Tải bản đầy đủ - 0trang
5 Case Study – Indigenous Life in Australia
The Health of Indigenous Communities
house indigenous peoples who may have lost land, become sick or suffered from
violence were at times overcrowded and unhygienic, and efforts to dress indigenous
people in European clothes in situations where water for washing was scarce could
promote infections (Mitchell 2007). In government compounds and reserves residents complained of head lice, bedbugs and ﬂeas and suffered epidemics of infectious disease (Mitchell 2007). Claims were made that thousands of indigenous
Australians died on government reserves from hunger and cold (Mitchell 2007).
Research on living conditions of indigenous Australians in cattle stations in the
1940s found that medical care was in short supply. A view of the dominant white
population was that it was a waste to spend resources on treating sick indigenous
workers and most hospitals in rural Australia refused to accept indigenous patients
(Mitchell 2007). For some conditions the treatment was in effect imprisonment. Up
until 1955 in the Northern Territory those suffering from leprosy could be transported in neck-chains to leprosaria for permanent incarceration (Mitchell 2007).
Overt and covert forms of discrimination are ongoing experiences for indigenous
Australians. In the 1960s in one New South Wales town indigenous Australians
were banned from the local public swimming pool because of prejudicial concerns
that the children would spread syphilis and gonorrhoea and that the men would
ejaculate in the pool and so impregnate white women (Mitchell 2007). The level of
active discrimination against indigenous Australians was apparent in legislation.
The Australian constitution of 1901 included clauses that stated that laws of the
Parliament would apply to people of any race, with the exception of the indigenes
as special laws would apply to them, and that indigenous people would not be
counted in any Commonwealth or State census. Indigenous Australians were then
not considered as citizens in their own country (Anderson 2007a). This led to the
situation where indigenous Australians were not able to access Commonwealth
social welfare provisions available to other Australians including old age pensions,
maternity allowance, unemployment and sickness beneﬁts (Walter and Mooney
2007). This form of legislative discrimination relating to social welfare survived in
some form until 1966 (Anderson 2007a).
In Western Australia a 1944 act granted citizenship to indigenous peoples if they
abandoned “their family and cultural connections” and lived like Europeans
(Mitchell 2007, 51). Even if indigenous Australians conformed to this standard they
were not eligible if they suffered from particular health conditions, including leprosy and syphilis (Mitchell 2007).
Negative impacts on the health of indigenous Australians continued throughout
the twentieth and twenty-ﬁrst centuries. As discussed in Chap. 3, poor health outcomes are strongly associated with poverty, and in 2002 the household income of
indigenous Australians was 59 % of non-indigenous households (Walter and Saggers
2007). But even a good income is less protective for indigenous Australians:
whereas a higher level of personal income is associated with higher self-assessed
health ratings for non-indigenous Australians this is not the case with indigenous
Australians for whom the ratings across different income levels remain about the
same (Walter and Saggers 2007).
5.6 Maintaining Disparities
It has been argued that differences in socio-economic status explains up to half
the gap in self-rated health status between indigenous and non-indigenous
Australians (Walter and Mooney 2007). Indigenous Australians are more likely to
live in poor housing conditions, especially in remote areas where 20 % of the population are in overcrowded households, and far fewer indigenous Australians own
their own homes compared to other Australians (Bailie 2007). Nearly a quarter of
all homeless people in Australia are indigenous Australians (Muthu and Grzeszczyk
Indigenous Australians are also disadvantaged in the education system – another
determinant of health. Most of the land legally owned by indigenous Australians is
in remote areas and few students may have access to secondary schools in these
locations. Participation of indigenous Australians in tertiary education has been low
and even declined in the 2000s (Dunbar and Scrimgeour 2007). Western forms of
education have further disempowered indigenous Australians and had a negative
impact on their social and emotional well-being through devaluing their language
and culture (Dunbar and Scrimgeour 2007).
Paternalistic responses from government to poor indigenous health outcomes
and health-deleterious environments have continued. For example, in 2004 an indigenous community group in Western Australia signed an agreement with the
Australian government under its afﬁrmative action policy where, in order to secure
funds for petrol dispensers, the community agreed to such things as ensuring that
their children would wash their faces twice a day, rubbish bins would be emptied,
that houses would be kept clean and rates would be paid (Baum 2007).
