Adaptation and Response of a Major Parisian Referral Hospital to the COVID-19 Surge: A Qualitative Study

Since the beginning of the COVID-19 pandemic, few studies have focused on crisis management of multiple services within one hospital over several waves of the pandemic. The purpose of this study was to provide an overview of the COVID-19 crisis response of a Parisian referral hospital which managed the first three COVID cases in France and to analyze its resilience capacities. Between March 2020 and June 2021, we conducted observations, semi-structured interviews, focus groups, and lessons learned workshops. Data analysis was supported by an original framework on health system resilience. Three configurations emerged from the empirical data: 1) reorganization of services and spaces; 2) management of professionals' and patients' contamination risk; and 3) mobilization of human resources and work adaptation. The hospital and its staff mitigated the effects of the pandemic by implementing multiple and varied strategies, which the staff perceived as having positive and/or negative consequences. We observed an unprecedented mobilization of the hospital and its staff to absorb the crisis. Often the mobilization fell on the shoulders of the professionals, adding to their exhaustion. Our study demonstrates the capacity of the hospital and its staff to absorb the COVID-19 shock by putting in place mechanisms for continuous adaptation. More time and insight will be needed to observe whether these strategies and adaptations will be sustainable over the coming months and years and to assess the overall transformative capacities of the hospital.

Did the design and planning of testing and contact tracing interventions for COVID-19 consider social inequalities in health? A multiple case study from Brazil, Canada, France & Mali

The COVID-19 pandemic has led to an unprecedented global crisis. It has exposed and exacerbated weaknesses in public health systems worldwide, particularly with regards to reaching the most vulnerable populations, disproportionately impacted by the pandemic. The objective of our study was to examine whether and how social inequalities in health (SIH) were considered in the design and planning of public health responses to COVID-19 in jurisdictions of Brazil, Canada, France, and Mali. This article reports on a qualitative multiple case study of testing and contact tracing interventions in regions with high COVID-19 incidence in each country, namely: Manaus (Brazil), Montréal (Canada), Île-de-France (France), and Bamako (Mali). We conducted interviews with 108 key informants involved in these interventions in the four jurisdictions, focusing on the first and second waves of the pandemic. We analyzed our data thematically using a theoretical bricolage framework. Our analysis suggests that the lack of a common understanding of SIH among all actors involved and the sense of urgency brought by the pandemic eclipsed the prioritization of SIH in the initial responses. The pandemic increased intersectoral collaboration, but decision-making power was often unequal between Ministries of Health and other actors in each jurisdiction. Various adaptations to COVID-19 interventions were implemented to reach certain population groups, therefore improving the accessibility, availability, and acceptability of testing and contact tracing. Our study contributes to identifying lessons learned from the current pandemic, namely that the ways in which SIH are understood shape how interventions are planned; that having clear guidelines on how to integrate SIH into public health interventions could lead to more inclusive pandemic responses; that for intersectoral collaboration to be fruitful, there needs to be sufficient resources and equitable decision-making power between partners; and that interventions must be flexible to respond to emerging needs while considering long-standing structural inequalities.

Hospital Governance During the COVID-19 Pandemic: A Multiple-Country Case Study

In response to the disruptions caused by COVID-19, hospitals around the world proactively or reactively developed and/or re-organized their governance structures to manage the COVID-19 response. Hospitals' governance played a crucial role in their ability to reorganize and respond to the pressing needs of their staff. We discuss and compare six hospital cases from four countries on different continents: Brazil, Canada, France, and Japan. Our study examined how governance strategies (e.g., special task forces, communications management tools, etc.) were perceived by hospital staff. Key findings from a total of 177 qualitative interviews with diverse hospital stakeholders were analyzed using three categories drawn from the European Observatory on Health Systems and Policies framework on health systems resilience during the COVID-19 pandemic: 1) delivering a clear and timely COVID-19 response strategy; 2) coordinating effectively within (horizontally) and across (vertically) levels of decision-making; and 3) communicating clearly and transparently with the hospital's diverse stakeholders. Our study gleaned rich accounts for these three categories, highlighting significant variations across settings. These variations were primarily determined by the hospitals' environment prior to the COVID-19 crisis, namely whether there already existed a culture of managerial openness (including spaces for social interactions among hospital staff) and whether preparedness planning and training had been routinely integrated into their activities.

