Egalite For Bebe? France's Free Child Clinics At Risk

Originally published on September 16, 2011 5:29 pm

Imagine if in nearly every town in America, there was a public health clinic that offered completely free services for parents and young kids. Whether you were rich or poor, you could drop in without an appointment for a checkup, vaccination or to ask the questions that plague new parents. The clinics would focus entirely on keeping you and your children healthy.

In France, they've had such a program for more than six decades, and it's been remarkably successful at helping French children get off to a good start. But now the system is being threatened by economic woes and immigration pressures.

Teaching Moms To Make Nutritious Meals

French children are raised to treasure fresh bread, strong cheese and their carnet de sante, a health diary. Since 1945, parents and doctors have dutifully charted the growth of les enfants in these little books.

In the waiting room at a preventive health clinic in the poor Parisian suburb of Corbeil, carnet de santes peek out of purses and diaper bags. These health diaries, and the public clinics, aptly embody France's aspirations of solidarity — the "Liberte – Egalite – Fraternite" emblazoned on town halls, monuments and the carnet de sante.

And, of course, one way a nation stays healthy is through good nutrition.

Isabelle Chakr, a pediatric nurse at the clinic in Corbeil, perches on a toddler-size chair leading a group of mothers in a game called Bebe Nut. She asks each mom to pick a card out of a deck: One has a picture of soda; others, fruit or nuts. Then she asks: At what age can a child start eating it? Soda is no good for young kids, the women say. But then someone draws the fish, and a lively debate begins about how best to prepare it.

This isn't an idle question. One woman is from Mali, her arms covered in elaborate red tattoos; another is a fully veiled Muslim woman from Turkey, and the food here, especially frozen fish, is strange to them. By encouraging these discussions in the more than 5,400 preventive health clinics all over France, health officials say these women are more likely to make nutritious meals for their children.

When the French maternal and child protection system, called the PMI, began in November of 1945, there wasn't much thought about frozen fish.

"It was right after the war, so there was high child mortality. There were malnutrition problems," says Dr. Brigitte Lefeuvre, who is in charge of children's preventive health at the French health ministry.

Today, she says the PMI clinics are still open to pregnant women and children up to age 6, even those in the country illegally. And unlike at private doctors' offices, there are no out-of-pocket costs.

"Every child, even the richest, has this right," she says. "This is absolutely not based on charity."

But the clinics are doing much more now than they did 65 years ago. An army of public-health nurses help mothers who feel isolated or depressed. They try to prevent and detect childhood disabilities and mental health problems, and teach positive parent-child interactions.

"All those health problems are going to cost money or are going to make those people less able to deal with work, for instance, or less healthy, and should be addressed when they are younger," Lefeuvre says.

The focus on keeping pregnant women and children healthy has paid off, she says. France has one of the lowest infant mortality rates in the world. Obesity and diabetes among children remain uncommon. And while the PMI is a small part of the country's broader universal health system, officials say having clinics focused solely on preventive care for children has an outsized payoff.

Clinics In Danger

Back at the clinic in Corbeil, after the game of Bebe Nut finishes up, some of the mothers discuss why they come to the clinic instead of using their health insurance to see private doctors for routine checkups.

Fatoumata Traore, a Senegalese immigrant, lives with her four children in the decaying public housing projects just outside the clinic doors. She says she prefers to come here because she doesn't need to pay. There are many professionals in the same place, so she can see a nurse, then a doctor, she says. She also says she thinks the doctors and nurses have more time to answer questions.

This kind of unfettered access, though, is now in danger of being eroded. France's economy is sputtering along, unemployment remains high, and local French authorities are struggling to maintain services.

Dr. Claudette Buisson oversees the 60 PMI centers in Essonne — a large area south of Paris with middle-class suburbs and poor outposts like Corbeil. She says that over the past year, she's lost a third of her budget, in favor of other local necessities like schools and roads. She's closed two clinics and is considering closing more.

"Prevention is like, how do you say? Cleaning house," she says. "You can see it when you don't do it. And I think that when they will see that we can't do prevention anymore, you will see that prevention was useful."

The French have long prided themselves on narrowing the gap between health and wealth. As recently as the late 1990s, researchers found no correlation between infant mortality and income in Paris. That's unheard of in places like New York City, where infant mortality was three times as high in central Harlem than on the tony Upper East Side.

But Christophe Langlongue, who monitors France's health systems for the Office of the Inspector General, says in France, a parent's earnings are more and more determining a child's health, including obesity.

And Langlongue says educated families often don't need the extra help the PMI provides.