In Chap. 3 the relationship between poverty, social class and health outcomes was
discussed. Higher proportions of indigenous peoples live in poverty and social
deprivation than the descendents of settlers and colonizers. This class difference has
a major impact upon health outcomes. But economic differences alone do not
account for differences in mortality rates between ethnic groups (Tobias et al. 2009).
Indigenous peoples have been forced into the market economy through displacement from traditional sources of food as their land has been altered or taken in the
name of economic development (Lambert and Wenzel 2008). In this context, diseases of poverty have been called diseases of colonization and racism as the experience and consequences of poverty are different for indigenes and settlers (Robson
2008). For example, an indigenous person in poverty is likely to be exposed to
poverty for longer, have fewer assets, have less choice in relation to housing, be
more likely to come under the surveillance of the police, and so on (Robson 2008).
Anderson (Anderson 2007b) argues that the assumptions underlying social epidemiological explanations of unequal health outcomes need to be critically assessed
for their relevance to indigenous peoples. For example, the centrality of work in
health outcomes argued by Marmot and colleagues as a result of the Whitehall
The Health of Indigenous Communities
Studies, noted in Chap. 3, may not apply for communities where labour force participation is low and extended families may play a more signiﬁcant role in sociality.
Anderson (Anderson 2007b) also notes that more research attention should be paid
to the reproduction of disadvantage across generations. Historical trauma theory has
been used by indigenous scholars to critically reﬂect on the history and impacts of
colonization across time. This theory originally developed in relation to holocaust
survivors and survivors of Second World War Japanese concentration camps
(Pihama et al. 2014). Historical trauma theory emphasizes the intergenerational
impact of trauma that promote dysfunctional behaviors like substance abuse and
interpersonal violence. Historical trauma has been deﬁned by Lakota scholar Maria
Yellow Horse Brave Heart as “cumulative emotional and psychological wounding,
over the lifespan and across generations, emanating from massive group trauma
experiences” (cited in Pihama et al. 2014, 251). It is argued that this wounding can
result from a number of mechanisms, including an identiﬁcation with the suffering
of deceased ancestors and unresolved grief for the loss of land and kin (Pihama
et al. 2014). A challenge from this perspective is to introduce new diagnostic categories into psychological classiﬁcation systems that point to the distal causes of
dysfunctional behavior, for example, “acute and chronic reaction to colonialism”
(Duran and Duran cited in Pihama et al. 2014).
Gaps in life expectancy between indigenous groups and settler groups change
over time with the example of New Zealand being illustrative. Variation can be
explained by signiﬁcant social and political changes, like shifts of populations from
rural to urban areas, the impact of economic restructuring and how it differentially
impacts on indigenous and non-indigenous groups, and so on. For example, between
the 1940s and 1960s the differences in mortality rates between Māori and other New
Zealanders decreased sharply. This was a period in which there was increasing
investment in public services (Woodward and Kawachi 2000). It was also a period
in which income inequalities in New Zealand diminished (Howden-Chapman
1999). The improvements in Māori health status relative to that of other New
Zealanders did not continue. As a result of neoliberal economic reforms of the mid1980s incomes for Māori declined in relation to those of other New Zealanders
(Brown 1999). The reforms had a worse effect on Māori than other groups.
Traditionally Māori have been found to concentrate in manual occupations such as
meat works jobs and process work in factories, and these manual jobs were negatively affected by the impact of the economic reforms. The loss of income from the
changing nature of work arrangements and increasing unemployment in New
Zealand in turn led to increased chances of Māori dying from premature death,
particularly for the middle-age group.
5.7 Evolving Health Initiatives
Evolving Health Initiatives
Settler societies have responded in different ways to indigenous health and indigenous health practices over time. Settlers and colonizers could actively suppress or
discourage the health practices of indigenous peoples. In New Zealand a Tohunga
Suppression Act of 1907 restricted the rights of Māori to go to a traditional Māori
healer, the Tohunga. Tohunga were specialists in health care practices, and with the
passing of the Act they could be imprisoned if they continued to practice (Belgrave
1985). The Act was established, in part, to direct Māori towards Western systems of
treatment. This was despite the fact that most Māori were living in rural areas with
very poor access to Western medical facilities, and that hospital boards were reluctant to admit Māori patients (Lange 1999). The Act was not repealed until 1962.
