Reconstruction

Lot of questions vie email and Facebook about Saturday's post about my appointment with the plastic surgeon on Friday.  An 18 month wait seem to confirm some idées reçues about "socialized" medicine.

The thing to remember about the French healthcare system is that it's a mixture of public and private.  Most doctors do not work exclusively for the public system.  Some are completely independent and others have a mix of hours at public hospitals, private clinics, and their own practices.

There are two different payment systems here:  state insurance (Assurance maladie) and private insurance companies (mutuelles).  The latter are usually offered as part of a job package (not unlike in the US).  The way it works is that the private insurance is meant to pay for extras that the state insurance does not cover.  A good example would be hospitalization.  Basic state insurance will cover 100% a hospital bed in a room shared by one or two other patients.  If you have private insurance, however, the mutuelle will pay the difference and you can get a private room.

So everyone, regardless of income or status, gets the basic stuff covered by state insurance.  That means that breast cancer treatment is entirely covered - surgery, chemotherapy, radiation therapy, tamoxifen, follow-up appointments, PET scans, MRI's, pain meds - and you never EVER see a bill or have to think for two seconds about how something will be paid for.  Just show your Carte Vitale (state insurance card) and everything is taken care of automatically.  It is incredibly efficient and I am in awe of their ability to provide this kind of cost-effective quality care with a minimum amount of bureaucracy.  Think of it as an "All care, no costly BS" system.

Extra stuff, however, will cost you or the mutuelle, extra.

So what happens with breast reconstruction?

First thing to get clear is that breast reconstruction after a mastectomy is covered by French state insurance.  It's not an extra - it's part of the basic state plan.  That said, the questions are:  how it will be done, when it will be done and where the surgery will occur.

The first question will be answered by me and my surgeon.  There are different options but what it looks like is that I will have to have implants.  I'm just too darn skinny and there isn't enough laine around my middle to use to make two breasts even though I'm not shooting for much here.  I have no desire to look like a Baywatch girl;  I'm thinking more along the lines of an 18th century coupe à champagne designed, they say, using the breast of the Marquise de Pompadour (or Marie Antoinette) as a model.






The when and where are equally complex.  Essentially, I have three options:

1.  The cancer clinic where I have been undergoing treatment now for nearly 2 years.  This was my first choice.  They know me and I know them.  I trust them.  My mastectomy went as well as could be given the circumstances and I still remember the kindness of the surgical team as I went under and the excellent aftercare given by the staff.  These people saved my life.

I can have the surgery done there but it will take 18 months at least before it can happen.  That's the news I got on Friday.  But that's not the last word.  There are other options.

2.  A private clinic that charges reasonable rates.  By "reasonable" I mean one where the bill will not go over what the French state insurances pays and what my private insurance (yes, we have one) will cover.  That's going to require some research and will take time.  There will be paperwork.

3.  A private clinic or plastic surgeon who has an excellent reputation but has fees that will far surpass my coverage.  This would also require research and a cold hard look at the state of our finances.  What is it worth to me and to my spouse to have this done?  5,000 Euros?  10,000 Euros?  20,000 Euros? Who knows.

Now that I am well-rested, well-fed and my head is in a better place, I can start thinking about what I want to do next.  Option 2 is the most realistic and I will start working on that this week.  I can ask both my GP and my gynecologist at the Franciscans here in Versailles for referrals.  If anyone reading this has a plastic surgeon they know and love here in France, please pass on the name.  I'd also really appreciate hearing from any Flophouse reader who has had breast reconstruction. How did it go?  Are you glad you did it?   I'm reading the material they gave me at the hospital and sounds like a lot can go wrong.  Scary, and all for something that is, strictly speaking, not necessary surgery.  Yvonne (Considering the Lilies) posted this photo.  This woman chose not to have reconstruction and instead used the space for a pretty incredible tattoo.  Something to think about...

The Path to French Citizenship: Certificate of French Nationality

I went down to the Japanese Embassy near Etoile last week to pick up my Japanese police report.  As always the Japanese consular officials were very efficient - I was in and out in under 15 minutes. I was dying to know what it looked like (and what is in it) but I will never know because it comes sealed in a brown envelope and I was informed (quite sternly) by the Japanese Consulate that only the French Prefecture has the right to break the seal and see the contents.

Another document we need is an official Certificate of French Nationality (Certificat de nationalité française) for my French husband and we soon discovered that Anne Sinclair was right - it is not as easy as it looks to actually prove that one is French.  What exactly is the purpose of this document?

Le certificat de nationalité française (CNF) est un document officiel, qui sert à prouver la nationalité française.
Il indique comment et pourquoi le demandeur a la qualité de français, ainsi que les documents qui ont permis de l'établir.
Il peut notamment être demandé lors d'une première demande de titre d'identité sécurisé (carte d'identité ou passeport), ou pour une candidature à un emploi dans la fonction publique.
(The Certificate of French nationality is an official document that serves to prove French nationality.It indicates how and why a person is French, as well as the supporting documents to support the claim.It can be required when a person first requests a secure identity document (identity card or passport), or when a person applies for a job in public service.)

Sounds like every French person has an interest in having one (just in case, mind you).  So how does one go about getting this precious document? Well, it depends on where the French person making the request is located (France, Paris or abroad) and whether or not he/she was born on French territory or abroad.  My husband's case is a bit tricky because he was born in Medea, Algeria in 1962 when Algeria was a French dominion.  In that case, we were told, my husband, once he has all the documentation, needs to apply at the Versailles Tribunal d'instance (which is happily not too far from our apartment).

