Governance, privatization and public health policy

1Research studies analyzing recent transformations of the state and the way state action is being reconfigured make much use of the notion of governance. Though researchers investigating this issue are not working within a perfectly homogeneous theoretical space and though the studies focus on what are often very different phenomena, this “second-order concept” [1] is often used to circumscribe and characterize three categories of change (among others); i.e., the greater role in shaping and implementing public policy now being played by 1) local communities and municipalities, 2) private-sector actors (businesses) and 3) international institutions, particularly the European Union. [2] These three developments, which may occur at different scales, are understood to undermine the state’s ability to act autonomously, [3] to relativize its tutelary role in producing public goods and services, and to call into question its leadership position when it comes to orienting and coordinating actors involved in producing public action. The notion of governance enables us to apprehend public action heuristically as the product of competition/cooperation between different groups of public and private actors, groups often organized into (horizontal) networks and active in exchanges situated at various scales (local, national, international). While some segments of the state continue to play a major role in developing and implementing public policy, they are now operating “in plainclothes”. [4] Furthermore, in several sectoral policies, the state is no longer the regulation centre. Lastly, the notion of governance helps renew our understanding of mediation and interaction between state and society, suggesting the relevance of moving beyond an institutional perspective focused exclusively on government powers and instruments and working instead to identify the negotiation and coordination mechanisms operative among “different groups, networks, sub-systems”; mechanisms “that will make government action possible”. [5]

2Several authors have focused on changes in relations between the state and the market [6] and on the role of private actors in producing public policy, [7] working to identify characteristics of the dynamics governing what has been termed a movement to “privatize” public action; e.g., market-sector companies’ involvement in delivering public goods and services, “the transforming of state actors into private-sector ones”, [8] governments’ increasing tendency to use knowledge, tools and standards developed in the market sector, and increased interdependence between public and private actors. This privatization phenomenon, which actually blurs the boundaries between public and private, is quite clearly at work in public policy touching the economy; that is, transportation, communications, energy policy, among others. But it has also been shown to be acute in other areas, such as internal and external security, [9] disease protection, [10] therapeutic and curative public health policy [11] and, in some countries, taxation. [12]

3On the other hand, the many existing research studies of recent changes in the public health policy sector [13] have not observed or emphasized any privatization movement in this particular field, and those that have mentioned it have done so only in passing. [14] Some research has of course stressed how the (regulator) state, [15] via the work of agencies specialized in health risk management, has helped diffuse managerial know-how [16] and market logic (while also making it possible to enact “norms opposed to the market”). [17] A number of studies have stressed the strength of resistances from interest groups on the one hand and coalitions of market actors on the other in processes of passing legislation or adopting public health policies. [18] Others have drawn attention to the involvement in France of organizations whose status is technically private – namely, not-for-profit associations founded in accordance with the law of 1901 – recalling that they have long been extremely active in matters involving French public health policy. [19] But most studies of new health policies have been more interested in the role of patients (e.g., in the fight against AIDS and other pathologies), in the characteristics of the science that informs public health surveillance and protection policies, in the socio-political processes of constructing public health problems and the institutional management of “public health crises”, and in the increasing involvement of the European Union and international organizations. [20] The growing role of market-sector actors in the actual production of public health has not been at the centre of political science or sociology analyses.

Local policies for combating overweight and obesity: privatization or hybridization?

4Recent major changes in public health policy [21] should nonetheless move us to pay more systematic attention to this research problem – specifically, changes in policy related to the now national and international public health concern to prevent obesity and overweight. Among the wide range of preventive and curative actions that have been developed to combat overweight and obesity, providing information and education on individuals’ – and particularly children’s – health is now thought of as essential. In France, health education campaigns are run by all sorts of national and local prevention actors: the Institut National de Prévention et d’Éducation pour la Santé (hereafter INPES), département-level health promotion organizations, specialized, private-status not-for-profit associations as defined by France’s Law of 1901, département-level services for the protection of pregnant women, new mothers and children, Ministry of Education services, municipal health and hygiene services, national public health insurance services, complementary health insurance organizations, etc. But one particular prevention program caught and held our interest: “Ensemble prévenons l’obésité des enfants” [Together let’s prevent obesity in children], hereafter EPODE. Designed and run by professionals in the fields of nutrition, management and marketing who work through a private social marketing agency, and funded by contributions from towns and cities enrolled in the program as well as subsidies from partner companies, some of which are part of the food and mass market retail sector, EPODE has managed to acquire a key position in shaping and developing arrangements for detecting and preventing child obesity. It is now operating in over 200 French cities and towns, including major cities such as Lille and Paris, and is perceived as a crucial player in public health policy around this problem. As such it has been presented by the Ministry of Health as particularly innovative, to the point where, in the eyes of the public authorities, it incarnates the most successful instance of public-private partnership (PPP).

5We studied the genesis and implementation of this program in four municipalities and at the national level, using the methodology specified below. We obviously make no claim that through this study of a single program we have exhausted or revealed all changes in state action in connection with public health policy, or have even synthetically identified the particular type of governance or dominant type of regulation operative – and prospering – in the policy sub-sector which combats obesity and overweight. Our three aims are more modest.

6First, studying the genesis and operation of this program and the relations obtaining between the private-status actors and organizations that run it and the many other actors involved is a particularly effective means of observing implementation of a policy for “governing citizens’ bodies”, [22] as well as the (difficult or non-existent) combining of state action and local action, the latter primarily municipal.

