If true to form, I would have entitled this essay, “Getting Sick in France.” But this would not cover the subject in hand. Indeed, I would suppose (and I can only suppose, because nothing dire has ever befallen me or my wife while in France—I can say this, that is, certain common ailments, a cold, nausea, headache, vomiting, etc. are pretty much suffered as they are in the U.S. of A.; it sucks for a while and you get over it—and also, as per usual, pre-existing conditions are not covered) that to be consistent with the point of view I have always tried to engage in my essays on life in France I should wait until I get sufficiently ill that it requires a visit to a French hospital or physician’s office.
However, I boldly have decided not to do so. The subject is on my mind, the keyboard is at hand, the usual is occurring around me: bright sun, French blue skies, gentle breezes, the shade of centuries-old trees, birds twirping, bees buzzing, pigeons cooing, swallows swooping and whistling (but only at sunset), and flies omnipresent. The only other subject that interests me at the moment, speaking of flies, is the possibility of directing my analytic gaze at the possible differential behavior of the French fly (I mean la mouche Française, the winged variety, as opposed to the zippered or buttoned variety).
I can make short work of the latter. Like the zippered or buttoned variety, French flies that fly are pretty much the same as anywhere else, so let me take care of this now.
[The essay that might have been:]
“French Flies“ [I hate to give up the linguistic possibilities of that title, the ambiguity, the potentialities for ironic usage, the hipness, but life sucks sometimes]
French flies, the winged variety, unlike the buttoned and zippered variety, are pretty much the same as anywhere else, but particularly the United States. They’re everywhere. They’re a nuisance. They suck.
Some of you will be astute enough to have noticed a slight modification in the essay above, kind of mortised into the essay proper (by the way, the mortise is a record for me: one paragraph consisting of four sentences, three of which had three words or less comprising them... the chances I let go by), from the prefatory remarks enclosed within the actual essay.
First I said flies (flying variety) here in France are like the zippered and buttoned variety, that is, not very much different. Then when referring to the zippered and buttoned variety (notice the steady heightening of titillation as I mention zippered and buttoned flies—there I did it again—not once, but four times so far) I said they were unlike anywhere else. Well, this isn’t quite true. I don’t know, not having studied, say, the Italian or Spanish types of flies (z & b types), but I would guess maybe in the other ”Latin“ countries of Europe, there may be similarities or even utter identity. Notice how I included France in this varietal geographic taxonomy of the continent of Europe and its currently constituted union of member nations, called “Latin?” This is something that Anglo-Saxon countries do (Britain, Ireland, not to mention the Scandinavians, maybe even the Teutons do as well, and the Slavs—I don’t read that press). They do this purposely, I’m sure, especially Americans (which still consider themselves, and therefore act, officially, like Anglo-Saxons—blue-eyed devils...) because of the sub-text that, being Latin, they are hot-blooded, and this explains their otherwise irrational unwillingness to go along with our hare-brained schemes geopolitically and economically speaking, because their heads are always, well, in their flies (the buttoned and zippered etc.).
The buttoned and zippered closures on men’s trousers are likely to be different than American men prefer, real American men I’m talking about (wink wink nudge nudge—oh wait that’s British...leer leer) in that they are shorter in length. Not because of any difference in endowment requiring less tailoring in this dimension (much as real American men would like to think so), but because these Latins will wear a nice pair of slacks with a shorter rise. If you don’t know what I’m talking about, ask a tailor, a woman, or a salesman at Barney’s. Otherwise let me suggest, you may, just possibly, be out of your depth reading this essay, or any essay, in this place, at this time, or any time. I expect people to keep up. Sometimes the fur flies thick and fast. The flies fly, but they are generally not thick, but of sufficient density in numbers, and not fast, being, in fact, kind of torpid, as it is summer, and it is the south of France and everyone is torpid. Even those seemingly anxiety-ridden always flitting American flies would be torpid down here. Let me put it this way, and then put finis to this unpleasant subject. While sitting here, just writing (I write, it’s not “just typing”) I’ve killed eight flies in the course of the production of one-and-a-half essays. And that’s by simply swatting with my hand, or with a copy of the 2007 edition of the French version of the Guide Gantié, a hefty, dense volume, printed on coated stock—it’s a brick.
