Paola Sillitti. © KA / Centre LIVES
A large-scale European study of 7,000 deaths reveals the extent of inequality in the face of the pandemic. The researcher behind this work, Paola Sillitti, analyses these results and warns of the challenges ahead for Switzerland.
What motivated you to undertake research on a European rather than a national scale?
It was the scale of the phenomenon. We felt it was essential to study it on a European scale. By working with harmonised data from 28 countries from the European SHARE survey (Survey of Health, Ageing and Retirement in Europe (link)), we were able to trace the trajectories of more than 7000 people who died before and during the pandemic, with detailed and comparable information on their socio-economic status, health and living conditions.
What does this comparative approach reveal that a national study cannot?
First, we identified common trends at the European level, such as higher mortality among people with lower economic or educational levels. Secondly, we identified marked differences between countries and regions, notably higher mortality in Eastern Europe, which invites us to explore the role of structural inequalities in health and social protection systems. This approach allows us to highlight common mechanisms while noting differences between countries.
A surprising finding from your study shows that people who reported good health were slightly more likely to die from COVID-19. How do you explain this paradox?
This result may seem counterintuitive. But there might be an explanation. Reporting good health does not mean the absence of risk factors: certain conditions may be minimised or not felt. Furthermore, people who perceive themselves to be in good health may have adopted fewer protective behaviours, thinking they are less vulnerable. They may have maintained more social contacts or been vaccinated later.
Your results show that people in severe financial difficulty were 24% more likely to die from COVID-19 compared with 15% for those without financial difficulties. Beyond the statistics, how did these inequalities manifest themselves in terms of access to healthcare and protection against the virus?
People in precarious situations are more likely to have jobs that do not allow them to work from home and to live in cramped or multigenerational housing. This makes it very difficult to limit contact and leads to increased exposure to the risk of contagion. I recently published another article in which I showed that these same people experienced a greater reduction in access to palliative care during the pandemic. This clearly illustrates that inequalities were reflected not only in the risk of infection but also in the quality and continuity of care received.
The study reveals a significant excess mortality rate in Eastern Europe (41% of COVID deaths compared to 24% overall deaths). What structural factors explain this geographical disparity?
This is a complex issue. It is probably a combination of structural factors related to healthcare systems and contextual factors related to public health. European and OECD statistics show that some Eastern European countries have lower funding for their healthcare systems and less developed healthcare infrastructure. These countries also have higher levels of social inequality and chronic disease, making the population more vulnerable. Our study did not aim to explain these causes in detail, but an in-depth analysis of the structural characteristics of health systems would provide a better understanding of these disparities.
What specific lessons should Swiss health authorities learn from your study?
Our study reminds us that COVID-19 was just one shock among many, and that other challenges – some predictable, others not – will test our healthcare system. The ageing population is a very concrete example of this. The SWISS100 study, conducted by researchers at UNIL, shows that the proportion of people aged 100 and over will increase dramatically in the coming years. This implies a growing need for complex and continuous care. Environmental shocks and their impact on health, as well as an unstable European geopolitical context are also expected to impact health systems. Switzerland must maintain an accessible, resilient and equitable healthcare system for all, particularly for elderly, isolated or vulnerable people.