Curing Patients, Connecting Lives: The Centre Médico-Social Bossuet, the West African Community, and the Struggle Against Tuberculosis in Paris, 1963-1979
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In the fall of 1979, word came down that the Centre Médico-Social Bossuet would shut its doors by the end of the year. Severe financial difficulties, combined with an overall decrease in West African labor immigration to France, constrained the Center's ability to do what it did best, namely provide medical and social services to the West African community in Paris and the suburbs. Upon learning of these plans, the West Africans who frequented the Center reacted with a combination of outrage and sadness. They formed committees and circulated petitions, interpreting its demise as a crushing blow not only for their health and the social services available to them but also for the broader effort to establish a basic level of humane and dignified medical treatment for all immigrant communities. The Center empowered them; its closing took away a critical tool for integration and an invaluable means of communication and advocacy. In letters they sent to the Center, patients expressed their ownership and attachment, explaining that it was one of the few organizations expressly servicing the needs of their community. In many ways, it also served as an African milieu, affording the opportunity to meet and converse with other West Africans from the same villages and countries of origin, while also allowing patients to speak their regional languages with one another and outwardly display their cultural identities through traditional dress. The Centre Bossuet provided a rare space outside of the dormitories (foyers) in which West African social relationships, culture, languages, and ethnic, regional, and national identities could thrive.
Is it possible that one semi-private medical center such as the Centre Bossuet could mean so much to a single immigrant community that its demise would be interpreted as such a serious blow to the community's well-being? Did it really provide such an important means to integration and community development through its services? Is it possible that the ailment that directed West Africans to the Center in the first place - namely tuberculosis - could actually serve as a path to survival and improved integration because it led them to this Center? A look at the Centre Bossuet and its interaction with West Africans proves that on all three counts, the answer is yes. This paper argues that for West Africans living in Paris during the 1960s and 1970s, tuberculosis and the Centre Bossuet's treatment options provided a means to survival and, eventually, integration and community development. The contraction of tuberculosis inevitably forced members of the West African community into contact with the Centre Bossuet, which provided critical services that strengthened this community and better positioned it within the host society. By exploring the Centre Bossuet's medical mission, we can better understand the issue of contagious diseases among West African immigrants and their impact upon these migrants' lives as well as the way in which a specific institution - the Centre Bossuet - conducted its own "struggle against tuberculosis" on behalf of the West African community.
But why the Centre Bossuet, why West Africans, and why tuberculosis? In fact, the Centre Bossuet created an intersection between the West Africans who arrived in France during the early post-colonial period and the host society and institutions attempting to accommodate them. The Center was one of many semi-private organizations such as SOUNDIATA and AFTAM that received government funding to assist West Africans and other immigrant groups. An exploration of the Centre Bossuet, therefore, allows for a critical examination of a "third-party" organization and its relationship with a particular immigrant community. Second, an analysis of the Centre Bossuet, tuberculosis, and West African immigrants reveals important aspects of immigrants' lives rarely explored in the historiography on immigration to France in the twentieth century, namely their susceptibility to disease, the delicate nature of their health, and the health care available to them. By understanding the means through which the Centre Bossuet dealt with tuberculosis among West Africans and the ways that these immigrants utilized the Center, we can better understand the precarious and difficult experience of immigration to France at this time as well as the ways in which a host society struggled to come to terms with this migration pattern and its consequences. Not only was tuberculosis a real problem for West Africans living in the Paris region, but it was also an issue that desperately needed attention from governmental and social organizations alike. The Centre Bossuet served as the quiet leader in the mid-twentieth-century struggle against this disease.
An examination of the Centre Bossuet and its struggle against tuberculosis also reveals how this disease changed socially over time. In the nineteenth century, as Sheila Rothman argues, tuberculosis affected people from all facets of life, regardless of geographical location, social class, or age. In the 1960s and 1970s, however, West Africans and other immigrant groups bore the brunt of this disease. For example, approximately fifty percent of the tuberculosis cases diagnosed in 1978 involved foreigners, who comprised only a small portion of the population. Tuberculosis preyed on these immigrants because of their difficult living conditions, their weakened immune systems in a new climate, and the long hours they worked to support themselves and their families in their countries of origin. These factors made them the perfect candidates to contract, spread, and suffer from this disease.