Hence, no real essay on flies, wordy or wordly. French or otherwise. I will say, because it’s fun, that the French for fly, as in the closure of a man’s trousers to allow the facilitation of nature taking its course, is braguette (naturally, it’s feminine—it’s just the way; in France the counterintuitive is the intuitive). It’s not a hard word to remember. Just remember what’s inside the braguette and remember baguette, also feminine, naturally, and the English homonymic cognate “brag.” Simple. Funny. Let’s move along here.
Back to the matter at hand.
I have the same scientific qualifications as any self-styled intellectual in Cambridge, the educational hub of the United States, North America, mayhap the world (there is the problem of the Indians and the Chinese, not to mention the Japanese, and there have always been Jews and Israelis — but for the time being we wily Cantabrigians still have them bollixed and bamboozled so they think the same thing is true of Cambridge, and hence they are disproportionately represented among the student bodies of Harvard and MIT, the world’s GREATEST UNIVERSITIES). To wit, I’ve read three-and-a-half chapters of The Selfish Gene, I’ve watched that DVD of Hawking’s A Brief History of Time twice (OK, one-and-a-half times; but I do refer casually to “Hawking” in conversation), I’ve riffled through and looked at the index of Guns, Germs, and Steel. I pretend to have an opinion about that guy Pinker jumping ship from Harvard to MIT, or was it the other way around. What the hell? What’s the difference? I affect a blasé, if not cynical mien and attitude on subjects clearly of deep intellectual import.
Therefore I can make observations on my own of people’s behavior, engage in conversation with neighbors and friends here in France, in two languages (which is one-and-a-half more languages on average than most Americans, your average Americans, can lay claim to mastery of—strictly speaking, and truthfully, I haven’t mastered French, but French people do think I’m Belgian when I speak, and that counts for something towards that virtual Master’s degree in a foreign language). As always I have collected anecdotal evidence, buttressed by reading the local French press, and that impeccable and unquestionable authority on life in Europe, the World, and beyond, the ”International Herald Tribune,“ which is kind of a distillation of the New York Times, a fact that, if anything, concentrates one’s sense of its veracity, and almost, but not quite, justifies their charging two euros and 20 cents an issue for a 28-page (on average) flimsy paper.
Therefore you can trust, as you have for a couple of years now, the basic truthiness, if not truth, of what I have to say here.
Here’s how the French behave when they’re sick.
They go to the doctor’s office. In fact, many of them each go to several doctor’s offices, even for the same illness. Some of them, possibly saving up for the opportunity, or, to exercise a certain efficiency, not to mention the national trait of extreme frugality with regard to consumables, e.g., to save fuel, wait to have an odd assortment of symptoms, which, even to the ignorant, seem to be unrelated and thus possibly a signifier of multiple individual illnesses. They then go to several doctors, parceling out the symptoms, or sharing them all with each consulting physician.
I don’t think I am necessarily describing the behavior of the majority of French, but clearly a significant minority. I say this because this behavior accounts in part for the virtual bankruptcy of the social service system devoted to preserving the national health. People—some people OK?—simply like to get the assurance of attentive care, and an accurate diagnosis, and proper treatment—well, really who knows the ultimate or primary cause of this behavior?—and because it’s free, they go for it. Big time.
Did you notice the “free” in the last sentence? Americans are sensitive to the issue of health care costs, because health care is expensive, and growing more so. And it’s in our face, on the news, every time we see a doctor, receive a hospital bill, fill a prescription, etc.
