Tom Goodwin
The factors causing indigenous health inequity are innumerable. However, one aspect that the literature, global institutions, and the United States appear to agree on, is that self-determination is core to effective indigenous healthcare. Self-determination is the right of Indigenous peoples to elect how to live within, and interact with, a post-colonial state.
It is widely recognized that self-determination is an important ingredient in the recipe for remedying the health inequity suffered by Indigenous people over the world. There are many explanations for this, but one important reason is that if healthcare is provided paternally by the colonial state, it may not be embraced by Indigenous people due to deep distrust caused by the colonial experience.
Self-determination in healthcare has two limbs. First, it requires a framework that promotes Indigenous peoples’ autonomous determination of how to receive and provide healthcare. Second, that framework requires appropriate funding.
With respect to the first limb, the United States has progressed significantly since the 1970s, when Congress established the National Indian Health Policy in the Indian Health Care Improvement Act of 1976. This promotes self-determination by centralizing Indigenous peoples’ involvement in the direction of healthcare services. This involvement is facilitated through ‘self-determination contracts’, which transfer aspects of the administration and control of funding for, and services associated with, indigenous health care to indigenous governments.
With respect to the second limb, however, insufficient funding is undermining the success of a propitious self-determination framework. This is highlighted by the recent litigation trend of federally recognized tribes suing the United States for larger portions of the funding pie.
Congressional funding, which provides most indigenous healthcare funding, is largely the product of political capital. Educating the political class and public about the importance of indigenous midwives may garner political capital needed to further fund indigenous healthcare.
The notion of “self-determining healthcare” is intangible, and difficult for lay people to understand without proper training. Indigenous midwives on the other hand, are tangible and relatable. They are typically indigenous women who provide culturally safe care to women throughout the reproductive process. They act as ‘cultural brokers between health systems and indigenous communities’, and are a component of culturally competent healthcare, which is an aspect of any self-determining healthcare system. However, indigenous midwives are often excluded from state-sanctioned healthcare processes.
Non-Indigenous people can empathize with the deeply personal nature of obstetric care, and the importance of a woman trusting her midwife. The public may therefore be more open to funding self-determining healthcare when they understand the importance of indigenous midwives. Although engaging indigenous midwives themselves may not be as expensive as, for example, surgeons, their centrality to culturally competent obstetric care may effectively engender empathy. Empathy can in turn stimulate discourse about issues requiring more funding like providing services in patients’ native languages; recuperating contract costs; strengthening indigenous government structures; and increasing mandatory spending on indigenous healthcare. Perhaps discourse can transform into political accountability.
International institutions like the United Nations and the International Confederation of Midwives have been campaigning for decades for recognition of indigenous midwives. However, it is also incumbent on state and federal governments, and within Indigenous peoples’ capabilities, to educate the public about the importance of indigenous midwifery as an emblem of culturally competent care.
Such discussion could generate much-needed political capital to increase funding of the United States’ self-determining healthcare framework, which would contribute to tackling indigenous health inequity.
Tom is currently undertaking an LL.M. in General Studies at Georgetown University Law Center as a Merit Scholar. He has a background in Australian native title law clerking at the Federal Court of Australia and as a litigator for the Australian Government Solicitor, and in legal education for Indigenous Australian law students through the National Indigenous Knowledge Education Research and Innovation Institute.
