France

France. Area-550,986 km². Population in 1932-41,840,000. Population density according to the 1926 census-74 persons per 1 km². Demographic data. France is a country where, since the 1860s, population growth has almost stopped. This is explained by low birth rates and relatively high mortality. In terms of birth rates, France occupies one of the lowest positions among European countries; mortality in it is higher than in most Western European countries (England, Germany, etc.). As a result, the natural increase is extremely small, in some years (1929) it was even negative (Table 1). Table 1. Natural movement of population in France (per 1,000 inhabitants). Years Birth rate Mortality Natural increase 19.0 18.8 18.2 18.3 17.7 18.0 17.4 17.3 16.3 17.5 17.7 16.5 16.4 17.9 15.6 16.3 15.8 15.8 1.5 1.7 1.8 -0.2 2.4 1.1 1.5 0.5 49% of France's population lives in cities. Rapid industrial development in France after the war and the shortage of labor due to the small population growth caused huge immigration to France from neighboring countries-Italy, Spain, as well as from Czechoslovakia and Poland. The annual number of immigrants, until 1930, reached 250,000-300,000. Since the economic crisis, i.e., in 1930, the influx of immigrant workers was severely restricted, and now, due to sharp unemployment, it is practically closed. Organization of healthcare. Despite the characteristic extreme centralization of state power and its organs, the organization of healthcare is decentralized and scattered among several ministries. The organization of healthcare is based on the law of November 15, 1902, which established and codified sanitary rules and established the highest sanitary body-the Higher Council of Public Hygiene, sanitary inspection, etc. The law of January 27, 1920, created the Ministry of Health, which existed until 1924, was then included in the Ministry of Labor, and was again restored in 1930 as the Ministry of Hygiene. The Higher Council of Hygiene (Conseil Supérieur d'Hygiène) has a consultative voice and includes 45 members appointed by the minister from a list presented by the medical faculties, Medical Academy, etc. The Council discusses issues of public hygiene, medical and pharmaceutical practice, production and sale of mineral waters, etc. In 1925, the Bureau of Social Hygiene was organized under the ministry, enjoying a certain autonomy.--In each department (all France is divided into 89 departments and 3 in Algeria) the prefect is responsible for the creation and functioning of sanitary institutions. At his disposal is the Departmental Council of Hygiene with a consultative voice, consisting of 10-15 members. Each department is divided into sanitary districts, headed by sanitary commissions of 5-7 members under the chairmanship of sub-prefects. The functions of these institutions include improving populated areas and housing, prevention of infectious diseases, supervision of epizootics, procurement and delivery of smallpox vaccine, medical assistance to the needy, hygiene in industry, schools, etc., care for foundlings, inspection of beverages and food products, supervision of dangerous and harmful enterprises, etc. In communes (the lowest administrative unit) the supervision of sanitary rules is entrusted to mayors, elected but subordinate to the prefect. They may issue sanitary rules within the limits granted by general laws. In every city with a population of over 20,000 inhabitants, in every resort with 2,000 inhabitants according to law, there are hygiene bureaus for supervising the implementation of sanitary rules. Their directors are doctors approved by the Higher Sanitary Council. Paris is singled out as a special sanitary district with its own separate organization. The same law established the Departmental Sanitary Inspection. In 1914 there were 28 organized inspections, of which only in 11 were the inspectors doctors-hygienists. In 1924, inspection was in 48 departments and in 36-doctors-hygienists. In 1931 there were already 77 departmental inspections, of which 70 were in the hands of specialist doctors. Since 1925, the number of local departments of social hygiene has also been growing rapidly, first fighting against tuberculosis, then including other functions. In February 1934, France had 55 departmental bureaus of social hygiene (Office d'Hygiène Sociale) and 34 departmental public departments of social hygiene, in addition to 185 municipal hygiene bureaus. The 1902 law, on which all this organization rests, is very outdated