Jean-Philippe Spano — In the area of health, are the challenges of today – and of tomorrow – similar in France and in the United States?
Jean-Charles Soria — Absolutely. The two countries are asking the same questions. How can innovation be handed on to patients? How can we ensure that this innovation benefits everybody, including the most in need? How can we achieve this when, in both countries, the hospital system is going through a profound crisis? It has to be said at the same time that France and the United States are not the only ones to be confronted by this situation: the crisis in the hospital system is global and was amplified by the Covid epidemic. Finally, what can be done to make sure that people do not have a selective view of this innovation? When, for example, it is a matter of limiting the effects of ageing, everyone is favourable to innovation. But when it’s a question of developing vaccines, many arguments rise to the surface …
J.-Ph. S. — You are right to recall that the crisis is not limited to one country or one continent. It is, in effect, global, which implies that there already existed underlying phenomena that Covid served to highlight. The problems that you mention are firstly of an organisational nature: problems of medical and also paramedical staffing levels – I am thinking in particular of the penury of nurses. This phenomenon was accentuated, in the United States as in France, by the flight of many professionals who are leaving the medical world for other sectors. Curiously, the United States is affected in the same way although it devotes more financial resources to health. You underlined something very important: the loss of citizens’
trust in science and medicine. How can we bring back confidence in a context marked by the publication left, right and centre, especially on social media, of information that is worrying and sometimes – as we saw during the Covid epidemic – disparate and contradictory? We see this for vaccination. How can it be that two countries that are so developed in this area have a vaccination rate so insufficient for various illnesses? I am thinking, for example, of the concerns about the vaccine against the papillomavirus, without even talking of the doubts that some French and Americans felt and still feel with regard to vaccination against Covid.
J.-C. S. — We shall come back to all these questions but, firstly, as regards the hospital crisis, I fully share your opinion: Covid did not cause this crisis. The epidemic was more the straw that broke the camel’s back. Hospitals suffered, in effect, before the upsurge in Covid, from structural problems: organisation, financing, attractiveness of the profession … Before, the health system relied on the self-denial of professionals. You practised medicine as a calling, forgetting yourself and giving yourself fully to others.
It is true that today in the United States, doctors and nurses are better paid than in France. And yet, the crisis of what is called ‘the great migration’ is every bit as real. A recent article in Time magazine revealed that last year 110,000 doctors had left the health sector. That is also the case for several hundred thousand nurses. This crisis in the United States is on a very great scale. It led firstly to the closure of certain community hospitals of small size that did not reach the critical mass. Many other establishments find themselves today in an extremely difficult situation because they could not increase all nurses’ salaries uniformly and were forced to close entire services. They had no other choice but to call on temporary workers – doctors, nurses, auxiliaries or physiotherapists
– who are sometimes paid twice as much as salaried staff.
This phenomenon may have momentarily made up for the lack of nursing staff, but it contributed to feeding the crisis since those who had stayed asked themselves: ‘Why should I stay loyal to my department or my hospital? I would do better doing replacements.’ Be that as it may, the crisis grew and many care structures – I am not just talking about hospitals, but also about retirement homes or centres for follow-up care – only continue to function thanks to these substitute staff. If this system continues for another one or two years, they will be obliged to shut up shop. The consequence is a deterioration in the quality of care. In addition, because of the closure of some services, waiting times will lengthen.
As I said, new generations, in particular those that are called in the United States millennials and Generation Z, attach real importance to quality of life and balance between their personal and professional lives. In my personal opinion, even when these young people decide to become nurses, auxiliaries or doctors that some may reject the idea that the profession justifies all sorts of sacrifices. They may want to be closer to the way of life of other professions.
Finally, the last element that feeds the unease in the health sector is the value that is attributed to the health of each of us. Societies will have to reflect seriously on this question.
J.-Ph. S. — At the beginning of our conversation, we talked about the subject of innovation. How can that bring a solution to some of the problems that the medical world faces today?