7Second, this case is useful for apprehending the mechanisms that govern the rise to legitimacy of a private actor in the public policy area of public health. Like security policy in France (see Sébastien Roché’s work on this), public health policy is understood to fall categorically within the French state’s sovereign competence and scope of activities, [23] and the involvement of private business enterprises has elicited much resistance, since public health is generally not to be considered a “commodity”. We try to shed light on some of the processes and mechanisms through which such a program has managed to become institutionalized in what is still a “recalcitrant” policy area. [24] Specifically, we show how EPODE is a quite particular example of the private public-policy actor. EPODE actors do not belong to the category qualified by Pierre Lascoumes and Dominique Lorrain as “black holes of power” because they do not act in an absolutely “discreet” [25] manner or operate like a “back-office” for “the public authorities” in accordance with an “unwritten division of labour” principle; nor do they have any legislative, executive or conflict-regulating powers. [26] And they do not really correspond either to the “moral entrepreneur”, a figure whose importance has often been stressed in literature on public policy following the seminal works of Howard Becker. [27] Though the program came into existence and began developing before the obesity problem got put on the public policy agenda, it was not at all involved in the initial moves to frame “unhealthy eating”, overweight and obesity as social problems (though today it is increasingly likely to assume this role); [28] it neither helped “sound the alarm” [29] nor proposed or defended the guidelines in which “solutions” to the problem were to be found. In fact, the actors running the EPODE program correspond most closely to the figure of the private entrepreneur [30] as depicted in recent years in economic sociology studies. [31] They seem to have managed to establish themselves for the long-term as actors on the boundary between two heterogeneous and in many respects antagonistic worlds: public health and the market.

8Third, studying how an actor such as this became established as a legitimate “operator” in public policy to combat obesity and overweight, and how it contributes to the execution of missions in the common good, is first and foremost an opportunity to identify original ways of “privatizing” public action.

91) We show how this actor goes beyond the tasks of diagnosing the problem, identifying targets for local public action, designing action instruments and even contributing to assessing the effectiveness of the action (all activities which indicate types of privatization which have already been identified in the literature); but it also plays an active role as well in the essential, properly political task of coordinating the activity of public actors and local organizations. We discover a partially “reversed” version of privatization, in which private actors help coordinate the action of public and association actors.

102) While some features of a movement to privatize public action may be discerned in this policy sub-sector, we may also highlight a reciprocal phenomenon of making private action public. We show that the nature of the institutional setup now governing implementation of the EPODE program is fundamentally hybrid – so much so that the very notion of “privatization” is no longer accurate to define the way public action is being reconfigured in this sub-field.

113) We also work to show that substituting a private service-provider for a public service-provider for certain tasks (particularly diagnosis, target definition, tool development and policy assessment) is not a perfectly neutral operation: it has significant impact on what it means to “do public health”.

12After briefly retracing the genesis of this “moral service implementer” we turn to how it has tried to legitimate its intervention in the area of child obesity prevention and managed to accommodate critiques of its private-sector origins and its business-oriented aims.

From an epidemiological survey focused on schools to a program for local action focused on towns and cities (1993-2004)

17What gave rise to the EPODE program was an initiative taken in 1992 – that is, before obesity and overweight were granted the controversial status of “public health problem” – by a not-for-profit organization named Fleurbaix Laventie Ville Santé or FLVS. Fleurbaix and Laventie are the names of two small towns in the north of France, the project’s first two experimental towns. The prevention activities initially contemplated by this new association structure did not target obesity but rather cardiovascular disease, highly likely to be caused by obesity and overweight. A physician and endocrinologist named Jean-Marc Horet working at the teaching hospital of Lille, with the support of head nutritionist, launched a nutrition education plan for the schools of Fleurbaix and Laventie. Dr. Horet’s plan was modeled on an experiment under way in a small town near San Francisco that had set up a community health program to reduce inhabitants’ cholesterol levels. It thus partook of the characteristic French tropism which consists of “transferring” policies and preventive interventions developed in Anglo-Saxon countries to France. [43] Dr. Horet’s undertaking may be described as environmental. His objectives were 1) to modify the “environment” of children’s nutritional choices by circulating information on what they were eating and what they should eat, in the hope of 2) getting them to transmit this information to their parents. A variety of actors – dieticians, teachers, physicians, teacher-training professionals – were called upon to write up information and prevention sheets and have them distributed in schools to children in the two towns initially involved. The preventive aspect of the project drew greatly on the frequent exchanges and strong ties between health and education professionals. In this first period, the issue was for program promoters to scientifically demonstrate the effectiveness of this environmental method of preventing cardiovascular disease. A team of researchers from the Institut National de Santé et de Recherche Médicale (INSERM) took on the task of drafting the protocol for an epidemiological study, data collection and analysis. They were scientifically interested not just in obesity but also chronic disorders such as diabetes and cardiovascular disease. [44]

18Starting in 1997 (that is, four years before the first PNNS plan was launched), the study underwent two significant changes: the focus shifted to preventing obesity, specifically in children, and the frame of action for the program was enlarged from schools to the towns themselves, as their involvement in it had been growing. This shift went together with changes in organization. Initially, Dr Horet had created a nutrition consulting agency, the aim being to collect funds for implementing the project and following up on the epidemiological study. The project’s first funding came from a few major pharmaceutical companies [45] and a large food industry company. In 1998 and 2001, the nutrition agency merged successively with a public relations agency specialized in food and health and founded by a former food-industry business manager, and a “social marketing” agency, specialists in setting up educational projects on nutrition. These two mergers and the “patent” success of the original experiment were incentives for its promoters to turn the initial epidemiological study into a program of action targeting a large number of cities and towns.

Institutionalizing and extending the action program (2004-2009)

19In 2004 the EPODE program was created and put in place as an experiment to be conducted in ten pilot cities or towns. Perfectly in line with the policy direction towards combating obesity and overweight that had been initiated by the PNNS in 2001, the program aimed to “gradually modify social norms and reduce inequalities in access to prevention [of overweight and obesity] by promoting a varied, balanced, manageable and pleasant diet and providing incentives to children and their families to increase their daily physical activity level”. [46] To attain these multiple demands, the program promoters set out to increase the number and variety of partners, establishing relations with scientists, health professionals, local communities, administrations and industrial companies. One original aspect of the program was that the town was thought of as a relevant local echelon for actions to promote prevention. Above all, the program proposed an “original method” for implementing health promotion actions, the overall aim being to make it easier to reach the objectives set by the national authorities.

