“The very thought of what crisis preparedness is is totally absent”

Interview of Didier Torny by François Bonnet, published in Mediapart on April 3, 2020

What do you see when you look at the French response to the Covid-19 pandemic?  

What struck me first is that all the work accomplished, basically from 2004 to 2012, seemed to have completely disappeared! This work led under the authority of a service of the Prime Minister involved almost all the ministries, the local authorities, interprofessional branches, and involved large budgets, as well as the creation of an institution, the Eprus. All this seems to have vanished into thin air.

Up to the vocabulary used by the authorities, all this knowledge seems to have been erased: no more “business continuity plans”, “degraded situation”, “scenarios” or “essential activities” (see this article « De la gestion des risques à la production de la sécurité. L’exemple de la préparation à la pandémie grippale » [“From risk management to the production of security. The Example of Pandemic Influenza Preparedness”]).

This is very troubling and raises a broader question for Government Science: how to maintain the memory of such investments made in the 2000s, and not just the issue of the stockpile of masks? How can this be done when a large part of the political staff has not lived nor experienced this type of event or has only withheld “It was a failure, it went too far”, in reference to what was said in France about the management of the H1N1 crisis in 2008/2009?

One might have thought that the political class had learned something about health issues in the 1990s and 2000s. But then another political staff arrived who had not gone through exceptional events, AIDS, contaminated blood, growth hormones, mad cow disease, asbestos, pandemics. A certain way of thinking about health crises has not been transmitted at all.

The administration is supposed to ensure the continuity of the State. Has this memory of crises and methods disappeared within these administrations themselves?

Maintaining memory in an administration or organization is a very complicated and expensive process. It requires infrastructure, staff, budgets, procedures, a whole host of things. With Covid-19 we have an extreme example of institutions and administrations that haven’t been sustained. Because the threat of an influenza pandemic, and an infectious pandemic in general, was losing credibility to the point of dissipating, they melted away.

So, yes, my first troubling thought was: where did it all go? And yet it is all there, all the documents and procedures are there! You reread the Pandemic Plan for 2011, all the measures are there: closing the day-care centers, the schools, the theaters, using collective buildings for health purposes… The issue of dependence on China for health devices (protection, medicines), but also for consumer goods or components, has been present since at least 2005. For example, asking large general retailers to assess their capacity to ensure supplies in all French regions and to build up stocks and find suppliers accordingly. Defining continuation plans by sector of activity. Everything is there, public and available, and yet there is this massive oversight!

And what resulted from this oversight in the management of this major health crisis?

Not only was there no preparation upstream, but it is the very thought of what crisis preparedness is that seems to be totally absent from government actions. One can criticize measures that were too limited or too late, but more fundamentally the very consequences of such or such measure taken after 14 March have not been anticipated, precisely because of a lack of preparation.

Schools are being closed, but no thought has been given to what the consequences will be, for whom, how and why. Organizing the care of the children of the medical and nursing staff? This had not been thought about either and therefore had to be organized after the decision was made.

This is what is most frightening: this very specific “culture” of what preparation for a health crisis should be has disappeared. I don’t want to be too hard on the government. But all the work accomplished in the 1990s and 2000s… there seems to be nothing left of it, except the names of the phases of the epidemic that come from WHO documents! The problem of the masks is only one of the consequences, most immediately visible, of the disappearance of this form of thinking.

Isn’t there a more ideological explanation, the commitment to dismantle or at least narrow the missions of the state, the forced restructuring of the health apparatus and the hospital?

More than ideology, it is the implementation of accounting and budgetary procedures, that many colleagues have studied in the hospital setting, that is operative. But this does not apply exclusively to healthcare. Remember the resignation of the Chief of Army Staff because he considered that he could not remain in his post because he did not have sufficient means to ensure the protection of the French population.

There is actually an administrative and political thinking built on accounting schemes in which the stock, the reserve is thought of negatively, as useless fixed assets and expenses. This is Bercy’s [the finance ministry] culture: to hunt down everywhere all the dormant reserves of public funds.

You can say that this is ideology, I see it rather as an administrative machinery gained by an obsession that public funds must always and everywhere be optimized, in the short term. And this surpasses all other forms of concern, linked to the extraordinary, the unpredictable, the exercise of sovereignty, in the long term.

