As a nurse in the infectious disease ward of a major Paris hospital, Marie is on the front lines of the battle against COVID-19. Over the past few weeks, dozens of new patients with the virus have arrived in her unit, medical students and nurses from other wards have been called in as reinforcements, and strict new precautionary measures have been imposed for hospital staffers.
As the human toll mounts, so too has workplace stress. “Fortunately, we’re a solid team, we can talk about it, and it’s what keeps us going,” says Marie (she declined to provide her last name — France imposes strict limits on civil servants’ right to divulge work-related issues and publicly criticize management). But, she says, “there are some difficult moments.”
Veteran nurses like Marie have seen their fair share of illnesses. But even they have been surprised by how quickly the virus can escalate — an observation shared by health experts from Wuhan to Brooklyn. “We have patients who deteriorate quite suddenly, and we don’t understand why,” she says. “I had a patient I was giving an IV to, we were talking, and a half-hour later I sent him to the ICU. He couldn’t breathe by himself anymore. They intubated him as soon as he got to the ICU. These are moments that aren’t so easy.”
A renewed sense of solidarity and shared purpose has helped Marie and her colleagues get through it. Likewise, she says she appreciates the support from the broader public, including the nightly rounds of applause. Since France’s nationwide lockdown began on March 17, coordinated cheering of health care workers at 8 PM has become something of a ritual — a moment to express common gratitude for those in the field of medicine, but also, at least in densely populated areas, a chance for neighbors to interact with one another from the safety of their own apartment windows.
By several standards, France has appeared to manage the virus comparatively well. National authorities haven’t wavered about imposing stay-at-home measures like in the United States or United Kingdom. And while Germany has offered more tests and recorded fewer deaths, the scale of the tragedy in France hasn’t been nearly as catastrophic as in Italy or Spain. At the same time, however, many French health professionals have expressed concerns about the country’s response to the pandemic. They worry their efforts have been hampered by a lack of both material and human resources — issues workers and their unions have raised for the better part of the past two decades. In some cases, they also worry they’re putting themselves at risk.
“We Start to Ask Ourselves Questions”
When the first patients with coronavirus began arriving in her ward, Marie says nurses were provided with high-quality protective equipment. “We started, at the very beginning, with medical gowns, which are very thick, with gloves, with hairnets, masks, and glasses, and now we’re on very thin disposable gowns, a small plastic smock, glasses — but now they say ‘maybe we need [the glasses], maybe we don’t’ — the hairnet and just a surgical mask.”
Last Friday, weeks into the pandemic, nurses at her hospital were finally provided with newly made protective visors. Still, Marie called the equipment situation worrying: “We feel like we’ve gone from wearing a scuba suit to all of a sudden, you know, just ‘go as you are.’”
Marie adds that nurses in her unit are no longer using one-time thermometers for coronavirus-positive patients as they did at the start of the outbreak. Instead, they’re encouraged to reuse thermometers between rooms. They’re also sharing sphygmomanometers, the devices used to gauge blood pressure. Nurses clean the equipment rigorously, she says, but naturally they worry about making even the slightest mistake.
Still, perhaps the most worrying question related to workers’ equipment is the mask situation. Separate guidelines apply for nurses in intensive care units, but under the latest recommendations from Parisian hospital authorities, most nurses at public hospitals in the French capital are now encouraged to use just two simple surgical masks per shift, replacing their facial protection every four hours. Both the quality and quantity of protection afforded are sources of concern.
For one, surgical masks only protect the wearer from transmitting airborne particles to others. Unlike the FFP2 or FFP3 models — Europe’s equivalent of the N95 in the United States — they do not also protect the mask-wearer from potentially dangerous particles. And while there is no universally accepted standard for the number of surgical masks that nurses should wear when interacting with patients who have tested positive for COVID-19, there is a general consensus that such masks are of very limited use. The World Health Organization, for its part, recommends that anyone wearing a surgical mask — not just health workers — replace it “as soon as it becomes damp.” For those on their feet for hours at a time — not to mention anyone who might take a water break — this is not an uncommon occurrence.
