France's COVID-19 response: balancing conflicting public health traditions.

Simmering beneath the surface of France's centrally coordinated response to COVID-19 is a long-standing tension between two French public health traditions. The first tradition has been the foundation of the French state's historical engagement with global humanitarian health, which we have previously described as state humanitarian verticalism. Instituted first in the French former colonies, it was widely used in France's international health assistance, including during epidemics, and is still part of France's global health assistance in low-income countries.1, 2, 3 The second tradition underpins France's state-provided, universal, and free health coverage. This approach takes health and non-health infrastructure into account when designing interventions, links the health system with the social protection system, and seeks to improve health by reducing inequality.

Historically the tension has been especially visible in francophone low-income countries. The Assistance Médicale Indigène, in place from 1899 to 1960, was intended to bring metropolitan France's universal and free public health care to French colonies. Instead, colonial public health efforts in the former colonies crystallised in state humanitarian verticalism to counter major diseases, starting with human African trypanosomiasis (sleeping sickness), a focus that survived beyond decolonisation. The tension was given a new spin both by the arrival of French “sans-frontièrisme” and the advent of the AIDS pandemic and epidemic-prone diseases like Ebola virus disease.

In France, the tension between these two traditions has flared intermittently. In confronting influenza A H3N2 in the late 1960s, the universalist French public health tradition decisively “won” the conflict between the two traditions, with the vertical humanitarianism approach—automatically used against epidemics overseas—virtually absent from the national response. By contrast, when influenza A H1N1 pdm09 became a threat in 2009, the French Government again chose an unbalanced strategy, but this time in favour of the other tradition. Centrally managed mass vaccination centres that bypassed primary care were opened all over the country. The threatened epidemic never arrived, but the government's response represented an inability to balance the two traditions and was subsequently considered a political failure.

Today, under the pitiless spotlight cast by the COVID-19 pandemic, the country's capacity to merge the two traditions is being tested. Moreover, this crisis is taking place in the context of France's health system that is heavily care oriented to the detriment of preventive approaches. This imbalance exacerbates the health system's fragility in the face of the COVID-19 pandemic.

The two public health traditions have influenced the French Government's unprecedented scientific response to the pandemic. France's COVID-19 Scientific Council was set up on March 10, 2020, by President Emmanuel Macron. Its members are a mix of medical (immunology, public health, virology, epidemiology, infectious diseases, modelling, intensive care, and general and family practice) and non-medical experts (social anthropology, sociology, information technology, and a representative of civil society). Half of the COVID-19 Scientific Council members have expertise in the French health system, while the other half offer expertise in public health, epidemics, and humanitarian crisis management in low-income and middle-income countries; five of us have expertise in both domains (social anthropology, immunology, and infectious diseases).

The COVID-19 Scientific Council is unpaid, autonomous from government, and, in the service of transparency, all of its advice is made public on the ministry of health's website. The council provides independent advice and the French Government makes decisions according to what it considers best for the nation together with political considerations. Although the media follow any apparent disagreement between the council and government closely, this modus operandi has proved successful so far, to the point that in parliamentary debates in early July the French Senate suggested extending the council in its role as scientific watchdog and pathfinder until late October, 2020, a suggestion later validated by the National Assembly.

In several advisories issued in recent months and weeks, the COVID-19 Scientific Council has proposed strategies that draw from both traditions.7, 8 Several of the measures proposed stem from state humanitarian verticalism. These measures include: a unified operational governance structure; basing the lifting of lockdown on rigorous and specific epidemiological criteria; a national testing and isolation programme; and maintaining physical distancing and protective measures, while progressively reopening travel and lifting restrictions on movement. Also influenced by this first tradition is overall COVID-19 planning based on four different post-lockdown scenarios—(1) pandemic under control, (2) several clusters signalling an epidemic flare-up, (3) a diffuse and silent second wave, and (4) an acute second wave—with associated prevention and protection plans for each scenario.

More directly rooted in the second tradition are restoring and rethinking hospitals and health services, establishing adequate stockpiles of personal protective equipment for the entire population, and creating an epidemiological surveillance system capable of detecting new cases and a possible resumption of the epidemic. Other measures that follow this tradition include adopting a strategy taking population-oriented risks into account, with different interventions tailored for three categories of the population (age >65 years and/or with chronic diseases, age <25 years, and age 25–65 years without chronic conditions), and regularly scheduling surveys to estimate immunity in the population. Notably, these measures represent an opportunity to adapt the health system to a changing world.

Merging and balancing humanitarian verticalist measures with complex state-provided universal health and social systems, which are themselves delivered across various complex layers of government administration, is challenging, especially given the high probability of a second wave of COVID-19. Should a second wave result in increased rates of infection and another lockdown, there will be tensions between health and social priorities, between young and old, and between urban and rural populations.

From the beginning, the COVID-19 Scientific Council's collective decision was to bridge the two traditions that have pulled French public health in different directions over the years. Our aim is to combine a robust state humanitarian vertical approach with reinforcement of social protection and the welfare state to mitigate the substantial socioeconomic consequences of lockdown. Our strong recommendation for the participation of civil society organisations in the COVID-19 response was not followed up by the government, unlike most of the measures we proposed.

Success will ultimately be judged not only by the biomedical evolution of the pandemic, but also by its social, political, and economic impacts on French society. For these reasons, it will be valuable to eventually compare the strategies adopted in different countries and evaluate their results, as well as the contrasting interfaces created between science and government.

Science and government must work together in times of crises, but it is not always clear how this should be done. We believe that scientific advice to government in times of crisis is best furnished by a dedicated, multidisciplinary council that is open and transparent, maintains direct access to the highest level of decision making, and is free from any hierarchical relationship with government. This approach underpins both liberty of expression and the authority of scientific advisers' critical and constructive voice.