Medical cannabis could soon get the green light in France after unprecedented trial

During a years-long experiment that ended on Tuesday, French health authorities gave patients suffering from serious illnesses the chance to use prescribed medical cannabis. As France prepares to put cannabis-based medicines on the market, patients look back at their experience of the trial.

Patience is a virtue. But when faced with indescribable pain on a daily basis, being virtuous is not the priority. At least it isn’t for Valérie Vedere, who was diagnosed with HIV in 1992 and then throat cancer in 2012.

“To appease the burning sensation I get from radiotherapy, I use cannabis therapeutically,” the 58-year-old living in Bordeaux says. “But I also experience pain from antiretroviral treatments for HIV.”

“It’s as if my hands and feet are being squeezed in a vice, which can lead to extreme burning and tingling sensations. I also have muscle spasms that generally take place at the end of the day,” Vedere explains. Her chronic pain is something that can’t be treated with painkillers like tramadol or other opioids. “It’s not suitable for the long-term,” she says.

When France launched a nationwide experiment to test the use of medical cannabis for patients with serious illnesses three years ago, Vedere was determined to participate.

“I had already been using cannabis to ease my symptoms illegally. Now, I would be able to use it legally and have consistent follow-ups with my doctor,” she says. After persuading her doctor that she was a perfect candidate for the trial, she finally became a participant in May 2021 – two months after the experiment was launched.

A leap in the direction of legal medical cannabis

The first results of the trial came trickling in two years later, in 2023. Patients felt their symptoms had improved significantly, with no unexpected side effects. No cases of substance abuse or addiction had been reported.

“Our evaluations show that between 30 and 40 percent of symptoms like pain, spasms, quality of life or epileptic seizures for example, have improved significantly,” says Nicolas Authier, a doctor specialised in pharmacology, addiction and pain who is also the president of the scientific committee tasked with monitoring the medical cannabis trial.

Preparations to make prescribed cannabis-based medicines more readily available, including in pharmacies, are now under way for 2025.

Read moreFrance launches public consultation on legalising cannabis

“Cannabis-based medicines are currently dispensed in hospitals or in hospital pharmacies, but in the long-run, most of them will become available in regular pharmacies much like any other drug,” says Authier.

The French National Agency for the Safety of Medicines and Health Products (ANSM) has until the end of the year to authorise approved cannabis-based products for medicinal use. Those products will then be granted temporary approval for five years – with scope for them be renewed indefinitely – pending a decision by European authorities to market the drugs.

Until then, the patients who were part of the trial will continue to have access to cannabis-based medicines. But as of Wednesday March 27, no new participants are able to join the trial.  

A total of 3,035 people took part in the unprecedented experiment and 1,842 are still receiving treatment today.

An unprecedented experiment

Before the trial was first launched across 275 health facilities in the country, a committee of interdisciplinary scientists – consisting mostly of healthcare professionals and patients – was set up. Together, they defined the conditions under which the experiment would be rolled out, what medicines would be used, the training pharmacists and doctors would receive, how patients would be monitored and the information they would receive.

Health authorities then allowed limited prescriptions for people suffering from five specific conditions: neuropathic pain, some drug-resistant forms of epilepsy, intense oncology symptoms related to cancer or cancer treatment, palliative situations and pathologies that affect the nervous system, like multiple sclerosis.

Patients were only prescribed cannabis-based medicines if available treatment was found to be insufficient, or if they presented an aversion to existing drugs.

Mylène, who is 26 and lives in Paris, has tried a cocktail of medications to combat her cephalgia – a condition that results in recurring and extremely painful headaches. “They are brutal. The pain is permanent, seven days a week. I haven’t had a break since they started in 2014,” she says. “And sometimes I get a particularly painful attack, and it’s as if two cinder blocks are being pressed against my head.”

“I tried all kinds of treatment. Paracetamol, ibuprofen, opioids like tramadol and even morphine. Either the medicine wouldn’t have an effect on me or the side effects were too intense,” the young radiologist explains. “I joined the trial in late December 2023 and started taking medical cannabis droplets morning and night. It’s almost been three months and I am already starting to feel relief. I feel a change that’s really starting to take effect.”

Depending on their condition, patients were given medical cannabis either in oil or dried flower form. Oil droplets were generally taken orally, while dried flowers were inhaled in vaporisers to prevent the potential health risks from burning the plant.

Cannabis-based medicines can have varying degrees of THC and CBD, the two main compounds unique to the cannabis plant, known as cannabinoids. While THC is its primary psychoactive compound, responsible for the typical weed high consumers can feel, it is most efficient in tackling pain. CBD, the second most prevalent compound in cannabis or cannabinoid, is still psychoactive but doesn’t have the same intoxicating effect as THC.

“The majority of patients were given cannabis-based medicines in oil form, which is the treatment that has the longest lasting effect,” Authier explains. “But oil droplets don’t prevent peaks of severe pain that can only be relieved by fast-acting medication … so sometimes we added dried cannabis flowers that patients could inhale using a vape. The effects don’t last very long but are very rapid.”  

However, in February 2024 the ANSM decided to stop prescribing medical cannabis in flower form.

“I wasn’t at the mediation meeting when the decision was taken so I can’t say for certain why,” says Authier. “It seems that the medical cannabis flower looks too similar to the illicit cannabis flower consumed for [recreational] purposes. So that could cause confusion and perhaps spark fears of a potential black market.”

“It’s all very debatable,” Authier adds, unconvinced.

For Vedere, both the oils and flowers are “indispensable”. Angered with the decision to stop prescribing medical cannabis in this form, she wrote an open letter to the French health ministry demanding an explanation.

“I don’t want to take opioids. And when I have sudden attacks of pain, the flowers are the only thing that relieve me,” says Vedere. “So I will just have to continue using the oil that I’m prescribed. As for the flowers, I’ll buy them illegally.”

Based on the five medical conditions that warrant this type of treatment, Authier estimates that between 150,000 and 300,000 people in France could be prescribed cannabis-based medicines, meaning that an entire industry has been holding its breath for the roll-out of the drugs.

While suppliers of the cannabis-based medicines used in the years-long trial were Israeli, Australian and German companies – those tasked with distribution were French.

Along with Germany, France could become the biggest market for medical cannabis in Europe, according to French daily Le Monde.

But despite the promise of a booming market, introducing these drugs to the French market and even getting the trial off the ground has been anything but a bed of roses.

The bad rep of cannabis in France

A few days ago, while attending a Senate hearing on the impact of drug trafficking in France, Finance Minister Bruno le Maire reiterated his position that the decriminalisation of cannabis was a no-go.

“Cannabis is cool and cocaine is chic. That is the social representation of drugs,” he said. “But in reality, the two are poisons. They are both destructive and contribute to the undermining of French society as a whole.”

Despite France being one of the biggest cannabis consumers in Europe, it also has some of the toughest laws against the drug. THC is still classified as a narcotic in France, with the maximum level permitted in any cannabis plant limited to 0.3 percent. CBD is legal as long as the cannabis plant does not exceed the permitted levels of THC.

There is still a lot of stigma around cannabis in France, even though public opinion on its medical use is hugely encouraging. According to a 2019 survey by the national Observatory for Drugs and Addictive Tendencies, 91 percent of French people say they are in favour of doctors prescribing cannabis-based medicines “for certain serious or chronic illnesses”.

Read moreCannabis in France: Weeding out the facts from the fiction

Still, attitudes around the plant are difficult to shift. “It’s impossible to completely shake off the stigma attached to the word cannabis, which is associated with narcotics. So we had to make a real effort to reassure [the medical community] throughout the experiment,” says Authier.

When it comes to medicinal cannabis, politicians and public health officials in France have expressed their concerns through two key arguments. First, that the roll-out of these medicines would be too expensive. And second, that the legalisation of medicinal cannabis will inevitably lead to the legalisation of its recreational use.

“Our objective has always been accessibility. Ensuring that patients have access to these medicines and that doctors prescribe them,” Authier counters. “It was never, as some like to believe, a Trojan horse move to then legalise recreational cannabis. That has absolutely nothing to do with our trial. Opium-based medicines exist without heroin being legalised.”

