Civil disobedience as a strategy for public legitimisation of a social problem
As noted above, the experimental squat was founded in an act of civil disobedience, namely the illegal occupation of an abandoned building, to which members of an activist collective then provided services. In 2007–2008, the squat took in some 40 individuals to whom a local street outreach team had been providing support and who met the admission criteria of having a severe mental disorder, having had ineffective and/or unsatisfactory contact with the health system, and living on the street. The squat became a community living space, with cultural and artistic activities. The Collective, however, tended to play down its existence in the media and with neighbours.
The 2008 Activity Report described the first 40 individuals quantitatively:
“[…] among 40 persons who spent at least one night at the squat within the past year, 22 (55%) came directly from the streets, 10 (25%) were referred by [organisational] partners, and 5 (12.5%) came from psychiatric hospitals. In terms of prevalence of psychiatric disorders, 16 (40%) had schizophrenia (of whom 65% had a comorbid addiction), 33% had a mood disorder (91% with comorbid addiction), 6 (15%) had three or more psychiatric diagnoses, 29 (72.5%) had previously consulted psychiatrists, 30 (75%) had undergone psychotherapy, 28 (70%) had received psychiatric medication, 38 (95%) health education and 57% had consulted a specialty service within a hospital… Among these, over the preceding year, 20% left the streets permanently and became engaged in a process of recovery and acquiring social skills.”
Within months of the experimental squat’s founding, members of the Collective connected up with heads of the city’s public health services, with the aim of negotiating the legalisation of the squat. A contextual condition is important to understanding how legalisation was made possible. Although in France, health services are financed by the central government, the origins of the Marseille public health service are particular [
26]. The municipal public health service was headed by two individuals who saw its work as the continuation of the 1990s harm reduction movement, but applied to the poverty and mental health fields of the present. Their understanding of the problems and proposed alternatives was similar to that of the Collective. In particular, the presence of a former homeless person in the Collective, the value attributed to notions such as self-help and empowerment, and the use of civil disobedience as a means of claiming fundamental human rights were perceived as qualities associated with the ideological heritage of the harm reduction model. Thanks to negotiations led by the two Marseille municipal public health administrators, the Collective and a university psychiatry professor, the Mayor legalised the squat.
One of the administrators later explained his support for the legalisation in these terms:
“The history of AIDS and addiction is such that we were intensely engaged with the question of harm reduction, and that means several things: the fact of having had to build something with others, of reaching out to the most marginalised and working on social cohesion and marginality through health and social approaches, and also having to work in a very experimental mode rather than with already established models. This background really helped us understand how to approach the mental health field, and it soon became obvious that the two approaches had many issues – and people, too – in common.”
On a practical level, the municipal public health service went on to play the role of mediator between the Collective and the municipal housing office, but also with the national government health services.
That the squat was an activist experience rooted in civil disobedience posed a problem in its evaluation. From the beginning, the squat’s supporters, namely clinicians, social workers, homeless people and junior researchers, used evaluation as a strategic means of producing evidence to support their demands. Although their principle objective was to bring about the recognition of the right to housing and treatment of homeless persons as a public problem requiring political solutions, they rallied around the immediate economic cost-benefit of the experimental squat, arguing that it avoided hospitalisation in some cases and reduced the number hospital days in others.
However, the squat supporters shared other, more operational goals. The first was to argue convincingly that the habitat they proposed facilitated access to effective care for people who were homeless and living with severe psychiatric disorders. A second, broader objective was to propose an experimental alternative to the then public and state-funded services and facilities for homelessness and for mental illness throughout France. The activists criticised what they saw as institutional paternalism and infantilisation, seeking instead the recognition of the competencies and strengths of individuals who had experienced homelessness, mental illness and their consequences – strengths which they could use and build on, and which until then had been ignored by the existing aid system [
23]. Hence, the experimental squat was laying claim to the status of a social laboratory where people could search for solutions by and for themselves [
21]. In interviews, it becomes clear that, without the squat as a forerunner, the
Un Chez Soi d’Abord programme would not have developed in France. Yet, from the viewpoint of the proponents of this first phase, it would be inaccurate to posit this sequence of events as initiating an evidence-based policy. Rather, it involved the political recognition of a public problem, one that sought to integrate and assert a plurality of competencies, especially of the people who were most directly affected. As one of the squat’s first residents recalled: “
In June of 2004, I met the homeless mission of Doctors of the World and the psychiatrist told me what he had just done at Yale, where he was working with a mixed team – health professionals and psychiatric users who had lived on the streets – and I was one of the first. He told me: ‘you have real competencies’.”