Communication and Information Strategies Implemented by Four Hospitals in Brazil, Canada, and France to Deal with COVID-19 Healthcare-Associated Infections

During the COVID-19 pandemic outbreak, COVID-19 healthcare-associated infections (HAI) and risk management became major challenges facing hospitals. Using evidence from a research project, this commentary presents: 1) various communication and information strategies implemented by four hospitals and their staff in Brazil, Canada and France to reduce the risks of COVID-19 HAIs, and how they were perceived by hospital staff; 2) the flaws in communication in the hospitals; and 3) a proposed agenda for research on and action to improve institutional communications for future pandemics. By analyzing "top-down" strategies at the organizational level and spontaneous strategies initiated by and between professionals, this study shows that during the first waves of the pandemic, reliable information and clear communication about guidelines and health protocols' changes can help alleviate fears among staff and avoid misapplication of protocols, thereby reducing infection risks. There was a lack of a "bottom-up" communication channel, while, when making decisions, it is crucial to listen to and fully take into account staff's voices, experiences, and feelings. More balanced communication between hospital administrators and staff could strengthen team cohesion and lead to better enforcement of protocols, which in turn will reduce the risk of contamination, alleviate the potential impacts on staff health, and improve the quality of care provided to patients.

Responses to Hospital Restrictions on Family Visits during the COVID-19 Epidemic in Mali and France

Few studies have focused on the presence of families in the hospital in the context of an epidemic. The present study aims to contribute to filling this gap by answering the following question: How did professionals, patients and their families cope with more or less drastic restrictions to family visits and presence during the COVID-19 pandemic in a French and a Malian hospital during the COVID-19 pandemic? Data were collected during the first two waves of the pandemic through 111 semi-structured interviews (France = 55, Mali = 56). Most of the interviews were conducted with staff (n = 103), but also with families in the case of Mali (n = 8). The investigators also conducted 150 days of field observations, 44 in France and 106 in Mali. Thematic analysis was applied using an inductive approach. Interviews were content analyzed to identify passages in the interviews that were relevant to these different themes. The study highlighted the difficulty for the medical-clinical system to provide appropriate responses to the many emotional needs of patients in a pandemic context. Families in France benefited from a support service to reduce stress, while in Mali, no initiative was taken in this sense. In both countries, families often used the telephone as an alternative means of communicating with relatives. The results showed that in the two contexts, the presence and involvement of the families contributed to a better response to the patients' psycho-affective demands and thus promoted resilience in this field.

Considering social inequalities in health in COVID-19 response: insights from a French case study

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation.

Interprofessional exchanges during COVID-19 at the Bichat Claude-Bernard Hospital: insights for research

The management of the COVID-19 epidemic has disrupted the organization of healthcare in hospitals. As part of a research project on the resilience of hospitals and their staff to the COVID-19 pandemic (HoSPiCOVID), we have documented their adaptation strategies in five countries (France, Mali, Brazil, Canada, Japan). In France, at the end of the first wave (June 2020), a team of researchers and health professionals from the Bichat Claude-Bernard Hospital organized focus groups to acknowledge these achievements and to share their experiences. One year later, further exchanges were held to discuss and validate the research results. The objective of this short contribution is to describe the insights of these interprofessional exchanges conducted at the Bichat Claude-Bernard Hospital. We show that these exchanges allowed: 1) to create spaces for professionals to speak, 2) to enrich and validate the data collected through a collective acknowledgment of salient aspects related to the experiences of the crisis, and 3) to account for the attitudes, interactions, and power dynamics for these professionals in a crisis management context.

How resilience affected public health research during COVID-19 and why we should abandon it

Resilience has accompanied the COVID-19 pandemic as a rallying motto, with calls by governments for a resilient society, resilient families and schools, and, of course, resilient healthcare systems in the face of this unprecedented pandemic shock. Resilience had already gained traction as an analytical concept in public health research for approximately a decade. It became a key concept despite the recognition of its lack of conceptual consistency. The COVID-19 pandemic presented itself as a perfect test-case and encouraged a multiplicity of studies on resilience and health care systems. In this commentary, we add to the existing critiques of resilience in the social sciences by reflecting on the effects of resilience when used to frame empirical inquiries and to draw lessons from the crisis. Resilience as a concept is unable to address crucial structural issues that health systems already faced throughout the world, and it remains a non-neutral political notion. We argue that we need to resist a generalised view of resilience and work with alternative imaginaries.

