Enshrining a First Nations Voice to Australian Parliament will advance global health equity

On October 14, Australians will vote in a referendum to decide whether to enshrine a First Nations Voice in the Constitution. This is a historic moment in Aboriginal and Torres Strait Islander people's recognition and self-determination, consistent with the UN Declaration on the Rights of Indigenous Peoples.1United NationsUnited Nations Declaration on the Rights of Indigenous Peoples.https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdfDate accessed: October 5, 2023Google Scholar Unlike New Zealand, Canada, and the USA (ie, comparable British settler colonial states), Australia has never signed a treaty with Indigenous peoples; neither are Indigenous peoples recognised in the Australian Constitution as the First Nations of Australia.2Williams G Should the Australian Constitution establish an Indigenous Advisory Body?.Aust Indig Law Rev. 2014; 18: 111-122Google Scholar The authors of this Comment and the greater health community in Australia stand united strongly in favour of the Voice. Over 125 health organisations recently signed an open letter3Grayson H Yes to the Voice ‘vital to closing gap’: peak bodies.https://www.medicalrepublic.com.au/yes-to-the-voice-vital-to-closing-gap-peak-bodies/99415Date accessed: October 5, 2023Google Scholar supporting a “Yes” vote for the Voice referendum, recognising that without such a mechanism, Indigenous Australians will still have worse wellbeing and health and lowered life expectancy than that of non-Indigenous Australians. The Voice will mean greater progress in wellbeing and health. It is consistent with public health principles and backed by the evidence4Verbunt E Luke J Paradies Y et al.Cultural determinants of health for Aboriginal and Torres Strait Islander people—a narrative overview of reviews.Int J Equity Health. 2021; 20: 181Crossref PubMed Scopus (16) Google Scholar, 5Luke J Verbunt E Zhang A et al.Questioning the ethics of evidence-based practice for Indigenous health and social settings in Australia.BMJ Glob Health. 2022; 7e009167Crossref PubMed Scopus (2) Google Scholar, 6Garces-Ozanne A Kalu EI Audas R The effect of empowerment and self-determination on health outcomes.Health Educ Behav. 2016; 43: 623-631Crossref PubMed Scopus (6) Google Scholar, 7Whitehead M Pennington A Orton L et al.How could differences in “control over destiny” lead to socio-economic inequalities in health? A synthesis of theories and pathways in the living environment.Health Place. 2016; 39: 51-61Crossref PubMed Google Scholar that policies and programmes that work for communities require listening to such communities, working with them, following their empowered leadership, and enabling their self-determined control. Part of truth telling and historical reckoning, particularly for non-Indigenous Australians, is to listen and respect the dignity of Indigenous people as knowers.8Abimbola S When dignity meets evidence.Lancet. 2023; 401: 340-341Summary Full Text Full Text PDF Scopus (6) Google Scholar The proposal for the First Nations Voice came from the Uluru Statement of the Heart—the result of a comprehensive consultative process among the First Nations people of Australia.9Davis M Williams G Everything you need to know about the Uluru Statement from the Heart. NewSouth Publishing, Sydney2021: 145Google Scholar The proposed Voice is in the form of an Australian federal advisory body, to comprise First Nations people, that will represent the views of Indigenous communities. The Voice will be able to make representations to the Parliament of Australia and executive government on matters relating to Indigenous Australians. This proposal from the First Nations people of Australia represents a generous reaching out to the rest of Australia as part of the reconciliation journey, much of which remains ahead. If backed by the majority of Australian people, the Voice will create conditions for better outcomes in housing, education and health—and consequently help advance global health equity. The referendum comes in the context of Australia's increasing recognition of its Indigenous identity as a global diplomatic asset. In 2021, the Australian Department of Foreign Affairs and Trade (DFAT) announced an Indigenous Diplomacy Agenda.10Department of Foreign Affairs and Trade (DFAT) of Australian GovernmentIndigenous Diplomacy Agenda.https://www.dfat.gov.au/publications/indigenous-diplomacy-agendaDate accessed: October 5, 2023Google Scholar In it, DFAT committed to promote sustainable development for all Indigenous peoples at home and abroad and to deploying Aboriginal and Torres Strait Islander diplomats to advance Australia's national interests. In 2022, the Australian Government announced through the Minister of Foreign Affairs that it was seeking public expressions of interest from individuals to be considered for the Ambassador for First Nations People. The position was filled earlier in 2023. According to the Minister, the Ambassador “will lead work to embed Indigenous perspectives, experiences and interests into our foreign policy” and “will also lead Australia's engagement to progress First Nations rights globally.”11Wong P Ambassador for First Nations People.https://www.foreignminister.gov.au/minister/penny-wong/media-release/ambassador-first-nations-people-0Date accessed: October 5, 2023Google Scholar Australia's image of itself, and its self-projection globally, is beginning to take seriously its Indigenous identity. Australia's new international development policy emphasises respectful partnership in the Indo-Pacific region.12Department of Foreign Affairs and Trade (DFAT) of Australian GovernmentAustralia's International Development Policy.https://www.dfat.gov.au/sites/default/files/international-development-policy.pdfDate accessed: October 5, 2023Google Scholar This is a much welcome and long overdue policy. It remains to be seen how well Australia will integrate this principle with geopolitics and health equity. There are also growing movements in Australia and globally towards decolonising and localising international development efforts.13Abimbola S Asthana S Montenegro C et al.Addressing power asymmetries in global health: imperatives in the wake of the COVID-19 pandemic.PLoS Med. 2021; 18e1003604Crossref PubMed Scopus (87) Google Scholar These movements ask that efforts to support disadvantaged communities and countries