“We had to deal with some rather dogmatic opinions and deconstruct a lot of beliefs or language to be taken seriously,” he confesses.

The first place to ever legalise medical cannabis was California, in 1996. Colorado followed suit four years later in 2000, then Canada in 2001, the Netherlands in 2003, Israel in 2006, Italy in 2013 and Germany in 2017. To date, around 20 countries in Europe have joined the list, each with their own set of rules and restrictions.

In France, it wasn’t until 2018 that serious discussions around medical cannabis emerged in the public sphere. And it took another three years before the trial began, in 2021.

Now that it looks like medical cannabis is here to stay in France, at least for the next five years, Mylène feels relieved.

“When I was accepted as a participant a few months ago, I thought ‘finally’,” she sighs. “I can see a real step forward and I hope it continues. I hope that it can become more readily available so that as many people as possible can be treated.”

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US Supreme Court hears arguments in abortion pill case

U.S. Supreme Court justices on Tuesday did not appear ready to limit access to the abortion pill mifepristone, in a case that could have far-reaching implications for millions of American women and for scores of drugs regulated by the Food and Drug Administration. 

It’s the first abortion-related case the court has taken since a majority of the current justices struck down the constitutional right to abortion in 2022.

A group of anti-abortion doctors had asked the court to restrict access to mifepristone and to limit when in a pregnancy it could be used. 

Key moments from the arguments:

The FDA approved mifepristone in 2000 as a safe and effective way to end early pregnancies. Last year the pill was used in more than six in 10 of the abortions in the U.S.

The central argument of the conservative group challenging mifepristone is that the Food and Drug Administration overlooked serious problems with the drug when it eased restrictions on the drug, including making it available via mail in 2021. 

Erin Hawley, who represented the doctors suing the agency, argued the FDA “failed to consider or explain … its wholesale removal of safeguards” on the pill.

Read moreThe long and winding history of the war on abortion drugs

But the FDA has long argued its decision to drop in-person appointments to get mifepristone, among other requirements, came after 20 years of monitoring its safety. In that period the agency reviewed dozens of studies in thousands of women in which serious problems — including hospitalization — occurred less than 0.3% of the time.

Hawley pointed out that FDA’s own prescribing label mentions that 2.9% to 4.6% of women taking the drug go to the emergency room. But Solicitor General Elizabeth Prelogar pointed to studies showing that half of women who go to the emergency room don’t get any treatment at all.

“Many women might go because they’re experiencing heavy bleeding, which mimics a miscarriage, and they might just need to know whether or not they’re having a complication, ” Prelogar said.

Because of the highly technical nature of reviewing drug data and research, courts have long deferred to FDA’s scientific judgements on safety and effectiveness.

Justice Ketanji Brown Jackson pressed Hawley on the legal basis for second-guessing the agency’s regulators.

“So what deference do we owe them at all with respect to their assessment that these studies establish what it is that they say they do about safety and efficacy?”

Hawley ran into questions as she argued that a nationwide rule curtailing mifepristone use was needed. 

She was repeatedly interrupted by Justice Neil Gorsuch, who voiced objections to such sweeping injunctions.

The case “seems like a prime example of turning what could be a small lawsuit into a nationwide legislative assembly on an FDA rule or any other federal government action,” said Gorsuch.

Normally when a court issues an injunction about a government policy it only applies to the individuals or groups in the case. But in recent years a growing number of justices on lower courts have issued “universal injunctions,” blocking federal regulations nationwide.

Gorsuch noted that there have been roughly 60 such rulings in the last four years.

Chief Justice John Roberts also seemed skeptical that a ruling reversing the FDA’s scientific judgments was necessary.

“Why can’t the court specify that this relief runs to precisely the parties before the court as opposed to looking to the agency in general and saying, ‘Agency, you can’t do this anywhere?’”

The Biden administration argued that the plaintiffs — a group called the Alliance for Hippocratic Medicine — didn’t have the right to challenge the FDA’s actions on mifepristone. 

The doctors who brought the suit argued that they might have to treat emergency room patients who experience serious complications after taking the drug. 

But Prelogar told the court that the doctors don’t have to prescribe mifepristone and they can abstain from treating patients who have taken the pill if they oppose abortion.

“They don’t prescribe mifepristone,” Prelogar said. “They don’t take mifepristone, obviously. The FDA is not requiring them to do or refrain from doing anything. They aren’t required to treat women who take mifepristone.”

Justice Samuel Alito, however, repeatedly pressed the government on who did have the right to sue over FDA’s decisions. 

“Is there anybody who can sue and get a judicial ruling on whether what FDA did was lawful?” Alito, who wrote the 2022 ruling that overturned Roe v. Wade, asked. 

Several justices pressed Hawley to provide real-life examples of doctors who oppose abortion being forced to treat patients who had suffered from abortion pill complications.

They also took issue with how many hypothetical problems Hawley raised in her argument against the FDA’s loosening of abortion pill restrictions.

“I don’t want to hypothesize,” Jackson said to Hawley, asking her to provide an example of a doctor who was unable to object to providing an abortion.

At one point, Justice Amy Coney Barrett also questioned an example one of the doctors provided of a colleague who had to perform a “dilation and curettage” procedure on a patient with complications. Barrett pointed out that those procedures are not just performed in cases of abortions but for miscarriages as well. 

Some of the justices also pointed out that doctors are already protected from performing abortions when they don’t want to by voicing conscience objection. 

Justice Brett Kavanaugh raised that point early on: “Under federal law, no doctors can be forced against their consciences to perform or assist in an abortion, correct?”

For more than a century, the FDA has had sole authority over assessing the safety of drugs and approving their sale in the U.S.

The agency first approved mifepristone in 2000 following a four-year review, including detailed safety studies submitted by the French manufacturer. In 2016, FDA loosened restrictions on the drug to allow it to be prescribed up to 10 weeks of pregnancy and allowed nurses and other medical professionals to prescribe it. In 2021, the agency said the drug could be sent through the mail, doing away with a longstanding requirement that women to pick the drug up in person.

Jessica Ellsworth, an attorney representing the New York-based Danco Laboratories, which makes mifepristone, asked the justices to consider how the case could upend the FDA’s decades-old system for regulating drugs, vaccines and other life-saving medicines.

“I think this court should think hard about the mischief it would invite if it allowed agencies to start taking action based on statutory responsibilities that Congress has assigned to other agencies,” she said.

U.S. District Judge Matthew Kacsmaryk’s decision last year marked the first time a court had issued a decision to revoke approval of a drug FDA had deemed safe. An open letter signed by nearly 300 biotech and pharmaceutical company leaders last year slammed the ruling as undermining Congress’ delegated authority to the FDA to approve and regulate drugs. If justices can unilaterally overturn drug approvals, they said “any medicine is at risk.”


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The war in Gaza is creating a health crisis that will span decades

Palestinian children wait to receive food cooked by a charity kitchen amid shortages of food supplies in Rafah

Ismael Mohamad/UPI/Shutterstock

The situation in Gaza is rapidly devolving into the worst humanitarian crisis in modern memory, and international health organisations have no long-term plans for addressing the territory’s post-war needs.

More than three-quarters of Gaza’s 2.2 million residents, half of whom are children, are internally displaced, trapped in one of the most densely populated areas in the world with minimal access to food, water or healthcare. Since 7 October, when Hamas militants from Gaza invaded Israel and killed more than 1000 civilians, Israel has intensely bombed the enclave, hindered the flow of humanitarian aid and decimated civilian infrastructure. As a result, more than 30,000 Palestinians have died in Gaza – mostly women and children – according to the United Nations, and more than 72,000 have been injured.

Yet, these figures signal only the beginning of the public health catastrophe. Those who survive the war will face lifelong health effects. Thousands of Palestinians will be living with missing limbs, compromised immunity, mental illness and other chronic conditions. Meeting their health needs will be a decades-long undertaking, one that no global aid organisation has adequately planned for.

The World Health Organization, the World Food Programme, UNICEF, the Palestine Red Crescent Society, CARE International and Doctors Without Borders all lack concrete, long-term plans to address health needs in Gaza, according to information each organisation shared with New Scientist. Save the Children and the International Committee of the Red Cross didn’t provide a response to questions about their long-term plans.

