by Lucy Wadham
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France is extravagant when it comes to healthcare spending, which represents just under 10 per cent of her gross domestic product. In 2000 the World Health Organisation ranked her healthcare system first among the 191 member countries surveyed, stating that it provided ‘the best overall healthcare’. The health system in the US, which spends a higher portion of her GDP than any other country, ranked thirty-seventh. Britain, which spends 6 per cent of her GDP on the health service, ranked eighteenth.
The principle, ever since the French Public Health Insurance System was set up in 1945, has always been to provide unlimited access to care, patients being allowed to see as many physicians – including specialists for whom no referral is required – as often as they like. Compared to their British counterparts, French practitioners, even those working in the private sector, have always had a great deal of freedom over where they set up shop, how they function and what they prescribe, yet the bulk of their income is paid by public funds. As healthcare costs have continued to soar, this has become more and more of a concern. In recent years the French State has made a concerted effort to reduce costs – a delicate business since the lavish healthcare system is one of those ‘privileges for all’ that the French public is loath to relinquish.
On the surface, the system is both extravagant and chaotic. To qualify for health coverage you have to pay an insurance premium calculated as a percentage of your income. In addition to this, you pay fees for most things at the time of use, unless you earn below a certain income, in which case you are exempt. You then claim between 70 and 100 per cent of the fees back from your insurer. The result of this system is a very high standard of care available to everyone, without the waiting lists that characterise the NHS. Given that you can identify on your payslip how much you’re paying for your healthcare, you can then form an opinion about whether or not the cost is justified. The system is a kind of compromise between egalitarianism and liberalism. All citizens are said to be equal, but choice and competition are fiercely protected. The insurer makes no distinction between public and private hospitals (which provide about 35 per cent of beds), and patients have complete freedom of choice.
There are, however, drawbacks to this extremely lavish system. And they are not just the obvious, economic ones relating to the ever-growing deficit (to which most French people, incidentally, are impervious). As my own experience would teach me, the effects of this munificent, normative and interventionist system have deeper and more far-reaching consequences. My firstborn, Jack, who was delivered without incident by one of Professor Minkowski’s lovely midwives, would suffer from an early age as a result of this subtle but persistent normative pressure. From the moment we left the hospital, I would find myself constantly battling against professionals from all walks of French life who wished to intervene to help my son become … well … more like everyone else. It started with the paediatrician, who put a dissatisfied dot on the growth chart in the back of his carnet de santé and urged me to consider growth-hormone treatment, since it was plain to see, at the age of eighteen months, Jack was hors norme (outside the norm).
I refused the pituitary growth-hormone treatment that was available and being prescribed to children at the time, simply because I had been tiny for most of my childhood (my father had made me hang from door frames) and thought that Jack would probably have a late growth spurt as I had. As it turned out, the treatment being offered to us had a good chance of being contaminated with Creutzfeld-Jacob disease, and its administration to 1,500 children in France between February 1984 and February 1986 would become one of the biggest medical scandals of the decade; five people were arrested for not having taken the product out of circulation once it was known to be contaminated. The fifty deaths from this terrifying, debilitating disease which resulted from the French treatment programme represented more than half of all known cases worldwide and probably presaged many more.
The next battle on my son’s behalf would be with a nursery-school teacher who announced that at his age he should no longer be drawing hommes-têtards, ‘tadpole men’. By this she meant stick men without bodies but with arms and legs coming out of their heads. I listened in amazement as she told me that this was a sign of arrested development. She recommended he see the school psychiatrist. We were on the street when we had this conversation and I remember laughing out loud at her proposal.
‘A psychiatrist!’ I said. ‘He’s only three!’
‘Madame,’ she said gently. ‘The sooner we deal with the problem, the better.’
When it became clear that I wasn’t going to agree, her manner hardened.
‘I think you should know that your son tends to place himself in the role of the victim,’ she explained.
At the time I was aghast, but this kind of psychobabble would prove quite common among teachers, who used it to strike guilt and fear into the hearts of all parents whose children didn’t fit the mould. Fighting this tendency towards the conformism inherent in French society took up a great deal of my energy as a mother.
One battle, which I actually lost, stands in retrospect as a kind of metaphor for all the minor battles I fought on behalf of my children’s individuality. Once again, the fight was with a member of the medical profession and again it concerned my son and his so-called abnormality. At the age of fifteen, Jack had, like many of his contemporaries, a pronounced slouch, which has since disappeared. Seeing his posture one summer, Sandrine, the anaesthetist, kindly recommended a professor who had a stellar reputation and who would certainly be able to help.
The professor in question examined Jack and prescribed a corrective, fibreglass corset (I had hoped that a few t’ai chi lessons might do the trick) to be worn night and day for a minimum of two years. Jack was to wear this mortifying contraption until he was seventeen! I protested to Laurent that these were pivotal years for the development of his self-esteem. He would be starting to date girls. Wearing callipers on his chest wouldn’t exactly help him pull.
