Henri Bergeron et al. Covid-19: Une Crise Organisationelle Sciences Po: Les Presses, 2020. 9782724626650
Jean-Paul Gaudillière et al Pandémopolitiqiue La Découverte, 2021. 9782348066153
Many countries have developed a narrative about the unique incompetence of their governments in dealing with the Covid-19 pandemic. This has been a convenient stick with which political opponents can beat those in power and biomedical elites can advance their claims to displace democracy and the rule of law as the source of state legitimacy. In the UK, there is a whole new genre of ‘insider’ books claiming that the pandemic would have been handled much better if only the policy had been driven by their authors rather than by the messy processes of democratic politics. The particular value of the two books reviewed here lies in their application of well-established bodies of social science literature to analyse the French response rather than treating it as a simple matter of moral outrage.
Bergeron and his colleagues are sociologists of organizations, with an established interest in crises, failures, catastrophes and disasters. Gaudillière and his colleagues are historians and sociologists, with a background of studies in health policy and public health. Taken together, they not only illuminate the French experience but provoke reflection about the reasons why so many countries adopted similar responses, while representing them as unique, and about the importance of developing a social scientific understanding of what has happened, rather than abandoning this to the world of biomedicine.
As Bergeron et al point out, the challenge of the pandemic was not unexpected. It was part of a class of disruptions of social order that had been attracting the attention of organizational sociologists since the 1960s, generating an extensive evidence base for public policy in the prevention and management of disasters. Planning specifically for a pandemic had been going on since the early 2000s. All of this thought, experience and expertise was abandoned in March 2020, with the creation of a novel institutional system, entirely decoupled from the existing knowledge base, and the adoption of novel interventions, particularly lockdowns, with no attempt to consider whether potential harms might exceed potential benefits, whether these new institutions might simply multiply problems of co-ordination rather than resolve them, and what an exit strategy might look like. The authors stress that their purpose is less to criticise these choices than to understand how and why they came to be made. Why was the pandemic treated as a problem of individual rather than collective action? Why did the response not draw on the theoretical frameworks that had been developed from studies of previous disasters? Why did the response not learn from the practical experience of managing previous disasters?
The authors address these questions across three chapters, dealing successively with the lack of preparation and elite panic when Covid-19 arrived in France at the beginning of 2020, with the struggles for power that accompanied the attempt to develop a co-ordinated state response, and with the challenges of creating institutions that would respond better to similar future events.
In France, as elsewhere, lockdown was initially justified as a response to the risk that hospitals would be overwhelmed, coupled with an insufficient supply of personal protective equipment and test kits. Implicitly, this was an admission that France had not prepared for this eventuality. According to rational theories of public policy, the lockdown decision should have been made following systematic comparison of options with the costs and benefits attached to each. In particular, alternative decisions should have been shown to lead to greater loss of life. As Bergeron et al point out, this story does not describe what actually happened. How did the French state and its expert advisers miss the early warning signs? Was it a collective failure of imagination that led them to discount the scale of the challenge, coupled with an assumption of cultural superiority over the Chinese and the Italians who had initially confronted it? Was it the result of state corruption and reluctance to challenge powerful economic interests, as in previous health scandals? Both of these popular explanations had been offered with the benefit of hindsight and did not help to understand the task of policymakers in dealing with an unfolding emergency. This had much more to do with the way in which the signals of that emergency, and the institutional capacity to respond, had been weakened over the previous decade. The state was less negligent than over-confident because it had not recognised that this process was occurring. Elite panic resulted from the sudden recognition that the capacity assumed by emergency planning no longer existed.
In the early 2000s, France had, like many other countries, embarked on a process of renewed planning for emergencies, including pandemic influenza, in response to a series of events like the Great Storm of 1999, ‘La Canicule’(heatwave) of 2003 and the 9/11 attacks in the US. This had been reinforced by regular exercises and a legal and institutional framework had been created as a basis for action. By 2019, responsibility had been located with an interdepartmental crisis management unit. However, the emergence of Covid-19 actually led to the creation by the Ministry of Health of another interdepartmental team, under its own leadership, which had no formal basis. Bergeron et al suggest that the plans had been eroded by a well-recognized process of organizational drift, where the attention of state agents had been diverted to other, more immediately pressing, issues. They were also affected by the misleading signal of the 2009 influenza pandemic, where many states were judged to have over-reacted to a novel virus with minimal impact on those who contracted it. Although networks of clinicians, especially intensivists and infectious disease specialists, were collecting information from Italy and China, there was no mechanism for this to be incorporated into civil service or public health thinking. The disease itself was relatively ill-defined at this stage with few signs or symptoms that would clearly distinguish it from other respiratory infections. The French state apparatus was distracted by the wave of civil unrest provoked by President Macron’s attempt to reform the pension system, and by preparation for the local elections, scheduled for 15 March, which were seen as important for renewing the democratic legitimacy of his government. The key event appears to have been an endorsement by the Institut Pasteur of modelling from Imperial College London, which projected potentially large numbers of deaths and hospitalizations, which had initially been treated with some scepticism.