The sensitivity of the French, no less palpable and apparent, and no less justified, is really attuned more to the high rate of taxes, as a result of the wide scope, depth, and breadth of the social safety net, which absolutely positively covers health care, but myriad other things we pay through the nose for, right out of our wallets. They merely get taxed to their eye teeth for same, all at once, as it were, So, if as a result of paying all those taxes, some service is offered on a completely and unquestionably free basis, you’re damn well going to take advantage of it. You don’t have to be as smart as a blue state American to understand that proposition. Indeed, not even red state Americans are so dumb they’d refuse the opportunities such an arrangement presents to any participating individual.
But in ways we cannot begin to imagine as possible, health care in France is free. Gratis. Not a plugged nickel. Gornisht, nada, and zip. If you’re a French citizen you show up at the showroom, excuse me, the clinic or cabinet (office) of a physician of your choice. show your identification, and you are examined and diagnosed and treated. No muss, no fuss, and not a red cent changes hands. Ever.
It used to be in France, before the socialists truly engaged the French consciousness and had an apparently ineffable effect on modes of social awareness, modes of governance and, most important, the core structure of the French system of taxation—say, at least 70 years ago, before paid holidays (what the hell, before any holidays), or mandated limits on the length of the work week, not to mention the work day—the entire French medical consciousness, among practitioners and the public alike, centered on the condition of the largest single organ in the human body. The liver.
Yes, there was Pasteur, and that whole bacteria thing. The French are a lot of things, but they’re not stupid, and they’re not unscientific. They didn’t need Napoleon to stop going to church. Virtually everyone is Catholic, but for decades something like only about 8% of the population actually attends church services on a regular basis. They’re essentially scientific minded (remember Madame Curie and Mr. Curie... Jacques Cousteau? eh? I’ll say no more). Hence they did take a very scientific “approach” to this whole matter of the liver. Or so it seemed to them. Even had they gone to church, I believe there is not a single reference to the liver in the entirety of the liturgy of the mass, but you'll have to check with a theologian on this one.
In practice, any ailment more or less was perceived as “une crise de foie,” literally a “crisis,” but more idiomatically a “malfunction” or “breakdown,” of the liver. Something like having trouble with the starter of your car—or maybe the whole engine, as that’s a better analogy, given the engine is generally the largest organ, uh, mechanism in the auto.
Une crise de foie was (and, in dark smoky bar/tabacs and cafés still is) a broad and encompassing diagnostic term. It could be a small crise or a big one. Never to be taken lightly, it can manifest itself in all sorts of ways, with palpitations, or light-headedness, with pains in the chest, or in the joints, in the back, the stomach, or the head. I could go on and on. The literature on this, if there were a literature on this, would be as rich and comprehensive of every conceivable human symptom of disorder of the body as “The Yellow Emperor’s Book,” which was the chief tract on Chinese medicine for over two millennia and which is a heavy volume, filled with many words filling many pages.
Une crise de foie was (and, see conditions above, often still is) treated with specifics, by way of remedy, and usually prescribed and administered in a manner very reminiscent of the manner in which what is now called homeopathic medicine offers ways of remedying the sick. In truth, the chief specific recommended, sometimes large doses, sometimes small, of that little bit of the “poison,” if you will, that somehow, through the mysterious processes of inscrutable nature, had fallen into an imbalance, which manifested itself in the specific sort of breakdown of the liver in question, was, one way or another, alcohol. A cynic might say this all boils down to “a little bit of the hair of the dog what bit ya’,” but this would be unfair, and would defy the innate scientific basis for such remedial strategies—at least the theory of them is scientific in appearance. Further, as we all know, if you boil down alcohol, no matter what form it takes, the good bits, the efficacious component, is lost in the clouds of steam above the boiler.
