative poverty, poor education and housing, along with high rates of imprisonment are contributing variables - the social determinants of health. However, these determinants are underpinned by neo-colonial ideas about citizenship and democracy such that political ideology is a further determinant of health. Aristotle describes the citizen as ‘one who deliberates’; yet for many Indigenous Australians the ideal of participating in public decision-making, with substantive equality, is one that is always elusive.
The popular understanding of citizenship as the right to vote, and a body of welfare entitlements, rather than a concept concerned with deeper political questions of who belongs to the national political community and on whose terms, leaves questions of power and ideology beyond policy discourse. It leaves underdeveloped the very recently accepted idea that Indigenous people should, in fact, be meaningfully involved in policy formation. However, as Noel Pearson puts it; ‘Aboriginal policy will never prosper if the Leviathan is not restrained in its cage, and self-determining humans seeking a better life are once again free to roam the continent’. In other words, which political arrangements might more evenly distribute the power to make decisions consistent with good health? Which political values support that capacity? Which political values’ influence might reasonably diminish?
While racism is officially recognised as a politically motivated determinant of Indigenous health, it remains a common experience in the public health system. Also, for many Indigenous Australians, the health system’s central role in the implementation of the ‘stolen generations’ policy is within living memory and helps to explain history’s legacy in contemporary politics. For Indigenous health policy, there is a deep mistrust that must be overcome with the same urgency as the more popularly understood social determinants of health.
The public acknowledgement of systemic racism is politically important, but further thought on what it means to be a substantively equal Indigenous citizen of a liberal democratic state precedes effective policy responses to the Commonwealth’s recent acceptance that:
Aboriginal and Torres Strait Islander people who have experienced discrimination are more likely to have high levels of psychological distress, to drink alcohol at harmful levels and to take illicit substances than those who have not. They are also less likely to trust the police, the local school, their doctor or their local hospital.
Discrimination is both an outcome and a cause of considered democratic exclusion. In contrast, international legal instruments such as the United Nations’ Declaration on the Rights of Indigenous Peoples provide a policy framework of inclusion. The Declaration privileges Indigenous membership of the national political community with reference to self-defined aspirations. These aspirations might arise from cultural perceptions of good health, realised through collective policy making voice. Collective voice is democratically important because Indigenous peoples maintain that group rights are inescapable constituents of individual liberty.
Democratically, the most important group right, and the most important political determinant of health, is the protected right to participate at every level of the policy process. It is only in this way that people have the political capacity to develop informed policy; equipped to contest inequities in the burden of disease. In jurisdictions, such as New Zealand, where relative indigenous ill-health persists but not to the same extent as in Australia, there has been guaranteed Maori representation in Parliament since the 1870s and, more recently, guaranteed representation on District Health Boards. This provides Maori with a protected share in national political authority. It ensures that cultural priorities and socio-political context influence policy discourse. It ensures that resistance to discriminatory measures is always possible and, indeed, expected by Maori voters. These arrangements do not provide a guarantee against racism or inequality; but they do give liberal democracy a better chance of considering the interests of all citizens. They also give people greater opportunities to make decisions for themselves about the constituents of good health. For both Australia and New Zealand, and other comparable post-settler societies, the political questions most significant to improved health outcomes are those of the former Maori party co-leader and government minister, Tariana Turia:
how do we ensure that our respective peoples do indeed shape their destiny? Whose voices are being heard? What peoples are represented in the advice that you [public servants] put forward?
Although sustained policy failure is Indigenous Australian health policy’s defining characteristic there are also instances of policy success. What these hold in common is meaningful Indigenous involvement in their development and close attention to relationships between culture and health.
This article gives the views of the author, and not the position of The Policy Space.