The Swiss healthcare system has a flattering reputation often associated with its leading-edge services. Less well known is the equally important role of social and community healthcare practices. These address less visible populations and can dramatically change their living conditions, without costing a fortune. Here, we take an in-depth look at a branch of medicine that is making vulnerability and research its battlefield.
The Swiss healthcare system enjoys a host of laudatory descriptives. Its coverage is considered universal, and the system efficient, state-of-the-art, one of the best in the world. However, a section of the population does not have access to it, or only partial access. Migrants, people with disabilities, unemployed, homeless, prisoners, sex workers, single mothers and many others. Many fall through the cracks or have difficulty accessing their rightful benefits. To prevent that from happening, we must be aware of the role social medicine plays in supporting the poorest of the population.
“Health is also the community,” says Professor Patrick Bodenmann, chief of the Department of Vulnerabilities and Social Medicine (DVMS) at Unisanté, who also holds the Chair of Medicine for Vulnerable Populations at the University of Lausanne (UNIL). “Along with biomedical data, social medicine also – and especially – takes into account all socio-economic determinants of health: difficult childhood, unemployment, migration, violence, and so forth. Everything that happens outside the doctor’s office has an impact on the state of physical and mental health. Practising inclusive social medicine means looking at the individual as a whole.”
An individual can, from one day to the next, end up in a “situation of vulnerability”, a key concept in social medicine. Vulnerability is fluid, he says. Being vulnerable today does not necessarily mean that it will be the case tomorrow. A case in point is the Covid-19 pandemic, which suddenly deprived part of the population of its income. More commonly, divorce or job loss can lead to isolation. Stories and life paths vary as much as the ailments needing treatment. “We have the whole world in our waiting rooms,” Patrick Bodenmann likes to say. These individual stories weave a complex web bringing together multiple issues. That is what drives social and community medicine, both on the ground and in academia.
Social medicine emerged in the 19th century, when social inequality was linked to health in industrialising cities. The founders of public health systems point to the vulnerability of certain population groups, especially workers, to industrialists. Squalid living conditions spread and favoured the spread of pulmonary tuberculosis. However, it took some time before the issue was studied formally. It was theorised for the first time in Great Britain in 1977, in the “Black Report”, which highlighted the systematic differences in health according to social position. A historic turning point.
In the early 21st century, the World Health Organization (WHO) published a report on the social determinants of health, establishing inequalities as a society-wide issue. While the United States and United Kingdom are ahead of the game, Switzerland is slow to make the issue a priority. First, as Patrick Bodenmann points out, because our system is described as ultra-efficient and inspires confidence, not to mention the taboo surrounding poverty in a rich country, and secondly, because forces focus on “technical” medicine, which is more prestigious.
“People talk a lot about advanced medicine because it is extremely expensive. It sends healthcare budgets sky high, treating a part of the population that is definitely not the largest,” says Claudine Burton-Jeangros, sociologist of health and medicine at the University of Geneva. “Advanced medicine looks at diseases, fixing problems that are rare. At the other extreme, social medicine is concerned with people who have physical and mental illnesses that are more ordinary and commonplace. It addresses the primary health needs of the population as a whole.” And it’s supposed to be less expensive. Plus, diseases that are not treated promptly are a burden on the healthcare system.
The first public policies to combat inequality in Switzerland were developed in the 1950s. Yet disparity persists today. The country lacks data that could target health inequalities and therefore address them more effectively. “In Switzerland, the importance of measuring equality is not there,” says Kevin Morisod, a physician and doctoral student with the DVMS at Unisanté, who focuses on health equality. “We collect very little information on individuals’ ethnic origin or socio-economic level, unlike countries such as the United Kingdom and the United States, which have population inequality indicators.” Information is collected by health insurance companies, which have all the data on the population’s health, the researcher says, but they are not required to make it public.
In 2019, the annual expenditure on healthcare was 8,858 Swiss francs per inhabitant, the second-highest amount after the United States. In terms of direct household costs, Switzerland tops world rankings. In Kevin Morisod’s opinion, the cost of a system that is “dense in human and material resources, with high quality care” is a genuine equality issue, including for those with health insurance. “Deductibles, co-payments and premiums that are not proportional to income can be tough for low and middle-income households to meet.” As a result, people sometimes do not get medical care for financial reasons, when they have to choose between food, housing and non-urgent treatments. This situation is not set to improve considering the average 6.6% increase in health premiums next year. It could push people already close to the poverty line over to the wrong side.
