section five

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Objectives

When you have completed your study of this section, you should be able to:

explain the concept of differentiated citizenship
identify the implications of differentiated citizenship for your own practice

What have you learned so far?

You've already seen how different approaches to understanding the demography of contemporary multi-ethnic societies can result in quite different models of multiculturalism. When people talk about multicultural policies and practice, they may well be bringing quite different assumptions to bear. Examining the concept of 'citizenship' is another route to understanding the complexity of multiculturalism and that is the subject for the final section of this module.

You should, by now:

be familiar with the concepts of race, ethnicity and multiculturalism
have a personal view of the ways in which the debates around these concepts relate to you as an individual, and how they have an impact upon shaping practice and policy.

The concepts discussed in this section are wide ranging in their implications. They introduce you to different ways of thinking about the management of difference. If you like, they provide an opportunity for you to check out your own starting point when you think of transcultural care. The ideas you encounter in this section are relevant to you making explicit the assumptions about difference you bring with you when you start to look at models of transcultural nursing.

A good deal of what has been discussed reveals the absence of a consensus in the United Kingdom about how we should describe diversity, and what we should do about it. Certainly, there are quite explicit policy statements - within the NHS, and within individual health care professions - about how ethnic diversity must be recognised, respected and responded to. However, this absence of a wider consensus about concepts and values results in very wide variations in the interpretation of, and responses to, those prescriptive policy statements.

In this section, we step back from implementation of multicultural policies to ask again, 'How do we think about ethnic diversity?' In doing so, we draw on analysis from political philosophy, which reminds us that citizenship is a legal and moral status that helps to define our relationship to the state, and to each other. You will be encouraged to think about how we might recognise the impact of different identity claims on how we experience citizenship rights and obligations as being applied fairly to us all.

This is another way to enter into thinking about ethnic diversity. This material provides a language and perspective that will allow you to consider again the challenge of developing multicultural policy, and practicing transculturally, in a way that can guarantee culturally safe health care within the United Kingdom. No easy answers are offered but, hopefully, it will clarify how you do, and how you might, think about transcultural health care policies and practice.

Read the following text

'Citizenship' involves a legal framework, binding the relationship between the state and ourselves in a web of rights and obligations. It also is a powerful way of repeating the discourse of nationalism by distinguishing between those who are really 'one of us' and those who are not.

Bottomore (1992) argues that citizenship is a status:

"bestowed on those who are full members of a community" and that "all who possess the status are equal with respect to rights and duties with which the status is endowed".

(Bottomore, 1992:18)

However, you've already heard about the various forms of resistance to the full recognition and acceptance of immigrants and minority ethnic populations. Some people will have considerable difficulty in acquiring citizenship and some who possess it may not be regarded by majority populations as fully deserving it.

Bottomore (1992) has usefully distinguished between 'formal citizenship' and 'substantive citizenship'. In this section, you'll first be introduced to this pair of concepts and then to another pair: 'universal citizenship' and 'differentiated citizenship'. This will lead you into a discussion about differentiated rights for minority groups and, in turn, to 'structural pluralism'.

1. Formal Citizenship And Substantive Citizenship

DEFINITIONS

Formal citizenship
Refers to a person's legal standing - it is defined as:
'Membership in a nation state'

Substantive citizenship
refers to a person's ability to access and enjoy the rights guaranteed a citizen and is defined as
'an array of civil, political and especially social rights, involving also some kind of participation in the business of government'.

Clearly, where there is racism and xenophobia in a country, formal citizenship status may not guarantee a person's ability to enjoy their substantive citizenship rights. In Britain, for example, unlike some other European countries, the great majority of minority ethnic people resident are formal citizens. However, personal, cultural and institutional racism may effectively limit their access to their substantive citizenship rights.

Where there is a history of overseas empire (for example in Britain, Germany and France), then the cultural and ideological residue of that history tends to inform people's responses to ethnic diversity. Ethnic and racial stereotypes are readily available to inform the majority ethnic populations' perception of minority ethnic communities.

Where there is a history of being oppressed (for example, in countries like Norway or Ireland), people may find it easy to believe that they have no capacity for racism or xenophobia - that they have been historically inoculated against being nasty to minorities. However, the reality would seem to be that all majority populations have exploited their national identity in order to:

regulate access to formal citizenship
qualify minority ethnic citizens' access to their substantive rights.