and now the question of creating new sanitary legislation has become acute. In general, the sanitary organization of France is underdeveloped and uneven across the country, many of its branches are weakly regulated and at the same time there is no connection between it with therapeutic medicine. Inspectors and directors of municipal bureaus are paid by departments or the city, but usually the payment is negligible, and the doctor engages in private practice, devoting only part of his time to the bureau. In the suburbs of Paris, where there are communist municipalities, large hygiene bureaus have been created with well-paid doctors. The rights of all doctors-hygienists are very limited, while the social hygiene bureaus have no rights at all, and are only information bodies and partly uniting disparate local organizations. A whole range of sanitary departments are scattered among other ministries. Thus, the Ministry of the Interior includes the general inspection of sanitary administration and a commission for the distribution of funds received from the tax on gambling houses-a major source of income for healthcare. The Ministry of Labor includes the administration of social insurance and mutual aid societies, hygiene and labor safety, labor inspection, the Higher Statistical Council. The Ministry of War oversees healthcare in the army, and the naval ministry-in the navy, as well as the corresponding military-medical and naval medical schools. The Ministry of Colonies manages healthcare in the colonies; the Ministry of Pensions-medical examination, prosthetics and assistance to the disabled. The Ministry of Agriculture is responsible for the control of food products and pharmaceutical preparations; the Ministry of Education-medical faculties, Medical Academy, Higher Vaccination Institute and school medical inspection. The Ministry of Justice includes medical assistance to prisoners, management of correctional-medical institutions for juvenile delinquents. The Ministry of Public Works includes the department of hygiene of stations and paths. At the Ministry of Finance and Posts and Telegraphs there are their own special sanitary departments. Finally, border protection is regulated by a special law of January 26, 1929. All the coast of France is divided into 5 sanitary districts, at the head of each is a director-doctor appointed by the Ministry of the Interior. Infectious morbidity. In terms of the level of morbidity from infectious diseases, France is less fortunate than a number of other Western European countries. Typhoid fever in France continues to remain at relatively high figures. Mortality from it in recent years is about 4.5 per 100,000 population, while in England this figure has dropped to 1.0 per 100,000. In 1931-33, per 100,000 population, annually died from typhoid fever in Paris-3.5, in Montpellier-6.1, in Marseille-17.7, in Toulon-20.8 persons, while in most cities in England the annual mortality from typhoid fever was about 1.0 per 100,000. Typhus fever has not completely disappeared in France; it is observed there in a mild form, of Brill's disease type (see Typhus fever). Smallpox has also not disappeared in France: from 117 to 162 cases of smallpox are registered annually (1931-33). Vaccination is compulsory by law (in the 1st year, at 11 years and 21 years). The fight against diphtheria is carried out by mass vaccination according to Ramon in schools.-Among chronic infectious diseases, tuberculosis and venereal diseases are widespread. In terms of mortality from tuberculosis, France occupies one of the highest places in Europe (see Tuberculosis). The fight against tuberculosis in France is basically of a philanthropic nature. The first dispensary was founded by Calmette in Lille (see Dispensary), but their number grew slowly before the war. After the war, on the initiative and with financial support from Americans (Rockefeller Commission), dispensaries and sanatoriums began to develop much more widely. In 1919, the National Committee for the Fight against Tuberculosis was created and public organizations with government subsidies began to appear. The fight is carried out through dispensaries, sanatoriums, preventoria for children and youth and sanitary education. Since organizations in each department are autonomous, the National Bureau of Hygiene and the National Committee are only coordinating bodies, not leadership and coordination. In December 1933, the following institutions for the fight against tuberculosis were functioning (Table 2).