Radiothérapie et lutte contre les cancers : défis de maintenance de l’unique accélérateur linéaire à l’Hôpital du Mali

Cancer incidence and mortality rates are increasing in West Africa. Cancer is a recent discipline in Mali and the means available to treat patients are insufficient. Mali has only one radiotherapy machine for the country and its malfunctions are regularly reported in the media. In order to understand the recurrent dissatisfactions linked to access to radiotherapy in Mali, we retraced the history of this machine and described its functioning. Based on semi-directive interviews with patients’ associations and health professionals involved in cancer care in Bamako, we describe how radiotherapy in Mali reveals global health issues through the intervention of numerous international cooperations. In addition, based on data collection from medical registers and institutional reports, we report that the average time to get a radiotherapy appointment is 3 to 6 months in Mali, but also that the radiotherapy machine has experienced 198 breakdowns between April 3, 2014 and September 24, 2021, which represents more than 54 weeks of cumulative downtime. Radiotherapy is a crucial element in the treatment of cancer and the lack of access to this treatment worsens the vital diagnosis of patients. While the Malian government is committed to universal health coverage reforms, strengthening cancer treatment facilities should also be considered a public health priority for Mali.

Are there reasons behind high Handrub consumption? A French National in-depth qualitative assessment

Background

Hand hygiene (HH) is the most important measure for preventing healthcare-associated infections. A significant correlation between alcohol-based handrub consumption (AHRC) and observed HH compliance rates has been established. In France, publicly reported AHRC displayed a large heterogeneity across healthcare facilities (HCFs). We aimed to describe programmes for promoting HH in the top and medium AHRC scorers and to assess factors and drivers leading to a high AHRC score in a panel of French HCFs.

Methods

We performed a nationwide qualitative comparative case study based on in-depth semi-structured interviews in 16 HCFs with high, 4-year AHRC scores, and a sample of seven university hospitals (UHs) with medium AHRC scores. Infection Prevention and Control Team (IPC) members (n = 62), quality managers/chief executive officers (n = 23) and frontline workers (n = 6) were interviewed, using a grounded theory approach and an iterative thematic approach.

Results

Ninety-one interviews were performed. There was a large heterogeneity in IPC structures and objectives, with specific patterns associated with high AHRC that were more organisational than technical. Four areas emerged: (1) strong cohesive team structure with supportive and outcome-oriented work attitude, (2) IPC structure within the organization, (3) active support from the institution, (4) leadership and role model. Among high AHRC scorers, a good core IPC organisation, a proactive and flexible management, a frequent presence in the clinical wards, and working in a constructive safety climate were prominent.

Conclusion

We highlighted that IPC structure and activity is heterogeneous, with organisational and behavioural characteristics associated with high AHRC score. Beyond technical challenge, our work underlines the importance of strong structure of the IPC and behavioural approaches in implementing key IPC programmes.

Lessons Learned From the Resilience of Chinese Hospitals to the COVID-19 Pandemic: Scoping Review

Background

The SARS-CoV-2 pandemic has brought substantial strain on hospitals worldwide; however, although the success of China’s COVID-19 strategy has been attributed to the achievements of the government, public health officials, and the attitudes of the public, the resilience shown by China’s hospitals appears to have been a critical factor in their successful response to the pandemic.

Objective

This paper aims to determine the key findings, recommendations, and lessons learned in terms of hospital resilience during the pandemic; analyze the quality and limitations of research in this field at present; and contribute to the evaluation of the Chinese response to the COVID-19 outbreak, building on a growing literature on the role of hospital resilience in crisis situations.

