Résumé généralIntroductionL’anémie est un problème majeur de santé publique particulièrement fréquent dans les pays à faible revenu, dont la RDC, et qui affecte avec prédilection les femmes enceintes et les enfants d’âge préscolaire. Elle est associée à un risque élevé de morbidité et de mortalité. Au cours de la grossesse, l’anémie peut entraver le développement du fœtus et peut affecter négativement la santé maternelle. Chez l’enfant, l’anémie peut en plus altérer le développement physique et mental si elle n’est pas rapidement corrigée. Il est généralement admis que la carence en fer est la première cause d’anémie et les stratégies de lutte suggérées par l’Organisation mondiale de la santé en découlent. Cependant dans la région du Kivu, il n’existe que très peu d’information sur les étiologies de l’anémie et sur la contribution du paludisme et de celle de la carence en fer dans sa genèse. L’objectif global de ce travail de thèse était de contribuer à l’étude de l’anémie et de sa relation avec le paludisme et la carence en fer, en milieu rural au Sud-Kivu.Méthodes Ce travail a consisté en trois études épidémiologiques menées entre 2010 et 2014 dans la zone de santé rurale de Miti-Murhesa dans la province du Sud-Kivu à l’est de la RDC. Il s’est agit de deux études transversales et d’une étude longitudinale prospective. Cette dernière a concerné des femmes enceintes enrôlées depuis le deuxième trimestre de la grossesse à leur première consultation prénatale (CPN1) jusqu’à l’accouchement. L’une des deux études transversales a aussi recruté des femmes enceintes au deuxième trimestre de la grossesse à leur CPN1 et la deuxième a consisté en une étude en grappes à deux degrés chez des enfants d’âge préscolaire en bonne santé apparente dans la communauté. Résultats La prévalence de l’anémie chez les femmes enceintes était de 17,6% et celle de la carence en fer (ferritine ajustée) de 8%. Le paludisme était présent chez 7,5% et l’hypoalbuminémie chez 44% des sujets. La concentration plasmatique du récepteur soluble de la transferrine était plus élevée en présence du paludisme. Les facteurs significativement associés à l’anémie étaient le paludisme [ORa: 11.24 (4.98-25.37); P < 0.001], l’hypoalbuminémie [ORa: 2.14 (1.27-3.59); P = 0.004] et des valeurs élevées de la protéine C réactive [ORa: 1.94 (1.10-3.45); P = 0.022]. La carence en fer n’était pas fréquente et n’était pas significativement associée à l’anémie.La valeur médiane (EIQ) de la concentration sérique de ferritine (ajustée pour l’inflammation) était plus élevée en présence de paludisme comparée aux femmes non impaludées [82.9 μg/L (56.3-130.4) vs 39.8 μg/L (23.6-60.8); P < 0.001]. Le paludisme était plus fréquent chez les femmes sans carence en fer [ORa 6,25 (1,47-26,57); P=0,021] et chez celles n’ayant pas utilisé de moustiquaire imprégnée d’insecticide [ORa 2,24 (1,12-4,51); P=0,024].A l’admission dans l’étude prospective, 9,5% de femmes de la cohorte présentaient une infection palustre. Après régression logistique, la fréquence du paludisme était plus élevée chez les primigestes, chez les femmes avec niveau socioéconomique bas et chez celles vivant à moins de 1683 m d’altitude ;les rapports de cote ajustés (IC 95%) étaient respectivement de [2,55 (1,05-6,19) ;P=0,039] ;[4,78 (1,36-16,76) ;P=0,033] et [2,34 (1,10-5,02) ;P=0,029]. Toujours à l’admission dans la même étude, la prévalence de l’anémie était de 32%. Celle-ci était plus fréquente chez les femmes impaludées [ORa :4,20 (2,00-8,80); P<0,001] et chez celles qui n’avaient pas bénéficié d’un déparasitage dans les 3 mois avant leur admission dans l’étude [ORa :2,33 (1,25-4,35)]. A l’accouchement, le petit poids de naissance (PPN) était présent chez 6,5% des nouveau-nés. Les prédicteurs du PNN étaient l’absence d’utilisation de la MII [ORa :4,17 (1,15-14,28); P=0.030], une faible taille (<150 cm) de la mère [ORa :5,56 (2,01-15,33); P=0.001] et la présence d’anémie chez la mère à la CPN1 [ORa :4,08 (1,50-11,10); P=0.006]. Chez les enfants d’âge préscolaire, l’anémie était présente dans 46,6% des cas et la prévalence de l’anémie ferriprive chez les enfants anémiques était de 16,5%. Chez les enfants sans inflammation, la carence en fer était de 4,4% (ferritine non ajustée). Les résultats de la régression logistique ont révélé que l’anémie était significativement et indépendamment associée à la carence en fer [ORa :4,10 (2,41-6,96) ;P<0,001], à une histoire de fièvre pendant les deux semaines avant l’enquête [ORa :1,58 (1,00-2,50); P=0,049] et à un faible périmètre brachial [ORa :1,87 (1,18-2,94) ;P=0,006]. Dans un deuxième modèle ayant exclu les enfants avec carence en fer, ce sont une histoire de fièvre dans les deux semaines avant