An unprecedented humanitarian disaster

The lack of planning for the coming decades of healthcare needs is partly due to the enormity of the current humanitarian crisis. Most people in Gaza are living in crowded conditions without sewage treatment and trash removal. On average, people have less than 1 litre of clean water per day. As a result, infectious disease is rampant.

A survey in a limited number of shelters in December and January found that at least 90 per cent of children under 5 years old have one or more infectious illnesses and 70 per cent have had diarrhoea in the past two weeks. “And that doesn’t account for the hundreds of thousands of people who aren’t in refugee shelters,” says Margaret Harris at the WHO.

Hunger is also widespread. Almost two-thirds of households eat one meal a day, and a quarter of the population faces imminent starvation and extreme malnutrition. Conditions are most dire in northern Gaza where 1 in 6 children are malnourished, according to the survey. Gaza’s health ministry reported on 7 March that 20 people, including 15 children, have died from malnutrition and dehydration. Poor surveillance means these numbers are likely much higher.

“The difficult thing about malnutrition in children is that it begets more illness,” says Tanya Haj-Hassan at Doctors Without Borders. Malnourished children are more susceptible to infections, which wears the intestine’s lining, making it difficult to absorb nutrients. “So, they become more malnourished, more immunocompromised, and it just becomes this vicious cycle that’s essentially a snowball down to death,” she says.

Bombing has made much of the territory unsafe. UNICEF found that by December, more than 1000 children had lost one or both of their legs since the conflict began – or more than 10 children a day, on average. And there are few options to obtain care for these injuries: as of 21 February, only 18 of the 40 hospitals in Gaza were still functioning, but with reduced capacity. “They don’t have drugs. They don’t have machines. They don’t have power. They might have a few doctors who are running an emergency room. So, there’s really no functioning health system,” says Selena Victor at humanitarian organisation Mercy Corps, which is providing emergency food in Gaza.

The overwhelming humanitarian crisis has left health organisations scrambling. “We’ve not seen such a level of violence, horror, fear and deprivation enacted on any population in modern history,” says Harris. “We are, in a sense, charting unknown territory.”

Gaza’s impending public health crisis

Even if the war ends tomorrow, survivors will face lifelong health consequences. Many will have physical disabilities. Others will have severe mental illness. Some may develop chronic lung conditions, heart disease and cancer from the chemical pollutants in bombs and destroyed buildings, says Harris.

The impact will be most severe for children. Persistent malnutrition early in life stunts growth and impairs brain development, causing deficits in cognition, memory, motor function and intelligence, says Haj-Hassan. It also weakens children’s immune systems, leaving them vulnerable to illness. Research shows that malnutrition during pregnancy increases the risk of babies developing obesity, hypertension, heart disease and type 2 diabetes. A February report from Project Hope, an international aid organisation, found that 1 in 5 pregnant women treated at a Gaza clinic were malnourished, as were 1 in 10 children seen there.

However, the most widespread harm will be the mental health effects, says Harris. “Just imagine what it’s like for the people who are going through this every day relentlessly. They have a terrible sense of uncertainty – no idea where to go, what’s going to happen next, where the next little bit of food is going to come from,” she says. Such traumatic experiences are associated with depression, anxiety, post-traumatic stress disorder (PTSD) and suicidal thoughts. In children, this trauma can disrupt brain and organ development and increase the risk of learning disabilities and mental health conditions. Without early interventions, these problems may continue into adulthood. “We’re going to see an enormous burden of mental illness that is going to be extremely difficult to deal with,” says Harris.

Adults who experience childhood adversity also have 12 times the risk of developing alcohol and drug use disorders and attempting suicide. They are more likely to have physical health conditions, too, such as heart disease or cancer. Young men who survive conflict have almost triple the rates of severe mental disorders, such as psychosis, compared with those who don’t experience war.

Current post-war plans are not enough

Given these consequences, long-term health plans for Gaza must be established. Such plans will have to address rebuilding infrastructure, developing mental and physical rehabilitation programmes and routinely screening for illness.

“It seems absurd to be talking about what the municipal authorities will look like when right now people are dying trying to get a handful of bread for their families. It just doesn’t compute,” says Victor. “But we need to think about it.”

Yet, most organisations have only just begun to do so. The few with protocols in place – including the Palestine Red Crescent Society and CARE International – address the next year or two, but not decades down the line. The WHO is developing plans to address health needs from April 2024 to the end of the year. “We’re working with several different scenarios. The good scenario is a ceasefire that helps us to then genuinely look at [long-term plans],” says Harris. The other plausibility is that the war continues.

This uncertainty, along with the looming question of who will govern Gaza in the aftermath of the conflict, makes future preparations extremely difficult. “Why we are desperate to see not just a ceasefire, but a peaceful resolution, is that until we’ve got that, any plan, anything we even consider, is just castles in the air,” says Harris.

Israel has limited aide organisations’ access to the region, and the few workers who are in Gaza can’t operate safely. “Half the time they can’t do anything. They can’t move around safely. Basic things like communications keep getting shut down,” says Victor. And many of them have died. For instance, a member of the WHO’s limb reconstruction team in Gaza, a 29-year-old named Dima Abdullatif Mohammed Alhaj, was killed by an Israeli airstrike alongside her 6-month-old baby, two brothers and husband, says Harris.

These dangers and hurdles complicate long-term planning. “You can make any plan you like, but if you don’t know what the needs are, you’re not going to make a very useful plan,” says Victor.

It will take an enormous amount of money to address the widespread devastation in Gaza. Margaret Harris at the World Health Organization says that early estimates suggest $204.2 million will be needed to fund its health emergency plan in Gaza for 2024 alone.

Meanwhile, a spokesperson for the Palestine Red Crescent Society says the organisation has a $300 million budget for its campaign in Gaza, which will run until the end of 2025. Roughly $38 million of those funds will be used for the health sector, including restocking medical supplies, deploying additional ambulances and preventing infectious disease.

This won’t begin to address the long-term health needs of Palestinians in Gaza. It is hard to estimate what will be needed now, but Harris says that in the long run “I think it is fair to say we’ll be looking at billions”.

Article amended on 12 March 2024

We clarified the role of Mercy Corps in the region


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France’s foreign doctors suffer insecurity as understaffed hospitals struggle to function

The situation for several thousand foreign doctors working in French hospitals has become more complicated since the end of the exemption scheme put into place during the Covid-19 pandemic. Nearly 1,900 of these practitioners have now lost their right to practise, a great loss for French hospitals already struggling with shortages of medical staff. FRANCE 24 spoke to some of them.

Karima*’s last visit to the prefecture was a complete nightmare, as her residence permit was not renewed. “All I have is a receipt”, she says. This is despite the fact that she has been working as a paediatric orthopaedic surgeon – including in the emergency department, where she is on call at least four nights a month – for the past two years in a hospital in the Parisian suburbs. “My colleagues in general surgery asked me to come help out,” says the surgeon, who is originally from a country in North Africa*. “I’m not going to let them down,” she says, although she doesn’t know how much longer she will be able to practise.

Even though the hospital has agreed to let her work, Karima is concerned that her contract, which is renewed every six months, will be allowed to expire. She is one of some 4,000 medical practitioners with qualifications from outside the European Union known as “Padhue” (for the acronym of praticiens diplômés en dehors de l’Union européenne) who have been working in French hospitals for years in precarious positions such as “acting intern”.

“The work I do is real work, the work of a practitioner, even though I’m on an intern contract for which I get paid 1,400 euros net and which has to be renewed every six months. The prefecture refused to renew my residence permit because of these breaches of contract,” says the doctor, who is constantly going back and forth with the authorities to try and stabilise her situation. “This time, the prefecture is asking me for a work permit provided by the regional health agency, which no longer wants to provide it, as the law has changed.” 

