Saturday, May 12, 2018

Germ Warfare

Drawings by Suzanne Dunaway
One day late in 1969, in a back office of Creedmoor psychiatric hospital in Queens, I hiked up my skirt and pulled down my tights. My boss Dr. Gideon Seaman, knowing I would soon be taking off for eight months in Europe, had brought along a huge syringe of gamma globulin and shot that horse dose of protective antibodies into the front of my thigh as I stood in front of him. I fell back onto a chair, passed out from the pain.

What country was he protecting me against? Italy. Why? Because, he said, it’s crawling with hepatitis. The locals would pick up the “infectious” A variety from eating their beloved mussels and clams – they were harvested from polluted waters and cooked, if at all, too briefly to kill any lurking viruses. The “serum” B kind they picked up from mothers as mere tots, preparing them to pass it on as adults through needles and sex; any guy I might pick up would likely have been infected since he was four. (If medical science had known about the C kind of hepatitis at the time – it didn’t – it would have also known that too was big in Italy.)

Today the shoe is on the other foot. Americans are much likelier than Italians to die of infections, mostly because of poor access to health care – not to speak of Italy’s conversion to farmed rather than wild shellfish. Former sins have left their mark on Italy, though, in that several key vaccines reached here decades after they became standard in the States. More cases of measles and congenital German measles are reported in Italy than in any other Western European country, with the number skyrocketing between 2016 and 2017 thanks to a know-nothing “No Vax” movement. And things may get worse: the measles vaccination rate for Italian toddlers fell steadily between 2010 and 2016.

My world-hopping clients often need to attend public travel clinics, which have a monopoly on vaccines against yellow fever and Japanese encephalitis. For decades this was a piece of cake: I wrote a prescription and an address, the patient showed up at the clinic any weekday between 9 and 12, and walked out a half hour later ten dollars poorer, with wisps of cotton taped to their arms. It was a poster child for public medicine. Now the party’s over – in 2013 my beloved vaccinators simultaneously started requiring appointments and stopped answering the phone.

Let me close with the strange case of tetanus. There are 400,000 horses in Italy and they are often healthy carriers of tetanus spores, including the ones you see roving the streets of Rome or Florence with police on their backs. Many of these healthy-looking animals gaily deposit manure laced with tetanus spores on the pavement, manure that then patiently waits for a passer-by to get injured so the spores can enter the body, wake up, and multiply. Italians now over fifty weren’t vaccinated as children, nor were most immigrants, so plenty of the people who show up in Italian Emergency Rooms with contaminated wounds should by rights receive not just a tetanus booster but also a shot of antiserum – a type of immune globulin hyper-packed with tetanus antibodies.

But as far as I know that antiserum has never once been administered, in any Rome hospital, to a single patient of mine. Emergency Room physicians go to great lengths to avoid giving it. They’ll tell patients that antiserum is no good two days after the injury (nope – it works even after three weeks). They’ll branish consent forms that claim it can transmit AIDS (possible in theory but nonexistent in practice). They’ll say tetanus was eradicated long ago (would that it were). Why those docs put up so much resistance is a mystery but it may be merely that the hospitals don’t keep the perishable antiserum in stock. An Italian team that studied tetanus prophylaxis in Naples’s public hospitals just a few years ago concluded, “Only 1.5% of the physicians correctly adhere to guidelines.” The upshot? More than a third of the cases of tetanus in the European Union occur in Italy, with 60 fatalities a year. So be forewarned: odd though it may sound for an otherwise proudly developed nation, Italy is one of those countries where you’ll want to make sure your tetanus vaccinations are up to date.
(This post is being published simultaneously as a Bedside Manners column in The American In Italia.)

