Pierre-André Juven is the co-author of “Pandémopolitique”, released in January 2021 (1). He discusses the emergence of the coronavirus by crossing this epidemic phenomenon with other health and political issues, to question our current health system.
In your book, you invite to consider the Covid-19 epidemic as a syndemic … Can you explain this notion?
Pierre-André Juven It is the idea that an infectious epidemic intersects with a multitude of health problems which, by interacting, give rise to a serious health crisis. What this term also says is that Covid-19 is a health issue, but also a social and political issue that highlights all the inequalities. Their interweaving, which is part of the body and exposes people to a greater or lesser extent to the virus, makes this pandemic a major social and political phenomenon beyond being a health phenomenon.
What has the pandemic revealed about these inequalities, particularly in health?
Pierre-André Juven Those most at risk, apart from the elderly, are those with chronic illnesses. They are mostly found in popular categories. The bodies of the precarious are the least able to withstand a global pandemic, because the living conditions of these people expose them more. Thus, the rate of overoccupied residences in Saint-Denis is 27%, it is 34% in Aubervilliers, against 15% in Paris. Finally, what post-containment studies have shown is that these populations were the most exposed because they continued to work, live in smaller dwellings and in medically under-endowed territories. Seine-Saint-Denis is one of the least well-endowed departments in terms of hospital beds (94e out of 100). When we combine all these inequalities and discriminations, inevitably, we are more exposed to the virus, to serious forms of the disease, to death.
You link these questions to that of sorting patients in the hospital …
Pierre-André Juven For leading politicians to say, “We didn’t have to sort the sick” is a major misconception. What public health experts have pointed out is that, in a situation like this, not sorting would be a professional error. With limited resources and constraints, it is necessary to establish priorities. And putting them up for debate is a democratic question. We can say that there was a clinical triage, in the sense that caregivers wondered who to prioritize in intensive care. What we invite to look at is not just the moment when we choose who we put first, but all the material conditions that caregivers have to work.
The fact of having so many beds, so many doctors, ventilators, the fact of having exposed populations to chronic diseases because of the very strong social and health inequalities in France … all this has contributed to clinical triage , predetermined by a multitude of reforms which fall under a form of systemic triage: beyond the pandemic, every day in the hospital, there are sorting operations, in a certain way, since it is necessary to remove patients to bring in others. Much debate and controversy has taken place in recent years around the idea of discharging patients because they are becoming too expensive. It is an economic and political triage operation.
“For leading politicians to say, ‘We didn’t have to sort the sick’ is a major misconception. “
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How could community health models, which you take as an example, help redefine this system in a more democratic way?
Pierre-André Juven Community health is an organization of care and health that includes the inhabitants, making them take part in health and care. It can be territorial, at the scale of a village for example, where mediators and public health intermediaries would be trained to explain what this epidemic is, the modes of contagion, the barrier gestures … It could be the doctor, but also an association manager, a sports coach. The idea is to mobilize all these actors and that, in return, the inhabitants take up these questions to adapt the management of health policies to the local area.
Measures like curfews and even confinement have major psychological impacts, and they should not be overlooked. But what would be the choice of the people? In certain territories, a majority would perhaps find it relevant to confine themselves for two weeks because, for example, we come back from vacation and we could collectively choose to slow down social life to measure the epidemic situation.
In this crisis, politicians had great difficulty in considering that the evolution of the pandemic was going to pass through the citizens. There is, for example, a need to integrate patient associations much more. The names of the devices mobilized speak for themselves: a defense council, war situations… All of this leads to a very autocratic management inspired by military logic which effectively excludes the rest of society.
We are probably moving towards a third epidemic wave. What lessons could we learn at this stage?
Pierre-André Juven We have talked a lot about the public hospital, but, paradoxically, in this crisis, it is only the receptacle of everything that we have missed elsewhere. It must be defended, of course, but the solutions must be found in a restored public health system and in the reduction of health inequalities. This is the first lesson. The second is that we need to breathe new life into the health system, trust the relays in the field, and consider that health policies cannot be managed solely from Paris.
“Pandemopolitics”, by Jean-Paul Gaudillière,
Caroline Izambert and Pierre-André Juven.
La Découverte, 306 pages, 15 euros.
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