Consequently, this paper's focus on the Centre Bossuet, its West African patients, and the scourge of tuberculosis constitutes an attempt to understand and explore the vulnerability of an immigrant population to disease while also probing the experience of West African immigration. Its broader theme - disease as a pathway to survival and improved integration - underscores the ways in which the integration of an immigrant group can happen through unusual and alternative means. While the paper takes a largely institutional approach, it does so with an eye on understanding the West African perspective in the diagnosis and treatment process. In fact, in seeking treatment at the Centre Bossuet, patients formed a strong bond with the organization, making it nearly unfathomable that ultimately the Center would cease its operations, as it did in 1979.
The Center's origins lay in the late colonial era. At its inception, the property at 8 rue Bossuet in the tenth arrondissement of Paris belonged to the government bureaucracy in charge of French West Africa, which acquired it on 14 April 1942. Under a 1 April 1949 agreement, the space was loaned to the social service division of the French Ministry for Overseas Colonies for ninety-nine years under the condition that it provided services to colonial citizens. Following decolonization, the purpose and scope of the Centre Bossuet changed dramatically. In 1963, the Center as it was known until its closing in 1979 began to take shape; 22 October of that year marked the Centre Bossuet's official declaration in accordance with the 1901 law governing associations in France. The Minister of Health's Colonial Services Division (Service de Coopération Technique du Ministère de la Santé) oversaw its activities. From here forward, the Centre Bossuet's major focus would be the provision of medical, social, and socio-medical services for West African immigrants.
Why did these patients visit the Centre Bossuet in the first place and what types of services did it provide for them? Overwhelmingly, West Africans patronized the Center to receive medical treatment. The importance of this mission separated it from peer organizations such as SOUNDIATA and AFTAM, which provided social services but not necessarily medical assistance. More specifically, the Center tried to attract and treat immigrants from all over Paris who were susceptible to disease, thereby improving their health and odds of finding success in France. Within the provision of medical care, the diagnosis and treatment of tuberculosis proved to be the most important medical service provided by the Centre Bossuet. While the Center treated other tropical and general illnesses, sexually transmitted diseases, psychological issues, and dental problems, the struggle against tuberculosis in the 1960s and 1970s proved to be the most critical health issue facing the Center and its patients.
But the Centre Bossuet was not the only organization concerned with tuberculosis. In fact, the disease's presence among immigrant populations in France was discussed and debated more broadly by the medical and political establishments. The Centre Bossuet was part and parcel of a widespread conversation between physicians and government officials concerning the ways to treat and prevent tuberculosis among immigrant groups. Other entities engaged in largely rhetorical debates concerning the disease, but the Centre Bossuet played the most active role, becoming a forceful leader in fighting and preventing tuberculosis. This was no small task. Many of the Center's patients lived in dormitories that were often overcrowded and run-down. Tuberculosis spread easily in these conditions. If West African immigrants were this disease's primary victims, conditions in the dormitories facilitated the spread of tuberculosis; the Centre Bossuet became these immigrants' treatment center of choice in their effort to regain and preserve their health.
In its approach, the Center emphasized prevention as much as treatment, which succeeded in impressing upon West African immigrants the need for continuous testing for this illness. Furthermore, patients viewed patronage of the Center as a means of helping one another while preserving and safeguarding their own health. In fact, a large number of West Africans visited the Center for the first time each year with the hopes of preventing or curing the illness. But even more impressive is the number of patients who returned frequently for tests throughout the year; some stopped by the Center two, three, four, and even five times each year for check-ups. Whether by word of mouth or referral by another organization, the Centre Bossuet attracted a wide variety of immigrants, some of whom had recently arrived and others who were relatively well established in Paris. Furthermore, the Center kept track of how many clients visited during their second and third stays in France. A return trip to France, therefore, meant another appointment at the Centre Bossuet.