l’enquête [ORa :1,62(1,00-2,62); P=0,05] et un faible périmètre brachial [ORa :1,96(1,24-3,13); P=005] qui étaient associés significativement et indépendamment à l’anémie.Conclusion L’anémie est fréquente en milieu rural au Sud-Kivu mais la contribution de la carence en fer est faible. Néanmoins, d’autres carences nutritionnelles lui sont associées :une hypoalbuminémie chez les femmes enceintes et un faible périmètre brachial chez les enfants de moins de 5 ans. Le paludisme, d’autres infections, des états inflammatoires ainsi que le manque de déparasitage sont également d’autres facteurs qui étaient associés à l’anémie. Chez les femmes enceintes, l’absence de prévention contre le paludisme par les MII, la présence d’anémie et une faible taille de la mère étaient des prédicteurs du PPN.Une lutte intégrée contre le paludisme et d’autres maladies infectieuses ainsi que l’amélioration de l’état nutritionnel sont des facteurs vulnérables à court et moyen termes pour réduire la charge de l’anémie. Ce qui, par conséquent, contribuera à la réduction de l’incidence du PPN.Il y a une nécessité à poursuivre la recherche pour (i) identifier d’autres causes d’anémie en incluant la recherche des hémoglobinopathies et autres anomalies génétiques, (ii) améliorer les connaissances sur les meilleures stratégies de lutte contre l’anémie en intégrant la prévention contre le paludisme dans un milieu où il y a une prévalence relativement élevée d’hémoglobinopathies et autres anomalies génétiques pouvant altérer l’érythropoïèse et/ou le métabolisme du fer. / Executive summary IntroductionAnemia is a worldwide public health concern, which is particularly prevalent in low and middle-income countries, including the Democratic Republic of the Congo (DRC). It affects mostly pregnant women and preschool children and is associated with a higher risk of morbidity and mortality. During pregnancy, anemia is associated with poor birth outcomes and can negatively affect maternal health. In children, anemia can also alter physical and mental development if not corrected quickly. It is generally assumed that iron deficiency is the leading cause of anemia, thus that assumption had influenced control strategies suggested by the World Health Organization. However, in the Kivu region, there is little information on the aetiologies of anemia and the contribution of malaria and that of iron deficiency in the aetiology of anemia is unknown. The overall goal of this thesis was to contribute to the study of the burden of anemia and its relationship with malaria and iron deficiency in rural South Kivu.MethodsThe data are from three epidemiological studies carried out between 2010 and 2014 in the rural health zone of Miti-Murhesa in the South Kivu province in eastern DRC. There were two cross-sectional studies and one longitudinal prospective study. In the latter, pregnant women were enrolled during the second trimester of pregnancy at their first prenatal visit (ANV1) and followed-up until delivery. One of the two cross-sectional studies also enrolled pregnant women in the second trimester of pregnancy at their ANV1 and the second consisted of a two-stage cluster study at community level in apparently healthy preschool children.ResultsThe prevalence of anemia in pregnant women was 17.6% and that of iron deficiency (adjusted ferritin) was 8%. Malaria was present in 7.5% and hypoalbuminemia in 44% of subjects. Soluble transferrin receptor concentration was higher in the presence of malaria. Factors significantly associated with anemia were malaria [ORa: 11.24 (4.98-25.37); P < 0.001], hypoalbuminemia [ORa: 2.14 (1.27-3.59); P = 0.004] and high values of the C reactive protein [ORa: 1.94 (1.10-3.45); P = 0.022]. Iron deficiency was not common and was not significantly associated with anemia.The median value (IQR) of serum ferritin concentration (adjusted for inflammation) was higher in the presence of malaria compared to non-infected women [82.9 μg/L (56.3-130.4) vs 39.8 μg/L (23.6-60.8 ); P < 0.001]. Malaria was more common in women without iron deficiency [ORa 6.25 (1.47-26.57); P = 0.021] and in those who did not use insecticide-treated mosquito nets [ORa 2.24 (1.12-4.51); P = 0.024].At admission in the prospective study, 9.5% of women in the cohort had malaria infection. After logistic regression, malaria was higher in primigravidae, among women with low socioeconomic status and those living at an altitude of less than 1683 m; the adjusted odds ratios (95% CI) were [2.55 (1.05-6.19); P = 0.039]; [4.78 (1.36-16.76); P = 0.033] and [2.34 (1.10-5.02); P = 0.029], respectively.Still at admission in the same study, the prevalence of anemia was 32%. This was more common in malaria-infected