Health is a multi-factorial subject. Thus a holistic approach that recognises and includes the physical, mental, social, ecological, cultural and spiritual aspects must be applied to management practices. One way in which this can be achieved is by looking at strategies which aim to reduce the structured social inequalities which create health inequities. This encompasses questions of poverty, social isolation and exclusion, education and training, living standards and environments, work and unemployment, access to health services, stress, addiction, nutrition and food, and indigenous infant mortality rates. Moreover, these strategies look at ways of abolishing the social, economic and political boundaries which limit people’s choices and opportunities.
This paper will identify some of the key health inequalities (access, life expectancy, smoking etc) suffered in the Western Sydney area by examining the structured social inequalities (class, gender, policy, ethnicity, education) which create them.Despite claims of Australia being a classless society, socioeconomic status is a key determining factor in the health and well being of its citizens. Depending upon where you are placed in the social hierarchy, access to health care and opportunities to improve your health status differs markedly.
One of the major health inequalities suffered by Sydney’s lower socioeconomic groups - particularly those in the west and southwest - is inequitable access to health care services. This is largely due to lower levels of unemployment, housing and income but locational disadvantage, isolation and exclusion also play a role.
In Auburn and Fairfield, where unemployment rates are up to 16% and median weekly income range between $590 and $650, access to health services are not always accessible [GEOS111 2000: pg20]. This can be shown in the NSW Health Surveys for 1997 and 1998 where up to 10% of people in the Western Sydney (WSHSA) and South Western Sydney Health Service (SWSHSA) Areas expressed difficulties getting health care [NSW Health 2000: access]. In comparison, only 5.7% of people from the Northern Sydney Health Area - which includes both Manly and Ku-ring-gai – reported complications getting health care [NSW Health 2000: access]. Both these places have unemployment rates much lower than 5% and their median weekly income exceeds $900.
NOTE: The figures for “difficulty getting health care” are representative of the LGAs relevant health area, not the individual LGA. So the figures for Manly and Ku-ring-gai are those of the Northern Sydney Area Health Service and the figures for Auburn and Fairfield are those of the Western Sydney Area Health Service and the South Western Sydney Area Health Service respectively. Nonetheless, it still shows the differentials in access by place. The data was collected from NSW Health Surveys and GEOS111 Study guide.
Using this data, we can assume that areas of higher socioeconomic status also have better access to health care services. People who are generally better off financially, have more health care options such as private cover. Additionally, those who can afford private health care are four to seven times more likely to undergo cardiac procedures such as heart bypass surgery than those in the public system [Walkom 2000]. This issue is of particular significance to Sydney’s west as Circulatory disease is one of the major causes of death.
In an ironic kind of sense, the recent collapse of the United Medical Protection Fund (UMP) will mean that people in the higher socioeconomic groups will endure the same pressures as their lower counterparts experience on a regular basis. UMP covers around 90% of the doctors in NSW. Without this safety net, doctors in the private sector will refuse to carry out operations which are not life threatening. Ultimately, this means that those who would normally seek surgery from private health care will now be forced to wait on public lists. Unfortunately, but realistically however, this outcome will only increase the pressures of those lesser off as the demand for public health services will escalate. Coupling this with lack of government funding for public hospitals and the billions of dollars being diverted to prop up the costly private health insurance system, it is easy to speculate some of the problems which could potentially surface.
Socioeconomic status does not only have an affect on access to health care but on a person’s life expectancy as well. It is commonly agreed upon that people who are lesser off suffer from lower life expectancies. If we take a look at Sydney again, one can see that the gap between rich and poor, healthy and sick, has been widening over the past 25 years. The following map on changes of wealth in Sydney represents the increased division between rich and poor (Map 1).
