The Emergency Room waiting area at l’Hôpital Avicenne is filled with orange chairs, one of which is occupied by a man in khaki pants who appears to be awaiting news about a loved one. It is eight o’clock in the morning, and a few doctors and nurses in scrubs are gathered in a nearby lab to discuss cases from last night’s shift. Outside of the quiet waiting room, there is a large hallway through which patients are transported on beds and in wheelchairs to rooms where they can be seen by a doctor.
To the left in this hallway is a tiny room where a doctor sits on-call to help sick immigrants receive medical care for symptoms of minor illnesses, such as the flu or a small infection. For many immigrants who lack health insurance, a public hospital is the only place where they can receive care for these types of ailments. The doctors who treat them in this tiny room, though, are not obligated to see these individuals separately. Immigrants could be asked to go through the triage system like every other patient, sitting for hours in orange chairs, waiting for their names to be called. Yet the doctors have decided to remain on-call and provide timely care—“We’re not going to punish them,” Doctor Vinh-Kim Nguyen believes.
Dr. Nguyen works in the emergency room of a hospital that “has always had a reputation for being different.” Originally called l’Hôpital Franco-Musulman, the French-Muslim hospital, Avicenne is a témoin—witness—to France’s recent immigration history and serves those who struggle to make their way in a new country. This hospital links two worlds, the places in northern Africa from which immigrants flee, and France, their new home. It unites people with France while reminding them of their differences, showing, according to Dr. Nguyen, the contradictory ways in which “France takes in people, even though it excludes them.”
“Accaparer les lits des hôpitaux parisiens”—Monopolizing the beds in Parisian hospitals
According to Paris’s Museum of the History of Immigration, the Franco-Muslim Hospital opened in 1935 when immigrants began flocking from France’s North African colonies—Algeria, Morocco, and Tunisia, which form the Maghreb—to France during the interwar years. These immigrants, too poor to live in Paris and without resources from the state, resorted to building homes in slums outside the capital. They began to fall victim to tuberculosis, alarming authorities of the public health risk that these communities posed without proper health care. Fearing that sick immigrants would “monopolize” the beds in Parisian hospitals, health authorities commissioned a new hospital to be built specifically for this patient population. Paris refused to sponsor the project, so the Franco-Muslim Hospital was built outside the city, in the suburb of Bobigny. The hospital was designed by a group of French architects, including Maurice Mantout, who designed the Grand Mosque of Paris, and Léon Azéma, who was named Architect of the City of Paris and was instrumental in designing the Exposition Universelle de Paris in 1937.
This hospital, along with housing, other clinics, and a police force, was created for “surveillance, protection, and assistance” under the Conseiller Municipal de Paris, Pierre Godin. It operated a “colonial” management of patients; the staff was trained to speak Arabic and Kabyle, and the hospital’s procedures conformed to Islamic custom. Meals, for example, were served without pork. Yet many of the patients that this hospital intended to serve felt they were instead quarantined and stigmatized; in 1937, nearly six hundred Algerians refused hospitalization in Bobigny.
Once World War II began, German occupying forces took control of the hospital. After the war ended, the French government opened the hospital to all patients in Bobigny and surrounding communities as France experienced a population boom during the 1950s. In 1962, the hospital opened to women and became affiliated with the Assistance Publique-Hôpitaux de Paris—the conglomerate of public hospitals operating in Paris and surrounding banlieues, or suburbs. Now a member of the public hospital system, Avicenne’s religious affiliation was scrubbed. Four years later, it became a university hospital as new buildings dedicated to different specialized medical services were built. As the hospital continued to grow, it was renamed Avicenne Hospital in tribute to physician, philosopher, and poet Ibn Sina, who used poetry to teach medical knowledge to his students in the eleventh century.
Despite a name that honors a great Muslim thinker and doctor, the religious roots that defined this hospital’s founding have been glossed over since its secularization in 1962. Now a fully secular institution serving an underserved religious population, Avicenne has been at the forefront of defining and redefining laïcité, France’s deep separation of church and state.
Worried about Catholicism’s influence in state affairs and inspired by the revolution that had taken place just over a century before, the French government codified the principle of laïcité on December 9, 1905. The new law aimed to “sharply [delineate] the realms of Caesar and God.” Article I of the French Constitution clearly states, “La République assure la liberté de conscience. Elle garantit le libre exercice des cultes sous les seules restrictions édictées dans l’intérêt de l’ordre public”—"The Republic ensures freedom of conscience. She guarantees the free exercise of worship under only the restrictions enacted in the interest of public order.”
In theory, laïcité, which does not translate well into English, grants all citizens religious freedom. In a man’s private life, he can practice whatever religion he chooses, or no religion at all; in the eyes of the state, however, he is just French. The government argues that this law is applied equally to all religions, and to a certain extent, this is true. For example, the president does not take the oath of office using a Bible and schools cannot stage nativity plays, though Easter Monday, Ascension Day, Whit Monday, and Christmas Day are all national bank holidays.
In practice, however, laïcité has alienated religious minorities as France has become increasingly diverse. Many feel that French enforcement of laïcité has disproportionately affected the country’s Muslim population. As the New York Times suggests, “Islam does not easily accept the ban on the public exercise of religion, whether it is the full veil for women or gender-mixed swimming pools, Friday Prayer that overcrowds mosques or halal food in schools.” Specifically, France’s recent controversial “Burqa Ban,” which bars Muslim women from wearing burqas and naquibs in public places, has been seen as a law of laïcité that has unfairly targeted Muslim women.