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Table 2. Form of institution and number of beds in them Preventoria public . . . Sanatoriums marine: 15 28 19 9 43 16 40 30 17 24 6 815 12 3L0 6 062 7 183 2 807 2 090 3 975 976 7 627 4 772 6S3 Sanatoriums mountain: Public.......... Sanatoriums plains: Public.......... Total . . . 59 505 "Founded by philanthropic organizations, but receiving subsidies from the state or municipalities. Under construction were 6 preventoria, 9 sanatoriums and 13 b-c-sanatoriums. However, it should be borne in mind (see Dispensaries, Tuberculosis), that dispensaries in France are essentially philanthropic institutions, lacking the social significance that they have in the USSR. Vaccination by Calmette is widely applied. On 1/1/1929, 152,009 children were vaccinated. Funds for the fight against tuberculosis are allocated by the government through the Ministry of Health, then from a special fund (tax on gambling houses, etc.); about 20 million francs a year are provided by the sale of tuberculosis stamps by the National Committee. Credits through the Ministry of Health, including the maintenance of sanatoriums, subsidies for preventoria, allowances for tuberculosis patients and long leaves for tuberculosis, amounted in 1934 to 58,995,000 fr., 6 2f Venereal diseases in France are widespread and do not show a tendency to decrease, despite the large growth of institutions for combating them. In recent years, cases of venereal diseases are as follows (table 3; fresh forms of diseases). Table 3. Years Syphilis Gonorrhea 1930...... 78,246 51,108 9,135 1931...... 99,712 59,291 9,843 1932...... 102,237 54,209 6,481 These data refer only to patients in public dispensaries and consultations; this does not include those being treated by private physicians (a huge mass of venereal disease patients are treated by private practitioners and are not registered). According to data from French syphilologists, 10% to 15% of the entire population is infected with syphilis in one way or another. During the war, venereal diseases spread so much that the government was forced to take special measures. A special department was created at the Ministry of the Interior and at the Ministry of Social Security. Parliament allocated credits for the fight against venereal diseases. The development of institutions for combating venereal diseases went at a faster pace, but here, as in the fight against tuberculosis, no decrease in morbidity is observed. Among pregnant women in consultations in 1932, out of 44,260 women, 7,155 syphilitics were detected (16.3%). In infant consultations in the same year, out of 62,587 children, 8,711 cases of congenital syphilis were detected. In prisons in 1932, 17,372 male venereals and 1,631 women passed through venereal consultations. The number of institutions for combating venereal diseases in 1932 was: dispensaries-552, rural venereal points-87, prison-189, anti-gonorrheal-188, institutions for combating congenital syphilis-803, special laboratories-78. Prostitution has been growing strongly in recent years in connection with the deepening of the crisis. Prostitution is legalized, prostitutes must register and undergo medical examination at certain intervals. Since 1920, there has been a National League for the Fight against Venereal Diseases. It owns a large institute of A. Fournier in Paris with a model dispensary, laboratories, School of Serology, etc. In addition, there is in Paris the A. Verno Preventive Institute, subsidized by the city and state and having branches in the provinces. The fight against cancer in France. According to statistical data, mortality from cancer in France is increasing; this is partly explained by the clarification of diagnosis and better registration. From 1908 to 1912, the average mortality from cancer was 78.4 per 100,000 inhabitants, in 1920-79, in 1925-74, in 1928-96. In absolute numbers, from cancer died in 1920-28,327 people, in 1928-39,140 people. The fight is conducted by the French League for the Fight against Cancer, scientific-medical institutions and so-called regional centers. In Paris, Lyon, Bordeaux there are in hospitals special departments for cancer patients. The largest center is the Curie Institute in Paris, having 3 departments: research, biological and therapeutic. This institute possesses the largest amount of radium in the world-14 g and 8 installations for deep radiotherapy at 250,000* volts each. In Viljuif near Paris there exists the largest and well-equipped cancer institute at the Paris Medical Faculty. In 1933, the number of anti-cancer centers increased to 25, of which 12 regional and 13 departmental. All of them are connected with local medical faculties and with local offices of social hygiene. The government allocated subsidies to these centers in the amount of 23 million francs for 1930-34. The League for the Fight against Cancer distributes a large amount of literature, in which it acquaints the population with the danger of cancer and the necessity of early diagnosis for treatment. Municipal hygiene and sanitation. The state subsidizes communes in the construction of water supply systems and drinking water supply in the amount of 50% of the construction cost. In 1930, these subsidies amounted to over 157 million francs. Many communes join together to construct water supply systems. In 1933, in all cities with a population of over 5,000 inhabitants, there was a water supply for drinking water. Out of 1,554 communes with a population of over 3,000 inhabitants, only in 261 (18.97%) there is no water supply. But qualitatively the drinking water supply is not as brilliant as quantitatively. Thus, in 1933, out of 37,967 communes of France, only in 11,000 (30%) the drinking water was of good quality, and in ^b/v small communes and villages water for the water supply is often taken from a polluted source, well, etc. In 1933, sewerage for waste water and filth existed in all cities with a population of over 3,000 inhabitants, but only in 25% of these cities is its organization at the level of modern technology. Slaughterhouses almost everywhere belong to cities and are under the supervision of special sanitary inspectors and veterinarians. Garbage removal in cities is carried out everywhere by municipalities, in some it is contracted out to private societies. In large cities there are garbage incineration stations.