This led to the loss of indigenous systems of knowledge in a range of areas, including childbirth practices (Kenney 2011). In other countries cultural traditions were
banned for health reasons. In Canada ceremonial gatherings like the potlatch and
the sun dance were at one time banned for fear of spreading tuberculosis (Kelm
Conversely, indigenous health practices could be taken up by the colonists.
Native American medicine had a variety of techniques to combat injury and disease,
such as splints for broken bones and moss to stop bleeding, and a number of herbal
remedies were taken into the European pharmacopeia, including ginseng, ipecac
and sassafras (Breslaw 2012).
In more recent times measures have been taken by health authorities in an effort
to empower indigenous groups. During the interwar years, public health interventions in rural areas of Europe and the Americas supported indigenous development
(Murard 2008). Since the 1970s there has been increasing interest in drawing on
indigenous health understandings to respond to health problems in the indigenous
community, with a particular ﬂourishing of healing and spiritual practices in drug
and alcohol treatment programmes in Canada and the United States (Brady 1995).
This can broadly be positioned within a process of cultural revitalization amongst
ﬁrst nations’ peoples. For example, the high rates of alcohol-related illness and
death amongst indigenous populations in North America and Australia have led to
a restoration of healing practices which are grounded in the view that substance
abuse is at least partially an outcome of cultural disruption, or a result of a rejection
of the “culture of the colonizers” (Brady 1995, 1487).
Developments in North America have been taken up by other indigenous peoples, such as indigenous Australians, although the Australian government was far
more reticent in embracing such moves than the Canadian government (Brady
1995). Concerns have been raised that the way that the concept of culture that has
been used in treatment programmes equates more with the idea of an authentic traditional past frozen in time, and that as such this constrains and narrows the options
for the social practices of indigenous people (Brady 1995). That is, culture has been
viewed as something static that needs to be recovered as opposed to something that
is dynamic and constantly evolving.
The Health of Indigenous Communities
Traditional healing practices and therapeutic regimes unsurprisingly differed
across different ﬁrst nations and indigenous peoples. In Australia healing practices
were usually private matters commonly involving the “removal of foreign objects
and alien forces from a person” (Bell cited in Brady 1995, 1494) or land-based
approaches such as going ‘out bush’. By contrast in North America therapeutic
practices could take the shape of group events and there are differences between, for
example, indigenous peoples of the North American plains and sub-Arctic huntergatherers (Brady 1995). But through cross-fertilization between different First
Nations and indigenous groups there have developed syntheses and hybrid practices
in therapeutic approaches, that may also include Western elements (Brady 1995).
Programs can combine elements of First Nations and Western systems, such as the
process used by Alcoholics Anonymous and Native American sweat lodges, through
to systems based entirely on the medico-religious systems of First Nations (Brady
Some research has demonstrated the positive impact of enculturation on health
indicators. Enculturation has been described as “a process of learning about, identifying with, and practicing one’s traditional culture” (Bersamin et al. 2013, 257).
Bersamin and colleagues (2013) explore how Alaskan natives, with higher levels of
enculturation or traditionality, identiﬁed by such items as whether they spoke their
native language, used traditional medicines and engaged in spiritual practices, had
higher rates of physical activity than other Alaskan natives. The Yup’ik people were
the focus of this study and they have a tradition of physical activity that includes an
emphasis on walking and hunting. Those with higher levels of physical activity had
lower body fat measures. Findings in North America that the HIV/AIDS epidemic
has been slow to affect the aboriginal population has led to suggestions that stronger
American Indian identity could be a protective factor in some way, such as the
engagement in community activities decreasing other risk behaviors associated with
HIV/AIDS such as alcohol use (Kelm 2010).
There is however a danger in homogenising the experience and outcomes of
indigenous peoples. To illustrate, traditional Kānaka Maoli in Hawai’i, who strongly
identify with their ethnic group, are signiﬁcantly more likely to have a diagnosis of
diabetes than integrated Kānaka Maoli, who identify with the mainstream culture
(Kaholokula et al. 2009). Similarly traditional Kānaka Maoli youth are more likely
to attempt suicide. A possible explanation for this is the higher levels of cultural
conﬂict and racism that traditional Kānaka Maoli may experience leading to these
poorer health outcomes (Kaholokula et al. 2009).
