When peasants die, there are no comets seen
William Shakespeare, Julius Caesar (act II scene II)
The connections that make society strong also make it vulnerable
Barry Hindes, Threads .
This report considers the failure of the French government to prevent the unnecessary deaths of 14,000 predominantly senior citizens during a heatwave in August 2003. Governments have frequently used risk management techniques to identify threats, and control risks at different levels: prevention, damage control etc. Unfortunately in France the government failed spectacularly from the start, by not confronting politically tough, but conveniently well hidden, issues like labour law, building design and social capital that contributed to the disaster. As the death toll rose their second mistake was to downplay and deny the disaster for the sake of political expediency in a manner that ultimately contributed to even more deaths.
This essay uses the ideas of Sen (the marginalised are more risk-prone) and Shiels (the marginalised are ignored) to show how the problems facing the elderly were exasperated, before applying Power’s theory of how the state selectively filters information to put itself in a politically sanctified position of believing it is incapable of responding to a problem faced by a marginalised group it has no interest in actively saving. It also hopes to illustrate a new type of disaster where a vital system people take for granted is overwhelmed by demographic forces.
A government’s lot is not a happy one. Since feudal times its mandate has been founded on securing the lives of its citizens, since it operates the public goods that provide protection (e.g.: armies, hospitals, meteorological services), and citizens have a Rawlsian belief that the weak (including those stricken by disaster) will be protected by the state. When a government fails to provide this basic need, it looses the trust of the people. Unfortunately for the state, it needs to exercise leadership and judgement by limiting the freedoms of its citizens in order to protect them, which may be unpopular (such as ordering cyclists to wear helmets). The state may be tempted to satisfy stronger political groups at the expense of not protecting weaker or diffused groups. Yet if a crisis does emerge, the state can try to salvage its trust with the public by downplaying its existence, its implications, and whether it really is the government’s business to intervene.
The French heatwave disaster of August 2003, where 14,000 mostly elderly victims died, is an excellent case example. Unlike other disasters with physical damage and articulate victims, heatwaves are silent killers that wipe out dispersed population groups. Often only the government through its statistical and medical services are aware of its magnitude. And since the most obvious causes of death can be pinned on the weather or the failure of victims to hydrate themselves, it is easy for governments to deny responsibility. Most damning in France’s case was the government’s reluctance to acknowledge the crisis, and adopt counter-measures earlier that would have saved lives.
This essay will show that (a) disasters are often rooted in a complicated arrangement of external and invisible factors, (b) interest groups who are responsible for these factors will disavowal responsibility, especially when links appears weak, (c) governments are therefore reluctant to pressure these groups, especially those who are politically stronger than those exposed to risk, and thus (d) risk control measures become more reactive than preventative. Yet when disaster strikes, governments may deliberately not engage whatever reactive response instruments they have left at their disposal, in order to hide the embarrasing fact that something bad occurred on their watch.
Setting the Scene
This report can rely on certain incontrovertible facts about what happened in August 2003 in France. Specifically: (1) in the first two weeks of August 2003 Western Europe, experienced a prolonged weather pattern typified by high maximum and minimum temperatures that could be considered a ‘heatwave’, (2) anecdotal evidence cited in the media, and later confirmed by Mattei, suggested that in this period medical and aged care facilities were understaffed, causing hospital wards to close, services to be withdrawn and/or remaining staff to undertake unmanageable workloads, (3) statistical records suggest a significant number of excess deaths occurred in this period, particularly amongst the elderly from hyperthermic causes, and (4) both the public and various political actors progressively formed the impression that France’s medical system had broken down, because of a number of reasons, and consequently (5) certain public servants and politicians were compelled to accept responsibility and resign from office, while those who survived the public backlash were made to reconsider the country’s approaches to aged care, labour hours and other policies.
The effects of the heatwave were aggravated by a number of background factors, which prevented the French health authorities adequately responding in sufficient time.
An ageing population
France, like other developed countries, has a growing proportion of elderly citizens. However demographically France more balanced than its neighbours thanks to a large, youthful and fecund immigrant population and generous maternity leave provisions. In 2000 16.1% of its population was aged 65 or older, compared with 12.1% in 1970 (Pison 2000). France also has the highest life expectancy for aged females in Europe; on average a 65 year old woman will live a further 19.8 years, while men can expect an additional 15.4 years (Giarchi 1996:193) and third highest for males (15.4%) in Europe . As the population ages not only does the demand for nursing home, respite and other facilities rises, but the supply of labour and taxpayers to support these facilities drops. Increased education, labour participation and vocational aspirations amongst women, traditionally the main providers of aged care, has also tightened the supply of aged workers. Although their workforce participation has perhaps lead to more tax revenue that as a Pareto dividend has helped pay for pensions and health costs, aged care remains a labour intensive activity.
The 35-hour week
In France much of the population in August 2003 were spending the summer holidays away from their workplace and families. Thanks to the Loi Aubry inaugurated by the previous Jospin administration on 1st January 2000, the working week for French employees employed in firms and organisations with twenty or more employees was cut down to 35 hours a week, calculated from an annual total of 1,600 hours. The move to the Loi Aubry was prompted by self-interested labour unions who prioritised providing greater leisure time for its members over increased remuneration. The government hoped that the law would spurn job creation, since the supply of labour hours that existing employees could provide were reduced, then new employees would be required to meet the labour demands of the existing workload. In 2002 the mandatory application of the 35 hour work week was imposed on all employers in France.
Along with the reduction in working hours came a more flexible framework for employers and employees to negotiate patterns of workplace attendance that would suit cyclical troughs and spikes in demand, and thus raise overall labour productivity. In the 2003 summer holidays, many vacationers spent longer periods away as a result of having accumulated large banks of leave credits.