women [ORa: 4.20 (2.00-8.80); P < 0.001] and in those who were not dewormed within the last 3 months prior to admission into the study [ORa: 2.33 (1.25-4.35); P = 0.008]. At delivery, low birth weight (LBW) was present in 6.5% of new-borns. Predictors of LBW were the lack of use of ITN [ORa: 4.17 (1.15-14.28); P = 0.030], a low height (< 150 cm) of the mother [ORa: 5.56 (2.01-15.33); P = 0.001] and the presence of maternal anemia at ANV1 [ORa: 4.08 (1.50-11.10); P = 0.006].In pre-school children, anemia was present in 46.6% and the prevalence of iron deficiency among anemic children was 16.5%. In children without inflammation, iron deficiency was 4.4% (unadjusted ferritin). Logistic regression analysis revealed that anemia was significantly and independently associated with iron deficiency [ORa: 4.10 (2.41-6.96); P < 0.001], with fever during the last two weeks before the survey [ORa: 1.58 (1.00-2.50); P = 0.049] and with a low mid-upper arm circumference (MUAC) [ORa: 1.87 (1.18-2.94); P = 0.006]. In a second model that excluded children with iron deficiency, history of fever in the last two weeks before the survey [ORa: 1.62 (1.00-2.62); P = 0.05] and a low MUAC [ORa: 1.96 (1.24-3.13); P = 005] were significantly and independently associated with anemia.ConclusionAnemia is common in rural South Kivu but the contribution of iron deficiency is low. However, other nutritional deficiencies are associated: hypoalbuminemia in pregnant women and low MUAC in preschool children. Malaria, other infections, inflammatory conditions as well as lack of deworming are also other factors that were associated with anemia. In pregnant women, lack of prevention against malaria by ITNs before ANV1, presence of anemia at ANV1, and low maternal height were predictors of LBW.Integrated control of malaria and other infectious diseases as well as improving nutritional status are among vulnerable factors in the short- and middle-term to reduce the burden of anemia in South Kivu. This, in turn, will help to reduce the incidence of LBW.There is need for further research to (i) identify other causes of anemia including hemoglobinopathies and other genetic disorders, (ii) improve knowledge of the best strategies for controlling anemia by integrating prevention of malaria in an environment where there is a relatively high prevalence of hemoglobinopathies and other genetic abnormalities that may alter erythropoiesis and/or iron metabolism. / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished

Jusqu'à la fin du XIIe siècle, la vie de Clovis, roi mérovingien et premier roi chrétien qui a régné sur le royaume franc sûrement à partir de 481 et jusqu'à sa mort, le 27 novembre 511, ne paraît avoir été que rarement transposée en images. À partir de 1200, en revanche, l'iconographie figurant le souverain mérovingien se développe, diffusée de plus en plus largement dans le royaume de France. Cette évolution traduit un changement qui s'opère dans l'intérêt porté à Clovis durant les trois derniers siècles du Moyen Âge. Afin de saisir la teneur de ce changement, la présente étude se propose d'analyser l'importance octroyée à l'image de Clovis dans le royaume de France entre 1200 et 1500. Pour ce faire, l'examen de l'iconographie clodovéenne encore connue a été effectué. Celui-ci permet d'abord, grâce à l'évaluation de l'abondance et de la propagation de l'imagerie clodovéenne dans le royaume, de rendre compte de l'importance de la diffusion de l'image du roi et de cerner l'étendue et la diversité du public auquel celle-ci s'adressait. Cet examen permet ensuite d'analyser les modalités de la mise en images de l'histoire du souverain, renseignant sur les variations du discours diffusé par l'iconographie. Enfin, l'étude de la signification des images et de leur fonction permet, à une époque où se forme ce que Colette Beaune nomme le « sentiment national » et où l'histoire du royaume est traversée par un des conflits majeurs de la période, la guerre de Cent Ans, de comprendre les raisons du développement de l'imagerie figurant Clovis et des variations de la place conférée au roi dans le discours iconographique diffusé, entre 1200 et 1500, dans le royaume de France. / Until the end of the 12th century, the life of Clovis, a Merovingian king and the first Christian king of the Frankish kingdom, who reigned from about the year 481 until his death on November 27, 511, seems to have been rarely depicted in images. From 1200 onwards, however, iconography picturing the Merovingian king expanded, spreading more and more widely in the kingdom of France. This evolution reflects a change in the interest accorded to Clovis over the last three centuries of the Middle Ages. In order to grasp the