Mask production and logistics, a tragedy in five acts

At the start of the coronavirus epidemic, the state had only a hundred millions of surgical masks in stock and no FFP2 masks.While it no longer existed on French soil of real industrial sector to produce masks, the State then reserved the low existing stocks for caregivers, and explained to the population that wearing a mask was "not useful ".

Faced with the risk of shortage, the state has placed multiple orders in China, and improvised to urgently recreate national production capacities.With more stocks and capacities, the state has gradually changed its speech, and now recommends wearing the mask.

State strategy and discourse on masks have thus been dictated by its low industrial and logistical means.How to understand this fiasco, when the stock of masks was, in 2010, 1.7 billion and then existed in France a factory capable of producing 180 million masks in the year?Back on an industrial and logistics tragedy in five acts.

Act 1: The creation in 2007 of the EPRUS, the logistical armed wing of the State

It all starts in the 2000s.At that time, health crises multiplied in France: in 2001, September 11 and the explosion of AZF raised the question of nuclear, radiological, biological and chemical risks;In 2003, the Sars epidemic spread with 4 cases in France, including one dead, and France saw an episode of dramatic heat wave;Finally, in 2005, the chikungunya epidemic developed and avian flu threatens to spread in Europe.

Faced with these health crises, the state is not well prepared.In their report on the response to the Sars epidemic (4 cases!), Clinicians believe that "if they had been faced with a more serious and lasting epidemic [...], the management capacities would have been quickly exceeded, with a likely exhaustion of the teams beyond two weeks ”.

Regarding stocks of products required in the event of a crisis, the state responds to the blow.The Ministry of Health, through the Department of Sanitary Emergency Situations (DESUS), created in 2004 within the Directorate General of Health (DGS), is responsible for buying public health stocks and managing them.While the amount and the volume of stocks only increase (they will reach a value of 765 million euros at the end of 2007, representing 100,000 pallets and around fifty references), the DESS is only equipped with "two logisticiansDedicated to the operational follow -up of stocks ”, which are spread over more than 72 sites, according to the report by Senator Jean - Jacques Jégou.

Politicians then realize that the state must better prepare for health crises and in particular the pandemic risk.In 2004, France acquired a government plan for prevention and struggle in the face of influenza pandemics of avian origin.In 2005, a very detailed report of the Senate was published on the epidemic risk.

In 2006, Senator Francis Giraud wrote a bill relating to "preparation of the health system for large -scale health threats".It led to what on March 5, 2007, the State created the establishment for preparation for risks and health emergencies (EPRUS).

This new establishment, financed on parity by the State and health insurance, is entrusted with two missions: 1) the creation of a health reserve;2) Logistics management of "means of combating serious health threats".The EPRUS, however, has very little management autonomy since it is placed under the close supervision of the Ministry of Health, within the framework of a binding agreement (as shown in the document below extracted from the Jégou report):

Framework agreement between the State and the EPRUS.Jégou report (2008)

He also faces a logistical catastrophic starting situation: the products are stored in a large number of establishments "whose status and contractual links with the EPRUS vary strongly";These sites are "dispersed" and "present heterogeneous conservation conditions";Stock monitoring is difficult because the computer tool is not "connected to the information systems for EPRUS providers";Finally, legal uncertainties surround the procedures of "lengthening the validity dates".

Act 2: Masks, state issue in the face of the influenza A (H1N1) crisis

While administrative problems have delayed his implementation, the very young Eprus had to face the influenza a in 2009.The State, which before the crisis already had a large stock (estimated at 765 million), is providing, and on the initiative of the Minister of Health at the time, Roselyne Bachelot, commands in surplus vaccinesand the famous masks.

Regarding masks, their supply then raises any problem.It must be said that since the awareness of health risks in the mid -2000s, the State, as revealed by the review Politis in early April, supported the establishment of a real French industry.

While the risk, in the event of a global pandemic, is that each country keeps its production, a memorandum of understanding was signed in 2005 by the Minister of Health, Xavier Bertrand with several groups, according to a logic which is close toThe Public Service Delegation.This protocol provides during the period 2005-2010 the purchase by the state of several million masks each year;that the State will be priority if necessary;that the company will have a buffer stock, etc..In total, the company must guarantee on French soil the manufacture of 180 million masks per year.

Ministerial protocol signed on December 26, 2005 revealed by Politis.