In the years after the Loi Aubry was introduced, unemployment indeed did fall, from 12.4% in 1997 to around 8.8% in 2001. Commentators cited a boom in leisure industries such as fitness centres where demand was influenced by the amount of free time customers had available to spend. However, strong economic growth was responsible for most employment generation - the Jospin government itself admitted that perhaps the new regulations only contributed to a fifth of new jobs being created, while less partisan economists gave even less credit. By the end of 2003 France’s employment rate moved upwards to 9.8% (Australian Department of Foreign Affairs and Trade 2004).
The best laid plans of the Loi Aubry failed as a result of policy practitioners assuming that the number of jobs a labour market provides (and thus can be ‘shared’) is constant. This mistake, known as the ‘lump of labour’ fallacy, forgets that the labour market is both dynamic and heterogeneous. The supply of labour is restricted by many factors unlikely to be adequately addressed by the market in the short-term, such as requisite training and geographical location. And the demand for labour constantly shifts, being sensitive not only to economic factors like consumer demand and interest rates, but also to government policies. As the Loi Aubry was effectively a wage rise since salaries were not adjusted downwards in response to a corresponding drop in hours worked, companies responded by choosing alternatives other than hiring new staff to meet production demand. Where the nature of the work permitted, jobs were either replaced by automation, or relocated offshore (increasingly possible for white collar employment, thanks to telecommunication technology, cheaper transportation and transfer costs, and harmonised industry standards within the European Union). Yet for other occupations where labour supply is inelastic, the shortfall in labour hours was made up by employers by compelling the existing staff to increase their own productivity by working harder (Bartlett 2003). For many of France’s medical, nursing and aged care workers, they simply were expected to carry out their existing workload with fewer staff available.
France’s health care system
France has a mixed public health system. There are 1,032 public hospitals with a total of 315,687 beds, staffed by “hospital practitioners” according to civil service guidelines. In a somewhat inflexible employment regime, salaries are based on a flat rate regardless of specialisation or location, and seniority determines promotion. Practitioners may engage in private practice subject to earning and time limits. 91% of funding for public hospitals comes from health insurance funds, allocated to each facility according to various economic, productivity and medical criteria. In addition there are 2,139 private establishments (with 170,382 beds), including user-pay clinics, and mostly religious non-profit hospitals which are heavily subsidised by state grants. There is a heavy amount of state supervision and regulation, both regional and national, which many claim is cumbersome. Budgetary cut-backs to public hospitals which started in the conservative Jospin government in 1995 and continued under Jospin in 1998 led to hospital bed numbers being cut, and foreign doctors being recruited at around half the pay of French doctors to deal with staff shortages. It is little wonder that given the inflexible and parsimonious work environment in public hospitals that 80% of French medical graduates in 1998 chose to work in private practice, and also in that year 20% of hospital practitioner positions remained unoccupied (Dorozynski 2000:333).
The situation in nursing homes is similar. According to Hubert Falco, 80% of French nursing homes are understaffed outside holiday periods, based on a benchmark of no more than two residents per employee. Older people who generally have lost the thirst reflex need to be monitored and cajolled into drinking to ensure they are ingesting enough fluids, a labour intensive activity (Knox 2003).
In August 2003, medical and nursing staff in public hospitals were working under the 35 hour provisions, with those on night-shift working a standard 32 hour week (de Kervasdoué 2002). Anecdotally, many public doctors working in essential services like accidents and emergencies stated they work well beyond 35 hours due to administrative requirements they are not allowed to shut down wards, and thus they are forced to carry the workload of absentee staff (Fouché 2002). Their obligation to serve made them politically weak compared with other labour sectors. Those in the private sector however have more flexibility to determine their own periods of engagement, and many elected to spend their holidays in the first two weeks of August. Patients who would otherwise have used these private clinics were therefore reliant on the already overstretched public hospitals, the carers of the last resort.
Like other European countries, the elderly tend to live in older dwellings, built before the introduction of air conditioning. 53% live in dwellings built before 1962 (21% before 1871) (Dooge 1992:173). In Europe, France has the second largest proportion of housing built prior to 1919 (21.0%) (Sak and Raponi 2002). At the start of 2003 only 6% of French houses had air-conditioning (Agence France-Presse 2004). In 2000 France had approximately 2.5 m2 of air-conditioned indoor space per inhabitant, slightly under the European Union average; by comParison in Italy, Greece and Spain there is around 6.0 m2 per person. And only about 2% of all centrally air-conditioned space in France existed in hospitals, compared with a European average of 7% (Centre d'Energétique 2003).
social capital is the sum of all informal, altruistic social interactions occuring between people in a community. The cornerstone of social capital is the trust neighbours have with each other.
The best known proponent of social capital, Robert Putnam, recently concluded that ethnically homogeneous neighbourhoods had higher levels of social capital than more diverse communities (The Economist 2004:53), since people are more likely to be altruistic towards their ‘own kind’. Klinenberg noticed in Chicago that while economically disadvantaged areas in Chicago had more deaths in the 1996 heatwave, some poor ethnically homogeneous neighbourhoods which showed evidence of social capital (in the form of extended family and friendship networks amongst its residents, which led to busier streets and lower crime) suffered fewer fatalities, even amongst its own minorities (2002:87). South Lawndale (85% Latino, 22% poverty level) had a heat death rate of four fatalities per 100,000, compared with a Chicago average (56% white, 18% poverty level) of seven fatalities per 100,000. Neighbouring North Lawndale (96% black, 44% poverty level) had a horrendous toll of forty deaths per 100,000; its homogeneity afforded no succour for social capital against a backdrop of the more potent forces of crime and illicit drugs.