This was the point at which policy elites recognized that France had neither the materials (PPE, tests, etc.) nor the hospital capacity to deal with the potential demand and, without further reflection or evidence, adopted the radical measure of lockdown. It was imposed nationally, without regard to local circumstances, as an expression of republican values of equality. The gradual implementation of closures through a series of proclamations from 12-17 March was intended to minimize the risk of population panic and resistance and to protect the elections on 15 March, for reasons already noted.
Like many governments, the French claimed to be ‘following the science’. However, the initial relationship between science and the state was confused and poorly co-ordinated. One of the first steps was to create a scientific advisory council on 10 March, led by an immunologist with experience in dealing with HIV/AIDS and Ebola. However, the members were appointed in an individual capacity and there were no formal linkages with the established public health agencies or their scientific advisory bodies. Members were predominantly researchers from elite institutions, although they were called upon to pronounce on issues of policy, like not cancelling the local elections. The council had no legal basis until 23 March and, even then, its authority was confused by poor drafting. In the meantime, a second expert committee had been established to advise on questions to do with therapies and testing. Bergeron et al point out that it is unusual for the French state to take much notice of scientific advice in policymaking at the best of times. However, it was odd that the established public health networks were so rapidly sidelined. While the justification given was that this was because the societal aspects of this pandemic were novel – and the council did include a sociologist and an anthropologist among its members – its pronouncements were so narrowly biomedical that the argument is not convincing. Calls for greater public engagement and a possible advisory body representing societal interests were ignored.
The government’s central crisis management unit was finally mobilized on 17 March. The next two months are a story of struggles to prise control of the response out of the hands of the health department and into the cross-government processes envisaged by prior emergency planning, where a more holistic approach to health, society and economy could be established. This is as much a matter of power as of practice. The initial establishment of the new, ad hoc, scientific council by the president dramatized the crisis and the unique ability of the nation’s leader to take control of the response. Over the next few months, the operational challenges of co-ordinating state agencies to deliver that response exposed the limits of that power and the need for other priorities to be given equal respect to those of the health ministry.
What lessons do Bergeron et al draw from the French experience? There will, no doubt, be numerous reports and reviews. Some of these will yield valuable data. But they will probably not generate any useful lessons because they will treat the crisis as unique rather than contributing to our cumulative understanding of events of this kind. They are likely to focus on assigning blame (or praise) rather than on understanding the structural or systemic issues that created the conditions for the crisis. Agencies will be reorganised without considering the adequacy of their resources for the task in hand. A few careers may be broken in the search for scapegoats. Technology may be tweaked. New laws may be passed. The state moves on and consigns each report to its archives. There is no organisational learning and the memories are lost as personnel move on or retire. Nevertheless, certain general lessons should be learned. The first is that of recognizing when an emergency is the sort of emergency that requires the plan to be triggered. The pandemic had some similarities to the 2003 heatwave in that it was a slow burn event whose catastrophic nature was only identified at a late point. Desk-top simulations start from the crisis and do not prepare people to recognise its unfolding. This requires an agency with a permanent commitment to collecting and collating information, constantly scanning for potential threats and ready to trigger agreed actions. The French health department was able to act unilaterally in March 2020 because of the uncertainty about the crisis and then acquired a lock on policy that was difficult to loosen.