What happened to those patients who were diagnosed with tuberculosis? In fact, there was no standard response to this illness. Some patients were institutionalized almost immediately in hospitals or sanatoriums, while others opted for ambulatory treatment. In some instances, patients chose to return to Africa rather than face the disease in a foreign country. There is more to the story, however, than simply how many West Africans were diagnosed, whether they accepted and received treatment, and how and where they pursued their recovery. The Center's social services remained actively involved in this process, providing information on the disease from the ways in which it was transmitted to how it developed and the course and duration of treatment. These explanations helped to ease the transition from diagnosis to treatment while eliminating the element of fear or uncertainty. Staff members also reminded patients that treatment for tuberculosis through the Centre Bossuet remained free of cost.
Following diagnosis, patients decided which course of treatment to follow. This is a critical point in understanding the Centre Bossuet's approach. First and foremost, this organization understood the needs of its patients, many of whom could not leave their work and risk their jobs. In an effort to assist them, the Center provided a variety of services, but the Centre Bossuet did not dictate treatment options; its patients chose the course of treatment themselves. This choice demonstrates the ways in which the Centre Bossuet empowered its patients. Patients could choose hospitalization, institutionalization in a sanatorium, or ambulatory treatment. Once the choice was made, staff members coordinated all aspects of the treatment process. In the end, the decision concerning treatment was left to the patients, not dictated by the Center's doctors and staff members.
Faced with this choice, many patients expressed concern that in pursuing treatment, they would be unable to continue working and sending money to their families and communities at home. This is where ambulatory treatment became a viable option. West Africans who were diagnosed with tuberculosis could receive this form of treatment and continue to work and live on their own terms. In fact, the interpreters who worked for the Centre Bossuet assisted greatly in the ambulatory treatment process. Beyond facilitating treatment, they also created important networks of sociability, and their employment remains vital in understanding the Center's approach to curing tuberculosis. In most cases, West African immigrants who were fluent in French and various regional languages such as Soninke found themselves employed as interpreters. They also worked as intermediaries between patients and staff members who were otherwise unable to communicate. In some cases, interpreters interacted with patients by visiting their private residences. During their visits, they frequently found themselves in a familiar setting: the dormitories that housed many of the Center's patients. Often, they themselves lived in dormitories or had done so previously. Familiar with this setting, interpreters could convey in proper cultural and social terms the severity of the disease and the necessity of seeking treatment without intimidating their fellow migrants.
These interpreters served as an important link between the Center's staff and its patients. They bridged linguistic, cultural, and social gaps between these two groups while facilitating the health care and social welfare of their fellow migrants. Their outreach to the West African community through personalized house calls further reinforced the Center's commitment as well as the interpreter's own dedication to improving the health of these immigrants by all necessary means. In this capacity, they connected these two cultures at a critical moment. Their employment at the Center indicates its propensity to negotiate and interact with rather than dictate to and control its patients. In a sense, these interpreters also became unofficial facilitators of West African community development, as they could pass on important information concerning other matters such as social events, housing vacancies, educational opportunities at the Centre Bossuet and other organizations, and news from countries and villages of origin. They also established important contacts between fellow immigrants, contributing to the continuing development of this immigrant community.
Interpreters certainly played an important role in ambulatory treatment, but not all tuberculosis patients chose this option. In fact, some West Africans reluctantly embraced a trip to the hospital or sanatorium. Many West African immigrants worked long hours in demanding industrial jobs. In fact, their working conditions constituted an important risk factor contributing to their susceptibility to tuberculosis. While recognized as an opportunity for a much-needed break from work, a stay in the sanatorium also presented another possibility. Those stricken with tuberculosis and institutionalized for an extended period could actually take the time to learn to read and write in French, a skill they often lacked upon arrival in France. This opportunity demonstrates the means by which tuberculosis and its treatment provided a chance for improved integration. Although opportunities to gain literacy certainly existed outside of the sanatoriums, which were not an ideal learning environment, these institutions nevertheless provided the chance for linguistic development rarely available to migrants who worked long hours. Some patients, then, viewed institutionalization as an occasion to pursue two important objectives: the recuperation of their health and the acquisition of important literacy skills. Better health and literacy increased the odds of successful integration into the host society. Tuberculosis treatment in sanatoriums and hospitals thus served as an unusual path to improved literacy and provided the necessary tools to ensure survival.