Dr Lillian Hayes of Sydney University, recently conducted a study on socioeconomic differentials of mortality in Sydney from 1970-1994. In her research she found that, “For men there has been an increase in relative mortality differentials between the most and least socio-economic disadvantaged groups: 12 per cent in the Sydney region and 19 per cent in rural NSW. In women the differences have remained constant” [Crowe 2000]. Additionally, her analysis found that improvements to overall mortality had had greater impact on advantaged rather than disadvantaged groups. This supports the existence of an ever widening gap and provides impetus for improvements in the health status of disadvantaged people. Another interesting thing that came out of the Hayes report was that the predicators she suggests for lower socioeconomic status are the same characteristics that the Western Sydney Health Service Area describes as endemic to their community [SWSAHS 1998]. Some of these qualities included: unemployment or low income, being a single parent, lack of education, unskilled/no qualifications, leaving school early, and whether people rented or owned their own homes.
Environmental influences on health are also a predominate feature of low socioeconomic status or class and vary from type of dwelling, to work spaces, social relationships or even natural occurrences such as pollution or dampness. People most likely to suffer from negative environments include: public housing residents, manual labourers, industrial workers and those generally associated with a lower level of financial security. In a paper by Dr Paul Beggs on the Spatial Analysis of Dwelling Crowding and Disease in Sydney, it was found that morbidity from bronchitis and emphysema is related to dwelling crowding [Beggs 1999: pg9]. Furthermore, Dr Beggs research shows that higher levels of crowding are consistently associated with socioeconomic indicators. He explains these results by stating that people with higher socioeconomic status have an increased ability to buy larger homes and thus do not experience the effects of crowding. This point can be further substantiated by taking a look at MAP2 which illustrates the crowding index for each local government area in the Sydney statistical division. Among some of the higher rating scores lie; Fairfield, Auburn, Bankstown, Blacktown and Canterbury. If one then compares this data with maps of standardised morbidity rates for bronchitis and emphysema, and standardised morbidity rates for all causes, it is possible to draw a link between places with high levels of crowding (which Beggs largely attributes to socioeconomic forces) and higher levels of disease [Beggs 1999: pg9].
Beggs also alludes to the detrimental impact of infective agents and respiratory irritants such as tobacco smoke in areas that are deemed crowded. The Western suburbs of Sydney tend to suffer from much higher rates of people who smoke. Most concerning is the growing proportion of this percentage in teenagers and young adults – particularly that of females. Statistics of the overall portion of males (16-24 years old) and females (16-24 years old) who smoke do not show much variation, however the intention to quit does. About 44% of Males in South Western Sydney have expressed a willingness to quit whereas only 29% of females have [NSW Health 2000: smoking].
By and large, tobacco attributable mortality rates are higher in WSHSA residents than in NSW overall. In the table provided on smoking status by sex in WSHSA and NSW, the Western Sydney figures consistently show higher numbers of smokers. Perhaps of even more concern however are the quit rate figures. Between the years of 1989 and 1997, the percentage of people to quit smoking in NSW has risen 6.6% [EIRE 2001: pg11-12]. Alternatively, Western Sydney figures only show an increase of 2.4%. The data from this table tells us that while Western Sydney continues to have a larger percentage of its population classified as smokers, attempts to promote better health or to remedy this problem have been either non-existent or insignificant. Another possibility is that residents of the WSHAS can not afford to seek medical aid such as counselling, nicotine patches or the like. Opportunities for people living in underprivileged areas to quit smoking are needed and more attention should be focused on underage smoking.
This section has only looked at a couple of the health inequalities associated with socioeconomic status or class. Topics not covered, but perhaps alluded to, include: obesity, increased rates of cardiovascular diseases, higher instances of cancer, dental health, mental health, immunisation of communicable diseases and suicide.
So far, this paper has established some of the health inequalities suffered by those who are of lower socioeconomic status. This section will look at gender inequalities, particularly those from disadvantaged areas. In order to keep this relatively brief, the focus will be on the South Western Sydney Health Area Service.