Rigid religious secularism permeates French society in a way unseen in the United States. According to Angeline Escafré-Dublet, a political science professor at Sciences Po in Paris, young women in public schools wear headscarves to school in the morning and walk straight to the restroom where they promptly remove them before attending class.
L’Islam du “Neuf Trois”—Islam in the Ninety-Third
This tension between public and private is ever present in Dr. Nguyen’s work at Avicenne, as he serves a religious patient population in a hospital that does not recognize religiosity. Located in the notorious ninety-third Seine-Saint-Denis department in France, Bobigny is a “symbol of the underserved suburb,” serving poor minorities, many of whom are immigrants from the Maghreb and other parts of the Middle East and Africa.
Though the French government specifically bans censuses from polling ethnic affiliation and religious belief, an estimated five million Muslims live in the country, which is just over 7 percent of the population. According to the Brookings Institution, between 35 and 40 percent of French Muslims live in neighborhoods like Bobigny on the outskirts of Paris, where they make up between 10 and 15 percent of the local population. According to Dr. Nguyen, over 150,000 individuals near the hospital lack any sort of documentation.
Approximately one-third of Muslim immigrants in Europe reside in France, making it, on paper, the most accepting country of Muslim immigrants in the European Union. The Muslim population in France is not monolithic, as there is broad ethnic and national diversity within this group of people. However, Brookings found that “what Muslims in France increasingly do have in common is their ‘lived experience.’” The Muslim French identity has been shaped by racism and microaggressions, the ghettoization of the suburb, and a lack of social services and other resources.
Bobigny and other underserved suburbs have become places where “drug dealers compete with career advisers to recruit teenagers.” Crime is high, tourists stay away, and residents are shunned by their Parisian neighbors who reside just thirty-two minutes away by Metro.
“Healthcare in France is particularly freighted with a post-colonial history”
It is within this historical, political, and demographic context that Dr. Nguyen and his colleagues tend to sick patients at Avicenne: “The medical problem is very much a result of the social issues,” he said.
Avicenne is one of three hospitals that serves undocumented patients, so in addition to running an “on-call” room for these individuals, it also has social workers who try to get people papers they need for proper documentation. Yet according to Dr. Nguyen, the problem is greater than determining whether or not a patient has papers; three-fourths of the hospital’s patients have specific religious needs, and many do not speak French or English. More importantly, due to laïcité, French law blocks these patients from receiving culturally and religiously sensitive care.
In a conference room with boxes of Ebola suits and Christmas decorations tucked away in the corner, Dr. Nguyen described how public medicine in France needs to be secular, while also serving a patient’s individual needs. He and his colleagues are working on methods that optimize individualized care, while adhering to laïcité.
A psychiatrist, who asked not to be named in this article, discussed “transcultural psychiatry,” a new method of medicine in France that emphasizes sensitivity toward the cultural differences between immigrant patients and French doctors when treating mental health illnesses. “When you have someone coming from another cultural context, you need someone to translate, not just the language, but the entire process,” he said in French, as Dr. Nguyen translated. For some patients, this hospital is one of the first places they see in France. Dr. Nguyen and his colleague describe the “severe trauma” many immigrants face during the perilous journey to Europe, which manifests in what they call “culture-bound syndromes.” They have cared for a child soldier, a woman who thought she was cursed, and a man who was convinced that witches followed him to France. When working with patients, Avicenne doctors will collaborate with traditional healers, translators, and other mediators to ensure patients are “more informed” and feel more comfortable with the treatments prescribed to them.
This new approach to psychiatry is controversial, as it highlights that which the French government has striven for years to blur: an individual’s personal identity. Many French citizens believe that this type of personalized care is racist. Yet in a part of Paris that is deeply suspicious of the French government but relies on its services for survival, this type of culturally aware form of medicine is key.
With a thick grey beard and warm smile, the psychiatrist is, like two-thirds of the hospital staff, a Muslim who fasts every year during Ramadan. Yet he is also the man who must patrol the hallways of the hospital to ensure religion is absent—if he sees someone using a prayer rug on the floor, he must ask that person to exit the building and pray elsewhere. According to Dr. Nguyen, the hospital does employ a priest, an imam, and a rabbi to administer last rites, but beyond this, it can do nothing about patient religiosity, even during times of illness and death, when religion and prayer can be one’s only comfort.
“The idea of total equality”
As laïcité celebrates its 110th anniversary this December, Dr. Nguyen and his colleagues continue to walk the line between providing transcultural care and respecting laïcité. Their work sits at the foreground of France’s debate about how to treat immigrants and religious minorities, and grapple with the country’s colonial past. “The colonial heritage of this hospital is swept under the rug,” Dr. Nguyen said, “because it offends the idea of total equality.”
Yet the remnants of that heritage are more present now than ever before. The shooters responsible for twelve deaths at Charlie Hebdo, and five deaths a day later at a Jewish supermarket came from the very neighborhood where Avicenne operates. According to Dr. Nguyen, “they were as French as French can be.”