20The formal channels and nature of this example of cooperation between organizations, the complexity of which we explain below, are the following: local government signs a contract with the FLVS association to get the EPODE program set up there; the cities in question first sign an agreement called a “commitment charter”; they then have to hire an “EPODE project head” (or call upon a municipal employee to spend a (variable) amount of his or her time coordinating the program at the local level). They also pledge to set up a “steering committee”, to be composed of at least one representative of the medical corps, teachers or other permanent Ministry of Education employees (e.g., school nurses), and elected officials. Meanwhile the FLVS hires the social marketing agency to “design the program and engineer the project as well as coordinate the set of actions recommended to cities to make the program operational, coordination to be overseen by the Expert Committee” (excerpt from the “Charte d’engagement des partenaires locaux” [local partners’ agreement]). It is the agency’s (remunerated) task to train local actors (particularly EPODE project heads; see below), disseminate healthy nutrition practice guides, propose obesity prevention activity ideas, centralize height/weight data collection, carried out within the framework of the program, from children from kindergarten (age 4) through the last year of elementary school (age 11-12), [47] and develop teaching tools – nutrition information sheets and, more recently, “action sheets”, designed as aids to launching actions that take into account the particular activities of the types of actors they are addressed to (elementary school teachers, physical education teachers, etc.), this last point constituting the core of EPODE technical expertise.

21But the program goes beyond providing expertise on how to promote health and design prevention instruments. It also provides a social engineering methodology and actively helps to coordinate local actors. The methodology makes it possible to guide or orient an entire set of actors who may have been more or less active up to that point, but are scattered, and to activate state (i.e. public) and community organization resources, even private-sector funding, to enable those actors to operate within a collective action framework stamped “EPODE”. The action is supposed to take the form of an integrated network: a local management centre is created and identified at the heart of which is the project director and steering committee who work in close collaboration with the national directorate of the EPODE program; regular meetings are scheduled with involved and potentially involved local actors; a shared public relations strategy is developed around local prevention actions (diffusion of the EPODE logo, posters, creation of EPODE events, etc.); information is disseminated regularly about the activities of the various actors [48] and the accomplishments of the national network; bi-annual national meetings of all municipal project heads are organized, etc. Every year, priority issues are identified by the EPODE national coordination committee, and member cities are invited to find ways of working on them locally using instruments and action tools developed by the agency. The national program also sends out calls for proposals to network-member cities; winning proposals are then funded by partner industries or administrations. The EPODE program thus performs the properly political work of running activities and coordinating local actors around a local policy perceived to be in the general interest.

22The success of the program can be summed up in a few figures. From 2004 to 2009, the number of French cities enrolled rose from 10 to 226, including Paris and Lille. The experiment has also been taken up by several other countries and regions of the world (Australia, Mexico, Belgium, Spain and Greece), enabling program promoters to claim that no less than four million people are concerned. Moreover, the European Commission – specifically, the Directorate General for Health and Consumer Affairs or DG SanCo – was quickly won over by the experiment [49] and has hired EPODE to develop a healthy practices guide to be used in local obesity prevention policy throughout the EU, the idea being for it to serve as a cognitive and normative basis for implementing similar policies in all European Union cities. Dr Horet is now considered a national expert, and there is hardly a scientific or institutional conference, televised debate, press article or radio program on the subject in which he is not included as a guest speaker.

23The success story just presented, a collective reference in program members’ discourse, is remarkable in many respects. How, in the space of ten years, did a modest epidemiological study carried out in two cities by a private actor manage to metamorphose into a method for action recognized by the European Union and operating in more than 200 French cities and towns and five countries? To answer that question, we need to analyze in greater detail the strategies that enabled program promoters to legitimate their intervention.

Legitimation by science

27Clearly, the quest for scientific legitimacy began very early in the experiment: Dr Horet brought in a Paris team of INSERM-associated epidemiologists almost immediately. At last count, 23 articles on the FLVS/EPODE experiment had been published in medical journals. Dr Horet is systematically indicated as co-author, as is the FLVS association president (who is also a member of the expert committee) in eleven of the articles and the program’s national coordinator in six. More interesting yet, five articles are signed “FLVS Study Group”. This procedure, widespread in medicine, is aimed at giving visibility to a cooperative group that has developed into a collective entity – above and beyond individually cited authors. The fact that the name of this group is identical to the name of the association manifests a desire to identify the experiment as a patented scientific activity. Furthermore, in eleven of the articles, the name of the experiment, which once again corresponds exactly to the name of the association, appears in the title, while in five other articles it is cited in the abstract. Altogether, only two articles – nonetheless co-signed by program members – make no explicit mention of the program. Though only one article actually assesses the experiment’s impact, [52] this hefty set of articles, all published in top journals, most of them international, works to accredit the actors’ claim that the EPODE program as a whole has a scientific foundation. Moreover, the publications have made it possible to “enroll” INSERM epidemiologists in the program, in the sense the term is used in sociology of science [53] – epidemiologists who in fact are more interested in the data collected for the experiment than in program evaluation.

28The experiment was “evaluated” for the first time in 1997. Changes in the two towns’ overweight and obesity rates were compared with the situation in control cities in the same region. The results were inconclusive. Indeed, the height and weight data collected reveal increased rates of obesity and overweight for the two cities up until 2000: 18.2% of boys and 10.2% of girls were overweight (obesity included) that year, whereas in 1992 the figures had been 14.1% and 9%. Undiscouraged, Dr Horet claimed the experiment could only produce the desired results over the long term and requested that the epidemiologists continue collecting the information. In 2004 the figures showed a sharp “improvement” for the program: 10.4% of boys and 7.4% of girls in the towns of Fleurbaix and Laventie were overweight, as opposed to 19.4% and 16% in the “control cities”, and the prevalence of obesity within lower-income families in the two towns was 15.2%, versus 26.9% in the control cities. The article presenting these results was accepted for publication in an international though not top-ranking journal, Public Health Nutrition, despite the obvious difficulty of imputing the results with any certainty to the policy measures implemented. (Even if we assume that imputation was valid, it remains to be specified which measures produced the results.)