In France, the heatwave death rate was particularly high in Ile-de-France, with 230% excess mortality (Hemon and Jougla 2003:32). This conurbation includes not just Paris but a number of less prosperous surrounding dormitory suburbs (banlieux) collectively known as the petite couronne, with a number of indicators consistent with a fractured community. For reasons that vary from unemployment in a post-industrial world, non-participation from mainstream economic and cultural life, welfare dependency and ethnocentrism, some of its departments have the highest crime rates in France (Keijzer 2004). Many communities in the petite couronne were built as large public housing estates in the last thirty years. The Ile-de-France also has the greatest concentration of foreign residents (12.9% compared with 6.3% for France overall (Observoire Régional de la Santé 1998) and these figures ignore visibly “foreign” French nationals). Also 35% of all France’s Muslims (EuroIslam 2002) reside here, a youthful community group that some think has rejected the kind of Gaullic secularist communitarian values needed for social capital to flourish in a multiethnic, pluralist country. If the electoral successes of the Front National in the banlieu electorates are any indication, there seems to be a significant degree of social disconnection on ethnic and generational lines. Paris’s North Lawnsdale would be either Seine-Saint Dennis (26.2% of the population being foreign citizens according to the L'Institut National de la statistique et des Etudes Economiques) or Val-de-Marne where the highest excess mortality rates from the heatwave were recorded: 260% and 270% respectively (L'Institut National de la statistique et des Etudes Economiques, 2004).
The social problems in the banlieux can be traced to high youth unemployment, caused by labour market inflexibility - a politically sensitive issue the French government doesn’t want to touch.
The heatwave Strikes
The deaths generally involved elderly, low-profile victims who often lived alone. This meant that unlike other disasters, there was a considerable time lag between when the death rate began to accelerate and when the public and the government became aware of its true scale, and could appropriately react. Quite often the victims were found days after they had died. The deaths tended to occur in isolation from each other, and could have been interpreted as being due to natural causes, aggravated by climatic conditions and the victims failing to hydrate themselves. Until it became a topical news item the true magnitude and effects of the heatwave was only felt by that proportion of the population involved in France’s medical, aged and mortuary services.
Neustadt and May, who believed that public management can be best understood by using historiographical methods, suggest that narratives are the best way to understand how problems occurred, as it best illustrates cause-and-effect phenomena. (1986:120). Temperature figures and mortality rates below refer to observations in the Ile-de-France region.
Late July. West Africa is hit by unseasonably heavy rain in July 2003, which pushes northwards an anti-cyclone system. The anticyclone makes its way over North Africa, warming itself from the hot air of the Sahara desert, before loosing momentum above the western European landmass, where it firmly anchors itself. As it holds back rain-bearing depressions from the Atlantic Ocean that cool Europe, the anticyclone funnels in more hot air from the Sahara. Throughout Europe temperatures daily maximum and minimum temperatures rose beyond their average (Stumme 2003).
In France from the 4th August, maximum temperatures of 35.0°C or greater are experienced at around two thirds of France’s 180 weather stations, with 15% having temperatures exceeding 40.0°C. Importantly there are consecutive days of high minimum temperatures which do not give adequate respite, especially to those living without air conditioning and instead depend on trapping cool air currents overnight for cooling. Economic losses included forest fires, disrupted riverine transport and crop losses - in Germany, estimates of 80% of crops being lost to heat were circulated by farming associations, with losses to the grain harvest alone costing around one billion Euros (Deutsche Welle 2003). The heat not just influenced consumer behaviour (beer and air-conditioner sales enjoyed a boom), but also the actual and potential short term labour participation, as workers elected to spend their summer vacation away from their stifling cities, or extend their absence from work.
1 - 5 August. From the 1st to 5th August, mean daily maximum temperatures progressively rise from 25°C (normal for summer) to 37.0°C. Then right through to the 14th, minimum temperatures will not go below 20°C. The mortality rate does not move upwards much beyond the August average. A text analysis of articles published in the French newspaper Le Monde during the period show that excessive heat was first only reported as a meteorological phenomenon, a threat to agricultural production, or as a factor aggravating other hazards, such as pollution, the forest fires and the inability for nuclear reactors to function at full capacity due to cooling issues.
6 - 7 August. Maximum temperatures hit 39°C, then slightly dipped to 38°C. The mortality rate jumps to double then nearly trebles (i.e.: 300%) the August mean. The first media report in Le Monde of a human fatality due to the heatwave came on the 7th August, involving a single 32 year old man (Le Monde 2003a) Even as mortality peaked in the following days the few Le Monde articles containing the word canicule (heatwave) mention nothing about heat deaths. Neither did the Ministry of Health make any comment.
8 - 10 August. The maximum temperature starts rising upwards to 39°C again, while the mortality rate plateaus at around 300%. The Ministry of Health becomes aware of the growing number of hospital admissions around Friday 8th August, when it identified a marked rise in admissions in the previous 48 hours (2003a). The Ministry tasks the National Institute of Medicine to specifically monitor for heat-induced deaths in conjunction with regional medical authorities. A public health warning is also issued on the 8th, with the advice seemingly targetted more towards active people or people responsible for infants. No reference was made about any fatalities that had occurred (2003b).
The 9th and 10th August fell on a weekend, and the Health Ministry did not release any communiqués. The first signs of public disquiet came from the president of France’s association of emergency physicians, Patrick Pelloux, who with first-hand knowledge of rising hospital admissions criticised the government’s inaction (Bosch 2003:624). Pelloux denies the deaths are ‘natural’, as the government stated in a communiqué, and anticipating worse to come, he mentions France faces a ‘veritable massacre’ (BreakingNews.ie 2003).
Monday 11 August. The maximum temperature stays at 39°C, but the mortality rate skyrockets to 450%. The National Institute of Medicine detects an escalation of admissions in public hospitals in France, mostly in the Ile-de-France. Some medical personnel and resources are mobilised to reopen wards closed due to staff absences, and elective surgery is postponed. In a press release the Health Ministry acknowledges there has been a rise in heat-related deaths since 6th August, in particular amongst ‘vulnerable’ people. The press release furthermore mentioned that measures are in place to monitor the situation and assist hospitals, and another public advisory is published (2003b).
Health Minister Dr Jean-François Mattei gave a news briefing from his holiday villa that evening, where he casually downplayed the threat (Erickson 2003).