Now let's turn to that other pair of concepts:

2. Universal And Differentiated Citizenship

Iris Marion Young, in an important 1989 article, provided a powerful critique of the idea of 'universal citizenship'. She showed that, in practice, the routine assumption of universal equality often marginalised the experience and interests of minority ethnic citizens. In fact, 'treating all people equally' routinely meant 'treating all people the same', in other words 'on terms and in relation to values that were normative in the majority ethnic population'. This led her to propose an alternative model in which the differences between citizens remain acknowledged. In this model, 'treating people fairly' means that you may have to treat them differently.

3. Differentiated Rights For Minority Groups

Kymlicka (1995) distinguishes between two types of ethnically diverse states:

Multinational states, in which ethnic diversity arises from the incorporation of territorially concentrated, previously self-governing cultures into a large state - usually as a consequence of federation or conquest. (Examples include countries like Switzerland, indigenous peoples such as native Americans in North America, and Australian aboriginals. Closer to home, you might consider the case of Wales, Scotland and Northern Ireland - to which power is currently being devolved)
Polyethnic states, where diversity arises from individual and family migration between countries.

Kymlicka suggests that the different historical circumstances underlying these forms of ethnic diversity have considerable political implications for the construction of the different facets of differentiated citizenship. He argues that:

the distinct historical experience of national minorities (in multinational states) allows for their pursuing self-government rights which would not be available to minority ethnic groups, in polyethnic states. These self-government rights involve jurisdiction over a particular territory, which is designated as being historically linked to the national minority. This is exactly the process which is currently apparent in the United Kingdom as the central government in Westminster seeks to give greater autonomy to the Irish, the Scots and the Welsh
for polyethnic minorities there are associated polyethnic rights - which he defines in terms of financial support and legal protection for certain practices associated with particular ethnic or religious groups
both national minorities and polyethnic minorities should have special representation rights defined in relation to guaranteed seats for ethnic or national groups within the central institutions of the larger state (Kymlicka 1995 : 6-7 and 26-33).

Let's take a closer look at each of these three types of right in turn.

Self Government Rights

For a nation state to allow a national minority to have jurisdiction over its own 'nation', whilst they are simultaneously citizens of the broader state, requires a moral and legal recognition of their distinctive experience and their unique location within the state. This particular expression of 'differentiated citizenship' is central to the current work in producing the international legal instrument 'The UN Draft Declaration on the Rights of Indigenous Peoples'.

In Australia, New Zealand, North America and Europe there are already clear instances of the application of elements of self-government rights to indigenous peoples. (Gayim and Myntti, 1997). Where such rights have been allowed, it has:

led to the development of policies which have contributed to the retention of traditional law and the resilience of community languages
provided a basis for a cultural resistance to the dominance of majority values and practices.

In the UK we might observe the different legal tradition in Scotland and the special provisions for broadcasting in Welsh and Gaelic. Even the fact that the English National Board of Nursing, Midwifery and Health Visitors exists reminds us of the acceptance of the differential rights of national minorities. However, the United Kingdom is not just a multinational state that has developed mechanisms for recognising the existence and distinctive needs of national minorities. It is also a polyethnic state, containing very considerable ethnic diversity.

Polyethnic Rights

Kymlicka's 'polyethnic rights' provide the basis for the state to support initiatives that protect specific religious and cultural practices, which:

may not be sustained through simple market forces
may be marginalised or suppressed by the deliberate, or unthinking, discrimination of the majority ethnic population within the country.

Special state support for health policies and funding to address the health interests of minority ethnic groups are one particular expression of polyethnic rights. However, facilitation of ethnically specific health care is no guarantee of their viability or success. Increasingly, over the last decade, the state has been willing to recognise the health care needs of minority ethnic communities. However, the production of explicit guidelines on culturally sensitive practice and their incorporation into National Framework Statements, does not guarantee their incorporation into practice. There has to be a sustained political will to monitor implementation and to challenge and remove the varying modes of resistance: personal, cultural and institutional.

For this reason alone it is apparent why special group representation rights are the important third element in group differentiated rights: they serve to place the particular interests of national minorities and minority ethnic groups within the power-broking institutions of society.

Special Group Representation Rights

If such representation is to be meaningful then these representatives must have a realistically powerful presence when participating in the struggle over the allocation of resources and the definition of priorities. Clearly, special group representation within the state institutions may itself be a critical precursor to the recognition and definition of self-government and polyethnic rights.

In your own field, significant minority representation within the senior management of professional nursing and health care bodies - within the NHS and individual trusts - would be necessary expressions of these special group representation rights in the UK. Nursing and health and social care does not consist only of the expertise and dedication of individual health care professions - it is also found in the struggle over the access to, and the allocation of, resources within the health care system. This is an essentially political process, which must not remain exclusively the domain of the majority ethnic group.

