France in shortage of masks: the origins of state decisions

At a time of the internal health controversy surrounding the pandemic - the lack of effective protective masks for caregivers and for the personnel essential to making the country's economy work even in times of crisis -, it is essential to restore the chronology of events that led our country to disarm in the face of the risk of a pandemic.

No doubt that after the return to an era of health security, commissions of inquiry will be created to shed light on the facts. With means of investigation other than ours today. But already, the complete reading of numerous official documents published makes it possible to re-establish an archeology of public policy choices.

To do this work, we must beware of a simplistic, personalized, excessive and expiatory approach. Not simplistic and personalized, because we will not find a text signed one day in an obscure office by a minister or a senior official and which would have said “now no more stocks of masks”. Not excessive and expiatory either, because it is not a question here of looking for a convenient scapegoat to expiate what is more likely the fruit of collective faults.

Most decisions were taken within the framework of a chain of shared responsibilities and lead us to the current situation, when many now speak of a chain of irresponsibility.

We will focus our attention solely on the question of equipping the State with masks, both in surgical masks deemed to be sufficient for patients who do not sputter in the face of others in this way, but also in so-called FFP2 masks, which guarantee a real facial protection barrier for all people exposed to the projections of virus-carrying droplets, starting with the entire medical profession.

To trace this genealogy of a series of decisions which disarmed France in masks in the face of a pandemic yet announced as certain in the future by many experts, we will follow a strict chronological account which begins in 2005 with a parliamentary report of alert on the present and future epidemic risks which obliges the French State to organize itself accordingly, to anticipate the worst, according to the famous adage: "to govern is to foresee".

The story will necessarily be a little long, but understanding the genealogy of such serious facts requires a little time, especially if you want to add concrete quotations.

Risk anticipation

On May 11, 2005, a report co-signed by MP Jean‑Pierre Door and Senator Marie-Christine Blandin entitled “Report on the epidemic risk” was made public.

The least we can say is that this text looks with lucidity and acuity at the new risks hanging over our modern, globally interconnected societies. It is recalled that acute respiratory diseases kill more than 3 million people a year. That these diseases are constantly evolving, forcing us to live in a universe where we will always have a late vaccine, especially with SARS.

All the experts predict that pandemics are bound to occur, and more and more often. One of the most recent official warnings comes from the United States. National Intelligence Service Director Dan Coats warns in his Global Threat Report, January 29, 2019:

He talks about

The mask, a weapon deemed effective in the event of an epidemic

In the 2005 parliamentary report, the conditions for protection against such an epidemic are set out, with the idea that will be repeated over and over until today, that it is a question of gaining time to leave it to scientists to take care of to find a drug and then, later, a vaccine:

Therefore, it is written in full that wearing a mask is a very effective tool of struggle, including to reassure populations, a mask more effective than that generally used for surgeons:

The rapporteurs nevertheless admit that the cost/benefit ratio is in favor of the mass purchase of masks:

This parliamentary report is followed by another, less than a year later, about avian flu. The recommended body of doctrine remains the same: barrier measures, plus masks, which we specify that studies conducted on the flu in Asia have shown to be effective: "A scientific study has shown that wearing masks in Hong Kong, during the SARS epidemic in 2003, led to a significant decrease in the number of respiratory ailments”. And here too the rapporteur recalls that "the recommended category for protection against influenza is that FFP2".

14 years ago, two parliamentary documents therefore wrote in black and white that masks are part of the essential panoply against the spread of a very contagious virus of the coronavirus type.

France equips itself massively with masks

The consequence is drawn from this by the Director General of Health heard by the commission. With regard to surgical masks, Didier Houssin provides the following clarifications:

As for FFP2 masks, he indicates that the government has acquired “already around 50 million” and that the objective is to acquire “more than 200 million” at the start of 2006. In 2006, in anticipation of a severe respiratory epidemic, the State therefore plans to store tens of millions of masks, including the famous FFP2. It must be said that the estimates of use are spectacular, given the rapid soiling of the masks and therefore the necessary renewal by the nursing staff “every 4 to 6 hours”. Consequently, “for healthcare personnel alone, the estimated number of masks needed is 2 million per day of the pandemic”.