The Swiss Health Observatory estimates that between 10% and 20% of the country’s population has already forgone care, treatment or medical check-ups due to cost.
Top of the list, dental care, as it is not covered. For example, it took Sarah*, 31, two years to have a cavity treated. She abandoned the idea of getting an IUD, which would have cost 400 Swiss francs, thus increasing the risk of unwanted pregnancy. As a doctoral student, she receives a small stipend and is not entitled to any government assistance because of her B permit. “Either you’re poor and receive aid, or you’re rich and have access to care. What happens to people in between?” the young woman wonders. Then there is Loris*, a father who feels that with his 2,500 Swiss franc deductible, “no care is reimbursed. I’m waiting to see if my case gets worse before going to a doctor.”
Poor monitoring of chronic illnesses can lead to frequent visits to the already overcrowded emergency rooms. Kevin Morisod points out that in some countries, “the emergency room is the gateway to the health system.” However in Switzerland, you have to go through your GP. Our complex, opaque healthcare system can be a maze, especially for migrants. Take Aden*, who arrived from Somalia as an asylum seeker in 2009. At the time, he had no understanding of the concept of a “family doctor”. He was treated at the CHUV and given antibiotics for three years because there is no centralised information. As a result, his health worsened, and he developed a resistance to the drugs.
Sociologist Claudine Burton-Jeangros also reminds us that for many people who are in a precarious situation, or without an employment contract, being sick can also mean not receiving any money or, in some cases, losing their job. It is not uncommon for illegal or undocumented people to refuse to go to hospital for fear of being reported. But they are entitled to care. Although official institutions can be daunting, structures like the Mobile Social Emergency Team (EMUS) or the many not-for-profit organisations, such as Médecins du Monde, work hard to make information, resources and medical care available. Outreach is needed to access people who are outside the system because they are undocumented or marginalised.
Another gap in the healthcare system is access to community interpreters, because they are not paid for in a standardised manner in Switzerland. “Language and cultural barriers are important issues. Interpreting costs are not covered by health insurance but paid for by the hospitals,” says Kevin Morisod, physician from the Department of Vulnerabilities and Social Medicine at Unisanté. And that carries a risk of misunderstanding or, if a family member does the translating, a breach of professional secrecy and anonymity. “Health literacy” problems, i.e. the lack of patients’ understanding of health and the health system do not only affect foreigners, but also Swiss natives. The organisation Lire et Écrire estimates that around 800,000 people are illiterate, half of whom were born in Switzerland and went through the compulsory school system.
On top of financial and cultural obstacles, current problems – pandemic, energy crisis, war in Europe, global warming – are putting a strain on the Swiss healthcare system. “Unfortunately, human distress is never-ending,” says Professor Patrick Bodenmann, who has dedicated his career to fighting inequality. He follows the news on refugees, with asylum issues only made worse by recent events in Eastern Europe. The migration situation is set to become more complex in the decades to come. “What is happening with Ukraine is unprecedented, both in terms of volume and reception. In the future, the health system will have to be redesigned.”
In June 2022, the canton of Vaud had a record number of 10,000 asylum applicants (figures from the State Secretariat for Migration) and as many special needs for health and other types of care. While many of the first refugees from Ukraine were of a socio-economic level that enabled them to flee the country, the second wave included people with less economic stability and therefore in poorer health, like migrants from other countries. And the press overlooked them too.
Another threat, in addition to present and future conflicts, is global warming, not only because of the displacement of populations that will push some people to emigrate from their countries, but also in Switzerland in terms of equality, Kevin Morisod says. “Heat waves cause increased mortality, mostly among the low-income elderly, who lack adequate housing and have less contact with the outside world. Homeless people experience greater insecurity due to situations like global warming and the pandemic.”
While social and community medicine faces many challenges, sociologist Claudine Burton-Jeangros points to another major challenge, i.e. recognising it as a formal branch:
“Social medicine must be able to prove its worth. By taking into account primary needs, it helps improve the health of the general population.” Patrick Bodenmann and Kevin Morisod take it further, “Social medicine is a priority. It is also our responsibility to communicate effectively about our work and research.”
