The patients in psychiatric hospitals in occupied France were not targeted by the Nazi euthanasia program Aktion T4, and they were not deported, except a group of patients in Alsace (which was under direct German control) who were sent to the Hadamar Euthanasia Centre in Germany and murdered there in 1944 (50 were deported, only one came back).

A catastrophic death toll

However, institutionalised psychiatric patients in France died in large numbers. In the beginning of 1940, there were about 110,000 patients in French mental health institutions. About 76,000 died during the war, and more than half of them died of undernutrition, of associated pathologies, and of pathologies particularly lethal to underfed people, like tuberculosis. The number of 40,000 deaths due to undernutrition circulated as soon as 1946, and it was revised recently to 43,000-45,000 using calculations based on the excess death rate. The case of the psychiatric hospital of Vinatier, near Lyon, shows the tragic scale of the situation. The death rate in this hospital in 1938 was 7.1%: it rose to 19.1% in 1940 and reached catastophic numbers in 1942 (45.6%) and 1943 (49.4%) before declining slightly (35.7% in 1944). Descriptions by doctors, as well as photographs, show men and women whose barely alive appearance - extreme emaciation, lack of fat and muscle - is similar to that of the people in the German concentration and extermination camps.

The historiography of the French psychiatric hospitals in occupied France has been the topic of a bitter and heated debate since the late 1980s, opposing psychiatrists, historians, and activists. I will discuss this in the conclusion, but first I will use the historians' version and interpretation of the events, and in particularly the study by Isabelle von Bueltzingsloewen published in 2007, L'hécatombe des fous.

The first deaths due to undernutrition were reported in autumn 1940, but they were not understood as such. Doctors were puzzled by the sudden increase in unexpected deaths preceded by a strange variety of symptoms including diarrhoea, oedema, or pellagra. A PhD dissertation of 1943 described it for instance as a "diarrhoea epidemic". Diagnoses was equally varied - cardiac arrest, syncope - and doctors did not know what to make of this. For Bueltzingsloewen, this initial lack of understanding can be explained by the fact that death by starvation was no longer in the French "mental universe", including the medical one. Doctors knew about malnutrition - the inadequate supply of nutrients - but not about undernutrition, when the energy and protein supply are insufficient to support the life of the individual. Occupied France was hungry due to the pillaging by the Germans of its food production, but it was not starving: France had not starved since the Franco-Prussian war of 1870 and even then it had been limited to Paris. It took several months - early 1941 - for psychiatrists to recognize that their patients were dying in huge numbers all over France, and that it was tied to lack of food. Some doctors were still looking at the problem as the effect of malnutrition, notably vitamin deficiency (vitamins had been discovered recently and were popular as a go-to explanation for diseases). And then there were beliefs that mental patients had higher nutritional requirements than regular people, or were more sensitive to nutritional deficiencies. In 1942, the idea that food restrictions were killing patients in psychiatric hospitals was (slowly) becoming mainstream in the medical community, who researched technical solutions such as novel and alternative sources of energy, protein, and vitamins that were available in wartime conditions. None of this was actually useful at national level: what was lacking was food.

While the psychiatric community had trouble understanding the problem, the Vichy administration was struggling with the organisation of food rationing. The specific problem of feeding aliénés the proper amount of food was barely identified and hardly a priority, and it was not equally catastrophic everywhere: some hospitals even reported that, in their own establishment, the crisis was being solved thanks to mitigation measures. A circular published in February 1941 was sent to Prefects by the State Secretariat of Family and Health, telling them to report on the "avitaminosis incidents" in psychiatric hospitals. Nothing practical came out of it. Another circular in March 1942 refused to grant food supplements to the patients of psychiatric hospitals, and urged those hospitals to be more efficient in terms of food supply, by preventing losses due to theft and by growing their own food. But a new circular in December 1942 did order that 25% of the mental patients were entitled to food supplements, which gave them a privileged status. The Vichy administration making such a move is odd considering that the regime was at the time even more aligned with the Nazis than before. It has been speculated that this was due to the influence of Hélène Sérieux, the wife of the Minister of Agriculture and Supplies Max Bonnafous: Sérieux was herself a psychiatrist and the daughter of the famous psychiatrist Paul Sérieux. Another possible reason for this change of heart may have been a report by biologist Lucie Randoin on the feeding and health of the patients of the Psychiatric Centre of Sainte-Anne in Paris: Randoin had concluded that the rations available to the internees were "incompatible with life".

The supplements granted by the circular of December 1942 remained minimal, and the impact of the circular is disputed. It did not solve the general problem of food supply since getting food in occupied France remained problematic. It seems, however, that there was a general decrease in the death rate: patients kept dying, but at a slightly slower rate.

->Why such a death rate?