On December 31, 2023, the exemption scheme that allowed establishments to employ Padhue staff under a variety of precarious arrangements expired, making it impossible for them to continue working. As of January 1, these doctors must sit highly selective and competitive examinations known as “knowledge verification tests” (épreuves de vérification des connaissances, or EVC) before they can be reinstated. Posts under the scheme are hard to come by, with 2,700 available for over 8,000 applicants in 2023, some of whom try their luck from abroad. As a result, the majority of the Padhue doctors found themselves out of the running this year.

After an outcry from French unions, the government finally promised to “regularise a number of foreign doctors” and renewed their temporary work permits another year so that they can sit the 2024 EVC.

‘I don’t understand why I’m not being judged on my experience here’

However, Karima’s problems are far from over, as she tried to sit the EVC in paediatric orthopaedic surgery in 2023 but her application was rejected. “They tell me that I don’t have the right diploma, that I need one in paediatric orthopaedics, but my country doesn’t offer this type of diploma! I don’t understand why I’m not being judged on my experience here. I operate on my own, I consult, I have my own patients,” she says. 

When she arrived in France in 2020, she did not have long-term plans to live on this side of the Mediterranean. “I had been sent to France for further training in orthopaedic surgery because I had noticed shortcomings in the department where I was working in North Africa,” she says. But after almost two years as an associate trainee at a university hospital in Nice, Karima found herself stuck in France because of the Covid-19 pandemic and the closure of her country’s borders. She also lost her job in North Africa. 

While in Nice, she worked on the front lines during the Covid-19 pandemic alongside French medical staff, lending a hand in intensive care. “We saved lives. And we’ll continue to do so. It’s what we do. Sometimes in the emergency department, I find myself in a situation where I have to react in a split second, do the right thing and make the right decision to save someone.”

‘I regularly pack my bags’

Sometimes Karima thinks about returning to North Africa. “I ask myself the question if I can go on in this situation. But I have a job that I love, especially the children. I’m attached to my patients. When I see in their eyes that they’re satisfied, I feel useful.” However, she is thinking more and more about leaving, as she wants a life where she can plan beyond a day-to-day basis. “I regularly find myself packing my bags. I hesitate to order new furniture.” Those close to her have suggested that she apply for a job in Germany “Some of my colleagues have gone there. They were accepted on the basis of their applications and took German language courses,” she says.

Against the backdrop of its overwhelmed healthcare system, France is in desperate need of additional medical staff, but risks losing thousands of these doctors to other European countries.  

Watch moreA country short of doctors: Exploring France’s ‘medical deserts’


Dr Aristide Yayi, originally from Burkina Faso, came to demonstrate in front of the health ministry in Paris, France to defend the rights of foreign doctors working in France on February 15, 2024. © Bahar Makooi, FRANCE 24

Dr Aristide Yayi is originally from Burkina Faso and qualified in forensic medicine in Dakar, Senegal. He has been working for three years as a general practitioner at the only residential care home for senior citizens (“Ehpads”, in France) in Commercy, a small town in the northeastern Meuse department. France’s elder care sector is in desperate need of doctors. “My contract runs until July 2024. After that, I don’t know what’s going to happen,” says Yayi. He wants to develop a pain management service for the Ehpad residents, but this project may never see the light of day if his situation does not become more stable. “I’ve been on one training course after another, with six-month contracts as an ‘acting intern’. It’s always uncertain and precarious. I feel like I’m being treated like a junior doctor,” he says.

Hospital services under threat without foreign doctors

Several hospital department heads, particularly in the Paris region, have warned that they will be “forced to close” if no more foreign doctors are hired. At his January 16 press conference, President Emmanuel Macron admitted that France needed these practitioners, saying he wanted to “regularise a number of foreign doctors, who help to hold our system together”. This promise was reiterated by newly-appointed Prime Minister Gabriel Attal in his general policy speech at the end of January. 

French unions are now demanding that this rhetoric be followed by action. At a meeting with the health ministry on February 15, they welcomed the previous day’s publication of the decree renewing temporary work permits for foreign doctors who undertake to sit the 2024 EVC. However, Olivier Varnet, general secretary of the National Union of Hospital Doctors FO, criticised the decree, saying it was “a first step” that “merely postpones the problem for a year”.

Meanwhile, foreign doctors are suffering, as almost 1,900 of them are unable to work at the moment. “My old department is desperately looking for someone to replace me. They’re really struggling. I was in charge of two units with 20 patients each. It’s absurd,” says Mostapha, who worked in a follow-up care and rehabilitation unit in Normandy. His contract as an “associate practitioner” was suspended on January 1, as he was not permitted to sit the knowledge verification tests. “The hospital wanted to keep me, but the regional health authority didn’t authorise it,” he says.

‘Some candidates failed, even with top marks’

A graduate of the Faculty of Physical Medicine and Rehabilitation in Algiers, he followed his wife, a French national, to France three years ago. “I don’t have any problems with my papers – I have a 10-year residence permit,” he says.

Mostapha joined his fellow doctors and a French union delegation received on February 16, 2024 by the Ministry of Health in Paris, France.
Mostapha joined his fellow doctors and a French union delegation in a meeting at the French health ministry on February 16, 2024. © Bahar Makooi, FRANCE 24

Mostapha hopes that his case will be examined more closely and that the new decree will enable him to return to work. However, he doesn’t really believe that taking the exam will help him get his career back on track: “I’m planning to take it again because for the moment there’s no other solution, although the chances of passing it are getting smaller and smaller because of the number of posts. It’s worse than selective.”

Many unions believe that the exam is more reflective of a quota system than an actual “verification of knowledge”. “Some candidates failed with an average of more than 15 [out of 20, a highly competitive result],” says Laurent Laporte, general secretary of the CGT’s Federal Union of Doctors, Engineers, Managers and Technicians. The unions say the test is “too academic”, “random”, “opaque” and “discriminatory for doctors working more than 60 hours a week”. The health ministry promised on February 15 to “reformulate the EVC” by making it more practical. 

*This person wishes to remain anonymous

This article has been translated from the original in French

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Patients at overwhelmed Gaza hospital are often ‘dying or doomed to die’

Emergency medical personnel who volunteered to work at the European hospital near Khan Younis tell FRANCE 24 of the dire conditions at one of Gaza’s last functioning medical facilities, where overwhelmed staff grapple with an acute shortage of medicine and have to make agonising choices over which critically injured patients to treat. 

Doctor Raphaël Pitti and nurse Imane Maarifi returned to France on February 6 after a gruelling 16-day stint at the overcrowded European hospital in southern Gaza, where thousands of displaced people have joined the injured and sick, seeking shelter and safety.   

Their account offers rare insight into the plight of the Palestinian enclave – a mostly no-go zone for the international media – much of which has been reduced to rubble after four months of devastating bombings and ground fighting.

In the opening stages of the Israel-Hamas war, Khan Younis witnessed an influx of tens of thousands of people fleeing the fighting in the enclave’s north. But in recent weeks, the southern city has itself become the focus of fierce clashes, leaving displaced Gazans at the mercy of daily bombardment.  

“The local population are caught in a trap, living in extremely difficult conditions,” said Pitti, an emergency physician who was part of a seven-member team of health workers sent by the NGO PalMed Europe. “People sleep out on the pavement, under makeshift shelters,” he added. “The streets are filthy and the recent rainfall has left stagnant water everywhere.”

According to the medics, some 25,000 people are currently amassed around the hospital near Khan Younis and around 6,000 are crammed inside the facility. More arrive each day, hoping to find shelter or treatment. 

“People lack everything,” said Maarifi, 37, whose last patient, a newborn baby, died of hypothermia in her arms. She recalled trying to resuscitate a patient on the floor in a corridor and seeing children steal gloves from her pocket “to make balloons out of them”.

‘Heartbreaking choices’

Israel launched its offensive after more than 1,100 people were killed in an October 7 attack on southern Israel by Hamas, the Islamist militant group that runs Gaza. Since then, more than 28,000 people have been killed in the Palestinian enclave, most of them women or children, according to health officials in the Hamas-run territory.

Israel and the United States accuse Hamas of using Gaza’s population as human shields and say Hamas and Palestinian Islamic Jihad members are operating out of hospitals in the territory.

The European hospital is one of the last functioning medical facilities in the enclave. In its overcrowded corridors, medical staff and volunteers try as best they can to provide care to the sick and wounded, in daunting conditions.