Efforts have also been made to involve indigenous peoples in the management of
health service provision so that indigenous peoples have a more inﬂuential role in
decision making processes and the implementation of decisions (Kelaher et al.
2014). Community involvement in governing bodies has been linked to improvements in health equity (Kelaher et al. 2014). For example, Aboriginal communitycontrolled health services have provided care to Aboriginal communities in remote
areas and the slowing down of mortality rates from diabetes and ischaemic heart
disease has in part been attributed to their work (Lau et al. 2012).
5.7 Evolving Health Initiatives
But the level of involvement of indigenous peoples in the management of health
services can change with the political currents. The Aboriginal and Torres Strait
Islander Commission, established in 1989 by the Australian Federal Government to
improve the conditions of the communities of indigenous Australians in cooperation with elected leaders of Aboriginal communities, was seen as a step towards
self-determination. It was abolished in 2004 and replaced with a government
appointed council (Muthu and Grzeszczyk 2011). Then again in 2008 a “Closing
the Gap in Indigenous Health Outcomes” agreement was made by the Council of
Australian Governments to address the life expectancy gap between Aboriginal and
other Australians. A major plank in this agreement was for government to work
with Aboriginal communities to overcome health inequities (Kelaher et al. 2014).
Māori health models have been developed in New Zealand with common components including a focus on self-determination, a focus on Māori collective structures such as whānau (roughly commensurate with family), hapū (a subtribe) and
iwi (a tribe), promoting Māori identity and promoting social justice (Boulton et al.
2011). Since the 1990s in New Zealand many Māori health provider organizations
have developed that have incorporated Māori principles of health practice – known
as hauora. Examples of how Māori principles could work in practice can be seen in
patients attending a youth alcohol and drug rehabilitation service taking the main
part in discussions with agencies auditing the service. This was an expression of
rights to self-determination, that was promoted in those young people using the
service (Chant 2011).
An attempt over many years to respond to some of the concerns raised in relation
to indigenous people’s access and use of health care services is to promote cultural
competence programmes in the education of health professionals. The goal of cultural competence programmes is to acknowledge the cultural and social inﬂuences
on the consultation between the health professional and the patient and to consider
or devise ways that takes these inﬂuences into accounts so as to facilitate better
patient outcomes (Paul et al. 2012). Paul and colleagues argue that to perceive oneself as culturally competent is in fact an indication of cultural incompetence. They
argue this on the basis that such a view assumes that complex historical and social
processes that are constituted under the term culture cannot be reduced to a speciﬁc
learnt technical skill (Paul et al. 2012). ‘Having competence’ suggests an achieved
endpoint, as opposed to an ongoing process of learning and reﬂection. The concept
of cultural competence has also been criticised for essentializing cultural differences, as opposed to promoting connections between peoples. This is not to abandon the goals of understanding in positive ways, but signals the complexity of
interactions between peoples (Paul et al. 2012).
The Health of Indigenous Communities
The history of colonization and its effects shows how devastating this process was
on the health of indigenous peoples throughout the world. Hundreds of years later
the effects of colonization are on-going. In addition to the experience of racism and
stigma that may be felt by anyone who is not part of the majority group, indigenous
peoples have faced the extensive loss of land and attempts to eliminate their culture.
In more contemporary times efforts have been made to try to redress some of the
wrongs of the past, which in the health sector has meant a process of experimentation with the revitalisation of indigenous health practices and modes of delivery and
some effort to recognize the role that indigenous peoples should play in the management and oversight of health services that are targeted at them. These are ongoing
developments and will no doubt continue to ebb and ﬂow on the basis of political
circumstances and social policy developments.
Anderson, I. (2007a). Policy processes. In B. Carson, T. Dunbar, R. Chenhall, & R. Bailie (Eds.),
Social determinants of indigenous health (pp. 231–252). Crows Nest: Allen & Unwin.
Anderson, I. (2007b). Understanding the processes. In B. Carson, T. Dunbar, R. Chenhall, &
R. Bailie (Eds.), Social determinants of indigenous health (pp. 21–40). Crows Nest: Allen &
Bailie, R. (2007). Housing. In B. Carson, T. Dunbar, R. Chenhall, & R. Bailie (Eds.), Social determinants of indigenous health (pp. 203–230). Crows Nest: Allen & Unwin.