Ambulatory treatment and institutionalization were not the only treatment options available; some West African patients decided to return to their countries of origin through medical repatriation. The idea of facing this disease in a foreign country remained too daunting. Such a departure forced the Centre Bossuet and its staff to broaden their horizons and work closely with similarly minded organizations in West Africa. The Center became part of a global fight against tuberculosis, spanning two continents, several cultures, and multiple languages. In the event of such a departure, for example, the Center contacted regional branches of anti-tuberculosis organizations in West Africa to coordinate treatment options. The Center also established an on-going partnership with the Service for the Struggle Against Tuberculosis from Kayes in Mali (Service de lutte contre la tuberculose de Kayes au Mali). Together, these organizations cooperated to facilitate treatment for patients who wished to return to their families without running the risk of terminating their treatment. By coordinating treatment options with the Service in Mali and branches of this organization in other West African countries, the Centre Bossuet fostered a smoother transition for repatriating immigrants while working to contain the spread of tuberculosis in West Africa. It also ensured that future immigrants from countries such as Mali knew of the services that the Centre Bossuet offered as well as its capacity to ease their transition and integration into French society. Medical repatriation, therefore, comprised an important aspect of the organization's services and obligations in the struggle against tuberculosis, while also affording an opportunity to wage a broader, multi-continent campaign.
The Centre Bossuet did not simply act as a diagnostic, referral, and coordination service. Staff members also tried to assist tuberculosis patients in navigating the logistical issues involved in pursuing treatment. In this capacity, the Center served not only as a medical advocate for its patients but as a bureaucratic and social one as well. Staff members assisted patients in innovative ways, surmising their needs and adjusting the Center's services accordingly. For example, they recognized that West Africans confronted a plethora of problems when they needed to leave their jobs to pursue treatment. Accordingly, the Centre Bossuet informed employers of their employees' conditions, ensured humane and fair treatment in treatment facilities, and relayed information to such government entities as the Social Security offices for record keeping and financial reimbursement. Beyond these administrative tasks, the staff assisted patients whose treatment demanded travel to hospitals and sanatoriums. When travel was required, most patients did so by train, and the Centre Bossuet's staff accompanied patients to train stations, helping them with their transport, assisting them in purchasing tickets, and serving as interpreters when necessary. The organization's staff also recruited volunteers to meet these patients at their destinations in order to ensure their safe arrival while coordinating transportation from the train station to the hospital or sanatorium. They not only demonstrated a willingness to assist West African immigrants medically but also served as social and bureaucratic advocates.
What happened after patients completed their treatment process? Most returned to their jobs. The transition back to employment, however, proved more difficult for some patients than for others. The dichotomy lay in legal versus illegal immigration status, and the Centre Bossuet provided services for both of these groups. Overwhelmingly, legal immigrants experienced an easier transition back to work. In cases where this return proved more complicated, they could look to the government for assistance. Those who possessed the residency permit (titre de séjour) often found themselves gainfully employed. Others who lost their jobs to the illness could enroll in the social security unemployment program while searching for a new source of employment. Although they lacked formal citizenship status, legal West African immigrants received many of the same services, consideration, and financial reimbursement as French citizens in their battle against tuberculosis, thereby erasing little by little the distinction between "citizen" and "legal immigrant." This new status was largely possible through the Centre Bossuet and its advocacy on behalf of the West African community.
Illegal immigrants, however, faced a much more uncertain future. If they lost their jobs during treatment, they possessed few means through which to protest their termination, as they were not legally hired in the first place. Second, illegal immigrants had none of the same financial protections as their compatriots who held a residency permit, and they could not file for unemployment insurance. Immigration status added another layer to the already complex diagnosis and treatment process; it proved almost insurmountable for those illegal migrants who faced this daunting disease. Those who arrived in France illegally could rely on few institutions outside of the Centre Bossuet for support. The Center and its staff opted to help these immigrants, recognizing their need for treatment and recovery regardless of immigration status. The organization provided the same level of advocacy for legal and illegal immigrants alike, achieving its goal of providing resources for all members of the West African community.
