Aboriginal Community Controlled Health Services: An Act of Resistance against Australia’s Neoliberal Ideologies

Round 1

Reviewer 1 Report

Thank you for the opportunity to review your paper.

Feedback and several suggestions to consider:

You statement in the abstract:  Aboriginal political leadership and advocacy during the 1970s and 1980s paralleled the development of neoliberalism in Australia has the potential to engage and urge the reader to want to know more (it certainly did me), and is a powerful and relevant opening to your well crafted piece.

Providing the historical and contemporary political underpinnings of what triggered the establishment of the ACCHO sector by Aboriginal and/or Torres Strait Islander activists, aiming to regain control of their lives and address colonial oppression is powerful.

You may consider inclusion of a brief statement about the fact the first ACCHO opened in 1971, and predated the Alma Ata statement and declaration of the principles of community primary health care by 7 years, thus Australian ACCHOs are absolutely global leaders in community owned and driven primary health care models.  See page 71 of Yupungathi and Meriam woman and social epidemiologist, cultural broker and social activist Dr Vanessa Lee - Ah Mat’s PhD thesis:

Aboriginal Community Controlled Health Services: Controlled or Controlling their own Destinies?

https://research-repository.griffith.edu.au/handle/10072/367501

On page 2 from line 79 onwards you refer to the UNDRIP.  Despite Australia ‘endorsing’ UNDRIP in 2009, it was one of 4 countries that refused to sign it.  Professor Tom Calma  highlighted this at that time: https://humanrights.gov.au/our-work/australias-support-declaration-rights-indigenous-peoples

Interestingly the other 3 nations that refused to sign this also built their ‘nationhood’ on a history of  invasion, racism, oppression in the colonisation of Indigenous nations and denial of sovereignty

“The UN General Assembly adopted a non-binding declaration protecting the human, land and resources rights of the world's 370 million Indigenous people, despite opposition from Australia, Canada, New Zealand and the United States’.  ABC News 2007,

https://www.abc.net.au/news/2007-09-14/australia-opposes-un-rights-declaration/669612?utm_campaign=abc_news_web&utm_content=link&utm_medium=content_shared&utm_source=abc_news_web.

A brief mention of this fact may further strengthen your position in this paper and take home messages.

I particularly like the way you have articulated internal and external self-determination and how ACCHOS are self-determination champions

I believe you work makes a valuable contribution to literature validating and clarifying the need for decolonising mainstream health and eradicating the colonial white deficit lenses that remain the ‘norm’ in Australian health and academic spaces.

I do hope that you write multiple commentary pieces/blogs based on this work to ensure the power brokers in health, white clinicians and those with political and funding clout in mainstream health can read your arguments and access the important messages you have articulated here

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

This is a most welcome contribution to the field of Critical Indigenous Studies. We are always trying to identify models which demonstrate that Indigenous Peoples can successfully resist colonial hegemony and racism to deliver badly needed services to their people. Although the Aboriginal Community Controlled Health Services no doubt struggle with inadequate resourcing from government, its very existence and presence amongst the people as they deliver primary health care is empowering. It therefore provides a suitable model for consideration.

This paper provides well-constructed, logical and suitably referenced arguments for the realization of the human rights of Aboriginal and Indigenous Peoples, which of necessity centers on the right to self-determination. The application of those rights through a successful Aboriginal designed and delivered service makes for an important contribution to the literature in this area. The paper is also well written and it was a pleasure to read.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

 

 Aboriginal Community Controlled Health Services review

 

 

 Commentary

 

This commentary makes an important argument on the issue of self-determination for Aboriginal and Torres Strait Islander Peoples as it relates to the provision of health services. It locates this discussion within an argument that neoliberal government policies undermine the health outcomes of indigenous peoples, and that the collectivist approach in the Aboriginal Community Controlled Health Services (ACCHS) they discuss, not only offers better health outcomes but also a site of resistance to neoliberal the hegemony of neoliberal rationality. As such, this commentary offers an important contribution to discussions of health. I would therefore like to see this commentary published. However, below I make some suggestions as to how it might be developed to enhance its quality for publication. Primarily, this is about joining the dots a little bit more for the reader to keep them connected to the main arguments being made, and giving some examples, again to help the reader better understand what the authors are promoting as a better health system. Please see specific comments below:

 

I found the abstract hard to follow. Below are some examples, I think there needs to be another light edit to help clarify the purpose and content of the commentary in the abstract:

 

·       Line 14, I think you need some kind of link between the two main points of the sentence:  Therefore, this paper aims to explore the role of ACCHS in resisting the pervasive nature of neoliberalism and demanding health equity for Aboriginal and Torres Strait Islander Peoples.

It’s unclear how resisting neoliberalism equates to demanding health equity. Either this needs to be written as two separate sentences or some connection made between them e.g. is it that in resisting the pervasive nature of neoliberalism and by association demanding health equity?