29But EPODE actors wished to go beyond medical and epidemiological evaluation and evaluation by their own expert committee. They moved to set up partnerships with other scientists, thereby consolidating their image of a program with academic ambitions. No fewer than four European universities volunteered to be key partners in the framework of the European Union project EPODE was steering (analyzed below). Universities were mobilized for actions judged crucial by program designers. Here again, in documents presenting the program, interviews with the press, and matters of symbolic resources, this partnership with researchers presents all the external, discursive signs of scientific respectability, and it does so in two distinct ways: 1) such partnerships are reputed to produce knowledge that may eventually fuel program actors’ thinking and their attempts to improve the technologies they use; 2) they help legitimate all program actions, in that directly involved actors now have firmer grounds for claiming that the program they were developing belongs to the closed circle of “evidence-based practices”. [54]

Legitimation through local action

30EPODE’s success is due in large part to the move to shift program focus from schools to mayors. The mayors quickly grasped why it was in their interest to sign up for the program: it would enable them to display concern for the health of their citizens at a relatively low cost, in connection with a public health problem considered politically profitable because associated with both children and social inequality. Moreover, EPODE’s theoretical perimeter of intervention is very wide. Its purpose is to “combat sedentariness by promoting physical activity of all sorts and to initiate children in a balanced diet, diversity, and the pleasure of being at the table” (excerpt from the local partners’ “Charte d’Engagement” [commitment charter] agreement). Meanwhile, the list of actions carried out in the field under the EPODE label reaches out in all directions: “taste week”, all-you-can-eat fruit and vegetable “salad bars” in the school cafeteria, “sports fortnights”, cooking classes ( “eat better without spending more”), closing a street to traffic so that children can walk to school more easily; setting up a “pedibus” (i.e., organizing a circuit to walk children between home and school); “solidarity gardens” (growing vegetables in the town’s public garden space and cooking them), reducing breakfast size, setting up a “baby gym”, scheduling hikes, re-arranging the school yard to make physical activities easier, etc.

31Not only are all these operations ideologically unobjectionable, but the EPODE program refrains from calling into question any initiatives that may already exist in the given city. Indeed, for the people in charge of implementing the program, any existing local initiatives are to be seen as acceptable and “good” if aimed at preventing obesity. [55] So when local government signs a contract with the FLVS association, the project promoters do not undertake any analytical inventory of existing practices, nor do they select “[existing] operations to be continued” in their own program on a cognitive and normative basis of previously identified “good practices” (identified, that is, either through past experience or international literature on the relative effectiveness of various preventive actions). This “ecumenical” approach to obesity prevention is ultimately not only consistent with other messages, reports and public projects in this area, [56] but also offers mayors the significant advantage of enabling them to bring together all local initiatives in a global municipal action policy.

32The program’s power also derives from its label, which has become a kind of flag for community organizations to rally round. While many EPODE activities are modeled on interventions and events that already existed at the national level, such as “taste week”, and though program promoters seek to develop their own new actions (above all supervised activities, interventions in the classroom), many obesity prevention activities have been organized by not-for-profit associations, Ministry of Education employees (nurses, teachers, school cafeteria directors in particular) and child day-care centers. These activities may well have already been in place before the municipality contracted with FLVS. In fact, these groups and organizations agree to use the EPODE label primarily because they hope it will help them catch the attention of the local press and so win greater recognition for their own actions and receive more support from the other institutions in exchange.

33

“I’m telling you, we didn’t have to wait for EPODE to do EPODE ourselves. What’s good is that it gave us some resonance. In the end we realized that [what we were doing] was really part of the program: athletic games, getting the children to move… What was new was that we got recognition for what we were doing. We’re better known. It’s easier to get material when you’re better known. We’ve got a reading workshop. We were able to get money for books on diet, DVDs. It’s easier.”

34

“I’m going to run EPODE activities to get [our] association better known and show what we know how to do. Because there’s a big [negative] story about this neighborhood. It’s to show another image of the neighborhood, to give it value.”

35Getting included and integrated into the program thus constitutes a strategic resource similar to the one provided to companies by norms and standards: actors can promote actions they consider important more effectively if they refer to the EPODE program than if they mention only their own competence and skills. [57] In this way, the EPODE label actually works to desingularize the EPODE project, situating it within a vaster – and more legitimate – collective.

36

“It helps strengthen us – we were already doing things at the school – [it helps us] get recognition. It enables us to justify our actions to parents by saying to parents, it’s not just us. Because at first the parents thought we were forcing their children to eat because we were bad and we wanted to make them cry! So in fact it [the program] brought recognition and gratitude, because we could say: ‘You see! It’s EPODE, it’s the town hall, it’s a program, it’s important, it’s national.’”

37Because EPODE is able to bring together local initiatives and get them working around its own label, it represents an important resource for mayors who want to show how committed they are to serving their fellow citizens. In exchange, those mayors have played (and continue to play) a fundamental role in institutionalizing and diffusing the program. Mayors and local elected officials (in some towns deputy mayors are more directly involved in the program than mayors), together with local project directors (once again, member towns and cities either hire a director or assign a municipal worker to perform the director’s tasks) become the national team’s primary interlocutors. Dr Horet claims that mayors are responsible for the quicker-than-expected expansion of the program. The following excerpt from an interview with him makes it quite clear how important mayors have been in legitimating the program, especially when the mayor in question is also a national political figure.