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Wednesday, May 2, 2018

Scorecard: Booze

United States          Italy
Drank any alcohol during the past year          67%                 84%
Drink alcohol almost every day                      6%                   50%
Liters of pure alcohol per person per year     8.82                 7.56
Alcohol abuse
            Men                                                    10.7%              1.3%
            Women                                                4.2%                0.8%
Binge drinking in past month                          16.9%              4.2%
Yearly deaths from alcohol per 100,000         2.91                 0.37
What’s Their Secret?
By tradition Italians consider wine and beer to be foods, not drugs, knocked back to enhance a meal rather than to get soused. When I was first getting invited to dinner in Italian homes, in 1970, the children would be served acquavino, water laced with a few drops of wine. I’m convinced this non-medical homeopathy innoculated them against later dipsomania. Those old habits have by and large held up nicely, but very recently some young Italians have started to imitate the tourists in their midst by converting to the northern European cult of Saturday night drunkenness. Let’s hope it’s just a fad.
As with many American phenomena that favor the all-or-nothing (think Tesla vs. SUV), the United States is overloaded with problem drinkers on the one hand and teetotalers on the other. I sip my way through two glasses of wine every evening with supper, more alcohol than 95% of American women.
Alcoholic beverages are sold in every Rome supermarket and at every corner store, at all hours. The exception is before a soccer match if the Rome or Lazio team is playing against an adversary with notoriously hard-drinking fans, such as Manchester United, in which case City Hall has been known to institute temporary bans in the attempt to keep hordes of drunken Englishmen from taking over the streets.
(Curiously, a horde of drunken Italians is something of a contradiction in terms. Liquored up Romans get cheerful and friendly, not raucous and rowdy. Turns out the way people act when they’ve been imbibing is due at least as much to cultural expectation as to the pharmacological effect of alcohol.)
You’re supposed to be 18 to buy, but this being Italy nobody at the checkout counter is checking IDs. When American “abroad” college students catch on, they tend to go off the deep end and can land in deep trouble – since I’ve lived here a half dozen are known to have fallen to their deaths out of windows, from bridges, or off walls, and that’s not counting the cases that have been hushed up.
A small glass of wine every day throughout pregnancy doesn’t cause fetal alcohol syndrome or anthing else, by the way, contrary to the prohibitionist terror campaign in the United States. Every adult Italian you see on the street was exposed to it and survived.
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Monday, April 16, 2018

Take Some Bling And Call Me In The Morning

Italians have never been much for Calvinist-type frugality. The Catholic hierarchy’s response to Luther’s 16th century revolt was a Counter-Reformation construction boom which aimed to woo back the faithful by dazzling them with ever more lavish churches. Rome’s Gesù is a prime example, with its dazzling colored marbles, swooping angels, and mouth-watering lapis lazuli columns. Same thing for clothes. Where my generation of American girls were taught to underdress – “look in the mirror before you go out, and remove one piece of jewelry” – Italian ragazze would toss on an extra necklace.
Public hospitals in Rome are shabby and General Practitioner offices run to the bare-bone, but in one medical niche the glitz principle holds: the vast private system. A ghostly for-profit shadow hovers alongside the National Health Service, complete with its own doctors (including me), laboratories, and hospitals. A private casa di cura or clinica will have an atrium decked out in Ficus benjamina, oil paintings, and design furniture, and rooms with disposable slippers and a comfy sleep-on couch for your spouse. A Italian patient of mine, exposed to the private system for the first time, cast his eyes around and said in wonder, “My God, this hospital’s so clean.”
Once you get past the glitter, Rome cliniche usually offer a narrow range of medical services. One may concentrate on childbirth, another on cancer, a third on cardiac catheterization, none covering all the bases and most preferring elective rather than emergency procedures – think hotels with operating suites. Here and there you’ll find a small intensive care unit, but they never have a real Emergency Room. A couple claim to cover emergencies 24/7, but the one time a patient of mine tested that boast the hospital flunked: she showed up with an asthma attack, something anyone with a medical degree should be able to handle, and was sent home without being examined much less treated because they “didn’t have the right specialist.” As the locals say with ironic intent, Tanto siamo in Italia, What can you do, we’re in Italy.
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Wednesday, April 4, 2018