Regarding the port of the mask, the emergence of the epidemic also leads the State to gradually refine a doctrine on the type of masks which must be worn and by whom (see table below).The state recommends that FFP2 protective masks are used not only by employees directly exposed to risk, in particular caregivers, but also by those who are regularly exposed to the public (for example at the counters or the boxes).

2006 Gippale Pandemic Pandemic Plan, Pandemic Gippal Plan 2009, C4 sheet on health measures.

Regarding anti-emission surgical masks, they must be used by possible and confirmed cases, as well as by certain employees of companies, when the risk is not aggravated.Regarding the population, "the state of knowledge and equipment possibilities for example, has not led, to formulate a general recommendation concerning the wearing of a mask by people living in the entourage of a possible caseor confirmed, or participating in collective life activities (public places and public transport) ».

In accordance with this doctrine, at the end of 2009, the State has a substantial stock managed by the EPRUS, which includes both surgical masks (around 1 billion, at a cost of 34,075,244 euros) and FFP2(around 700 million, at a cost of 185,677,625 euros).The amount of stocks held by the EPRUS has increased in 3 years from 765 million to more than a billion at the end of 2009, according to figures published by the Court of Auditors in 2010.

Act 3: After influenza A, which masks should be stored and which must store them?

But while a lot of threshing has been done on flu A (H1N1), it does not affect France, and the State and its Minister of Health are accused of having wasted taxpayer's money.This is then an opportunity for the State to review its policy, and a series of three more or less questionable decisions on masks and their stocks will then intervene between 2011 and 2013.

First, in July 2011, the High Council for Public Health (HCSP), issued an opinion on the strategy to adopt vis-à-vis the stock state of respiratory masks.If the opinion underlines in fatty text (see below) that "the stock state of respiratory masks must consist of anti-projections masks and respiratory protective devices", it slightly evolves the doctrine on masks.For employees frequently exposed to the public, the HCSP recommends wearing surgical masks rather than type FPP2, especially because they are better tolerated.

Above all, with regard to the port of the mask by the population, it is ultimately not recommended, on the basis of its alleged ineffectiveness to cope with the seasonal flu.

Stock Repair masks, use and dimensioning.High Public Health Council (2011)

However, the opinion stipulates that faced with a virus presenting a high risk, the mask can be effective: "In the context of a high risk such as SARS, the systematic review of observational studies suggests a high preventive effectiveness of masksanti-projection and respiratory protective devices.In the prevention of seasonal flu, the analysis of the seven trials, which constitutes the highest level of evidence reachable for the evaluation of these interventions, does not highlight the effectiveness of respiratory masks in the general population ".

Second, on November 2, 2011, a ministerial instruction relating to the preparation of the response to exceptional situations in the health field introduced a distinction between two types of health products: "strategic stocks" held and managed by theEPRUS in its platforms, which must allow "the state to maintain an intervention capacity [...] in reinforcement of conventional and tactical means ”;"Tactical" stocks, located in certain "health establishments", to allow an "early waiting for mobilization, if necessary, strategic stocks", and whose acquisition "is taken care of by thehealth establishments ".

On the logistical level, such a distinction is relatively astonishing: why make a distinction between "strategic" and "tactical" stocks, if the purpose of strategic stocks is simply to be able to restock the tactical stocks which are detained locally?

Finally, on May 13, 2013, the General Secretariat of Sûreté and National Defense (SGDSN) enacted a doctrine to protect workers in the face of highly pathogenic diseases with respiratory transmission.

Workers' protection doctrine in the face of highly pathogenic diseases with respiratory transmission.SGDSN (2013)

While the document indicates that "highly contagious infectious disease with respiratory transmission comes from the strict framework for" health and safety at work "insofar as a major health threat", the SGDSN decidesAmazing that it is up to "each employer to determine the opportunity to constitute stocks of masks to protect their staff".

The decision appears all the more incomprehensible and questionable, as the document highlights the very great complexity that there is for employers to size the stock.

Act 4: a budgetary logic creating the industrial and logistical disarmament of the State

With these three decisions, all the elements are then in place to lead to the current disaster.Summons.First, since wearing FPP2 masks is no longer advised by HCSP only for employees directly exposed to risk (caregivers) who work in health establishments, and that these establishments must now have a stock of “tactical", Why then keep a“ strategic ”state of FFP2 masks?