“Naturally, we start to ask ourselves questions,” Marie says of all the equipment changes. “We wonder if the recommendations are linked to studies that have been done that show all these protections aren’t useful . . . or are they linked to the supply?”
Bruno Lamaille, fifty-two, is even more skeptical. An administrative employee who now works as a full-time union representative and general secretary of the General Confederation of Labour (CGT) at Hôtel-Dieu hospital in central Paris, Lamaille also sits on the hospital’s health and safety committee. He says he was taken aback when the director of the hospital informed him of the new mask guidelines in late March.
“I reminded him that I did not condone putting all of my colleagues into danger,” says Lamaille. “When the director of the hospital tells us the guidance is two masks per day, especially in the current conjuncture, it’s clear. You have proof that we have a mask shortage.”
Others have also sounded the alarm at the highest levels of the medical profession and in government. On March 20, Hervé Boissin, head of the safety commission at France’s National Order of Doctors, directly criticized the government for the apparent mask shortage, warning that without proper equipment, “doctors will fall one after the other.” Meanwhile, as investigative news site Mediapart reported, France’s leading public health officials were also privately concerned at the lack of masks available for the general public in the early stages of the outbreak. Just as authorities publicly discouraged people from covering their face when outside, internal communication showed government officials scrambling to take stock of facial protection available in France and rushing to order masks from abroad.
“Overwhelmed by Events”
Lamaille and his fellow CGT union representatives at Hôtel-Dieu also believe there’s a much bigger problem at hand. They say hospitals in Paris that should be treating COVID-19-positive patients are needlessly unprepared to do so — starting with the facility that they know best.
Located on Île de la Cité, just a stone’s throw from Notre Dame in the heart of the French capital, Hôtel-Dieu is one of the world’s oldest continuously operating hospitals, tracing its origins back to the seventh century. However, due to funding woes, it has shuttered many of its services in recent years, including surgical departments and intensive care units, all the while barely managing to keep open its emergency room. Just last year, Paris health authorities finalized the sale of roughly a third of the hospital’s square meterage to a private-sector contractor. Novaxia has promised to fill the space with biotech and medical labs, student housing, and a food court. But in the meantime, Hôtel-Dieu is not treating coronavirus patients — even as union officials insist they could handle the load if allotted the proper resources.
Instead, Hôtel-Dieu has become a COVID-19 testing center. Visitors with symptoms are encouraged to leave samples, only to be rerouted elsewhere if results come back positive. According to the CGT, this plan creates a separate set of hazards, as potentially infected people risk spreading their illness.
“This person who might have tested positive for COVID, we’ve made them go outside, to come to the hospital, and then we tell them to go back home, and then we tell them to leave again to seek care at [another hospital],” says Jean-François Grand, forty-six, a worker who oversees the system of locks and doors across the hospital and also sits on Hôtel-Dieu’s health and safety committee. “You see the problem.”
Grand pins the blame on upper management in the Paris hospital network. Like just about everywhere, authorities are forced to make difficult, high-impact decisions on the fly, but they’re also running into challenges that are rooted in a lack of resources.
“We’re totally behind, we’re overwhelmed by the events, this is something that’s of an incredible scope,” Grand continues. “Today we’re faced with an extremely large pandemic, and they don’t know how to keep the top of the pressure cooker on.”
Paris hospital authorities did not respond to a request for comment.
Reforms, Reforms, Reforms
France’s public hospital system remains one of the best in the world. But as health professionals and the general public alike increasingly acknowledge, it has come under immense pressure in recent years — and, as a result, perhaps isn’t exactly the crowned jewel it used to be.
Since President Jacques Chirac’s time in office, the government has imposed a series of purse-tightening adjustments. There was the 2002 reform that overhauled funding criteria for hospitals, the 2009 reform under Nicolas Sarkozy designed to balance budgets across the system, the 2016 reform under François Hollande that transferred oversight of investment and human resources to new committees in charge of multiple hospitals at once, and the 2019 reform under Emmanuel Macron that enhanced the authority of these new boards.
