“Mutual” obligation in Indigenous health: can shared responsibility agreements be truly mutual?

In 2004, the Australian Government announced a new approach to the provision of services to Indigenous communities.1 Part of the initiative involved the forging of “shared responsibility agreements”, defined by the government as being agreements in which “both governments and Indigenous people have rights and obligations and all must share responsibility”.1

Shared responsibility agreements are based on the concept of mutual obligation. While intuitively the meaning of “mutual obligation” might appear to be clear, in practice it is not, as Aden Ridgeway, Federal Parliament’s only Indigenous member, pointed out quite forcefully in a Senate debate.2 Prominent Aboriginal leaders Pat Dodson and Noel Pearson3 describe mutual obligation as “a natural principle of human society”, which, in Aboriginal terms, is normally referred to as “reciprocity”. According to Larissa Behrendt,4 Professor of Law and Indigenous Studies at the University of Technology, Sydney, “the concept of Aboriginal reciprocity implies that those who have resources share them with those who do not, and that those who receive this generosity have the same duty to provide for and share with others”. We believe that the Australian Government’s new approach smacks of paternalism and imposition and, in the absence of both respect and equality, runs counter to the Aboriginal notion of reciprocity.

We believe that there has not been adequate dialogue and negotiation between the government and Indigenous communities in relation to shared responsibility agreements. How that dialogue is initiated and how it is then used to promote policy are crucial, and there has been too little debate on these two issues.

Late in 2004, the details of a shared responsibility agreement between the government and Mulan Aboriginal Community in the Kimberley region of Western Australia became public. Part of that agreement was that the federal government would supply the community with a petrol bowser on the proviso that members of the community meet certain standards of personal and community hygiene. These included washing children’s faces twice a day and families keeping their homes free of rubbish (see Box). Not surprisingly, the proposal provoked considerable public debate.6

On the one hand, it has been argued that the Mulan community wanted to enter the agreement with government and that the wishes of the Mulan community should be respected by those who, like us, are opposed to such contracts.3 On the other hand, we are concerned that the “choice set” that Mulan was offered was very restricted (perhaps simply “take it or leave it”).

The current Australian Government appears to favour neoliberalism in the market place, the central tenet of which is freedom of choice of the consumer. But for neoliberal markets to work well, there is a need for well informed consumers and freedom of choice over a wide range. We are not proposing market solutions for Mulan, but want to draw attention to the issue of choice. What choices were the Mulan community offered? Are the “consumers” of Mulan well placed to judge whether the benefit they will get from a petrol bowser will be worth the “price” they have agreed to pay? Is the government in a position to ensure that the price is paid or even to monitor the “payment”?

While the leadership of Mulan has publicly assured the Australian community that they are comfortable with the terms of the agreement,7 we have general concerns about whether such “mutual obligation” deals respect communities’ autonomy. The literature on the social determinants of health shows strong links between autonomy and health.8,9 A community which has autonomy and self-respect is more likely to be a healthy one. Such a community is able to build trust, respect, reciprocity and, in turn, improve health standards within the community. Encouragement from the outside can foster these features, but trying to impose them will not work and may be deleterious.

There are also human rights issues, and the need to avoid solutions that discriminate against Indigenous people. For example, it would be discriminatory if the “rewards” involved in mutual obligation agreements only provide Indigenous people with access to infrastructure that other Australians expect or take for granted (which, incidentally, is the case for petrol bowsers).

It can also be argued that the government’s concept of mutual obligation breaches Australia’s international obligations and denies certain basic rights to Australia’s Aboriginal and Torres Strait Islander citizens. The rationale is one of social control. This, for example, breaches Article 1 of the International Covenant on Civil and Political Rights: people’s right to self-determination and the right to freely pursue their economic, social and cultural development.10

An understanding of the background to this initiative is important. The government’s mutual obligation scheme comes in the wake of, firstly, its continuing refusal to apologise, as an act of reconciliation, for the “stolen generations”. This is seen by many as a denial of the mental and spiritual havoc wreaked by colonialism and dispossession of land and culture. Instead, the government has supported “practical reconciliation” — “addressing social and economic disadvantage”.11 Mutual obligation is a natural extension of this “let’s fix it” approach. Secondly, the disbanding in April 2004 of the Aboriginal and Torres Strait Islander Commission (ATSIC),12 an organisation based on principles of self-determination, is a direct lead-in to the policy of mutual obligation. ATSIC’s successor, the new National Indigenous Council (NIC),13 is not a representative body, as the government has acknowledged: “Members of the NIC have been chosen for their expertise and experience in particular policy areas and are not representing particular regions, organisations or agencies. The NIC is not a replacement for ATSIC and not intended as a representative body.”13

Given that, to our knowledge, there is little evidence for the effectiveness of mutual obligation strategies in the context of improving health, it is relevant to examine such strategies in terms of the principles applied in formulating guidelines for ethical conduct of research in Aboriginal and Torres Strait Islander communities. According to the National Health and Medical Research Council guidelines,14 it is crucial to involve the relevant communities in the development of any research proposal in Indigenous health. The guidelines are based on the principles of

• reciprocity — in the context of research, reciprocity implies inclusion and recognition of partners’ contributions, and ensuring equitable benefits of value to communities or individuals. “. . . communities have the right to define the benefits according to their own values and priorities”14

• respect — a respectful relationship induces trust and cooperation;

• equality — the equal value of people;

• responsibility — includes, among other things, “the mainten-ance of harmony and balance within and between the physical and spiritual realms”14

• survival and protection — protecting culture and identity; and

• spirit and integrity — an overarching value binding all others into a coherent whole. “Any behaviour that diminishes any of the other values could not be described as having integrity”.14

Thus, the government’s mutual obligation scheme does not appear to comply with the principles of respect; almost certainly those of responsibility; and perhaps, most importantly, the overarching notions of spirit and integrity. To demonstrate reciprocity, the guidelines suggest the need for the researcher to show “willingness to modify research in accordance with participating community values and aspirations”. Again on this criterion, government policy would appear to be deficient.

Any research proposal in health today is likely to be rejected if it cannot show how it would quantify any changes it is attempting to bring about. These standards should apply even more to policy. There needs to be some evidence-based attempt to determine whether the policy works. Our concern at this level is simple. What performance indicators are appropriate for Mulan, for example? Good policy needs to establish these in advance. There is a need to conduct research to establish whether, and if so to what extent, shared responsibility agreements work — and what “works” means in this context. It would have been useful to gather this evidence before beginning to implement the policy. It is now crucial to get that evidence as soon as possible.

We believe that the most important strategy for improving health in Aboriginal communities such as Mulan involves building up infrastructure — management, economic, social and human infrastructure.15 If a community lacks leadership and good management and does not have this infrastructure then all other efforts will fail. This aspect seems to have been neglected by government. Many Indigenous communities need help to be able to help themselves on their own terms.

Secondly, respect is needed — respecting the preferences of Aboriginal and Torres Strait Islander peoples. Strategies to improve Indigenous health will only get off to a good start if the people want the strategies, and their autonomy has been respected in allowing them to make choices regarding the strategies. Thirdly, there is a need to avoid being paternalistic or patronising. If mutual obligation is an option that Indigenous communities seek, then there must be an adequate range of choices offered, respect for the preferences of the people, and ways of monitoring whether the obligations on each side are in fact carried out.