J.-C. S. — You have to distinguish between two aspects. On the one hand, innovation in medical-scientific content, that is to say the advances in science and medical and surgical techniques; and, on the other, innovation in the organisation of the health system. Artificial intelligence no doubt constitutes one of the responses to current challenges. We have dictation software that is exceptional and permits the production, for example, of documents of a very great quality. We also have artificial intelligence algorithms that might be able to improve the questions asked of the patient before the first doctor-patient interaction, to grasp better his problem and improve the treatment. For example, when the patient is an isolated person, without children, without friends, the artificial intelligence system immediately highlights these elements: a note of caution, in such a case, that it is necessary to put in place a somewhat closer follow-up.
To get back to science, I should like to stress the extraordinary acceleration of technological and medico-scientific advances that permanently arise to question the manner of organisation of the health system, whatever the speciality. The cancerology of the 1940s until the end of the 1990s was always the same: surgery, rays and chemotherapy. But, since, surgery has been totally revolutionised by mini-invasive techniques, robots, video-assistance and ambulatory surgery. Radiotherapy has made huge leaps as well. As for systemic treatments, we have gone from pure chemotherapy to targeted therapies, hormonotherapy, immunotherapy or cellular therapy … J.-Ph. S. — I agree. In daily practice, artificial intelligence can help to improve the treatment of the patient and better respond to his expectations. Especially by speeding up the diagnosis and the definition of a therapeutic strategy.
Having said that, one gets the impression, listening to you, that the technology is a Ferrari and the organisation the engine of a Citroën 2CV. What solutions do you advise?
J.-C. S. — On the one hand, the digital revolution has to penetrate hospital walls. Why should it be easier to order a pizza with a mobile than to manage the orders of medicines and patient requests? I know that there are very innovative Franco-American companies that are currently working on projects. Some American hospitals have decided to equip nurses with modern telephones instead of pagers that serve no purpose. You can give the patient the portable number for the nurse responsible for him. With this system, instead of disturbing everybody, the nurse concerned is directly approached. Health structures must be able to use the opportunities offered by digital tools and artificial intelligence. There exist today big Franco- American companies that are the jewels of artificial intelligence and that benefit from the excellence of French mathematics. France is in effect the country that has the greatest number of Fields Medals. Even if technological progress is especially being made on this side of the Atlantic, there is a real synergy in this area between France and the United States.
The other side to innovation is exactly what you said: more autonomy must be given to health system players. On this point, I must say that the United States, where many experiments are being conducted on a local and regional scale, is more advanced than France. Without putting into question the control exercised by regional health agencies, France could perfectly easily create wider spaces of liberty which could take the form of a contract. Some hospitals, some independent surgeries, some health centres could be authorised to bring in changes to their organisation without having to seek permission from the authorities. All this would, of course, be conducted within a precise framework – which does not have to be very restrictive – and the results assessed after two years.
J.-Ph. S. — In effect, the autonomy of some centres or hospital groups could be a solution on the model of the autonomy of universities.
There are two other themes that I should like us to mention. First of all, the question of databases – a subject that you know well. One has the impression that, in the United States, the system is much more flexible and more accessible than in France. This is less true in the domain of oncology where we have recently put into place the celebrated Onco Data Hub in partnership with Unicancer centres and some hospital centres. How could we benefit from a greater opening to American databases, which we know can be very useful in the construction of algorithms stemming from artificial intelligence?
J.-C. S. — It is clear that France has some extraordinary assets since, because of national health insurance, it has national databases, which is not the case in the United States where there are just a few health insurance sectors – such as Medicare or Medicaid – which concern only certain parts of the population. And yet, these extremely rich French databases – which are regional, national and hospital- based – are subject to a law which is not French, but European, the GPDR. The aim of European lawmakers was to protect individuals by preventing their data from being used without authorisation and spread all over the world. The problem is that the protection of personal data is subject to an extremely restrictive interpretation which, in reality, betrays the spirit for the letter and encloses France in a sort of straitjacket. I must admit that I have no obvious solution except for a commitment by politicians in favour of an easing of the rules.
J.-Ph. S. — This is a magnificent example of an area where France can seek inspiration in the American experience and vice versa. Let’s end on two other aspects.
In medical research, is France on the case? There again is the problem of reorganisation, attractiveness and the lack of an overall strategic vision. There is one point which apparently functions better in the United States than in France: the financing of research. The American system, through partnerships between private and public entities, between the academic world and industry, allows the mobilisation of much more substantial means. In France, as you said, there are excellent researchers, excellent doctors, thinking heads, but the nub of the battle, the money needed to advance, is lacking.
