Australians, on the whole, are fortunate when it comes to their health.
Generally, people enjoy a high standard of living and access to universal health care, and Australia consistently ranks well on measures such as life expectancy and mortality rates.
But beneath gross measures of health and high OECD rankings lies deeply-entrenched, longstanding inequalities.
The gap in health outcomes between Australia’s rich and poor is substantial, and has been laid bare for all to see over the course of the pandemic.
In NSW, COVID-19 has disproportionately impacted lower-income areas in Sydney’s west and south-west, home to the city’s most linguistically and culturally diverse communities.
Here, people are less likely to be able to work from home, more likely to live in overcrowded households, and more likely to face barriers when trying to access health care.
A similar situation was seen in Victoria last year, when an outbreak forced nine high-density public housing towers in Melbourne — with a similarly high concentration of ethnic minority and migrant populations — into a hard lockdown.
Social scientist Julie Leask from the University of Sydney says the fact poorer, more diverse communities are being most impacted by COVID-19 is not by chance, and reflects “deep inequities in society”.
“[The pandemic] is an opportunity for all of the public to see the mechanism by which poverty and social exclusion actually influence health,” she says.
Health inextricably linked to wealth
In Australia, health inequalities are felt most acutely by Indigenous people and those living in socio-economically disadvantaged areas, including in rural and remote Australia.
Unsurprisingly, COVID-19 now threatens Aboriginal communities in western NSW — already battling high rates of chronic illness and overcrowding — as well prison populations, which experience higher healthcare needs.
The reasons for health disparities are varied and complex, but can largely be explained by unequal access to resources such as good housing, adequate income, educational opportunities, and social support.
These are known as the “social determinants” of health, and they function as a gradient across the whole population.
The higher a person’s socioeconomic position, the healthier they tend to be. The lower their position, the more at risk they are of illness, disability and premature death.
Public health researcher Ben Harris-Roxas says measures of advantage and disadvantage rarely exist in isolation, and that people most affected by COVID-19 are often facing multiple challenges at once.
“These things sort of hunt in packs,” says Dr Harris-Roxas, from UNSW.
“Education, for example, affects life opportunities, it affects household composition, and it affects engagement with police and the justice system.”
Poverty, mobility, and high-density households
In south-west and western Sydney — areas with typically lower median household incomes and lower levels of education — many people don’t have the luxury of being able to work from home.
A large proportion of the population work in industries like aged care, manufacturing, transport, construction, and retail — jobs that keep the city running, but put workers at higher risk of being exposed to COVID-19.
“One of the things people often don’t understand is that not a lot of Sydney’s jobs are actually very accessible from south-west Sydney,” says Dr Harris-Roxas, who lives in the city’s west.
“So you’ve got a big population that has to move around quite a lot for work.”
At the same time, many of these people live in large, multigenerational households, which means they are not easily able to isolate themselves from others if they become exposed to the virus.
Other people may struggle to comply with public health orders because of government subsidy payments that are either delayed or insufficient to cover the cost of supporting their families.
Professor Leask, who lives in south-west Sydney, says social and economic circumstances have often been overlooked during the pandemic, but they play a huge part in whether or not people have the ability to comply with restrictions.
She says while some government policies can directly reduce the risks faced by vulnerable communities, there are other major structural barriers that are harder to change.
“Some families will have two people in a two-storey mansion, and some families will have 10 essential workers … [with] two or three people in the same bedroom sleeping at night,” she says.
“To change those determinants of health is a longer game.”
Inequality set to worsen
Before COVID-19, the average income in the most wealthy 20 per cent of Australian households was nearly six times higher than the lowest 20 per cent, according to a 2020 joint report by the Australian Council of Social Services and UNSW.
The report found that gap has been widening over the past two decades, and is expected to increase further due to the pandemic’s impact on employment.
“COVID-19 struck disproportionately at the incomes of lower-paid workers, especially women and young people and their families,” the report states.
But the impacts are not just financial.
In August, additional lockdown measures, including a nightly curfew and one-hour time limit on outdoor exercise, were introduced in Sydney’s COVID-19 hotspot areas in a bid to reduce transmission. Yesterday the exercise limit was lifted.
Professor Leask says although it’s important to clamp down on the spread of Delta, the tougher restrictions have the potential to further entrench inequalities in an already disadvantaged population.
For families with school-aged children, limited resources and space at home can make remote learning an enormous challenge.
“Some of the [health] orders are having massive impacts on families that I don’t think governments are really able to easily imagine,” Professor Leask says.
“Things like a family who are already vulnerable, struggling with a child who needs therapy, who are holed up in a small flat and not able to get a break from each other.”
The mental health impacts of lockdowns are also likely to be felt most acutely by people in crowded homes, with limited resources and less access to outdoor spaces.
Dr Harris-Roxas says for people from refugee and asylum seeker backgrounds, the increased presence of police and military has the potential to be traumatic if they have previously had negative experiences with authorities overseas.
“One of the things we also have to note about [this region] is that there are a higher proportion of people who have had dealings with the criminal justice system,” he says.
“Consequently, an intervention with prominent policing doesn’t work well with groups who might have had negative interactions with police in the past.”
Cultural barriers and health literacy
The pandemic has also highlighted the importance of health literacy skills, which tend to be reduced in areas of disadvantage and among people with diverse backgrounds.
In some of the city’s most affected local government areas, more than 60 per cent of people speak a language other than English at home.
“[South-west and western Sydney] is very multicultural. It’s really characterised by a large proportion of migrant communities,” Dr Harris-Roxas says.
It’s not just language barriers that make people more vulnerable (and haven’t been helped by delays in government translations). People who are more disadvantaged tend to have less access to healthcare services, too.
“Disadvantage affects your ability to even do things like understand the circumstances in which you need to be tested for COVID-19, or where you go to seek further information,” Dr Harris-Roxas says.
People in higher-income groups, on the other hand, have better rates of health literacy, are “motivated towards health-seeking behaviour”, and generally have an easier time seeking help.
Lower health literacy is also associated with an increased reluctance to accept vaccines.
Professor Leask says when it comes to public health messaging, inclusive, timely, and “high-quality translations” are essential to reaching diverse communities.
“There is a lot of reliance on multicultural community leaders to help with amplifying public health messages and translations, but they’re usually not paid, and they should be,” she says.
“Their time is not valued by governments, even though they’re so crucial.”
Harnessing community strengths
Despite the challenges faced by people in south-west and western Sydney, Dr Harris-Roxas says the community has done well to significantly minimise the spread of COVID-19.
But he says the heavy police presence and deployment of military personnel contradicts public health efforts at times.
Professor Leask suggests policing should be “an added extra” and not the centre of the public health response.
“I’d prefer to see armies of health promotion people, than the army,” she says.
Rather, providing financial support and harnessing the strengths of the population — including the interconnectedness of the community — is key to improving compliance and positive health outcomes, Dr Harris-Roxas says.
“One of the big challenges, not just in responding to COVID but in health promotion generally, is to make sure that we’re not actually exacerbating health inequality,” he says.