"Like every country in the world, we ran out of gowns, gloves, hydroalcoholic gel, we couldn't distribute as many masks to our caregivers as we would have liked. In his speech on Monday 13 April, President Emmanuel Macron stressed that the crisis had revealed "weaknesses in our logistics".
But at the same time, he relativized these weaknesses, stressing that the crisis was difficult to predict, and that most states had been caught off guard. Was France's relative logistical unpreparedness inevitable?
That is not what logistics theories, particularly humanitarian theories, or the history of our health crisis response system suggest. There are very clear theories on how to respond logistically to unpredictable crises. These have been developed by researchers who have been working on humanitarian logistics for the past two decades.
Humanitarian professionals are faced with a situation similar to that of states faced with a pandemic: the challenge is to respond to crises (earthquakes, tsunamis, etc.), which we know can happen, but we are unable to know when or where they will occur.
The devil is in the details
How do humanitarian logisticians organize themselves to respond to crises? Here are two key points from the excellent online course from the Humlog Institute of the Hanken School of Economics, a reference on the subject.
The first point is that there are three phases to be distinguished in terms of logistics: preparation, immediate response, and finally reconstruction. The key and decisive phase is that of preparation. The effectiveness of the immediate response depends on the quality of this preparation.
The phases of humanitarian logistics. Kovacs and Spens, 2008
The challenge during this phase is to make every effort to be able to respond effectively and quickly in a timely manner. The first step is to identify the resources that will be needed in the event of a crisis, from the most complex to the simplest.
Then it is a question of ensuring that these resources will be available quickly in the event of a crisis, which involves holding stocks of products. Finally, it is a question of thinking about how these products can be quickly projected to where the crisis occurs.
With this in mind, the logisticians of the Médecins Sans Frontières (MSF) association store 15,000 essential items on their platforms in Mérignac, Brussels and Dubai, which can be loaded onto planes and sent to the four corners of the globe within 24 to 48 hours.
Secondly, the strategy that will be established to respond to a crisis cannot be dissociated from logistics. At the time of the crisis, it is all a matter of detail, and it is crazy to think when designing the strategy that "logistics and stewardship will follow anyway".
If one thing is missing, the response may be compromised. This presupposes that the response strategy finely integrates all the logistical constraints, and even that the response is based on the logistical constraints that can be anticipated.
With this in mind, MSF has developed a series of kits, which contain all the material needed for certain emergencies (vaccination, nutrition, etc.), and are stored in containers that only have to be loaded onto a plane when the emergency occurs. The logistical expertise required led MSF to set up an MSF Logistics subsidiary in the 1980s.
A succession of health threats
To say that we did not know what to do in terms of logistical preparation is to ignore the results of research in humanitarian logistics, but also the recent history of the French government's health response system to crises.
When we look back at this history, we see that at the beginning of 2000, France was not ready. However, at that time, the State was facing multiple crises with a health impact: in 2001, it was 9/11 and the explosion of the AZF factory; in 2003, the SARS epidemic and then the heat wave; in 2005, chikungunya and avian flu. Politicians then became aware that the State must be better prepared.
Employees of a medical equipment company in China during the SARS outbreak in 2003. Peter Parks/AFP
In 2004, France adopted a plan to deal with influenza pandemics. In 2005, a Senate report was published on epidemic risks. In 2006, Senator Francis Giraud drafted a law, which led to the creation in 2007 of the State Establishment for the Preparation of Health Risks and Emergencies (EPRUS).
This new establishment has two missions: the creation of a health reserve and the logistical management of "means to combat serious health threats".
The aim is for the State to acquire an operator whose mission is to prepare a logistical response to health crises. And this is very necessary. In 2007, stocks of emergency medical products, valued at more than 700 million euros, were managed by the Ministry of Health's Department of Health Emergencies, which, according to the report submitted by former Val-de-Marne Senator Jean-Jacques Jégou, has only "two logisticians dedicated to the operational monitoring of stocks".
According to the same report, the situation initially taken up by EPRUS is thus catastrophic from a logistical point of view: products are stored at nearly 72 sites throughout France, in establishments offering heterogeneous storage conditions, and the monitoring of these stocks is very difficult due to the lack of an integrated information system.
A major step backwards
Within a few years, however, the EPRUS, which brings together some thirty people, will become more professional. Several millions will be invested in a central platform at Vitry-le-François in the Marne, and a storage scheme integrating zonal platforms will be set up.
Storage master plan. Establishment for the preparation of health risks and emergencies (EPRUS)
While everything seemed to be in place for the State to gradually build an efficient logistics tool, like MSF and its subsidiary MSF Logistique, in 2016 the State dissolved the EPRUS.
In that year, the establishment was integrated into the French Public Health Agency, despite the scepticism of a Senate report, which feared that the EPRUS would be "drowned" in the future structure of around 500 people, and would become incapable of responding to emergency situations in extremely short time frames".
How can it be explained that such a logistical surge did not take place in 2010? Let's mention here two determining factors.
The first is the fact that from the outset the State gave only a small margin of manoeuvre to the EPRUS. Thus, according to the State-EPRUS framework agreement, all purchases must be validated by the Ministry of Health. We are far from a strong coupling between strategy and logistics, the establishment being considered as a "strict logistician", in the words of Jean-Jacques Jégou's report.
Secondly, the 2009-2010 influenza A epidemic, during which the government, with foresight, ordered vaccines and masks from EPRUS, will have only a weak impact, and will spread the idea that the government has done too much.
In March 2010, Health Minister Roselyne Bachelot was heard by the Senate commission of inquiry on the role of pharmaceutical companies in the government's management of the H1N1 flu. Miguel Medina/AFP
While the amount of EPRUS stocks rose from 765 million in 2007 to more than one billion at the end of 2009, the State will endeavour to reduce them, following a logic that is much more budgetary than logistical.
To this end, it is transferring responsibility for the stock of certain products such as masks to employers. It dilutes the responsibility for stock management (and therefore for financing) between the EPRUS, which will be responsible for strategic stocks, and health establishments, which will be responsible for tactical stocks.
Before the coronavirus crisis began, the EPRUS was thus far from having grown in strength and, on the contrary, had lost some of its weight: it is a small logistical operator drowned in a large agency that now only has control over a part of the health stocks, which are now distributed among a multitude of actors.
We are living the consequences. Faced with the coronavirus, instead of relying on a strong logistics operator, France is faced with a poorly prepared and diluted organisation, which will lead to chaos over masks, but also to stock shortages of reagents needed for tests, etc. Without going back over this chaos, well documented by the newspapers, how in the future should the State be better prepared?
Let us mention two key points. Firstly, any preparation will have to be thought out on a European scale. Of course, health is a prerogative of the Member States, but a virus has no use for it. The challenge for the future is to pool European stocks of emergency products on platforms spread across the continent and to ensure that Europe has the production capacity to deal with a crisis.
Secondly, the public authorities should give logisticians and their expertise in the design of the power response. In writing this article, I have consulted dozens of reports, and none of them mention having consulted logistics specialists in general, and humanitarian specialists in particular.
One possibility would be for France, lagging behind our German neighbours, to create a large Ministry of Logistics, and for it to take responsibility for emergency preparedness.