38

“And then we were outdone by the Association des Maires, namely because [a former government minister] was in it – fairly emblematic people. They said: ‘We want to do promo for EPODE. In terms of social cohesion and a change in our city hall work methods, this is good for us, it creates a positive dynamic, we want to develop it.’ So now we’ve got 200 EPODE cities – it all happened more quickly than expected.”

39An “EPODE mayors club” was created that brings together the mayors of all member cities. The club is both a political resource network to be mobilized to defend the project and an agent that promotes the “adventure” to mayors still hesitant about whether to take the plunge. Mayors who have signed an EPODE contract are uncommonly persuasive when it comes to touting the merits of the experiment and “selling” it to their peers. Moreover, the individuals in charge of developing EPODE internationally organize trips to member cities for foreign delegations. We have here a fairly classic illustration of the neo-institutionalist claim that institutional entrepreneurs need dense networks of united actors in order to be successful. [58] The point would have to be further substantiated, but we can already hypothesize, given the critical mass of the program now and the “institutional power” of the many labels that now “give their backing to” its actions, that the enrolment of new cities reflects what Paul DiMaggio and Walter W. Powell called “mimetic isomorphism”. [59] Beginning with the support of a few nationally renowned mayors, the program has thus been able to spread with remarkable speed across French national territory – somewhat like the epidemic it intends to combat. [60]

Legitimation through recognition from national and European Union institutions

40The program has thus acquired legitimacy through its ability to bring together and aggregate a network of actions and local initiatives around its label. But in order for that label to be judged effective and useful by local actors and for EPODE to continue to grow, it seemed necessary to its promoters to link the program to national and European Union institutions.

41EPODE’s initial strategy was to align itself with PNNS guidelines. The idea was to transpose PNNS messages onto local operations targeting the population’s everyday life. EPODE thus linked itself indissociably with a national program that other actors had developed, and it is PNNS officials who validate EPODE action tools, though the contact between the two entities remains minimal. This “symbolic embedding” operation has been so successful that many of the local actors we met with thought that EPODE and the PNNS belonged to the same world. Indeed, many of the persons we interviewed thought of EPODE as an “emanation of the ministry” and a “public entity” itself in a field where, as we have mentioned, private initiatives (apart from those initiatives originating with not-for-profit associations) are likely to elicit distrust and resistance. [61]

42Connections between the social marketing agency and central state government offices have also taken a variety of forms. When the PNNS was created in 2001, the private agency designed its logo. It was also performing other services in state- and agency-run national information and education campaigns. But the Ministry of Health is not the only national actor to have approved and underwritten the program. Other ministries, such as Food, Agriculture and Fishing, Education, and Youth and Sport have publicly declared their support, either financial or institutional. EPODE program promoters constantly cite that support in the program’s public relations documents, which displays those public-entity logos. The EPODE internet home page sports an impressive list of supporting public institutions.

43

“So the public partners – either the Ministry of Youth and Sport, the Ministry of Health, the Ministry of Education, the Ministry for Small and Medium-size Businesses, Agriculture… for us it’s recognition. Some bring in funds, like the Ministry of Sport; then there’s research via the PNNS, also the Ministry of Health… So first there are ministries, and we submit a file that is analyzed by a committee that thinks about our file and gives its opinion, and then the minister sends us a note to tell us they agree to support us. We’ve been very well received. All we ask is recognition, and that gets us support from the public authorities.”

44While it is doubtful that the founders of EPODE imagined from the outset being able to give their program a European Union dimension, [62] it is not at all hard to imagine that doing so immediately appeared as if it would be very useful for 1) developing EPODE into an international program – one strategic priority – and 2) strengthening the program’s legitimacy at the national level. In fact, “international guidelines” – i.e., the “good practices” already being used in local battles against obesity – were already being developed within a setup involving four European universities. Some of the meetings held in connection with the international program were an opportunity for program promoters to demonstrate to potential partners the extensive know-how of the EPODE program. They also represented an opportunity to “sell” the experiment to foreign guests who were themselves local elected officials.

45It would be risky to suppose that obtaining and assembling numerous labels sufficed, [63] by a mere mechanical transfer process, to institutionalize an initiative like EPODE. More must be done to turn an initiative or program into an institution than to piece it together from other institutions, however legitimate those institutions may be in the field in question. The conceptual framework put forward by Pierre François [64] in what is in part a rereading of Wittgenstein’s and Weber’s works seems to us of great relevance here: 1) an initiative or “empirical proposition” – label – can only become an institution if the actors using it grant it the role of an institution in their decisions and practices; 2) those practices have to be regular, and actors have to note that regularity and internalize the practices as “normal”; 3) the practices have to be adapted to the environment they are situated in. These three conditions seem to have been met in the case we are studying. It is reasonable to affirm that the EPODE label now regularly functions in many social arenas (though not all) as a normative and cognitive reference or touchstone, eliciting trust and commitment from a variety of actors, despite the fact that the institutionalization process is far from complete and is even regularly threatened. In a word, EPODE makes sense, in several ways, to the actors who use or refer to it. We have also stressed the importance in the institutionalization process of winning the solidarity of other labels and the support of united actors. Here again, EPODE seems to have been able to develop and combine the benefits of what Lucien Karpik defined as “impersonal judgment arrangements” (i.e., other labels) and “personalized trust arrangements” (here in the form of the mayors’ network). [65] The decisive contribution made to the institutionalization process by the institutional ties these entrepreneurs were able to develop patiently over time is clear: EPODE quickly found itself embedded in a vast fabric of institutions and support, which its promoters were then able to closely identify with their own activity; institutions and support that in turn furthered institutionalization of the EPODE program. [66] This strategy has recently succeeded anew, and that success is highly significant: on May 27, 2010, then health minister Roselyne Bachelot deemed it proper that all “EPODE cities” should be automatically stamped “PNNS cities”. [67] The EPODE label is therefore no longer sheltering behind those that manifest the legitimacy of the central public authority; it has become the equivalent of those labels. [68]

46But while this policy makes it possible to bring together a great number of actors in a collective project, to unite them behind a common banner, therefore helping to ensure the visibility of each and all, it cannot conceal the conflicts that have arisen regarding the very nature of the program: Can public health be promoted by private for-profit enterprises?

