|
Power
is better than Justice for health.
The
average life expectancy of Aboriginal people in Australia is 15-20
years less than white Australians. (Gray and Sagger 1994:121).
There
is a staggering difference between the health of Indigenous Australians
and the broader Australian population. The core dynamic involved
in the answer is power. Power is the ability to interact with your
environment, to be able to change it and adapt to it. The fundamental
driving force behind individuals and communities ability to maintain
their health comes down to this single important concept in it’s
myriad of cultural, gendered and coercive expressions. To have health
you must have power, economic power to ensure food security, institutional
power relations to preserve you and your children’s security
and cultural power to engage in meaningful social transactions with
others in your group. Power does not have to be exploitative, Focault
(1980) described the entire social fabric as embedded in power relationships
which are transformational and interactive. It is impossible to
separate from it, wherever two people come together there is a power
dynamic. The power may be constructive or destructive, but either
way, nothing happens without power.
Many perceptions of health are blind to the importance of power.
The WHO’s Alma Ata (1978) declaration in which health is defined,
relates health to participation in multiple dimensions in the social
environment, however the key concept missing is power. Australian
Aboriginal people envision a far clearer perspective in their definition
of health, one in which places power, through control of physical
and community dynamics, at the core of health.
Health
to Aboriginal people is a matter of determining all aspects of their
life including control over their physical environment, of dignity,
of community self esteem and of justice.
(National Aboriginal Health Strategy Working Party Report 1989:
ix-x)
This focus on power does not negate justice but it distinctly
addresses a set of relations which are further upstream than justice
and underpin notions of justice. The description of health inequalities
utilizing Rawl’s models of justice as explored in Daniels,
Kennedy and Kawachi’s (2002) article superficially relegates
public health initiatives to maintaining a norm of fair equality
of opportunity. This normative approach is blind to who sets the
norm and establishes what is "fair". Although the four
target areas proposed by the authors; early life intervention, work
environment, nutrition and income re-distribution are significant
measures to address the health needs of the most disenfranchised
sections of the population, they merely alleviate the poor health
outcomes without addressing the upstream factors of dispossession,
oppression and the limitation of power. How are these interventions
different from those proposed by The Rockefeller Foundation, which
emphasized the maintenance of the US work force, to serve the interests
of multinational corporations, through public health initiatives.
(Brown 1979). Although in their conclusion they re-affirm that "upstream
is precisely where we need to look" through " governments
giving high priority to the provision of social services that reduce
mortality". They rest their arguments at the level of the state
and government responsibility for health.
This focus upon the state and the government is another power blind
analysis in which the state is seen as serving the interests of
its population rather than its own interests. In contrast to Daniels,
Kennedy and Kawachi’s paper, McKinley and Marceau (2000:29)
is prepared to look far further upstream towards the state itself
in recognizing that there is "extensive debate in the social
sciences over the structure, functioning, and power of the state
this debate is yet to penetrate the public health establishment".
This analysis is particularly relevant to Australia Indigenous peoples,
who historically faced state repression, murder and the removal
of their children. (McKendrick et al 1990: 349-350). There is a
paradox in relying upon the state to alleviate social and political
inequality when often these inequalities have been perused in the
interests of state power, Farmer (1999) expands upon this in his
paper Pathologies of Power,
Similarly
unpromising are approaches that rely overmuch on appeals to governments:
careful study reveals that state power has been responsible for
most human rights violations and that most violations are embedded
in "structural violence" — social and economic inequalities
that who will be at risk for assaults and who will be shielded.
(Farmer 1999:1486)
He
further advocates for a reworking of the directions and philosophy
of health agencies, that they need to be "grounded in the struggle
for social and economic rights, an agenda suited to public health
and medicine" (Farmer 1999:1486). If sustainable health for
all is to be addressed by focusing on upstream factors, one of the
hard questions needs to be, "how upstream are people willing
to go". Addressing justice, through reducing inequalities,
is a step in the direction of equitable health but is only going
part of the journey.
References:
Brown, E, F., (1979) "Rockefeller Medicine Men". Berkeley:
University of California Press
Daniels , N., Kennedy, B., and Kawachi, I., Justice is Good for
Our health. Boston review (Online): http://bostonreview.mit.edu/BR25.1/daniels.html
(accessed 27/5/02)
Farmer, P., (1999) "Pathologies of Power: rethinking health
and human rights" In American Journal of Public Health, Vol
89, Issue 10, 1486-1496
Foucault, M., (1980) "Power/Knowledge". Pantheon, New
York
Gray, D. and Saggers, S., (1994) "Aboriginal ill health: the
harvest of injustice." In C. Waddel and A.R. Peterson (Eds),
Just health: Inequality in illness, care and prevention, Melbourne,
Churchill Livingstone, p119-133.
McKendrick, J., et al, (1990) "A unique mental health framework
for Victorian Aboriginal People" In The Medical Journal of
Australia, Vol 153, September 17, p349-351
McKinlay J., and Marceau, L. (2000) "To Bodly Go…"
In American Journal of Public Health, Vol 90, No1, p25-33
National Aboriginal Health Strategy Working Party (1989),"A
National Aboriginal Health Strategy". Australian Government
Printing Service, Canberra
World Health Organisation, (1978), The Declaration of Alma Ata,
Geneva: World Health Organisation.
|