Read moreMalnourished, sick and scared: Pregnant women in Gaza face ‘unthinkable challenges’

“You have volunteers doing the work of orderlies, nurses doing the work of doctors, and doctors standing in for surgeons,” said Maarifi, lamenting a critical shortage of medicine and equipment.

“There are no sheets, sterile drapes or compresses,” the nurse added, and the dwindling supply of painkillers has to be used sparingly. Her voice choking up, she recalled having to make “heartbreaking choices” between “a child hit by shrapnel” and another “whose leg had been torn off”. 

In addition to the injured, the hospital is overwhelmed by patients suffering from chronic diseases, respiratory problems or illnesses linked to poor living conditions. 

“We can no longer do any dialysis or chemotherapy. Patients who need treatment are either dying or doomed to die,” said Maarifi. She cited the case of a pregnant 24-year-old patient with diabetes who developed complications due to the shortage of insulin, lost her baby and died the next day.

‘Collapse of public health’

“We are heading for a collapse of public health in Gaza,” said Lucile Marbeau, spokesperson for the International Committee of the Red Cross (ICRC), which works in partnership with the Egyptian Red Crescent (which is in charge of coordinating international aid to Gaza) and its Palestinian counterpart. 

“The war-wounded are amputated on a daily basis, the chronically ill can no longer receive treatment, and living conditions are stoking fears of a resurgence of diseases such as polio, cholera and chickenpox, which we won’t be able to treat,” Marbeau added.

She pointed to the worsening situation in nearby Rafah, on the border with Egypt, where desperate Gazans are gathering as Israel’s offensive pushes further south.

The city of around 270,000 inhabitants has seen its population increase sixfold since the start of the war, and is now home to more than 1.3 million people. Like Khan Younis, it has become a sprawling camp for displaced people crammed into tents and makeshift shelters.

Marbeau spoke of “deplorable hygiene conditions”, noting that water treatment plants have stopped working, depriving the population of toilets. “Access to drinking water is also very difficult and people are not getting enough to eat because the prices of the few foodstuffs available have soared,” she added.

Humanitarian aid ‘a drop in the ocean’

On December 22, the UN Security Council passed a resolution calling on all sides in the conflict to allow “safe and unhindered delivery of humanitarian assistance at scale” into the enclave. But more than a month later, NGOs on the ground say only a trickle of the required aid has reached the people of Gaza.

“It’s a drop in the ocean,” said Marbeau, who also flagged the need for specific equipment to carry out repairs to basic infrastructure, such as plumbing work to improve access to drinking water.

The UN resolution also urged all parties to guarantee the “protection of humanitarian workers” and their “freedom of movement” throughout the enclave – conditions that are far from being met. 

“Access to the north of Gaza is still impossible because of the security conditions there,” said Marbeau, whose team has been unable to visit northern parts of the enclave since the beginning of November. “It is now the most deprived area and we are unable to help vulnerable people there,” she added. 

Expectations of an imminent Israeli ground offensive on Rafah have raised further alarm – particularly given that the border city is also the entry point for critically needed humanitarian aid from Egypt.

“A ground offensive in such a densely populated area would have dramatic consequences for the civilian population,” Marbeau warned. “We must, at all costs, show greater respect for humanitarian law in this conflict if civilians are to be spared.”

This article has been translated from the original in French.

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An unspoken pain: Tackling France’s infertility problem

French President Emmanuel Macron this week announced a plan to revive France’s sluggish birth rate and tackle the country’s growing infertility problem. More than three million people in France suffer from what Macron described as “the taboo of the century”, making it one of the country’s biggest public health issues. So why has it never been treated as such? 

Macron promised steps to boost France’s declining birth rate during a televised press conference on Tuesday, calling for a “demographic rearmament” of the country. The call came after France recorded its lowest annual birth rate since World War II, with 678,000 births registered in 2023 – a sharp 6.6 percent drop from the previous year. Despite Macron’s “announcement”, the plan has actually been long in the making, and is part of a bioethics law that the French parliament approved in 2021. 

France has long been proud of its comparatively high birth rate, described as a “French exception” in Europe. But recent trends have undermined the country’s status as the continent’s baby-making champion – and highlighted a growing fertility problem.  

A 2022 report commissioned by the government showed that as many as one in every four French couples who have tried to conceive naturally for 12 months or longer are unable to do so. The World Health Organization (WHO) defines this as infertility – a condition that currently affects as many as 3.3 million people in France. 


Among them is Virginie Rio, the president and co-founder of the infertility support group Collectif Bamp!, which advocates better treatment for infertility. 

After trying but failing to conceive naturally for several years, Rio sought help through Medically Assisted Procreation (MAP) and managed to get pregnant. But her long journey was fraught with challenges and mistreatment, not least because of a lack of understanding and compassion from doctors. 

“I was told that women had psychological problems, and that I needed to relax more,” she said, pointing to sexist prejudice surrounding the issue of infertility. “The discourse makes women feel very guilty. They’re made to feel as if it’s their fault that they can’t have children,” Rio explained. 

The underlying causes  

Multiple studies have shown that a woman’s age plays a key role in her ability to conceive. A study published in the Upsala Journal of Medical Sciences in May 2020 showed that a woman under the age of 30 had an 85 percent chance of getting pregnant within a year, while a woman aged 30 had a 75 percent chance. At 35, her chances dropped even further, to 66 percent, and at 40 to 44 percent. 

But these types of statistics are guilt-tripping and hardly show the full picture.

“The stigma that women are the only ones responsible for infertility is deeply rooted in peoples’ minds,” said Élise de La Rochebrochard, a researcher at the French Institute for Demographic Studies (INED). “We shouldn’t reinforce this belief, making women the only ones responsible for reproduction – since it’s also an issue for men,” she said. 

There are many reasons why a growing number women wait until later in life before trying to have a child. Sociologists point to women making up a much larger part of the workforce and to widespread access to contraceptives. Many young adults put their family creation plans on hold as they seek professional and emotional stability, or  wait until they have struck the right work-life balance. But the longer people wait to seek help for an infertility problem, the more difficult it gets for them. 

Medical conditions, such as endometriosis, polycystic ovary syndrome (PCOS) and sperm production disorders, are also to blame for the uptick in infertility rates. 

Read moreFighting endometriosis: ‘I don’t know what it means to be free from pain’

A meta-analysis published in 2017 showed that the average concentration of gametes in sperm had dropped by 50 percent between 1973 and 2011. Several reasons have been cited for the sharp reduction, including smoking, alcohol consumption and obesity, but also the exposure to pollution and endocrine disruptors, which can be found in many plastics and which interfere with the body’s hormones. 

“The decline in sperm quality is a worrying issue, but there’s no need to panic,” said Micheline Misrahi-Abadou, a professor of biochemistry and molecular biology at the University of Paris-Saclay. She said today’s gamete concentration average of 40 to 50 million gametes per millilitre of sperm is still more than enough to impregnate a woman. 

So what are the remedies?  

When medical conditions stand in the way of a pregnancy, hormone treatments can help. In France, Medically Assisted Procreation, or MAP, has been available to all women since 2021 and no longer requires them to fulfil the medical criteria of infertility. But many doctors say hormonal treatments are not always necessary and, in some cases, not even the best route to pregnancy. 

“A part of the three million people who are estimated to suffer from infertility may be due to couples going straight for MAP,” said Misrahi-Abadou, adding that she understood why some do not want to take the risk of waiting to become parents. 

“Infertility is a terrible suffering, and is experienced as a tragedy, especially when the cause is unknown. But MAP can be an additional source of suffering, with an average failure rate of 40 percent,” she said. 

Couples who choose MAP treatment have to undergo a multitude of tests and treatments that can be both expensive and stressful. But infertility is not only a social challenge, it is also a professional one. 

“MAP protocols are often time-consuming and unsuccessful, which can make it difficult for people to reconcile their work with the treatment they are getting,” Rio explained.  

“Employers often expect their employees to be productive and present, but MAP treatments can require taking time off work.”