The Centre Bossuet's position in the diagnosis and treatment of tuberculosis among West African immigrants demonstrates the important and varied roles that this organization played in the lives of these migrants. It was not just a medical center dispensing medicines, diagnoses, treatments, and advice. In fact, the Center played a far more active part, conducting its own campaign against tuberculosis. Staff members coordinated leaves of absence with employers, assisted in the transport and check-in process for patients who chose hospitalization, served as translators and interpreters, and ensured that the Center's goal of providing humane, fair medical services free of cost was upheld at other institutions. The Center facilitated treatment options without dictating them, allowing patients to choose the course of action best suited to their individual needs. Staff members helped these patients retain their dignity at a moment when they found themselves most vulnerable to a potentially fatal disease. Finally, the Centre Bossuet's efforts reveal that its mission went beyond the provision of medical and social services. The Center battled against a disease that seriously threatened this group of immigrants, and it thereby became an important social and medical advocate for the West African community.
After looking at the ways in which the Centre Bossuet assisted West Africans in confronting tuberculosis, it is easier to understand why, when the Center announced its closing, its patients reacted with such dismay. They were losing not just a clinic but also a medical and social advocate that assisted them in the fight against disease and in a host of other ways that remain beyond the scope of this paper. In contracting tuberculosis, West African immigrants wound up receiving many of the same services, payments, and consideration that French citizens would if they found themselves in the same predicament. The lines between citizen and immigrant blurred for just a moment, and West African immigrants became more familiar with organizations such as the Centre Bossuet that could assist them in various ways, even after the conclusion of their treatment. In a roundabout sense, tuberculosis opened a door to survival and improved integration through interaction with organizations such as the Centre Bossuet. The Center embraced this opportunity, readily extending the tools necessary to facilitate the West African community's development.
SOUNDIATA and AFTAM stand for "Soutien-Union-Dignité dans l'Accueil aux Travailleurs Africains" and "Association pour la Formation Technique de Base des Africains et Malgaches résidents en France," respectively. Together with the Centre Bossuet, they represented the semi-private "third party" organizations that emerged in the 1960s and attempted to assist West Africans in achieving a decent standard of living. In particular, SOUNDIATA and AFTAM provided dormitory-style housing, social services, and educational opportunities.
Archives de Paris, 1209W, "Centre Médico-Social Bossuet," art. 9 [hereafter CMSB], Association pour l'Accueil Médico-Social des Migrants, "Centre Bossuet: Budget Provisoire pour 1981 Note de Présentation Dépenses de Fonctionnement" (Paris: Association pour l'Accueil Médico-Social des Migrants, 1980).
CMSB, R——-, Mme le Dr. et MP F——-, "Rapport sur le Centre Médico-Social Bossuet" (Paris: Inspection Générale des Affaires Sociales, 1976). All names have been shortened in the footnotes to protect the individual privacy of those involved in the Centre Bossuet. Furthermore, patients' and employees' names have been omitted entirely from the discussion to achieve the same goal.
I use tuberculosis as the primary example of the types of medical care and services provided by the Center. The Center kept the most thorough records on its diagnosis and treatment of tuberculosis, and my discussion here reflects this rich source material. Furthermore, the issue of tuberculosis was not simply a problem identified by the Centre Bossuet and its staff. Several different entities throughout France, including government ministries and private associations, recognized the challenges posed by the prevalence of tuberculosis within the West African population. Consequently, a discussion of tuberculosis reflects not only the Center's medical services, but also serves an opportunity to explore a widespread problem from the perspective of one institution that treated a specific group of immigrants.