But the professor had put the fear of God into Laurent. If Jack didn’t wear the corset, he had warned, he would have to undergo drastic surgery, which would involve sawing through his spine at the neck. I gave in.
The corset was so constrictive that at first Jack couldn’t sleep and would tear it off in the middle of the night – the crowning metaphor for a system that had always tried to confine him. In the end I stopped making him wear it. Laurent and I were separated by that time and the corset stayed in the cupboard, only to be brought out when Jack saw the professor or his father. After two years of this charade, the doctor announced that the results had been extremely satisfactory and that, thanks to the corset, we had eluded the worst. I could tell from Jack’s expression that he was bursting to tell that smug little man that he had hardly ever worn it, but he stayed quiet.
8
Education
Freud, Maths and the Cult of Reason
When that nursery-school teacher had told me that my three-year-old had masochistic tendencies and invoked the psychiatrist, I was still sufficiently contaminated by my British scepticism to laugh. But as the years went by and I became more caught up in bourgeois Parisian society, the ubiquity of psychoanalytic theory began to work its spell on me. Many of my husband’s friends were in analysis – mostly as an intellectual pastime – and would discuss their treatment at dinner parties, but always in the most abstract of terms. The conversation would never take on a personal note, as it would have on the Upper West Side of Manhattan. It would remain beautifully theoretical, like Bettelheim or Barthes or Derrida. For in this Catholic culture, what was interesting was not the personal or the symptomatic, but the collective and the universal.
Since May 1968, psychoanalysis – entirely dominated in France by Freudian theory – has exerted a considerable influence on all of society. Along with Marx, Freud was the emblematic figure of the ’68 barricades. In the search for a viable alternative to Catholic values – one that would correspond to the deepest natu
re of the French people, with their obsession for order, hierarchy but, above all, gratification – Freudian theory, with its emphasis on the libido, was a perfect solution. The media – both low-and-highbrow – have always spread the word, often wheeling out Freudians as experts on all aspects of society from the most banal to the most serious. Pioneered by Elle magazine, all women’s magazines now have their resident Freudian analyst who will answer all your problems from sporadic orgasm to coping with your child to dealing with your lover. The psychiatrist affiliated to your child’s school or university is invariably a Freudian, as is the hawk-eyed therapist attached to the local kindergarten who will keep watch over your toddler’s drawings.
The theory of the unconscious, one of the most influential of the twentieth century, captured the French imagination in particular, due to the beauty of its all-encompassing nature. Freud’s system never claimed to be scientific and as such cannot really be refuted. It is, as his disciples tend to show, a matter of faith. Like the Catholic Church before it, the Société Psychanalytique de Paris (SPP, the union of Freudian analysts in France) requires obedience as well as respect for tradition. It does not accept refutation or change. It is probably no coincidence that recent developments in psychotherapeutic techniques, which began by contesting Freudian hegemony, are thriving in Protestant societies and struggling in Catholic ones. As W. H. Auden put it in his essay on the Protestant mystics, if the Catholic approach to faith can be summed up by the words ‘We believe still’, Protestantism will always be a matter of ‘I believe again.’
Because of the dominance of Freudian theory, the revolution in therapeutic practices brought by more recent cognitive and behavioural therapies is decried in France, where they are seen as prosaic, limiting and quintessentially Anglo-Saxon. The pragmatic approach to mental illness, which tends towards the search for an alleviation of symptoms, does not seem to interest the French psychoanalytic community. In 2004 the SPP managed to put pressure on the French government to suppress a report by the state research institute, INSERM, which revealed the relative success of cognitive and behavioural therapies in curing mental illness.
As one Freudian analyst, Jacques-Alain Miller, a member of the SPP, explained: ‘The patient arrives with symptoms and he finds throughout the course of the therapy that they are simply a screen onto which he is projecting his internal strife. Psychoanalysis doesn’t mend his past but enables him to accept it. Because psychoanalysis is not a medical procedure, it is difficult to evaluate its success.’
To practitioners like Miller, the cure is not the point. For the small handful of pioneers attempting to spread cognitive, behavioural and other ‘problem-solving’ therapies in France, this kind of highly theoretical approach is a form of irresponsibility. For them, the role of the practitioner is not to enable the patient to accept his or her suffering but to work for a cure and provide some kind of accountability to the patient in the process. The idea of accountability, of course, infers an equal relationship between therapist and patient, who becomes, in some sense, a client receiving a service. For the analysts of the SPP, this contractual approach not only belittles the almost mystical experience of the psychoanalytic process but also diminishes the high-priestly status of the analyst.
Auden’s observation of Protestant culture, which champions the I and the Now over the We and the Then of Catholic cultures, is nowhere more relevant than in France, where an enduring taste for collective worship is expressed in contemporary society through a passion for the Common Cause. French people are never happier than when their individuality is being dissolved in a movement, a street demonstration or a beautiful, all-embracing theory like that of Sigmund Freud.