substance of this change, this study analyzes the importance attributed to the image of Clovis in the kingdom of France between 1200 et 1500. To this end, an examination of known Clodovian iconography has been conducted. First, this evaluation of the quantity and spread of Clodovian imagery in the kingdom allows us to determine the magnitude of the dissemination of the king’s image as well as the scope and diversity of the public to which it was addressed. This examination then allows us to analyze the modalities of depicting the sovereign’s history, based on variations in the message spread by the iconography. Finally, the study of the meaning of the images and of their function yields – at a time when what Colette Beaune calls the “national sentiment” is forming and when the kingdom encounters one of the major conflicts of the period, the Hundred Years War – an understanding of the reasons for the development of the imagery depicting Clovis and for the variations in the place accorded to the king in the iconographic discourse spread between 1200 and 1500 in the kingdom of France.

Esta tese analisa a trajetória, os desafios e as perspectivas da regulação em saúde suplementar, contextualizados num ambiente de grandes transformações do papel dos Estados nacionais e das relações entre a Economia e a Política no âmbito mundial e no Brasil. As interrelações entre economia e política são a base para importantes mudanças no papel do Estado brasileiro, do arcabouço regulatório e da regulação da saúde suplementar em particular. A tese tem início com o desenvolvimento de uma análise sobre o panorama político e econômico mundial, de modo a identificar suas influências sobre o Brasil e o setor de saúde brasileiro. À luz deste arcabouço analítico, é desenvolvido um detalhamento retrospectivo dos principais normativos que compuseram a regulação em saúde suplementar, editados por intermédio da Agência Nacional de Saúde Suplementar ANS. Para tanto, foi construído um banco de dados que servirá não apenas para a pesquisa da tese, mas para outros trabalhos a serem desenvolvidos posteriormente. O estudo desse material permitiu identificar uma trajetória da saúde suplementar marcada por três diferentes tônicas, que tem se desdobrado a partir da cena das grandes transformações mundiais. As conclusões aqui obtidas sobre a trajetória da regulação foram ainda apreciadas, por meio de pesquisa com todos os atuais e antigos dirigentes da ANS. Adiante, foi realizada uma breve análise dos efeitos produzidos por cada uma das tônicas anteriormente descritas, bem como discutidos os principais desafios que se colocam na ordem do dia na agenda da saúde suplementar no Brasil. É interessante destacar que discussão da perspectiva futura da regulação da saúde suplementar no Brasil se dá sobre um pano de fundo de profundas transformações no plano da política e das relações de hegemonia e poder na esfera global. Por fim, o trabalho aqui apresentado tem a finalidade de contribuir para o desenvolvimento do tema e sugerir aperfeiçoamentos de modo a aprimorar o planejamento, a gestão e a regulação da saúde suplementar, buscando relações público-privadas mais harmoniosas e eficientes no tocante à assistência e promoção da saúde. / This thesis analyzes the trajectory, challenges and prospects of private health insurance regulation in Brazil in a context of changing of hegemony and relationship between economics and politics. This scenario of economy and political change is the basis for the Brazilian State agenda on health regulation. This work analyzes the worlds economic and political landscape in order to identify its influence on Brazil and on the Brazilian healthcare industry. Based on this framework, we develop a retrospective analysis of the major private health insurance regulatory policies enacted by the Brazilian National Health Agency ANS. In this way, a database was built not only for research thesis, but also for later studies. Subsequent analytical study has identified three different waves in the Brazilian regulation trajectory. Results were, then, checked by all current and former ANS directors. This work, also analyses the effects of those three waves and discusses the main challenges of health insurance regulation agenda in Brazil. It is worth noting that discussions of future regulatory policies in Brazil take place on the grounds of critical changes in policy, power and hegemony over the world. Lastly, this work provides contribution to the development of the theme and suggests enhancements to improve planning, management and regulation of health, seeking more harmonious and efficient public-private relations in the field of disease prevention and health promotion.