At different levels those who formulate national and local policy on ethnic relations are finding themselves faced with articulate and sophisticated critiques of their policies. The minority communities themselves - in becoming established and developing their own social and political infrastructures - have found a point of leverage into the majority institutions. There is an incipient European network of minority ethnic activists, who work through community organisations, academic networks and anti-racist organisations to continually update their analyses and to strengthen each other's national activity.

A major element in this activity is a critique of the limits of 'liberal multiculturalism' and an explicit confrontation of the state's exploitation of minority and other workers. At the core of this extensive, if diffuse, activity is a claim to power, and not merely a request for respect. Clearly this activity qualifies for the label 'political' and the majority, in determining their response to it, declare their politics.

4. Structural Pluralism

In the UK, we tend to take it for granted that the nation state is a normal form of political organisation - in which the state provides a coherent system of institutions and regulation, which provide the legal and organisational infrastructure for regulating a defined territory (the country). As the current painful processes of nation building in the countries of the ex-Soviet Union reveal, social democracy of this kind is not a natural or inevitable form of social organisation (Brubaker, 1996). Indeed, the idea of a people united by a common identity, a nation, can express itself through a range of political forms. It has, for example, in relatively recent history been powerfully expressed through the values and policies of German and Italian fascism. The form of political and administrative system that we take for granted in Britain has, in fact, a very particular nature and history.

Cultural pluralism has often been tolerated in the private domain of the home, whilst the public domain of work and the state has remained the exclusive terrain of the majority population (Wrench and Solomos, 1993). The language of 'host and migrant', of 'cultural deficit' and of 'the national interest', have all provided an acceptable coded language through which cultural pluralism has been effectively undermined (CCCS 1982, Smith 1994).

The privatisation of cultural pluralism to domestic space is most explicitly challenged by the promotion of structural pluralism: a deliberate promotion of ethnic diversity in institutional and structural terms. European examples of resistance to the construction of Mosques, or the British resistance to the creation of Muslim schools reveals how different is the acceptability of institutional autonomy, as opposed to private diversity (Husband 1994).

In terms of health care in the United Kingdom structural pluralism implies a willingness to facilitate alternative, community based, forms of health care provision, which address minority health care needs from within their cultural expectations. It implies an institutional flexibility with the possibility of cross referral between a minority ethnic health care sector and a generic national service. This does not demand competition or resentment, but can be a basis of mutual collaboration in health care training and practice.

The autonomy of ethnic groupings to pursue their own interests within the broad political framework of the state is a key characteristic of structural pluralism. It reflects in real terms the analytic insight into ethnic identity provided by Wallman (1986) when she distinguished between ethnicity as 'consciousness of kind' (a social psychological sense of identity) and ethnicity as 'structure' (the infrastructure of institutions and organisations that enable the living of one's ethnicity).

There is a sense in which ethnicity is social psychological, a sense of 'who I am'. But, in the absence of a place where I can speak my language, express my faith with others and seek health care compatible with my culture, then how shall I express my identity in action? This celebration of my ethnic or national minority identity does not make me, necessarily, a less trustworthy and responsible citizen. Patriotism toward a country does not depend upon a shared 'national' identity. Switzerland alone is an adequate demonstration of this fact.

A model of multi-culturalism that allows for this connectedness between the fabric of society and a personal sense of ethnic identity is one which incorporates and promotes the necessary structural pluralism consistent with a true acceptance of the diversity present in the country.

Differentiated citizenship, and the associated group differentiated rights provide the necessary political framework for this to be possible. The idea of differentiated citizenship:

challenges our complacency in thinking about difference
excludes the comforting and familiar claim to 'treat everyone equally'
underscores the importance of continuing to understand the individual in the context of their group membership
makes explicit the reasonableness of minority ethnic clients' claims to be treated differently
provides a political framework to the nursing profession's claim to provide individualised holistic care
provides an institutional focus which explicitly challenges professional bodies and health trusts to concede real power to minority ethnic interests, because of their citizenship rights, not out of some generosity borne of some paternalistic culturalist sensitivity.

Exercise 5.1 Reflective activity

This Section has required you to think about how equal citizenship may be compatible with treating people differently. Treating everyone the same IS NOT an acceptable expression of cultural sensitivity.
1. How do you personally respond to the arguments about differentiated citizenship?
2. How would a serious commitment to the principles of differentiated citizenship impact upon your community of practice?

Exercise 5.2 Group activity

Discuss how the language of differentiated citizenship may help to match health and social care needs to appropriate health and social care services.