Cette thèse s'inscrit dans le cadre du projet ANR HOST (Hôpital : Optimisation, Simulation et évitement des Tensions) qui vise à étudier et résoudre le problème de tension aux urgences hospitalières. Le projet cherche premièrement à définir rigoureusement la notion de tension et puis d'utiliser des outils mathématiques pour proposer des solutions qui prennent en compte la complexité du système de santé. Malgré la récurrence des phénomènes de tension, ils sont limités dans le temps et sollicitent par conséquent des solutions à court terme. La difficulté de trouver des solutions efficaces est principalement due à l'incertitude et au dynamisme caractéristique du service des urgences. D'une année à une autre, l'intensité de l'épidémie, et donc le nombre de patients se présentant aux urgences peut varier drastiquement. De plus, pour un même nombre de patients, il est difficile d'estimer correctement la charge de travail qu'il représente. L'objectif de cette thèse est donc de proposer des solutions stratégiques, tactiques et opérationnelles de gestion des ressources en prenant en compte les aléas caractéristiques des urgences. D'un point de vue stratégique nous étudions la distribution optimale de la capacité de travail sur une période épidémique. Ensuite, nous traitons le problème de confection des postes de travail journalier en fonction de la dynamique de la demande. Nous étudions également la possibilité d'affecter des postes d'astreinte aux médecins pendant les périodes épidémiques. Finalement, nous traitons le problème d'affectation des heures supplémentaires aux ressources dans un contexte plus opérationnel. / In France, the problem of overcrowding in Emergency Departments (ED) is particularly relevant today because of increasing admissions and budget restrictions in health establishments. Formally, overcrowding can be defined as a situation where the demand surpasses the service capacity. Studies that have dealt with ED overcrowding have mostly dealt with issues of patient flow management and resource management.Our work focuses on resource management and more particularly on the impact that human resources have on ED overcrowding. In the first part of the study, we formulate the capacity allocation problem in a generic form. As such, we examine the capacity management problem and derive interesting properties for a general demand distribution and a normal demand distribution. Then, we examine the cyclic shift scheduling problem as it exists in ED. This research allows us to examine different cyclic scheduling strategies and answer the question of whether lack of flexibility in the schedules has an impact on the waiting time of patients. We propose an original stochastic linear formulation for the problem that accounts for the non-stationary work demand. After that we evaluate two scheduling mechanisms to reduce overcrowding in EDs: on-call duties and overtime hours. We study the conditions under which these mechanisms can be beneficial. The on-call duties problem is modeled as a two-stage stochastic optimization problem and the overtime management problem as a Markov decision problem.

It is known that the epidemics changed the daily life of the populations bringing the fear of death as a companion of thousands of individuals in several Provinces of Brazil in the second half of the nineteenth century. Thus a set of actions of the provinces governments having as protagonists the medical hygienists were enlarged. Through the Public Hygiene Boards, visits were made to vessels, markets, warehouses, homes and in all spaces, and establishments that could cause damage to public health in the conception of such men of science. In this sense, this study entitled: The medical order on the flood: Hygiene and Epidemics in Imperial Alagoas (1850-1882) aims to understand the impact caused by the epidemics in the Province of Alagoas in the second half of the nineteenth century, and the main actions of physicians Sanitarians, amid the epidemiological outbreaks, as well as the changes in customs proposes by medical thought in this period. / FAPEAL - Fundação de Amparo à Pesquisa do Estado de Alagoas / Sabe-se que as epidemias mudaram o cotidiano das populações trazendo o medo da morte como companheira de milhares de indivíduos em várias Províncias do Brasil na segunda metade do século XIX. Assim, um conjunto de ações dos governos das províncias tendo como protagonistas os médicos higienistas foram ampliados através das Juntas de Higiene Pública que buscavam operar visitas às embarcações, aos mercados, armazéns, casas e em todos os espaços, e estabelecimentos que pudessem provocar danos à saúde pública na concepção de tais homens da ciência. Neste sentido este estudo intitulado: A ordem médica sobre o alagadiço: Higienismo e Epidemias na Alagoas Imperial (1850-1882) têm como objetivo compreender o impacto causado pelas epidemias na Província de Alagoas na segunda metade do século XIX, e as principais ações dos médicos sanitaristas, em meio aos surtos epidemiológicos, como também as mudanças nos costumes propostas pelo pensamento médico neste período.