La première version des Chroniques des rois, ducs et princes de Bretagne a été rédigée par Pierre Le Baud sur commande de Jean de Châteaugiron,seigneur de Derval, et est achevée en 1480. Deux manuscrits nous sont parvenus de cette rédaction : l’original conservé à la Bibliothèque nationale de France (ms fr.8266) a été édité partiellement en 1907 par Charles de La Lande de Calan, alors que le deuxième, appartenant à la Bibliothèque municipale d’Angers (ms. 941) et copie du premier, n’a jamais fait l’objet d’une transcription.Cette édition transcrit le manuscrit 941 dans sa totalité, c'est‐à‐dire les trois livres rédigés sur 406folios. Cette transcription analyse également la méthode de compilation du chroniqueur, les particularités linguistiques du copiste et les variantes par rapport au manuscrit 8266 de la Bibliothèque nationale de France. Un glossaire ainsi que des index des personnes, des lieux et des sources permettent d’éclairer les aspects historiques, géographiques et culturels présents dans cet ouvrage. / The first version of "Chroniques des rois, ducs et princes de Bretagne" was ordered by Jean de Châteaugiron, lord of Derval and Pierre Le Baud finished writing it in 1480. Only two manuscripts reached us : the original, preserved at the Bibliothèque nationale de France (ms fr.8266),was partially edited in 1907 by Charles de LaLande de Calan, whereas the second, which canbe found at the Bibliothèque municipale d'Angers and is a copy of the first, was never transcripted. This edition transcribes the manuscript 941 in its entirety, meaning all the three books written on over 406 folios. This transcription also analyses the method the chronicler used to compile the text, the linguistic characteristics of the scribe andthe differences with the manuscript 8266 of theBibliothèque nationale de France. A glossary, aswell as an index of persons, an index of locations and an index of sources, will also enlighten the historical, geographical and cultural aspects of this publication.

Les Composés Organiques Volatils d’origine Biogénique (COVB) émis par la végétation représentent 1PgC.an-1 à l’échelle globale. Ces COVB, une fois émis dans l’atmosphère, peuvent participer à la formation d’ozone troposphérique ainsi qu’à la formation d’aérosols organiques secondaires et donc à la pollution atmosphérique. C’est pourquoi, il est important de quantifier le plus précisément possible les taux d’émissions de COVB et de mieux comprendre quels sont les facteurs environnementaux qui contrôlent ces émissions. Il est bien connu que les émissions de COVB sont contrôlées par la lumière et/ou la température mais elles peuvent également être influencées par d’autres facteurs comme le stress hydrique, bien que son impact soit encore mal compris. En effet, il a été montré que le déficit hydrique pouvait augmenter ou diminuer les émissions de COVB selon son intensité, sa durée et l’espèce étudiée. Dans le cadre du changement climatique, une intensification de la sécheresse est attendue en région Méditerranéenne avec une augmentation de la température, une diminution des pluies ainsi qu’une prolongation de la période de sécheresse. Ce changement climatique pourrait donc modifier les émissions de COVB. De plus, les effets d’une sécheresse appliquée sur plusieurs années sont encore mal connus. Dans cette étude, nous nous sommes intéressés à la réponse des émissions de COVB du chêne pubescent (Quercus pubcescens Willd.)face au stress hydrique attendu en région méditerrannéenne avec le changement climatique. / Biogenic Volatile Organic Compounds (BVOC) emitted by vegetation represent 1PgC.yr-1 at the global scale. These BVOC, once emitted into the atmosphere, can participate in the troposheric ozone formation as well as secondary oragnic aerosols and, consequently, on the atmospheric pollution. That’s why, it is very important to quantify, as accurately as possible, the BVOC emissions and to improbe the knowledge about the environmental factors which drive these emissions. It is well known that BVOC emissions are controlled by the light and the temperature but they can be impacted by other factors such as water stress. Nevertheless, these mechanisms are not well understood yet, since it has been shown that water stress can increase or decrease BVOC emissions according to the intensity and the duration of stress. In a context of climate change, we can expected an intensification of summer drought in Mediteranean area with an incerase of temperature, a decrease of rainfall as well as an elongation of stress period. This climate change could modify BVOC emissions. Moreover, the effects of a water stress applied during several years are not known. In this study, we wanted to evaluate the impact of water stress, expected with climate change, on BVOC emitted by Downy oak (Quercus pubescens Willd.), main isoprene emitter of Mediterranean region.

