France’s response to COVID-19
This Strategic Comment was originally published in August 2020.
France experienced one of the world’s worst outbreaks of COVID-19 in the spring despite its excellent public-health system, and cases are rising once again. The use of top-down, centralised control measures in the French system slowed its response to the fast-moving crisis and contributed to the high death toll.
When the novel coronavirus, SARS-CoV-2, emerged as a global public-health emergency in January 2020, France appeared to be in a strong position to prevent it from gaining a foothold in the country and spreading widely. It had singled out pandemics as a major ongoing threat in its national-security doctrine. For France’s leaders, the 11 September 2001 terrorist attacks against the United States and subsequent anthrax attacks had raised the spectre of biological terrorism and acted as a spur to initiate detailed pandemic planning. In the mid-2000s – after the SARS epidemic of 2003, and facing the prospect that the H5N1 bird flu could become transmissible between humans – the authorities began stockpiling medical supplies and engaged in continuity planning, while cabinet ministers participated in numerous crisis-response exercises. The defence-and-national-security white papers of 2008 and 2013 took the pandemic threat seriously, viewing it as a potential rupture stratégique (strategic upset) that should guide worst-case planning. President Emmanuel Macron’s 2017 national strategic review adopted a similar perspective.
In addition, France’s healthcare system is among the world’s best and includes world-class biological-research establishments such as Institut Mérieux, the Institut Pasteur and the major pharmaceutical company Sanofi. The French government and Institut Mérieux had helped China open its maximum-security virus-research laboratory in Wuhan – the first facility in Asia equipped to handle the most dangerous class of pathogens – while the Institut Pasteur operates in Shanghai in partnership with a high-security virus laboratory there. By mid-January, French researchers had begun developing a diagnostic test for the virus, while government officials arranged for excess face masks in France to be delivered to Wuhan after its production facilities shut down on 23 January.
Despite these factors, at least 30,223 people in France had died of COVID-19 as of 28 July, which is 463 deaths per million inhabitants. It should be no consolation to France’s leaders that a small number of other countries have been worse hit, including the United Kingdom, some member states of the European Union (Belgium, Italy, Spain and Sweden) and the Canadian province of Québec. Deaths per capita in the US states surrounding New York City, which were severely affected in March and April and where the pandemic has now largely subsided, have reached 1,650 per million. The US as a whole has lost 459 people per million, and with the current proliferation of cases in the southern and western parts of the country, its death rate per capita will soon exceed France’s.
‘[G]iven the speed of disease onset and progression, the timing of each policy decision made by France’s leaders has had a significant impact on outcomes.’
One should be cautious about drawing straight-line conclusions about the effectiveness of government responses to the virus from case and death counts alone. The scientific community has not found satisfactory answers to important questions about the heterogeneous impact of the virus around the world. However, given the speed of disease onset and progression, the timing of each policy decision made by France’s leaders has had a significant impact on outcomes. It is possible to identify four such decisions that have had negative effects on public health: slowness in implementing a national lockdown; the failure to implement widespread testing and contact-tracing; the reduction in stockpiles of personal protective equipment (PPE), which occurred before the crisis; and poor public communication, particularly with regard to the use of face masks.
COVID-19’s sudden arrival
On 30 January there were five known cases of the disease in France, all the result of international travel. By 27 February there were only a handful more. Yet by this time the case count in northern Italy had begun rising exponentially from low levels, indicating that the virus had been spreading undetected for at least several weeks. The rise in Italian cases caused alarm among leaders in Europe, but no one outside Italy took decisive action in the first days of March to limit the spread of the virus. On 6 March the French government placed several hospitals in eastern France and the Paris area on a Plan Blanc (‘White Plan’) war footing. However, on the same day, President Macron made a point of attending a play in a popular Paris theatre without a face mask, hoping to demonstrate that business as usual could continue. He did not know at the time, given the lack of available testing, that the virus was spreading rapidly through the city.