Healthcare issues must be debated outside the hospital, the experts say. “It is in the way society is organised that we can ensure that people don’t get sick. Our society must be designed to reduce inequality and ensure integration, by taking direct action to improve socio-economic determinants of health,” says Claudine Burton-Jeangros. Social medicine requires upstream work on access to education, land use, planning, housing, anti-discrimination, job insecurity, etc. In short, prevention is better than cure. /
At the CHUV’s gynaecological consultation services, senior physician Martine Jacot-Guillarmod is surrounded two midwives who know about deafness and hearing impairments, and are fluent in sign language and cued speech. “This system is mainly based on personal initiatives. It must be standardised to guarantee access to care for the deaf* and hearing impaired,” says Véronique Grazioli, research manager from the Department of Vulnerabilities and Social Medicine at Unisanté. The Swiss Federation of the Deaf estimates that 10,000 people are deaf from birth and 1 million have a hearing impairment in Switzerland. “These people often don’t dare to ask the doctor to repeat information. That can lead to complex situations. Not understanding how to take medication, for example.” The research conducted by Unisanté, in collaboration with the CHUV, covers people with deafness and hearing impairments to improve access and quality of care. “We need to work on training, so that staff have tools to improve communication. Simple measures, such as allowing for twice the time in consultations and bringing in people with specialist resources are also essential.” *
This term includes both deaf people and those who identify themselves as such.
Some people repeatedly go to the emergency room with a problem that could be better treated by another department. “We define a ‘regular’ as someone who has come in five or more times in the last 12 months,” explains Patrick Bodenmann, chief of the Department of Vulnerabilities and Social Medicine at Unisanté. “In the canton of Vaud, we estimate that this phenomenon concerns one person in seven, but that it represents 12% to 15% of all emergency consultations.”
However, the researcher and his team report that 80% of these regular patients have an attending physician. “To start with, the relationship with the emergency room is very subjective. Then, the healthcare system can seem opaque for many, especially those in a vulnerable situation. Another explanation for doing it is that it may be reassuring to go to a big health institution with extensive technical capabilities.”
However, this situation does not work for anyone. Medical staff are under pressure, since these consultations can limit their ability to rapidly attend to patients who need urgent care. And people who go in for non-urgent reasons, often hypertension, diabetes or loss of medication, do not get the quality of care they expect. “This situation also increases the risk of discrimination against regulars, and that’s a big problem.”
To improve the quality of the working environment for emergency room staff and the care of regulars, a nursing team was enlisted to take direct action on site. The system uses a computer programme that automatically alerts the nursing team when the person is identified as a regular. “As soon as the individual has completed their visit to the emergency room, a case manager from the nursing team contacts the person to guide them to the service that can best meet their need.” This system has already reduced the number of consultations by 20% in one year. “The relationship with illness can be very different from one individual to another, and is sometimes influenced by the person’s culture. That is why case managers should have transcultural clinical skills.”
The mission of Unisanté (University centre for primary care and public health) is to describe inequalities, understand their causality and implement solutions to reduce social inequalities in health. The centre was created on 1 January 2019 from the merger of the University Medical Polyclinic, the University Institute for Social and Preventive Medicine, the Institute for Work and Health of French-speaking Switzerland, Promotion Santé Vaud and the Mobile Social Emergency Team. In addition to fieldwork, the academic unit studies the various groups at risk of inequality (the deaf and hearing-impaired, emergency room “regulars”, sex workers, etc.). Unisanté has about 880 employees staff spread over more than 15 sites in the Lausanne area and the canton of Vaud.
In Swiss francs, the annual amount spent on healthcare per inhabitant in Switzerland
Percentage of the Swiss population who have ever forgone medical care for financial reasons
Non-medical factors that influence health outcomes and the conditions in which people live, learn, work, etc. And the range of social, political and economic factors that shape the conditions of everyday life.
The differences in health status and inequality in access to care. They are a direct result of people’s social condition in relation to income, professional position or education.
A state of social instability related to the absence of one or more securities, e.g. in employment.
When insecurity becomes chronic and affects several areas of life.
Absence of unfair or avoidable differences between groups of people, whether defined socially, economically, demographically or geographically, or on the basis of gender, ethnic origin or disability. Is achieved when everyone can realise their full potential for well-being.
In 2020, the average poverty line was 2,279 Swiss francs per month for a single person and 3,963 Swiss francs per month for a month for a household with two adults and two children under 14 years of age.
Misalignment between needs and available resources, increases the likelihood of undergoing harm, a fluid concept that can affect anyone over the course of a lifetime.