There is a significant comorbidity between anxiety/depression and functional gastrointestinal syndromes, such as irritable bowel syndrome (IBS) and functional dyspepsia. The pathophysiological link between emotions and the gut is not known. A model of an emotional motor system (EMS) which reacts to interoceptive and exteroceptive stress has been proposed. EMS consists of specific brain structures including anterior cingulate cortex (ACC), amygdala, hippocampus and hypothalamus and mediates their communication to the rest of the body (including the gastrointestinal tract) through the hypothalamus-pituitary-adrenal (HPA) axis, the autonomic nervous system (ANS) and by a pain modulation system. The aim of this thesis was to test the EMS model by studying the relationship between symptoms of anxiety and depression and IBS-like symptoms in patients with recurrent unipolar depression, in patients with IBS and in a sample of a normal Swedish population. The peripheral limb of EMS (ANS, HPA axis and the pain modulations system) was tested in patients with IBS and control subjects. Spectral heart rate variability was used to investigate ANS function in patients with refractory IBS and in healthy controls. The HPA axis function was tested by a weight adjusted low dose dexamethasone suppression test in control subjects. The influence of catecholamine degradation on pain modulation was tested by analyzing val158met catechol-o-methyl transferase (COMT) polymorphism in patients with IBS and in control subjects. We found a significant relationship between symptoms of anxiety/depression and IBS-like symptoms in patients with recurrent unipolar depression, in patients with IBS and in a sample of the normal population. Interestingly, patients with recurrent unipolar depression in remission had no more IBS-like symptoms than controls, indicating that the gastrointestinal symptoms may resolve when depression is treated to remission. Patients with IBS have an increased mid-frequency power in rest and in supine position (after tilt test) compared to healthy controls indicating an increased sympathetic ANS drive. The symptoms of diarrhea and early satiety has in the litterature been associated to the stimulation of corticotropin releasing hormone (CRH) receptors and was also in our study related to HPA axis function tested by a low dose dexamethasone test. Interestingly both hypo- and hyperfunction of the HPA axis was related to these symptoms in control subjects. The val158met COMT polymorphism was associated to IBS-like symptoms. Control subjects with IBS-like symptoms (defined by the upper quartile in total GSRS-IBS score) had a higher frequency of the met/met and a significantly lower frequency of the val/met genotype. Also patients with IBS tended to have a lower frequency of the heterozygous val/met genotype so we conclude that this genotype may be protective against IBS/IBS like symptoms. In addition, the val/val genotype in patients with IBS was associated to diarrhea symptoms. Conclusions: Our results support the model of an emotional motor system in the genesis of functional gastrointestinal symptoms by the finding of the association of IBS-like symptoms and mood disturbances, and by finding alterations in the peripheral limbs of EMS (ANS, HPA axis and catecholamines) in subjects with IBS and IBS-like symptoms.