"Social inequities of health are particularly widening for children," he says. "For example, if you see obesity, five years ago the difference between the children of rich people and children of poor people was less than today."

Less affluent women are getting fewer prenatal checkups, and only 60 percent of children now are meeting nationwide targets for well-child exams.

That divide is worrisome to the PMIs' most ardent supporters, like Dr. Marcelle Delours. She's an elegant Parisian who oversees the clinics in Paris, a city with vast pockets of poverty and a steady stream of new immigrants from Africa, Asia and Eastern Europe. And yet, Delours insists that the PMI cannot become the equivalent of some threadbare American public health clinics.

"We want to make sure that we can offer services to very diverse populations, because we want to keep our services open to all," she says in French. "And if we start to select which populations we serve, we're going to end up with ghettos, and we absolutely want to avoid creating ghettos."

Delours says middle- and upper-income women suffer from isolation and postpartum depression just as much as anyone else, and they need help too.

But the clinics — where visits are free — are becoming more essential for middle-class women for other reasons. Private pediatricians are retiring en masse. And young doctors aren't choosing the low-paying field of family medicine. Those who remain are charging more than government insurance pays, which means French families are reaching deeper into their pocketbooks.

We're On Our Own

Laurence Quadrine lives in a tasteful but aging apartment in Paris. She's a former attorney who now raises her six kids while her husband works on the stock exchange.

She started taking her youngest children to the neighborhood PMI after her regular pediatrician stopped accepting new patients.

Today, like many days, she's walked all over Paris: to the clinic with her 9-month-old son, Gabriel, and 3-year-old daughter, Marie, then to school to pick up her other kids. Now, finally, she has everyone settled at the kitchen table for an afternoon snack of ice cream, chocolate and prunes for Marie because as we discover, she's constipated.

For all this work, Quadrine gets little help.

Government cash subsidies for families have been scaled back for middle-income households, she says. Her law firm made it difficult to balance work with children.

We don't really have much aid, she says. We're on our own.

That a French mother could consider herself to be on her own is probably a jarring notion for a nation so fiercely proud of its pledge of solidarity. And while it's unlikely that France will abandon its maternal and child health programs, it remains an open question whether social changes and economic reality might intrude into such a sacred French ideal.

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Sarah Varney reports for our series Beginnings that the system is being threatened by economic woes and immigration pressures.

SARAH VARNEY: French children are raised to treasure fresh bread, strong cheese and their carnet de sante, a health diary. Since 1945, parents and doctors have dutifully charted the growth of les enfants in these little books.

(SOUNDBITE OF CHILD LAUGHING)

VARNEY: In the waiting room at a preventive health clinic in the poor Parisian suburb of Corbeil, carnet de santes peek out of purses and diaper bags. These health diaries, and the public clinics, aptly embody France's aspirations of solidarity: the Liberte, Egalite, Fraternite emblazoned on town halls, monuments and the carnet de sante.

ISABELLE CHAKR: Okay. Coca-Cola, Pepsi? (French spoken)

VARNEY: And of course, one way a nation stays healthy is through good nutrition. Isabelle Chakr is a pediatric nurse at the clinic in Corbeil. She's perched on a toddler-size chair leading a group of mothers in a game called Bebe Nut.

CHAKR: (French spoken)

VARNEY: She asks each mom to pick a card out of a deck. One has a picture of soda...

CHAKR: (French spoken)

VARNEY: ...others fruit or nuts. Then she asks: At what age can a child start eating it? Soda is no good for young kids, the women say. But then someone draws the fish and a lively debate begins about how best to prepare it.

UNIDENTIFIED WOMAN: (French spoken)

VARNEY: This isn't an idle question. One woman is from Mali, her arms covered in elaborate red tattoos; another is a fully veiled Muslim woman from Turkey, and the food here, especially frozen fish, is strange to them.

WOMAN: (French spoken)

VARNEY: By encouraging these discussions in the more than 5,400 preventive health clinics all over France, health officials say these women are more likely to make nutritious meals for their children.

WOMAN: (French spoken)

VARNEY: When the French maternal and child protection system called the PMI began in November of 1945, there wasn't much thought about frozen fish.

WOMAN: It was right after the war, so there were high child mortality. There were malnutrition problems.

VARNEY: Dr. Brigitte Lefeuvre is in charge of children's preventive health at the French Health Ministry. Today, she says the PMI clinics are still open to pregnant women and children up to age 6, even those in the country illegally. And unlike at private doctors' offices, there are no out-of-pocket costs.

LEFEUVRE: Every child, I mean even the richest, have this right. You know, this is absolutely not based on charity.