The literature on tuberculosis and disease more generally in nineteenth-century America and France is quite thorough. For example, see Andrew R. Aisenberg, Contagion: Disease, Government, and the 'Social Question' in Nineteenth-Century France (Stanford: Stanford University Press, 1999); Rothman; Bertrand Taithe, Defeated Flesh: Medicine, Welfare, and Warfare in the Making of France (Lanham: Rowman and Littlefield, 1999). What the literature lacks, however, is a definitive look at tuberculosis in the mid-twentieth century. This paper and my dissertation more broadly aim to fill this gap and encourage other historians of twentieth-century France to take another look at tuberculosis as an important topic in contemporary history.
CMSB, Association pour l'Accueil Médico-Social des Migrants, "Centre Bossuet: Budget Provisoire pour 1981 Note de Presentation Dépenses de Fonctionnement" (Paris: Association pour l'Accueil Médico-Social des Migrants, 1980); Centre Médico-Social Bossuet, "Rapport d'Activité 1977: Service Social" (Paris: Centre Médico-Social Bossuet, 1977); Letter: A——-, Dr. (Département de Paris, Direction des Affaires Sanitaires et Sociales de Paris) to M V——- (Directeur des Affaires Sanitaires et Sociales de Paris), Paris 1980.
CMSB, Association du Centre Médico-Social Bossuet, "Rapport d'Activité, Année 1977: Service de Pneumo-Phtisiologie" (Paris: Association du Centre Médico-Social Bossuet, 1977). The statistics used in this paper from the 1977 report are not the only statistics available to support a discussion concerning tuberculosis and its diagnosis and treatment amongst the West African immigrant population. In fact, the Centre Bossuet kept similar statistics for each year throughout the 1970s and included them in the annual "Rapport d'activité." These annual statistics are remarkably consistent throughout the decade, and the 1977 batch was chosen because it reflects the overall trends observed by looking at each year's statistical breakdown. For annual statistical breakdowns, see the "Rapports d'activité" in CMSB.
CMSB, Association du Centre Médico-Social Bossuet, "Rapport d'Activité Année 1976: Service Social/Activité Médico-Social" (Paris: Association du Centre Médico-Social Bossuet, 1976) and Association du Centre Médico-Social Bossuet, "Rapport d'Activité 1975: Service Social" (Paris: Association Médico-Social Bossuet, 1975).
Sheila Rothman demonstrates the vast array of treatment options available in nineteenth-century America, including relocation to cities with higher altitudes as well as sojourns to tropical islands, etc. Rothman's book speaks to the patient's experience in living with tuberculosis, an innovative approach that avoids relying solely on institutions or the medical establishment for insight into this disease. I use Rothman's approach as an inspiration for my own attempt to try to understand the Centre Médico-Social Bossuet as an institution that interacted very closely with West African immigrants while also providing them with a point of contact with the French population through health care.
Ibid.; CMSB, Centre Médico-Social Bossuet, "Rapport d'Activité Année 1974: Annexe Etude de la Population féminine ayant fréquentée le Centre Médico-Social Bossuet au cours de l'année 1974" (Paris: Association Médico-Social Bossuet, 1974).
CMSB, Association du Centre Médico-Social Bossuet, "Rapport d'Activité Année 1976: Service Social/Activité Médico-Social" (Paris: Association du Centre Médico-Social Bossuet, 1976); and Association du Centre Médico-Social Bossuet, "Rapport d'Activité 1975: Service Social" (Paris: Association Médico-Social Bossuet, 1975), 13.
In the 1960s and 1970s, a majority of the West Africans arriving in France to work hailed from the Fleuve River valley region, which runs through Mali, Senegal, and Mauritania. The Soninke group remained the predominant ethnic group at this time. The partnership between the Centre Bossuet and the Service for the Struggle Against Tuberculosis from Kayes in Mali reflected the predominance of Malians amongst the Center's patients and the Center's continuing concern for them once they returned to Mali.
Ibid.; CMSB, Le Président du Conseil d'Administration, Centre Médico-Social Bossuet, Letter to M le Directeur FAS pour les Travailleurs migrants Services des interventions sociales 2ème Bureau, Paris, 1977; and R——-, Mme et Dr. et MP F——-, "Rapport sur le Centre Médico-Social Bossuet." (Paris: Inspection Générale des Affaires Sociales, 1979).