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