Self-Determination and Indigenous Health: Is There a Connection?

This article is an excerpt from E-IR’s free-to-download Edited Collection,
Restoring Indigenous Self Determination. View all of E-IR’s Publications here.

Self-determination is not only a basic human right to which all peoples are entitled as a basic requirement of justice, it is also a basic human need to which all peoples can lay claim as a fundamental component of their well-being. In other words, I am committed to the view that when their basic need for self-determination is met, peoples’ lives generally will go better, and when it is not, their lives generally will go worse. To give substance to this view, I will engage in a cross-disciplinary exploration of the relationship between self-determination and indigenous health outcomes. More specifically, I will explore the hypothesis that meaningful self-determination in the form of greater individual and communal life control is a contributing factor to improved levels of indigenous physical and mental health, and, conversely, that control and domination by others is a contributing factor to ill-health and elevated levels of mortality in indigenous communities worldwide.

There are many different ways of defining self-determination, but perhaps the most useful in this context is in terms of the theory of human capabilities. To enjoy the capability for political self-determination is to enjoy a meaningful measure of control over one’s political environment or a capacity “to participate effectively in political choices that govern one’s life” (Nussbaum 2008: 605). To be freely self-determining in the political sense is part of what it means to be capable of living a free and fulfilling human life, and as such is partly constitutive of individual well-being (Sen 1999: 36-7; Sen 2001: 11). Amartya Sen, the primary architect of the capabilities approach, puts it thusly: “Human beings live and interact in societies, and are, in fact, societal creatures. It is not surprising that they cannot fully flourish without participating in political and social affairs, and without being effectively involved in joint decision making” (Sen 2002: 79). While self-determination is most readily understood as an individual capability, my intention here is to focus on its significance as a collective capability, by which I mean a freedom whose nature “requires that it be sought in common” (Taylor 1994: 59). [1] Defined in these terms, self-determination is a capability that can only be realized in common by the members of a distinct political community, working together within shared political institutions to determine the laws and policies that will shape their individual and collective futures. The collective capability for self-determination encompasses the freedom to determine the character and boundaries of the political community itself, including the criteria for membership and political participation; the freedom to establish institutional mechanisms of collective deliberation and decision making that reflect one’s own identity, language, and cultural norms; and perhaps most importantly of all, the freedom to make decisions that best reflect the values and priorities of the members of one’s community in the absence of external interference or domination (Murphy 2014).

There is, in fact, a necessary interdependence between freedom as the capability for individual self-determination and freedom as the capability for collective self-determination, for it is simply illusory to speak of having meaningful control over the political decisions that govern our everyday lives within a political system imposed, by and largely, under the control of some external authority. Yet this is precisely the situation faced by most of the world’s indigenous peoples, who have seen their collective capability for self-determination drastically restricted, if not effectively eliminated, as a consequence of colonization and modern state-building. The loss of self-determination has proven to be a source of intense frustration, anger, resentment, insecurity, and despair for indigenous peoples around the globe. It is also, in the eyes of many, one of the primary causal factors behind the tragic physical and mental health outcomes that plague indigenous communities virtually everywhere they are found, whether it be in the developing world or in the highly developed democracies of the modern West. How might these two phenomena be connected? What is it about the loss of self-determination that potentially leads to ill-health and premature mortality? One possible explanation is that indigenous communities that lack control, specifically over the administration and delivery of their own health services, enjoy poorer services leading to poorer health outcomes. There is some evidence to suggest that this is indeed the case, and that when indigenous peoples take greater control over health, this can lead both to better care and better health (Kalt 2008: 224-31; Dixon et al. 1998; Moore et al. 1990; Waldram et al. 2006: 276-8; Lavoie et al. 2010: 7). But is there something about the loss of political self-determination per se that is contributing to this ongoing health crisis? I believe there is, and recent research conducted in the fields of social epidemiology and social psychology helps us understand why this might indeed be the case.

I turn first to the research conducted by Michael Marmot and his colleagues on the social determinants of health inequalities. The first significant conclusion to emerge from this research is that inequalities in physical and mental health outcomes are strongly correlated with social and economic status. Specifically, people who enjoy higher social status generally have better health outcomes and people who enjoy lower social status generally have poorer health outcomes. The second key finding is that the explanatory link between health and status is autonomy: the degree of control people feel they have over their lives (Marmot 2004: 2). People with greater perceived control over their lives tend to be healthier, while those with lower perceived control tend to be less healthy. Lower perceived life control contributes to negative health outcomes both by influencing detrimental health behaviors (e.g. smoking, alcohol consumption, poor diet, physical inactivity) and through the production of chronic stress (Marmot and Bobak 2000: 133). The link between perceived control and health has been established in relation to a wide variety of health afflictions, including heart, lung and kidney disease, diabetes, mental illness, suicide, and deaths resulting from accidents and violence—the very same afflictions that are the leading causes of morbidity and mortality in indigenous communities worldwide (Marmot 2004: 6 24; 2005: 1100-102). Marmot’s research began with a focus on health in the workplace, but it has since expanded to cover a variety of different life domains and a variety of different interpersonal, social, economic, and political factors influencing health. In all of these domains, the conclusion that emerges is always the same: life control, or the capability “to lead the lives they most want to lead,” is essential to people’s health (Marmot 2004: 248).

