Didier Sicard is a leading French specialist in infectious diseases, a former head of the internal medicine department at the Cochin public hospital in Paris and emeritus professor of medicine at the Paris-Descartes university, who was for eight years, until 2008, head of France’s bioethics advisory committee, the Comité consultatif national d’éthique pour les sciences de la vie et de la santé, for which he continues to serve as an honorary president.

Sicard, 83, was also closely involved in establishing an overseas branch of the Institut Pasteur in Laos, whose principal mission is the prevention of infectious diseases in the country and the wider South-East Asia region.

Mediapart turned to him for his expert insight into the current Covid-19 virus pandemic. In this interview with Joseph Confavreux, he explains why such a pandemic was predictable – and indeed was predicted – long ago and why others of the sort remain probable unless the source of such infectious diseases is not rooted out, notably the illicit trade in wild animals for sale in wet markets. Medicine, he says, “can only be effective if one considers a wide view of society, one which is not limited to scientific data”.

Sicard believes the World Health Organization, funded by states it “cannot displease”, is incapable of effective action in such crises and calls for the establishment of an independent international medical authority of experts to investigate health issues.

He also argues that the unpreparedness in France for coping with such a crisis (as has also been evident in other countries) is the result of many years of deterioration – and not only budgetary – of its healthcare system. He believes it has lost sight of its founding mission as a public health service, and that the clinical examination of patients has lost place to a focus on scientific wizardry.

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Mediapart [Joseph Confavreux]: What is your view, as a specialist in infectious diseases, on this virus?

Didier Sicard: I am surprised at its violence, even if a third or half the people who come into contact with it present no symptoms, and its capacity to trigger an immune reaction which is what causes all its seriousness and can kill you within a few hours if you’re not taken into care by a well-structured intensive care unit. What is excessive is the body’s reaction – more than the virus itself – which overwhelms the capacity of the organism.

It is certain that the virus comes from bats, which undoubtedly have the most solid immune system of all the mammals present on the planet. They have established a considerable line of defence against this virus, which does nothing to them, and it is probable that the virus, in order to overcome the immune response of bats, has had to rise in scale and increase its virulence and its aggressiveness. The human system is in all probability surprised by what it judges to be a significant aggression, totally new and, in panic, triggers such an immune response that it cannot be endured by the organism.

Mediapart: Did you expect to witness anything of the order of what we are experiencing at the moment?

D.S.: Yes, absolutely. All the medical students I have had before me during the past 40 years can testify to that. I have always said that our incapacity to reflect on our contacts with the animal world would trip us up. If we hadn’t gone and cut up a few big monkeys in the Congolese forest we would never have had Aids, which first transmitted itself from monkeys to humankind. We are in a chain of perpetual relation with animals.

Apart from cancers, the most important diseases causing immune system inflammation are almost all transmitted by animals. We should consider ourselves as being part of a living chain that includes cows just as much as coleopterous insects. That reminds us that we are extremely vulnerable, but also that, as used to say [French clinical researcher] Jacques Leibowitch, a doctor and specialist of Aids who recently passed away, we are all the stronger by being conscious of our place in the living order.

Mediapart: What are the benefits that could be found from the investigation which you call for into animal origins of the current disease?

D.S.: All our current energy is concentrated on the arrival point of the virus – medicines, a vaccine, intensive care – but the point of origin is just as important if we want to understand what is going on today, and to avoid a new, yet more dangerous epidemic tomorrow. In the same way that we investigate the origins of food in a restaurant which led to food poisoning, it is necessary to investigate the animal origins of the current epidemic.

We haven’t explained everything as of the moment we’ve said that bats are the origin of the virus. In this instance, the pangolin, like the civet during the SARS epidemic, was no doubt the intermediary host of the virus, between bats and humans. But the problem resides in the flourishing market for pangolins, although theoretically banned, and in the fact of having placed together bats and pangolins in the [wet] markets.

China buys for a fortune these animals supposed to have considerable therapeutic value. This leads to a rampant consumption of bats, which live a long time and without cancer, in the cause of an absurd amalgam according to which, by ingesting them, one can benefit from these virtues – as also with the scales of pangolins which are reputed for the sexual potency they are supposed to provide.

The Chinese have thus got hold of the African pangolin with clandestine networks, notably via Nigeria, producing in this way consumption on a scale which didn’t exist before, even if some pangolins from Laos or northern Vietnam were already consumed. Science of course needs to work on genomes, but also to understand the consumption of wild animals, the trading circles. If the medical sector leaves all these issues to economists we will not understand what’s really going on, and medicine can only be effective if one considers a wide view of society, one which is not limited to scientific data.