Now that we know where to apply, we turned to the issue of what documentation will be required.  Turns out that this is quite tricky and depends on the category of the person making the request.  There are no fewer than five cases and they are worth examining because they are a snapshot of French nationality law as it is applied today:

Personne née en France, d'un parent né également en France (a person born in France of a parent also born in France):  This is the infamous double jus soli rule that says that anyone born in France with at least one parent born in France is French even if the parents and grand-parents were foreigners.

Personne française par filiation (French by filiation)  This is transmission of nationality by blood, also known as jus sanguinis.  Anyone with a parent who is French is French by right of blood (droit de sang).  This must be proved by producing documentation about one's parents and also one's grand-parents.

Personne devenue française par acquisition volontaire (décret ou déclaration de nationalité) (Person who voluntarily acquired French nationality by decree or declaration) These are the naturalized citizens who became French by either applying for it or by decree (it can be simply conferred on a person in some cases).

Personne devenue française pendant sa minorité, en raison de l'acquisition de la nationalité française par l'un de ses parents (Person who became French as a minor child because one of his/her parents acquired French nationality)  So this means any child with foreign parents who became French by naturalization during that child's minority received French citizenship as a result.

Personne devenue française par acquisition de plein droit à sa majorité, par naissance et résidence en France pendant 5 ans (Person who acquired French citizenship at his/her majority, by birth and residence in France for at least five years).  This is a combination of jus soli and what you could call residency-based citizenship.  The two requirements are that the child be born in France and have resided in France for at least 5 years during his/her minority.  From this it seems that having lived 13 years outside of France during one's minority still gives a child born in France the right to French citizenship.

My husband falls under the category of "Personne française par filiation" which means that he is now calling the authorities in both the Limousin and Normandy (his parent's regions of origin) in order to get official copies of their birth certificates and those of their parents (his grand-parents).  Frankly, he finds this all a bit annoying - his reaction seems to have mirrored that of Anne Sinclair.  He was also not amused when I suggested that he might find some surprises in his family tree - a Spaniard or an Italian, perhaps?

The delicious irony of all this, of course, is that the people who have the least amount of paperwork to provide for a CNF are the naturalized citizens (i.e. the foreigners) whereas the French who have been French for generations by blood and soil have to provide a pile of official papers proving Frenchness going back at least two generations.   Was this really what the Right had in mind?  Probably not.  So I guess we can just consider this another unintended consequence of laws designed to harass the "foreign" which result in enormous inconvenience for the "native-born."

Language, Nation, and State

It was a good Christmas at the Flophouse.  I had a number of books I had been lusting after and, lo and behold, Santa (via La Poste) graciously fulfilled my wishes.  Ever since late December, I've had my nose in a book (actually I've had my nose in a book since I was 5 years old much to the despair of my loved ones) and I've just finished one that I thought you might be interested in: Language, Nation, and State: Identity Politics in a Multilingual Age (Europe in Transition: The NYU European Studies)

It's a book of essays edited by Tony Judt and Denis Lacorne about language and identity - topics that people tend to have very strong feelings about.  All of the essays in the book are excellent but there was one that I thought was outstanding.  

"Difference Rights and Language in France," by Alain Fenet, a professor of International and European law at the Université de Nantes.  Throughout her history, France has been a multi-lingual nation and this was still true up until the 20th century.  I remember a trip to Brittany about 20 years ago where I met an farmer whose standard French was very strange (he had a very odd accent.)  I asked my family about it and they explained that his first language was Breton, a Celtic language that is still spoken by people in that part of the world.  I found this comforting - a confirmation that one could have an accent, or not be a native French-speaker, and still be French.

Though French has been the official language of France since the 17th century, there is a world of difference between a nation's language policy and the "facts on the ground."   It took centuries before multi-lingual France become mono-lingual France and even today there are holdouts in the provinces.  Call these people "the enemy within" which, in some ways, remains just as threatening as the external enemy, the Anglo-Saxons and the growing hegemony of English.  Fenet shows how laws to protect the French language:  Bas-Lauriol Law (1975), the amendment to the French Constitution (1992) which says, "French is the language of the Republic," and the infamous Toubon Law (1994), were also fine weapons in the hands of those wishing to eliminate regional differences and marginalize local languages in the Hexagon.

Then came Europe to the rescue with the European Charter for Minority Languages.  This EU charter recognizes that there are many languages  in Europe and offers some protection against their elimination.   This posed quite a problem for the French government and in 1999 the Conseil Constitutionnel did indeed declare that the Charter was incompatible with the French Constitution since:

The Charter conferred 'some specific rights to groups of speakers of regional and minority languages, in territories where these languages are used' and 'tended to recognize a right to practice a language other than French not only in private life but also in the public sphere.'

How did the story end?   It didn't.  We are the year 2012 and this is still an on-going issue, a festering sore in the heart of an otherwise blissful and trouble-free Europe. France is hardly alone here - see this document for progress of countries on the implementation of the Charter.  Very recently Francois Holland, the Socialist candidate for the French presidency was questioned about it during a campaign stop in Strasbourg.  He responded as any good politician would - he promised to "engage discussion" which in my mind indicates that any decision on this will be put off as long as possible.

Back to the book.  All of the above came from a reading of just one of the ten essays in this book.  Trust me, all the other essays are just as good, just as rich, and you can read about and admire the language policies of many states:  Switzerland, Israel, Canada, Ukraine, Belarus and California.  The book is a bit pricey but worth every penny.