Italy imposed a nationwide quarantine order on 9 March, by which time the total number of cases in France had increased from 100 on 1 March to about 1,000. The increase in French cases appeared to be trailing Italy’s by only about ten days, yet the French government refused to delay the first round of municipal elections scheduled for 15 March. Schools were told on Friday 13 March to close down the following Monday. Cafés and restaurants were ordered to shut their doors from 15 March, yet officials continued to argue that it was safe for citizens to gather to vote later the same day. Proceeding with the elections created a sense of confusion among the public, and turnout (46%) was substantially lower than for the first round of the previous municipal elections in 2014 (63.5%). Macron declared that a nationwide lockdown would take effect on 17 March. When it began, one sixth of the population of Paris had already left the city for the provinces.
‘President Macron made a point of attending a play in a popular Paris theatre without a face mask, hoping to demonstrate that business as usual could continue. He did not know at the time, given the lack of available testing, that the virus was spreading rapidly through the city.’
It is impossible to say with certainty how many lives could have been saved had a lockdown taken effect on 12 or 13 March instead. However, we do know that this was a period in which cases were rising exponentially, from 423 on 6 March to 32,964 on 28 March. The lockdown eventually succeeded in reducing new infections to controllable levels, and deaths per day began to decline after the peak of 1,438 on 15 April. The home-confinement order was lifted on 11 May after the number of new cases per day had decreased from the thousands to the hundreds. From early June, the seven-day-average number of new cases per day remained at about 500 until the last ten days of July, when it rose quickly again to 1,123.
As for the French economy, the lockdown caused an immediate and severe recession that was far more significant than in those countries that were able to pre-empt or suppress the virus, such as Japan, Singapore and South Korea. Presumably France has also suffered serious public-health costs that are as yet impossible to tally: the consequences of deferred hospital procedures and delayed treatment of other medical conditions will only begin to be measured during the coming months and years.
What else went wrong?
The government’s earliest failure, which is still ongoing, concerns testing and tracing. Although France was an early leader in developing tests, it chose not to test and trace cases systematically and aggressively, as Germany, Singapore, South Korea and Taiwan were doing. The countries that were quick to implement testing and tracing managed to sharply limit the spread of the virus even though the available testing kits had false-negative rates of over 20% (they compensated for the reliability problem simply by carrying out very large numbers of tests.) This failure stemmed from France’s highly centralised approach to the crisis in which all things not explicitly authorised were forbidden. For example, the German government encouraged private laboratories and organisations to test people as quickly and as frequently as possible and facilitated the production of open-source testing kits. Private laboratories in France, on the other hand, were prohibited from performing tests until mid-April – as were veterinary labs, which have considerable means and experience as a part of the country’s well-developed agricultural sector. This was the Napoleonic system of top-down, centralised control at its worst.
A decade ago the government’s stockpile of PPE included 1.25 billion face masks and the health minister at the time was actually accused of having ordered too many. These supplies expired and were not renewed because of decisions taken during the presidencies of Nicolas Sarkozy and François Hollande that are now the subject of a parliamentary investigation. This meant that, during the pandemic, front-line healthcare workers faced an immediate PPE shortfall. Face masks did not become generally available to the public until after the peak of infections in March and April had passed. These errors were compounded by the fact that the government has been unable to communicate clearly with the public, its messaging proving to be both confusing and overbearing. It downplayed the importance of testing, just before encouraging mass testing. And when faced with a face-mask shortage, health minister Olivier Véran declared that masks were ‘not useful’ or even harmful to the public if used improperly, just before they were made compulsory in shared indoor spaces.
The public’s trust in the government – including in Macron, who was unpopular before the crisis – is now damaged. France is a country where even people not born at the time of the 1986 Chernobyl nuclear disaster know the authorities tried to convince the public that the radioactive cloud would stop when it reached the French border. The government’s early dismissal of face masks may be remembered in a similar way. The governments in hard-hit Italy and Spain, by contrast, have remained quite popular. In the second round of the municipal elections, held on 28 June, no one from Macron’s La République En Marche party was elected mayor in any significant city or town. This does not bode well for the future of the party and its politicians. The French people have historically been quick to punish the leaders of l’État when it does not deliver for them.
What went right?