be rooted in principles of justice and equity, and based on the needs, perspectives, and preferences of those countries and communities, not on those of actors in high-income countries and communities. These calls echo similar calls that have been made for decades by First Nations Australians in relation to engagement with non-Indigenous Australia. Nowhere have these calls being more salient—locally and globally—than in the realm of health. This is not surprising, given that most development initiatives have direct and indirect links to health. Earlier this year, WHO passed its first resolution on Indigenous Health, calling for global actions plans for Indigenous global health within the next 5 years;14World Health OrganizationThe health of Indigenous Peoples. Seventy-Sixth World Health Assembly Agenda item 16.3.https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_ACONF1-en.pdfDate accessed: October 5, 2023Google Scholar Australia has much to share and learn from others. Health is one of the areas in which Aboriginal and Torres Strait Islander Australians have shown consistent leadership, at home and abroad. For example, the Lowitja Institute, which is one of a kind globally, is Australia's National Institute for Aboriginal and Torres Strait Islander Health Research.15Arabena K Moodie D The Lowitja Institute: building a national strategic research agenda to improve the health of Aboriginal and Torres Strait Islander peoples.Med J Aust. 2011; 194: 532-534Crossref PubMed Scopus (13) Google Scholar With its origins dating back to 1997, it has championed Indigenous health research and capacity strengthening by working with communities, researchers, and policymakers, with Aboriginal and Torres Strait Islander people setting the agenda and driving the outcomes. The Lowitja Institute recently founded an academic journal on indigenous health with a global remit: First Nations Health and Wellbeing—The Lowitja Journal. Models such as the Lowitja Institute should be at the forefront of Australia's Indigenous Diplomacy Agenda. Before the Lowitja Institute was founded, however, there were Aboriginal Community Controlled Health Organisations, which pioneered, beginning in the early 1970s, a model of primary health care based on the principles of social determinants of health.16Pearson O Schwartzkopff K Dawson A et al.Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia.BMC Public Health. 2020; 201859Crossref Scopus (30) Google Scholar Aboriginal Community Controlled Health Organisations came into being because of the inability of mainstream health services to effectively engage Aboriginal communities with their services.17Panaretto KS Wenitong M Button S Ring IT Aboriginal community controlled health services: leading the way in primary care.Med J Aust. 2014; 200: 649-652Crossref PubMed Scopus (129) Google Scholar This was before advocacy for such a model began at WHO in 1978 through the Alma Ata Declaration.18World Health OrganizationReport of the International Conference on Primary Health Care, Alma-Ata, USSR.https://iris.who.int/bitstream/handle/10665/39228/9241800011.pdfDate: 6-12 September 1978Date accessed: October 5, 2023Google Scholar At the conference in Alma Ata, Indigenous Australians used their experience to help shape the vision of the Declaration, which called for community-based and multisectoral delivery of primary health care services.18World Health OrganizationReport of the International Conference on Primary Health Care, Alma-Ata, USSR.https://iris.who.int/bitstream/handle/10665/39228/9241800011.pdfDate: 6-12 September 1978Date accessed: October 5, 2023Google Scholar The Declaration remains one of the most influential global health statements of all time. First Nations health was a major motivation in the founding of the Australian Global Health Alliance. Founded in 2016, the Alliance is a national membership association of global health organisations in Australia and actively seeks to strengthen the global health ecosystem overall. At its founding was a commitment to Indigenous health in Australia. It is the only country of the Organisation for Economic Co-operation and Development whose global health alliance has First Nations health as a founding principle. With the current shift in Australia on Indigenous recognition and the recognition that First Nations people are central to planetary health,19Redvers N Celidwen Y Schultz C et al.The determinants of planetary health: an Indigenous consensus perspective.Lancet Planet Health. 2022; 6: e156-e163Summary Full Text Full Text PDF PubMed Google Scholar the Voice is an opportune mechanism to consolidate action on determinants of global and planetary health. In its new strategy, the Australian Global Health Alliance committed to advance the work of decolonisation of global health and localisation of global health activities as a central working pathway principle. Indigenous health and global health are often taught separately in Australian universities, and advocacy for both causes have typically been conducted separately. But it is clear that both movements have a lot in common, have often coalesced in the past, and ought to be thought of in the same breath. The Indigenous Diplomacy Agenda will inevitably involve Australia's global health diplomacy. Global health diplomacy means integrating First Nations equity at home and abroad as part of any investment in global health. All these efforts—locally and globally—will be made stronger by a constitutionally enshrined First Nations Voice. The many lessons from and experience of First Nations people in improving Indigenous health equity must be at the centre of Australia's engagement in global health diplomacy and efforts to advance health equity globally. As members of the Australian global health community, we strongly endorse the First Nations Voice as an important initial step towards recognising the world's oldest continuous living human civilisation, one that listens and responds to design solutions for better health outcomes, contributes to the progress of global and planetary health, and—most importantly—gives future generations of Australians from all cultural backgrounds a foundation to thrive, independent of political cycles. SNL is a consulting editor at The Lancet, and Executive Director of the Australian Global Health Alliance. SA is Editor-in-Chief of BMJ Global Health. PS, BC, JM, HE, AP, JF, and IA declare no competing interests.