Desde sua eclosão na década de 1980 na forma de epidemia, a AIDS tem sido principalmente associada a homossexuais masculinos: inicialmente partindo da literatura médica, essa visão espalhou-se também para o público leigo e mantém-se viva no imaginário popular, ainda que, a partir da década de 1990, tenha havido um movimento para reconhecer a parcela cada vez mais vitimada pela síndrome: mulheres heterossexuais. A essa progressão, deu-se o nome de feminização do HIV/AIDS, uma narrativa sobre uma suposta mudança no perfil da epidemia. No entanto, é possível encontrar informações sobre ocorrências da doença em mulheres desde muito antes, e é por meio de uma análise discursiva acerca do tema que este trabalho nasce: embora a epidemia da AIDS nunca tenha deixado de ter mulheres como parte expressiva de seus portadores, os discursos e narrativas desde 1980 vêm sistematicamente falhando em incluí-las e direcionar políticas de prevenção e combate que levem em consideração as particularidades das vivências femininas ou a complexidade de sua vulnerabilidades – parte de um sistema intricado de influência bidirecional entre cultura e materialidade. Utilizando metodologias, conceitos e textos de diversas áreas de produção de conhecimento, me proponho a analisar a inserção do corpo feminino na narrativa da epidemia HIV/AIDS privilegiando a historicidade e as diferentes versões desse objeto. / Since its occurrence in the 1980s in epidemic form, AIDS has been mainly associated to homosexual males: initially put forth by medical literature, this view spread to the non-expert audience as well and is kept alive in people’s imaginations, even though by the 1990s there has been a movement towards recognizing the group increasingly victimized by the syndrome: heterosexual women. This progression has been dubbed feminization of HIV/AIDS, a narrative about a supposed change in the profile of the epidemic. However, it is possible to find information about occurrence of the disease in women since much earlier, and it is through a discoursive analysis around the subject that this work came to be: even though the AIDS epidemic has never been without women as an expressive part of its carriers, mainstream discourse and narratives have since the 1980s systematically failed to include them and direct prevention and treatment politics that take into account particularities of femalehood or the complexity of its vulnerabilities – part of an intricate system of bidirectional influence between culture and materiality. By using methodologies, concepts, and texts from several fields of generation of knowledge, I propose to analyze the insertion of the female body in the HIV/AIDS epidemic focusing on the historicity and the different versions of this object.

A backbone network is the central part of the communication network, which provides connectivity within the various systems across large distances. Disruptions in a backbone network would cause severe consequences which could manifest in the service outage on a large scale. Depending on the size and the importance of the network, its failure could leave a substantial impact on the area it is associated with. The failures of the network services could lead to a significant disturbance of human activities. Therefore, making backbone communication networks more resilient directly affects the resilience of the area. Contemporary urban and regional development overwhelmingly converges with the communication infrastructure expansion and their obvious mutual interconnections become more reciprocal. Spreading failures are of particular interest. They usually originate in a single network segment and then spread to the rest of network often causing a global collapse. Two types of spreading failures are given focus, namely: epidemics and cascading failures. How to make backbone networks more resilient against spreading failures? How to tune the topology or additionally protect nodes or links in order to mitigate an effect of the potential failure? Those are the main questions addressed in this thesis. First, the epidemic phenomena are discussed. The subjects of epidemic modeling and identification of the most influential spreaders are addressed using a proposed Linear Time-Invariant (LTI) system approach. Throughout the years, LTI system theory has been used mostly to describe electrical circuits and networks. LTI is suitable to characterize the behavior of the system consisting of numerous interconnected components. The results presented in this thesis show that the same mathematical toolbox could be used for the complex network analysis. Then, cascading failures are discussed. Like any system which can be modeled using an interdependence graph with limited capacity of either nodes or edges, backbone networks are prone to cascades. Numerical simulations are used to model such failures. The resilience of European National Research and Education Networks (NREN) is assessed, weak points and critical areas of the network are identified and the suggestions for its modification are proposed.