Methods

We conducted a scoping review of evidence on the resilience of hospitals in China during the COVID-19 crisis in the first half of 2020. Two online databases (the China National Knowledge Infrastructure and World Health Organization databases) were used to identify papers meeting the eligibility criteria. After extracting the data, we present an information synthesis using a resilience framework. Articles were included in the review if they were peer-reviewed studies published between December 2019 and July 2020 in English or Chinese and included empirical results pertaining to the resilience of Chinese hospitals in the COVID-19 pandemic.

Results

From the publications meeting the criteria (n=59), we found that substantial research was rapidly produced in the first half of 2020 and described numerous strategies used to improve hospital resilience, particularly in three key areas: human resources; management and communication; and security, hygiene, and planning. Our search revealed a focus on interventions related to training, health care worker well-being, eHealth/telemedicine, and workplace organization, while other areas such as hospital financing, information systems, and health care infrastructure were less well represented in the literature. We also noted that the literature was dominated by descriptive case studies, often lacking consideration of methodological limitations, and that there was a lack of both highly focused research on specific interventions and holistic research that attempted to unite the topics within a resilience framework.

Conclusions

We identified a number of lessons learned regarding how China’s hospitals have demonstrated resilience when confronted with the SARS-CoV-2 pandemic. Strategies involving interprovincial reinforcements, online platforms and technological interventions, and meticulous personal protective equipment use and disinfection, combined with the creation of new interdisciplinary teams and management strategies, reflect a proactive hospital response to the pandemic, with high levels of redundancy. Research on Chinese hospitals would benefit from a greater range of analyses to draw more nuanced and contextualized lessons from the responses to the crisis.

[Innovations in medical waste management in a new referral hospital in Niamey, Niger]

INTRODUCTION

Public hospitals in Africa are experiencing major organizational dysfunctions, which are particularly acute in waste management. The opening of a new reference hospital in Niamey offers the opportunity to study the implementation of an innovative waste management system.

PURPOSE OF RESEARCH

The objective of this study was to document the agents’ representations, practices, and construction of waste management standards in a new tertiary hospital in Niamey. We sought to study the implementation of innovative materials in waste management and the progressive construction of protocols, habits, and levers of adaptation. This research was carried out using a socio-spatial approach and essentially mobilized the tools of qualitative investigation.

RESULTS

Our study highlighted that a hospital waste management culture is progressively established, thanks to an effort to plan activities, to promote the sector, the activities and the emergence of a profession organized around waste management. However, the distinct waste management sectors are struggling to stabilize due to the differentiated statuses and perceptions of the agents. Finally, the success of hospital waste management depends on waste collection at the city level.

CONCLUSIONS

The Niamey referral hospital is intended to be an infrastructure of excellence, a showcase for neighboring countries. In this respect, our study shows that it is crucial to invest in planning, the enhancement of the profession and the recognition of all the agents involved in waste management.

Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali)

BACKGROUND

All prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems.

METHODS

We will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available.

DISCUSSION

We will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

In the era of humanitarian crisis, young women continue to die in childbirth in Mali

Maternal mortality occurs mostly in contexts of poverty and health system collapse. Mali has a very high maternal mortality rate and this extremely high mortality rate is due in part to longstanding constraints in maternal health services. The central region has been particularly affected by the humanitarian crisis in recent years, and maternal health has been aggravated by the conflict. Sominé Dolo Hospital is located in Mopti, central region. In the last decade, a high number of pregnant or delivering women have died in this hospital.

We conducted a retrospective and exhaustive study of maternal deaths occurring in Mopti hospital. Between 2007 and 2019, 420 women died, with an average of 32 deaths per year. The years 2014–2015 and the last 2 years have been particularly deadly, with 40 and 50 deaths in 2018 and 2019, respectively. The main causes were hypertensive disorders/eclampsia and haemorrhage. 80% of these women’s deaths were preventable. Two major explanations result in these maternal deaths in Sominé Dolo’s hospital: first, a lack of accessible and safe blood, and second, the absence of a reference and evacuation referral system, all of which are aggravated by security issues in and around Mopti.

Access to quality hospital care is in dire need in the Mopti region. There is an urgent need for a safe blood collection system and free of charge for pregnant women. We also strongly recommend that the referral/evacuation system be reinvigorated, and that universal health coverage be strengthened.

