A Lausanne-based researcher is working to bust the myth that Switzerland is too rich to escape the impact of low socioeconomic status on health, and to integrate this often-ignored risk factor into public health interventions.
It probably comes as no surprise that the World Health Organization (WHO) considers alcohol abuse, physical inactivity, salt intake, tobacco use, obesity, high blood pressure, and diabetes to be key risk factors for today’s major non-communicable diseases (NCDs). Due to their well-documented roles in the development of cardiovascular and metabolic diseases or cancer, each of these risk factors is targeted in the WHO’s Global Action Plan for the Prevention and Control of NCDsexternal link.
But for Silvia Stringhini, a lecturer at the Institute of Social and Preventive Medicine (ISPM) in Lausanne, there is a crucial entry missing in the WHO’s list: low socioeconomic status.
“As long as people smoke or are obese because of socioeconomic disadvantage, if these root causes aren’t addressed, you risk having [public health] interventions that do not work,” Stringhini says.
“For example, we have seen a drop in the international prevalence of smoking, but not for the disadvantaged sections of the population – they still have a very high rate of smoking.”
Stringhini’s research at the ISPM focuses, as she puts it, on “social-biological transitions”: how socioeconomic factors become “embodied” biologically to produce social differences in health.
Last year, she was the lead author on a paper published in the prestigious medical journal The Lancetexternal link, which showed that low socioeconomic status – as estimated by study subjects’ occupational title – was associated with a 2.1-year decrease in life expectancyexternal link between the ages of 40 and 85. To reach their conclusions, the researchers analysed data on 1.7 million people, including those in Switzerland.
Stringhini believes these results cast a glaring light on a major gap in public health research, as well as policy interventions like the WHO action plan.
“It’s much simpler for governments, and institutions to address behaviours – to tell people to stop smoking, for example – than to focus on changing societal factors, and on making sure people are equally capable and have equal resources,” she explains.
She and her colleagues anticipate another publication in the coming months showing that individuals with low socioeconomic status also age more rapidly than those in a higher bracket, with social factors having a greater impact on walking speed – a key indicator of healthy functioning – than other risk factors like smoking and obesity.
Hidden health risk
“In Switzerland social disparities are very large, and we can all see this with our eyes: there are very poor people on the streets, but on the other hand, there are the richest people in the world,” Stringhini says.
“As long as there is social inequality or inequality in wealth, there are inequalities in health. This is sometimes ignored in Switzerland because of the perception that everyone must be well because the country is doing well, and that it’s impossible that there are differences in health. But there really are.”
Several of the studies Stringhini and her colleagues have led focus on Swiss populations, notably in the western hubs of Lausanne and Geneva. For example, the CoLausexternal link study, which involved a survey of over 6,000 Lausanne inhabitants, showed that women with low educational levels – a key indicator of socioeconomic status – were five times more likely to be obese than those with a higher education level. The less-educated women were also more likely to smoke, have lower levels of physical activity, and have higher levels of total cholesterol in their blood.
Other studies show that Lausanne residentsexternal link whose occupation involves manual labour have higher levels of inflammatory markers in their blood, and that there are social differences among Geneva residents’external link participation in breast cancer screening.
Levelling the playing field
But if unequal socioeconomic circumstances are to blame for these health disparities, what can governments and public health organisations do – short of making every person a millionaire?
Stringhini argues that the answer lies in the fact that in many cases, the ability to make healthy lifestyle choices – to quit smoking, take time to exercise, or purchase less-processed foods – is a luxury. Therefore, solutions should be sought that empower the socioeconomically disadvantaged to take the same healthy steps that rich people are lucky enough to be able to choose every day.
“[Many] strategies tend to think about risk factors as individual choices, though now we know this is not the case – there are circumstances that make people choose one thing over another,” she explains.
“For example, if salt content in food is reduced by legislation, everyone is affected equally. On the other hand, when you advise people to not add salt to their food, only those that are capable of responding positively to this advice are going to have a decrease in salt intake… and this tends to increase social inequality.”
Changes to the notoriously expensive Swiss health care systemexternal link could also help improve access to both preventive medical care and treatment, Stringhini says.
“The health care system in Switzerland, compared to other countries, is more able to exclude the poor from certain services, for example from access to dental care.”
As the evidence connecting socioeconomic status and health mounts, awareness of the link and the impact for public health interventions is growing. But change is slow, Stringhini says, in part because it is simply much more difficult to change the socioeconomic roots of health disparities than it is to target individual behaviours and lifestyle choices.
Stringhini adds that one thing that will help is more health data – particularly on social differences at the national, rather than the international level.
“When we talk about social differences in a global arena, policymakers tend to think about the differences between countries, and rarely differences within countries. In some cases, even this is difficult to assess as the data simply do not exist.”
Poverty and income inequality in Switzerland
According to the Organisation for Economic Co-operation and Development (OECD), Switzerland ranks above average in terms of my many metrics of well-being – including income, employment, health, education, and life satisfactionexternal link – in comparison to the 34 other member countriesexternal link. Nevertheless, Switzerland is not immune to poverty and social inequality.
The Swiss Federal Statistics Officeexternal link defines an absolute poverty thresholdexternal link based on a social subsistence level, meaning that people are considered poor “who do not have the financial means to acquire goods and services necessary to an integrated social life”. This threshold was set according to the Swiss Conference for Social Assistance at CHF2600 per monthexternal link ($2735) per person in 2015. The following year, in 2016, one in five Swissexternal link were reportedly unable to meet an unexpected bill of CHF2500, according to the Survey on Income and Living Conditionsexternal link (SILC), and 7% were at a persistent risk of poverty, meaning they were at risk for three of the four previous years, including the most recent.
Because poverty is a relative term, the European Union also sets a threshold for defining a country’s risk of poverty in comparison to other nations. This threshold is set at 60% of the median equivalent disposable income of a country’s population. By this measure, in 2016, the risk-of-poverty threshold was CHF29,796 per year in Switzerland – a criterion that described one in seven single-person households.