La consanguinité, soit l'union productive de conjoints partageant des allèles identiques provenant d'un ancêtre commun, s'est accumulée au fil du temps au Québec ancien. Parallèlement, le Québec a été victime de plusieurs épidémies. Le but de cette étude est d'évaluer la relation entre la mortalité des enfants et la consanguinité dans les périodes épidémiques du Québec ancien entre 1720 et 1830. D'une part, l'hypothèse émise est que les enfants ayant des gènes homologues sur plusieurs loci auraient un taux de mortalité significativement plus élevé comparativement aux enfants non consanguins, en raison du désavantage des homozygotes. D'autre part, les individus consanguins peuvent avoir une survie plus favorable en raison de l'effet d’enracinement, combien de générations une famille est établie dans la colonie, présent dans la mesure de la consanguinité. De plus, l'avantage social d'une famille étroitement liée peut favoriser la survie de l'enfant en accordant plus de soutien social aux parents et de surveillance de l'enfant. Les courbes de survie de Kaplan-Meier sont représentées graphiquement et des modèles de régression de Cox sont exécutés pour explorer et démêler partiellement les rôles des facteurs génétiques et environnementaux. Les immigrants, les naissances multiples et les individus sans généalogie du Registre de la population du Québec ancien (RPQA) et de l'Infrastructure intégrée des microdonnées historiques de la Population du Québec (IMPQ) sont exclus. Au total, 610 412 individus sont analysés dans les modèles de Cox. Les rapports de risque pour les épidémies augmentent avec l'âge et les rapports de risque pour la consanguinité éloignée ressemblent souvent au groupe référence, les non consanguins. De plus, les effets diffèrent selon le sexe et le groupe d'âge. Généralement, si les enfants avec une consanguinité proche, ceux identifiés comme consanguins avec seulement trois générations ascendantes, ne subissent pas de surmortalité dans un groupe d'âge précédent, les modèles de Cox signalent une survie défavorable de ces individus lors des épidémies. Des effets sous-jacents tels que des processus de sélection et des variables de contrôle relatives à l’enracinement peu robustes guident les résultats de l'interaction entre les épidémies et la consanguinité, de sorte que la prémisse reste à valider. / Consanguinity, the productive union of spouses sharing identical alleles from a common ancestor, accumulated over time in Colonial Quebec. Concurrently, Quebec was the victim of several epidemics. The aim of this study is to evaluate the relationship between child mortality and consanguinity in epidemic periods of Colonial Quebec between 1720 and 1830. On the one hand, it is hypothesized that children with homologous genes on many loci would have a significantly higher mortality rate compared to non consanguineous children, due to homozygote disadvantage. On the other hand, consanguineous individuals may have a more favourable survival because of the effect of settlement, how many generations a family has been in the colony, present in the measure of consanguinity. Further, the social benefit of a closely bound family may favour child survival by providing more social support to the parents and child supervision. Kaplan-Meier survival curves are graphed, and Cox regression models are run to explore and partially disentangle the roles of genetic and environmental factors. Immigrants, multiple births and individuals lacking a genealogy from the Registre de population du Québec ancien (RPQA) and Infrastructure intégrée des microdonnées historiques de la Population du Québec (IMPQ) are excluded. Altogether, 610,412 individuals are analysed in the Cox models. Hazard ratios for epidemics increase with age and distant consanguinity hazard ratios often resemble the no consanguinity reference group. Further, the effects differ by sex and age group. Generally, if closely consanguineous children, those identified as consanguineous with only three ascending generations, do not undergo excess mortality in a previous age group, the Cox models signal an unfavourable survival of these individuals during epidemics. Underlying effects such as selection processes and unrobust control variables for settlement guide the results of the interaction between epidemics and consanguinity, so the premise, though convincing, remains to be validated.