La Petite danseuse de quatorze ans (1881) de l’artiste français Edgar Degas (1834-1917) représente et déforme plusieurs catégories sociales et artistiques de son époque. L’œuvre peut ainsi être lue comme une mise en abyme à la fois des changements sociaux et des peurs qu’ils suscitent quant aux redéfinitions du rôle et de la place de la sculpture dans l’art et de l’art, des classes sociales, de la science et de la femme dans la société qui s’opèrent dans la seconde moitié du 19e siècle. D’une mise en contexte de l’œuvre à une analyse de la figure de la ballerine, en passant par une lecture du monde de la poupée et de la criminalité, nous chercherons à montrer comment l’œuvre offre une lecture subversive des valeurs qui sous-tendent ces catégories structurelles du Paris industriel. Ce jeu des catégories fait de la Petite danseuse une œuvre instable et ambiguë à l’image, peut-être exacerbée, de la société. La sculpture de Degas joue avec et surtout entre ces divers pôles de la société parisienne, décloisonnant ceux-ci et proposant une autre façon de comprendre la société contemporaine. Prenant ancrage dans un discours critique postmoderne, féministe et postcolonialist, le présent travail se propose ainsi de réactualiser la fonction critique de l’œuvre. / The Little Dancer Aged Fourteen (1881) of French artist Edgar Degas (1834-1917) represents and deconstructs all at once, many social and artistic categories of its own time. The work represents social changes and the fear that they generate as it relates to the place of sculpture in art and of art, social classes, science and women’s role in society. Degas’ sculpture plays with and between these structures, deconstructing them and offering new ways of understanding contemporary society. After putting the work in context, we look at the link it has with dolls, how it addresses criminality, and how it questions the ballerina image. The Little Dancer then becomes an ambiguous, unstable and indefinable work reflecting in an acute way its society. Rooted in postmodernism, feminism and postcolonialism, we will explain how the sculpture offers a subversive reading of the values subtending industrial 19th Century Parisian constructs.

L’accès financier limité aux soins de santé a suscité l’instauration de politiques sanitaires de subvention des soins en Afrique. Au Burkina Faso, une ONG, en complémentarité avec la politique sanitaire nationale subventionne à 100% depuis septembre 2008 les soins et les médicaments pour les enfants de moins de cinq ans dans le district sanitaire de Dori. L’intervention regroupe formation du personnel soignant, supervisions et suppression de paiement des soins et des médicaments. L’objectif de l’étude est d’analyser l’effet de cette intervention sur l’adéquation des prescriptions médicales. Neuf centres de santé ont été pris en compte. Au total 14956 ordonnances d’enfants de moins de cinq ans ciblés par l’intervention ont été sélectionnées par échantillonnage systématique à partir des registres de consultation un an avant et un an après l’instauration de l’intervention. Quatorze prescripteurs ont été interviewés. Les prescriptions ont été analysées par comparaison au référentiel de l’OMS ainsi qu’au référentiel national. Le discours des prescripteurs a été analysé en vue de comprendre leur perception de leur changement de pratiques depuis de début de la subvention. L’intervention a eu pour effet de diminuer l’utilisation des injections (Rapport de cote (RC) =0,28; p<0,005) dans le cas des infections respiratoires aiguës (IRA). Elle a entraîné une diminution de l’utilisation inappropriée des antibiotiques dans les cas de paludisme seul (RC=0,48; p<0,0005). Le nombre moyen de médicaments par ordonnance a également diminué de 14% dans les cas d’IRA (p<0,0005). Les prescripteurs ont affirmé pour la plupart que leurs pratiques se sont soit maintenues soit améliorées. L’intervention a entrainé une amélioration de l’adéquation des prescriptions médicales dans certains cas. / The limited financial access to health care has encouraged the creation of health policies for subsidizing care in Africa. In Burkina Faso, an NGO, in line with the national health policy has been subsidizing care and medicines for children under five years in the health district of Dori since September 2008. The program includes training of health workers, supervision and removal of fees for health care and medication. The aim of the study was to analyze the effect of this free care program on the adequacy of drugs prescriptions. Nine health centers were taken into account. A total of 14,956 prescriptions of the target group of children under five years were collected from consultation records a year before and after the introduction of free care program. In addition, fourteen prescribers were interviewed. The prescriptions were analyzed in comparison to the WHO and the national reference. The prescribers’ responses were analyzed to understand their perception of their change in practice since the introduction of the free care program. The study showed that the free care program had an effect by decreasing the use of injections (Odds Ratio (OR) =0.28, p < 0.005) in acute respiratory infections (ARI) cases. It also led to decrease in inappropriate use of antibiotics in the case of malaria (OR=0.48, p<0.0005). The average number of drugs per prescription was also found to have decreased by 14% (p<0.0005) in ARI cases. Several prescribers asserted that their practices are maintained or improved. The program leads to an improvement in the adequacy of drugs prescriptions.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