Second is the nature of the frame within which the crisis is viewed. Is a pandemic a health crisis or a societal crisis? The initial response framed it as a challenge to the health system, to be managed according to biomedical methods and priorities. It took some months for the social and economic costs of this framing to be acknowledged. Again, desk-top exercises do not provide for the frame to be discussed, especially if they are led by the health department. These are discussions that should take place in advance. How far should public policy focus on protecting very frail old people from one particular cause of death at the cost of wrecking the economy that paid for their care? Thirdly, there needs to be a better understanding of the requirements for effective emergency action. Crises arising from terrorism, natural disasters or nuclear safety failures are dealt with by well-established agency systems with clear protocols and recognized systems of power and authority. Pandemic response had large elements of improvisation, muddle and confused responsibility. This may be inevitable in dealing with loosely coupled professions and organizations but it should be acknowledged and studied. Finally, planning exercises often struggled to engage the people who would actually be responsible for crisis management and to prepare participants for the unexpected. Scientific and policy elites needed to be better trained to deal with crises. Advanced technical and scientific education did not develop skills in dealing with unpredictable problems. The exercises that were set, like the emergency simulations, were bounded and solvable. People were not rewarded for risk-taking or innovation, in science or in policy. On the policy side, professionals lacked sufficient understanding of scientific method to question the advice they were being given: on the scientific side, the underlying positivism of their position led to a bogus certainty in the presentation of knowledge. Both groups were preoccupied with models of charismatic leadership and poorly equipped to understand the distributed and situational leadership more characteristic of real organisations. Science and technology were stripped from their social context as if they could solve the challenges of pandemic management on their own.
Gaudillière and his colleagues place French pandemic management in a longer historical and cultural context through the metaphor of ‘triage’, by which they mean not merely the clinical prioritisation of mass casualties in battle or civil emergencies but the choices made more generally about resource allocation by public or private organizations. To what extent were the possible courses of action available to the French state constrained by prior decisions about where to invest? They begin from detailed accounts of the run-down of national stocks of personal protective equipment (PPE), first assembled in response to a perceived threat from H5N1 influenza in 2003-05, and the transfer of responsibility for maintaining stocks for health workers to local employers, particularly hospitals. Audits following the 2009 influenza pandemic had concluded that the national stock was too large and costly. By 2017, much of it was out of date and had to be destroyed. The government decided to maintain a buffer stock, which would be constantly renewed as was drawn down to meet the routine needs of the health system, although the official intention continued to be that it would also cover symptomatic patients in a serious pandemic. The supply of surgical masks, in particular, was judged to be a poor investment. Although French policy, unlike that in many other European countries, had always envisaged the supply of masks to the whole community, senior public health figures had long privately considered that this would be ineffective and a waste of taxpayers’ money. In this respect, although Gaudillière et al do not make the point, they reflected the international consensus in their field – both of the UK’s Deputy Chief Medical Officers expressed the same view in March 2020. While the policy did not change, resources were not allocated to support it and stocks were not sufficient at the time they were called upon.
Similarly, the use of PCR tests was constrained by the limited supply of materials, people and resources. Although the system responded promptly to the news from Wuhan, it was never intended to sustain mass population screening, which the public health leadership also thought to be of limited value. Testing was to be used to monitor health system workers and to support the diagnosis of patient presenting with acute respiratory conditions, especially those at high risk because of age and/or co-morbidity. Gaudillière et al argue that this forced policymakers towards lockdowns because they could not operate the Test, Trace and Isolate (TTI) strategy adopted elsewhere. The government choice to concentrate on a few specific uses of tests was attacked by sections of the medical profession, who advocated the wider use of local, rather than central, laboratories with additional purchases of equipment and testing materials, regardless of cost. However, the testing would only have been of value if it had been supported by effective contact tracing and isolation. In practice, people testing positive were reluctant to pass on details of their contacts to inexperienced tracers or to self-isolate without recognition of the inevitable costs.
The imagery of the pandemic placed hospitals at its centre and made heroes of intensive care teams. In reality, the picture was more complex. Some hospitals saw a reassertion of medical power, relative to that of the administration – but this also asserted hierarchies that blotted out the experiences of nurses and other professionals who had to deal with death on a scale for which they were not prepared. In practice, of course, the work of the administration never went away, in co-ordinating services, procuring supplies and liaising with other organisations to spread the workload. What the pandemic did expose, though, was the unadvertised practices of triage, both economic and clinical. Hospitals have always been constrained by the financial resources available to them but the impact had become more nuanced with the rise of health economics since the 1960s and the questions it posed to clinicians about the marginal benefits of interventions. Did this patient really need to stay another night in hospital, especially if it took their costs beyond the tariff for reimbursement, or could the bed be freed for a new patient whose needs might be more urgent and fully reimbursed. Similarly, there had always been a finite number of intensive care beds, leading clinicians to make decisions about the likelihood that a particular patient would benefit from this brutal experience, relative to other possible candidates for admission. Covid relaxed the economic pressures, but did not abolish them, and forced an adjustment of the cut-off points to intensive care. These issues are familiar to anyone who studies health care but had not been forced into public debates, especially as they contribute to many inequalities of outcome. By focussing mainly on the economics of the hospital or the physical condition of the candidates for intensive care, they excluded wider social and economic impacts.