So you are advised to take it straight. Many crises are best ministered to with red wine, which I believe was (and, blah blah blah, still is) the most frequently prescribed remedy. However, take care, as there are nuances here. As many nuances as there are varieties of grape, and types of red wine, and vintages, and levels of maturity and degrees of baumé, or brix (look it up, I warned you, I expect people to keep up and there’s no waiting here, temporizing while you find references to these esoteric matters). Sometimes you want a Bordeaux, sometimes a Beaujolais, sometimes it’s a crise so deep and alarming, nothing but a Burgundy will do. Then there are the considerations of which varietals to emphasize: your Mourvedres, your Syrahs, your Pinots, your Merlots, etc. etc. etc. And you thought wine was simply a matter for connoisseurs and oenophiles.
Some crises de foie are so severe that specific remedies are suggested for ingestion not only by the patient, but the attending, um, physician, the relatives standing around looking mournful, friends, attending experts, perhaps the negociant and even the vintner himself. Some are of such grave concern that the only remedy will be not even the wine itself (too weak), but a distillation of it, usually some form of eau de vie (you didn’t think they call it “water of life” for purely metaphoric reasons, did you?) and could depend on the region in France in which you found yourself and your malfunctioning liver. It could be a marc, a cognac, an armagnac, a Calvados, poire William, and so forth.
It may not surprise you to learn, as part of this inquiry into the health system of France, and the ways in which the good citizens of this still great country, adhere to them, that many believers in this particular pharmacopoeia advise that, in addition to providing a cure to various forms of crises de foie (or almost any other organ), one may ensure good health and will prevent such crises from ever occurring by the regular ingestion, while in a healthy state, of various of these specifics. One must pay careful attention that one varies the form of the specific, though copious amounts of wine in the course of a full day seems to be generally accepted as permissible, to be followed, at the end of the day (though there are adherents, especially in rural communities, who believe that a bit at the start of the day instead, or perhaps even better at both ends of the day) by a swallow or two of the water of life will guarantee that one’s life will be lengthened immeasurably.
Nowadays, with the flexibility that the stresses and demands that modern life places on your typical Frenchman, you find a sort of amalgam of the old ways and the new to their liking: regular ingestion of the classic preventatives to crises de foie, and willing, if not enthusiastic, participation in the free health care system.
I have had occasion many times in my essays based on observation of French life in the hinterlands and the great cities of this land to remark on the prudence and good sense of its citizens, and it would be unfair if I were not to say that most French people are generally prudent in their participation to access to health care. Nevertheless, as I alluded to above, the health care system in France is not itself very healthy, not from a fiscal perspective. In fact, it is in a condition that economists refer to as “deep shit.” I barely understand the science of economics myself, so I will not comment. However it is clear that one kind of crisis is evident and unrelieved, and the French government has no liver, so to speak, so the crisis will not be solved by sending a case of Médoc (literal or figurative) to the Assemblée Nationale, even if the right-wing party of the new president did manage to hold a majority there in the recent elections.
President Sarkozy has many ideas on how to solve this aspect, as well as many others that exist, of the overall fiscal crisis the country is slowly suffering. Most of these require the administration of another specific, namely money. Being as how there is no more money in the exchequer to apply to the problem of the absence of funds in the health care system, this money will come from the pockets of those most affected, the beneficiaries of the liberal health care system: the people themselves, it is expected, will pony up modest sums (preposterously small, if not ridiculous sums, if I may editorialize a bit, with my native United States citizen with an up-to-date passport’s sensibility in full play) when they pay a visit to the doctor.
