Somehow, this country has never achieved any kind of treaty or formal settlement of relationships between the newcomers and the original inhabitants of Australia. There were battles and negotiations and agreements, but unlike in comparable countries — Canada, New Zealand and the US — no settlement was translated into the nation’s legal framework (the term “lack of closure” does come to mind).

An agreement between the government and the Greens to hold a referendum along with the next federal election gives us an opportunity to fix this gap. The Coalition supports the idea of recognition (at least in the preamble), so it may be possible for the referendum to have bipartisan support, which is important because we don’t pass many referenda — eight out of 44 so far.

This truly is health system business, because recognition matters for the health of Aboriginal Australians, and for their health care.

There is no way to run a randomised trial on it, but there is good policy logic to argue that the greater longevity gap for indigenous people in Australia is partly related to the absence of any formal settlement of the terms on which our modern country is established.

Ian Ring and David Firman (MJA, 1998) are among several who suggest that lack of recognition, among other factors, may be involved. Citing evidence that a sense of control over one’s life helps with longevity, they concluded that: A greater sense of control may only come from a wider acceptance and recognition of a valued role for Australian indigenous people in Australian society.

Recognition would also provide a more solid basis for the efforts of the health system to provide better care for Aboriginal patients. It’s not so long ago that Aboriginal people were excluded from our public hospitals, or were placed in special “back wards”.

Since the transfer of responsibility for health from ATSIC to the health portfolio in 1995, things have significantly improved. More funding goes to the Aboriginal community-controlled health sector, with good evidence of impact on health outcomes; and the mainstream health system has been responding (however slowly or in patches) to its responsibilities.

But there is a problem at the heart of this endeavour. Staff in hospitals and health services are often doing creative energetic interventions to respond to the needs of Aboriginal patients, including finding ways to establish trust and rapport in an intercultural relationship.

At the same time, there is a strange kind of denial. The system operates on an underlying premise that “we treat everyone the same, no one is special, nothing special is happening here”.

And so among the policies and procedures that set standards and guide improvement efforts in the health system you will find high level policy statements with beautiful wording about cultural respect and equity, but a lack of the serious operational plans, strategies, quality assurance measures and protocols that you would normally expect for any situation that substantially affects good health care delivery.

I bet, for example, that it is easier for staff in any hospital in Australia to get an interpreter for almost any language on the face of the earth than for local Aboriginal languages.

Why is this so? I suggest that it is part of the outworkings of a larger denial at the centre of our national life.

When you look at health services in Canada, New Zealand and the US, there are still lots of problems, but there is a sense that special measures are on a sounder policy footing, and the system thus finds it easier to enact and sustain good ideas.

There are many reasons to support recognition — such as basic respect, fairness and the politics of reconciliation after any conflict. The need to improve health and health care for Aboriginal people means that this is also important health system business.

*Judith Dwyer, professor of health care management at Flinders University, and a research program leader for the Lowitja Institute (formerly the CRC for Aboriginal Health), says the announcement  should also be seen as an important health system issue. This article is based on one published in the December issue of The Health Advocate (published by the Australian Health and Hospitals Association).

Peter Fray

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