Tuesday 12th August. Paris suffers its highest maximum temperature, with 40°C, and the mortality rate peaks at 620%. A hotline telephone service is established offering preventative advice, and receives 12,000 inquiries on the first day. Mattei orders the mobilisation of the Red Cross and some military hospitals, while the Ministry of Health in another press release acknowledged a shortage of space in mortuaries in Paris region. Two articles in Le Monde make reference to claims by a group of doctors that fifty deaths due to excessive heat had occured, and the crisis is worsening in the public hospitals. Raffarin from his Alpine retreat dismissed complaints from his political opposition about the rising death toll as ‘inappropriate’, and said that for weeks the health service had been preparing for this busy period (Gentleman 2003).
Wednesday 13th August. The maximum temperature drops suddenly to become only 30°C, but the death rate is a dramatic 550%. A number of articles aree written about deaths in hospitals with a more alarmist tenor, and included reports of the first government reaction - that it was monitoring the situation and would convene a meeting within two days. Mattei, still on holiday, was verbally abused as he inspected a nearby hospital where 20 patients had died, and the Greens Party calls for his resignation (Les Vertes 2003) . He comments for the first time that hospitals around the country were overfilling with casualties. Finally in the evening Raffarin activates Plan Blanc(‘White Plan’), an emergency set of protocols meant for major disasters. Plan Blancempowers hospital authorities to recall medical staff from leave back to duty and coordinate with government authorities the use of additional facilities and personnel, ranging from opening military hospitals to the public to using refrigerated trucks as temporary morgues (United Press International 2003). Many of these measures had already been in place, albeit piecemeal and poorly coordinated between different levels of government, suggesting that declaring Plan Blancwas more symbolic than practical.
Thursday 14th August. Both Mattei and Raffarin return to Paris. Plan Blancgoes into effect six days after the Health Ministry knew the hospitals weren’t coping, but on this day the maximum temperature would only reach 27°C. The death rate too is dropping, down to 200%. At a press conference Mattei suggests a preliminary figure of 3,000 excess deaths (Nau 2003), describing the magnitude of the heatwave to be of ‘epidemic proportions’.
Friday 15th August, and beyond. By now the weather and death rate are normalising. The only thing useful left for the government to do is to deal with a backlog of bodies needing storage and disposal. Ironically the 15th falls on a bank holiday, so burials need special dispensations from mayors.
The outcry from the public and the political opposition builds up as the estimated death toll rises with each new revision. Initial estimates produced by the Health Ministry of 1,500 to 3,000 are eclipsed by a professional organisation of undertakers estimate of around 10,000. President Chirac returns to Paris on the 21st after a three-week holiday in Canada, where he had not released any media statements concerning the heatwave. He convenes a Cabinet meeting to assess what had been the government’s response during the disaster, and he publically pledges that deficiencies in the health system will be fixed. In what was cynically regarded as an attempt to deflect blame away from the government in the form of a eulogy, President Chirac frames the disaster in terms of a social issue, and not a failure of leadership: "Our society must become more responsive and attentive to others, to their problems, their suffering and their vulnerability," he warned. "These dramas again shed light on the solitude of many aged or handicapped citizens" (Gentleman 2003).
Later he and other senior members would hold a state funeral for the bodies of 57 unclaimed Parisians, uncomfortably closing this unfortunate episode.
The AftermathThe mortality rate rise corresponded to the intensity of the heatwave.
Excess mortality was particularly acute for people aged over 75 (70% more deaths than usual), but was also significant for people aged 45 to 74 (30%).
The highest concentration of excess mortality in absolute and relative terms was felt in the centre of France, in particular in the Ile-de-France region that surrounds Paris (134%), where 32.9% of excess deaths occurred. Paris had in total a 127% excess mortality rate, although in the surrounding dormitory towns the rates were higher. Perhaps reflecting the influence of social capital, excess mortality rates were lower in smaller rural communities, and higher in the larger cities.
The causes of death responsible for excess mortality were recorded to be heat related (heatstroke, dehydration, hyperthermia etc). Deaths associated with cardiovascular or cardiopulmonary causes were also considerably higher than normal.
The people representing excess mortality died in hospitals (42%), homes (35%) and retirement homes (19%). The fact that only 3% of excess deaths occurred in private clinics perhaps illustrates how socio-economic privilege provides a greater degree of personal security (Hémon and Jougla 2003).
Eventually on 25th September a finalised official figure was given by assessing excess mortality - the number of fatalities that occurred over and above a baseline level of mortality that would have been expected at the same time of the year. INSERM arrived at a figure of 14,802 excess deaths (60% more deaths than usual) for the period from 1st to 20th August, with these observations:
In the ensuing public out roar, a number of reasons were given as reasons to why so many preventable deaths occured. This reflects not just on blame management carried out by involved parties with political agendas and no interest in declaring responsibility, but also the number of factors at play. These factors can be separated between pre-existing conditions (the lack of air-conditioning), and those that would only have come into play as the crisis evolved (the activation of Plan Blanc ). Identifying potential and actual problems in any system (risk assessment), and determining how they should be dealt with (risk management) is a scientific discipline in itself, but in practice it may be corrupted by both political and subjective influences, as well as simply having incomplete information.
However political realities demanded that the fault be quickly placed on one person. Dr. Abenhaim resigned on the 18th in forced circumstances, making the point that the government had ignored his repeated requests for additional resources. Mattei, his boss, said that Abenhaim failed to provide sufficient warning in enough time for him to react, although Abenhaim, along with several media commentators and members of the political opposition, considered the resignation was arranged to deflect attention away from the government.