In general, it is assumed that women live longer than men. This claim is quite apparent in South Western Sydney where the age-adjusted death rate for all causes is 818.5 deaths per 100000 for men and 513.6 deaths per 100000 for women. However, in the context of the inner outer divide, these rates are relatively high. In the Northern Sydney area for example, the age-adjusted death rate for all causes is 676.8 deaths per 100000 for men and 453.9 deaths per 100000 for women [NSW Chief Health Officer 2000]. The variance in death rates between Northern and South Western Sydney illustrates differences in lifestyle, socioeconomic status and health awareness.
Men are more likely to smoke and drink too much alcohol, while their traditional involvement in high-risk activities such as sport, dangerous jobs and driving means they are injured, or die of injuries, more frequently than women. Furthermore, men tend to visit the doctors less than women do. The NSW Health Surveys for 1997 and 1998 show that the percentage of males from the SWSHSA who visited a GP in the last 12 months was 86.7% whereas the same figure for women was 89.8% [NSW Health 2000: doctor]. Although a lot of the causes for higher death rates in men are difficult to remedy, more can be done in the way of the promotion and awareness of these issues so that men (particularly in Western Sydney) can have a better chance at mitigating the impacts.
Despite the fact that women have higher life expectancies, they are not excluded from health inequalities. Women from low socioeconomic groups are significantly more likely to suffer from cardiovascular and lung disease and diabetes than women from high socioeconomic groups [SWSAHS Women 2001].
In regards to older women, social isolation and physical disabilities such as osteoporosis and arthritis significantly affect their general health and are the main impacts on morbidity. Younger women on the other hand are more likely to suffer from stress, eating disorders, body image, smoking, sexuality and relationship issues. It is also essential that plans designed to prevent violence against women and ameliorating its long term effects are implemented [SWSAHS Women 2001].
The previous two sections have concentrated on the social and economic consequences of health from structured social inequalities – this section will look at the impact of politics. There have already been some mentions of political decisions and how they effect the lesser off in this paper (investment into private health insurance at the expense of government funding for public hospitals and community-based services and care). Everyday new decisions are made which ultimately affect the health outcomes of Australian citizens. Unfortunately however, these decisions cannot and do not satisfy everyone’s needs. Once again, those who do not have the capacity, opportunities or access to decent health care facilities often end up even more disadvantaged. In the case of Sydney, these people are largely represented by those living in the West.
One of the more recent additions to the gap between rich and poor, healthy and sick, was the abolition of the Commonwealth Dental Health Program in 1996. This has had serious implications for people most in need, especially in the rural areas of NSW. Dental care of the preventive type is an optional service which is affected by the ease or difficulty of accessing it. Without the support of the Commonwealth Dental Health Program people who need oral care most no longer have the same opportunities as they did and most likely will choose not to pursue it. ACOSS, the Australian Council of Social Service, is determined to “get this gap filled” [Acoss 1997].
If the whole of NSW had experienced the mortality rate of the least socio-economically disadvantaged group, we calculate that from 1990 to 1994 there would have been 18,800 fewer premature deaths” [Crowe 2000]. There is a strong correlation between socio-economic status and health. Income level is positively correlated with health status: the lower the income, the lower the status of health. This situation is compounded by the fact that people on low income are less able to buy goods and services related to health and less able to pay the costs involved in accessing them.
Additionally, gender differences (physiological, psycho-social, average income etc) make the development of mitigating strategies difficult as they are so complex. A way in which gender differences can be overcome needs to be devised.
This paper has shown that social polarisation is evident. The involvement of politics, Government officials and policy makers, need to look at ways of “narrowing the gap” between the two distinct class groups which are emerging. It would be irresponsible to allow current trends to persist, strategies to reduce health inequalities need to be formed.
Though the formal health system is of great importance to the wellbeing of all Australians, more preventative (rather than curative) measures need to be put in place. The study of structured social inequalities helps one to understand some of the underlying factors about why people become ill. Strategies aimed at reducing health inequalities need to acknowledge the political, economic and social factors which determine ones opportunities, capacity and ability to improve their health outcome. Before any major shifts in the narrowing of health inequalities within Sydney are achieved, the health sector needs to reduce the structured social inequalities which create them.
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