Care and Migration Experiences among Foreign Female Cancer Patients in France: Neither Medical Tourism Nor Therapeutic Immigration

Abstract

This article is based on a sociological study carried out on foreign cancer sufferers seeking health care or diagnoses in France. The present study brings into perspective two major dimensions. First, it contributes to deconstructing the antithesis between medical immigration and medical tourism: two concepts that are more akin to exogenous categories (population governance and population flows within the current global context) than to a true anthropological perspective of patient experiences and their biographical consequences. Second, it will show how mobility offers an important insight into patients’ use of health care services, and identify the inequalities they experience and the ways in which they try to overcome them.

Keywords:

• Medical immigration
• medical tourism
• cancer
• life course
• mobility
• migration

Notes

[1] On a wider scale, the literature on ‘gender and migration’ tends to focus on the persecutions these women flee from and the economic dynamics linked to female migrations, such as sex trade networks and care activities (Falquet et al. 2010), while taking into account how social relationships (the interplay between gender, class, race, and sometimes generation) are renegotiated over here and over there (Morokvasic-Muller et al. 2003). However, on the theme of gender, disease and migrations, the studies of Adam-Véniza (2012) on HIV-positive African women seeking asylum are also relevant.

[2] The study was financed by Institut National du cancer (the French National Institute for Cancer Research) in the framework of the INVUSO programme (2010–2013).

[3] This study will not address end-of-life situations that raise the question of whether or not patients return to the country of origin to ‘die' (see e.g. Pian 2012, 2015).

[4] Other profiles appeared during the study, especially those of women who were seeking asylum and had arrived illegally (these two profiles can overlap). Focusing on a seemingly homogeneous profile, the objective is to show how a wide variety of experiences can hide behind this apparent homogeneity.

[5] Faced with the threat of terminal cancer, it appears that families usually reach a consensus to look for healthcare in France in the belief that chances for recovery, or more precisely remission, are higher. To be confirmed, this theory would need to be explored in the country of origin. However, should treatment in France be unsuccessful and the situation become life-threatening, the question of returning to the country of origin in end-of-life situations frequently causes heated discussions within the family sphere (see e.g. Pian 2015).

[6] This often is the case for wealthy travellers from Maghreb and sub-Saharan Africa who cover their own costs.

[7] Geographic proximity to their temporary address and/or urgent appointments means that it is common for newly arrived foreign patients to use private clinics for their first tests. Nevertheless, once cancer is diagnosed, these establishments redirect the patients to their public-sector counterparts so as to avoid dealing with any ‘visa’, or treatment-related issues, as there are no social services units within their facilities.

[8] Created in 2000, AME is affiliated with Social Security for undocumented foreigners. Until its reform in 2011, it was subject to three conditions: illegal residence, proof of having lived in France for three months and financial means under a certain threshold. Among other things, the 2011 reform reduced the ‘healthcare basket’ and introduced a 30-euro stamp duty for adult beneficiaries. French law provides a procedure in the form of funding for urgent and vital treatment (Fonds pour soins urgents et vitaux) for foreigners who cannot claim AME, however, the circular of 16 March 2005 excludes short-term visa holders from this provision (COMEDE 2014a, 2014b). Tourist or short-term visas are not residence permits (titres de séjour), therefore, holders are not entitled to access the French welfare benefits system.

[9] The French law on the right to stay for healthcare reasons (le droit au séjour pour soins) established in 1998 was revised in June 2011 by the Besson law, and is today defined by Article L 313 – 11 11° of the Immigration and Asylum Code (Code de l'entrée et du séjour des étrangers et du droit d'asile). The prefect is responsible for the administrative decision of granting a healthcare visa, following assessment by a Regional Health Agency (ARS) doctor. In 2009, in France, 74 per cent of healthcare visa applications were successful (granted by ARS doctors) and cancer represented 4.8 per cent of diseases cited as the medical reason. (In 2008, Brittany accounted for 2 per cent of this national figure.) These data, obtained in February 2012 from the French Department of Health (Direction générale de la santé), do not necessarily match the real number of residence permits authorised by the Prefect, despite the existence of corroborative data. The way in which applications are treated seems to vary significantly depending on the particular region and prefecture. As such, a 2014 COMEDE (Committee for the Health of Exiled Persons) report notes ‘a more stringent assessments of health criteria from ARS doctors in Paris Ile-de-France or from the Police Prefecture doctor for the granting of healthcare visas to sick foreigners, in contradiction to the General Directorate of Health Ministerial Directive of 10 November 2011. These developments are also accompanied by stricter administrative requirements. In breach of the regulations, the prefectures of Paris and of Hauts de Seine (Paris area) require proof of one year's residence in France to register an initial healthcare visa application. These prefectures sometimes even refuse applications if the applicant does not provide monthly evidence of French residency’ (2014, p. 79). The right to stay in a country for health reasons can lead to the issuing of a temporary residence permit (CTS) that states ‘private and family life’ (vie privée et familiale) if the applicant can attest to permanent residence in France; a criteria that prefectures interpret as a residency period of at least one year in France. A temporary authorisation for healthcare stays (APS) can also be granted, particularly when the residency condition is not met. However, numerous prefectures deliver APS visas instead of CTS ones. APS visas mean that foreign patients remain in an extremely precarious social and legal situation because they do not authorise employment and are valid for only a few months (3–6 months, renewable). They also make it very complicated for patients to leave the territory and do not grant access to certain social benefits such as the allowance for disabled adults (Allocation Adulte Handicapé).

[10] A parallel can be drawn here with the ambiguities surrounding the definition of transit category (Pian 2009) and the challenges of ‘migration management’ (Oelgemoller 2011).