It would appear that there is also an amplificatory effect of placing together animals on the markets, with a threshold effect, in which the contagiousness is not the same at a certain level of concentration which remains to be determined, but which shows a logarithmic rise in the possibility of contamination – which would not be at all the same according to whether we are talking about a few individuals in contact with others, or [in the case of] several hundreds.

Mediapart: What is your opinion of the response in France to this epidemic?

D.S.: The current government finds itself at the end of a process that goes back over several decades. I have for years witnessed a deterioration in the medical capacity of hospital response provisions, of teaching conditions and an abandoning of the public health system, of which the government of [current French Prime Minister] Édouard Philippe is simply the heir. France, which was a major country in public healthcare provision, has totally abandoned this view on general healthcare of populations, as is demonstrated by the total disinterest of students in the discipline, which only the least well-graded take up.

Even if there are excellent individual public health specialists, there is no prestigious school that attracts students such as is the case at Harvard, where public health is just as renowned as oncology or immunology. The creative energy that one finds in oncology, in surgery or in molecular biology does not carry through to vaccination, patient blood management, the problems of alcohol or tobacco. The “safety-first principle” has ended up as serving as public health policy.

I can recount a cruel experience regarding this issue. In 2015, the Haute Autorité de Santé [‘The high authority for health’] asked me to preside over an international conference on reducing risks for drug users. It was the result of a year’s work, with an exceptional bibliography carried out by Inserm [France’s national institute for health and biomedical research]. We organised 48 hours of conferences at the health ministry, with experts from all over the world who sent their reports in advance. We gathered together with a large jury composed of doctors, nurses, police officials, drugs users, associations and magistrates. And we concluded with a unanimous, 18-page report notably calling for the abrogation of the 1970 [French] law on the criminalisation of drugs which prevented users from going to hospital, and [the need] to lead a true public health policy.

We asked for the publication of this report, but the Haute Autorité de Santé, then led by Agnès Buzyn [later French health minister, 2017-2020], simply replied, “I do not support your conclusions”. That illustrates the indifference towards public health in our country, caught in a vice between the interests of different lobbies and the indifference or impotence of ministers.

Mediapart: Is it not simply for budgetary reasons that there is this deterioration in hospitals and the public health system?

D.S.: No, it’s neither uniquely nor principally a problem of money, as demonstrated by the fact we spend as much – even more – on health than Germany. The problem is more profound. Since for about 15 years, a ‘hospital economy’ model has been encouraged which has led to an absolute split between patients who bring in money, like those who need protheses or plastic surgery, and those who cost money, like users of alcohol and drugs, or chronic patients and those in precarity. Hospitals were, silently and structurally, placed in the trap of telling themselves “if we don’t take the patients who bring in money we will no longer be financed”. And they thus completely neglected public health.

The counter-adjustments were made on nurses’ salaries, and recruitment, and the whole of hospital personnel has the impression that their establishments have forgotten their public service mission. This despondency among doctors and nursing staff is not only linked to government policies but also with medical care itself, which now only considers to be noble that which appears to be scientific. Many doctors, with a passion for medical imaging, the wizardry of the latest scanner or the deciphering of a new genome, hardly have an interest anymore in the clinical examination of a patient, above all when it’s a drug or alcohol user.

This is witnessed also in the poor consideration with which society regards general practice doctors, from who hardly nothing is expected other than a prescription or being sent to a specialist doctor, whereas they have unique expertise. Lots of medical students finish their studies without having learnt how to examine a patient by touching them.

So we are not faced with a political or budgetary problem in the usual sense of the term, but rather faced with a multi-factor phenomena of collapse for which it would be too easy to make a scapegoat of the current government. The responsibility for the current crisis seems to me to be shared. I don’t remember many doctors sounding the alarm about the number of [stocks of protective] masks or tests [for virus infection]. The fundamental problem is the abandonment of any general public health policy.

Mediapart: Do you believe there is a balanced relationship between the political executive and the scientific world, or do you see here weaknesses on one side or the other?

D.S.: It’s very difficult, because the politician must not base themselves on doctors because they would then lose independence. And the medical profession is not here either to lead the world. To place medicine as all-powerful, like to make ethics all-powerful, is a catastrophe. So it is necessary that the relationship be a close one, that scientific [advisory] councils be numerous, but I don’t believe that politicians should ask for a sort of stamp of approval from doctors and state that they take one or another decision because the medical corps demands it.

Mediapart: The French president has announced a major programme for the hospital system. Do you believe in the possibility of a true turnaround in policies towards hospitals?

