Rethinking Disease Preparedness: Incertitude and the Politics of Knowledge.

This paper argues for a rethinking of disease preparedness that puts incertitude and the politics of knowledge at the centre. Through examining the experiences of Ebola, Nipah, cholera and COVID-19 across multiple settings, the limitations of current approaches are highlighted. Conventional approaches assume a controllable, predictable future, which is responded to by a range of standard interventions. Such emergency preparedness planning approaches assume risk - where future outcomes can be predicted - and fail to address uncertainty, ambiguity and ignorance - where outcomes or their probabilities are unknown. Through examining the experiences of outbreak planning and response across the four cases, the paper argues for an approach that highlights the politics of knowledge, the constructions of time and space, the requirements for institutions and administrations and the challenges of ethics and justice. Embracing incertitude in disease preparedness responses therefore means making contextual social, political and cultural dimensions central.

[Tolerating uncertainty: Towards a competence-based approach]. / Faire de la tolérance à l'incertitude une compétence médicale.

Uncertainty in inherent to every aspects of medical practice. As the concept of uncertainty in healthcare is still to explore, deciphering the determinants and the roots of this uncertainty would benefit from the insights of various disciplines, such as epistemology, sociology, mathematics, or philosophy. The urgent need to improve physician's ability to cope with uncertainty, has been recently highlighted by the COVID-19 pandemic. Besides, the concept of uncertainty tolerance has been proposed, and could serve as a relevant basis for approaching uncertainty, in medical education. Thus, we propose at first to discuss the uncertainty tolerance framework from Hillen et al. Then, from an educational perspective, we outline some avenues regarding how uncertainty tolerance could be thought, in a competence-based approach, and discuss several educational activities, which have proven efficient in promoting uncertainty tolerance among medical practitioners abroad.

Troubles musculo-squelettiques, pratique instrumentale et ressentis des musiciens d'orchestre professionnels en confinement dû à la COVID-19

Résumé Introduction: Les musiciens d’orchestre professionnels souffrent fréquemment de troubles musculo-squelettiques liés à leurs conditions de travail. Au printemps 2020, le confinement et l’arrêt des activités professionnelles liés à la pandémie de la COVID-19 pouvait présenter une opportunité de récupération mais également augmenter leur incertitude professionnelle et être source d’émotions négatives. Objectif: Le premier objectif est d’évaluer l’évolution des troubles musculo-squelettiques des musiciens professionnels liée à l’arrêt des activités professionnelles provoqué par la COVID-19. Le second est d’examiner l’impact de l’incertitude professionnelle générée par la pandémie et le confinement sur la pratique instrumentale, en fonction des émotions qu’elle a provoquées. Méthode: Un questionnaire sur la pratique instrumentale et les troubles musculo-squelettiques a été renseigné par 439 musiciens d’orchestres français en 2019 (période d’activité professionnelle). Pendant le confinement (avril 2020), un second questionnaire portant sur ces variables ainsi que sur l’incertitude professionnelle, les émotions, l’épuisement émotionnel et le vécu du confinement a été renseigné par 172 musiciens. Résultats: La pratique instrumentale et la prévalence des troubles musculo-squelettiques ont chuté entre les périodes d’activité et de confinement. L’incertitude professionnelle pendant le confinement corrélait aux émotions négatives. L’épuisement émotionnel médiatisait les relations entre l’incertitude et l’effort perçu à pratiquer son instrument, d’une part, et le plaisir ressenti, d’autre part. Conclusion: Pour les musiciens d’orchestre confinés, l’incertitude était associée aux émotions négatives. Jouer de son instrument demandait plus d’effort et n’était pas un facteur de bien-être, soulignant les difficultés pour une reprise de l’activité professionnelle dans des conditions qui limiteraient le risque de blessures. Introduction: Professional orchestra musicians frequently suffer from musculoskeletal disorders related to their working conditions. In the spring of 2020, the lockdown and the interruption of their professional activities because of the COVID-19 pandemic could have presented an opportunity for them to recuperate but could also have increased their professional uncertainty and been a source of negative emotions. Objective: The first objective is to evaluate the evolution of musicians’ musculoskeletal disorders in relation to the interruption of their professional activities due to COVID-19. The second is to examine the impact of professional uncertainty caused by the pandemic on their instrument practice as a function of the emotions it generated. Method: A questionnaire concerning instrument practice and musculoskeletal disorders was completed by 439 French orchestra musicians in 2019 (period of professional activity). During lockdown (April 2020), a second questionnaire measuring these variables as well as professional uncertainty, emotions, emotional exhaustion, and the lockdown experience was completed by 172 musicians. Results: Instrument practice and musculoskeletal disorders decreased between the periods of activity and lockdown. Professional uncertainty during lockdown correlated with negative emotions. Emotional exhaustion mediated the relations between uncertainty and the effort perceived when practicing one’s instrument on the one hand and the pleasure experienced during practice on the other. Conclusion: For orchestra musicians in lockdown, uncertainty was related to negative emotions. Playing their instrument required more effort and was not associated with well-being, emphasizing the difficulties regarding the resumption of their professional activity in conditions which would limit the risk of injury.

