The health crisis has been going on for four months. The danger of an epidemic seems to be receding but the human, social and economic damage is revealing itself every day. Already the first assessments of our country's attitude during the crisis are taking shape. The Montaigne Institute has just published a detailed report analysing French public action during this crisis. How was crisis management organised at the highest level of government? How were the political and medical powers articulated? What latitude did the territories and companies have to act despite the extreme centralisation of the organisation of public health? How was the reciprocal mistrust between political power and society expressed? These are all questions whose answers will help to draw lessons from this experience, in order to face the future.
UP' presents to its readers extracts from the report "Public action in the face of the Covid-19 crisis", coordinated by Nicolas Bauquet of the Institut Montaigne, a platform for reflection, proposals and experimentation devoted to public policies in France and Europe.
The battle is not definitively won, faced with a virus that nobody can know today whether it will disappear like SARS, or return even more deadly like the Spanish flu. But France, like the rest of Europe, seems to be gradually emerging from the state of health emergency. At the same time, everyone is aware that it is entering a state of economic emergency. The halt in productive activity, which is particularly brutal and deep in our country, the context of the global economic crisis, the structural imbalances that now threaten the integrity of the single European market and the sustainability of the euro zone, are opening up a phase of profound uncertainty, and perhaps a major social crisis, against a backdrop of mass unemployment.
To face these challenges, what is the political state of our country after four months of crisis? And what lessons can we learn from this exceptional period, an experience that has exposed the strengths and weaknesses of our institutions and political system, and transformed the relationship between the State and the social body? There is no doubt that the coming months will see a flourishing search for individual responsibility at all levels.
However, it seems urgent to carry out an investigation into the way in which each of the players in this crisis has responded, at his or her level or in his or her place, to these exceptional circumstances. It is this collective response that has enabled the system to hold up, thanks to the mobilisation of carers, the responsiveness of companies, the civic-mindedness and solidarity of civil society, and finally to a process of deconfinement that now appears to be under control. At the same time, this crisis seems to have left a political link even more fragile today than four months ago.
For when France enters the health crisis in February 2020, the bond of political confidence is already very damaged in a "France in pieces", whose multiple fractures have been revealed, and even aggravated, by the Yellow Vest movement. The pension reform adds to the political tension, a few months before the municipal elections, which appear to be lost in advance for the executive. But while the health crisis, in many countries comparable to ours, provokes a reflex of sacred union around its leaders, in France, it has at times exacerbated and widened political mistrust: Exacerbate, because the widespread feeling of having been the victim of a state lie on the issue of masks further damages the relationship between citizens and government; widen, because the episode of maintaining the first round of municipal elections, under the pressure of a political class that the "revolution" expected from candidate Macron should have swept away or at least replaced, widens the divide between the French and all their representatives. Worse, during the crisis, it was the bond of trust between the French and their state that now seemed threatened.
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Crisis management organization
Everywhere, the response to the health crisis on the part of the political authorities is paradoxical. On the one hand, it implies a central role for each government, which alone is able to coordinate the fight, take the initiative, set the strategy and mobilize the necessary resources. The pandemic was a moment of affirmation of the centrality of politics, and also a moment of return to the national level.
But the health crisis is also the moment par excellence when "the State cannot do everything", or at least not on its own. Firstly because the State does not know everything, faced with a virus that is still largely unknown, and that it must rely on scientific expertise that is only worthwhile because of its independence from political injunctions. Then because it needs the mobilisation and commitment of all the players, and first and foremost of the citizens themselves, whose behaviour is the key to the success or failure of a health struggle.
The challenge of crisis management systems is therefore to make "full" use of the centrality of power without overplaying its verticality. The aim is to clarify where the strategic decision is made while keeping the lines of communication as short as possible, and to decentralize as much as possible the methods of its implementation, in order to allow each of the players to adapt the overall strategy in a context of great uncertainty, where taking the initiative and feedback are essential factors of success.
This balance is particularly crucial in the early stages of the crisis, where the capacity of health systems to detect weak signals and the capacity of political systems to move from warning to mobilization are crucial.
The French choice of centrality and verticality
In the face of the health crisis, the French executive has chosen to assert its centrality, but even more so, its verticality. From the beginning of the pandemic, the place of decision was symbolically established within the Defence Council, meeting around the President of the Republic, just before the Council of Ministers. At the same time, the choice was made for an essentially political crisis communication, centred on the solemn speeches of the President of the Republic and the Prime Minister. It is from this specifically French dyarchy that a crisis management system marked by verticality was organised.