The authors of the 2022 infertility report recommended better public information, starting from secondary school, as well as targeted consultations in a bid to identify the factors affecting fertility. They also stressed the need to label food products containing phytoestrogens – which can cause infertility problems. Finally, they suggested more training on the issue for doctors and other health professionals. 

Neglected issues  

Meanwhile, researchers are trying to pin down the underlying factors of infertility.

“Identifying the causes of infertility is an essential prerequisite to improve treatments,” said Misrahi-Abadou, adding that genetics is an especially important tool to do so. “Like in all medical specialty fields, it’s possible to use DNA analysis to look for the causes of infertility,” she said. “The ultimate goal is to define a targeted therapy with medication that can act directly,” said Misrahi-Abadou, who heads the first reference laboratory for genetic infertility at the Bicêtre Hospital in Paris.    

The experts interviewed by FRANCE 24 agreed that infertility has not been taken seriously enough in France. They hope Macron’s announcements will be followed up by action.  

“Infertility is still an issue that is mistreated by society, and the people concerned are mistreated too,” said Rio, adding that her advocacy group’s calls for action have long been ignored. Misrahi-Abadou added: “Infertility is not a fatal disease and so it’s considered less serious than other pathologies.”  

Taking Macron’s ambitions into account, does this mean that the “taboo of the century” will now finally be broken in France? The experts are not so sure. “Infertility is a taboo, but it’s not the only reproductive health issue that remains difficult to talk about,” de La Rochebrochard said. “Menstruation and abortion are both topics that are still not talked about enough.” 

Infertility, sterility and reduced fertility are three different concepts.

  • The WHO defines infertility as the inability to conceive after one year or more of regular unprotected sex.  
  • Sterility is the total inability to conceive or impregnate, regardless if the woman or man undergoes treatment. 
  • Reduced fertility is a drop in the number of estimated births per woman. In France, the fertility rate came to 1.68 children per woman last year, compared with 1.79 in 2022, according to the national statistics office INSEE. This can partly be explained by a general drop in the number of women of child-bearing age (between 20 and 40 years old), but also other factors, including lifestyle choices.

This article was translated from the original in French.

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Transforming HIV prevention in Europe

This article is part of POLITICO Telescope: The New AIDS Epidemic, an ongoing exploration of the disease today.

The world’s battle to end the HIV epidemic is being fought on two fronts. The first involves getting as many people as possible who are living with the virus diagnosed and rapidly onto antiretroviral medication. This reduces the virus inside their bodies to such a low level that it is undetectable and therefore cannot be passed to others. The approach is known as “undetectable = untransmittable” or “U=U*.”

The second front is focused on protecting people from contracting the virus in the first place, even if they have been exposed to it — an approach known as pre-exposure prophylaxis, or PrEP. Taken as prescribed, PrEP makes a person’s body almost entirely resistant to HIV infection.

There is a critical need to bring forward new PrEP options that are informed by and designed for the communities that could benefit from PrEP in Europe.

Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences

PrEP comprises antiretroviral drugs that can be taken intermittently, around the time someone expects to be sexually active. They protect against the virus in two ways: by increasing the production of antibodies in the cells in the rectal or vaginal lining, making them less receptive to HIV in the first place, and by interfering with the ability of HIV to replicate in the body.

Nearly 5 million people around the world have taken PrEP at least once — including about 2.8 million in Europe — and it has been shown to reduce the incidence of HIV infection during sex by 99 percent. In the European Union, new HIV infections have fallen by about 45 percent since PrEP was licensed in 2016, although this decline is also partly due to U=U.

PrEP as part of combination prevention strategies

Missing doses or running out of PrEP can mean becoming susceptible to HIV again. I via Shutterstock

Today, PrEP comes primarily in the form of an oral tablet, which has the advantage of being cheap to produce and easy to store. But it is not a universal solution. Because it needs to be taken regularly while someone is sexually active, missing doses or running out can mean becoming susceptible to HIV again. What’s more, in the same way that some bacteria are developing resistance to antibiotics, the HIV that does enter the bodies of people who have paused or discontinued their use of PrEP has a greater chance of being resistant to subsequent antiretroviral medications they may then need.

PrEP taken in tablet form is also an issue for people who need to keep their use of PrEP private, perhaps from family members or partners. Having to take a pill once a day or two or three times a week is something that may be hard to hide from others. And some people, such as migrants, who may not be fully integrated with a country’s health care system, may find it hard to access regular supplies of daily medication. Limitations such as these have prompted the development of alternative, innovative ways for people to protect themselves that are more tailored to their needs and life situations. These include longer-acting drugs that can be injected.

Like existing oral medications, injectable PrEP works by preventing HIV from replicating in a person’s body, but its effect lasts much longer. In September, the EU approved the use of the first intramuscular injectable that can be given every two months. Gilead is, until 2027, running trials of another injectable option, which, once the required efficacy and safety have been demonstrated, could be administered subcutaneously just once every six months. This would be more convenient for many people and more adapted to the circumstances of certain populations, such as migrants, and may therefore lead to better adherence and health outcomes.

HIV continues to be a public health threat across Europe, where in 2022 more than 100,000 people were newly diagnosed with HIV.

Jared Baeten MD, PhD, vice president for HIV Clinical Development at Gilead Sciences

Further ahead — but still in the early stages of development and testing — are patches and implants, which would provide a continuous supply of antiretroviral drugs, and immunotherapies. Immunotherapies would comprise a broad spectrum of naturally produced or manufactured antibodies against HIV, which, in theory, would pre-arm their bodies to resist infection.

As more types of PrEP become available, we will see a greater awareness of its benefits, as more people are able to find the version of PrEP that best suits their living conditions and personal requirements. This is a fundamental principle of “combination prevention,” or innovative interventions that reflect the specific needs of the people they are trying to reach.

Preparing for the future

Despite clear scientific evidence of the benefits of PrEP, there are still some hurdles we need to overcome to make it a powerful tool to end HIV altogether. These include investments and funding in prevention and availability, and programs to combat stigma.

Although the EU licensed PrEP in 2016, availability varies across the bloc. In France, the U.K., Spain, Germany and, more recently, Italy, oral PrEP is available at no cost to those who would benefit from it. In Romania, although PrEP is included in the country’s new HIV National Strategy, it is not yet funded, and it is only available via non-governmental organizations that rely on external funding sources. And in Poland, Hungary and Bulgaria, PrEP is not state funded and there are no current plans to make it so. In many member states, even though PrEP is technically licensed, in practice it can be hard to get hold of, in particular for specific communities, such as women, migrants or trans people. Potential users may find it hard, for example, to access testing or even doctors who are willing to prescribe it.

Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences

Another key challenge that health systems and providers face is communicating the importance of PrEP to those who would most benefit, and thereby increase uptake. Many respondents in multiple studies have indicated that they don’t feel HIV is something that affects them, or they have indicated that there is a general stigma in their communities associated with sexual health matters. And some groups that are already discriminated against, such as sex workers, people who inject drugs, and migrants, may be hesitant to engage with health care systems for fear of reprisals. Again, injectable PrEP could help reach such key populations as it will offer a more discreet way of accessing the preventive treatment.

“There is a critical need to bring forward new PrEP options that are informed by and designed for the communities that could benefit from PrEP in Europe,” says Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences. “At Gilead, we are excited to engage with communities and broader stakeholders to inform our trials efforts and partner with them in our goal to develop person-centered innovations that can help end the HIV epidemic in Europe.”

Europe is leading the world’s efforts toward ending HIV, but, even in the bloc, PrEP usage and availability varies from country to country and demographic to demographic. If the region is to become the first to end the HIV epidemic entirely, the European Commission, the European Parliament and the governments of member states will need to lead the way in fighting stigma, promoting and prioritizing HIV prevention in all its aspects including innovation in therapeutics strengthening the financing and funding of healthcare systems, and establishing effective pathways to zero transmission to end HIV entirely.

“HIV continues to be a public health threat across Europe, where in 2022 more than 100,000 people were newly diagnosed with HIV,” says Baeten. “HIV prevention is critical and has the potential to change the trajectory of the epidemic, but stigma and other barriers limit the impact that PrEP medications can have on reducing HIV infections in Europe. We all have a responsibility to collaboratively partner to make this work.”