Medical help and medical personnel. Since the time of the French Revolution, medical assistance has been declared by law to all those in need. But only since the end of the 19th century did this assistance become a reality, and then only within certain limits; private practice physicians' unions jealously watch the development of public medical assistance. The law of 1902 clarified the rules of the law of July 15, 1883, according to which all indigents have the right to full free medical assistance. The law of June 30, 1838, extremely outdated but still in force, formulates the rules of medical assistance and the internment of mental patients. The law of April 15, 1916, repeatedly supplemented, established free medical assistance to all tuberculosis patients, pregnant women and parturient women. The organization of medical assistance depends on the department council, and in Paris on a special department of public charity, under whose jurisdiction all hospitals are. In each commune there is an official charity bureau, receiving a subsidy from the authorities and helping indigent patients with allowances. In recent years, partly under pressure from the union of private physicians, there has been a tendency to charge patients in public hospitals depending on the patient's income. Thus, according to the rules of the Hospital Association of 1924, only families with an income below 15 francs a day are exempt from any payment, with an income of 'from "8

France. Patients aged 16 to 18 pay ¹/₆ of the hospital fee, those with income above 25 francs pay in full. With the introduction of social insurance in 1930, actually ²/₃ of the population of F. receive medical care free of charge, but even before social insurance and from the beginning of the 19th century, mutual aid societies developed widely in F., providing their members with treatment in case of illness, a small pension, and maternity insurance. In mutual insurance societies for maternity in 1926, there were 147,573 members, in school societies in 1924 there were 4,143,940 members, grouped in 18,787 societies. The capital of all mutual aid societies in 1926 amounted to 725 million francs. The state grants societies an allowance of 1.5 francs per year per member over 18 years of age. In large private enterprises (railway companies, factories, etc.) there are local mutual aid societies, in which entrepreneurs contribute part of the expenses. With the development of public medical care, social insurance, etc., in recent years, the role of private practicing physicians has somewhat decreased, although it remains extremely significant to this day. Doctors in F. are recruited from the petty and middle bourgeoisie and are an element with a narrowly individual, private approach to the matter of public health. Medical education is provided as follows: there are 9 medical faculties and 15 medical schools, where students complete the first two years. To enter a medical faculty, in addition to a high school diploma (baccalaureate), a special one-year course at the natural sciences faculty is required. Until 1913, the course at the medical faculty was 4 years, from 1913 medical teaching was reformed and the course extended to 5 years. By the law of March 6, 1934, from 1935 the course was extended to 6 years, which with the natural sciences faculty will make 7 years. The maintenance of a student for seven years of study makes the profession accessible only to students from a financially secure environment. Hospital internship begins from the very first year of the medical faculty and lasts 6 years. The percentage of foreign students is very high (up to 15% of all medical students), but they do not receive the right to practice. Until 1892, there was the title of feldsher (officier de sante), which was then abolished. In 1926, there were 585 doctors per million inhabitants, i.e. one doctor per 1,710 inhabitants. Since the war, there has been a concentration of doctors in cities, and excellent roads and the automobile that each doctor usually possesses allow him to serve a large area. In 1932, the number of medical personnel was: doctors-25,255, dentists-7,357, midwives-11,011 and pharmacists-10,893. In Paris in 1932, there were 6,141 doctors, 2,061 dentists, 978 midwives and 1,991 pharmacists. In 1932-33, throughout F. and Algeria, 1,292 state medical diplomas and 170 university diplomas (without