A nearly identical message emerges from the research conducted by Richard Ryan and Edward Deci in the field of social psychology. Ryan and Deci are the originators of self-determination theory—an empirically derived theory of human development and well-being which identifies three basic psychological needs that “are universally required for humans to thrive” (Ryan and Sapp 2007: 75). First and foremost is the need for autonomy. To live autonomously is to live a life that is self-endorsed, a life that accords with one’s genuine values and preferences. The opposite of autonomy is the feeling that one’s life is being restricted, controlled, or dictated by forces that one does not freely or willingly endorse. The second is competence, which refers to our basic need to master certain skills or techniques that enable us to operate more effectively in the world and to achieve our desired ends in life. The third, relatedness, refers to our basic need for social connectedness, our need to feel a sense of belonging and a sense of importance to a larger social order or social grouping (Ryan and Sapp 2007: 75-6; Deci and Ryan 2012a). While each of these basic needs is essential to healthy development and psychological well-being, Ryan and Deci are unequivocal in their conclusion that none is more important than the need for autonomy (Ryan and Sapp 2007: 91). Self-determination theory has been empirically tested in a wide variety of social settings and environments, and these studies confirm that when any of these basic needs, especially the need for autonomy, is frustrated, psychological ill-health in the form of depression, anxiety, reduced self-esteem, feelings of hopelessness and passivity, and social dysfunction is the result (Ryan and Deci 2008; Ryan and Deci 2011).

The basic message that emerges from both of these research programs is that when people lack autonomy—when rather than feeling in control of their own lives, people instead feel that they are being controlled or dominated by others or by their social, economic, or political circumstances—their mental and physical health tends to deteriorate, and for those who feel the least autonomous, the outcomes are generally the worst (Marmot 2007: 1155-6; Ryan and Deci 2011: 59; Deci and Ryan 2012b: 85, 100-1). It should therefore come as no surprise that indigenous peoples, who are amongst the most socio-economically marginalized and politically disempowered peoples in the world, also have some of the worst health outcomes. And not only do indigenous people suffer from the same mental and physical ailments the foregoing theories would lead us to anticipate, they suffer, and die, from them disproportionately in comparison with the relatively more empowered non-indigenous populations with whom they co-exist (see, e.g. Marmot 2005: 1100-1). The ongoing denial of indigenous self-determination would therefore appear to be doubly destructive of indigenous health. It inflicts its damage, first of all, by eliciting feelings of anger, resentment, injustice, hopelessness, and despair that are the triggers for chronic stress and the negative health behaviors that prevail amongst those seeking to cope with chronic stress; and second of all, by maintaining indigenous peoples in a condition of domination and subordination, thereby denying them the most fundamentally important political means of satisfying their basic psychological need for autonomy.

In suggesting these conclusions, I maintain a healthy respect for the observation that sorting out the social and political determinants of health in any population is a very complex and uncertain undertaking, and that the available “evidence suggests that there is a range of factors at work, from the material to the psychosocial, and that it is difficult to assign ultimate primacy to any one” (Hertzman and Siddiqi 2009: 33). This observation is especially important in the context of the present discussion, given that systematic empirical studies of the relationship between self-determination and indigenous health are virtually non-existent. [2] Nevertheless, given the compelling relationship that exists between control and health in so many other domains of human life, it would be surprising if control in the political domain turned out to be entirely irrelevant. Indeed, given the overarching importance of collective self-determination in shaping the social, cultural, legal, and economic contexts that in turn help shape so many of the choices and decisions we make about how to live our lives, it would be even more surprising if it did not turn out to be of enormous relevance.

Notes

[1] The quote from Taylor actually refers to the idea of a “communal good,” but it is equally apt in this context.

[2] Perhaps the closest thing we have to an exception here is the remarkable study conducted by Michael Chandler and Christopher Lalonde on suicide amongst indigenous communities in British Columbia, although they are inclined to interpret their results through the lens of cultural continuity. Be that as it may, the conclusion that emerged from this research is that indigenous communities which have secured a degree of self-government and local control over community services, and which are actively engaged in the defense of their territorial rights and the revitalization of their traditional cultures, experience low to non-existent rates of youth suicide, whereas communities which have achieved little progress in these areas experience drastically increased levels of youth suicide (Chandler and Lalonde 1998; cf. Hunter and Harvey 2002: 16 and Kirmayer et al. 2003: S18 where greater emphasis is placed on community control as the underlying causal factor that explains Chandler and Lalonde’s study results). In another study with important implications for the themes under discussion in this paper, Tiessen et al. (2009) find a correlation between greater perceived community control and improvements in the psychological well-being of individual community members, although they do not specifically link the concept of communal control to the idea of indigenous political self-determination.

References

Chandler, M.J. and Lalonde, C.E. (1998) “Cultural Continuity as a Hedge Against Suicide in Canada’s First Nations.” Transcultural Psychiatry, 35(2): 193-219.

