Bureaucrats and Bleeding Hearts: Indigenous Health in Northern Australia
UNSW Press, $49.95
I FIRST ENCOUNTERED Tess Lea at an Australian Anthropological Society Conference some time in the late nineties, although I don’t recall actually being introduced. I was fascinated by an exchange between Tess and one of the co-presenters of the session I was speaking in. My presentation was a fairly mediocre and forgettable account of “Aboriginal health strategic research policy” – which in retrospect was as paradigmatically misplaced and incomprehensible in this forum as ethnography may be for many public servants. It contrasted sharply with a much more engaging and entertaining presentation by a public service insider, who reeled through a series of personal anecdotes about bureaucratic work in the environment portfolio. The audience responded well and the presenter evidently enjoyed his own repartee. “Why do you do that?” Tess asked with penetrating incision, referring to his joking style. I can’t remember his response – I am not even sure that he understood the point of the question. But I do remember the emotionality of the moment as the merriment and rapport in the room evaporated. Like the allegorical bunny he was snared in the glare of the ethnographer’s headlights – transfixed yet inexorably drawn towards an inevitable and uncomfortable demise.
Bureaucrats and Bleeding Hearts evokes that same moment of unease. It is an anthropological study of the culture of public health governance in Northern Australia with a substantive focus on Aboriginal health. Perhaps the most significant innovation of the book is the critical manoeuvre that shifts the “anthropological lens away from Aborigines and onto planners, policy officers and professionals operating inside the Northern Territory’s health bureaucracy.” This is not an uncommon strategy for critical anthropology but is still relatively unusual in the study of Aboriginal health, although there are some precedents such as Kim Humphery’s 2001 study of health professionals in the Northern Territory, Forgetting Compliance: Aboriginal Health and Medical Culture (Northern Territory University Press).
Lea’s book is in three parts. The first explores the bureaucratic context of the study the Territory Health Service and the second shifts focus to explore how this institution socially reproduces and in particular how professionals within the bureau “learn about and then attempt to execute their vexed responsibilities.” In the third section Lea shifts her gaze again to consider the service relationship between the health service professionals and Aboriginal people – an encounter which is mediated by staff who have become inculcated within “a bureaucratic mode of apprehending the world.”
Over the last four decades anthropology has abandoned its singular preoccupation with “exotic” or “native” cultures and broadened its critical gaze to encompass the institutions of (post)modernity. This approach is to a certain extent distinct from the traditional ethnographic enterprise of representing the culturally unfamiliar “other.” In the ethnography of the everyday world of bureaucratic work the ordinary is rendered unfamiliar when it a viewed and represented from the epistemological vantage point of the participant outsider. Bureaucrats and Bleeding Hearts makes an extremely intelligent and provocative addition to this the well established canon of studies of bureaucratic organization.
Notwithstanding the value of this form of analysis it can be very challenging for the organisational native. Unlike the subject of traditional ethnography, the bureau-native will frequently read the ethnography of themselves only to find their taken-for-granted world transformed by an abstraction that can be disturbing and confronting. It has been interesting, to that end, to sample the range of responses to the book from policy colleagues in Aboriginal health. Some clearly have been very engaged and liberated by their reading of Lea’s analysis. Others have responded more testily with claims of over-generalisation or factual error (an irony given some of Lea’s more substantive analytic points) even while conceding some of the key insights.
In her second chapter Lea recounts the development of a specific Territory Health Service strategy. In her representation, the development of Strategy 21 (“the spirit in dull prose”) was a “labour-intensive” process that distilled an emotionally charged passionate engagement with service professionals (involving approximately 600 people over a period of eighteen months) into a banal five page document. Here Lea reveals the dynamics of the bureau’s policy “animism” (borrowing from a much older anthropological concept – where animism represented the belief that spirits inhabit natural objects of phenomena). This is a key to her overarching analytical strategy:
“With bureaucrats giving disembodied self-descriptions of how the policies they produce came into being, and analysts not caring for the dramas going on behind the scenes, policy artifacts are endowed with an affective dimension that is denied to their formulators. Policies act, they have political effects: they transform and transfigure, they are well or ill regarded, they use words strategically and intentionally to regulate and circumscribe the options of others. We might give this faith in disembodied analyses of governmentality – in which the objects have become subjects and the subjects have become objects – an anthropological name: policy animism!”
Aboriginal health brings a unique focus to this organisational ethnography. Aboriginal people constitute just under a third of the population of the Northern Territory. For the Territory Health Service professional the burden of Aboriginal ill-health is an inescapable and pressing challenge. It is a challenge which brings into sharp focus a critical moral dilemma: why do institutional structures, such as the Service, in the face of continued failure (to “fix the problem”) continue to do more of the same? There is a bigger question of persistent Indigenous health inequalities which arguably requires a broader analysis of the economic and social determinants of Indigenous health than is possible within the canvas provided by this ethnography. Nevertheless, Lea provides an illuminating account of the social processes of institutional self-replication.
Bureau-professionals learn the helping art through a range of social processes – including induction workshops, cultural awareness programs and everyday interactions: “Swapping tales, authoritatively from an instructor’s virtual pulpit in front of a whiteboard, or as the collegial constructions of a coordination meeting, in the enforced democracy of a butcher paper or whiteboard exercise, in debriefing gossip, purposively or unintentionally according to context, reproduces the tacit knowledge one must acquire to have an eye for the look of a thing, an ear for its sound.” Health facts, too, have a social life – in another moment of discomfort for the persistent positivist – and Lea reveals how health data, like gossip and other moral tales of the frontier, inculcate the bureau-professional within the worldview of the service. Successful programs attain an iconic status, not just because of their outcomes, but because their narratives meld seamlessly within the discourse of the helping professional who is compelled to intervene but paradoxically must restrain their own agency while acting to enable Aboriginal control.
It is perhaps surprising that culture has remained a relatively poorly charted component of the policy terrain given that it is a pivotal construct in Aboriginal health policy. Indigenous health policy as a field of study has been framed, in the main, by social and historical studies the Aboriginal health movement, the political economy of Aboriginal health or the politics of federalism. There is a growing body of critical inquiry that has engaged with Aboriginal health policy discourse – but very little in the way of the fine-grained ethnography that Lea has produced.
Of course the particularity that is a necessary feature of ethnographic investigation is in part its limitation. The Territory Health Service is in its own way a unique institutional structure. It is quite unlike the Commonwealth health bureaucracy. Notwithstanding the Commonwealth’s role in the direct administration of Aboriginal health programs, it is not completely mired, like the Service, in the problems of service delivery to remote dispersed small populations. The Territory Health Service is also quite different from the health bureaucracies of the larger jurisdictions such as Victoria and New South Wales, with their own distinctive service structures and huge metropolitan populations, in which Aboriginal health is only momentarily on the bureaucrats’ radar. In a joking anecdote like the ones that attracted Tess’s razor sharp attention a decade ago, a colleague of mine who had just returned south from a stint in the northern bureaucracy wryly observed that when Indigenous health comes up in the southern bureau the senior executives wring their hands, shake their heads and mutter gravely “We should do something!” “Do what?” he presses. “We must consult… yes consult,” and heads nod vigorously in earnest assent.
This moment of gravely reinforced inaction is probably as paralysing as the institutional dilemmas Tess Lea so skilfully charts for the north. No doubt the momentary southern discomfort passes quickly. Bureaucrats and Bleeding Hearts should provoke disquiet, but it is also a productive and intellectually engaging piece of work. •
Ian Anderson is the director of the Centre for Health and Society and the Onemda VicHealth Koori Health Unit at the University of Melbourne