Interview with Bernard Mossé, scientific director of NEEDE Méditerranée, with François Crémieux, general manager of the Public Assistance Hospitals of Marseille (APHM) and Émilie Garrido-Pradalié, director of innovation at APHM.

#1 The direct and indirect impacts of the ecological crisis on health issues

One of the essential missions of the Assistance publique-Hôpitaux de Marseille (APHM) is to reduce health inequalities and access to care, including prevention, education, and support for illness. The Marseille context requires the development of exceptional measures related to poverty: migrants living on the streets or in shelters, unaccompanied minors, insecure women, drug addicts...

The ecological crisis is one of the direct or indirect causes of these difficult health situations: aggravated living conditions, notably due to climate disruption affecting living conditions, housing, mobility, or life expectancy; respiratory problems linked to air quality changes in large cities...; or directly with the emergence of new diseases or the migration of vector-borne diseases.

These conditions impose an increased responsibility on the public health service, which must adapt itself to limit the hospital's impact on its environment; and open up by working in complementarity with the associative world, the liberal world, with primary care medicine, for example in the treatment of disabilities or street psychiatry. And open health centers in neighborhoods where there is nothing...

In accordance with the missions and values of its 18,000 professionals, the APHM supports the project to create a hospital ship intended not only for rescues and care for shipwrecked individuals in the Mediterranean but also for their support until they are brought ashore in a safe place.

Bernard Mossé: We will discuss together the impacts of the ecological crisis on health. Can you provide us with a general overview, given the problems you face in your leadership roles at the Hospitals of Marseille?

François Crémieux: In the face of such a broad question, I would distinguish between indirect impacts and direct impacts. There is a major impact of climate disruption both on the living conditions that depend on the good health of populations and on diseases directly linked to the environment.

The first is the indirect impact of the ecological crisis on health. We observe it in major climatic events that impact social cohesion, mobility, education, urban organization, etc. The ecological crisis influences health factors such as demographics, life expectancy, educational conditions, and notably on mobility, which I will return to. Therefore, the first observation, without a direct link to the care provided by the public assistance, is that the ecological crisis has a major impact on living conditions. And thus on the interactions between the various large spaces on a global scale.

Then there are impacts that go further and are direct impacts on disease and on everything we call “environmental health.” I particularly see the emergence of new diseases linked to climate disruption, or the displacement of diseases that were historically contained in certain regions of the world and are now moving. In particular, vector-borne diseases. For example, diseases transmitted by mosquitoes that were previously confined to tropical areas are now moving towards our regions due to climate disruption.

To summarize, a first impact on populations and a second on diseases. That is my somewhat general response to a question that is equally broad.

Bernard Mossé: Is this an impact that you are already feeling concretely in the hospitals of the APHM?

Émilie Garrido-Pradalié: Yes, of course, there are concrete examples of changes in care, particularly in the pulmonology services of the Nord hospital where new analyses on health are developing, and actions are increasingly focused on prevention regarding people's exposure to dangerous contexts: whether related to housing, the professional environment, or air quality changes in large cities like Marseille...

Bernard Mossé: Are you referring to allergies or heatwave episodes? Have you measured the increase in these cases in the hospitals?

Émilie Garrido-Pradalié: Well, as a good Mediterranean, I would say that the issue of heat and heatwaves is not addressed by populations in the same way everywhere in France, nor around the Mediterranean.

François Crémieux: To go in the same direction, it is clear that the heatwave of 2003 was an opportunity for massive awareness in northern France of our inadequacy both in terms of living conditions and patient care: the heatwave primarily killed elderly people in northern France, a geographical area that was not accustomed to caring for these individuals who themselves were not educated in managing heat. The south of France, which was certainly not spared, had significantly fewer deaths. And we see that since the heat episodes, we are now, both in terms of training professionals, training caregivers, training patients themselves and their relatives, much better equipped to handle temperature spikes than we were 20 years ago. That was indeed 20 years ago, not really yesterday! And so, yes, we feel that there has been both an awareness and an adaptation.

But another important element to note regarding environmental impact is that, until now, the question of the link between environment, living conditions, and health conditions was generally perceived as reserved for populations in exceptional and unfavorable situations. For example, those living in particularly degraded housing or working conditions. Everyone has been aware for a long time that working in extreme temperature conditions, hot or cold, is a source of risk. But there was still the idea that, overall, this concerned limited, targeted populations, and that if we acted locally, we could solve the problem. We have recently realized that this is not the case, that the impact of the environment on our health concerns everyone and not necessarily in the same way. I think there is an awareness that the conditions in which we are housed, educated, transported, and cared for all have a global impact on our health. This is the consequence of the emergence of the concept of “One Health”, of one health; the awareness that we live in an “ecosystem,” to borrow a trendy term, which means that our health is at least as dependent on the environment in which we live as on what we can do ourselves.

BM: In this regard, concerning the heatwave, but we can extend it to other areas such as water management, do you not think that Northern countries have a lot to learn from the behaviors of Southern countries, as they have been accustomed to the issues of water stress and heat for much longer?

F.C.: I think that, in general, there are two facts that explain what you just said. Firstly, it happens that the South has been facing environmental rigor issues for a long time, even if we are all the south of someone else; but overall, the South has developed strategies around the relationship with nature, whether it is irrigation, managing heat, sunlight, wind, cold, sand, etc. And so indeed, there is much to learn from Southern countries because they have this experience of confronting environmental adversity.

The second reason why we have much to learn from the South is that the North has largely compensated for its wealth: through air conditioning in summer, heating in winter, and medications. So, do we have much to learn from the South? Probably, but we also have much to transfer to the South that has allowed the development of the North, particularly in terms of infrastructure, equipment, technology, science, etc.

This better distribution of development is all the more necessary today as we are increasingly interdependent, especially regarding health.

Biographies

François Crémieux is a senior health official with a unique and diverse background. He holds degrees in economics from the universities of Paris Dauphine and Lancaster (UK) and in public health from the Paris Diderot medical school. Since June 2021, he has been leading the Assistance Publique-Hôpitaux de Marseille, the APHM. He has had a long career as a hospital director, taking him from the Clermont hospital center in Oise to the hospital in Kosovska Mitrovica in Kosovo, including advisory roles with Marisol Touraine, Minister of Social Affairs and Health, and as deputy to the General Directorate of APHP under Martin Hirsch. His commitment is reflected in various actions: a volunteer in Bosnia in the 1990s during the war; a long-time member of the editorial board of the journal Esprit; an advocate for a frontline hospital to reduce social inequalities in access to care.

Emilie Garrido-Pradalié is a hospital director in charge of innovation at the APHM. She holds degrees in theoretical and applied economics from the University of Montpellier and in computer science and information systems from the École des Mines d'Alès. She began her career in the public service within the Metropolis of Montpellier led by Georges Frêche. She joined the CHU of Montpellier in 2008 to lead change management activities with human resources, medical and non-medical staff, and then the APHM to lead research from June 2018.

Bernard Mossé is a historian, responsible for Research, Education, and Training at the NEEDE Mediterranean association. He is a member of the Scientific Council of the Camp des Milles Foundation – Memory and Education, for which he was the scientific leader and coordinator of the UNESCO Chair “Education for Citizenship, Human Sciences, and Convergence of Memories” (Aix-Marseille University / Camp des Milles).