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No. of bitstreams: 1 Dissertação final.pdf: 768757 bytes, checksum: 9894ec4500e698c28af9e7007a02eb9e (MD5) Previous issue date: 2015-04-16 / This study analyzes profiles and career paths of directors and counselors from the following federal agencies: ANEEL, ANATEL, ANP, ANVISA, ANS, ANA, ANCINE, ANTAQ, ANTT e ANAC. We observe dimensions relating with conditions which, in theory, allow more decision-making autonomy to Brazilian federal regulators: 1) regulator’s level of expertise and skilled knowledge, watching his trainig area, level of education and previous experience in the regulated sector; 2) the existence of party affiliation before his appointment to the post at the agency; 3) the existence of cases of renewal regulators, beyond the government mandates of different presidents; 4) the professional origin of regulators and destination after their performance in regulatory agencies. At the same time, it is observed the institutional design of these Brazilian agencies and how some aspects of its structure and process can interfere with the outcome of the regulatory process, specially in regard to how regulators are indicated. Among the main results of this work, we highlight the strong connection between the training area of regulators and the playing field of regulatory agencies; the recovery of post-graduate courses in qualifying a candidate for a federal regulatory agency; and the proof of previous professional experience in the regulated sector, indicating that Brazilian regulators have relevant indicators of specialization and expertise in the sector. There have also been cases of indicated and reappointed regulators by different presidents, reinforcing the hypothesis that value expertise. Regarding political capture, stands out that just under a third of tregulators had previous party affiliation before their appointments. Most regulators are selected within the public service, but most of them will work in the private industry sphere, reinforcing the evidence that there may have been capture during their mandates in the agency. It is clear, also, a trend of strengthening of agencies’ bureaucracy from the end of the first term of President Lula, movement wich has increased in President Dilma Rousseff’s first term. / Este trabalho analisa o perfil e as trajetórias de carreira dos diretores e conselheiros das se-guintes agências federais: ANEEL, ANATEL, ANP, ANVISA, ANS, ANA, ANCINE, AN-TAQ, ANTT e ANAC. São observadas algumas dimensões que se relacionam com condicio-nantes que, em tese, permitiriam uma maior autonomia decisória do regulador brasileiro federal: 1) o nível de expertise e conhecimento especializado do regulador, observando sua área de formação, nível de escolaridade e sua experiência prévia no setor regulado; 2) a existência ou não de filiação partidária antes de sua indicação para o cargo na agência; 3) a existência ou não de casos de recondução de reguladores, além dos mandados governamentais de diferentes presidentes; e 4) a origem e o destino profissional do regulador após sua atuação na agência reguladora. Paralelamente, observa-se como foi elaborado o desenho institucional destas agências brasileiras e como algumas características de sua estrutura e processo podem interferir com o resultado do processo regulatório, especialmente no que se refere à forma como os reguladores são indicados. Entre os principais resultados do trabalho, destacam-se a forte co-nexão entre a área de formação dos reguladores e o campo de atuação das agências reguladores; a valorização de cursos de pós-graduação na qualificação de um candidato para uma agência reguladora federal; e a comprovação de experiência profissional prévia no setor regulado, indicando que os reguladores brasileiros apresentam indicadores relevantes de especialização e expertise no setor. Também ocorreram casos de reguladores indicados e reconduzidos por presidentes diferentes, reforçando a hipótese de valorização da especialização. Com relação a captura política, se destaca que pouco menos de um terço dos indicados possuía filiação partidária anterior à nomeação. A maioria dos reguladores é selecionada dentro do serviço público, mas boa parte deles vai trabalhar na esfera privada do setor, reforçando os indícios de que pode ter havido captura durante os mandatos na agência. Percebe-se, ainda, uma forte tendência de fortalecimento da burocracia das agências a partir do final do primeiro mandato do presidente Lula, movimento acentuado no primeiro mandato da presidente Dilma Rousseff.