VARNEY: But the clinics are doing much more now than they did 65 years ago. An army of public health nurses aid mothers who feel isolated or depressed. They try to prevent and detect childhood disabilities and mental health problems and teach positive parent-child interactions.

LEFEUVRE: All those health problems are going to cost money or they're going to make those people less able to deal with work - should be addressed when they are younger.

VARNEY: The focus on keeping pregnant women and children healthy has paid off, she says. France has one of the lowest infant mortality rates in the world, obesity and diabetes among children remain uncommon. And while the PMI is a small part of the country's broader universal health system, officials say having clinics focused solely on preventive care for children has an outsized payoff.

WOMAN: (French spoken)

VARNEY: Fatoumata Traore, a Senegalese immigrant, lives with her four children in the decaying public housing projects just outside the clinic doors.

FATOUMATA TRAORE: (French spoken)

WOMAN: (Through Translator) She prefers to come here. (French spoken)

TRAORE: (French spoken)

WOMAN: (Through Translator) You don't need to pay. She thinks the doctor and the nurse have more time to answer the question.

VARNEY: This kind of unfettered access, though, is now in danger of being eroded. France's economy is sputtering along, unemployment remains high, and local French authorities are struggling to maintain services.

(SOUNDBITE OF CONVERSATION)

VARNEY: Dr. Claudette Buisson oversees the 60 PMI centers in Essonne, a large area south of Paris with middle-class suburbs and poor outposts like Corbeil. She says over the last year she's lost a third of her budget in favor of other local necessities like schools and roads. She's closed two clinics and is considering closing more.

WOMAN: Prevention is like cleaning house. You can see it when you don't do it. And I think that when they will see that we can't do prevention anymore, you will see that prevention was useful.

VARNEY: But Christophe Langlongue, who monitors France's health systems for the Office of the Inspector General, says here in France, a parent's earnings are more and more determining a child's health, including obesity. And Langlongue says educated families often don't need the extra help the PMI provides.

CHRISTOPHER LANGLONGUE: Social inequities of health are particularly widening for children. For example, if you see obesity, five years ago, the difference between children of rich people and children of poor people was less than today.

VARNEY: Less affluent women are getting fewer pre-natal checkups and only 60 percent of children are meeting nationwide targets for well-child exams. That divide is worrisome to the PMI's most ardent supporters like Dr. Marcelle Delours. She's an elegant Parisian who oversees the clinics in Paris, a city with vast pockets of poverty and a steady stream of new immigrants from Africa, Asia and Eastern Europe. And yet, Delours insists that the PMI cannot become the equivalent of some threadbare American public health clinics.

WOMAN: (Through Translator) We want to make sure that we can offer our services to very diverse populations because we want to keep our services open to all. And if we start to select which populations we serve, we're going to end up with ghettos, and we absolutely want to avoid creating ghettos.

VARNEY: Delours says middle- and upper-income women suffer from isolation and postpartum depression just as much as anyone else, and they need help too, she says. But the clinics, where visits are free, are becoming more essential for middle-class women for other reasons. Private pediatricians are retiring en masse, and young doctors aren't choosing the low-paying field of family medicine. Those that remain are charging more than government insurance pays, which means French families are reaching deeper into their pocket books.

(SOUNDBITE OF AN INFANT)

VARNEY: Laurence Quadrine lives in a tasteful but aging apartment in Paris. She's a former attorney who now raises her six kids while her husband works on the stock exchange. She started taking her youngest children to the neighborhood PMI after her regular pediatrician stopped accepting new patients. Today, like many days, she's walked all over Paris: to the clinic with her 9-month old son Gabriel and 3-year old daughter Marie, then to school to pick her other kids up, and now finally, she has everyone settled at the kitchen table for an afternoon snack of ice cream, chocolate and prunes for Marie because, as we discover, she's constipated.

LAURENCE QUADRINE: (French spoken)

VARNEY: For all this work, Quadrine gets little help.

QUADRINE: (French spoken)

VARNEY: Government cash subsidies for families have been scaled back for middle-income households, she says. Her law firm made it difficult to balance work with children. We don't really have much aid, she says. We're on our own.

UNIDENTIFIED CHILD: (French spoken)

QUADRINE: (French spoken)

VARNEY: That a French mother could consider herself to be on her own is probably a jarring notion for a nation so fiercely proud of its pledge of solidarity. And while it's unlikely that France will abandon its maternal and child health programs, it remains an open question whether social changes and economic reality might intrude into such a sacred French ideal. For NPR News, I'm Sarah Varney.

CHILD: (Singing in foreign language) Transcript provided by NPR, Copyright NPR.