the right to practice) were issued. In recent years, due to the crisis and unemployment of doctors, there has been some decrease in the number of medical students and diplomas issued. For secondary medical personnel, a state diploma was established in 1922. For them, there are quite numerous private and state schools, usually with a 2-year course. For social assistance sisters in 1933, there were 85 special schools with 3,000 students (28 hospital, 32 Red Cross, 21 private), the course is three years. In 1929, there were 11,750 certified sisters, 8,004 nun-sisters, also certified, 1,562 sisters for social assistance for tbc, 820 sisters for maternal and infant care. Hospital affairs. Hospitals are divided into state, municipal or city, and private. The first category includes military hospitals, partly hospitals for the mentally ill and some university clinics. The largest number of beds is concentrated in city and municipal hospitals. To this must be added hospitals created by philanthropists or charitable societies. The latter usually conclude contracts with the city for the admission of patients, for whom the city pays at a low tariff. The number of hospitals has been growing rapidly in recent years, many old hospitals are being moved out of cities and renovated. In 1929, throughout F., there were 1,301 state and public hospitals (not counting private ones) with 151,514 beds, i.e. one bed on average per 300 inhabitants. In 1934 (March), in all departments, except Paris, there were already 1,631 hospitals with 163,879 beds. In quality, hospitals are extremely diverse: less well-equipped (for the poor)-free, better-equipped-payable. All equipment and apparatus are manufactured in F., which is a major supplier of this equipment on the world market. In addition to hospitals, in March 1934, there were 196 public laboratories (municipal, departmental, etc.). Resort business. The resorts of F. are extremely numerous and diverse. In addition, F. produces and exports abroad a colossal amount of mineral waters (Vichy, Contrexeville, etc.). In total, there are about 200 resorts (mineral waters, mud, climatic stations). Almost all resorts are operated by private societies, except for Aix-les-Bains, which belongs to and is operated by the state, as well as Vichy, which belongs to the state but is leased to a private company. 90% of resort visitors belong to the large, medium, and petty bourgeoisie. The main income of companies operating resorts comes from casinos and roulette, which are found in almost every resort. 60% of this income goes to the state. A special fee is charged from resort visitors depending on the hotel in which they stay. Its amount is determined by the local municipality. Treatment is carried out everywhere by private practicing physicians. Protection of motherhood and childhood. In F., women do not enjoy political rights, and the legal rights of a married woman are very limited. Paternity searches are not conducted. Protection of motherhood is actually reduced to the encouragement and subsidies of numerous families, for which rather large sums are allocated in the state budget, but rather fruitlessly. In recent years, however, there has been a rapid growth of preventive and treatment institutions for mothers and children, but since the social foundations of legislation do not change, the influence of these institutions is very weak. Any propaganda in favor of birth control is strictly prohibited by law, which does not prevent the contraceptive industry from flourishing and even exporting its products abroad. Propaganda in favor of increasing birth rates essentially applies only to the working classes, since among the bourgeoisie birth control has become a system. The law of July 30, 1913 allows a working woman to leave her employer in case of pregnancy without notice and without paying him a penalty for leaving. A pregnant woman has the right to leave for 4 weeks before and 4 after childbirth, but without any allowance from the enterprise. It is clear that this system forces a pregnant worker to work even during the 'right to leave.' She is given an allowance by the commune in the amount of from 50 centimes to 1.5 francs per day. Under the law of October 24, 1919, a mother nursing a child receives an allowance of 15 francs per month. In enterprises with more than 100 female workers, the law may require the employer