The moral career of poor patients in free clinics

Abstract

This paper explores the lived experiences and the identity processes attached to attendance at free clinics. It draws on a qualitative study of 94 patients and 37 professionals who were interviewed at four free clinics in France. Since these facilities are for the poor and for people without health coverage, attendance reflects a medical experience as well as an experience of assistance, both of which have an impact on healthcare utilisation. Nevertheless, the meaning attached to the recourse to free clinics and the patients’ lived experiences change over time and depend on interactions with clinic staff. This study proposes a typology of care recourse modes (occasional, regular and inconsistent attendance) crossed with different types of lived experiences. Occasional attendance and distant patient–professionals relationships, often due to the humiliation that some people feel when they have to ask for social assistance, characterise the first time people have recourse to care. Patients commit to regular follow-ups only when they have come to terms with their position in the medical and assistance system, doing so by rationalising and adjusting their identity. Our aim in discussing our findings is to gain greater insight into the utilisation of healthcare by different population groups and in different contexts.

Introduction

The whys and wherefores of caring for the poor and the resources for this care are issues that have long been addressed. In Europe, hospitals set up in the Middle Ages focussed primarily on succouring the indigent in a spirit of Christian charity rather than on curing the sick. However, medical establishments did gradually become professionalised. At the same time, the rationale underlying the care of the destitute changed and moved away from its charitable tenet toward principles based on repression, social assistance and later on health insurance (Geremek, 1987; Foucault, 1973). In France, when the Sécurité Sociale¹ became widespread during the second half of the twentieth century, the problems of healthcare access for people in social difficulty seemed solved for a while.

In theory, the French welfare system guarantees access to healthcare for anybody residing in the country. However, over the past two decades changing economic structures and family ties have deprived huge segments of the population of the benefits of the welfare and healthcare system (Gallie & Paugam, 2000). The eighties witnessed the exclusion of some groups from healthcare. Medical and social reasons prompted some patients to forgo healthcare or to go to the emergency rooms at public hospitals, causing overcrowding at these facilities (Chauvin, 2002). This can be explained by the complexity of the social welfare system, the practices and constraints of healthcare professionals, and patients’ behaviours. Furthermore, some patients were unable to establish their rights to public health coverage, others did not take the necessary steps to access healthcare while yet others could not afford the medical costs owed by the patient. Consequently, France tailored its welfare system to address the issue of healthcare exclusion. At the same time, humanitarian organisations (NGOs) and later the public hospitals set up free clinics (separately from the Emergency Room (ER)) to provide the poor with medical care (according to a social assistance mode).

NGO free clinics are exclusively for the poor; the other facilities are located at outpatient consultations in public hospitals. Both types of clinics do not ask patients to make any down payments or fill out any administrative forms prior to care. The clinics provide consultations and drugs free of charge and offer social assistance focussed on helping the patient obtain health insurance. The organisation and operations of the free clinic services are especially designed to deal with the intricacy of the medical and social problems of people in precarious situations, something that the public hospital ER is ill-equipped to do (Dodier & Camus, 1998).

Free clinics have a special role in the French healthcare system since they serve the poor whose entitlement to health coverage has not been acknowledged. Therefore, free clinics provide care that also includes aspects of social assistance. Since the first sociological studies on social assistance, it has been shown that assistance establishes a ‘poor person’ status (Simmel, 1971). Earlier studies also argue the discreditable nature of assistance since it materialises one's inability to provide for one's needs on one's own and manifests one's dependence. As Coser points out, the very fact of receiving assistance condemns the poor to a specific career, changes their former identity and becomes a stigma influencing their social interactions (Coser, 1965).

However, individuals are never entirely determined by their position in the medical and social assistance system. Even when experiencing a discredited situation, individuals still have some freedom in, and power over their relationship with professionals and in their negotiation of a more gratifying identity (Arkin, 1980)—either within the medical system (Adams, Pill, & Jones, 1997; Werner & Malterud, 2003) or within the welfare system (Paugam, 1991; Snow & Anderson, 1987). Dynamic processes are involved since identities are not fixed but changing, especially during social interactions within the institutions (Dubar, 1991).

We focus on how the medical dimension and the social assistance dimension of care in free clinics give rise to specific identity processes and interactions between patients and professionals. Our hypothesis is that attending a free clinic may reinforce a patient's feeling of belonging to an underprivileged category and may influence healthcare behaviours; and that in turn, a patient may develop adjustment and rationalisation strategies to cope with the stigma.

The concept of moral career accounts for an individual's changing situation by addressing its objective and subjective dimensions concurrently. The concept specifically includes the individual's different social positions in light of his or her attitude toward these positions and his or her motivations and desires (Becker, 1963). Several sociologists describe the transformations during individuals’ moral careers. In the case of chronic diseases, Bury (1991) underscores how the three phases in the career of a sufferer (i.e., onset; explanation and legitimisation; and lastly adjustment) correspond to an individual's gradual acceptance of the disease and resulting adjustment of his or her identity. In the case of recourse to social assistance, Paugam (1991) shows that at the outset of the trajectory of social declassification, people reject the status of welfare recipient, a rejection prompting them to deploy welfare avoidance strategies. Their attitudes and behaviours start changing as they receive and become increasingly dependent on regular help. Welfare recipients’ moral career is then marked by the negotiations of their identity through self-justifications or rationalisations—to a point where they can no longer see their life without the benefit of assistance. Our hypothesis is that similar processes may be at work when poor patients attend free clinics.

The purpose of this article is to understand the evolving relationship with free clinics and changing patient expectations and relationships with the staff, by attaching them to the identity and relational processes involved in the recourse to free clinics. We focus on the moral career of free clinic patients and the cycle of changes in the presentation of self to oneself and to others (Goffman, 1961). Thinking in terms of moral career underscores the dynamic aspects of free clinic attendance modes as well as patients’ lived experiences. It also emphasises that patients’ trajectory is not ‘random’; it has direction and milestones.