Rules Italian Style

After a decade of widowhood my ex-mother-in-law, Mariada, finally made a visit to the Italian telephone company offices to change her account from her late husband’s name to her own. Employee: “If you want to change the name, Mario has to endorse it. You can just sign his name here.” Mother-in-law: “I can’t sign it for him, he’s been dead for ten years.” Employee, helpfully: “Why don’t you step outside with the form and sign it in the corridor? When you come back in I’ll pretend it’s the first time I’ve seen you.”
Glossary: infrazione
A petty violation of the law. A colleague was explaining the route to drive to the University: "You drive down Via del Quirinale to Largo Santa Susanna, and then… no, you're too American, you can't." "Can't what?" "Well, then you have to make a slightly illegal left turn, a small infrazione, it's the only way to get there."
Italian rules often seem made to be broken, but they can turn inflexible when you least desire it. I helped a schizophrenic patient through infinite red tape to get an Italian disability pension, a welcome supplement to his meager wages from a manual job an hour’s drive from home. One week after he received his first pension check he was notified that now that he had been certified as disabled his driver’s license had been automatically revoked.
The casual lawlessness rubs off on you. I shocked a friend by distractedly bypassing a dozen cars waiting at a California tollbooth and sneaking back into the line. I shocked myself by swearing to the State of New York I’d lost my drivers license when I’d actually handed it in to the authorities here in return for an Italian one. I shocked my mother by suggesting over the phone she sign my name to a jury duty summons; once she’d recovered, though, she said what the hell and practiced my signature until she could forge it on the dotted line, savoring the glee of transgression after 65 years of walking the straight and narrow.
Italians’ behavior is governed by the ad hoc and the ad personem. They consider Americans’ reliability to be rigidity, our rules to be unwarranted limits on options, our planfulness a brake on spontaneity, our constant pleases and thank yous a defense, our lofty ethical precepts hypocritical cop-outs geared to avoiding immersion in the complexities of human relations. Romans prefer a “half date,” a mezzo appuntamento, to a definite one, and they don’t hesitate to cancel at the last minute if they’re feeling tired or antisocial. When I told a friend this seemed rude, he said an unwilling dinner guest wouldn’t be fun anyway.
Italians disdain rule-worshippers just as illiterate people disdain those who can’t remember anything if they don’t write it down. My friend Daniela once made a U-turn on an empty small-town street in Switzerland. A woman leaned out her second-floor window and yelled a reprimand. Daniela – who hails from Italy’s relatively law-abiding North – responded by making another U-turn, then another, then another… Italians are great at improvisation and seat-of-your-pants, farm by the phases of the moon when they’re not designing Maseratis, and always feel more secure having a low-tech backup. They wear a condom but pull out anyway. They shine during Third-World travel: when things go wrong, stick with the Italians, who get busy devising a fix while the Americans are sitting around waiting for the authorities to show up. Neapolitans call it l’arte di arrangiarsi, the art of muddling through.
There are traffic lights in Rome deemed unnecessary by popular opinion. You’ll be honked at if you stop.
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Tuesday, March 13, 2018

Mario and Nikolas

Recently I’ve been thinking a lot about a patient I’ll call Mario. He was a ministerial employee, happily married, and totally nuts. Under his façade of normality lay a vast web of paranoid delusions that linked his family, the Church, and both Cold War antagonists in a delicate equilibrium. All through the 1980s I prescribed antipsychotic medication under supervision, and he did just fine. But when the Berlin Wall fell in 1989 the web no longer held, the balance wobbled, the web fell apart, and Mario snapped. He first confessed vague violent fantasies, then disappeared from treatment, only to resurface in prison, after stabbing his cousin.
What reminded me of Mario in these last weeks was the rather similar story of Nikolas Cruz, the Parkland, Florida mass murderer. Both were deeply disturbed, both were armed, both were obsessed with fantasies of violence, and in both cases outside events – in Cruz’s case the death of his mother, in Mario’s the end of the Soviet empire – cut whatever inner restraints had prevented acting on those fantasies. What made the difference between one man wounded and 17 teenagers dead was the weapon: Cruz carried an AR-15, Mario a kitchen knife.
Nikolas walked into a Florida gun store, passed the laughable instant background checks, and walked out with his gun. In Italy you can’t buy a pistol, or carry any firearm on the street, without a license (porto d’armi) issued by the police.What you need to get that license:
1) A specifically authorized specialist physician (not me, and not your own General Practitioner) must certify your mental health. So much for Mario or Nikolas.
2) A specifically authorized physician must certify that you have no visual, hearing, or other physical problems that would interfere with proper use of a firearm.
3) You must have a clean criminal record, with no history of violent crimes or restraining orders.
4) You must not be an army deserter or a conscientious objector.
5) You must have had proper training in gun use and safety, either in the army or a certified two-month civilian course.
6) You must provide a list of all the people you live with.
7) You must demonstrate a specific reason for being at high risk of violent attacks – owning a jewelry shop or working as a security guard will do. Few people meet the test, and certainly not Mario or Nikolas.
You have to reapply for your carry license every year, and you can only own 200 bullets at a time.
If you only want a weapon firearm for sport* or hunting the process is easier – you can buy a few shotguns on the basis of just criteria one through six, with a license good for six years. But by law you have to report every acquisition of a weapon or ammunition to the police within three days. You must also store your guns in such a way that children, thieves, and household members who are mentally ill, alcoholics, or drug addicts can’t get hold of them; and transport them to and from the shooting range or game reserve unloaded and locked away. If a family member goes to the police about fights at home, the cops will come take away your guns.
Moral of the story: there are one tenth as many guns in Italy per capita as in the US. And one tenth as many gun deaths, even if you include suicides, accidents, and the Mafia.
*A reader has pointed out that air guns used for target practice can be purchased without a license.
entrance of my conference hotel in Louisville last week