Barta, T. (2005). Mr Darwin’s shooters: On natural selection and the naturalizing of genocide.
Patterns of Prejudice, 39, 116–117.
Baum, F. (2007). Social capital. In B. Carson, T. Dunbar, R. Chenhall, & R. Bailie (Eds.), Social
determinants of indigenous health (pp. 109–134). Crows Nest: Allen & Unwin.
Belgrave, M. (1985). “Medical Men” and “Lady Doctors”: The making of a New Zealand profession, 1867–1941. Ph.D. dissertation, Victoria University of Wellington, Wellington.
Bersamin, A., Wolsko, C., Luick, B., Boyer, B., Lardon, C., Hopkins, S., et al. (2013). Enculturation,
perceived stress, and physical activity: Implications for metabolic risk among the Yup’ik – The
center for Alaska native health research study. Ethnicity & Health, 19, 255–269.
Boulton, A., Gifford, H., Kauika, A., & Parata, K. (2011). Māori health promotion: Challenges for
best practice. AlterNative: An International Journal of Indigenous Peoples, 7, 26–39.
Brady, M. (1995). Culture in treatment, culture as treatment: A critical appraisal of developments
in addictions programs for indigenous North Americans and Australians. Social Science &
Medicine, 41, 1487–1498.
Breslaw, E. (2012). Lotions, potions, pills, and magic: Health care in early America. New York:
New York University Press.
Brown, M. (1999). Policy-induced changes in Māori mortality patterns in the New Zealand economic reform period. Health Economics, 8, 127–136.
Bryder, L. (1982). Lessons of the 1918 inﬂuenza epidemic in Auckland. New Zealand Journal of
History, 16, 97–121.
Chant, L. (2011). Whānau ora: Hauora Māori models of kotahitanga/co-operative co-existence
with non-Māori. AlterNative: An International Journal of Indigenous Peoples, 7, 111–122.
Dunbar, T., & Scrimgeour, M. (2007). Education. In B. Carson, T. Dunbar, R. Chenhall, & R. Bailie
(Eds.), Social determinants of indigenous health (pp. 135–152). Crows Nest: Allen & Unwin.
Feagin, J., & Benneﬁeld, Z. (2014). Systemic racism and U.S. Health care. Social Science &
Medicine, 103, 7–14.
Fredericks, B. (2008). Which way that empowerment? Aboriginal women’s narratives of empowerment. AlterNative: An International Journal of Indigenous Peoples, 4, 6–19.
Howden-Chapman, P. (1999). Socioeconomic inequalities and health. In P. Davis & K. Dew (Eds.),
Health and society in Aotearoa New Zealand (pp. 67–81). Auckland: Oxford University Press.
Kaholokula, J., Nacapoy, A., & Dang, K. (2009). Social justice as a public health imperative for
Kānaka Maoli. AlterNative: An International Journal of Indigenous Peoples, 5, 116–137.
Kelaher, M., Sabanovic, H., La Brooy, C., Lock, M., Lusher, D., & Brown, L. (2014). Does more
equitable governance lead to more equitable health care? A case study based on the implementation of health reform in Aboriginal health Australia. Social Science & Medicine, 123,
Kelm, M. (2010). Past into present: History and the making of knowledge about HIV/AIDS and
aboriginal people. In D. Herring & A. Swedlund (Eds.), Plagues and epidemics: Infected
spaces past and present (pp. 193–212). Oxford: Berg.
Kenney, C. (2011). Midwives, women and families: A Māori gaze. AlterNative: An International
Journal of Indigenous Peoples, 7, 123–137.
Kunitz, S. (1994). Disease and social diversity: The European impact on the health of nonEuropeans. Oxford: Oxford University Press.
Labonté, R. (2008). Introduction to part III. In J. Green & R. Labonté (Eds.), Critical perspectives
in public health (pp. 136–149). Abingdon/New York: Routledge.
Lambert, L., & Wenzel, E. (2008). Medicine keepers: Issues in indigenous health. In J. Green &
R. Labonté (Eds.), Critical perspectives in public health (pp. 180–191). Abingdon/New York:
Lange, R. (1999). May the people live: A history of Māori health development 1900–1920.
Auckland: Auckland University Press.