Tensions between public and private: a conflictual partnership

49The EPODE program is the result of two types of public-private partnership. First, as pointed out, the program involves mobilizing and coordinating the actions of public actors (teachers, public hospital nurses, youth counselors, etc.), community organizations and associations (athletic associations, parent-teacher associations) and in some cases private ones (school cafeteria suppliers, supermarkets, etc.). A private, for-profit agency – Agence Protéines – is active in performing this task. But the public-private partnership goes beyond a private actor’s involvement in coordinating public, associative, and private actors; it is also manifest in the way the entire operation is funded. Of the 12,000€ that the Agence Protéines annually bills the FLVS/EPODE association for setting up and coordinating the program in a single city, only 6,000€ are actually paid (as contributions) by the city or town government. The remaining 6,000€ (which covers the as-yet-unpaid services that Protéines bills the FLVS/ EPODE association) comes out of funds collected by the association from a club of industrial partners made up primarily of food firms; their annual contribution has been set at 100,000€. [73]

50As becomes clear from a cursory visit to the program’s internet site, where food company logos rub up against those of state ministries, this “public-private partnership” is considered by the promoters to be one of the four “pillars” of the program. In fact, having access to private industry manna is what makes it possible to lower the cost of the service for local governments and bring in greater resources than those that might be collected from public actors alone. Private-sector funding, then, may be one explanation of the program’s extremely quick progress throughout France. It would also explain the European Union’s interest in the program. The 2007 EU White Paper, A Strategy for Europe on Nutrition, Overweight and Obesity-related Health Issues, suggested modifying the “environment” that “shapes” “an individual’s knowledge, preferences and behaviours… related to lifestyle and eating habits” – the lead-in to the presentation of a program that member states but also “the food industry and civil society”, together with “actors at the local level such as schools and community organizations”, should participate in; a program aiming to better inform people in matters of diet – including through product labeling and advertising, to improve accessibility of a healthy diet, and to encourage physical activity. [74] EPODE promoters’ emphasis on the virtues of public-private partnership was without a doubt highly influential in winning European Commission recognition for the program.

51Meanwhile, that partnership has been at the root of most criticism of the program in France. During our interviews with representatives of national and regional public health departments, who at times see themselves as competing with EPODE in obesity prevention, the participation of private companies in a public health program was often presented as reason enough to denigrate the initiative. [75] And those representatives are particularly critical of the fact that the vast majority of preferred program partners are food industry or mass marketing corporations, the very actors assumed responsible (at least in part) for the increasing prevalence of overweight and obesity in the French population (in that they distribute products of “aberrant” nutritional quality, put pressure on supermarket prices and thus move industrial food producers to skimp on ingredient quality, etc.). For this varied set of actors, the EPODE enterprise is “necessarily” questionable because it obeys specific economic imperatives and thus cannot disinterestedly defend the common good – in this case, public health. Some INPES and DGS officials criticize the program for operating as a moral front for food industry participants, thus limiting these actors’ own capacity to negotiate with such companies to change their product composition (a reference to the negotiations around “voluntary commitment charters” mentioned above). [76]

52

“I’m extremely reserved [about the EPODE program]. We’ve been following the tobacco industry for a long time. It’s had a certain strategy for avoiding regulation and taxes by showing it’s doing prevention… But in terms of image, that strategy is not well regarded. Well, we know full well that the next wave in all of this is the food industry: tobacco and food are closely linked. We know that the food industry is trying to keep from being the next one on the individual’s list to have to pay out millions in compensation. Among the things they’ve done, there’s 1) setting up lobbies at the European Commission level to avoid regulation and taxes, 2) being on national committees, and 3) showing they’re doing prevention…: ‘look, we’ve got to show we’re doing prevention to get a good image and avoid paying taxes’. And the main strategy is to favor public-private alliances. That enables them to steer clear of constraint measures… If only EPODE had public interests it would be all right. Do you think that [name of a firm and program partner that produces chocolate] is there to get away from obesity? Oh no! They’re showing they’re good pupils.”

53This critique of public-private partnerships is to be found not only among EPODE “competitors” but also in the social and political spheres in which the program is trying, unsuccessfully for the moment, to put down roots.

54

“For the French, public is wonderful, private’s the devil. When I presented EPODE at the city hall of [name of a city in the north of France], [the town’s Socialist mayor] was in power. Well I’ve got a lot of measures going in the framework of a network for fighting severe obesity. We’ve got a lot of actions going on treating obesity in underprivileged districts. We organize actions in social centers [in that city]. So in the year and a half leading up to the municipal elections, [the mayor] was looking for ideas that she could put in her platform. So we’re sitting around the table, and I say, ‘On child obesity, in fact, the role of the city is really to try to promote activity, to arrange things so people can move around more, to include that aspect of things.’ And I describe a little the role of the city in EPODE. She says to me, ‘Oh, what you’re proposing is good! It’s an excellent idea.’ So I say, ‘Right, it’s the EPODE concept.’ She was sitting next to a city councilor and I see him whispering something in her ear and then, just like that, she moves on to something else. [Laughter]
– What do you think he whispered to her?
– ‘EPODE equals private, the [political] right, capital.’ [Laughter] Key words like that.”