J.-C. S. — This is a very interesting question. Scientific research, and medical research in particular, is seen in the United States as a major source of job creation. It is this research that will allow the emergence of new companies in the biotechnology, med-tech and biotech sectors and also big pharmaceutical laboratories and big national institutes. The United States has decided that health is a major subject. It has a National Institute of Health with different branches that are very well equipped. Governments have turned research into a national sovereignty issue. The fact that the United States could produce vaccines while France, the country of Pasteur and of jewels of the pharmaceutical industry like BioMérieux or Sanofi, was incapable of doing so is a troubling indicator.
J.-Ph. S. — Fortunately, there was Moderna Therapeutics, which is French finally because it is headed by a Frenchman …
J.-C. S. — Moderna is not a French company, but an American company, founded in the United States with technology developed in several places in the world. But, in effect, its CEO, Stéphane Bancel, is French. Similarly, the Frenchwoman Emmanuelle Charpentier who, in 2020, received the Nobel Prize for Chemistry with Jennifer
A. Doudna for the development of the ‘genetic scissors’ CRISPR- Cas9, completed part of her studies in the United States and founded a Swiss-American company to take advantage of the results of her research.
The French political class must understand the strategic value of research. We do not carry out research for the sake of it. From a societal point of view, research leads to discoveries that improve people’s lives and that also lead to the creation of companies and wealth. In the United States, applications for patents and the creation of companies are strongly encouraged. In France, by contrast, it is very difficult for a university professor and hospital practitioner to obtain an authorisation to set up their own company. There again, the American example could be useful.
J.-Ph. S. — As you rightly stressed, Franco-American cooperation exists with laboratories such as BioMérieux which have been in the United States since 1988, with a first establishment in Saint-Louis, Missouri. There is also collaboration between Sanofi and Pasteur and the American government. This is a positive feature, but it is not enough.
J.-C. S. — If I can permit myself a final comment, it is necessary to understand that in terms of innovation and medical research, Franco-American cooperation has been extremely productive and remains very close. It must not be forgotten that, until World War II, all the great American doctors used to come to train in France. The main schools of neurology, cancerology, infectious diseases or internal medicine were French. After that, impoverishment due to World War II and the huge technological boom led to a levelling-up. Today, it is the French élites that go to train in the United States. French medicine, however, remains very respected and medical and scientific collaboration between the two countries continues at a high level. This has permitted the acceleration of many discoveries, including for some infectious illnesses such as AIDS. As for Covid, even if the vaccines were not developed in France, France contributed in a very meaningful way to the understanding of this illness. French doctors were the first to understand that Covid killed largely because of a huge surge of inflammation in the immune system. They alerted their American counterparts very early on through many video-conferences on the gravity of the pandemic, especially on the fact that, apart from the acute state, there was perhaps a stage of underlying chronic inflammation. To come back to oncology, I would add that very important programmes have been set up between the big pharmaceutical firms and the National Cancer Institute in France with a view to developing anti-cancer agents.
J.-Ph. S. — Effectively, there is already, and fortunately, cooperation at several levels – industrial as well as academic – between France and the United States. There is also a Franco-American mixed committee for cooperation in science and medicine under the aegis of the Higher Education and Research Ministry which organises – most recently under Frédérique Vidal, who was minister in 2021
regular exchanges around the themes we have mentioned. What else needs to be done to improve Franco-American cooperation and especially to respond together to the challenges of tomorrow?
J.-C. S. — I should like to come back to a major issue of which we talked at the beginning of this conversation. We have been witnessing for some years a very worrying concern: the loss of trust, as much in France as in the United States, in the classic actors of the scientific world. Today, the word of a great world expert who has devoted 50 years of his life to becoming what he is counts for as much as that of someone who has 50,000 followers on Twitter and who has never studied the subject. How can Franco-American cooperation help specialists to regain citizens’ trust? This trust will not return because governments or medical structures have made great statements. It will return if our children, who live in that world, manage to become the loudspeakers of reason and help eradicate false information. The solution will come from basic users, who have no medical or scientific knowledge, but who succeed in finding warning mechanisms capable of distinguishing the true from the false. There is there, I believe, a very tempting reflection to be conducted on both sides of the Atlantic.