The primary objective of this thesis is to differentiate between the risk factors for pre-and post-monsoon cholera epidemics in rural Bangladesh by analyzing the complex interaction between select environmental, cultural/behavioral, and socioeconomic variables over space and time. In rural Bangladesh, cholera epidemics correspond with the annual monsoon: the first, and smallest, occurs between March and June, while the larger cholera peak occurs between September and December. The differences between the spatial and temporal patterns of seasonal cholera are analyzed, and the risk factors are calculated for pre-and post-monsoon cholera epidemics. The theoretical approach that underlies this medical geographical study is disease ecology, which espouses that risk of disease is caused by an interaction between people and their environment. This thesis is structured around a holistic understanding that human-environment interactions are inseparable. In Bangladesh, the monsoon season typically starts between May and June. The 1992 and 1993 cholera peaks occurred just before the monsoon in April and March respectively, while the 1994 cholera peak occurred between April and June. In 1992 and 1993 cholera incidence increased in the post-monsoon period, and peaked in October. The 1994 post-monsoon cholera peak occurred in November. There is a regular temporal pattern to cholera, as the peaks followed a seasonal pattern with the smaller epidemic occurring in the pre-monsoon period and the larger epidemic occurring in the post-monsoon period. This study shows that there are different risks associated with pre-monsoon cholera epidemics and post-monsoon cholera epidemics. The two main risk factors associated with cholera incidence pre-monsoon were bari population (i.e., crowding) and a house located within the flood controlled area. These two variables were even more strongly associated with post-monsoon cholera incidence to a greater degree, along with a number of other variables including water use, sanitation practices, and socioeconomic status.

This thesis offers a detailed account of early polio epidemics (between 1918 and 1945) in Johannesburg, where the disease was particularly severe. At this time, little was known about the poliovirus, and such limited understanding affected the public health and medical initiatives taken during this period. These actions are highlighted in the thesis, along with the responses of the media and lay public to the disease. The effect of war on the management of the disease is also examined, as it siphoned off vital medical personnel and jeopardised disease control. It also lent an emotional overlay to the way the disease was perceived, as `battle' rhetoric became the parlance used against polio, which was personified as the `enemy' of innocent children who were disabled at the whim of the virus. The epidemic of 1944-1945 was the first to be systematically investigated, by Dr James Gear as part of his groundbreaking polio research; he later became part of an international team of researchers who contributed to the development of a prophylactic vaccine within a decade of this epidemic. / History / M.A. (History)

Asiatic cholera has been called the scourge of the nineteenth century, for it caused the untimely death of millions throughout the world. During its four visits to the United States, unknown thousands of Kentuckians fell victims to the disease. In attempting to prevent the dreaded scourge, Kentuckians became more conscious of the need for cleaner cities, pure water and adequate sewage disposal. Modern waterworks facilities, sewage treatment and disposal facilities have provided the means by which the United States has conquered this scourge of the nineteenth century, for with these facilities cholera is the easiest of all communicable diseases to prevent. But, as with the eradication of any disease, constant vigilance and continued use of modern scientific knowledge are necessary to prevent its return. The disease is presently ravaging India and the Far East, and with modern jet travel it could bypass quarantine stations and enter the United States undetected. The “seeds” of the pestilence could be sown across the nation within a few hours. The only safeguard is modern sanitation facilities, for no permanent inoculation or miraculous cure has been developed. Today many rural areas of Kentucky and other states use wells and old cisterns that are, or could easily become, contaminated by human fecal matter. A fifth visit from cholera should not be necessary to correct the ignorance and complacent attitudes concerning inadequate sanitation facilities that exist in these areas of the nation. This study attempts to show the horrors of cholera’s four visits to Kentucky, and how the fear of the disease stimulated interest in public health.