This may have accelerated in the last decade, but this is nothing new: even in the 2000s, it had been very complicated, for example, to build up a national health stock. This was undoubtedly made possible by the weight of WHO announcements, its ability at the time to make people believe in the threats and its recommendations to States. The episodes of SARS in 2003 and H5N1 in 2005 were very important in convincing people of the reality of the pandemic threats, of the necessity of this very expensive preparation and storage of antiviral drugs or masks.

Isn’t there a distrust of the executive towards administrations and, in particular, towards the large health agencies, which are often criticized for their cumbersomeness and lack of responsiveness to the unexpected?

Over almost thirty years – since the first health agency in France – their history is one of mistrust, whatever the government. Each time there has been a crisis, their name and organization have been changed, merged or new ones created. The management of the scientific expertise of the current crisis is part of this long history.

For a long time, scientific expertise was second, since the fundamental choice was not to put the economy on hold. In the face of this type of crisis, arbitration is always delicate: it is the result of linking the threat and its economic and social consequences. It is clear to all analysts that the adjustments made up to March 12 by the government on large gatherings were aimed at preserving the economy as much as possible, due to the lack of belief in a real epidemic affecting France. 

It is remarkable that the High Council of Public Health (HCSP), which is responsible for infectious and transmissible diseases, and Public Health France (SPF), which is in charge of health monitoring and the management of the health reserve, are not part of the scientific council. The president of the HCSP was simply invited to the third meeting, on March 16, and the scientific director of SPF indicated as a “correspondent” at the fourth meeting on March 23 (source here). In a press release of March 20, the HCSP recalls its role in providing recommendations with six advisory opinions published since February 14 and the importance of an independent expert structure (source here).

And then there was the Italian overflow, a surprise effect, then panic, and then the changeover in the face of the experts of the Scientific council. The lack of preparation then left no room for intermediate measures. The primary objective became to limit the number of deaths and the congestion of hospital structures. From then on, due to the lack of masks and tests, and the inability to trace cases, a default strategy was adopted, as Professor Delfraissy, Chairman of the Scientific Council, explained.

1, we don’t have the masks, 2, we don’t have the tests, 3, we don’t have the other protections, and 4, we haven’t prepared anything… All that remains are extreme measures such as the containment and shutting down of a large part of the economic and social functioning. These are two measures that the government initially refused to even consider, and of which it can only now consider the edge effects pointed out by its Scientific Council in the second part of its March 23 advice.

These “edge effects” are all warning points on the supply of means of protection for those who are still working, the ambulatory care which must continue for other pathologies, the management of the deceased’s bodies, the psychic health, the spiritual accompaniment, the role of NGOs, etc. Here we find part of the long list of preparatory tasks which, because they are not dealt with upstream, become alerts downstream of decisions.

In terms of health crisis, governing is less a matter of foreseeing the unforeseeable than of anticipating the consequences of decisions deemed necessary by the organization of the preparation.

François Bonnet’s article “Gérer le Covid-19: pourquoi l’Etat et l’exécutif ont tout oublié” [“Managing the Covid-19: why the State and the executive have forgotten everything”] was published in Mediapart on 3 April 2020.

This interview was done by Skype on Tuesday afternoon, March 31. It has been revised and amended on a few points by Didier Torny. 

Several documents can be read in addition to this interview:

This article by Didier Torny in the journal Réseaux: Torny D. (2012) De la gestion des risques à la production de la sécurité. L’exemple de la préparation à la pandémie grippale, Réseaux, 171, 45-66.

The July 2010 report of the National Assembly’s commission of inquiry into the H1N1 flu and the government’s response

The July 2010 report of the Senate Committee of Inquiry on the same subject

Senator Francis Delattre’s report in 2015

This column published in Le Monde on March 30, 2020 by Claude Le Pen, a specialist in health economics: “Coronavirus : “En 2007, la France avait su mettre au point un dispositif de protection très ambitieux contre des pandémies” [“In 2007, France had managed to develop a very ambitious protection system against pandemics”].

And this expert report “Avis d’experts relatifs à la stratégie de constitution d’un stock de contre-mesures médicales face à une pandémie grippale” [“Expert advice on the strategy for stockpiling medical countermeasures in response to an influenza pandemic”] submitted in May 2019 to Public Health France (SPF).

Image 1 – Photo source: Prachatai “covid-19”. March 2020. Flickr-CC0 1.0

Image 2 – Photo source: F. Paterson “Plus de thermomètre plus d’alcool”, Paris, 20 mars 2020

Image 3 – Photo source: muffin “Coronavirus masks”. 30 March 2020. Flickr-CC-BY