The department had ample evidence of an impending disaster: the dominant, stationary anti-cyclone weather pattern would have allowed forecasters to predict with solid confidence that the heatwave would continue for several days, and France had suffered killer heatwaves in recent years (Murray 2003). In fact a public health advisory was issued on the 8th, four days before deaths peaked. Abenhaim did admit that some mistakes were made in the handling of the crisis, but he draw more attention to ongoing issues, such as the lack of air-conditioning in nursing homes. A Ministry of Heath report on the heatwave tabled in September cited compartmentalisation throughout the health system, hindering 'anticipation, organisation and coordination' at the beginning of the crisis (Crabbe 2003:773). This still does not excuse Mattei’s decision on the 11th not to activate Plan Blanc , or even adopt more gravitas in the interview from his villa, when at that time his ministry had already noted overfilling wards. However it illuminates the problem of the ‘wait-and-see’ method of active surveillance, when an authority effectively decides to intervene only after a situation deteriorates to the requisite level causing enough bodies to meet a benchmark.
Still, there was considered commentary about the various root causes of the disaster. Dr. Pelloux stated that many lives could have been saved if hospitals were adequately staffed and resourced (Service France 2003), adding the following day that France’s public health policy needed an ‘autopsy’. The Greens used the heatwave as an argument for combatting global warming. Within Raffarin’s own government the 35-hour work week and the number of public holidays afforded to French workers was criticised. And among some political and intellectual circles there was a call for the public to reexamine how French society treated their elderly and other vulnerable, invisible people living in the margins. The French government later in a measure designed to be a symbolic and practical gesture of atonement (bourne by the public and criticised by some unions), abolished one of France’s eleven public holidays and committed the savings and taxes generated to a special fund intended for the welfare of the elderly and disabled.
The Risk Chain
At this point, it is prudent to adopt a risk analysis methodology that models cause-
and-effect, to appreciate the full situation. Fone and Young (2000:81-3) have developed the ‘risk Chain’, that breaks down a situation where a loss (or gain) results, into six sequentially interlocking links:
Environment -> Hazards -> exposure -> peril -> Outcome -> Consequence
The Environment. The circumstances in which a loss occurs; e.g.: the weather, labour relations etc.
The Hazard/risk Factor. The conditions within an environment that influence the probability of a loss occuring, and/or its magnitude if one ensures; e.g.: heat.
Exposure. The extent to which somebody or something experiences the hazard/risk factor, being a function of frequency (likelihood of occurrence) and magnitude (severity of a loss); e.g.: how often people labour in the mid-day heat ?
Peril. The process where the exposed hazard contributes to a loss; e.g.: hyperthermia.
Outcome. A quantifiable result that ensues from peril; e.g.: death.
Consequence. What long-term effects result from a loss, not necessarily what a risk regime is designed to avoid; e.g.: political backlash.
The point of the Risk Chain is to show the various points at which a government can prevent and respond to a disaster. Solutions directed at "early" links are preventative and pro-active, while "later" links are reactive. It is not easy for governments to respond early, either by infringing liberties or spending money, when the looming signs of a crisis are not evident (how hard has it been to ban chlorofluorocarbons ?).
Preventative Actions at the Environment Level
Just as prevention is better than cure, controlling the risk at the earliest juncture is more likely to be cheaper and safer than reacting later once a crisis brews. In the context of the risk chain an ‘environment’ might be defined as an entire identifiable and delineatable domain of interrelated entities and processes underpinned by physical and/or social laws, which by virtue of its own existence creates hazards. Regardless if it is abstract (like the global bond market or consumer confidence), or material (a stretch of road, the weather), an environment by its nature would likely to affect a large number of different people and organisations. Metaphorically, it is the source where ‘root causes’ originate, or the ‘swamp’ that needs to be ‘drained’.
However, in practice for many types of threats governments do not often adopt preventative measures at early stages along the chain, that is, by changing the environment to eliminate a risk.
Unclear responsibility. In some ways an environment can also be considered a ‘public good’ (or in the case of hazardous environments , a ‘public responsibility’ ?). This unfortunately creates the effect where ownership of a problem becomes diffused, and there is no clear line of responsibility directed to addressing a risk, save from whatever decision comes from a consensus of concerned stakeholders.
Conflicting interests. Different people with different values, perceptions and objectives often operate in the same environment. Changing the environment in order to address the risk concerns of one group of stakeholders might conflict with the interests of another group (e.g.: in natural resource management, clearing forests to create firebreaks might suit local residents but antagonise environmentalists). Governments in this position dislike being forced to apply the leadership needed to forge a compromise that ensures the long-term sustainability of an environment for the common good, as the decisions chosen may cost it political support.
Value judgements. Social environments may consist of the constructs or influence of other forms of social organisation, like the family or clergy, that the government may prefer to keep separate from its own secular, rule-based governing processes (e.g.: evangelising patriotism, family values or multiculturalism amongst society)
Cause-and-effect. The number of degrees of separation between the environment and the peril sometimes obscures their relationship, especially if the effect is not physically apparent (e.g.: asbestos), or is subject to a lengthy time delay (e.g.: obesity), or if through ignorance or political design people blame a correlated but non-causal attribute instead (e.g.: violent crime and ethnicity). At the very least it makes the link contentious and weakens the argument for collective action.
The Political ‘Environment’
We can also more abstractly define ‘environment’ as the social milieux where the problem of aged care resides. In this case the ‘environment’ consists of a series of overlapping rights and responsibilities exercised by all parties concerned, each with their own set of interests, and underpinned by social conventions and law. The offspring of the aged generally want the ability to balance their home and employment life with responsibilities to their parents. Private providers of aged care services may want to operate as profitability as a minimal level of quality will avail, while managers of public providers may not even have profit as an incentive to provide a safe, dignified existence for its aged residents. The state wants to maintain the public’s trust that it gives security for all its citizens (either directly, or by creating the necessary conditions in society), and at the same time provide it and other areas of government concern with an adequate level of funding. Depending on the depth of social capital in a community, neighbours may have some attachment for each other. And the aged themselves desire to be safe, comfortable, autonomous and needs-fulfilled, at least cost to themselves personally. France, like many countries, has a mixed aged care system where family-based care is underpinned by institutions funded through three notoriously complicated caisses, or insurance funds, which also provides for pensions, home help, some hospitalisation and a myriad of other benefits (Giarachi 1992:195). While a mixed health system shares the burden on both families and the state, two problems emerge:
Perceived Roles and Moral Hazard. Citizens can misconstrue the state’s role. Rather than being seen as the 'savior at the last resort' because of its perceived role in guaranteeing the security of the population, citizens might instead be tempted to form the view that the state will take full responsibility. As a result of this premise a ‘moral hazard’ emerges when citizens modify their behaviour and withdraw their participation, such as when families frequently left their aged parents at day-care centres. From the other end, the government may see aged care as a private matter for which it is obliged to provide some assistance, but it may overestimate the capacity and will of families in being the primary carers. This is not to say that governments will deliberately seek to delude themselves of the competency of these primary carers, to pretend a problem doesn’t exist; however at an operational level it might be perfectly rational for managers to allocate their limited resources towards problem cases that have no chance of helping themselves (e.g.: the isolated elderly), while presuming those with access to families will muddle through.