One proposal would have the citizen pay a mere euro, a single euro, a lonely and individual bi-metal coin of that denomination, as, what we call in the U.S., a “co-payment” to help defray the cost of providing the state-of-the-art care the French receive otherwise for free at this present time. A euro coin is used in supermarket parking lots to provide temporary use of a shopping cart (the euro is returned when your shopping visit is done). A euro buys in your typical French bakery, at least in the hinterlands, 1.18 baguettes. It buys 5/6 of a cup of espresso (and the accompanying right to sit as long as you please sipping it, not to mention the glass of water you’re entitled to ask for by law in any café throughout the land). A total of a single euro acquits you of the social obligation to leave a token pourboire (a friendly tip for the waiter, more token than emolument, but still meaningful to the French) with each visit to the café, let us say three, maybe four times—in 20 or 30 cent increments. A euro will buy you 94% of a liter (94 cubic centimeters, you MIT grads) of diesel fuel (most of the cars these days are turbo-diesels, not least of the reasons being that the fuel is cheapest for these types of engines—kind of vin ordinaire for treatment or prevention of crises de foie), and a liter of diesel will get you about 12 kilometers down the highway, which is the distance to Aups from my house in Fox, that is, the shortest route to the cabinet of a doctor; there is a bar-tabac a lot closer, maybe one-eighth of a liter's worth of fuel away, and the drinks are cheaper.
In short, a euro is nothing (it looms larger than that, of course, when we have to pay our mortgage each month on our little hacienda here in the ancient hills of Provence—but this isn't about us). Yet the outcry at such an outrageous idea—to pay a single euro out of one’s pocket for a single doctor’s visit, that is, for every single doctor’s visit to pay a euro—is not dissimilar to the reaction to the rape of the Sabine women (among the Sabines of course—the average Frenchman doesn't give a fig about this outrage, and, I daresay, even fewer Americans). The act would be looked upon not so very differently, that is, that a visit intended to seek salutary attention from a medical professional would be accompanied by a violation to one’s pocketbook (the second largest organ in the body, one might say, in jest of course).
There is a similar idea being floated that each citizen pay an annual, single franchise of ten euros (I’ll spare you the homely, if immediately poignant and down-to-earth examples of what ten euros would buy—I hope you get the idea; if not, I’ve lost you anyway...). That is, they would pay a "deductible" (which is what franchise means in this context) of ten euros for a surgery let us say, a hospital stay... Outrage and violation are too mild to describe the expressive distress this idea evokes.
Now that I’ve introduced the idea of a hospital stay, let me offer this information.
Rather than suggest that the sorry financial state of the French health care system (which, incidentally, the World Health Organization, which rates health care systems nation by nation throughout the globe on an annual basis, rates as the best in the world, and have done for a few years running; in other words, the French health care system is not only at the leading edge of losing money, but is doing so by providing exemplary care) lies entirely at the feet of its exploitative greatest beneficiaries, the French citizenry, let me tell you how the doctors behave.
As it’s all free anyway, and state-controlled, single-payer, and a nod is as good as a wink to a blind horse, the doctors, being even smarter on average than the average French citizen, who often feels free to use and abuse the system with impunity, with the system taking no steps to stem the tide, never mind control it, or even simply take revenge, assuming the state were capable of an emotional response, the doctors, as I say, provide not only great care, but do it in spades. If your condition calls for a hospital stay, say for a procedure and tests (or one or the other), it calls, or may as well, for a stay of several days just as well as it does for what would be an adequate, but shorter, period. In the United States, I’ll remind you, standard practice says that even for many major surgeries, what’s adequate is a one-day stay. Hack it off, and send you home.
Not here in France.
True story: while we’ve been here this visit, our dear dear friend, whom I’ll call Regine, was diagnosed, during a routine annual test, with a case of a serious common disease that, in her case, was caught early and was not at an advanced stage. Nevertheless, it called for surgery, and the feeling was, sooner better than later, and she was scheduled for a visit to the hospital in a nearby coastal city (about an hour and fifteen minutes away) for a procedure and whatever might ensue. Fortunately, the size of the lesion that was removed was as small as suspected, and there will be follow-on additional therapy, but not much more.