France is noted for the degree of health inequality within its population, although differences by race or ethnicity are difficult to document because of legal restrictions. However, the picture seems to have been similar to elsewhere with the elderly, the economically marginal, those with co-morbidities, and ethnic minority populations particularly at risk. Often, of course, these categories overlapped and reflected shared experiences of precarious or poorly-paid work in manufacturing or distribution. The ‘working from home’ classes were as well-protected in France as anywhere else. Disadvantaged groups, experiencing higher rates of sickness and more severe impacts, were further disadvantaged by the triage processes of the hospitals. As elsewhere, hospitals and care homes responded to risk by banning visitors, with little thought given to the psychological impact on patients or residents. For all the rhetoric of well-being and autonomy in their care, the elderly, in particular, were rendered invisible.
The economic triage practiced by the hospitals reflected their underlying weaknesses, dating back over a decade when funding had failed to keep pace with the growth in demand, with the intention of stimulating higher productivity and a ‘turn towards ambulatory care’. Gaudillière et al chronicle the consequences in terms of deteriorating quality of care, shortages of personnel and poor labour relations. Although the reform programme was intended to shift work towards out of hospital care, by, for example, incentivising day surgery for many conditions, cuts to hospital budgets had not been matched by increases in primary or community care budgets. Public health agencies were in equally poor shape. As already noted, they were short of resources for testing and of field epidemiologists. Skilled professionals were dispersed and isolated within a number of organisations. Local agencies lacked competence and central agencies lacked knowledge. In this respect, France compared unfavourably with the UK – the authors do not seem to have fully caught up with the fragmentation and contraction of UK public health services since 2012. Population health had given way to biomedicine.
Infectious diseases, and the risk of pandemics had only returned to the political agenda after the terrorist attacks of 9/11. This framed the issues in terms of biosecurity. Preparation was led by surveillance to inform individuals’ own precautionary actions – state preparation was focussed on critical economic sectors and forces of order. There was no drive to prevent public health catastrophes, merely to limit their impacts: protecting key state and private infrastructures, and associated personnel, rather than vulnerable groups. According to the plans, anticipation was dominated by investments in vaccines and therapies, to be stockpiled and distributed according to state priorities. Questions of the provision of care and access by anyone other than the forces of order were dismissed, with massive closures of hospital beds rather than the retention of a reserve capacity to deal with pandemics. Gaudillière et al contrast this with the approach adopted in Asian countries, as a result of their experience with the original SARS-CoV-1 virus and with MERS. These countries envisaged a response based on Test, Trace and Isolate, widespread use of masks in public spaces, a focus on infection risks in health care and other institutional settings, and the use of mass quarantines.
French weaknesses in the training and supply of epidemiologists and other public health specialists had been revealed in system failures at the time of ‘La Canicule’, the 2003 heatwave (See Abenhaim 2003), but had not been remedied. There was a particular limitation on the capacity for epidemiological modelling to inform policy, at both regional and national level. In consequence, there was heavy dependence on the model constructed by a team from Imperial College in London, which had fuelled much of the pressure for lockdown in the UK. Although French scientists were suspicious of the parameters, the data and the programming, they had no other resources immediately available.
On 12 March, President Macron had declared that ‘health does not have a price’ and that the state would spend whatever was necessary to protect citizens, care for the sick and save lives. As Gaudillière et al observe, anyone with any knowledge of policy or management would silently add that all of this comes at a cost. If ordinary budgetary constraints are removed, there are new opportunities for private gain from public funds. As with other crises, we should ask who benefits from the ways in which responses are framed. The authors set the pandemic response within a long-term context of addressing health problems with technoscientific solutions purchased from private corporations. The market in health care is not a means of achieving competitive efficiency but a pseudo-market for creating private value at public expense. The same phenomenon is apparent in the UK, where public auditors and anti-corruption investigators are trying to unscramble the web of suppliers of PPE and test kits, often with ownership trails leading back to tax havens and anonymous beneficiaries. The long history of NHS IT failures was forgotten by the eagerness to sell it apps for citizen surveillance or movement control, regardless of the ethical or civil rights issues that these might generate.