This has taken several forms in succession. From 27 January to 17 March, the State's response was steered exclusively through the Ministry of Health, where a crisis unit headed by Jérôme Salomon, Director General of Health, was set up three days after the first case of contamination in France was identified. Until the start of containment, it is the only body to coordinate the State's response to a crisis that is still being tackled solely from a health perspective.
It is this choice in particular that places the Regional Health Agencies (RHAs) in the front line: organization of hospitals and the healthcare network, but also logistics of mask distribution, patient transfers, etc. However, these offices, which are intended for the financial and administrative management of healthcare structures, are in no way prepared for emergency action. This primacy of the health sector in crisis management has not made it possible to bring together the various State services in the field. This has made it possible to detect weak signals and adapt quickly to a changing situation, free from political interference and bureaucratic blockages. A striking example of this is the delay in integrating public laboratories into the mobilisation of testing resources.
It was only on 17 March that the inter-ministerial crisis unit (CIC) was activated, within the Ministry of the Interior, associated with the Ministry of Health, under the control of the Prime Minister. This is where the confinement of the country was orchestrated, marked by extreme centralisation, which is reflected in interministerial arbitration sometimes at a level of detail that reflects the almost total lack of margin of appreciation left to other levels of public authority. At the heart of the verbalising State, the ICC cannot be the heart of the strategising State: whether it be the management of the shortage of masks or the management of tests, the major issues are dealt with elsewhere, in a web of initiatives that mobilise the ministerial cabinets in a dispersed order.
The preparation and conduct of deconfinement lead to a further modification of the crisis management mechanism. First with the creation, on 2 April, of the "Castex Commission", directly attached to Édouard Philippe. Freed from any operational responsibility and entirely devoted to the strategic preparation of deconfinement, this commission aims to extricate itself from the daily arbitrations and to create a dialogue with the State's major partners.
After this transitional phase, and once deconfinement had been implemented, a new mechanism was announced on 20 May, with an interministerial crisis centre headed by Prefect Denis Robin, a single body for coordinating the State's response to the crisis, integrating the cells of the Ministries of the Interior and Health, and involving the prefects and the directors general of the ARS.
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Why make it simple when you can make it complicated?
Throughout these four phases of crisis management at the highest level of the State, we find the same structural difficulties in orchestrating its response, and above all in allowing the public authorities to address others than themselves.
Indeed, what is striking is the not only complex but also largely confidential nature of these different structures. This prevents a clear identification of the decision-makers by actors outside the sphere of central administrations. The multitude of interlocutors, coupled with a lack of definition of access and exchange channels, results in the primacy of personal contacts and a largely informal functioning.
All the testimonies, from both inside and outside the State, point to an extreme centralization of the response to the crisis, accompanied by a rigid hierarchical functioning and little room for manoeuvre given to intermediate levels and deconcentrated services. These three factors contribute to lengthening the circuit of information flow, extreme concentration of decision-making and a loss of responsibility at all administrative levels.
Finally, while it is usually at the heart of crisis management practices and the operation of the unit dedicated to it, the communication issue does not seem to have been the subject of a clearly established strategy, based on the definition of a limited number of transmitters, strict coordination of messages, and the definition of a balance between mobilisation and security.
Medical power, political power
The dialogue between scientists and politicians, and the distribution of their roles during the health crisis, is a structuring element of the response to the pandemic.
In France, the first phase of the crisis was marked by the low weight of the bodies that could have played a warning role and established themselves as the scientific interlocutors of a political power that keeps as a priority, until the first week of March, the continuity of political and economic life.
The High Council on Public Health, set up in 2007, includes among its missions to "provide public authorities, in conjunction with health agencies, with the expertise needed to manage health risks", and one of its four commissions is devoted to infectious and emerging diseases. It was referred to it by the Directorate General for Health on 3 February, but it did not give its opinion on the management of confirmed cases of infection by the new coronavirus until ... on 5 March. Nor did the High Authority for Health play a warning or advisory role in the first phase of the crisis. The French Public Health Agency, which has an "Alert and Crisis Department", is placed under the direct supervision of the Ministry of Health, and did not play an autonomous role in assessing the crisis.
Thus, no medical or scientific structure appears to be in a position, during the first phase of the crisis, to play an independent role of reference for both the executive and the general public. Faced with this vacuum, the month of February was marked on the contrary by the emergence, in the media space, of medical figures who concentrated attention and set themselves up as a sort of counter-power, taking advantage of the weakness of political speech.
