A share in public authority for indigenous peoples

If we are prepared to accept the ethnic discrepancies in our health system, what does this say about our conceptions of justice and the values we hold? Dominic O’Sullivan says we need political arrangements that allow indigenous peoples to be included, not merely consulted, in policy development.

Life expectancy differentials between indigenous and non-indigenous populations are not unique to Australia. However, the Australian differential in the median age of death, in the order of 20 years, well exceeds that of similar jurisdictions – Canada and New Zealand, for example. The explanations are complex and complicated and the subject of extensive clinical research. However, profoundly political questions also need to be considered; opportunities for good health are partly attributable to the ways in which political ideas about citizenship, human rights and self-determination create or constrain indigenous opportunities to influence policy development.

The health system is an important input into human well-being, but its suitability for all, not just some, people is an essentially political concern. Systemic efficacy is influenced by how, by whom, and for whom policy is developed. The philosophical tensions, contradictions and inconsistencies that distinguish contemporary indigenous health policy are grounded in considered political choices – the views that people hold about the terms of indigenous belonging to the liberal democratic state. Political systems and the values that create those systems shape people’s opportunities to influence the burden of disease. They determine just how much a society will accept ethnic discrepancies in health outcomes and just how much political authority indigenous peoples might enjoy in the policy process. Indeed, a community’s preparedness to accept ethnic discrepancies in health outcomes is a mark of its conceptions of justice, and the values it holds about citizenship and social inclusion.

Citizenship’s traditional unresponsiveness to the rights and aspirations that indigenous peoples claim is principally explained by the concept’s universal and undifferentiated character. While for example the World Health Organisation proposes a human right to ‘the highest attainable standard of health’, opportunities for substantive and meaningful deliberation in setting policies to that end are not always and unconditionally available to indigenous citizens. Yet there is alternative scope, within the liberal paradigm, for differentiation of a kind that would allow indigenous people to claim an active and substantive citizenship where policy could develop with greater attention to social values and priorities, and with greater responsiveness to the particular and immediate needs of a given community.

For citizenship to hold tangible democratic meaning for all people, it needs to provide a coherent account of the rights and responsibilities that come from ‘belonging’ to the liberal state. Equitable political participation does not assure a just distribution in the burden of disease, but it does mitigate against policies that perpetuate disadvantage by providing indigenous peoples with the ‘political voice’ to influence the ways in which public policy makes decisions about the relative justice of conflicting demands on the state.

Political arrangements that allow indigenous peoples to be included, not merely consulted, in policy development distinguish Canada and New Zealand from Australia for example and may help to explain relatively better indigenous health outcomes. In both examples, citizenship is broadly understood and differentiated to allow indigenous peoples to participate collectively in public affairs, as well is individually, and to have cultural imperatives considered in policy development.

For New Zealand Maori, guaranteed parliamentary representation distinguishes citizenship’s practical meaning. Maori representation on District Health Boards is also guaranteed and must be at least proportionate to the Maori share of the district’s population. Guaranteed representation weakens the exclusive connection between ‘Whiteness’ and national sovereignty in favour of a political philosophy that is more inclusive in its understanding of what it means to ‘belong’ to a national political community. Guaranteed opportunities to participate at every level of the policy process, moderates the state’s coercive capacity, and allows for more sharply focused policy development.

Differentiated citizenship might then provide indigenous peoples with the political space necessary to work out what it is, exactly, that they want from the health system and to claim it in ways that do not depend on liberal egalitarian justice alone. Differentiated citizenship allows indigenous peoples to attend to relationships between health and cultural and economic security, by making citizenship an active, rather than passive concept, where the right to be different is positively constructed. The ways in which difference is fairly and reasonably expressed concerns the relationship between citizenship and self-determination which represents a particular view of the proper terms of indigenous belonging to the liberal state and challenges the prevailing proposition that public sovereignty resides only with state institutions.

Instead, it proposes that indigenous peoples might reasonably enjoy a particular share in public authority through relative and relational autonomy because group rights – such as the rights to land, language, and culture – have been found to have positive associations with health.

This article introduces ideas from Dominic O’Sullivan’s book Indigenous Health: power, politics and citizenship published this month by Australian Scholarly Publishing.