In the end, the
Un Chez Soi d’Abord programme maintained two characteristic traits of the experimental squat that preceded it. The first was the strategy of approaching public problems through the theme of health, and particularly mental health. The second concerned the need to take the evaluation of its activities seriously, namely, of the ‘civil disobedience’ alternative in the French context, where the psychiatric field has been historically reluctant to accept evaluation [
27].
The transition between these two moments – local experimentation and its national uptake – poses two corollary questions regarding the relationship between scientific expertise and politics, and regarding the part played by the users themselves in the intervention process, whether in the context of the social experiment or of the scientific experimental model that followed. Yet, as we will now see, while bottom-up knowledge produced from this local experiment paved the way for broader experimentation, in the long run, it was the top-down work of actors from the central government administrations which led to the implementation of a nationwide RCT.
Furnishing evidence: a political strategy of the State
Even if social movements in health sometimes achieve their goals by judiciously exploiting international scientific discourse [
28], scientific arguments alone cannot make social problems visible [
29], let alone influence public policy concerning the social problems at hand [
3]; ‘extra-scientific’ factors need to be taken into account [
30]. Immediate and broader structural contexts are required to place scientific arguments on a political agenda.
In the present case, during the almost 2-year initial phase, supporters of
Un Chez Soi d’Abord received little support from central government state agents. Few actors from the relevant ministries became involved. Nevertheless, those who did succeeded in supporting the experimental project by using translation strategies aimed at ‘convincing the unconvinced’, particularly those who controlled the financing of this experimental intervention and its evaluation. By translation, we refer to the ways in which an idea, object, action or interaction is contested and reformulated as it is detached from one sphere of action and reformulated and adapted to another.
1
Translation was by no means a simple process, as can be seen in the lively debates that ensued at national government level. Before funding came through, the commitments made by the then Minister of Health had provoked a series of exchanges at the level of central government. The construction of the Un Chez Soi d’Abord experiment and its funding resulted from intense negotiations within the state apparatus, during and after the 2010 Report on homelessness and health, raising questions such as under which central government branch the programme fell and who could legitimately fund it. As one ministry official noted.
“Madame Y, in the Sécurité Sociale [Public Health Insurance] branch, doesn’t understand that they don’t only fund healthcare. We don’t have the same cultural values as the people in the Health Department. For them, [the RCT] had to do with the Psychiatry and Poverty Outreach Teams. We said ‘no: it’s socio-medical, it’s pluridisciplinary, and you have to take the social component into account’. For the different administrations, the issue was: ‘Is this just an extension of the Psychiatry and Poverty Outreach Teams?’ With the Health and the Sécurité Sociale departments, it was: ‘Is this worth putting money into?’.”
Within each of these administrations, actors who favoured the project took ownership of the research dimension and exploited it to gain influence and legitimacy within their own departments. They called on the Institut de Recherche en Santé Publique (the IRESP, or Public Health Research Institute), an intergovernmental, cross-institute research ‘meta-body’, to strengthen the scientific legitimacy of the project, and used this organisation to rally their more reticent colleagues to the idea of funding an evaluation. A scientific argument could compensate for prioritising a specific group, namely homeless persons with psychiatric disorders. Within the falling logic of the rationalisation of budgetary decisions and of the French universalist culture, numerous civil servants and central government officials gave low priority, thus benefitting a narrow target population. As detractors of the Un Chez Soi d’Abord programme, they used two types of arguments to defend their position. First, they stated that the programme did not fall within the scope of their jurisdiction (“It’s is social welfare, whereas we work on healthcare and public health”; “It’s healthcare, but our job has to do with homelessness”). The coordination of partners from different fields was even more complex when those concerned with welfare did not even consider the target population to be a priority: “We have poor people who aren’t crazy!”