At the same time, the World Health Organization (WHO), the first point of reference for each of the government authorities, has been slow to sound the global alert because of the truncated nature of the information given by the Chinese government and the direct pressure it exerts on the organization. It was not until March 11 that the WHO officially declared a pandemic. It is precisely at this point that awareness at the highest level of the State was raised in France, and the country entered another phase of the crisis, where medical power, hitherto marginalized, would suddenly occupy the space of public decision-making.
Doctors at the State's Bedside
It was in fact on 11 March that Emmanuel Macron decided to create the Covid-19 Scientific Council, placed under the authority of the Minister of Health, Olivier Véran, "to enlighten public decision-making in the management of the health situation linked to the coronavirus". It is chaired by Professor Jean-François Delfraissy, and includes ten other experts. On March 24, the Covid-19 Analysis, Research and Expertise Committee (CARE) is created, composed of twelve researchers and physicians, and chaired by Françoise Barré-Sinoussi, Nobel Prize for Medicine. But it is the Scientific Council that will soon play a key role in the political and media management of the crisis by the executive.
From 12 March, the Scientific Council launches the scientific alert at the highest level of the State, by presenting to the President of the Republic the models [today controversial by Neil Ferguson of Imperial College London, who is particularly alarmist. It was then that the executive switched to health priorities, closing schools and then containment. The apparent initial absence of science was to be followed by a precedence given to the Scientific Council, behind whose authority the government could sometimes give the impression that it was sheltering itself.
From 16 March, it is the alliance of political and medical power that will bring France to its knees in a confinement of almost two months.
But this new configuration suffers from several weaknesses, and first of all from the nature ad hoc of the Scientific Council, which deprives it of the symbolic foundation of a major independent research institution.
Political power and medical power: in France, these two powers actually have a lot in common, starting with a certain culture of verticality, which may explain certain aspects of the management of the health crisis, such as the marginalisation of town medicine in relation to hospitals, but also the low priority given to public health. The result is both a lack of scientific strategy to build an effective knowledge apparatus for monitoring the epidemic, and an uncertainty of opinion on the source and authority of the scientific word.
The response to the crisis in the territories
Viewed from the territories, State action has been characterized by the striking paradox of extreme centralization, particularly in the modalities of containment, and the absence of the State in the face of the most pressing challenges, such as the supply of masks or the organization of massive tests. The State appeared to be hampered by its own organization, particularly because of the lack of a clear chain of command between prefects and regional health agencies (ARS). It also appeared closed in on itself, trapped in a logic centred on maintaining public order, often disconnected from the concrete challenges that local actors had to meet, in an emergency, to ensure the continuity of essential services and respond to the concerns of their constituents.
Seen from the territories, this first phase of the crisis was in fact marked by a paradox. On the one hand, it was experienced as a particularly strong moment of centralisation, even caricatured in some of its expressions, demonstrating that the State is still capable of acting in every corner of the country, at least to bring it to a halt. At the same time, however, this State has often demonstrated its disconnection from local realities, its inability to act, or even its sheer absence.
The role of companies during the crisis
In a health crisis that very quickly becomes an economic shock, the government's speed in protecting businesses was unanimously praised, even if the main challenges are still ahead of us. But in the face of the pandemic, companies are also those that protect employees and their health. They are the ones who maintain the services that are essential to the life of the country. They are also the ones who can provide the equipment or technological solutions needed to fight the virus.
Among the companies, those with operations or partners in China were able to draw on their experience to implement early crisis management and deploy health protocols that mobilized employees around the dual objective of protecting their health and maintaining business. Many of them mobilized to fight the pandemic, notably by providing protective equipment.
However, faced with the shortage of masks, the State chose to manage the supply issue alone, without exploiting all the expertise that certain distribution or logistics groups could have brought to the table.
On March 13, Prime Minister Édouard Philippe issues a decree requisitioning the stocks and production of masks, which extends to the stocks, imports and production of companies.
For some particularly exposed companies, the requisitioning of masks creates new difficulties and even threatens the continuity of their business.
Above all, this decision means the sudden cessation of all mask purchasing and delivery activities by French companies. While France has very large distribution groups with very extensive purchasing networks in China, and can also rely on flagship international logistics services, it is the State that undertakes to canvass, negotiate and deliver the hundreds of millions of masks needed, in a context of exacerbated international competition.