As a global pandemic, the World Health Organisation might have been expected to exercise global leadership. In practice, Gaudillière et al suggest, it was a weak presence. While other commentators have seen this as a matter of politics, particularly the influence of China and the US and their mutual desire to resist external criticism of their national efforts, Gaudillière et al anchor this in the longer-term history of WHO, particularly the erosion of the ‘horizontal’, primary care-led, model of health systems adopted at Alma-Ata in 1978. This had provided for health needs to be integrated into a holistic view of community needs and development. This had, however, been inconsistent with the interests of private suppliers and NGOS, like the Gates Foundation, that were allied to a technoscientific model of ‘vertical’ programmes focussed on particular diseases, as identified by the metrics of DALYS (Disability Adjusted Life Years). These top-down programmes were inflexible and lacked community engagement but allowed for the continued marketing of private goods and services. The weaknesses of this approach were demonstrated in the WHO’s conspicuous failure to manage the Ebola outbreak in West Africa in 2013 but had not led to change because of the interdependence between WHO, private interests and selected NGOs.
In the final section of the book, Gaudillière et al develop their own thoughts on an alternative strategy. They begin with a discussion of the market-based Gates Foundation model, which envisages large public subsidies to private interests and ignores the established traditions of public health interventions. Against this, they outline a reassertion of the model of the commons, resources freely shared by communities before the enclosure movements of the 17th and 18th centuries. This approach has recently been examined by the economist Elinor Ostrom, in the work for which she was awarded a Nobel Prize in 2009. Pandemic management could be a matter for local communities, drawing on collectively-generated resources distributed or applied according to local understandings of need. They examine the application of this approach in various contexts, although few have been entirely successful. In a more limited way, though, the greater socialization of health care in Europe does seem to have led to a lower death toll from Covid than under the market system operating in the USA. This might suggest that more radical democratization of control over pandemic management could have had even greater benefits, particularly in relation to socially excluded or marginalized groups. Various models are considered, although, again, most were short-lived. The authors then turn to the importance of an ecological approach that considers the health impacts of development pressures on natural resources and the extent to which these promote or facilitate microbial crossovers, antibiotic resistance or disorders resulting from the contamination of air, water or food. The pandemic is a syndemic, where the health crisis exposes a range of other crises in systems of governance, dominant ideologies and assumptions about the good life, captured in their title, which links pandemics, democracy and politics in a single neologism.
Both of these are ‘instant’ books, products of a particular historical moment in the course of the Covid pandemic, and should be evaluated as such. For a UK reader, their interest is the degree to which their account of the early French response to the pandemic echoes our own experience and, I suspect, that of a number of other developed countries. The account given by Gaudillière et al of the decay of the national PPE stockpile after 2009 is exactly paralleled by ours. Although this had been identified as an issue in 2016, it was not acted upon, although the UK failure was compounded by the diversion of civil service resources to managing Brexit. Bergeron et al’s explanation of how the French health ministry took control of the response, and the subsequent struggles to wrest control from the limited pool of scientific advisers that it recruited, is particularly persuasive. They have clearly identified a gap in disaster research and planning for the recognition and response to slowly-developing events. While the French state had been through this experience in the 2003 heatwave, it had failed to learn any wider lessons, much as Bergeron and colleagues predict will happen with the Covid pandemic. Gaudillière et al suffer perhaps from publication before the scientific contestability of non-pharmaceutical interventions like masks, school closures, restrictions on movement and so on was fully apparent. There is still more work to be done on how these came to be accepted with very little evidence of effectiveness and the resistance of policy elites to commission robust studies that would establish this. Their call for a new eco-politics of health was shared by many commentators from the left who saw a revolutionary moment of the kind identified by Debord and the situationists. However, like many of these moments, it seems to have passed. The authors never fully grasp the contradictions of pointing to communitarian institutional models which depend upon donations from economic actors disposing of surpluses or from taxes levied upon both participants and non-participants in these ventures. Many of them have struggled to move on from charismatic foundations to the routines of permanency. Despite this, it is valuable to have a more comprehensive documentation of the ‘new normal’ project than has been set out in short-format blogs or print media articles.
Taken together, these books are a useful complement to Greer et’s (2021) edited collection of relatively brief national case studies, showing something of the depth of investigation that will be needed to understand the elite panics and isomorphic responses in many developed countries. Of course, the study we all really want to read is the one of why Sweden did not experience the same panic, although Anderberg (2022) is a useful start…
Johan Anderberg, The Herd: How Sweden chose its own path through the worst pandemic in 100 years, Scribe. 9781913348908
Lucien Abenhaim (2003) Canicules, Fayard. 9782213617602
Scott L Greer, Elizabeth J King, Elize Massard da Fonseca, and André Peralta-Santos (2021) Coronavirus Politics: The Comparative Politics and Policy of COVID-19, University of Michigan Press. 9780472038626