55We see that, far from being consensual, public-private partnerships are a source of axiological conflict that is constantly threatening the durability and reach of the program. EPODE program heads like to defend the presumed benefits of public-private partnerships in the field of public health as a kind of normative proposition. They regularly shake their heads at how people in France are “incapable” of thinking that private enterprise could make positive contributions to realizing a common good like public health. And they actively militate to end demonization of such partnerships. However, their position-taking and activism have not sufficed to dissipate all criticism or neutralize occasional attacks against the program. To protect themselves and circumvent potential and real resistances, program promoters have engaged, as we have seen, in major “institutional work”, [77] work made up above all of obtaining legitimate labels and personalized support from mayors. But it is important to see how these efforts are further facilitated by a highly original type of organization, which we shall now describe.

Two-headed organization and a moral filter

56The organizational setup at the base of the EPODE program is extremely complex. The program is organized around three main entities: [78]

1. The FLVS association, a not-for-profit organization founded at the same time the original experiment in the two northern French cities got under way; the FLVS is the legal entity that sets up contracts with cities that decide to enroll in the EPODE program; it is in charge of collecting money from municipal authorities and private enterprise foundations;
2. The private social marketing agency, produced by the merging of three agencies (see above); it designs the social engineering necessary for getting the local cooperation dynamic going as well as “technical” tools for implementing prevention policies;
3. The “expert committee”, made up of five scientists – a sports medicine physician, an epidemiologist, a nutritionist, a psychologist, a pediatrician – and Dr Horet.

57

“It does have to be said that without Dr Horet and S. Distin, EPODE would not exist. It’s really the fusion of two personalities. S. Distin brought her experience as a head of business and her experience of social marketing, and J.-M. Horet his experience as a physician – that’s why it works. They telescoped. You can have a fine research project, but if you don’t have marketing and public relations, it doesn’t work. It’s a tandem pure and simple, and it’s what makes it possible to move forward and be a leader, to have clever things that really work.”

58That this complex two-headed organizational system, often quite opaque to the uninitiated, managed to develop and to maintain and refine itself over time is down to the fact that it fulfils a fundamental role in the relations that program promoters entertain with relevant segments of the environment they operate in. We hypothesize that the formal organization of the program operates like a “moral filter” that mitigates the tensions provoked by the private-public partnership. The arrangement stipulates that the FLVS association, not the Protéines private company, will sign contracts with mayors and collect industry “donations”. It is only later that it turns to the Protéines company, which then bills the association for its services. Not only does this type of organization formally separate local communities and other local actors from the Protéines private company and food industry actors, rendering the two sets of actors more or less impermeable to each other, [79] but it also symbolically effaces, more or less successfully, the business and market nature of the program itself. Lastly, it makes it possible to obtain funds from foundations and private companies, which thus partake, though indirectly (since the food and mass marketing industries are directly subsidizing only the FLVS association, not, of course, the Agence Protéines), in the activities and success of another private, for-profit company.

59

“People see Protéines as something like the devil. It’s the agency that does public relations for [name of a fast food company]. It’s a bit like the devil, whereas the association, if you will, is the showcase of respectability. My main role, if you will, is to provide respectability. But the role I would like to play is that it wouldn’t be just a showcase anymore.”

60The way the EPODE program is organized thus constitutes a moral filter in the sense that it is a necessary intersection point [80] for exchanges of financial and symbolic resources between the two network poles, public and private. Without the mediation provided by the EPODE program, those exchanges could not take place.

61

“But [our company] does it a lot [i.e., gets involved in actions to promote the sale of healthy food in stores]. Ok, so nutrition is not done exclusively by [EPODE]. Nutrition is not done only by EPODE. It is in fact a marketing agency that does it… So it’s complicated to handle – I say that in all honesty. [Our company] has its own public relations teams and already plenty of tools – I see them, there really are a lot of things. How to consume inexpensively but well, a balanced diet; recipe cards to make people want to prepare balanced meals – it’s a reality. But in spite of everything, [our company] does business. We can’t always link [our company] to [EPODE]… Because [our company] can’t… On the leaflets that [EPODE] writes, there can’t be one of [our company’s] products because it’s still [EPODE]. So in fact, we’re advertising for [EPODE]. We can’t put [our company name], or if we do, we put our little partner logo – that’s how it is.”

62In the end, the move to acquire “public-sector” labels (the European Commission, enrolling public-sector researchers, ministries, local communities) and the quite unique organizational setup these entrepreneurs have developed may be interpreted as different yet convergent strategies for effacing the doubly private-sector origin of the initiative. We would suggest that the mayors’ network is also part of this filtering arrangement, in that it constitutes an efficient committee for defending the program against critics. When loud, heavily publicized, discordant voices relay the criticism that “an increasing number of food industry companies [are] sponsoring the program”, as in French MP Valérie Boyer’s 2008 report, [81] these local elected officials speak up in unison on the national stage to try to dispel any suspicions that might be cast on the program.

63* * *

64Examining how France’s obesity prevention policy is being implemented through the prism of the action of a now central actor has brought to light some singular features.

65Alongside INPES’ national-level prevention messages and policy actions specific to the Direction Générale de la Santé at the national and regional levels, the local level now appears heavily implicated in obesity prevention policy. This observation contrasts with the conclusions of many analyses emphasizing the state’s and its regional representatives’ (possible) (re)investment of policies for monitoring and controlling the biological bodies of citizens. Cities and towns – municipalities – have only seldom been at the centre of analyses of public health policies in France, [82] though, paradoxically, they did play a crucial role in the management of epidemics up until the mid-twentieth century and it is at the municipal level that organizational and institutional innovations in social and health policy has been most likely to be developed, [83] including during the recent period. [84] Legislatively, the only official powers granted to cities and towns have been 1) to function as a kind of public health police, administratively and technically overseeing application of hygiene, safety and environmental protection regulations, and 2) (optionally) to administer social aid. The example of the combat against obesity shows that just when the state is ostentatiously reaffirming its central role and competence in public health policy, in practice the tasks involved in implementing public policy are being performed in many regions of France by the municipalities, which benefit in this from substantial support from a private actor that is both policy tool designer and co-coordinator of local public action. Stuck between a European Union echelon that wants to diffuse the same public policy model throughout its jurisdictional territory and a network of mayors ready to defend the legitimacy of their local initiatives, state services at the regional level seem to have quite limited ability to act in places where the EPODE program has been able to establish itself. Clearly if we want to grasp the meaning of transformations of state action in the area of public health it is not enough to examine formal changes in institutional and legal arrangements. It would be advisable instead to increase the number of case studies, a synthesis of which would then enable us to make more fully substantiated general observations. Only by doing so can we hope to fuel sounder thinking on the supposed “tutelary role” played by the state in the design and implementation of new “biopolicies” – a role whose existence has been proclaimed perhaps a little prematurely in some Anglo-Saxon literature, as Luc Berlivet has suggested. [85]

66Another interesting point in this case lies in the original way that tasks are distributed between public and private actors in the framework of public health policy.