Manage the risk in precariousness situation: The example of epidemic of COVID-19

This article will analyze the risk of individuals living in precarious conditions, under the perspective of uncertainty. Results came from the analysis of weekly phone conferences and individual interviews (15) during the period from April to July 2020. Attitudes toward risk are above all plural, and can be related to the diversity of dimensions of precariousness and risk representation, but also to others determinants that shape behaviour. Risk representations in those times are uncertain yet steeped by fear, partially because of this group vulnerability to the disease (comorbidity). People organize their way of seeing the world in time of pandemic through the perception of protected and unprotected spaces, symbolic (the home) or social spaces. It allows them to reduce the uncertainty and the feeling of powerlessness, and also to continue to overcome the day to day life. Equally, fatalistic discourses hold this function against the uncertainty and lack of control that constitute their life's. The data, captured in the immediacy of experience and analyzed within sociological and anthropological frameworks, informs the way those people appropriate the measures recommended by public health authorities. © 2022 Elsevier Masson SAS

Trompe-la-mort

Résumé Contexte L’incertitude est consubstantielle de la pratique psychanalytique, fondée sur une ouverture à l’inconnu. La règle fondamentale en institue l’expérience au fondement de la cure. Elle est tout à fois la réponse méthodologique la plus ajustée aux logiques du sexuel infantile et le ressort privilégié de son appropriation subjective. Objectifs L’auteur souhaite opposer à cette incertitude féconde une incertitude fondée sur une dépendance vitale qui, sur fond de lien passionnel, tend à figer le processus analytique et vise la destruction de la cure. Partant, il s’agit de problématiser le régime d’incertitude propre à l’expérience-limite. Cette expérience de « lutte à mort contre la mort » s’engage lorsqu’une emprise apparemment sans issue s’exerce sur un être humain et le dépossède « d’un droit impersonnel à la vie » (N. Zaltzman, 1998). De quels ressorts la pratique psychanalytique dispose-t-elle dans un tel contexte ? Méthode L’auteur s’appuie à la fois sur une pratique clinique de psychanalyste et son travail de superviseur auprès d’équipes confrontées à des cliniques de la grande précarité. Les champs anthropologiques ou artistiques sont également convoqués pour explorer les logiques de l’expérience-limite. L’auteur met à l’étude le concept de pulsion anarchiste proposé par Nathalie Zaltzman : il en propose un réexamen critique tout en soulignant sa grande valeur sur le plan clinique. À l’horizon de ce questionnement, l’auteur interroge la psychanalyse au regard de la crise environnementale, pensée comme expérience-limite à venir. Résultats Quelles sont les ressources d’une psychanalyse aux prises avec l’expérience-limite ? Le travail clinique en régime anarchiste assure la constitution d’une résistance singulière au cœur des zones de mort. Elle a vocation à armer psychiquement les sujets pour soutenir une capacité à jouir de l’existence malgré tout, sans sombrer dans la psychose, l’apathie, l’aliénation. Traversée par l’expérience-limite (la crise de la Covid-19, par exemple), une psychanalyse travaillée par la pulsion anarchiste peut, en retour, entreprendre un travail de réexamen de ses fondements et de déplacement de ses paradigmes fondateurs. Conclusion Ce texte interroge les changements de paradigme cliniques et théoriques requis par un régime spécifique d’incertitude, celui de l’expérience-limite. Le questionnement clinique se double d’une interrogation anthropologique, sur fond de crise environnementale. Ce texte constitue une première approche et s’efforce de poser quelques jalons au cœur d’un chantier considérable. Background