Lau, P., Pyett, P., Burchill, M., Furler, J., Tynan, M., Kelaher, M., et al. (2012). Factors inﬂuencing
access to urban general practices and primary health care by Aboriginal Australians: A qualitative study. AlterNative: An International Journal of Indigenous Peoples, 8, 67–84.
Lawford, K., & Giles, A. (2012). An analysis of the evacuation policy for pregnant ﬁrst nations
women in Canada. AlterNative: An International Journal of Indigenous Peoples, 8, 329–342.
Mitchell, J. (2007). History. In B. Carson, T. Dunbar, R. Chenhall, & R. Bailie (Eds.), Social determinants of indigenous health (pp. 41–64). Crows Nest: Allen & Unwin.
Murard, L. (2008). Designs within disorder: International conferences on rural health care and the
art of the local, 1931–39. In S. Gross Solomon, L. Murard, & P. Zylberman (Eds.), Shifting
boundaries of public health: Europe in the twentieth century (pp. 141–174). Rochester:
University of Rochester Press.
Muthu, Y., & Grzeszczyk, G. (2011). Analysis of the Australian and Canadian governments’
aboriginal policies. AlterNative: An International Journal of Indigenous Peoples, 7, 15–25.
Nikora, L. W., Hodgetts, D., Carlson, T., & Rua, M. (2011). Māori and medications: What happens
when the pills go home? AlterNative: An International Journal of Indigenous Peoples, 7,
Palmiste, C. (2008). Forcible removals: The case of Australian Aboriginal and Native American
children. AlterNative: An International Journal of Indigenous Peoples, 4, 75–88.
Paul, D., Hill, S., & Ewe, S. (2012). Revealing the (in)competency of “cultural competency” in
medical education. AlterNative: An International Journal of Indigenous Peoples, 8, 318–328.
Pearson, D. (2001). The politics of ethnicity in settler societies: States of unease. Houndmills:
Penney, L., Barnes, H. M., & McCreanor, T. (2011). The blame game. AlterNative: An International
Journal of Indigenous Peoples, 7, 73–86.
Pihama, L., Reynolds, P., Smith, C., Reid, J., Smith, L. T., & Te Nana, R. (2014). Positioning historical trauma theory within Aotearoa New Zealand. AlterNative: An International Journal of
Indigenous Peoples, 10, 248–262.
The Health of Indigenous Communities
Pink, B., & Allbon, P. (2008). The health and welfare of Australia’s Aboriginal and Torres Strait
Islander peoples. Canberra: Australian Bureau of Statistics and Australian Institute of Health
Reid, P. (1999). Te pupiri i te ao o te tangata whenua. In P. Davis & K. Dew (Eds.), Health and
society in Aotearoa New Zealand (pp. 51–62). Auckland: Oxford University Press.
Robson, B. (2008). What is driving the disparities? In K. Dew & A. Matheson (Eds.), Understanding
health inequalities in Aotearoa New Zealand (pp. 19–31). Dunedin: Otago University Press.
Robson, B., & Harris, R. (2007). Hauora: Māori standards of health IV. A study of the years
2000–2005. Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare, School of Medicine and
Health Sciences, University of Otago, Wellington.
Sorrenson, M. (1956). Land purchase methods and the effect on Maori population, 1865–1901.
Journal of the Polynesian Society, 65, 183–199.
Taonui, R. (2012). Māori urban protest movements. In D. Keenan (Ed.), Huia histories of Māori:
Ngā tāhuhu kōrero (pp. 229–259). Wellington: Huia.
Tobias, M., Blakely, T., Matheson, D., Rasanathan, K., & Atkinson, J. (2009). Changing trends in
indigenous inequalities in mortality: Lessons from New Zealand. International Journal of
Epidemiology, 38, 1711–1722.
Walter, M., & Mooney, G. (2007). Employment and welfare. In B. Carson, T. Dunbar, R. Chenhall,
& R. Bailie (Eds.), Social determinants of indigenous health (pp. 153–175). Crows Nest: Allen
Walter, M., & Saggers, S. (2007). Poverty and social class. In B. Carson, T. Dunbar, R. Chenhall,
& R. Bailie (Eds.), Social determinants of indigenous health (pp. 87–107). Crows Nest: Allen
Whitinui, P. (2011). The treaty and “treating” Māori health. AlterNative: An International Journal
of Indigenous Peoples, 7, 138–151.