Prevention and care of hepatitis B in the rural region of Fatick in Senegal: a healthcare workers' perspective using a mixed methods approach

Background

In countries where hepatitis B virus (HBV) is endemic, including Senegal, the World Health Organization recommends systematic HBV screening of pregnant women and vaccination at birth to prevent mother-to-child transmission (MTCT). This study investigated healthcare workers’ (HCW) knowledge and practices regarding HBV prevention and care in the rural region of Fatick in Senegal, as well as challenges they faced in implementing prevention activities related to HBV MTCT.

Methods

A mixed-methods survey was conducted between May–July 2017 among 112 HCW working in 15 healthcare facilities in two districts of the Fatick region using face-to-face questionnaires and semi-structured interviews. Descriptive statistics and chi-square/Mann-Whitney tests were used to analyze quantitative data, while qualitative data were analyzed thematically.

Results

The study population included 87 HCW in the quantitative component (83% women, median age [interquartile range, IQR] = 35 [31–40] years) and 11 in the qualitative component. A knowledge gap was observed in key areas of HBV infection: only 24, 51 and 38%, respectively, correctly reported that early HBV acquisition is associated with a high risk of developing chronic infection, that perinatal transmission is one of the main modes of HBV transmission in Senegal, and that three to four doses of HBV vaccine are required to ensure immunization in children. Despite good acceptability of systematic screening of pregnant women and vaccination at birth, only 48% of HCW mainly involved in prenatal care and 71% of those involved exclusively in vaccination routinely performed these two key interventions. HCW reported several structural barriers that may hinder their implementation: a lack of training in HBV and in counseling, poor availability of rapid diagnostic tests (RDT), high costs of both screening and treatment, a lack of adequate information on treatment options and missed opportunities for vaccination at birth.

Conclusions

HCW working in the Fatick region may be insufficiently trained and supported to effectively implement HBV prevention strategies. Our findings suggest an urgent need to strengthen MTCT prevention in this region, by improving HCW knowledge in key areas of HBV infection, providing RDT and antiviral treatment at low cost, and enhancing community-based interventions for the timely vaccination of newborns.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4416-3) contains supplementary material, which is available to authorized users.

Conceptual analysis of health systems resilience: A scoping review

System resilience has long been an area of study, and the term has become increasingly used across different sectors. Studies on resilience in health systems are more recent, multiplying particularly since the 2014 Ebola epidemic in West Africa. The World Health Organization (WHO) is calling for national governments to increase the resilience of their health systems. Concepts help define research objects and guide the analysis. Yet, to be useful, concepts need to be clear and precise. We aimed to improve the conceptual understanding of health systems resilience by conducting a scoping review to describe the state of knowledge in this area. We searched for literature in 10 databases, and analyzed data using a list of themes. We evaluated the clarity and the precision of the concept of health systems resilience using Daigneault & Jacob's three dimensions of a concept: term, sense, and referent. Of the 1091 documents initially identified, 45 met the inclusion criteria. Term: multiple terms are used, switching from one to the other to speak about the same subject. Sense: there is no consensus yet on a unique definition. Referent: the magnitude and nature of events that resilient health systems face differ with context, covering a broad range of situations from sudden crisis to everyday challenges. The lack of clarity in this conceptualization hinders the expansion of knowledge, the creation of reliable analytical tools, and the effectiveness of communication. The current conceptualization of health systems resilience is too scattered to enable the enhancement of this concept with great potential, opening a large avenue for future research.

40 years after Alma-Ata, is building new hospitals in low-income and lower-middle-income countries beneficial?

Public hospitals in low-income and lower-middle-income countries face acute material and financial constraints, and there is a trend towards building new hospitals to contend with growing population health needs. Three cases of new hospital construction are used to explore issues in relation to their funding, maintenance and sustainability. While hospitals are recognised as a key component of healthcare systems, their role, organisation, funding and other aspects have been largely neglected in health policies and debates since the Alma Ata Declaration. Building new hospitals is politically more attractive for both national decision-makers and donors because they symbolise progress, better services and nation-building. To avoid the ‘white elephant’ syndrome, the deepening of within-country socioeconomic and geographical inequalities (especially urban–rural), and the exacerbation of hospital-centrism, there is an urgent need to investigate in greater depth how these hospitals are integrated into health systems and to discuss their long-term economic, social and environmental sustainability.