These analyzes are in line with those of the General Secretariat for Defense and National Security (SGDSN), under the direct authority of the Prime Minister, expressed in the "Influenza Pandemic Plan" made public on January 6, 2006. It is affirmative: the mask is to be generalized, for the sick of course, for caregivers (but the FFP2), but also for people "essential to the operation of essential services and / or in repeated and close contact with the public". We can even consider wearing it in “public spaces as a precaution”, specifies the plan.

And the government's fight strategy is based on the stages of an epidemic that has become a pandemic, at the maximum stage (the one we know today in France with Covid-19).

The recommendation is clear:

The SGDSN updated this plan on February 20, 2009 and it is more assertive. The use of the FFP2 mask is extended. In 2006, its use “will be extended as far as possible to essential people...”, whereas in 2009, it “must be provided for”. Even better, it is planned to encourage everyone to acquire such a mask.

In the technical sheets that complete the flu plan, sheet C4 on health barrier measures (published in September 2009) refers to the case of people in a professional situation. The same recommendation is of course found there, but this is justified by the invocation of four French organizations linked to health (the National Institute for Research and Safety, the French Agency for the Safety of Health Products, the General Directorate of Health, the Higher Council for Public Hygiene) plus the WHO, all of which are converging on a strategy of maximum respiratory protection for the greatest number (caregivers and people exposed to the public).

Hearing today from the highest authorities of the State that wearing a mask is not essential therefore has great difficulty in carrying conviction by re-reading the recommendations of the Prime Minister's service only eleven years ago.

The H1N1 epidemic, the tipping point

It is in this context that an event will occur which will, paradoxically, be both the turning point for the application of these precautionary measures and their gravedigger for the future.

A decree of December 3, 2009 is published concerning “the distribution of kits intended for the treatment of patients affected by the type A (H1N1) influenza virus”. It is planned to distribute a box of masks to each patient who has remained confined to their homes, drawing on the national stock, because it is a public health imperative.

But we know that the response was deemed disproportionate, because in the end the H1N1 virus was not as severe as expected and did not turn into a pandemic. The Minister of Health at the time, Roselyne Bachelot, got off with political indictments of mismanagement and taunts of all kinds, because of massive purchases of vaccines that were not used, orders from laboratories which were finally canceled with millions of euros in penalties. In an interview with Ouest France on March 20, she said:

In a senatorial report on the execution of the 2009 finance law, signed by Philippe Marini, current LR mayor of Compiègne, we learn that the total cost of the fight against H1N1 is estimated at around 1 billion euros, of which 150 million for the purchase of masks.

Philippe Marini then shares "several questions" which are in fact criticisms of the effectiveness of the device: "significant quantities of masks were, first of all, ordered when few seem to have actually been distributed", "the delivery schedules show late receipts of orders which raises the question of the advisability of such purchases which, obviously, were going to arrive too late for the pandemic”.

But this a posteriori judgment ignores that under the fire of the health struggle no one can predict when the pandemic will end. The arguments he mobilizes are aimed at the EPRUS (preparedness and response establishment for health emergencies). This public establishment manages the means of combating serious health threats, both from a human point of view (the health reserve) and from a material point of view (purchase and storage of emergency health products). According to the senator,

To sum up: this organization helped to logistically manage a potentially serious health crisis by ensuring that no one ever ran out of protective masks. But it is called upon to merge into “pooling”, one of the keywords of contemporary managerial management of public services, where everything is done to “rationalise”, understand in order to save money.

The beginning of medical disarmament

We are dealing here with a real bias in reasoning that we find for example among anti-vaccines about measles. They say (wrongly) that the vaccine could cause disorders like autism in vaccinated children, when, they add, the risk does not even exist. However, measles is a disease ten times more contagious than the flu, and deadly. As a result, its eradication through routine vaccination has long been a global public health priority.

So, in effect, measles has pretty much disappeared from our lives. It is a disease that no one encounters around him anymore. We have forgotten the damage it can do, its high mortality. But it is precisely because there is a vaccine, which must be administered to everyone!

April is also #poetrymonth so we learned how to write an acrostic poem today about spring!😊🌱🌷☀️ https://t.co/m1IrRihzaV

— 𝕄𝕣𝕤. 𝕃𝕝𝕠𝕪𝕕 Wed Apr 24 21:52:42 +0000 2019

Likewise, here the power hammer reaction to crush the H1N1 virus played an effective role and therefore the pandemic did not occur. However, the method is criticized on the accounting level alone, without taking into account the result.

