Elections loom large in France’s pandemic policies
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o439 (Published 10 March 2022) Cite this as: BMJ 2022;376:o439
Doctors in France have mixed views about the government’s handling of the covid-19 pandemic, but they agree that the presidential and parliamentary elections—to be held in April and June—are key factors in setting pandemic policy.
President Emmanuel Macron said in his new year wishes that the pandemic could end in 2022. Public health took precedence at the beginning of the crisis, but since the second wave of covid-19 in August 2020, the economy and social pressures have become the focus.
The phased lifting of restrictions in June 2021 marked a big change. “For the first time, a date was chosen without taking account of either the incidence or hospitalisation rates of covid,” says Mahmoud Zureik, epidemiology and public health professor at the Versailles-Saint-Quentin-en-Yvelines University.
By then, the vaccination campaign was well under way. Although delta had displaced other variants of covid-19 during the previous autumn, the government took “very timid” new measures to contain it, based solely on whether hospitals could cope, says Zureik.
Furthermore, the government’s contradictory messages have created confusion. After introducing a health pass (evidence of vaccination, previous infection, or a recent negative test result) for entry to enclosed public spaces in January 2022 the French authorities upgraded this to just evidence of vaccination or recent recovery from infection. Soon after the new pass had come into force, health minister Olivier Véran was talking about abolishing it “well before July.” At the beginning of March, the prime minister Jean Castex said it would be “suspended” on 14 March. Obligatory masks will all but disappear at the same time.
Doctors TheBMJ spoke to agree that the government is relying too much on the high vaccination rate in France, which stood at 74.8% of the population aged 5 and over on 9 March. They regret that preventive measures are being overlooked as the population becomes increasingly weary of restrictions, but the falling numbers of covid infections are still high. “With new cases reaching a daily record of more than 500 000 on 25 January, it was illogical to loosen the rules before the fifth wave had peaked,” says Jacques Battistoni, president of MG France, the country’s largest union of general practitioners. “The government was no doubt more concerned about election prospects than public health.”
Djillali Annane, head of the intensive care unit at the Raymond-Poincaré Hospital in Garches, believes the government should have waited until the pandemic subsided at the end of the winter. “We must still be extremely careful,” he says. “Hospitals and intensive care units (ICUs) have not yet returned to normal,” he told TheBMJ on 7 March.
Zureik says, “Even though it did not admit it, the government had clearly decided to allow the virus to circulate freely. This is still the case.” But Philippe Amouyel, epidemiologist at the Lille teaching hospital, sees it differently. “The decision has nothing to do with letting the virus circulate freely,” he says. “It does that all on its own, and is creating a natural immunity in France and other countries.”
Marking Macron
The new health pass was intended to encourage rather than impose vaccination. Macron was widely reported as saying he wanted “to piss off” the people who refused to have shots. “Anything that encourages vaccination is good,” says Zureik, “but Mr Macron shouldn’t have said that. Insults are always a bad idea.”
Battistoni says the numbers of first vaccinations did rise around the time of Macron’s remark, but this could be because the vaccination pass was brought in soon after. “I am old school, and think Mr Macron could have made the point another way.”
The “purely political” comment was taken out of context, says Amouyel. Macron was responding to the numerous delays to surgery and treatment in French hospitals as increasing numbers of unvaccinated patients were being admitted to ICUs with covid-19.
For Annane, “the worst thing a doctor can do is to try and force a treatment on a patient. It almost always fails.” Even though at that point Macron had still not announced he would run for re-election, “he was clearly taking a swipe at the political far right, a hotbed of anti-vaxxers. But this neither surprises nor shocks me.”
TheBMJ asked interviewees to assess the government’s management of the pandemic. Some gave low marks for the chaos at the start of the crisis, but high marks for its management later.
Battistoni gave a score of 4 out of 10 for the beginning, when there were no masks, no protective equipment for healthcare workers, and no tests. But he would give an 8 now. He is less severe in his assessment than some of his colleagues, because as a union chief, “I am closer to the difficulties than most. I attend a lot of meetings with the authorities and see how complicated each stage of the pandemic can be.”
Annane gave the government a score of 5 overall, as it “has never caught up from the catastrophic start” and has merely replaced initial problems with new ones. Amouyel gave 7 out of 10, rising to 8 at times. He credited the government for anticipating the fourth wave in July 2021 and bringing in the health pass to public spaces.