Despite the opinion of the HCSP on the need to have a stock state of surgical masks and FFP2, and the instruction which emphasizes that the strategic stock is supposed to be there "in support of tactical means", the stock of masksFFP2 State will no longer be renewed.Each health facility will have its stock of FPP2 masks, which it will finance on its budget, and this will be as many savings on the EPRUS budget...And of the State, which finances it at par with health insurance!

Second, since it is up to employers to provide stock stocks for their employees, and that the HCSP has not clearly stipulated that the State had to provide the population, the stock state of surgical masks should no longer bedimensioned that to provide sick people and those around them.This does not represent many people, and the state will therefore not renew the entire stock of masks.Over the years, it will decrease by ten, to go from one billion to 123 million at the end of 2019.

In this context, the State will not then renew the agreement it had signed with the mask producer...And thus reveal an industry he had himself created!The factory will close in 2018...But it is not very serious, since if necessary, there are now producers in China, cheaper, and that we can very easily restore!

The budget trap has thus closed, using a series of decisions which go completely against the goal initially pursued by the State when it created the EPRUS.

The establishment, which in the mid-2010s was largely professional, by adopting a logistics master plan, with a modern central platform in Vitry-le-François, an information system, etc..(see below), has at the same time lost responsibility for managing many stocks of health products.

Health emergencies and health countermeasures: Role and missions of the EPRUS, logistics operator of the Ministry of Health.Presentation by Laurent Théveniaud, assistant to the head of the EPRUS health products pole, at the 43ᵉ days of the APRHOC (2012)

In this context, obviously arises the question of the usefulness of this small operator that is EPRUS and a merger project with the Institute of Health Sun (INVS), and the National Institute for Prevention andHealth education (INPES) was born at the end of 2014.

In his information report on the 2015 EPRUS, Senator Francis Delattre is at least skeptical about the interest of such a merger.The number 1 recommendation he formulates in his report is as follows: “In order to guarantee the efficiency and efficiency of the EPRUS integration project within the future National Public Health Agency, preserve a certainAutonomy of the function of response to health crises currently assumed by the EPRUS within the new agency, while avoiding duplicates of support functions ».

His fear is clearly that this small agency is drowned in the big one, and that budgetary arbitrations are done against it.However, the merger will be in 2016.Since then, in the three reports of the France Public Health Agency published since that date, it has been clear that it has not mentioned much preparation activities...

Act 5: Coronavirus and industrial and logistics chaos of masks

It was then that in early 2020, the coronavirus spread at high speed.While he would have to be able to rely on a strong logistics operator created precisely to prepare the response to health crises, and a French industry allowing him independence on masks, France faces it with a disintegrated logistics organization andWithout national production capacities.

At the start of the crisis, there is no longer a French industrial sector, and as for masks, stocks are diluted between three types of actors:

Such an organization does not allow you to know how many masks are stored in the territory, is exploded between multiple places, under storage conditions which are not homogeneous, is based on various information management systems...In short, we find here the list of reasons that had led to creating the EPRUS!

The rest, everyone knows.In January, the Ministry of Health notes that it has only a hundred millions of surgical masks in stock, that there is no longer a French production sector, and that there is a risk of shortage.He then plans orders in China.While the epidemic accelerates, and the population is increasingly wondering about the usefulness of the masks, the government prefers to make the French believe that they are not useful, the time that orders arrive.

However, as a survey provided with Mediapart reveals, orders are difficult to come, because the state manages the supply clumsyly: instead of placing group orders, several small orders are placed by the Ministry of Health;While Public Health France must, as is its mission, manage orders, the operator is little endowed with human resources and is quickly deemed to be not very responsive;To compensate for public health failure France, the State created an interministerial logistics coordination unit on March 4, responsible for making “commando” purchases of masks;At the same time, within other ministries, regions, town halls, businesses, everyone orders almost masks, which competes with the orders of the State, which itself is in competition with ordersother countries;Faced with the risk of shortage for the most exposed staff, the State then has no choice but to requisition masks by decree, and to push French industrialists to convert to increase the French capacities which have largely decreasedthe last years ;In this global context of shortage, the temptation of everyone for oneself is important, and some do not hesitate to appropriate the orders of masks of other actors who arrive in France from China, while others hide their stockmasks, etc.

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By Aurélien Rouquet, professor of logistics and supply chain, Neoma Business School

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

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