Thus, several factors affected the position of state officials vis-à-vis the project, such as their department’s general culture, sub-cultures within each department, and their own professional trajectories. One civil servant, for example, suggested that the scientific aspect of Un Chez Soi d’Abord was made more strategic because she could relate it to the ‘field epidemiology’ she had conducted during her career: “I was game from the very start because it was a unique approach and off the beaten path, and we had already tried so many things that didn’t work! But, then, to get the Department involved, you had to use a research strategy! … That was a time when the administrators were very resistant, which gave us the idea of funding research, especially the qualitative aspect … We knew it was going to be tough [to support the programme], I mean, just think: crazy homeless alcoholics, and we were giving them money!”
Another official, who had worked in the national programmes on AIDS, prisons, mental health and emergency care recalled enthusiasm for experimentality:
“What I thought was unique and exciting about it was the notion of recovery, of harm reduction. We were failing with these groups. What I like is the innovative aspect. It’s interesting to accompany change, to see how the Americans had done it … […] Madame X, over in the social welfare administration, her position was, ‘let’s do it, we’ll find the money, this is activism’.”
In the social welfare administration, as had happened with Marseille public health officials, what limited support existed was motivated by the ideological kinship between Un Chez Soi d’Abord and harm reduction: “I’m originally a toxicologist. In the 1990s, I tackled HIV […]. Anyway, you have to take risks. ‘You take a good psychiatric patient, you put him in normal housing and if you do the right follow-up, he’ll lead a normal life?’ People said, ‘You’re nuts! You won’t get any results and it’s going to cost a fortune’.”
These ‘rationally argued alliances’ developed more or less formally among actors from various backgrounds. The determining coalescing factor was a shared common belief that what was at stake in
Un Chez Soi d’Abord were inequalities in health and access to healthcare. The then Minister of Health, who shared this conviction, summed up her political orientation in these terms:
“The issue of social inequalities in health can only put a strain on a Health Minister. The health system creates enormous neglect, which can start to look like horrific mass relegation … I think the tremendous progress we’ve made in life expectancy and good health has to do, above all, with things like good nutrition, appropriate housing, education, and so forth. In short, the social perspective on health allows for huge advances, which are incredible reservoirs for improving health.”
The support is more notable given the particular cultures of the different ministerial departments. The officials most receptive to the development of the Un Chez Soi d’Abord type RCT (who also happened to belong to those departments with the least funding discretion) tended to prefer qualitative evaluation. Yet, they valued the experimental and evidence-driven aspect of Un Chez Soi d’Abord and thought they could justify it as an exception to the institutional culture of the central administration missions. Similarly, the supporters of the Marseille squat proposed an RCT methodology because they thought it could provide a “high standard of proof” that would reassure the funders.
Contacts members of the squat had with actors in the Welfare Ministry could also be considered a guarantee of sorts:
“When we do research, experimentation, I advocate randomisation. Either you do research or you don’t. For me, randomisation was important. The more off-the-wall the hypothesis, the more you need scientific rigor. There is no more neutral approach to programme evaluation than randomisation […]. Politicians and administrators want numbers. For them, qualitative data is just verbiage.”
Within the cabinet of the Health Minister, the experimental and scientific nature of the project was, in retrospect, perceived as a major source of legitimacy, as one of her advisors explained:
“Everything about the project was new. It was designed as an experiment, which was quite new for France, and that was good. What I liked was the really scientific aspect, with international studies, statistics. There was a whole research team behind them, it was well thought out, with lots of statistical tools.”
In fact, the Minister, who had a scientific background, was explicit: “
A randomised trial? It’s the only way to advance in this field. The amount of amateurism and the unreliable nature of much health research is obvious.”
The agency of minor actors
The funding basis of the intervention was established after several months of discussion. A public health research laboratory in Marseille, already convinced of the scientific value of an RCT, was mandated responsibility for the evaluation, while that for steering the project was given to a new, inter-ministerial body, with the intent of breaking down barriers in public policy aimed at solving housing problems.