*U=U is true on two premises: taking HIV medicines as prescribed and getting to and staying undetectable for at least six months prevents transmitting HIV to partners through sex. Undetectable means that the virus cannot be measured by a viral load test (viral load <200 copies/mL)

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French doctors vow to ‘disobey’ bill stripping undocumented migrants of healthcare rights

A push by France’s conservative-led Senate to strip undocumented migrants of their access to free healthcare has sparked a public outcry among workers across the medical profession, many of whom have pledged to ignore a measure they describe as an ethical, sanitary and financial aberration.

Medical practitioners voiced their dismay in a flurry of media statements after senators from the right-wing Les Républicains amended a government-sponsored immigration bill last week to axe a scheme known as State Medical Aid (AME) – which provides free healthcare to undocumented migrants who have settled in France.

The amended bill, which will be examined by the National Assembly next month, was swiftly panned by health officials, who warned that it would present a threat to public health and that long-term costs would far exceed any initial savings.

The head of the Paris hospital consortium AP-HP said scrapping the AME would allow diseases to spread undected and ultimately increase the burden on France’s health system. The Federation of French Hospitals (FHF) described it as “humanitarian, sanitary and financial heresy”.

On Saturday, some 3,500 health workers signed a letter pledging to “continue to treat undocumented patients free of charge and based on their needs, in accordance with the Hippocratic Oath” they took. “Patients from here and elsewhere, our doors are open to you. And will remain so,” they added.

That would effectively mean working for free, said Antoine Pelissolo, a psychiatrist at a hospital east of Paris who co-authored the letter. “If they see a patient who is not covered (by health insurance), they will not be paid,” Pelissolo told AFP. “It’s a very strong stand.”

‘Guided by ideology rather than medical concern’

Set up in 2000, the AME gives undocumented migrants access to the free healthcare provided under France’s health insurance scheme. Beneficiaries must prove they have resided in France for at least three months and have a monthly income of less than €810 ($860).

The scheme has long been a favourite punching bag for critics on the right and far right, who accuse it of inciting illegal immigration – at a growing cost to French taxpayers.  

Last year, the AME counted 411,364 beneficiaries for a total cost of €1.2 billion, up from €900 million in 2018, according to the Inspection Générale des Affaires Sociales (IGAS), a government auditor.  

During debates in the Senate last week, Bruno Retailleau, the head of Les Républicains’ delegation, flagged the “steady increase in recent years, both in the number of AME beneficiaries and its total cost”. He added: “It is only natural that we look for ways to cut certain costs.”

In its amended bill, Retailleau’s party replaced the scheme with a more restrictive “emergency medical assistance” (AMU), which would cover only cases of “severe illness and acute pain”.

Read moreUndocumented workers left in limbo as French immigration bill delayed

The move betrays a sketchy understanding of healthcare, said Professor Pierre Tattevin, the deputy head of the French Infectious Diseases Society (SPILF), noting that the aim for medical workers is precisely to treat diseases before they become severe and acutely painful.

“It’s called prevention: if you treat something early, it will cost you less in the long run,” he explained, arguing that the debate over AME was “guided by ideology rather than medical concern”.

Cost of reform set to outweigh savings

While AME spending has increased in recent years, in line with immigration numbers, it still accounts for just 0.5% of France’s public health spending. According to an IGAS report from 2019, the scheme’s beneficiaries have lower healthcare costs than the general public, averaging around €2,600 per year – against a national average of roughly €3,000.

“The idea that AME costs us money is completely misguided,” said Tattevin. “Scrapping it would cost us a lot dearer than any savings it might generate.”

Earlier this month, some 3,000 health workers signed an op-ed in Le Monde warning that AME’s abolition “would lead to a deterioration in the health of undocumented workers, and more generally that of the population as a whole”.


Signatories included Françoise Barré-Sinoussi, the 2008 Nobel Prize laureate who helped discover HIV/AIDS, and Jean-François Delfraissy, the head of the scientific council that advised the French government during the Covid-19 pandemic.

They pointed to a recent precedent in Spain, where a 2012 law “restricting access to healthcare for illegal immigrants led to an increase in the incidence of infectious diseases and higher mortality rates”. The reform was finally repealed in 2018.

“If you bar part of the population from access to care, it will necessarily have repercussions,” said Tattevin, who also signed the Le Monde op-ed. “It could take months or years to show, but we would end up with hidden epidemics that eventually affect the wider public too,” he added.

A negotiating ploy?

Experts have largely debunked another criticism levelled at State Medical Aid: that its purported generosity induces migrants to choose France over other destinations.

In 2019, France’s former Human Rights Ombudsman, Jacques Toubon, lamented the “false idea that the ‘generosity’ of a scheme such as the AME would lead to an increase in illegal migratory flows by creating a ‘pull effect’”. Instead, he argued, “studies show that the need for care is a completely marginal cause of immigration”.

A 2022 study by France’s National Centre for Scientific Research (CNRS) found that fewer than 10% of France’s undocumented migrants cited healthcare as a factor in their decision to move to the country. A separate survey by the IRDES healthcare research institute found that only half of those eligible for AME actually benefit from the scheme, owing to administrative obstacles and a lack of information.

Read moreMost migrants eligible for French state medical aid have not accessed their rights

Prime Minister Élisabeth Borne echoed Toubon’s words in a speech to the National Assembly in December 2022, aiming to “dispel misconceptions” about AME.

“No, state medical aid does not fuel illegal immigration. It’s a question of protection and public health,” she told lawmakers at the time. “No plans to migrate to France are motivated solely by the existence of this scheme.”

While Borne reiterated her stance last week, France’s hardline Interior Minister Gérald Darmanin, the immigration bill’s chief sponsor, has previously voiced support for a reform of AME in a bid to win over support from the right – only to backtrack in recent days.

On Sunday, Health Minister Aurélien Rousseau pledged to defend the scheme, saying he “understood” the doctors’ complaints. “The government will fight to ensure that they do not have to exercise civil disobedience,” he told France Info radio.

“One has the impression that it’s all part of a negotiation, that EMA’s abolition has been thrown in the mix only to be removed at the last minute,” said Tattevin. “That way they can say they’re open to compromise and argue that their law isn’t as harsh as critics say.”

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‘Like Waze, but for toilets’: The start-up hoping to solve Paris’s public urination problem

A new application that rewards businesses for making their toilets accessible to the public and helps users to find them is being rolled out in a Paris suburb. If everything goes to plan, the ICI Toilettes app could make its way into the capital – right in time for the Olympics. 

Public urination is high on the list of critiques of the French capital, along with rats, noise, and people not picking up their dogs’ business. Referred to in France as le pipi sauvage, or “wild peeing”, the propensity for public urination – which is technically illegal and mainly male – is explained by many factors, though a lack of available public toilets is a fundamental one. 

Over the years, Parisian leaders have proposed a number of innovative solutions but, so far, to no avail. In 2018, for instance, certain arrondissements (districts) introduced bright red, eco-friendly uritrottoirs, public installations whose name was a portmanteau of the French words for “urinal” and “sidewalk”. They were criticised for being too visible and only useful for men, and then vandalised by protesters.

The newest scheme to combat the ongoing problem comes from a start-up from the western city of Nantes called Urban Services.

ICI Toilettes (“Toilets HERE”) has two main functions. First, it is a geolocation application that helps users locate public toilets and allows them to update the status of the facility if it is in disrepair. This helps members of the public find the closest functional bathroom in real time and keeps local authorities informed about the state of the city’s sanitation infrastructure.

“It’s like Waze, but for toilets,” says founder and Urban Services CEO Thomas Herquin, referring to the crowd-sourced traffic app. 

The app’s second function is to create a network of local businesses that extend their facilities to the public, all of which are visible on the application. This expands the city’s sanitation capacity by making certain bars and restaurants de facto public toilets. These “partners” are given €100 each month by the local authorities for their participation – ICI Toilettes says this is one-twelfth the cost of setting up and maintaining a public restroom.

