I wrote a piece for the Summer 2021/22 edition (Issue 36) of the Hive (the Australian College of Nursing’s quarterly publication). Cite as: De Souza, R. (2021). Lessons on exclusion from past pandemics. The Hive, 36, 16–17. You can also download a pdf of the article for your own personal use.
I have three pandemic stories about health inequity. The first is a painful family one. In July 1961 in Moshi, Tanzania, my aunt died of hospital-acquired smallpox caused by the variola virus five days after giving birth to her newborn son, who died a day later. She left behind her devastated family and a thirteen-month-old daughter. She had been immunised while at school, so we don’t know what happened. We know that some vaccinations in East Africa at that time were unsuccessful because the liquid vaccine had to be refrigerated otherwise it became inactive within three days. The smallpox vaccine was produced in Nairobi or England and it is possible that temperatures were not maintained during shipping or when the vaccine was transported to distribution centres or health clinics. It could also be that a more severe form of smallpox was present in Tanzania at the time.
Closer to home there were the smallpox epidemics of 1789, 1829-32 and the 1860s in Australia (McWhirter, 2009). Smallpox arrived with settlers fifteen months after the first fleet arrived in Australia. Macassans were originally blamed for its arrival, but there was no smallpox in Macassar at the time of the First Fleet. Smallpox was widely believed at the time to come from Asian countries because Asians were thought to be diseased and different. However, smallpox was endemic to Britain and to a lesser degree Europe. The three epidemics all had a major impact on Aboriginal populations but less so on European settlers.
Smallpox was managed in different ways in the various Australian colonies. Vaccinations became available during the 1829-32 epidemic, but there was no legislation with regard to smallpox in Aboriginal communities. Rather than having compulsory vaccination imposed, vaccination occurred in an ad hoc manner if an individual settler or doctor was concerned about an Aboriginal person. In Victoria, where I live, the smallpox epidemic of the 1860s had a devastating impact on Aboriginal people. In the racial hierarchy of the time, white settlers were seen as superior to Aboriginal people and people of color. Aboriginal people were thought to be already at risk of dying, both individually and as a “race”, and were not seen as a threat as a vector of disease or of being in need of a public health response.
Chinese people were also seen as inferior and unsuitable for integration into colonial society. However, they were seen as a threat to British dominance, by virtue of their industriousness and because their numbers swelled through the gold rush era and they were characterised as a source of disease. A smallpox outbreak in 1857 in Melbourne, singled out Chinese people as the source of the threat, despite it being traced to a sailor from Liverpool, led to demands for the compulsory vaccination of Chinese. An outbreak of smallpox in 1887 was attributed to Indian hawkers or to recently arrived Chinese. The Tasmanian Chinese Immigration Act 1887 required that all Chinese entering the colony be compulsorily vaccinated, and this was carried out by the Superintendent of Vaccinations, C.E. Barnard, even as compulsory vaccination was being challenged among the European population on the grounds of contravening individual liberty.
And now to the present. In Victoria, where I live, where the unfair structural arrangements in our society have been exposed. Nine public housing towers with high populations of migrants and people of refugee background in North Melbourne and Flemington were put in lockdown without notice (Ghumkhor, 2021). This racialised response was also seen in Sydney, where people in the western suburbs were policed heavily compared to the eastern parts of the city.
These pandemic examples from the past and recent present show that although we might be in the same boat “some people have yachts and superyachts” (Siouxsie Wiles). There’s the global inequities of vaccine distribution, which are as evident now in terms of Covid as in my Aunt’s time. At the time of writing this (December 2021), Canada had a total vaccination rate per 100 people of 155.67 while Tanzania had a rate of 1.63, compromising the effectiveness of vaccination as a public health strategy (Carey, 2021). We know that this massive disparity will have far reaching impacts. Low vaccination rates mean that the virus can continue to spread and increase the risk of new variants emerging globally. Considering health equity would ensure that the places that needed the vaccine the most could be supported with resources. This is true also of Australia where there was a lack of prioritisation of vaccine supply for the people with the most need (e.g. essential workers in precarious work, people living in high density housing). An equity lens would require targeting people living in ‘LGAs of Concern’ with early intervention to promote understanding of restrictions, vaccine uptake, and Covid-safe work practices (Reeders, n.d.).
The second and third examples show how race and racial hierarchies have played a part in how infectious diseases are managed in settler colonies like New Zealand and Australia. Fueled by fear, we have turned to carceral responses and policing particular areas rather than making public health responses toward equity. These responses rather than community led solutions have been traumatising and reduced trust in population groups that already are distrustful or disengaged from health services (Liddle, 2021). The lack of financial assistance for international students and essential workers spread across different contexts has also exposed how some communities are seen as less worthy of respect or care.
Bringing in an equity lens reveals the limitations of health communication during the pandemic. Firstly, health messaging has not always been accessible for people from culturally and linguistically diverse communities. Initial messaging did not take into account fluency in a language other than English or take into account low health literacy, or diverse work and social contexts that such communities live in, such as the prevalence of precarious essential labour, irregular shift work or multi-generational households. The pivot to digital technologies has also made life more difficult for marginalised communities. Whether for accessing online consultations, or the requirement to use apps to check in at venues and facilities using QR codes, to home schooling and working from home, the mandatory use of unevenly distributed technology has widened existing health inequalities. Once again, the assumption that middle-class, English speaking communities are the Australia public health needs to serve have prevented us from achieving positive outcomes for all. We need far more engagement with marginalised groups and to welcome their participation in producing healthy outcomes for their communities if we don’t wish to repeat the exclusions of the past.
10 January 2022 from Dr Nadia Chaves, Clinical lead and Chair of C-19 Network clinical governance committee, Infectious diseases specialist
Thank you for this article, Ruth. I just wanted to mention re your latest article – the C-19 consortium (made up of a consortium of 5 community health organisations – IPC, DPV, EACH, Star health and cohealth) was contracted by Vic gov in 2021 to specifically target vaccinations for at-risk and underserved communitiues including people in social housing, people who are experiencing homelessness, asylum seekers and refugees and people from CALD communities.
We set up vaccination clinics in all the housing towers who were locked down. This has enabled a very high double vax rate in these housing estates. It was great they were able to be prioritised- the main rate limiting step was access to enough vaccine through federal government and also the lack of staff.
I do believe there are opportunities to better engage and empower people with intersections of being underserved outside social housing as well. This includes- people with mental health issues, disabilities, people with preferred language other than English, those with low health literacy and low socioeconomic backgrounds. With Omicron, boosters and children’s vaccinations, unless we better care for these communities they will continue to bear the largest burden of COVID-19 pandemic.
Carey, T. A. (2021, November 14). The number that matters in the COVID pandemic is a relative one: vaccine inequity. The Conversation.
Ghumkhor, S. (2021, October 4). Pandemic policing in “multicultural” Australia. Al Jazeera.
Liddle, C. (2021, September 29). Get rid of curfew to restore public confidence in health leadership. The Age.
McWhirter, R. (2009). Smallpox and vaccination in Tasmania. Papers and Proceedings: Tasmanian Historical Research Association.
Reeders, D. (n.d.). We ought’ve known – Bad Blood. Retrieved October 1, 2021, from