However, Regine is languishing in the hospital, under the supervision of the medical staff, being tested and monitored, though she feels fine, feels “great” in fact (it was reported to me that on the day after the procedure she was planning to demonstrate some gymnastic routines she does regularly as part of her personal regimen to “prove” to the doctor that she was ready to go home—that was Friday, the procedure having been done mid-day Thursday—but she will be staying until Sunday; doctor’s orders). I have had major surgery, as has Linda, several times, and in three out of four instances we were sent home from the hospitals, listed among the top 20 in the United States, the day after we went under the knife. Our bills, in the United States, had we had to pay them in their entirety, amounted to five figures for the one day of intensive, world-class, care for those 24+ hours.
I am sure Regine’s care was no less superlative, and the costs, in proportion, no smaller. But whereas for-profit insurers, negotiating the convoluted financial arrangements that ultimately defray the cost of care in the U.S., try to ensure that costs are minimized or at least contained, there is no such oversight or safety valve in the French system. Or at least no effective one. What is at risk for France, where the care is impeccable and universal, without regard to ability to pay or severity of need, is that it is in great danger of rupture—thereby threatening the ability to maintain not only the level of care, but the very ability to deliver it to the populace that falls sick altogether.
The reasons are various, no doubt, and include the two broad matters I’ve tried to illustrate: the unchecked exploitation of the system by a sufficient portion of the population to make such behavior untenable, and the relatively unmanaged (and perhaps somewhat understandable) propensity of the professional health care providers to utilize the system to its maximum capacity, irrespective of the resources to maintain its operation at this level.
There is another factor, among the many I speculate exist, and that is illustrated by a conversation I had with Regine’s husband, whom I’ll call Bertrand. Clearly deeply concerned with this threat to Regine’s health, not to mention the long-term risk of shortening her life, however small (though greater than if she did not have the disease in the first place), Bertrand demonstrated an uncharacteristic response to the circumstances. In fact, very bright, resourceful, and innovative in many respects, and generally well-enlightened in so many facets of modern life that anyone living in a first-world country must stay abreast of, Bertrand betrayed a bewilderment and ignorance of medical facts, not only about Regine’s case, her disease, the procedure to be performed, and the staging of the necessary therapies to ensue, but, I had the vague sense, ignorant about the whole business of staying healthy in general. This both fascinated me, in the abstract, and concerned me, as his friend. I provided some tutorials in very basic terms, about matters I have the feeling, but no proof, that Regine’s doctor must also have provided, and in Bertrand’s presence.
I don’t know enough to say it’s typical, even of people in our own country, that is, to say that Bertrand’s reaction is typical, or that it’s typical to evince a general lack of knowledge that I think people of a certain age should begin to acquire, as they enter their middle years, and look forward beyond them, so they can anticipate what their role will be in terms of participating in their own medical treatment. And that, of course, requires a certain level of understanding and insight that it never occurred to me until now was actually a function of the way in which the whole society deals with these things.
It is possible, and, finally, to put all joking aside, that the virtues of universal free health care, such as the French do provide, getting high marks for performance and very low marks for management of the operational facets of the whole machine, are offset by the troublesome side effects, or artifacts, of providing a benefit that many of us feel should be available to all without question in a way that allows people to take it completely for granted. If ignorance is the result, and the wages of ignorance—ignorance of the consequences of abuse, ignorance of the simple economic formulation that there is no such thing as a free lunch, ignorance of the difference between being exploited for low wages and exploiting the system by refusal to pay a pittance to preserve an invaluable benefit, ignorance on the part of the practitioners of their responsibilities to be stewards of the system, as well as providers of the system, and ignorance of how our own bodies work, and what doctors must do to them to keep them healthy—is destruction of the system from the inside out, well there is only one sensible response. And that is, indeed, to lay it all at the lobes, as it were, of that incredible organ, the liver. And as a result to keep that organ as happy as can be, never mind the effects on our state of mind, by putting our lips around the neck of whatever bottle we can put a hand on that contains the vital essence of the fruit of the vine in whatever form it presents itself to our mouths.