Sunday, March 4, 2018

Can’t Stop Talking About Italy…

The same Expatclic website that kindly featured Stethoscope On Rome as their Blog of the Month at the beginning of February has now published a nice interview with me about my life in Italy. The questions from an Italian woman living in Indonesia were very thoughtful, so it was fun to think about them and come up with answers. If you’re interested, you can read the whole interview here.

Sunday, February 25, 2018

Foreskin Follies

I grasped his penis with both hands.
Urine was spraying into the air, while my fellow-intern at Morrisania Hospital in the South Bronx stood by holding a bladder catheter ready for use. Water retention due to heart failure had poor Mr. Jones’s body so swollen from the waist down that the business end of his urinary system was buried in edema, and the high-dose diuretic we had shot into his vein only made matters worse by turning him into a human fountain. My job, which I confess was complicated by spasms of laughter, was to squeeze away the excess fluid from his foreskin so my similarly incapacitated colleague could have a chance at finding the hole.
This may have been the only time I laughed out loud in three years of hospital duty as a resident specializing in internal medicine. A more typical form of emotional self-expression was crying in the stairwell.
We eventually managed to get the catheter in, stop giggling, and retire to our on-call rooms for a few hours sleep. It was only at morning rounds, presenting the case to our team, that we caught on to what was really going on with Mr. Jones. His problem lay as much in his isolation as in his heart: for weeks, while his legs ballooned progressively from human to elephant proportions, he had been holed up in his single-room-occupancy digs without any human contact, before his landlady happened to knock at his door, see the state he was in, and call an ambulance.
During my medical training in 1970s New York City we saw patients like that all the time, so bereft of social connections that they could slide downhill toward end-stage disease, or into the grave, without anybody pushing them to seek medical care. I’ll never forget one 17-year-old heroin addict, infected by a dirty needle, who lay in septic coma for five days on the floor of her studio apartment, before a sister chanced to stop by just in time to save her life. In Italy, where as Luigi Barzini said the only fundamental institution is the family, a teenager would never be abandoned like that to her own resources. Here, even junkies bring their dirty laundry home on Sunday for mamma to wash.
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Saturday, February 17, 2018

Reading The Tea Leaves

Every Wednesday for 20 years my apartment was cleaned by a man named Giuseppe Sonnino, commonly known as Peppino The Jew. He was a world-class professional who spoke Roman dialect so dense that my native informant friend Mariateresa regularly missed words. The Nazis had failed to find his hiding place in a Gentile neighbor’s apartment when they swept through Rome in 1943. His brother did get picked up, and survived Auschwitz, but never talked sense again.
Wherever he worked Peppino would shuffle around in felt slippers, so his every step would buff the floor. For our parties, whose guests were the grubbiest of 1960s types, he insisted on answering the door and passing around drinks in a white jacket with gold-colored buttons. His pride was so fierce that when once he saw that a client had left two treasury bills in plain view on a table with a strand of hair in between, thinking to test the help’s honesty, he quit on the spot. Toward the end of his life, he cleaned better with galloping Alzheimer’s disease than anybody else could with intact mentation.
Peppino had great faith in my powers. I remember how one day in the ‘80s he set a friend's laboratory report in front of me and asked me for an interpretation. At first I shook my head at this absurd request, but he was so crestfallen I agreed to take a look.
What he’d handed me was a flimsy pink National Health Service form with blurred numbers scrawled next to enigmatic abbreviations. I deciphered the first ones as hematocrit 35%, red blood cells 4,000,000, white blood cells 9000, eosinophils 10%… "She's a little anemic, but probably not by losing blood, maybe she's been ill recently, though judging by her white blood count I’d say she doesn’t have an infection at the moment. It does look like she may have hayfever…" Transaminases SGOT 7, SGPT 9, gamma-GT 60. I was warming up: "She should probably cut down a bit on the wine, it’s affecting her liver, but there's no serious damage." Fasting blood sugar 98, BUN 15, creatinine 0.9, urine red cells 0, white cells 2-3: "No diabetes, her kidneys work fine, no signs of urine infection." The exercise sat somewhere between Sherlock Holmes and Tarot cards. Sodium 138, potassium 3.4. "Does she have high blood pressure? Yes, that’s what I figured. Do you know if she's taking a water pill? Yes? Well it’s driving her potassium down a bit, she needs to eat more fruit." Sedimentation rate 25 "…She's in her 50s, like you? Then this is normal for her age, if she were younger it would be a sign of inflammation…"
It astounded me to see how much information was stashed in those numbers.
Another time Peppino brought me his own EKG. When I interpreted it over my kitchen table his mouth fell open – for him the needle’s tracing was an oracular mystery that could only be read by the cardiologist who had actually strapped on the electrodes.
Sometimes I miss those days when doctoring in Italy was half sorcery, and physicians competed with the hordes of operators telling fortunes on live TV. And I also miss Peppino.
A version of this post is being published simultaneously in my column in The American In Italia, Bedside Manners.
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Thursday, February 8, 2018