A atenção à saúde compreende múltiplas formas de prestação de serviços, sendo o hospital a instituição nuclear para os sistemas de saúde. Em maio de 2009 iniciou-se uma epidemia que evoluiu para escala mundial, com novo subtipo de vírus influenza identificado como Influenza A (H1N1)09pdm, caracterizado pela alta demanda de consultas e internações hospitalares, o que impactou na gestão e custos do serviço. O objetivo da pesquisa foi estudar o consumo de serviços hospitalares dos casos suspeitos e confirmados de Influenza A(H1N1)09pdm no Instituto Central do Hospital das Clínicas da FMUSP (ICHC-HCFMUSP), entre maio e dezembro de 2009. Tomando como informação inicial os registros do banco de notificações e do de saídas hospitalares do Núcleo de Informação em Saúde do HCFMUSP, foram selecionados 430 indivíduos que preencheram os critérios de inclusão da pesquisa e que levaram à 632 internações hospitalares. Em 26% (n=112) das pessoas e em 22,3% (n=141) das internações foi confirmada a suspeita para infecção por H1N1. Nas internações de casos suspeitos, a mediana de duração da internação foi de 5+17 (0-161) dias e 23,4% (n=148) foram admitidos nas UTIs, com mediana de internação 4,5+7,8 (0-46) dias. Nos casos confirmados, a mediana foi de 5+19,1 (0- 161) dias de internação e 26,9% (n=38) de internações em UTI com 5+8,3 (0-31) dias. O pico de notificações de casos suspeitos e confirmados foi no mês de agosto, com 31,6% (n=200 das 632) internações de casos suspeitos e 44% (n=62 das 141) internações de casos confirmados. A Influenza A(H1N1)09pdm impactou o consumo de serviços, mostrando-se presente em muitas enfermarias do ICHC, o que implicou grande consumo de procedimentos diagnósticos e terapêuticos / Healt care comprises multiple ways of services, where hospitals are the nuclear reference institution of health services. In may 2009, a new pandemic influenza vírus subtype was identified as Influenza A(H1N1)09pdm, wich was characterized by high demand for hospital visits and hospitalizations. This research aimed to study the hospital service expenditure on confirmed and non-confirmed hospitalizations associated with Influenza A(H1N1)09pdm at Instituto Central do Hospital das Clínicas FMUSP (ICHC - HCFMUSP), between May and December of 2009. It was analyzed the registers from the notification database and output hospital database from the Information Health Department. According to inclusion criteria, it was found 430 people with 632 hospitalizations with 26% (n=112) patients and 22,3% (n=141) hospitalization for confirmed cases. For non confirmed hospitalizations, the median length of stay was 5+17 (0-161) days with 23,4% (n=148) of ICU admissions with median length of stay 4,5+7,8 (0-46) days. For confirmed cases, the hospitalization length of stay was 5+19,1 (0-161) days with 26,9% (n=38) on ICU admissions with median length of stay 5+8,3 (0-31) days. The notification peak was on August with 31,6% (n=200 from 632) hospitalizations form non-confirmed cases and 44% (n=62 from 141) confirmed cases hospitalization. The Influenza A(H1N1)09pdm impacted on service expenditure, because of its distribution in several wards from ICHC wich implied high expenditure of diagnosis and therapeutic proceeds

Based on extended research on Chinese medical and epidemiological archival material dating back to the beginning of the 20th century, and on six months of internship in epidemiology in Beijing’s Medical School and in Haidian District’s Centre of Disease Control and Prevention, this thesis explores the conjunction of three major epidemiological crises in modern Chinese history with processes of State formation: the 1911 Manchurian pneumonic plague, the 1952 germ-warfare, and the 2003 SARS outbreak. Analysing the three crises as Events in line with Alain Badiou’s epistemology it seeks to establish how different strategies of governmental fidelity to the imagined cause of each crisis have led to distinct modes of organisation and valorisation of the social: Republican China and its decline to fascism; the clash between professional revolutionaries and technocrats in Maoist China; and the emergence of the “Harmonious Society” of mass exploitation and repression today. This conjunction between State formation and epidemiological Events is explored with the use of Foucault’s genealogical method in a quest for a historical materialist approach that posits at its epicentre processes of class composition, decomposition and recomposition, and their contested enclosure by the governmental apparati of capture. The present thesis thus examines the three major epidemiological crises of modern China as forming grounds for biopolitical strategies that give rise to modes of subjectivation and circuits of debt/guilt within the context of the class struggle. And at the same time, it aims to create a new field of investigation for anthropology: the relation of State and Event, from a viewpoint that contests the accepted relation of event and structure expounded by Marshall Sahlins, proposing as the main object of this investigation the conjunction between necessity and will that can never be reduced either to the naturalism of historical determinism, nor to the culturalism of subjective contingency.