A shift in primary care
Jean-Paul Hamon, honorary president of the Fédération des Médecins de France, which represents non-hospital doctors, raised his rating for the government from 3 out of 10 to 7. One of his biggest gripes at the beginning was that the government sidelined community practitioners completely. “It told patients with suspected covid to ring the general health emergency number rather than their GPs, and to renew their prescriptions for chronic diseases directly with their pharmacists,” he says.
The government did not call on unions of non-hospital doctors to discuss the pandemic until 18 February 2020, after health minister Véran had taken over from Agnès Buzyn. Even then, in a two hour press conference with former prime minister Edouard Philippe, Véran overlooked non-hospital doctors, thanking their hospital colleagues for their hard work and never mentioning that most deaths in doctors from covid were in non-hospital practitioners. “Governments have always forgotten us, but never to this extent,” says Hamon.
That changed when vaccinations were rolled out in December 2020, and general practitioners became central to the campaign, he adds. “Even so, there is still a way to go in involving non-hospital doctors and nurses in diagnosis and shortening hospital stays.”
Hamon gives the government full marks for adding a child psychiatrist to its advisory scientific council in early 2021, and for not bowing to pressure from some doctors to impose a second strict lockdown when the second wave hit in August 2020. “Mr Macron knew that the French people’s morale would not stand it, and the wave turned out not to be as severe as had been feared. It is not easy to govern right now.”
Court action
For months, the French government has been under fire for allegedly mishandling the crisis. Legal complaints have flooded in from individuals, patient associations, and medical practitioners. Recently, the Court of Justice of the Republic, which hears cases against ministers in office, threw out nearly 20 000 complaints, all filed at the behest of lawyer Fabrice Di Vizio. Most opposed the health pass and pressure to vaccinate. Targets were prime minister Jean Castex, Véran, education minister Jean-Michel Blanquer, and junior transport minister Jean-Baptiste Djebbari. The public prosecutor has already indicted Véran’s predecessor Agnès Buzyn with endangering life, and is conducting a judicial investigation into the performance of Véran and Philippe.
Several doctors single out Blanquer in particular for having bungled the school health measures. “I would give him 2 or 3 out of 10, rather than zero, because the situation is even worse in the UK than in France,” says Zureik. The minister “changes the school protocol every five minutes,” says Hamon. It was “absurd” not to postpone the new term in January, adds Annane. “There were four different protocols in a week, and since then children have been a huge accelerator in spreading the omicron [variant].”
Vaccine sceptics
Epidemiologist Antoine Flahault, founding director of the Institute of Global Health in Geneva, regrets that the French government has not done more to convince sceptics to be vaccinated. “Portugal and Spain have succeeded in changing their minds, without making vaccinations compulsory, [by] introducing a pass or offering cash incentives,” he said.
He also regrets that France has fallen so far behind in vaccinating children aged 5 to 11. “It’s a great shame, and is due in part to French paediatricians’ traditionally lukewarm attitude to vaccinations,” he says. Some French speaking paediatricians believe children with natural immunity are more resistant to infectious diseases in adulthood, says Flahault, citing Jean-François Bach, a member of the French Academy of Sciences, as one scientist behind the theory. These paediatricians recommend vaccinating children against what they consider to be dangerous diseases—poliomyelitis, diphtheria, tetanus, and whooping cough—but oppose vaccination against “benign” diseases such as measles, chickenpox, flu, and now covid-19, in children with no underlying health problems.
At the beginning of the pandemic, children were regarded to be at low risk of complications from covid-19, but now “we know they are easily infected, and can still suffer severe complications, including inflammation and even death,” says Flahault. “In Europe, 80% of children hospitalised with mild or even severe forms of covid-19 have no other diseases and seem to be just as vulnerable to long covid as adults are.” In France, a study showed that 77% of the 82 children aged under 13 hospitalised between August 2021 and January 2022 had no comorbidities.1
Flahault’s harshest criticism is against France in the position of European Union presidency, and the EU in general for failing to take a strong lead on air quality. “Now we know that the virus is transmitted by aerosols, it is clear that ventilating enclosed spaces is the key to ending the pandemic,” he says. “Ninety nine per cent of infections occur indoors, and we spend more than 90% of our time indoors.”
Footnotes
Competing interests: I have read and understood TheBMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: commissioned, not externally peer reviewed.