67We have so far identified “classic” modes of privatizing public action – classic in that they have already been observed in and formulated for other fields or sectors, [86] specifically in research that makes the point that diagnosis is now being done, policy targets identified, strategies devised, instruments designed and policies evaluated by private actors using knowledge and technology initially designed in the framework of market activities. But the present study reveals the existence of other types of privatization, which to our knowledge are quite unprecedented. First, France’s public authorities cannot be said to have delegated the task of implementing specific actions and interventions here to private actors, in which case they would, according to Patrick Hassenteufel, [87] be regulated and supervised more or less closely by that same state, its departments or some of its “second-rank” institutions, as in the case of health agencies. [88] In the policy we have described, a different, partially [89] reversed variety of privatization may be observed, in which a private actor contributes decisively to the fundamental work of coordinating public-sector and community organization actors. Indeed, the “moral service implementers” that are part of the EPODE program are helping fulfill the properly political functions of bringing actors together, getting them to work together and initiating, running, and publicizing (cf. “labelization” and public relations strategies) actions that are ultimately carried out by public agents and community association partners.

68However, as we see it this case does not really involve privatization but a kind of hybridization of public and private actors. This hybridization is to be discerned first in the formal and informal organization of the program, which brings together in network fashion [90] a private public relations agency, a community association, [91] and local, national, and European Union authorities. Hybridization may also be discerned in the structure for funding the program: funding is ensured at once by cities, food industry companies and now by national government departments. [92] Hybridization can also be detected in the private operator’s moves to make itself “public”, mirroring the move to “privatize” public policy described above. Moves to win all sorts of public labels to the cause, the solemnly announced inclusion of state representatives (PNNS, Ministry of Health, Ministry of Food, Agriculture and Fishing) on two EPODE program committees, [93] and the move to equate a private label ( “EPODE city”) with a public label ( “PNNS city”) are all operations that work powerfully to blur the market and business nature of the initiative. Lastly, hybridization is observable in the nature of approaches to program implementation. The partially reversed privatization mentioned above may also be thought of as producing a coordination mode itself hybrid: while some operations (diagnosis, policy target identification, strategy development, policy instrument design, policy action assessment, etc.) are carried out almost exclusively by the private actor, coordination and the actual running of the public policy are carried out collectively. The institutional arrangement governing program implementation therefore cannot be described as a system that allows for cooperation/coordination between private structures and public institutions; rather, it is the result of a combined historical privatization-publicization process. It is therefore fundamentally hybrid. And that hybridization can ultimately be thought of as the product of a gradual, not fully teleological [94] strategy implemented by private entrepreneurs seeking to establish themselves and to act and continue acting at the junction between two heterogeneous worlds long disconnected from each other: public health and the market. [95]

69We wish to conclude by stressing that the operation that consists in entrusting to private companies the work of establishing a diagnosis, devising a purposeful strategy and developing public policy instruments is not without effect on what it means to do public health. As Elke Krahmann has shown, [96] delegating the performance of certain operations and activities to market actors amounts to more than a mere transfer or change of suppliers that has no effect on the substance of the good to be realized. We can therefore claim that the EPODE program exhibits some of the new forms of governmentality that other analyses, inspired by Michel Foucault’s work, have brought to light in the field of public health. [97] Prospering in a neoliberal context from which the welfare state would seem to be withdrawing, a context in which individual liberties and responsibilities (in that order) have been granted immense value, the fight against obesity, similar in this to other public health policies, aims primarily to change individual behaviors. Such public policies set out to help individuals – conceived as autonomous, capable of acting rationally (or becoming rational) – to become responsible, the understanding being that if only they are given the right information and references, they will, of their own volition, make choices that will be good for their health. [98] In so doing, this new type of public health policy fuels the development of what may be thought of as an “atomist political fiction”, [99] that of apprehending individuals, their lifestyles and social action outside of the socio-economic factors and collective interdependencies that shape and determine them. Our study helps refine these conclusions. Turning to a marketing company (one now doing “social marketing”) that is also a public relations company, a company that develops technologies of the self based on knowledge generated in the market sphere, not only helps reproduce public health policies that aim to act primarily on individual behaviors, but also helps diffuse a market-type anthropological conception of the “psychological” dynamics fueling those same individual behaviors. The targets of public policy have come to be thought of as consumers with lifestyles that have pernicious effects on their health (smoking, alcohol consumption, lack of physical exercise, poor diet, “anomie”, etc.) and that can be acted on, depending on the circumstances, through tools such as price, quality, information technologies and public relations. [100] The figure of the individual that suffuses the policy studied here is quite consistent with this understanding. That figure is not homo economicus, who acts entirely on the basis of rational calculation [101] and reacts “mechanically” to market signals. It is instead the consumer as shaped by “marketing”, [102] an individual who has to be convinced and won over by playing on such experiences as pleasure, desire, and self-esteem. [103] Thinking of public health policy targets as consumers to be seduced or won over – this is the remarkable consequence of certain moves to privatize public action [104] in a policy area – public health – that involves a good which we nonetheless stubbornly declare not to be a “commodity”.
 [105]