 

·       Line 15: How is it going to explore this role? Through an evaluative commentary? I think something needs to finish that sentence and to explain what the structure or process of this evaluation is going to entail.

 

·       Packing in a bit too much into the abstract, it’s hard to follow any argument is going eg ‘Aboriginal political leadership and advocacy during the 1970s and 1980s paralleled the development of neoliberalism in Australia’ Sounded like  the commentary was going to connect these two issues, but instead the article releases them is very separate. Perhaps now the authors have had a bit of a break writing this commentary, they could go back and more clearly pull out the main arguments of the commentary for a better flow for the abstract. And/or get a colleague who is new to this piece of work to help them identify what would work better for taking a reader through the main points.

 

·       Lines 21-22, the authors say that they “assert ACCHS revenge the gold standard” rather than assert, the authors need to describe what the key arguments they make are that allows them to come to this conclusion.

 

Introduction section: again, I think there is room for a light edit for the authors to imagine what an international readership not familiar with ACCHS needs to know – see:

Lines 31 to 32:  “loose coalition of young Indigenous activists who emerged in Redfern, Fitzroy and South Brisbane” it’s likely that for an International readership Redfern and Fitzroy probably hasn’t much meaning and I’m not sure whether this level of detail is useful for the overall argument being made. Instead, I recommend the authors summarise the key points they want to make it rather than directly quote e.g. did it emerge out of local suburbs of the city of Brisbane?

 

Lines 33-34: its unclear what black power leaders are being discussed, suggest a small change along the lines of, “the Australian black power leaders or even “these black power leaders” (given that black power movement originated in the US and it could be read as such).

 

Line 35-36. Similarly here, it would be nice to join the dots for your reader, remembering that your readership is international, for example, you might consider adding the phrase “during this time” to start the sentence “ CHS were established by supporters …”

 

Lines 42+ that state that this organisation is never simply about healthcare provision. This seems like a really important issue, I would like a brief synopsis of this process, rather than being presented with a set of facts that left the reader having to assume how they interconnect. It would be great if the authors could explain the history and development, perhaps in their own words and then follow it with references rather than feeling the need to build a narrative through other publications. Here for example, it would be useful for a brief explanation of how it starts as a black power movement which identifies how poor health outcomes were produced by structural racism in the health system, and therefore they needed an alternative health system, which then directs attention to the need to create, and/or enlist help to create, an organisation that ultimately becomes the ACCHS …. (i.e. given the importance of the history, bit of discussion about how this was set up would be great)

 

Lines 53-54: I recommend the authors include some recognition that neoliberalism is an international economic rationality, before then discussing how neoliberalism developed specifically in Australia.

 

Lines 115 On how individualism is the problem. This is a great quote, but for a reader unfamiliar with the wider literature it’s not clear why individualism would create racist inequalities, so I recommend you unpack this argument a little to explain to your reader who doesn’t know this literature well why or how individualism would lead to paternalism, for example, is it that neoliberal rationality creates the argument that indigenous people are failing to make good individual choices as measured by the health outcomes because the broader (racist) social structures that inform health outcomes are ignored? I think joining the dots for the reader to explain the problem with individualism would also then better justify the conclusion drawn in line 125 of: Rather than encouraging self-determination for Aboriginal and Torres Strait Islander Peoples, neoliberal frameworks maintain justifications for the Australian state to control the agenda and affairs of Aboriginal and Torres Strait Islander communities

 

 

Lines 172-3: ‘Through the provision of culturally responsive and comprehensive care, ACCHS reduce experiences of racism and barriers to accessing care, which progressively improves the wellbeing of Aboriginal and Torres Strait Islander communities (25).’

It would be good to know a bit more about this, what is culturally responsive and comprehensive care in practice? How does it reduce barriers to accessing care and/or improving the well-being of its communities it serves? You make the case that this comes from the bottom-up approach, perhaps to help the reader understand what you’re talking about it would be good to either give a bit more information or give an example to give a feel for how they actually do this in practice. If you want to inspire readers to consider how they might take up the lessons learnt from ACCHS in their own work, then giving a bit more detail about what this alternative approach involves would be great.

 

 

Lines 199+: The authors discuss how this organisation resists neoliberal individualism through a collectivist value applied to health and resistance to notions of individual responsibility for health, again it will be really good to have an example to give the reader a feel for what this is like in practice.

 

Lines P233 “In the Australian state, neoliberalism maintains colonial power and restricts self-determination of Aboriginal and Torres Strait Islander Peoples”. This conclusion would be better supported if the authors did what I suggested above

 

Finally, References need checking, I’m not sure if they are all complete, e.g. number 19 and 33 look incomplete, suggest checking through all of them that they’re complete and follow the same formatting.

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf