Thermalism

France is Europe’s thermal capital, with no less than 770 hot springs or 20% of the total. This makes France the European leader for hydromineral resources, according to the Conseil National des Établissements Thermaux (National Council of Thermal Establishments or CNETh). This supremacy has prevailed over the centuries. Since Antiquity, French hot springs have been frequented by the elite and the destitute alike. Over time, as science progressed, these evolved from miraculous waters into thermal springs with recognised healing properties. With 19th-century capitalism, thermal establishments became highly fashionable, set in green and pleasantly designed surroundings, like perfect little towns.

Nowadays, and despite current chaotic trends in the sector, French mineral springs are still a significant driver of tourist flows, with nearly 600,000 people visiting 90 thermal resort resorts every year. After the structural and economic crisis of 1990-2000, the sector seems to have got a fresh impetus from dynamic actors confident of its future and who believe that their diversified offer is in line with the current needs of the population.

Lexical clarification

The term Thermalism refers to “all the means deployed for the therapeutic use of thermal spring waters, the operation and development of springs and thermal resorts” (Centre National de Ressources Textuelles et Lexicales – CNRS) while thalassotherapy, not prescribed and not refundable (under the public health insurance system), is “the supervised use, in a special marine site, of the benefits of sea products for preventive or curative purposes. It uses heated seawater to transfer various organic compounds into the blood” (Meziani and Alegria, 2015).

According to Mr Jazé-Charvolin (2014: p. 2), the word “thermalism” was first used in 1845, to refer to the medicinal use of mineral waters. It was not until 1933 that it was used in its current sense. The term can be replaced by the expression “therapeutic hydrology” or the more technical term “crenotherapy”.
In the 1960s, Fontan and Duhot started studying the hydromineral effect. They believed that medicinal waters are natural spring waters having therapeutic properties. Unlike water from ordinary springs, thermal waters derive from rainwater that has seeped very deep into the earth. In the depths of the earth, these waters absorb various gases and dissolved mineral elements (iron, salt, calcium, etc.). In a final phase, they rise to the surface through folds or faults in the earth and emerge as a spring.

In France, there are four categories of thermal water: cold water (< 20°C); mesothermal water (from 20°C to 35°C); thermal water (from 35°C to 50°C); and hyperthermal water (from 50°C to 82°C, with the record temperature reached at Chaudes-Aigues in Cantal), which is often radioactive. There is a further category: sodium chloride waters, bicarbonate (or carbonic) waters, sulphate waters, sulphurised waters and oligometallic waters. We owe this classification to the Commission des eaux minérales (Mineral Waters Commission) created in 1854. Developments in physics and chemistry in the 19th century facilitated research into the mechanisms of thermal waters. Enhanced knowledge of the waters and therefore of their particular characteristics meant their application could be better targeted and potentially more curative. This early form of “service médical rendu” (criteria used to classify treatments in terms of their therapeutic value) therefore served to silence sceptical doctors. This institution led the way from empirical thermalism to scientific thermalism, making the virtues of the waters tangible (Jazé-Charvolin, 2014). Thermalism not only concerns the water itself, but all its derivatives as well: gas, steam, and mud. Pelotherapy is the therapeutic use of mud from hot springs.

Thermal establishments in France (113 according to the CNETh) offer various treatments. These include the standard 18-day course of treatment refunded under the social security system as well as the “cure médicale libre” (a course of treatment of more than ten days) and the “séjour santé” (health stay of a shorter duration), both of which are non-refundable. While these types of treatment differ in duration, they are identical in terms of the treatments themselves. Thermal water is also used for more fun purposes in thermal recreational centres or for wellness purposes in spas (within the thermal establishments or in adjoining outbuildings).

The exploitation of thermal waters has also given rise to terms to describe the places themselves. According to Lise Grenier, the expression ville d’eaux (“water town”) only appeared during the Second French Empire. “It’s Vichy par excellence” (1984: p. 30). This expression is made up of two terms. The term “town” is incorrect because many of the “water towns” in these days were not strictly speaking towns but large villages (“Les villes d’eaux: des eaux sans ville?” [“Water towns: waters without a town”], Carribon, 2014). While the term is exaggerated for modest resorts, it is appropriate for the most prominent thermal resorts, where thermal complexes comprising health facilities, casinos and hotels and complemented by numerous other facilities have flourished most. The term “waters” refers to the element in all its forms: mineral water, water from fountains, water from natural and artificial lakes, etc. The ville d’eaux of the 19th century was indeed attempting to emulate the garden city model, bringing people closer to nature.

Initially a civilisation passed down from one century to the next and a practice bequeathed like a cultural heritage, the ville d’eaux was above all a platform for socialisation not found in the industrial towns. […] it is not merely a town like many others, but a specific town that owes its international reputation to thermalism.

Bernard Toulier, 2006: p. 10

Like “ville d’eaux”, the term “station thermale” (thermal resort) is also ambiguous. The law of 13 April 1910 states that “any municipality, part of a municipality or group of municipalities that contain one or more mineral water springs or an establishment exploiting one or more mineral water springs, may be set up as a hydromineral resort’ (Carribon, 2019). A century later, and until 2006, classified tourist resorts were divided into six categories: seaside, tourist, winter sports, mountain, thermal and health resorts. The law of 14 April 2006 simplified this jargon keeping only one category: “the classified tourist resort, accessible only to localities that have been designated as tourist municipality. Among the 468 classified tourist resorts in 2021, 89 have one or more active thermal establishments, that is to say intended for approved thermal cures. This is referred to as “thermal resorts”. This name also applies to municipalities in which the thermal establishment has closed down but where thermal or fitness infrastructure still exists (e.g., Saint-Nectaire). However, while the term “thermal resort” is used in this generic sense by professionals and the public at large, it is not accurate from a scientific point of view (see “tourist resort”).

From the “industrialisation of thermalism” in the second half of the 19th century to contemporary thermalism

A prosperous period during the Second French Empire, the Belle Époque and the Années Folles (the roaring twenties)

Although thermal sites had existed since Antiquity in France (as testified by the remains dotted around the country), thermalism really gained momentum in the 18th century with the rise, among other things, of scientific research on the subject (Équipe MIT, 2005; Penez, 2005; Boyer, 2005). Under the guidance of their doctors, members of the aristocracy and the bourgeoisie visited places specifically dedicated to caring for the body… and the soul. From these practices, a form of health tourism emerged; a tourism “driven by self-care” (Équipe MIT, 2011, p. 49).

The scientific validation of the therapeutic virtues of natural elements (water, air and sun) is a powerful argument for understanding the link between health and tourism. It explains why the recréation or “reconstitution” of body and mind has long remained in the hands of doctors, who frequently oversaw the opening of resorts (Brighton, Saint-Gervais, etc.). But these places of therapy also allowed spa clients to develop a new relationship with the body, involving a change in the way they used the places themselves, where pleasure and encounter, as well as play, gradually but inevitably prevailed over therapeutic treatments.

Équipe MIT, 2011: p. 48

Since its origins, thermal therapy has very much been a tourist practice. It is in fact “a chosen recreation practice [not a recreational practice], whereby one moves from one’s place of residence to another place” (Stock and Sacareau, 2003: p. 23). Spa clients occupy a site, a resort or a thermal town away from their usual place of residence and in which they interact with other individuals. If they are ill, they have the opportunity to relieve their ailments with thermal waters and have full leeway to choose the place that suits them best. But under the guise of taking care of their health, visitors were also seeking wellness, leisure time and the right to do nothing in places outside of their daily routine. For the elites, it was mostly the quest for hedonism, idleness and a light-heartedness. This meant that the number of “real” spa clients could be very low, especially in the most reputable resorts.

From the second half of the 19th century to the Années Folles (1920s), French thermalism enjoyed a prosperous period. In the 19th century, the resorts became increasingly accessible in the wake of the railway revolution, made possible by the technical progress of the time. It allowed the most remote resorts to develop (for example Cadéac in the Hautes-Pyrénées; Bouneau, 1994) and consolidated the more well-known ones. The success of thermal resorts was also due to fierce “marketing” activities (see the posters and tourist guides) around the resorts, which were seen at the time as the right places in which to invest. Business corporations were thus created, bringing together enough capital to offer customers a coherent product that combined spas, hotels, casinos, sports activities, etc. Napoleon III had a key role in driving this enthusiasm, both through his role as a “trendsetter”, with his appetite for thermal resorts for health, pleasure and diplomacy purposes, and through his role as “chief urban planner”. The most obvious proof of his involvement is the total transformation of Vichy through his intervention after his first visit there in 1961 (Grenier, 1984). The consequence of this spa craze was a surge in client numbers, which tripled between 1850 and 1870.

Far from undermining the future of French thermalism, the War of 1870 encouraged it. All the more so because, from an economic point of view, the War of 1870 was just a blip, and after 1875, under the Third Republic, the economic recovery attracted businessmen seeking to invest in thermal resorts and the mineral water business.

Dr Authier and P. Duvernois, 1997: p .45

At the end of 1913, 14 thermal centres stood out: Aix-les-Bains, Cauterets, Châtel-Guyon, Contrexeville, Dax, Evian, La Bourboule, Le Mont-Dore, Luchon, Luxeuil, Plombières, Royat, Vichy and Vittel (Authier and Duvernois, 1997). During the Années Folles (1920s), the most popular resorts remained unchanged; only those in the Vosges disappeared, with the exception of Vittel.

The times of treatments practised in a carefree atmosphere of luxury and pleasure (forbidden or otherwise) came to an end with World War II. Admittedly, it was not an abrupt change as it in line with the social demands arising after 1918 (Carribon, 2001), but the whole philosophy of French thermalism had been upended.

A practice within the remit of social security (1947-1988)

In 1947, French thermalism changed in scope. It bid farewell to aristocrats, movie stars and other adventurers attracted by the high life of the villes d’eaux. Following the creation of social security, spa therapies were treated as medicinal products and thus refundable, with the duration of stay strictly limited. The villes d’eaux fell once again into the hands of doctors. At first, this medical focus may have seemed beneficial, since the number of spa clients surged: from close to 250,000 in 1952 to over 635,000 in 1988. However, this new clientèle was far less wealthy than their predecessors and came from increasingly diverse segments of the population.

Moreover, the influx of clients with social security coverage, coupled with treatments of an excessively medical nature and the total absence of wellness services, drove away the wealthier clients (Authier and Duvernois, 1997).

Rich private patients and foreigners, having flocked to the French resorts during the interwar period, had now largely deserted them. Instead, medical thermalism became almost entirely dependent on state funding, with all the associated uncertainties.

G. Weisz, 2002: p. 105

As implied by G. Weisz (2002), French thermalism was arguably surviving on the life-support system of the state. On the one hand, it was highly dependent on the behaviour of clients with regard to reimbursement through the social security system, and on the other hand it was vulnerable to changes in public policy (Conseil National du Tourisme – CNT, 2011).

A desire for revival in the 1990s and 2000s despite the crisis

This vulnerability has been noted since the end of the 1980s. The decline in conventional thermalism started in 1988 (peak attendance level). The workforce fell considerably: from 636,439 in 1988 to 486,723 in 2009, or a decrease of 23.5%. This structural and economic crisis was due to several factors: the elimination or sharp decline of certain diseases (especially those contracted in the former colonies), increasing competition from certain drugs, patients’ reluctance to take three weeks off to undergo a refundable treatment, low patient turnover, the end of university courses in crenotherapy, the over-specialisation of French resorts, the appeal of foreign resorts with modern structures open to fitness clients (Tunisia, Italy, Israel etc.) and finally competition from thalassotherapy.

Thalassotherapy re-established the link between the hedonistic and medical dimensions of thermalism by masterfully combining healing with the pleasure of water. Claims of thalassotherapy’s therapeutic value (as recent as the 1980s) were serving as a pretext for wellness and fitness activities.

Équipe MIT, 2011: p. 56

Surprised by and interested in the success of the fitness practice, some thermal resorts gradually began to invest in this area as well. But the reluctance of doctors to endorse the practice considerably delayed the process. For Christian Jamot (1996), the conversion came far too late: Ten years too late! In the late 1990s and early 2000s, any reference to the thermalism of yesteryear and to hedonistic pleasures was prohibited for fear of discrediting strictly medical thermalism. In 2011, the CNT noted that thermal resorts were struggling to diversify outside of medical treatments.

Today

Thermal resorts must restore their appeal. The way forward lies in introducing tourism by developing fitness and recreational facilities. The fitness market has been very poorly exploited by thermal establishments, which remain overly focused on medical treatments. We have been robbed by thalassotherapy, having left our doors wide open.

J.F. Béraud, former director of the Route des Villes d’Eaux, President of the Fédération Thermale et Climatique since 2015, Le Moniteur, 2 April 1999

Drawing lessons from a decade of crisis, spa professionals are now promoting thermal health tourism, divided into two branches: medical tourism (well-being) and wellness tourism (Ill. 2). The first, based on scientific studies to prove the validity of treatments, includes preventive medical tourism (doing what it takes to maintain good health), curative medical tourism (learning to live with a chronic disease such as asthma in resorts focused on treating the respiratory tracts) and post-operative medical tourism (physical and mental recovery post surgery). The second relates to practices where thermal water is used for recreational and sensory purposes.

Ninety percent of the total turnover of the establishments is generated through thermal treatments covered by state social security (thermalism approved by social security) or only 0.15% of the total reimbursable services covered by state health insurance (CNETh, 2021).

 

Since 2009, the workforce has been increasing slowly reaching 598,582 in 2018 (+23% in almost 10 years). There was a slight dip in 2019, however, due to short-term issues (closures due to damage or the presence of bacteria) rather than rejection by patients. Nevertheless, in a context of economic crisis, the withdrawal of the state social security remains a risk.

Treatments in France can be divided into 12 categories (Ill. 3). It is no surprise that anti-rheumatism treatments are the most popular, followed by those for the respiratory tracts. The nomenclature includes 101 treatments, making it one of the most extensive in Europe.

This over-representation of rheumatology is due to the old age of the spa patients, at an average of 63 (Férérol, 2021). This has been a constant feature throughout the recent history of French thermalism (Jamot, 1988). The second characteristic is the large proportion of women clients, at 60.7% in 2017 (DAMIR – CNETh data). Once again, this is not a new trend: in 1986, the proportion of women was 62.5%.

Statistics on wellness clients are limited. Interviews and regional surveys indicate that wellness clients are much younger than medical thermalism patients. According to a study conducted in the Auvergne Rhone-Alpes region, the “wellness tourist” is mostly female (60%) of an average age of 42. Clients are also predominantly urban, with half residing in a town of at least 100,000 inhabitants.

National attendance on the rise but mixed regional performances

Economically, the market is currently shared by three groups: Chaine Thermale du Soleil, Valvital and Eurothermes. But there is now a new entrant: France Thermes. Starting out with the Bagnoles de l’Orne resort, since the last two years France Thermes is pursuing an active acquisition policy with the takeover of the thermal resorts of Chatel-Guyon, Vichy, Salies de Béarn and Néris-les-Bains. Large groups have also shown interest; L’Oréal has acquired the management company of the Saint-Gervais-les-Bains and La Roche Posay resorts.
Spa business plays an important role at a local level, more so since 85% of establishments are located in municipalities of less than 10,000 inhabitants. According to CNETh (2021), the industry provides 9,442 direct jobs to 70% of seasonal workers (but long-term), 40,300 indirect jobs and 55,930 induced jobs. Moreover, every 100 spa clients create six new jobs.

 

Geographically, France has 90 thermal resorts concentrated in three main regions: Occitania, Nouvelle-Aquitaine and Auvergne-Rhône-Alpes. The leader is Occitania with nearly 30% of patients, followed by the South-West, with Dax at its centre and Rhône-Alpes.

The most striking trend is the decline of the Auvergne resorts since 1983 (Ill. 4). Once home to the leading resorts of the Belle Époque (c. 1871-1914) and Années Folles (1920s), it nosedived in the 1990s; this was the area most impacted by the national crisis. In contrast, the resorts on the Atlantic coast, drawing from their heliotropism and the dynamism of local actors, have seen their attendance numbers surge (Rochefort: 4,262 clients in 1983 and 19,112 in 2019; Saujon: 335 in 1983, 4,426 in 2019). In relative terms, this means that the Nouvelle-Aquitaine resorts, excluding the Landes and the Pyrénées-Atlantiques, have gained in prominence, with their share of national clients rising from 2.3% in 1983 to 7.7% in 2009 and to nearly 10% in 2019.

As CNETh pointed out at the “Les Thermalies” exhibition in 2021, COVID-19 has hit the sector very badly. Due to the near-total closure of thermal structures throughout 2020, only 200,000 clients underwent medical thermal treatments. This represents a 67% drop compared to previous years. Nevertheless, given the persistence of thermalism through the centuries, we can hope that this crisis is just a passing turbulence and that 2022 will see strong recovery.

If Jacques Prévert is right and we do indeed “recognise happiness by the noise it makes when it leaves”, then we also realise the essential nature of spa treatments when we are deprived of them. […] Like a hot spring that rises up from the depths and finally springs out, our profession is accustomed to rebounds.

Claude-Eugène Bouvier, 2021, Managing Director of CNETh

Marie-Eve FEREROL

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