Deci, E.L., and Ryan, R.M. (2012a) “Self-determination theory.” In: Van Lange, P.A.M., Kruglanski, A.W. and Higgins, E.T. eds. Handbook of theories of social psychology: Volume 1. Thousand Oaks, CA: Sage Publications.

Deci, E. L., and Ryan, R. M. (2012b) “Motivation, Personality, And Development Within Embedded Social Contexts: An Overview Of Self-Determination Theory.” In: Ryan, R.M. ed. Oxford Handbook Of Human Motivation. Oxford: Oxford University Press.

Dixon, M., Shelton, B.L., Roubideaux, Y., Mather, D., and Smith, C.M. (1998) Tribal Perspectives on Indian Self-determination and Self-governance in Health Care Management. Volume 1. Denver, CO: National Indian Health Board.

Hertzman, C. and Siddiqi, A. (2009) “Population Health and the Dynamics of Collective Development.” In: Hall, P.A. and Lamont, M. eds. Successful Societies. How Institutions and Culture Affect Health. New York: Cambridge University Press.

Hunter, E., and Harvey, D. (2002) “Indigenous Suicide in Australia, New Zealand, Canada and the United States.” Emergency Medicine, 14: 14–23.

Kalt, J.P., Henson, E.C., Taylor, J.B., Curtis, C.E.A., Cornell, S., Grant, K.W., Jorgensen, M.R., and Lee, A.J. (2008) The State of the Native Nations: Conditions Under U.S. Policies of Self-Determination. New York: Oxford University Press.

Kirmayer, L., Simpson, C. and Cargo, M. (2003) “Healing Traditions: Culture, Community and Mental Health Promotion with Canadian Aboriginal Peoples.” Australasian Psychiatry, 11(1): S15-23.

Lavoie, J.G., Forget, E.L., Prakash, T., Dahl, M., Martens, P., and O’Neil, J.D. (2010) “Have Investments In On-Reserve Health Services And Initiatives Promoting Community Control Improved First Nations’ Health In Manitoba?” Social Science and Medicine, 30: 1-8.

Marmot, M. (2004) Status Syndrome: How Your Social Standing Directly Affects Your Health and Life. London: Bloomsbury.

Marmot, M. (2005) “Social Determinants of Health Inequalities.” Lancet, 365: 1099-104.

Marmot, M. and Bobak, M. (2000) “Psychosocial and Biological Mechanisms Behind the Recent Mortality Crisis in Central and Eastern Europe.” In: Cornia, G.A. and Pannicià, R. eds. The Mortality Crisis in Transitional Economies. New York: Oxford University Press.

Moore, M., Forbes, H. and Henderson, L. (1990) “The Provision of Primary Health Services Under Band Control: The Montreal Lake Case.” Native Studies Review, 6: 153-64.

Murphy, M. (2014, forthcoming) “Self-Determination as a Collective Capability: The Case of Indigenous Peoples.” Journal of Human Development and Capabilities. DOI:10.1080/19452829.2013.878320

Nussbaum, M. (2008) “Capabilities as Fundamental Entitlements: Sen and Social Justice.” In: Brooks, T. ed. The Global Justice Reader. Oxford: Blackwell Publishing.

Ryan, R.M. and Sapp, A. R. (2007) “Basic Psychological Needs: A Self-Determination Theory Perspective on the Promotion of Wellness Across Development and Cultures.” In: Gough, I. and McGregor, J.A. eds. Wellbeing in Developing Countries. From Theory to Research. New York: Cambridge University Press.

Ryan, R. M., and Deci, E. L. (2008) “Self-Determination Theory and the Role of Basic Psychological Needs in Personality and the Organization of Behavior.” In: John, O.P. Robins, R.W. and Pervin, L.A. eds. Handbook of Personality: Theory and Research, New York and London: The Guilford Press.

Ryan, R. M., and Deci, E. L. (2011) “A Self-Determination Theory Perspective On Social, Institutional, Cultural, And Economic Supports For Autonomy And Their Importance For Well-Being.” In: Chirkov, V.I., Ryan, R.M. and Sheldon, K.M. eds. Human Autonomy In Cross-Cultural Context: Perspectives On The Psychology Of Agency, Freedom, And Well-Being. Dordrecht: Springer.

Sen, A. (1999) Development as Freedom. New York: Knopf.

Sen, A. (2001) “Democracy as a Universal Value.” In: Diamond, L. and Plattner, M.F. eds. The Global Divergence Of Democracies. Baltimore, MD: Johns Hopkins University Press.

Sen, A. (2002) “Response to Commentaries.” Studies in Comparative International Development, 37(2): 78–86.

Taylor, C. (1994) Multiculturalism. Examining the Politics of Recognition. Princeton: Princeton University Press.

Tiessen, M., Taylor, D. and Kirmayer, L. (2009) “A key Individual-to-Community Link: The Impact of Perceived Collective Control on Aboriginal Youth Well-being.” Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 7(2): 241-67.

Waldram, J.B., Herring, D.A. and Young T.K. (2006) Aboriginal Health in Canada. Second Edition. Toronto: University of Toronto Press.

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