An Article On Death I've Published Elsewhere…

A piece I wrote about death, specific deaths, and their impact on my medical practice and myself has recently been published in Hektoen International: A Journal Of Medical Humanities. To check it out click here: “Endings.”

Blog Of The Month

A very nice site for expatriate women called Expatclic is featuring Stethoscope On Rome as their Blog Of The Month. Check out their little interview

Wednesday, January 31, 2018

Scorecard: Supersize Adults

                                                United States  Italy

Overweight or obese               67%                 40%

Obese                                      38%                 10%

What’s Their Secret?

When I moved to Rome I resigned myself to getting fat. To my surprise, a year later I had lost 10 pounds.

My new shape blended in with my surroundings. Italians are lately the second-thinnest people in Europe, next to the French; a woman who’s medium-sized by American standard is hard put to find clothes she can squeeze into in Rome boutiques.

How do they stay slender while tucking away all that pasta, olive oil, and gelato? Chiefly, because their attitude toward food is, well, normal. They eat three squares rather than constantly stuffing their faces, they savor their food instead of packing it in, they cherish the collective mealtime ritual of sitting down together at length to break bread with family and friends. Grazing and raiding the refrigerator are concepts as un-Italian as Taco Bell, and six months living under the disapproving gaze of my mother-in-law until my ex- and I found an apartment cured me of both.

That cultural norm of eating when they’re hungry instead of using food as a pacifier means Italians are less likely to get hooked. Food addiction, once you’ve acquired it, is a particularly hard habit to shake. Here’s why: it’s common knowledge that recovering junkies, smokers, or alcoholics have to stay away from their favorite substance altogether. One sneak fix, one fag after one supper, one highball will send the slipper-up back to addict hell. Since you can’t both stay off food and stay alive, the obese are obliged to achieve that impossible goal of eating – consuming the substance they’re addicted to – in moderation. 

The kind of stuff that goes in Italian mouths counts too, of course. They put real food on their plates rather than fat- and sugar-packed processed products, quench their thirst with water rather than soda, love vegetables, and after dinner are more likely to eat a peach in summer or an orange in winter than a slice of chocolate cake.

I can’t find any reliable statistics from mid-century, but between watching postwar movies and decades of personally eyeballing the locals I can guarantee you that skinny hasn’t always been the rule. When I first sat on Italian beaches in 1970 I was amazed at the plus size bosoms and bottoms that were wrapped in those skimpy bikinis. Later when fashions changed, Italians’ sensible food culture made slimming down a relative cinch: just slash your standard portion of pasta by half, eat one less course at every meal, and voilà in a decade the national figure shrank from Rubens to . . . Raphael.
P.S. It helps, needless to say, that Italians habitually use their feet instead of their car, and take the stairs without considering it torture! 

Wednesday, January 17, 2018

Hamming It Up

I once had a heart disease patient named Edoardo, the father of a friend, who had angina pectoris so severe he couldn’t cross the room without pain. Back then, in 1989, angioplasty and stenting hadn’t yet been invented, but surgeons did know how to unplug coronary arteries using open heart surgery and he definitely needed it. There was only one problem: in Italy at the time bypass surgery meant at least a one in four chance of dying on the table.

Those were not odds I felt I could recommend. I turned for help to my trusted cardiologist, the late Alberto De Feo, who came up with a solution in the form of brand-new European Union regulations. My patient followed Dr. De Feo’s instructions to the letter. He drove to Monte Carlo on the French Riviera, stayed three days in a hotel hanging around the roulette tables, then went to the Emergency Room of a specific hospital clutching his chest and claiming the pain had just started. He could – and did – get bypass surgery in France and charge the bill to the Italian National Health Service, but only if it was a real emergency. 