First launched in 2021 in Nantes, the application has now made it to the populous suburb of Montreuil on the eastern edge of the capital. The service is set to be rolled out in Grenoble and Urban Services is currently in talks with Saint-Denis, the municipality just north of Paris.

The big prize, Paris, is also in view, as France makes a big investment push before the 2024 Olympic Games. In late September, the start-up was awarded a conditional grant by the ministry of tourism. Urban Services stands to earn between €100,000 and €200,000 if it manages to set up a network of 100 partner retailers in Paris by June 15, 2024 – a number Herquin says will raise the capital’s public toilet capacity by 25%.    

The idea for the app came to Herquin when he was searching for ideas to enter a start-up competition in Nantes that he ended up winning. For market research, he surveyed people on what they thought were the biggest problems they face while commuting. The first was their ability to charge phones, the second, and much more difficult to resolve, was access to sanitary facilities.

Herquin maintains that the restaurants and bars that share their toilets should be considered “complementary” to what is already in place in the city. However, he adds, his application does provide its own benefits.

“According to our research, 85% of women do not use public toilet facilities for several reasons (like hygiene and comfort) so we offer them another option,” says Herquin.

Public urination, Herquin points out, is a serious issue with serious financial consequences. “In Paris alone, 56,000m2 of walls and doors are ruined by urine every month. That can be very costly,” he says.

On whether his business has the potential to help resolve the issue, he is less certain. “The main people who require our services are women. Men seem to have found a solution already, although it is not very clean,” Herquin says.

“But we do hope, with time we can help change the culture.”

What’s more, ICI Toilettes gives people the confidence to go and ask businesses to use their bathrooms, a feature that will particularly serve tourists who are unfamiliar with the French language or their customs related to restrooms. 

In Montreuil, finding the ICI Toilettes sticker is increasingly easy. The service has now been adopted by 10 businesses.

For Putsch café in central Montreuil, signing up with ICI Toilettes doesn’t seem to have changed much except for an extra €100 in the cash register each month. “I know some restaurants can be strict, but we’ve always been open,” says Laurine Ragot, a server at the café. “But we have seen an increase since the app, especially women and people with children desperate to pee.”

Putsch, a cafe in Montreuil that has signed up for ICI Toilettes, November 9, 2023. © Gregor Thompson, FRANCE 24

ICI Toilettes is a welcome change in a city where authorities have long been criticised for the lack of public sanitation infrastructure. Women’s association Maison des femmes de Montreuil recently described the situation as a “hygiene scandal” in French daily Le Parisien

Since signing on with Urban Services in June, “Montreuil has gone from seven public toilet facilities to 17,” says Montreuil’s Deputy Mayor Luc Di Gallo. 

For now, the businesses signed up to ICI Toilettes are concentrated in the city’s centre. The plan is to increase this number and distribute participating establishments more equally throughout the city. 

But ICI Toilettes is no silver bullet, says Di Gallo. People cannot access the app without a smartphone, and it wouldn’t be a viable option for businesses near busy areas like markets, which are unlikely to sign up because they could be inundated by the public.  

“For instances like this, it’s probably better to build public toilets that can [serve] significantly more people.” 

As part of a larger strategy, the response from the public has been “extremely positive”, says Di Gallo, adding that it makes the city more inclusive by meeting the needs of “women, the elderly and disabled people”, who have described the difficulties they encounter when out in public with no access to facilities.

“Of course, we also hope that those who degrade our public spaces will now be more inclined to use a toilet,” Di Gallo says. 

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Atopic dermatitis: Timely access is needed now

Moderate-to-severe atopic dermatitis (AD) is not just an itch and may not just go away on its own.

It is neither a small rash nor just some dry skin, and it doesn’t only impact children.

The fact of the matter is that one in three pediatric AD patients have moderate-to-severe disease. Not all will outgrow their AD; those that don’t face a lifetime of disruptive symptoms. A lifetime of intense itching, redness, inflammation and discomfort can have a profound impact on an individual’s physical and emotional well-being.

Misunderstandings about the complex nature of the condition means that AD is often managed with less-than-optimal outcomes. However, too many people require more than just topical and anti-inflammatory treatment. In fact, millions who live with moderate-to-severe AD without the necessary treatment experience lifelong implications, impacting life events such as education, career, marriage and personal family decisions.

Furthermore, AD has implications beyond the individuals living with it. Being a caregiver for someone living with AD can have substantial mental, physical and financial consequences. For example, research has shown that parents can spend approximately 22 hours a week applying any treatment they can find for their children – including moisturizers, wet wraps or bleach baths – to alleviate painful, chronic, debilitating flare-ups of inflamed, raw and bleeding skin.

Ensuring children with AD and their caregivers have appropriate access to effective treatment can be vital to address the frustrating, inefficient and recurring cycle of time-consuming visits to general practitioners.

Ensuring children with AD and their caregivers have appropriate access to effective treatment can be vital to address the frustrating, inefficient and recurring cycle of time-consuming visits to general practitioners to try and manage symptoms and stop chronic flare-ups. Importantly, this approach would not only improve health outcomes, but it could also positively impact AD patients and their families.

Impact of AD is beyond the visible and the individual

While it is easy to think of AD as a skin disease, the lifetime impact of the condition on a person is more than what people see.

While it is easy to think of AD as a skin disease, the lifetime impact of the condition on a person is more than what people see.

For instance, missing school and social activities can become a normal occurrence for children with severe AD. Their daily routine is frequently overshadowed by appointments, treatments and flare-ups, as well as the emotional burden of shame and low self-confidence about their physical appearance. This burden results in some children struggling to keep up with their peers, which has a bearing on their quality of life and their educational and social development. A study has shown that 12.5% of children under three who have severe AD experience developmental delays in motor skills, communication, relationships and play.

An often-overlooked aspect of living with AD is that the condition can lead to significant sleep disturbances, often caused by persistent itching.

“Sleep is a huge factor that’s affected by AD and lack of sleep affects every aspect of your life. It doesn’t allow you to concentrate in school if you’re sleep deprived [and] you’re definitely more moody,” explained Dr. Patrick Finklea, a pediatrician and parent of a child living with AD.

As children get older, AD-associated issues broaden the gap with their peers, leading to increased social difficulties, isolation and a significant mental health impact. According to a survey from the National Eczema Association, 20% of parents say that their child is bullied at school because of their eczema (including AD, the most common form of the condition) and 75% highlight that their child experienced lower self-esteem as a result.

In addition to the physical and emotional strain on caregivers, the financial burden of attempting to alleviate a child’s chronic symptoms, arising from lifestyle adjustments, lost wages and out-of-pocket costs, are substantial. Caregivers may also have to consider a career change or give up work altogether due to the demands of looking after someone with AD.

Act now to ensure a brighter future

It is vital to stop thinking about AD as a childhood issue – one that will be outgrown. Instead, it needs to be prioritized as a serious lifelong condition and recognized as a chronic and debilitating disease with lasting and profound impacts.

It is vital to stop thinking about AD as a childhood issue – one that will be outgrown. Instead, it needs to be prioritized as a serious lifelong condition and recognized as a chronic and debilitating disease with lasting and profound impacts; a disease that not only affects the individual but also the social ecosystem.

In Europe alone, the total direct cost to society associated with moderate-to-severe AD is estimated at €30B annually.

Given the substantial individual and societal costs of AD, decision-makers need to urgently implement an effective response to meet the needs of patients. In Europe alone, the total direct cost to society associated with moderate-to-severe AD is estimated at €30B annually. Therefore, prioritizing investment in early and effective AD interventions – including timely access to specialists and effective treatments – can have significant impacts on the overall cost and outcomes of disease management.

As MEP Sirpa Pietikäinen (EPP, Finland) said at a POLITICO Spotlight debate last year, “Countries always reimburse the cheapest drug on the market, then the next cheapest, then the next one. This ladder approach is wasting money and enabling the condition of the patient to deteriorate so much they can’t recuperate.”

We call on decision makers to implement evidence-based policies to improve access to care and prioritize timely intervention to manage AD – all with the aim to advance the health and well-being of individuals and contribute to the long-term economic and social prosperity of society.

MAT-GLB-2305184 V1.0 | October 2023

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