The decision to experiment with another public action model resulted from the coalition of certain minor players in the field of intervention, who shared common values and deployed a successful strategy for leveraging funds. These actors shared the belief that policies to counter exclusion had failed. They shared a culture of harm reduction and experimentation, a public health culture, and a culture that values user participation. In
Un Chez Soi d’Abord, they saw an opportunity to act upon the social determinants of health, recognise the value of experience-based knowledge and continue supporting the harm reduction movement. Key figures in the central government administrative services who shared these convictions opened the way to experimentation through a ‘top-down’ study that valued a randomised, scientific design with a national scope, because they grasped the issues at stake in terms of transforming public policy. Specifically, they referred to the rise of the epidemiological paradigm in public action, beginning in the 1990s with the AIDS epidemic in France. They had contributed to this model, for which scientific evaluation had provided a privileged means of ex ante evaluation of legislative proposals for social policy [
31].
In addition, the coalition deployed a strategy that favoured the possibility of reducing health costs for the state by reducing the length of hospital stays, and this in a context where budgetary choices were being increasingly rationalised.
Agency, structures of political opportunity and the transfer of knowledge
The
Un Chez Soi d’Abord programme took the specific shape of a randomised trial constituting the first step towards an evidence-based policy. As we have seen, the introduction in the health and social field of an RCT that was national in scope resulted from a process of translation, itself the result of an alliance between proponents of a social movement and minor actors in national government services. During the different stages of the experimental squat and the genesis of the
Un Chez Soi d’Abord project, however, certain protagonists’ capacity for agency seems to have been more effective than structures of political opportunity [
14]. On the one hand, two windows of opportunity allowed actors to further their cause. Municipal elections in Marseille provided a propitious moment to seek legalisation of the experimental squat, while nationally, the presidential campaign similarly enabled government supporters and others to push for
Un Chez Soi d’Abord. On the other hand, the political environment in which the social movement against homelessness found itself is insufficient for grasping either the successful transformation of an initially local experiment into a national policy of experimentation or the choice of a RCT as the experiment to undertake at the national level.
This process, however, also led to a transformation in the status of the cause being defended. It is striking to note the manner in which players were able to form a coalition both locally and within government administrations and to exploit a representation of their cause as a viable technical solution validated by scientific expertise (i.e. being housed improves health and access to care), when other players would have gladly given precedence to the political argument (i.e. everyone has a right to housing and to healthcare). The cause originally defended through the experimental squat was so transformed, or ‘lost’, in translation as to be unrecognisable to those who had been present on the ground since the squat’s origins. As actors who advocated horizontal decision-making, many could no longer relate to the inter-ministerial project, vertically steered by the state and financed primarily with health funds. Neither could they recognise their ethical position in the RCT evaluation, which randomly assigned participants in the
Un Chez Soi d’Abord study to experimental (i.e. housing first, with no treatment criteria) and control groups (i.e. housing and treatment ‘as usual’). While local activists had been present when the various parties were brought together, some reluctantly gave in to the randomisation scheme while others flatly rejected it:
“I disapprove of the idea of random selection. If you interview me, you will hear me yell and scream. It is absolutely stupid to say, ‘we’re going test a control group and another group and we’re going to see who comes out best’. So you cut off a rat’s paws and compare it with a rat that has paws. You don’t need to do an experiment to figure out who will come out best!”
“Say I have a patient. He’s going to die in the streets, from AIDS, and he is in the control group. That really gets to me! … Do you really need a control group to show that when someone doesn’t have housing …?”
To be persuasive, Un Chez Soi d’Abord proponents chose to promote the evaluation through scientific expertise of its potential economic viability rather than the right to housing or the use of knowledge based on the experience of persons with histories of homelessness and psychiatric disorders. The transformation of the original experiment, a therapeutic squat, from a participatory object into a scientific object succeeded in terms of the decision to experiment with a new way of supporting homeless persons with severe psychiatric disorders, but it failed in relation to the principle of participation. This happened for several reasons, including that the time-frame of the political agenda did not permit the elaboration of a participatory type of study, and that the minority coalition decided to focus on the scientific argument that seemed the most effective for persuading the wariest administration and at securing funding corresponding to the nature of the experiment (‘scientific’ funds). Finally, scientific backing was also a strategy for shifting the balance of power away from the ministries by mandating the RCT leadership to a new inter-ministerial actor, the Délégation Interministérielle à l’Hébergement et à l’Accès au Logement (Interministerial Delegation for Access to Shelter and Housing), which assures the coordination of national services for access to housing for the homeless. The latter sought institutional and political legitimacy from the IRESP, which was charged with scientific responsibility for the project.