Uncertainty is consubstantial with psychoanalytic practice, which is based on an openness to the unknown. The fundamental rule institutes the experience on which the treatment is based, and is, at the same time, the most appropriate methodological answer to the logics of infantile sexuality and the motor of its subjective appropriation. Objectives To this fertile uncertainty, the author opposes an uncertainty based on vital dependancy that, on account of passionate bonding, tends to freeze the analytic process and threatens to destroy the cure. Therefore, it is a question of problematizing the regime of uncertainty proper to limit-experiences. This experience of “death struggle against death” is engaged when an apparently hopeless hold is exerted on a human being and dispossesses him/her “of an impersonal right to life” (N. Zaltzman, 1998). What resources does psychoanalytic practice have in such a context? Method The author draws on both his clinical practice as a psychoanalyst and his work as a supervisor of teams confronted with situations of extreme precarity. Anthropological and artistic fields are also called upon to explore the logic of the limit-experience. The author examines the concept of the anarchist drive theorized by Nathalie Zaltzman: he proposes a critical re-examination while underlining its great value on the clinical level. In the wake of this questioning, the author questions psychoanalysis with regard to the environmental crisis, conceived of a limit-experience to come. Results What resources does psychoanalysis possess in its struggles with limit-experiences? Clinical work in the anarchist regime secures the constitution of a singular resistance in the heart of the death zones. Its vocation is to psychically arm subjects with a capacity to enjoy existence in spite of everything, without sinking into psychosis, apathy, or alienation. Marked by a limit-experience (the Covid-19 crisis, for example), a psychoanalysis worked-through by the anarchist drive can, in return, undertake the work of re-examining of its foundations and of displacing its founding paradigms. Conclusion This text questions the clinical and theoretical paradigm shifts required by a specific regime of uncertainty, that of the limit-experience. The clinical questioning is coupled with an anthropological questioning, against the background of the environmental crisis. This text constitutes a first approach and tries to lay down some milestones in the heart of a considerable construction site.

[Patient experience, epistemic authority and health challenges: the example of long COVID]. / Expérience patient, autorité épistémique et enjeux sanitaires : l'exemple du Covid long.

Since February 2020, hundreds of thousands of patients have been left with persistant symptoms after their infection. Along with their clinicians, these patients are exposed to a high degree of uncertainty and the urgent need to produce conceptual frameworks aimed at recognising, treating and validating their experience as patients suffering from new and protracted symptoms and witnessing debates as to how these symptoms should be qualified. In this respect, long covid illustrates the need to combine the collective experiential knowledge of patients and scientific knowledge for the benefit of the patients, clinicians and research.

[From hero to deserter, figures of the caregiver at the time of COVID-19]. / Du héros au déserteur, figures du soignant au temps de la Covid-19.

In the context of the COVID-19 pandemic, psychologists from various departments of a hospital centre in the Paris region intervened with the establishment's nursing and non-nursing staff. They gathered testimonies related to the experience of the first wave of this health crisis. They offer their interpretation of the event, which highlights the climate of uncertainty that reigned, both in its health and political dimensions.