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As I would soon discover, the greatest rampart against individuality in French society is L’Ecole Publique (State school), and the most formidable guardians of the norm are the teachers therein. But I should not, as the French say, ‘spit in the soup’, by which I mean I should be grateful for what I have. When it comes to the education that my children have received at the hands of the French State, I would not, in retrospect, exchange it for the education that is available in Britain to my friends’ children. My children were both, for all my elitist schooling, better educated than I was. They can do maths, for a start. They have a chronological and comprehensive sense of history, while I have a patchy one (confined mostly to Tudor Britain, Gladstone’s army reforms and the Second World War). They know the teachings of Western civilisation’s key philosophers, from Plato to Descartes to Sartre. They have a decent understanding of how the immune system works and what a gene is, and they have a deep and extensive knowledge of French literature.
The reason for this is that from the age of six, they were burdened with unbelievable amounts of homework and saddled with all the things that modern British pedagogy decries: rote-learning, dictation, relentless competition and exams. They sometimes seemed to me like rats in a cage. There was hardly any sport or art and no drama. If they wanted to practise a sport, they could do so in their precious free time, on Wednesday afternoons, and if they did, it would tend to be in an atmosphere of fierce competition.
Before the French State took over the business of educating its children, schools in France were in the hands of the Church and, in particular, the Jesuits. St Ignatius de Loyola, the founder of the Jesuit order, believed in obedience as the key virtue and ordered total submission to the will of one’s superiors. This hierarchical vision of education was championed by Napoleon, who had himself benefited from the rigours of Jesuit teaching methods and who set up a system of lycées that he dreamed would be run by ‘Jesuits of the State’. It did not take me long to realise that Napoleon’s dream had come true. For the teaching staff, my children were vessels to be filled. Their capacity to receive information was the sole measure of their success. No other criteria – not creativity, or imagination, or physical prowess – were used to assess their quality as human beings.
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Nowhere is the French obsession for nobility more clearly reflected than in the education system, which is, despite its egalitarian philosophy, extremely hierarchical. The teaching body is divided between those who have passed the vertiginously difficult agrégation and are forever glorified in the eyes of society (no matter how lacking they may be in pedagogic skills) and those who have taken the more practical teacher-training programme, the CAPES (Certificat d’Aptitude au Professorat de l’Enseignement du Second Degré), and who are perceived as second-rate and treated as such in their careers. My son Jack, a survivor of and convert to the French education system, once tried to explain to me his urgent desire to sit the agrégation.
‘If you pass it, Mum, and most people have to sit the exam at least three times before they do … But if you pass it, you never have to prove yourself again. You become an intellectual god.’
Beyond my surprise that a nineteen-year-old should aspire to such stasis was a sense of despair that my own child should have been so contaminated by France’s obsession for intellectual status.
Behind Jack’s explanation lies a shocking reality: that you can pass an exam in your early twenties, be shrouded in glory and never, ever be fired. In most societies a degree or diploma is a starting block after which the individual must prove his or her professional worth. In France the right academic qualification will set you up until retirement. French lycées are filled with these agrégés, literally ‘whole’ beings, dangerously imbued with their own sense of entitlement. These are the mandarins of French academia who, in the name of excellence, block any reform that might represent an attack on their status.
The student body is also divided: there are more or less noble paths – Academic versus Technological – and more or less noble disciplines – Maths and Sciences carry considerably more value than the Arts. Maths – in obedience to France’s most influential philosopher, René Descartes – is the final arbiter of intelligence. But above all, Maths is seen as the great leveller. There is no need to come from a
cultivated background to have an affinity for Maths. If you are blessed with a gift for numbers and at the age of sixteen choose the most prestigious of all the baccalaureate options, in which Maths carries the most weight, you are destined for greatness. Napoleon, who spoke poor, heavily accented French, excelled in Maths and was consequently able to succeed. Maths in France is the contemporary Latin. My daughter, who inherited her father’s Maths brain, on entering the sixth form took it as the principal subject of her baccalaureate. She noted that her teacher strove to teach it in the most abstract way possible, keeping it as firmly divorced from the uses of everyday life as it could possibly be.
This attachment to an archaic and non-pragmatic pedagogy is compounded by a deep and lasting problem of denial. The republican obsession with equality means that no one – neither the politicians attempting educational reform, nor the teaching body itself – will ever admit to their underlying belief that some are more noble than others. This means that it is utterly impossible ever to tackle the reality of a diverse student population, or ever properly address the needs of those children in difficulty, especially if they happen to belong to an ethnic minority. Talk to a French secondary-school teacher, an agrégé employed by the Ministry of Education for life, and you will quickly hit the bedrock of their prejudice. Their huge self-importance, coupled with their egalitarian ideology, makes them despise notions like ethnicity, diversity or special needs. Perhaps part of the reason for this is that they lack the human gifts required for nurturing these children.