A qualitative sociological survey conducted in four free clinics in the Paris area and in a big provincial city provided the data for our analysis. The main materials were collected over a four-year period (1995 to 1998). During that time, 94 face-to-face interviews were conducted with patients. Individual interviews and group interviews were also conducted with 37 staff members (physicians, nurses, nurse’s aides, social workers, and receptionists). The in-depth interviews were completed with non-participant observation at the free clinics, hence providing a deeper insight into the interdependent relations between the patients and the staff. However, this paper is mainly based on our interviews with patients (the other data having been analysed elsewhere, cf. Parizot, 2003).

The interviewers (mainly the first author) contacted the respondent-patients while they were in the waiting room at the clinics or, on rarer occasions, after the patients had seen a physician, a nurse, or a social worker. The interviews lasted an average of 45 minutes (lasting up to two hours and a half when the patient was inclined to share) and took place at the clinics where privacy was preserved. Almost all the interviews were audiotaped and transcribed in full. The interviews explored the patients’ relationship with the free clinic, their utilisation of the healthcare and social services, their health perceptions and experiences, and their social situation.

When the sample was defined, our purpose was not the statistical representativeness of the people attending free clinics. We attempted to build a sample covering all customer profiles, with a focus on gender, age, nationality, health status, and types of recourses. However, the survey was hampered by a linguistic constraint since we did not interview foreigners who couldn’t speak French (accounting for a mere 7% to 13% of the total attending population according to the clinics). This limitation aside, overall our sample matched the profile of clinic customers. Sixty percent of the respondents were men, average age was 37, half of the interviewees were foreigners, and the vast majority had precarious housing conditions. Only about one third had their own home and about another third were living more or less temporarily with friends or family; the others were homeless or living at a hotel, in a shelter, or a squat. The interviewees were very different in terms of their health status and reasons for recourse. Some consulted the clinics for occasional, benign disorders; others were treated for chronic disorders (mainly for an HIV infection; but also, in some cases, for cancer). Some were not ill or medically treated on the day of the survey but were there to meet a social worker (who usually handled their request for health coverage) or simply to spend a few hours in a heated, friendly place. Most of the respondents had not been attending the free clinic for long. On the day of the interview, about one third had only been coming for a month or less or had only consulted once. Less than a quarter of the respondents had been coming to the clinic for two years or more.

Our study is grounded in a comprehensive sociological analysis of the interviews to elucidate the meaning people attributed to their experiences, the way they interpreted their social and health condition and their present and past attendance at the institution. Two authors reread approximately one third of the interviews and methodically discussed their analyses. For each interview, our work focused on obtaining a global, comprehensive outlook of the patient’s situation in his or her relationship with the free clinic, the medical system and assistance. A similar comprehensive analysis was used to examine the second third of the interviews but the researchers did not systematically confront their views on this part. We were able to highlight different attendance modes at the free clinics and different types of lived experiences by the patients. After our first analyses, the last third of the interviews was conducted and analysed according to Glaser and Strauss’s “grounded theory” approach (Glaser & Strauss, 1967). These interviews allowed us to fine-tune our typology and gain a greater insight into the studied phenomena.

We drew up a typology that emphasises the different attendance modes at free clinics and lived experiences of the recourse to healthcare. As our purpose was to apprehend the patients’ own standpoint, their health disorders were not considered a priori as a primary factor in the relationship with the free clinic and its staff.

Furthermore, the retrospective approach adopted during the interviews as well as the comparison of people’s discourse at different times during their dealings with the free clinic allowed for the ex post reconstruction of the individuals’ trajectories through the institution they attended.

Occasional attendance at free clinics concerns people whose health does not require long-term medical follow-up or who have only been attending the facility for a short time. When they come to a free clinic, they usually have specific medical requirements. Their relationship with the free clinic is mainly based on medical care. The patients appreciate the opportunity of free care and the benefit of occasional social services, such as assistance in obtaining social protection or sorting out administrative procedures. However, they do not expect the complete management of their problems either because they do not think they need it or because they do not dare ask for it. Two types of lived experiences of occasional attendance are distinguished: humiliation and pragmatism.