Woodward, A., & Kawachi, I. (2000). Why reduce health inequalities? Journal of Epidemiology
and Community Health, 54, 923–929.
Institutions of Health Care
Abstract The organization of health care institutions is not one of stability, but of
constant change. It varies over time and from country to country. This chapter
explores the development of the hospital and primary care in the community through
a range of examples. A case study of how care for the elderly is provided in China
is developed. The chapter addresses debates around the price and cost of health
services, evidence-based medicine, rationing debates and accountability, and concludes that the international trend of rationalizing our institutions of health care may
lead to greater efficiency or a more equitable distribution of services; however, it
may also give rise to debates around humanitarian ethics and our sense of moral
Keywords Hospitals • Primary care • Complementary and alternative medicine •
Medical training • Heroic medicine • Clinical gaze • China • Health rationing •
Evidence-based medicine • Quality assurance
The organization of health care institutions is not one of stability, but of constant
change. This chapter focuses on the development of the hospital and primary care
sectors and efforts that have been developed to control growing expenditure on
health services and to ensure the quality of services. Although there are a variety of
ways of funding hospital and primary care services and differences across countries
in the mix of public and private provision of services, there are some commonalities
in the influences on health care delivery. One commonality is the requirement to
ration services, which in turn has provided an impetus to determining what types of
treatment are effective and to standardize the delivery of health care practices.
© Springer International Publishing Switzerland 2016
K. Dew et al., Social, Political and Cultural Dimensions of Health,
6 Institutions of Health Care
The hospital is in many ways the centrepiece of the health system. Hospitals are
viewed as the pinnacle of scientific achievement in medicine, and they attract the
most spending on health care (Mooney 2009). Hospitals also perform a cultural or
social function in that they powerfully represent the specialisation of knowledge
and the reliance on sophisticated medical technology. They foster a philosophy of
intervention that pervades other sites in the health care sector (Davis 1981).
Hospitals did not always have this status. It was not until the nineteenth century
that hospitals became doctor-centered (Granshaw 1989b). Medieval hospitals were
often founded by churches and served the charitable and other functions of churches,
and could be leprosariums or almshouses. Inhabitants led a semi-monastic life with
the sick cared for by lay people or servants and an emphasis on “bed rest, warmth,
cleanliness, and an adequate diet” (Carlin 1989: 31). In the late 1700s attempts were
made to distance the hospital from the almshouse, with the term ‘infirmary’ being
used to denote newly established voluntary hospitals. Philanthropy of the propertied
classes increasingly replaced church charity as funders of these institutions (Porter
1989). Historian Roy Porter (1989: 152) argues that in these early stages of capitalism the infirmary “threw a cloak of charity over the bones of poverty and naked
In the United States prior to the early twentieth century hospitals were places for
people who had no one to care for them – “the homeless, paupers, travelers, seamen
in a strange port, unmarried pregnant women” (Breslaw 2012: 180). Specific curing
institutions, such as The Pennsylvania Hospital in Philadelphia, started to appear in
the late 1700s, but prior to this few Americans would have seen a hospital (Rosenberg
1987). An impetus for the founding of hospitals in America was to distinguish
between the undeserving poor – who would be confined to the almshouses, and the
worthy poor whom philanthropists were willing to support (Rosenberg 1987). In
addition hospitals could act as institutions of medical training and so keep American
physicians from having to travel to overseas destinations such as Edinburgh and
London to further their education. Another bonus was that the skills learnt in hospitals where the wards were filled with the worthy poor were transferable and would
benefit the wealthy who would be attended by physicians in their homes (Rosenberg
From the eighteenth century hospitals increasingly came to be used as centers of
medical training, laboratories of medical research and then as an institution of healing (Seidler 1989). The medical profession itself took on a greater role in establishing medical institutions (Granshaw 1989a). Hospitals added to the prestige of
clinicians and provided opportunities for them to enhance their clinical skills
(Breslaw 2012). Medical practitioners could also gain teaching monopolies through
hospitals. Consultants received large incomes from teaching and from the ability to
establish private practices as a result of reputations gained at the teaching hospitals.
Consultants also gained a monopoly over access to research facilities (Waddington
1977). Those who occupied hospital posts came into contact with the philanthropists