Previously the traditional model of family support was quite evident, indeed France’s civil law of 1804 codified the Obligation Alimentaire- the legally enforceable obligation that people were required to ensure the welfare of their needy kin, and could not be disinherited from a parent’s estate. Its influence has considerably weakened since a universal old age pension was established in 1983 (Twigg, J. and Grand, A. 1998:141), which more effectively addressed equity issues for poorer families.
Balancing capacity. A hybrid system is only effective when one side alone has enough capacity to cope with peak demand; if not, then depending on how vital a government values a given service, that side will have to surrender its autonomy and accept the extra workload, or the system is at risk of failure. The main problem in France was that families and aged care workers alike went on holiday at the same time. The responsibilities for the temporary care of the elderly was passed to different providers, who were too overstretched to provide satisfactory care. Ultimately the emergency departments in the public hospitals, who could not refuse patients, bore the brunt of caring for the elderly who at this stage now suffered dehydration as the result of earlier neglect.
So, one side in a hybrid system (a) may be tempted to welsh out of its responsibilities, or (b) discover that they do not really have the power to determine how much it is obliged to contribute. While it is tempting for the state to apply laws that thrusts the responsibility of aged care into the private sphere (e.g.: asset testing government pensions), it can be equally tempting for the private sphere (usually the offspring of the elderly) to avail themselves of government resources. Whenever such ambiguity arises, strong, publicly endorsed leadership might at least solve part of the problem. An effective leader can determine which stakeholders should be responsible for managing a risk and at which points, and they can then get their risk management plans endorsed by the stakeholders. At the very least good leaders make stakeholders aware of potential risks and invite them to collaboratively manage it with other stakeholders. Just as importantly, leadership also introduces a human element of intuition, foresight, ethics and accountability into a decision making process that might otherwise be ignored by the two sides of a hybrid system, who do not see themselves as solely responsible for the system’s totality.
Chirac’s comments about the need for French society to be compassionate towards the vulnerable could be interpreted as a message designed to encourage citizens to believe that the welfare of the elderly is their responsibility. Unfortunately his homily was delivered after the heatwave. One may conclude at this point that adopting effective leadership within a chaotic ‘environment’, hindered by unclear responsibilities, value judgements, conflicting interests and invisible causes, is a key preventative action. Failing to acknowledge the existence or importance of a threat is denial.
Preventative Actions at Other Levels
Instead of changing the environment, a risk control strategy might directly target the hazard (i.e.: heat). In the case of heatwaves, this obviously means cooling dwellings where vulnerable people live, and in the context of public policy, it means creating the set of circumstances that promotes access to suitably cooled accommodation.
As mentioned, France has a low take-up of air-conditioning. taxes on electricity designed to encourage energy conservation has been blamed by Michaels (2003) as a reason why power hungry air-conditioners are not common in France, a net exporter of electricity. Two facts contradict Michaels, an environmental spokesperson of the Competitive Enterprise Institute : in Europe, France is actually a relatively high user of electricity, with only Slovenia, Switzerland, Belgium and the four coldest Scandinavian countries consuming more power per capita (Nationmaster.com 2003). Furthermore, French electricity is retailed comparatively cheaply at US$0.134/kWH, compared with US$0.146/kwH averaged by other European OECD states (rates are even higher in Spain, Portugal and Italy) (National Energy Information Center 2003). Demand for electricity soared through the heatwave, so clearly it is not a price elastic commodity.
Instead air conditioning is less common in France’s homes and hospitals due to their age. In the case of high-density Paris, it is difficult to install ducted systems in existing apartments, while possibly town planning regulations restrict the use of individual fascia units that disturbs a building’s aesthetics. Falco promised to ensure that 80% of France’s 10,000 nursing homes will contain at least one air-conditioned room by June 2004 (Agence France Press 2004), although one wonders if a national directive will conflict with municipal planning laws.
Chicago, rebuilt after the Great Chicago Fire of 1871, does not share Paris’s architectural legacy (except its own highly functionalist Chicago School traditions) and thus has more modern housing stock equipped with air conditioning. Still, Klinenberg makes the point that electricity prices were a deterrent for poor people to purchase and use air conditioners in the 1995 Chicago heatwave (2002:160). The Center of Disease Control (CDC) observed that 50% of heatwave deaths could have been prevented if the victims had an operating air conditioner. For the impoverished whose energy bills represent a large slice of their incomes, electricity] consumption is highly price-sensitive. The US government runs the Low-Income Home Energy Assistance Program (LIHEAP) which transfers payments to states to subsidise the heating and cooling costs of disadvantaged groups. Like other targetted assistance programs it was subjected to funding cuts since the mid-1980s, and that year a bitter winter depleted Illinois’s LIHEAP budget.
When a hazard is inevitable (such as heat outside air-conditioned buildings), governments can still try to reduce the likelihood that the community will come in contact with it. Depending on both the severity of the risk and the behaviour of the community, the state might just issue warnings about a hazard (e.g.: like on cigarette packets), or it may seek to totally restrict exposure by imposing physical, legal, economic and administrative barriers (e.g.: erecting fences around power pylons, compelling motorcyclists to wear helmets, taxing cigarettes, or, in the case of heatwaves, controlling class times in schools).