The experience of humiliation stems from the shame felt by some when they have to ask for free care. It runs contrary to their reference values of financial self-sufficiency. Furthermore, attending a facility for “the poor” or “the excluded” materialises their fall in social standing. So, receiving care at the facility represents the ordeal of status declassification. A 41 year-old woman commented:

Another case in point is a 26 year-old man who saw his inability to attend private clinics as a marker of his social declassification:

If these people manage to overcome their reluctance and finally ask for free care, it is chiefly due to their fear of worsening health or to the importance they attach to being healthy (primarily so they can work). The medical character of free clinics somewhat abates the discredit attached to assistance and helps them to accept aid more easily. However, so as not to present a “welfare recipient” self to themselves or to others, they attempt to minimise the extent of the aid they receive. Actually, they often postpone their recourse to care and, as far as possible, keep their attendance to a minimum. They limit their requests to the medical field since they do not want to benefit from any of the available social services. At the same time, they are reserved with staff members. This is way of remaining detached from an experience they have trouble assuming and of preserving their dignity by asserting their rejection of a discredited situation.

For instance, a 39 year-old woman who attended a public hospital after attending an NGO free clinic, highlighted how going to the same facility for many different health concerns may be experienced as ‘taking advantage’. She explained:

Importantly, the experience of humiliation occurs at hospitals as well as at NGO-operated clinics. Actually, it is not so much the characteristics of the care facility (and specifically whether or not it is exclusively for the poor) that are felt to confer a stigma as the inability “to manage on their own” without the help of institutional assistance. For instance, this stance was underscored by a 42 year-old man who said:

For another 43 year-old man, the positive appreciation of the social worker did not quell his deep-seated uneasiness at being assisted:

However, not all patients feel that resorting to a free clinic represents a humiliating ordeal. Actually, patients experiencing pragmatism manage to find reasons, which are not self-demeaning, for their recourse to the clinic, thus enabling them to use the available services pragmatically. Overall, their rationalisation is grounded in a dual outlook. One, they realise that they need medical care. Since health is one of their values, taking steps to remain healthy is “normal behaviour” over and above (or, at least, theoretically over and above) any financial or administrative contingencies and considerations about assistance. Two, they see the institutional aid as temporary. These patients also refuse the long-term status of “welfare recipients” but unlike the people experiencing humiliation, they rationally use the provided aid as a means of “managing” until they are self-sufficient. “The time needed to sort things out,” as many of them said. A 30 year-old woman, for instance, explained that she did not feel uncomfortable asking for free care:

These patients do not see receiving care free of charge as discrediting assistance. A case in point is another 30 year-old woman who talked about her interview with a local social worker who refused to give her the documents required to consult in the public healthcare system:

Consequently, the patients make use of the services of the social workers at the free clinics whenever they need to and do not attempt to limit the scope or frequency of their recourse to care. However, as long as the attendance remains occasional, the object of their recourse is still chiefly medical care. The manner in which the care is provided is central to their relationship with the free clinic and to their judgement of the facility.

When health insurance is still not available after several visits or when patients do not want to consult elsewhere, most of them gradually ease into the regular attendance mode. They usually feel that they are being properly cared for, that the reception is welcoming, and that social assistance follow-up is efficient. They feel comfortable at the facilities. All these factors prompt them to settle down into a regular care-management relationship. They then receive medium term medical and social assistance follow-up or go to the free clinic in much the same way as they would go to an ordinary care facility. They become accustomed to receiving easily accessible, free medical care, and to attending the free clinic for all their health problems, even minor ones. (Whereas usually patients in the occasional attendance mode only have recourse to care when they fear they have serious health problems.) We distinguish three lived experiences of regular attendance, which are usually in successive order, and which shape the above-defined moral career: initiation, settling-in, and demanding.

The initiation phase corresponds to the time spent internalising the operating rules and standards in effect at the facility. Once these are assimilated, the patients become increasingly self-sufficient within the facility. But the initiation phase also involves the social and symbolic aspects entailed by regular attendance at a free clinic. Actually, when attendance lasts over time, patients can no longer justify their recourse by considering it temporary and short-term. Some patients also come to realise their dwindling chances of finding a situation that will soon enable them to dispense with assistance. So, they have to transform the meaning of the care they receive so they can continue to go to the free clinic without gainsaying their values or feeling shame. At the same time, their social and personal identity changes quite quickly. The change is influenced by the features of the clinic and by the staff members’ motivations, among others. Particularly in hospital, the staff insist on every citizen’s right to care. During the initiation period, patients increasingly tend to define themselves as “entitled” to care and not as “welfare recipients”. NGO patients are also touched by volunteers’ efforts to develop friendly and respectful human relationships. Patients tend to define themselves - and to be defined - as “worthy” of care rather than as “welfare recipients”. In both types of clinics, the quality of the care and the welcome turns the process of asking for assistance into a less distressing experience. For instance, a forty year-old man commented:

