Yet in recent days, France’s failure to organize any credible COVID-19 vaccine program has exposed deep flaws in both its health and political systems—ones that could prolong the pandemic, cause thousands of unnecessary deaths, and threaten the reelection chances of President Emmanuel Macron in just over a year.

Consider the evidence: Less than two weeks after coronavirus vaccine campaigns began rolling out across the world, about 4.2 million Americans and about 4.5 million Chinese have so far been vaccinated. A full quarter of Israel’s population has already been vaccinated. Britain, with the same population as France, has vaccinated more than 944,000 people. And Germany has jabbed the arms of about 239,000 people, out of a population of 83 million.

Now take France: As of Monday morning, 515 people in the country had received their first shot of the two-dose Pfizer-BioNTech vaccine; that figure is not missing any digits. Under mounting pressure to explain his performance, French Health Minister Olivier Véran said late afternoon Monday that “several thousand people” were immunized during the day.

Still, that vague figure lags drastically far behind other rich countries—and for several reasons.

In a decision for which the government is now paying a high price, officials decided months ago that it would administer the COVID-19 vaccinations only through the country’s 60,000 or so general practitioners. That is unlike the yearly flu shot, for example, which is given at thousands of neighborhood pharmacies or by regular nurses. Coronavirus vaccines are not mandatory, far different from 11 diseases like mumps and measles, which are obligatory for children to attend school.

“There is a very, very cautious approach not to oblige people to get vaccinated,” says Emmanuel Rivière, director general in France of the polling agency Kantar Public. Behind the government’s reasoning is the deep reluctance among millions of French to accept the COVID-19 vaccine, partly reflecting a general distrust of government, as well as a distrust of profit-making Big Pharma.

Vaccine suspicions

About four in 10 French are highly reluctant to be vaccinated against the coronavirus—a far higher proportion than that of almost any Western country, according to an Ipsos poll of attitudes across several countries. Kantar found in November that the widespread skepticism stems partly from a deep distrust of government, as well as the lightning speed at which the coronavirus vaccine was developed. “People will accept their kids getting shots for diseases,” Rivière says. “But they say it takes at least 10 years to develop a vaccine.”

The COVID-19 vaccine rollout has shaved years off the process thanks in part to an unprecedented global collaboration between drugmakers and researchers, plus the adoption of new innovative drug development techniques. It helps of course that regulators are under tremendous pressure to review and approve the clinical trial data as soon as possible.

Nonetheless, doubts linger in France. And faced with that reality, French officials have opted to tread carefully—so carefully, in fact, that the vaccine campaign virtually stalled at launch.

One problem, for example, is a government rule requiring each person to consult a doctor before being vaccinated against COVID-19, to discuss possible health risks, and then to sign a written consent form. Those measures have helped slow down the effort to roll out mass vaccinations in senior-citizen nursing homes, which have seen large numbers of COVID-19 deaths. Many residents deemed to be unable to make independent choices require consent from relatives.

To many, the rules seem to be absurd regulatory overreach. France has had a higher COVID-19 death rate than the U.S.: More than 65,000 French have died of the virus, among a population that is one-fifth that of the U.S. Some believe the slow vaccine rollout might cause needless deaths. “There are large costs in this delay in terms of lives lost,” says French economist Antoine Lévy, who estimates that the government, by not investing heavily in mass vaccinations, might pay a far higher economic price if it fails to end its virus spread. “We have been forced to endure a lot of constraints with the lockdowns, and the government has had to be authoritarian,” he says. “But it also has to be efficient.”

Previous stumbles

The lack of efficiency has highlighted far broader problems with France’s vaunted health care system, which operates on a centralized, top-down structure. Those problems arose early in the pandemic and have greatly complicated the vaccine rollout. As the COVID-19 crisis emerged last February, French officials—including Macron—told the country that face masks would make little difference in containing the virus. It later emerged that France had virtually no national stockpile of masks. Similarly, officials insisted that only those with active COVID-19 symptoms needed to be tested. In reality, the country had a dramatic shortage of tests, until well into April.

“People got the impression that the government simply invented reality,” says Marie-Estelle Dupont, a Paris psychologist and author on issues related to French attitudes. “There was a lot of confusion about masks and then tests. Now people do not trust the government anymore.”

Winning back that trust will take major efforts—but would be crucial in stemming the pandemic.

In a major article in Le Figaro newspaper last Friday, Lévy, the economist, suggested the government scrap the pre-vaccination consent rules and allow all health professionals, including army medics, to immunize people en masse. The article, which he says simply collated other people’s ideas, has attracted intense commentary on TV networks and among government officials. That has amazed Lévy.

“It’s very worrying that these ideas seem to be novel among the French public,” he says, “We should have been debating this back in April. We are in Kafka territory here.”