Adams has noticed that people for various reasons treat risk differently and thus have varying attitudes about what role the government should have in reducing their exposure to hazard (1995:141-2).
Individualists. Believe that individuals, rather than the ‘nanny state’, should be free to choose the level of risk they themselves are prepared to be exposed to, and that this level can be determined through market forces.
Hierarchists. Believe that the state (automatically assumed to be knowledgeable and holding the citizen’s best interests at heart) is in the best position to determine the level of risk citizens should be exposed to.
Egalitarians. Believe that both the state and the individual need to come to a consensus over what level of risk is acceptable.
Fatalists. Do not believe risk can be mitigated.
It may be possible to derive a link between each of the four personality profiles above and their attitudes to the optimal level of government intervention (individualists wanting a laissez-faire approach, egalitarians wanting government to strive for equity, hierarchists prefering a clear, rule-governed regime based on meritocracy, and fatalists doubting either governments or individuals can make a difference). Unfortunately, this model does not assume that people or governments have perfect knowledge about a situation, and indeed in France people probably made decisions under-appreciating the lethality of the heatwave. The problem of people trusting organisations that rely on incomplete information is that when these organisations fail, the hierarchists and egalitarians may feel disillusioned. This could be one reason why there was a greater sense of outrage in hierarchist France than individualist, neo-liberal Chicago, where Americans regard misfortune as being the necessary price that an individual might have to pay if they want to participate in a deregulated, open economy, if they are not blaming the victim themselves.
For most threats risks are mitigated at the peril link, the event where a once potential hazard causes a loss. Unfortunately unlike other threats with enough prominent signs to scare a population into accepting government policy, the dangers of heatwaves do not become apparent until this point.
It makes economic sense when protecting a large population with limited resources and foresight to accept that not every threat can be anticipated and prevented, and instead they should respond once the peril emerges. Reacting at the point of peril provides some protection to a public who do not want their lifestyle limited to activities devoid of risk. This however is predicated upon the nature of the threat - can a situation be effectively dealt with once the event occurs ? (regulators monitor aircraft maintenance more strictly than cars since the consequences of aeroplane’s engine failing are more dire); and, is this option more economical than prevention ? (governments do not carry out mass flu vaccinations because those who succumb can be easily cured).
The most effective method of intervention in France would have been the prompt detection of vulnerable people suffering heat-related conditions and attendance of medical personnel. The state does not actively involve itself with monitoring the health of citizens inside their own private homes. For the aged there is a means-tested ‘Home Help’ (aide ménagère ) service where carers can be dispatched to the homes of the aged for a limited number of hours per week, however the registration procedures have been criticised for being cumbersome and not responding to emergencies (Giarachi 1992:205). Without state support, having friends and family members who could check on their welfare became a matter of survival for the elderly.
If reacting at the peril level is going to be policy, then the government needs to be certain that they can identify a crisis (even with incomplete information and subjective influences), and are prepared to make a pro-active decisions, even if they go against other interests. Unnecessary intervention gives the impression of incompetence or over-reaction, wastes resources and not just disrupts the public, but conditions them against reacting to further alerts. Justifiable intervention (such as activating Plan Blancpromptly) carries political risks, in that it highlights that the government was either unprepared or it understated the crisis in a previous public announcement. The dangerous feature about heatwaves is that its silence makes it too easy for a government not to respond, since it is tempting to leave the public largely ignorant about the magnitude of a disaster. A less conspiratorial explanation could be that governments are more (politically) risk adverse when faced with an uncertain situation. With a logic similar to curious teenagers who throw firecrackers onto bonfires to confirm that an action will lead to a predicted adverse outcome, the French government held off Plan Blanc until it had enough data from the National Institute of Medicine to confirm that, yes, they were indeed in the midst of a crisis, albeit now at a point beyond salvage.
The losses that come from a peril are the outcome; in the case of heatwaves the outcomes include ailments deleterious to health, and intervention here involves medical treatment.
Unfortunately the government failed to address control risk at this link: due to lax labour laws there were not enough medical workers available, and thus nearly half of all fatalities (42%) occurred in hospitals.
The aftermath of many public policy failures often includes a backlash against the government and the institutions perceived responsible. The advent of electronic media quickens the delivery of information and formation of public opinion in democracies, but does not serve as a suitable forum for contemplating underlying issues more broadly. An event can be contextualised by the media to narrate a ‘sexed-up’, sanitised or otherwise biased version of events, and it is this narration that defines how people will interpret the event. Governments are increasingly familiar with how the media operate, and through public relations practitioners can seek to have policy failures interpreted by media outlets in a manner that is politically advantageous. Having failed to control risk at earlier links, the government could only hope to minimise the spread of bad publicity.
The mayor during the 1995 heatwave in Chicago, Richard Daley, knew that a predecessor was deposed over his failure to handle a blizzard. He calculated that it would not be in his interests to give the heatwave more prominence beyond it simply being hot weather, and in the year of Newt Gingrich’s ascent he too wanted to appear fiscally conservative. So mayor Daley publicly censured the city’s Chief Medical Examiner after he had announced a link between the looming death toll and the heat (Klinenberg 2002:173), and in an act one senior paramedic described as murder by public policy, he refused to deploy extra emergency resources. After it became apparent mayor Daley had miscalculated badly, city Hall’s response was to convene a hand-picked mayor’s Commission on Extreme Weather Conditions. This assuaged the rising media interest immediately after the heatwave, and it presented a set of politically safe findings : that the heatwave was a freak cataclysm, that at risk people should rely on community rather than government support structures, and that there was hardly any difference in mortality between whites and African-Americans.