to provide special rooms for nursing mothers and give them an hour a day for feeding. Abandoned children are cared for at the state's expense. By the law of July 23, 1923, a special 'national allowance' was established for large families. It is granted to families not included in the lists of income taxpayers. The allowance is 90 francs per month, starting from the 3rd child up to 15 years of age, if the latter is not enrolled in a vocational school or workshop. Almost all departments give allowances from 100 to 1,000 francs per year for a child in large families. Under the law of July 15, 1893, medical care for the sick and pregnant women is free in case of need. Finally, the social insurance law of 1930 established all types of free care for pregnant and parturient women. Infant mortality is gradually decreasing (Table 4): Table 4. Infant mortality in France. Years Mortality per 1,000 live births Years Mortality per 1,000 live births 1912 .... 1913 .... 1923 .... 106 114 1930. . . . 1931 .... 1932 .... 78 76 76 The number of illegitimate children on average fluctuates from 8 to 10%, in Paris this proportion reaches 25-30%. Among illegitimate children, mortality is very high. Thus, in 1927 it reached 137.5 per 1,000 compared to 78.5 among 'legitimate' children. The percentage of stillborn children among illegitimate children is also very high, as is the mortality rate among abandoned children cared for by the state. In some departments in recent years it reached 80-90%, the average mortality for them in 1927 was 190 per 1,000. The role of medical institutions for the protection of motherhood and childhood is still very weak, but the network of these institutions has grown strongly in recent years (Table 5). Table 5. Type of institution Number of institutions on 31/XII 1933 Prenatal consultation clinics.................. Maternity shelters and hospital departments.................. Mother and child homes and shelters........ Dispensaries for infants . . . . . Nurseries................... Centers for placement in families . .

Centers for the protection of motherhood and infancy ............... 418 114 4 482 570 105 In 1930, in 26 departments, there were sections for the protection of motherhood and infancy under the Hygiene Bureau. In Paris, there is a central school for training nurses and doctors for social-medical service of infants and mothers—one of the best-equipped institutions in Europe. The government and private societies subsidize summer colonies for children. In 1931, there were 840 such colonies, admitting 265,802 children. There is no compulsory school inspection; therefore, its organization varies in different departments. In fact, inspection exists only in large cities and in primary schools. In 1924, inspection was present in 19 departments, in 1931—in 33. For mentally retarded children, of whom, according to Dr. Rubinovich (a French psychiatrist), there are about 50,000, there are 7 boarding schools, 3 day schools, and 30 'additional' special classes. The health budget is divided among several ministries, although the main amounts appear in the budget of the Ministry of Hygiene, reestablished in 1930. The budget of this ministry amounted to 1,303,073,100 francs in 1933. Overall, the central budget for health care has barely increased in recent years, and since 1934, it has been cut by 30%. Meanwhile, health care expenses in the departments are growing rapidly. In 1927, they spent 994,550,343 francs on health care, in 1930—1,440,022,213 francs. In addition, one must add the budget of numerous private philanthropic institutions. But if we analyze the expenses of the Ministry of Health, the picture is different. Thus, in 1933, out of the total amount of this budget, 300 million were spent to help large families. Bonuses for births amounted to 21 million—a also negligible figure. 19 million go to additional allowances for large families. 405 million were spent on assistance to the elderly, the disabled, and the incurably ill. About 100 million francs were spent on subsidies for the construction of cheap apartments. Thus, expenses for purely medical measures and for social hygiene occupy a small place in the budget. In addition to budget allocations, a significant source of income for the Ministry of Health consists of revenues from theaters, cinemas, clubs, betting on horse races, from casinos and gambling houses.