Even now, after thirty years of European Union rules easing the obstacles to medical country-hopping, such picturesque Emergency Room theatrics are still not entirely obsolete…
P.S. It was lucky this particular heart patient was Italian; I think most Americans wouldn’t have managed to carry off the trick (and might have been more squeamish about its ethics). Pay attention on any Rome bus and you’ll find at least one native casually improvising melodrama. The ancient theatricality of Italian culture gets an extra boost from a school system based on gaming oral examinations in front of an audience…

Sunday, January 7, 2018

Drugs (Not) On The Market

One day last October I was sitting at a computer screen at my office’s reception desk scrolling through the images of a patient’s CAT scan – my own computer wouldn’t do because I’m an Mac girl and all radiology CDs in Italy are Windows-only – struggling to keep my concentration on the patient’s insides and ignore the chaos around me.
My secretary Mariateresa was speaking into a phone and her voice succeeded in penetrating my defenses. “Robertino needs his hepatitis B vaccine? No, I’m sorry, there’s no point in taking an appointment with the pediatrician, because that vaccine is unavailable at the moment. The Haemophilus influenzae shot? Same story, I’m afraid.” This was so startling that I abandoned the CAT scan images and indulged my curiosity: “Not available? How can that be? Those are obligatory vaccines. Kids can’t start school without them.” Mariateresa shrugged dismissively, “Of course, that’s exactly the point. Every fall parents scramble to get their kids vaccinated, and every fall there aren’t enough vaccines to go around. This year the missing ones are hepatitis and Haemophilus, last year it was meningitis and measles-mumps-rubella.” If you think about it this kind of shortfall is inexcusable. Italy has universal population registries, so it could easily calculate the number of necessary doses ahead of time, but hey that’s our beloved Bel Paese.
The Italians have a saying about the marvels of Rome, “Non basta una vita,” a lifetime is not enough to see them all. Well, the same goes for its foibles – after 39 years here I’m still encountering new ones.
Generally speaking Italy is a great country to buy medications: list prices trend low, and anyone with a National Health Service prescription pays zero or close to. The authorities are able to swing this by bargaining ruthlessly with the drug companies over prices. Just a couple of months ago California-based Gilead Pharmaceuticals agreed to accept $11,000 for each course of hepatitis C treatment with their new pill Epclusa. That may sound like a lot but it’s far lower than the $75,000 they get in the States. If Gilead hadn’t agreed to cut the price of Epclusa, it wouldn’t have been included on the National Health Service formulary and no doctors in Italy would prescribe it.
The ins and outs of the system keep us docs on our toes. The yearly vaccine debacle may have been new to me, but I’ve always known the pharmaceutical supply chain to be iffy. Things change fast. Yesterday you could buy the equivalent of the tranquilizer Ativan only as generic lorazepam, today there’s only brand-name Tavor. This week the antibiotic metronidazole is on pharmacy shelves only as Flagyl, next week only as a generic, the week after only as Deflamon, then for six months it’s unavailable under any name. During the entire 2013-14 flu season neither of the two approved anti-influenza drugs, Tamiflu and Relenza, could be found anywhere in Rome. Premarin, the classic hormone pill and vaginal cream, disappeared mysteriously from Italian pharmacies in 2009 and has never shown up again. Yes, I know the US runs low on a drug now and then, but here shortages are too commonplace to warrant a mention in the paper much less headlines.
Then there’s the way brand names keep biting the dust. The Italian companies that make the meningitis vaccine and the one against measles-mumps-rubella change every few years. For a decade I prescribed menopausal women a rub-it-in estrogen skin gel called Gelestra (Estrogel in the States), but at the end of 2014 it became Ginaikos – same gel, same pharmaceutical company, same dose, same formulation, same color box, but pharmacies won’t dispense it unless my prescription bears the new name.
Almost all medications found in the US or the UK are on the market here, plus some that either are new and got approved here first or are left over from the Jurassic era. But like so much else in Italy, getting hold of a specific drug can sometimes be a crap shoot. Don’t even consider having your supply shipped from home – it’s close to impossible to extricate prescription drugs from Italian customs, which is on the lookout for them.

Moral of the story: if you’re coming to Italy and there’s a medication you really really need, bring along enough to last you for the duration.
Sorry for the long gap between posts – vacation intervened! A version of this one has been published as "Musical Drugs" in my The American In Italia column, Bedside Manners