Along with a reduced stream of state funding, the measures have worked to change the face of the system. Funding limits have forced hospitals to make do with fewer resources, managers have new business-like incentives to show that services under their watch are effective and productive, and health care workers have felt the resulting pinch. Nurses, care aides, and administrative staff aren’t just working under more difficult conditions — but as civil servants, their baseline pay has barely budged in a decade. All of this has come as the number of those seeking care has risen.
“The problem is that politicians and health care workers aren’t on the same wavelength,” says Marie, the Paris nurse. “Clearly, we don’t have the same wishes. They’re looking for savings. They see the financial side, we see the human side.”
One of the most visible effects of the funding crunch is the decline in hospital beds — an especially vital issue today. To be sure, France still measures up relatively well. At 6 hospital beds for every 1,000 residents, according to the Organisation for Economic Co-operation and Development (OECD)’s latest figures, it has a higher rate than both Italy (3.2) and the United States (2.8). But it lags behind neighboring Germany (8 per 1,000 residents), and the trend has only worsened in recent years. As the OECD and European Commission found in a joint report last year, the number of hospital beds in France fell by 15 percent between 2000 and 2018 — while the population grew by 10 percent over the same stretch.
When it comes to intensive care units, the gap is even larger. Before the onset of the crisis, France could point to just 5,500 beds in intensive care units — about five times less than the count on the other side of the Rhine. The shortage of beds became most apparent as the virus began to peak in late March. With France’s Grand Est region reeling from the outbreak, authorities transported around sixty patients across the border to Germany.
“We kind of feel like we’re picking up the pieces,” says a nurse at a ward transformed into a COVID-19 treatment unit at a hospital in Strasbourg, one of the most affected areas in France. “We don’t have enough time to do everything, we don’t have enough time to check on the patients, we don’t have enough time to talk to the patients, we don’t enough time to debrief the new staff that come on.”
“Heroes in White Coats”
“Having other kinds of policies wouldn’t have prevented the virus,” says the nurse who asked to remain anonymous for fear of professional repercussions. “But other kinds of policies would have improved our response.”
It hasn’t been for want of trying. Health care unions have long called for more state funding. And starting in March of last year, emergency room personnel launched a series of strikes and protests that eventually reached nearly 250 different services nationwide. At the core of their demands were salary hikes and major increases in the health budget as a whole. They were ultimately rebuffed, with the Health Ministry instead granting one-time bonuses and agreeing to a more modest funding hike, while refusing to commit to recruit new staff or open more beds.
Given all the stonewalling, some are skeptical of the government’s recent shift in rhetoric on health care. In a speech delivered days before introducing the country’s lockdown last month, President Macron hailed France’s “welfare state” as a “precious resource” and paid homage to the “heroes in white coats.” Later that month, the president yet again showered praise and promised a “massive” investment plan in hospitals at the end of the crisis.
Bruno Lamaille says he’s still waiting on action: “It’d be good if the government could stop this politics of austerity to the detriment of the health system and health professionals.”
A post-coronavirus plan for hospitals commissioned by the president’s office and leaked to the press suggests such an outcome is not imminent. Drawn up by France’s public investment bank, the Caisse des Dépôts, the proposal calls for the state to restructure existing hospital debt, but it also calls for the expanded use of public-private partnerships and further financial support for private clinics and hospitals.
Still, this is an early-stage proposal — and the public appetite for strengthening public services appears as strong as ever. In one recent study charting out the post-virus political landscape, nine in ten said the government should make it illegal to weaken public hospitals, with a plurality favoring “massively expanding” state spending in general “even if it increases the public debt.” A fresh set of proposals jointly issued by unions and environmental groups — including the CGT, Solidaires, Attac, and Greenpeace — underlines the potential for the Left to tap into this renewed interest in collective welfare and wealth redistribution. (It, too, calls for a new government plan to expand public services.) Even beyond the singular question of funding, the pandemic has fueled broader recognition of those deemed “essential” workers and their daily struggles. Like elsewhere around the world, the question is how this translates politically.
Marie pauses when asked about Macron’s choice of words to describe her and her colleagues. “We’re heroes in spite of ourselves,” she says. “He says we’re heroes because we’re his last chance. If health care workers weren’t working, nobody would get out of this.”