D.S.: Yes, I think there is a possible emergence of awareness of the deterioration of response provisions and the sufferance experienced by healthcare staff. The problem is that we don’t have an organisation chart for public health capable of reconstructing what has been damaged. Usually, it is leading specialists in one type of disease or another who are asked to give their advice or establish reports. And the question of knowing who we provide care to once again threatens to prevail over that of why and how we provide care.

France is without doubt a paradise for healthcare when one is a seriously ill patient, for example suffering from cancer. But it totally overlooks the social fabric of morbidity, the [social] precarity which predisposes people to diseases, and also handicaps. The spotlights remain focussed on those eminent doctors who interest themselves in major illnesses and the very ill, whereas those who concentrate upon public health are considered to be just dreamers or humanitarian workers.

Mediapart: Paradoxically, in the current situation hospital doctors have nevertheless regained a form of power, in the noble sense of the word.

D.S.: Yes, for the simple reason that they have found themselves carrying out the essence of their profession, namely being close to patients, diverting death, in a situation where each gesture can save a life or not manage to do so. In this context, the question is no longer asked about whether the patient brings in money or not, if they are rich or poor, useful or not. And the hospital financial director who might come to visit the service would be chased away with raised slippers!

The administrative powers in hospitals have become such that they distress doctors. When I was chief consultant at the Cochin hospital [in Paris], I already used to worry about spending too much money on one or another patient. I asked myself if the aim of the hospital was compatible with that of one or another patient. Today, the distress is much worse, and the feeling of a loss of direction is such that many of my colleagues have said to me lately, “You’re lucky to be retired, you wouldn’t be able to stand the atmosphere anymore”.

Mediapart: What did you learn from your time in Laos, where you practiced medicine and helped to set up a branch of the Institut Pasteur?

D.S.: It taught me that when one doesn’t have sophisticated means of investigation, one must look at day-to-day gestures, at people’s lives, behaviour. That’s how, when I was a doctor there, I was able to bring to light an epidemic of beriberi by observing how people cooked rice.

In the middle of the 19^th century in Vienna, Ignaz Semmelweis, who was then a young medical student, observed how, in a maternity ward, almost 20 percent of women died giving birth, whereas they numbered just 2 percent in another hospital. Without knowledge of the germ theory, he had made the link with the fact that in one service medical students came to help with giving birth, which was not the case in the other. Now, these students carried out post mortem examinations in the morning, and thus transmitted diseases in the afternoon. Semmelweis was a pioneer in [the required practice of] hand washing, but he was looked down upon by the doctors who had a supreme contempt for such matters which appeared little scientific. Global observation remains however the basis of all medical work.

Mediapart: You have called for the creation of an international health tribunal. What would this be?

D.S.: I am not a constitutionalist, but I think that the World Health Organization [WHO] doesn’t have the capacity to do anything because it is in the hands of states. I had direct experience of this 40 years ago. Doctor Hiroshi Nakajima, who was then head of the institution, was looking for a doctor to investigate the ‘barefoot doctors’ in China. That was how my interest in Asia led me to spend two months in a small village close to Shanghai, where I was able to watch these young people – trained over a few months – inject cortisone in cases of the slightest fever, a medicine that works well in the short term, using non-sterilised syringes and in this way transmitting hepatitis B and C.

When I gave my final report to the WHO branch in Manilla, which was at the time headed by a Chinese man, I explained that these young people were useful for providing primary care, but that they shouldn’t carry out injections without having better medical foundations; and I was told that that it was totally unthinkable to write up such a report.

Whatever the qualities of people who work at the WHO, this organisation cannot displease states which compose it and finance it, and so [cannot] provide information and engage in necessary action. I therefore argue for an international structure, like that created regarding Iran and the nuclear issue, with leads controls by independent specialists. At the slightest alert by the specialists, an international task force could then intervene and, if need be, transfer cases to an international high tribunal. The terrestrial globe as it exists needs a supranational structure that carries authority if we don’t want epidemics of this type [Covid-19] to multiply in the future.

Mediapart: As a former president of France’s bioethics advisory committee [Comité consultatif national d’éthique pour les sciences de la vie et de la santé] do you believe that we are faced with new ethical challenges, and if so which?

D.S.: No. After my departure from the committee my successor produced excellent advice on epidemics, at the time of the H1N1 flu [virus strain]. Concerning accompaniment in death, I think we are looking at eternal issues. What is no doubt unprecedented is the confinement [lockdown on public movement] on such a scale, which is linked to the fact that we were caught off-guard, because of a lack of preventive and therapeutic means, but which in my opinion is more an issue of political and psychological problems than ethical questions.

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