A woman also said:

During the initiation period, the patients perceive the pre-requisites for establishing a good relationship with physicians and other staff members. They adopt - more or less consciously - a behaviour that will gain acceptance. For instance, a thirty-five year old man explained how he could get to know the nurses better and feel closer to them:

Gradually, they get to know the professionals and the professionals get to know them. Patients begin to enjoy meeting several staff members each time they visit. They also realise that it is possible to establish relationships that are not within the strict confines of the technical procedure. Anonymity gradually vanishes. For instance, during her first visits to a free clinic, a 39 year-old woman said that the defining character of the personnel was their “professional dedication”. Several months later, she changed her appreciation and said that it was their human qualities:

After the initiation phase, most patients settle into a regular relationship involving medical and social care management. They now systematically rationalise the help they receive either as citizens entitled to care or as human beings worthy of receiving help (Parizot, 2003). Expressing some sort of justification of assistance helps them overcome their reluctance and break with the detachment they maintained with the staff during the first visits. Personal ties are forged with some of the team members, a factor that places the relationship with the clinic on a symbolic level different from the level of discreditable assistance. The free clinic becomes a reference facility for them – a meaningful place in their lives, not only for their health but often for their social life in general. For instance, many patients said that even if they stopped receiving health care, they would go back to the clinic to let the staff know how they were, and “say hello”. Actually, our observations as well as the interviews with the professionals show that this happens regularly. For instance, a 30 year-old woman said:

At this stage in the relationship, the patients pay close attention to what accompanies the therapeutic procedure per se. They often recognise that the provided service is not merely medical. The welcome service and responsive listening gain in importance and are not actually distinguished from the medical function. Sometimes they are even considered as the first contribution of the free clinic. A 50 year-old man who attended the NGO free clinic explained it in these words:

The care-management relationship often takes shape as a combination of social, medical and psychological support. The patients see it as a sign of responsive listening and of personal respect. The staff-patient interactions become true relationships involving exchange, following the dynamics of reciprocity similar to relationships between friends. This is paramount in a context of social discredit. For instance, we observed that some patients gave staff members a gift in recognition of their aid. Many respondents actually talk about their relationship with the staff in terms of family relationships or relationships between friends or family members. It is known that economic precariousness often disrupts social and family ties. In regular attendance, the very isolated find a little of the emotional warmth they no longer find anywhere else.

“Here, it’s like my family, you know,” said a thirty year-old man.

Another thirty-four year-old said about a volunteer:

The words of a fifty year-old man about “his” physician are also meaningful:

The experience of demanding care creates very different relationships between the staff and patients. Similar to what happens during the settling-in experience, this group systematically rationalises its recourse to assistance. However, their patients needs come first and their focus is almost exclusively on their right to assistance, to a point where they are unable to adjust to the constraints of the facilities. They become very forthright in demanding care and insist on dictating what sort of care they want and how it should be provided.

In most cases, the people are dealing with serious medical or social problems. Their multiple handicaps are the only things on their mind, so much so that they can see no logical reason for any restriction to their demand for assistance. Specifically, they do not either understand or accept that the facilities may append financial, administrative or organisational constraints to their demands. A case in point is a thirty year-old man who was going to the hospital for the medical follow-up of his HIV infection and for social work:

The man justified his uncouth manner that was misunderstood by the staff members:

The demanding attitude is part of an overall mistrust of institutions in general. This group often has a feeling of being intentionally dispossessed of a legitimate claim. They also fear that they are being denied access to the latest medical innovations – an attitude that, of course, can also be found in people without any particular social problems. Consequently, they tend to ask for or even demand many examinations and drug prescriptions.

During this phase of the moral career, patients very seldom develop strategies to gain acceptance and appreciation. On the contrary, armed with the conviction of their rights they openly and sometimes bitterly upbraid any staff member who does not work to meet their demands. A woman commented:

Another case in point is a twenty-eight year-old man who openly challenged the constraints he had to meet to receive help from the institutions:

The patients are also often navigating between their feeling of satisfaction with the quality of the service they receive and the feeling that their needs and desires are not being satisfied. In these conditions, relationships with staff members become strained. The patient’s demanding attitude restricts the professionals’ margin for initiative and deprives them of the symbolic retributions that are often necessary to keep doing a hard job. A nurse’s aide reproached this group of patients in these terms:

In the clinics we studied, few people experience the demanding phase. At the NGO clinics, patients are usually grateful to the volunteers providing services without pay. Since the image of the clinic at the public hospital projects an image of a competent technical facility, the social side of its services is considered as an additional task that the staff is not formally obligated to ensure. Mostly, patients seem to be aware that demanding care and criticising put them at risk, i.e., the risk of being shunted to the side-tracks of the assistance system. The man with an HIV infection who was extensively quoted above said:

The third mode of attendance, which we call inconsistent attendance, concerns but a small proportion of the population. It mainly applies to marginal people who have trouble settling into a social-medical assistance facility. Their medical requirements of the free clinics are inconsistent, as testified by a 42 year-old man who said he came to a free clinic because of a “late winter cold.” However, when asked whether he had seen a physician, he merely answered:

Often, the attention they pay to their health or treatment vanishes once the symptoms have disappeared and they have trouble taking the prescribed treatments. Steps recommended by social workers are also seldom taken. Inconsistent attendance should be correlated with their attitudes toward health and medicine; attitudes very dissimilar from the reference standards of the personnel at the medical facilities. The patients often do not attach much importance to the medical milieu’s values concerning the requisite behaviours for hygiene, health, and care. On the one hand, these concerns may seem secondary to finding food, shelter, clothes, and resources. On the other hand, living conditions and representations of the body admittedly have an impact on the attention devoted to the body and on the sensitivity to bodily signs (Boltanski, 1971; Blaxter, 1990). The decline of self-image caused by exclusion often entails a gradual detachment from one’s own body – to the point of blunting the need to look after it.

Actually, the - often huge - differences between the staff and the patients’ representations of the time when a physician “must” be seen hamper any stabilisation within the free clinic. The conflicting representations are likely to spark mutual misunderstandings. But above all, marginal people are generally unable to comply with the institutional constraints that would allow them to enter into the sphere of assistance in a regular manner. Of course, some use the social or health services over time but in a disorganised manner. For instance, some resort to a facility for a while. Then, just as the formalities for the social services or medical follow-up are initiated they stop attending for a time, only to resume attendance at a later date, behaving all the while as if they had never stopped coming.

Some patients are even reluctant to comply with the constraints when they find a temporarily satisfactory balance in their marginal lifestyle. This may be called an experience of service instrumentalisation. The people say they are satisfied with their marginal lifestyle, at least for the time being, and reject any assistance that may jeopardise it. Their daily life is organised around a few remunerative activities (odd jobs, begging, makeshift arrangements, and so on) and around the opportunities for obtaining aid. Attendance at a free clinic is part of this approach, since they find access to medicine and occasional help from the social service at the facility. Remarkably, this group uses the services to continue their marginal life. They enjoy receiving help without having to give much back in return. However, medical as well as social follow-up is jeopardised. For instance, after several months a twenty-seven year-old man had still not taken any of the steps, recommended by the free clinic social worker, to obtain health coverage. He stated:

Nevertheless, most of the time inconsistent attendance concerns people who are experiencing the material and moral hardship of extreme precariousness. Although they express the desire to break with their marginality, they are experiencing such disruptions that their instability precludes any regular social and medical follow-up. Their social, medical and sometimes psychological difficulties often seem closely connected. At free clinics, they experience the crisis of marginality. Their recourse serves as stopgaps for different problems in their lives and encompasses more than the medical field strictly speaking. But they find it very hard to benefit fully from the available care and services. They often give up on the goals they set with the physicians or social workers, especially due to the magnitude or duration of the requisite steps. A 27 year-old man admitted that he was too “disorganised” to reach his goal:

The patients do not deal well with the constraints of assistance, especially when the constraints bring them face to face with a reality they find hard to bear. For instance, the same twenty-seven year-old shrewdly explained:

Whatever the lived experience during inconsistent attendance, the patient’s relationships with the staff members are also inconsistent. Because the people in this group do not care much about complying with clinic rules, they might occasionally give in to violence since they often cannot cope with any constraints whatsoever or they suffer from psychiatric disorders, alcohol or drugs problems. Inconsistent attendance upsets and sometimes discourages the free clinic personnel not only because of the patients’ behaviour but also because instability lowers the chance that the staff’s actions will be successful. Nevertheless, it happens that patients do manage gradually to settle into their relationship with the facility because of the attention they receive and the flexibility of the suggested care and services. In such cases, the clinics we studied facilitate this group’s entrance into the sphere of assistance and may foster the gradual restructuring of their self through regular and affective relationships with staff members.