Health disarmament will then begin with the ministerial instruction of November 2, 2011 (cited in several reports but not found online today because replaced by others since, no doubt) concerning the strategy in the face of exceptional health situations. It introduces a distinction between two types of health product stocks which until now were jointly managed in a large "national health stock" created in 2001. Some stocks become "strategic" and must be purchased and managed at the national level, by EPRUS. They include drugs (antivirals, antidotes, vaccines, iodine tablets, etc.), medical devices and personal protective equipment (masks, coveralls, gowns, examination sheets). So many products that directly engage the responsibility of the State in the event of a serious health crisis.

Opposite, so-called “tactical” means (meaning less important than strategic) are identified, which are products and equipment located in health establishments where SAMUs or SMURs are located. The philosophy is that these stocks make it possible to activate an early reaction and as close as possible to the field, pending the mobilization, if necessary, of strategic stocks.

In this instruction, it is specified that the acquisition of tactical stocks is borne by the health establishments and financed by credits relating, in the accounting nomenclatures imposed on hospitals, to their missions of general interest and aid to contracting (MIGAC).

Faced with criticism of the national overstocking during the H1N1 flu and the sending to health establishments of stocks which then remained on their hands, a first reorganization began, allowing the State to share its responsibility in the preventive acquisition sanitary stocks.

The process is therefore irreversible. Because even if the list of so-called tactical products remains its responsibility, and the allocated budget is the result of the management dialogue between the hospitals and the ministry, the government is introducing a split that is conducive to future arbitration that could become unfavorable to the maintenance of a high effort to stock all useful products in the event of an epidemic, including masks.

Thus a decision which can be justified by a rhetoric of optimization of means at the most relevant geographical level, will become, by a bias well known in public policies, a first step towards the abandonment of initial objectives, by creating the first links in a chain of disempowerment.

The FFP2 mask would no longer be useful?

On May 16, 2013, the General Secretariat for Defense and National Security publishes its “Doctrine for the protection of workers against highly pathogenic diseases with respiratory transmission”.

Right from the introduction, he makes it clear that the managerial aspect is a common thread in his choices: "The present doctrine is the result of interministerial work carried out with a view to efficiency and overall economy, relying in particular on the feedback acquired during the pandemics of the past decade", including H1N1 in particular. It is based on the opinion of the High Council for Public Health (HCSP) of July 1, 2011.

The SGDSN retains that

Thus, on July 1, 2011, the consensus of September 2009 disappeared. The INRS, the Afssaps, the DGS, the Superior Council of Public Hygiene of France and the WHO, mobilized to defend an FFP2 mask for all exposed employees, see their recommendations evacuated and the wearing of a surgical mask must now suffice .

The SGDSN decrees that:

People would therefore be embarrassed by the most protective mask, which would justify that they would not put it on systematically and that it would be necessary to be satisfied with advocating the use of a less protective mask. Perfect syllogism.

Therefore, the SGDSN, led by State Councilor Francis Delon, considers that the responsibility for the respiratory protection of workers by masks should be passed on to employers: "It is up to each employer to determine the advisability of building up stocks of masks to protect its staff”. Accompanying this with a particularly disincentive speech of recommendations which clearly underlines the negative points:

We find here a politico-accounting tactic of the State that the territorial elected representatives know well: the financial discard. The State discharges a responsibility by transferring it, without (all) the budgetary means that go with it, to other actors. It is up to them to arbitrate between accepting everything and finding the means required, or not assuming all the new responsibility for lack of means. The chain of disempowerment thus acquires new links.

Drop the masks! Or the trap that closes

The situation of shortage of masks currently encountered by our country began to close at that time, by successive shifts, with decision-makers who are convinced that they are doing well.

The victorious campaign against H1N1 was (too) massive and would have generated “waste” amounting to several tens of millions of euros. For the sake of being more respectful of public money, subsequent governments and parliamentarians have justified limiting spending in the future, including for epidemic prevention structures, all in the context of permanent denunciation of the supposed mismanagement within hospitals and therefore a strong restriction of their budgetary capacities.