In recent years French hospital personnel have suffered from low morale due to poor working conditions, bad pay and a lack of public recognition, all of which were compounded by two decades of ill-conceived reforms to the hospital system with excessive cuts to bed capacity and dysfunctional changes to hospital management. This legacy is now under review because of its negative impact during the pandemic. Nevertheless, these workers have responded remarkably – and sometimes heroically – during the COVID-19 crisis. The Plan Blanc, devised in 2004 to cope with a sudden influx of hospital cases due to a pandemic or terrorist attack, had been used successfully after the 13 November 2015 terror attacks in Paris, which left 130 dead and hundreds more injured. The plan was extended to all of France on 13 March. In announcing the nationwide lockdown on 16 March, Macron borrowed from one of then-prime minister Georges Clemenceau speeches during the First World War to prepare the country for something like a wartime medical mobilisation.
In the weeks that followed, hundreds of ill patients were transferred across the country (and even to Austria, Germany, Luxembourg and Switzerland) by military aircraft, navy ships, medical trains and buses, even from far-flung overseas departments and territories, to relieve the most severely taxed hospitals. This served a public-health purpose, but officials were also eager to invite media coverage of these transfers to communicate symbolically to the French people that the central government remained in control of the situation.
‘[France’s] unemployment plan has been criticised for its openness to abuse from unscrupulous firms but it has succeeded in its main objective of preventing a surge in lay-offs and bankruptcies.’
The most successful element of France’s response to COVID-19 has been in providing for the social welfare of those affected by the disease and related recession. A plan was enacted on 25 March to provide furloughed employees with 84% of their previous net pay, with a ceiling set at 4.5 times the current minimum wage. The scheme was inspired by the success of Germany’s Kurzarbeit social-insurance system that curbed unemployment and kept businesses open during the financial crisis of 2008–09. Support funds began reaching recipients in only 12 days. The unemployment plan has been criticised for its openness to abuse from unscrupulous firms but it has succeeded in its main objective of preventing a surge in lay-offs and bankruptcies. This has kept consumer solvency and demand at levels higher than during the 2008–09 financial crisis, with the follow-on effect of stabilising the housing and banking markets. In April the government indicated that some US$115 billion (4% of GDP) of emergency funding would be made available to business. France’s debt-to-GDP ratio has increased from 100% in 2019 to 120%, caused both by rising spending and the contraction in the economy. France’s GDP shrank by 5.3% in the first quarter of 2020 and 13.8% in the second quarter, with a projected contraction of 9–12.5% for 2020 overall.
Outlook
France and Germany have agreed on the need for an initial EU-wide recovery fund of US$575bn, notwithstanding past German refusals to mutualise sovereign liabilities. This has led to the creation of a broad political coalition to overcome resistance from the ‘frugal four’ (Austria, Denmark, the Netherlands and Sweden) to the provision of EU relief grants to individual member states. The EU27 agreed to a temporary financing instrument, the ‘Next Generation EU’ initiative, on 21 July. This includes a ‘Recovery and Resilience Facility’ of some US$773bn, which features US$359bn in direct relief grants for member states. These funds are to be allocated within three years, with 70% frontloaded in 2021 and 2022. France expects to receive US$46bn of these EU funds (about 1.7% of its GDP), which it will direct towards its US$115bn relief effort for private-sector industries. The EU’s spending efforts over the next three years – its regular budget plus Next Generation EU spending – will roughly double, rising from 1% to 2% of EU GDP.
A parallel can be drawn here with what happened during the strategic revolution of 1989–90, when François Mitterrand and Margaret Thatcher faced the prospect of German unification with reluctance. At the time, the leaders of France and Germany resolved the tension by ‘Europeanising’ the problem at hand, launching a European political and monetary union that eventually led to the Maastricht Treaty and the creation of the euro. Forty years later, the Franco-German pairing has shaped the course of events once again. It remains to be seen whether this will usher in a new phase of progress in the EU’s integration process or whether this will be a one- off occurrence. The result will largely depend on the EU’s collective success or failure in overcoming the continuing economic fallout from the pandemic.
This, in turn, will be determined by the next stages of the still poorly understood pandemic’s course. European countries including France fear a so-called ‘second wave’ later this year, even as the first wave continues to roil the US and the countries of Latin America. An air of anxiety has descended upon London and the European capitals, with an upsurge in cases in the second half of July – Spain’s seven-day-average number of new cases per day has risen from about 500 to 2,000, and France’s from about 500 to 1,123 – alongside the recognition that the most lethal period of the Spanish flu epidemic was during its reoccurrence in the autumn and winter of 1918.
Editor: Paul Fraioli
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