Screening, diagnosis and care cascade for viral hepatitis B and C in Yaoundé, Cameroon: a qualitative study of patients and health providers coping with uncertainty and unbearable costs

OBJECTIVES

To document patients' and healthcare professionals' (HCP) experiences with hepatitis B virus (HBV) and hepatitis C virus (HCV) diagnosis and care, as well as consequences of these infections on patients' life trajectories in Cameroon, an endemic country in sub-Saharan Africa.

DESIGN

Qualitative sociological study combining in-depth interviews and observations of medical consultations. Interviews and observations transcripts were thematically analysed according to the following themes: circumstances and perceptions surrounding hepatitis screening, counselling and disclosure, information provided by HCP on hepatitis prevention and treatment, experience of access to care and treatment, social/economic trajectories after diagnosis.

SETTING

HIV and gastroenterology/medical services in two reference public hospitals in Yaoundé (Cameroon).

PARTICIPANTS

12 patients affected by HBV and/or HCV (co-infected or not with HIV), 14 HCP, 14 state and international stakeholders.

FINDINGS

Many patients are screened for HBV and HCV at a time of great emotional and economic vulnerability. The information and counselling delivered after diagnosis is limited and patients report feeling alone, distressed and unprepared to cope with their infection. After screening positive, patients struggle with out-of-pocket expenditures related to the large number of tests prescribed by physicians to assess disease stage and to decide whether treatment is needed. These costs are so exorbitant that many decide against clinical and biological follow-up. For those who do pay, the consequences on their social and economic life trajectories are catastrophic.

CONCLUSION

Large out-of-pocket expenditures related to biological follow-up and treatment pose a real challenge to receiving appropriate care. Free or reasonably priced access to hepatitis B and C treatments can only be effective and efficient at reducing the hepatitis disease burden if the screening algorithm and the whole pretherapeutic assessment package are simplified, standardised and subsidised by comprehensive national policies orientated towards universal healthcare.

Viral Hepatitis and a Hospital Infrastructure in Ruins in Cameroon

Ethnographic material dealing with the contemporary viral hepatitis B and C epidemics in Cameroon provide a window onto the acute constraints and shortcomings of hospital care for patients, families, and health care workers. Although viral hepatitis has long been an invisible epidemic in international and global public health regimes, in Cameroon, it is diagnosed, made visible, and felt as a financially daunting and feared disease. Building on Ann Stoler's framework of imperial ruins, I consider hepatitis as an iatrogenic disease, emerging from scarce and unsound hospital infrastructures, such as blood transfusion techniques, as well as colonial public health vaccination practices. Such hospital technologies continue to produce anxieties, risk and excessive health expenses and hence cast their shadows on the future.

Rationing hepatitis C treatment in the context of austerity policies in France and Cameroon: A transnational perspective on the pharmaceuticalization of healthcare systems

New powerful drugs against hepatitis C can cure the disease, but they are not widely distributed because their exorbitant prices are destabilizing healthcare systems in both African and European countries. This article takes access to hepatitis C treatments since 2013 in France and in Cameroon as a lens to analyze the rationing of pharmaceutical treatments in relation to recent transformations of health systems. Access to these treatments is analyzed thanks to ethnographic observation and interviews lead in Paris and Yaoundé, with patients, associations, health professionals and public health experts. In Cameroon, rationing takes place through various layers of socio-economic restrictions, and no patient organization advocates for hepatitis treatment. In France, access to hepatitis C treatments has become politicized, and collective mobilizations have denounced rationing as a threat to the promise of universal social security. In this study, we examine Africa's long experience with rationing in the context of structural adjustment, and we bring together experiences in France and Cameroon. This article analyses the phenomenon of the pharmaceuticalization of healthcare systems, that is to say the growing use of pharmaceuticals in healthcare systems, by documenting the social and political construction of scarcity. Indeed, whereas pharmaceuticalization is a concept that has often been used in situations of drugs abundance, a parallel analysis of rationing highlights a political economy of pharmaceuticals that shapes public health debates and policies according to an economy of scarcity, especially in times of austerity.