While the economic measures put in place very quickly by the government played an essential role in safeguarding businesses, the latter were not really considered as partners in the fight against disease in the deconfinement phase, which limited their ability to take initiatives to promote the resumption of activity in a secure environment.
A crisis of mutual distrust
At the height of the crisis, the political and health powers alone continue to occupy the centre stage of responsibility. However, in times of pandemic, it is the behaviour of all citizens that is the main key to the success of health policy, and the adherence of the largest possible part of the population to the proposed measures becomes crucial.
The Scientific Council, and in particular its Chairman, Jean-François Delfraissy, are particularly aware of the risks of a break with society. In its opinion of 20 April on the conditions necessary for the launch of deconfinement, the Scientific Council stresses that "the lifting of deconfinement must be widely supported by our fellow citizens, who are called upon to play an active part in it", and launches this formula: "trust in order to keep trust".
The lack of any follow-up to these requests underscores two of the shortcomings that characterise the state's management of the health crisis: the weakness of the public health dimension, and the lack of political confidence in civil society.
The war against the virus, as announced by the President of the Republic, is first of all a war of professionals, the doctors, supported by logistics, but where the third line, made up of ordinary citizens, is not called upon to do anything other than follow instructions, under penalty of being fined. In a tweet of 11 May, the Minister of the Interior noted that since the beginning of the confinement, nearly 21 million checks have been carried out and 1.1 million tickets issued. More than the mobilization of citizens, it is the mobilization of law enforcement agencies that is the focus here.
The strong willingness of citizens to commit themselves, beyond obeying the containment instructions, has not been placed at the heart of the public authorities' strategy. Despite some successful local experiences, the associations have been little involved in a health struggle for which their capacity for contact with the population could have been valuable.
The particularly sensitive issue that crystallizes the mistrust between civil society and the State is that of masks. Much has been said about the issue of State disarmament and the shortage situation, the extent of which was discovered by officials in February. This issue is indicative of the relationship between the State and civil society: the difficulty for the former to acknowledge a mistake or difficulty and to call for help from the latter.
More than the lack of stocks of masks, which has been the lot of most European countries, it is the choice not to call on citizens to manufacture them that reveals a fundamental reluctance on the part of the State to rely on society.
In turn, society's lack of confidence in the State is expressed in particular through forms of digital denial that hamper the State's ability to transform itself to meet the expectations that are expressed towards it. This is evidenced by the low priority given in France to digital tools in the fight against Covid-19. In addition to the bureaucratic blockages, linked to the weak digital culture within the State, to a culture of compartmentalization and control of information, there is also a societal blockage, created by the fear of digital technology as a tool for social control and as a threat to privacy. These concerns are legitimate, and the risk of setting precedents for restrictions on freedoms cannot be taken lightly. But the rejection of digital technology now seems to pre-empt any debate on the role it could play in serving the collective interest, as illustrated by the political tension surrounding the StopCovid project.
Emergency redesign
To provisionally conclude this first assessment, which is a precursor to many others that will no doubt come, we should not forget one essential fact: on the whole, the system has held up. The hospital system has been able to reorganise itself and accommodate the flow of patients without giving rise to traumatic scenes of patient triage, even if in some areas the carers have been confronted with critical situations. The State was quickly able to put in place support mechanisms that allowed for continuity of economic life. Essential services were maintained thanks to the mobilization of State services, local authorities and businesses. The communication networks, the true lifeblood of the nation, have never been interrupted. Finally, the State has demonstrated its ability to make itself heard in the country - with audience records that have brought the political word into an unprecedented number of homes, and a general obedience to government directives which, whether it is rooted in civic-mindedness, fear of fines, or fear of disease, has been remarkable.
Too often, however, these results have been the result of a fine thread, formed by a limited number of people who, at all levels of public action, have been able to go beyond the narrow circle of their competences to assume their responsibilities in the face of the reality of the emergency. Rather than on the redistribution of these competences, between the different levels of the State, or between the State and local authorities, it is on this spirit of realism and responsibility, and on these personalities who have emerged from the crisis, that the new phase of reshaping public action must be built. This overhaul is now the most urgent need if we are to deal with the other emergencies that await us: in the face of the economic crisis, the social crisis and the generational divide that is set to widen dramatically, only renewed political ambition in the fields of health, education and housing can restore meaning to public action and to our collective life, which is threatened by centrifugal forces.
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