Likewise in France during the disaster the government downplayed the crisis, hoping to frame the situation as purely meteorological. After the heatwave, the French took a different tactic. While Mattei and Abenhaim argued over the amount of warning given, Chirac chose to broaden the public debate over what the proper role of government should be. His comments implying the public had a responsibility to its underprivileged can be seen as promoting a communalist approach to welfare, underpinned by shared values and charity. This contrasts with the bifurcated, mutually antagonistic aspects of France’s industrial relation system, which underpins the welfare state and led, which many in Chirac’s camp believe, to the ill-conceived Loi Aubry. Chirac’s aforementioned eulogy to the Republic after the heatwave acknowledged the French public’s high expectations that their society should protect its vulnerable, yet articulates a Reaganesque Government is the problem message that there are limits to capacity of the public sector to deliver on ‘private sphere’ commitments, explicitly directing the focus on family responsibility.
‘Below the Radar’ - Policy, Risk and Visibility
A heatwave is an interesting kind of disaster to study, since its utter ordinariness, isolated victims from a generally ignorant public and lack of any accompanying physical damage or spectacular imagery, allows the actions of a government uninfluenced by public opinion to be observed. Firstly, one has to make a few assumptions - that the deaths were unintended, that the government seeks to retain the confidence of its citizens, that the government knew that it was not in its interests to draw attention to the disaster when possible as it exposed its own shortcomings, that the rising death toll was known by the government, and that the government (contrary to appearances) thought it had the capacity to respond. The argument ultimately comes down to whether Abenhaim briefed Mattei sufficiently or Mattei ignored his warnings, but on the balance of probabilities we can assume the latter, because (a) the hot weather and its effects on the fires, crop failures etc was already a subject of many pieces of Cabinet agenda in early August, (b) France had suffered killer heatwaves in the recent past, (c) the department issued a health warning on the 8th August, which quite possibly required the minister’s approval, and (d) Mattei is a physician by training and probably would have noticed the dangers himself.
A model is needed to chart how public policy processes anticipate, process and respond to threats which are inherently unpredictable and (conveniently) elusive to define, both at the point a disaster is unfolding, and after once the committees start to circle.
Amartya Sen and Scarcity
Amartya Sen believed that famines were influenced not just by the reduced supply of food, but also by the market responding to segments of the population with more buying power ('command'), causing prices to rise beyond the reach of less affluent consumers (1995:215-20). If one applies Sen’s theory, using nursing services as an analogy to food, we see that the disadvantaged were placed in the greatest danger by relying on the overstretched public hospitals and aged care facilities. Medical professionals, as economic agents themselves, were naturally inclined to work for private instead of public providers, who in turn relied on contracted foreign professionals from developing countries to meet labour shortfalls (passing on skill shortages internationally). Like marginalised peasants without tradeable skills, the elderly are dependent on familial and state support, but to make matters worse their needs (cleaning, supervision etc.) are labour intensive. A labour shortage cannot be solved as quickly as a capital infusion or air-dropping sacks of grain, especially if families free ride state support, labour unions demand reduced hours and labour productivity cannot be boosted (one seriously doubts nursing homes can be automated).
Sen’s thesis becomes multi-dimensional when workers (like public hospital doctors) are hired from developing countries - the problems of the marginalised in a dominant country are solved by extracting the productive component from poorer countries. Flanagan (2004:109-28) illustrates this paradox with child care and subservient gender roles in her provocative tract ‘How Serfdom Saved the Woman’s Movement’. One inequality subsumes another.
Randy Shilts and Marginalisation
Randy Shilts’s account of the early days of AIDS showed that the mainstream media greatly underreported the silent epidemic until heterosexuals and celebrities began dying (1987). Governments at all levels were ignoring the problem or failed to coordinate their resources correctly. Just as risk assessments can be corrupted by subjectivity, prejudice and politics, the dangers afflicting marginalised communities may be ignored by the media, a vital institution that should identify governmental oversights and generate community censure when necessary.
Could the elderly be ‘marginalised’ in a country known for reserving park benches for its veterans ? The lack of social networks and financial resources led to many victims to depend on the publicly-funded, under-resourced health care system, and the intersectionality was also evident in Chicago where many elderly were too poor to afford air conditioning. The other feature of age discrimination that led to deaths was ‘invisibility’, in that rising mortality amongst the age was largely unreported by the media, and thus became a non-issue to government. Like America’s gay community in the early 1980s, the elderly in France had a low profile, and their deaths were downplayed not just as a natural consequence of hot weather, but also through subtle discrimination. The underreporting can be attributed to a systemised and subconscious form of discrimination through Harris’s ‘fair innings argument’ : the death of somebody younger is more tragic and less inevitable than for somebody older who has already lived through a greater part of their expected lifespan (1997:669-72).
No major French magazine featured the heatwave as a cover story. Boyer scanned France’s print media, and noted that media reports on the heatwave largely focussed on the effect heat had on agriculture, footballers and animals during in the first half of the heatwave (2003:876) . While King has identified an unprofessionally close relationship between the French government and sections of the French press, who jointly connived to suppress reports about a extortionist threatening the country’s rail networks (2004:12), in the second half of the heatwave the media was robustly critical of the government. The situation was framed by the media as a human interest story, then as a political moot point (with some writers pontificating about public attitudes to the elderly), rather than as an ongoing disaster requiring a collectively supported solution.
Samantha Power and Denial
Samantha Power considered how governments not just selectively interpret events, but how pressure is put to bear on public servants not to inform government about facts that would oblige them to take action that interferes with other political imperatives. During the massacres in Rwanda, for example, State Department officers were routinely told to downplay atrocities so that the President would not be compelled to send peacekeepers, an option highly unpopular in the United States since Somalia. She developed a framework that explains how deniability is artificially established by governments (2003a).
Denial of Fact. As primary collators of information, governments can be more holistically aware of situations than other institutions, and may choose to ignore or refute facts. In France the government knew that the number of heat-related illnesses were rising on the 8th August (when it had conducted its own survey over the previous two days), but did not admit its hospitals were in crisis until much later.
continued as French heatwave disaster of August 2003 - II