The three prevention operators (EPRUS, the Institute for Health Surveillance, and the National Institute for Prevention and Health Education) all saw their revenues drop between 2010 and 2014, with the total restriction amounting to around 54 million euros, a decrease of 24%.

We then started to ask the question of the stocks of masks (among other things) to finally convince ourselves that the FFP2 masks were not so essential for the public. So we come to consider that the sovereign protection mission with regard to populations is based primarily on the storage of surgical masks.

And since the FFP2 masks are intended for health personnel, then why not transfer the responsibility for their acquisition to each health center?

It is this mechanism that Francis Delattre, Senator Les Républicains, describes in his parliamentary report made on behalf of the Finance Committee dated July 15, 2015 under the title: "Establishment for preparation and response to health emergencies (EPRUS ): how to invest in the health security of our fellow citizens? »

It explicitly addresses the issue of protective masks.

And the rapporteur continues his presentation of the change in doctrine and provides justifications:

Certain products will no longer be stored "because of the greater availability of certain products and their marketing in community pharmacies" or because "of the transfer of responsibility for constituting certain stocks to other actors (for example, establishments health and medico-social establishments for the FFP2 protective masks of their staff)”, further specifies the report of the senator.

Things are said: if other actors can sell them or can buy them, what is the point of forcing the State to make preventive stocks? ! The chain of disempowerment then ends.

The accounting principle supplants the precautionary principle

The managerial and solely accounting concern therefore ends up here taking over and leads to forgetting the very reasons for which it was planned to make these stocks, according to a logic of "just in case", never taking the risk of being at the mercy of a break in supply from French or foreign manufacturers, for example.

Because the short-termism of the vision thus defended completely forgets that a pandemic, by definition, is a globalized epidemic, which can cause disruptions in supply chains. As a result, even the national industrial apparatus may be seriously disrupted, especially if the workers in charge of manufacturing future masks refuse to go to the factories for a legitimate fear for their health.

And, in order to avoid ordering too many doses of health products and to avoid having to cancel with penalties at the time of an epidemic that would have been less severe than expected or suppressed by the use of these protections (case of H1N1), Francis Delattre emphasizes that “the Minister for Health has decided to develop a new method of acquisition”: the reservation of production and acquisition capacities from laboratories.

This tool, also called “sleeping contract” will thus be used for vaccines against pandemic-type influenza. A public procurement notice was published by EPRUS on August 8, 2014 concerning

This contractual device, straight from British pragmatic liberalism, was therefore imported into France by Marisol Touraine, then Socialist Minister of Health.

It's basically a "pre-order" just waiting to be activated. This perfect accounting rationality becomes the subject of one of the recommendations of the rapporteur Les Républicains:

The precautionary principle: storing to be sure to have in the event of a crisis, because it is vital, is replaced by logic: being sure not to store too much because it is essential not to spend more than necessary .

Reasoning criticized today by many experts, when by a bureaucratic-accounting approach, moving away from any forward-looking political vision, we have forgotten, step by step, the major health alerts that prevailed in these choices of mass preventive stocks .

The State has therefore gradually disarmed itself, at the risk of endangering citizens, starting with non-hospital health professionals, who are just as directly in contact with patients as their hospital colleagues.

All of this was done with the perfect good conscience of senior civil servants and politicians from right and left who were keen to participate in "good management of public funds", gradually forgetting the primary purposes, committed that they were on a path (politicians speak of “path dependency”) which makes them go ever further towards a new objective in which they have entered, losing sight of the starting point.

This forces the current members of the government to painfully explain, to the detriment of the WHO recommendations and contrary to the Asian cases, that the mask is useless for a large part of the population or that we do not know. to serve. And that it would therefore be appropriate for the state not to adopt an “Asian” strategy of protecting its citizens through masks and massively distributed disinfection gel, coupled with massive testing.

The authorities also place many workers and their employers in the face of a contradictory injunction: “we ask you to go to work” but “we cannot provide you with the means guaranteeing your minimum protection”.

The orders announced on Saturday for 250 million masks do not change the fact that a drastic overhaul of our body of preventive doctrine will be necessary before the next pandemic breaks out. We will have to draw all the consequences of the current crisis.

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Arnaud Mercier, Professor of Information-Communication at the French Press Institute (University Paris 2 Panthéon-Assas) and founding authors The Conversation France

The original version of this article was published on The Conversation.