Nuts To Starbucks

Brigida, you’re like a cup of coffee, bitter on top but sugar underneath. I’m going to stir and stir to get your sweetness from the bottom of the cup into my mouth.

- Neapolitan song

When I was a kid there were three foods I hated: Coca-Cola, peanut butter, and coffee. Now there are only two, because coffee, like flattery and sports cars, is one of those things Italians do better than anyone else.

Everybody agrees the very best brew is the intense nectar made in the bars of Naples, where coffee is a cult as well as a metaphor. Nobody really knows why. Some think the secret’s the choice of beans, others the roast, others the water. More mystically-minded locals believe it lies in the ritual – “Here coffee isn’t loved because it’s good, it’s good because it’s loved.”

Neapolitans make the best coffee at home too, with an ordinary stove-top machine, because of their attention to detail. Here’s some of their tricks: break in any new Moka pot with a plain-water dry run, never contaminate its inner surfaces with soap, fill with water just so, choose the best beans (Illy will do), heap your grounds into a perfectly calibrated mound, resist the urge to tamp it down, set your flame to barely cover the base, leave the cover left open for aeration, drop a little bonnet over the central post to prevent spray, turn off the heat just in the nick of time, give it a quick stir in the pot before pouring, and never ever reheat. Try, but you’ll never quite make the grade.

Italians traditionally end every meal with an espresso and seem always to be wandering off to the corner bar to knock one back. But when it comes to total coffee consumption northern Europeans win hands down – Finns average 21 pounds of dry beans per capita per year, Italians just seven and a half.

A hard-core Italian coffee lover drinks his espresso straight up, no milk no sugar, like a Bourbon lover who disdains water and ice. I say he advisedly, because women are expected rightly or wrongly to prefer theirs served up in gentler form. My colleague Vincenzo likes his coffee lungo, with extra water, but in a bar the long one will inevitably be set down in front of me rather than him. When my husband and I order one plain and one macchiato I always get served Alvin’s, the one with a touch of milk.

Italian espresso is so dense with flavor that people think it must also be loaded with caffeine. Wrong – it actually packs less of a punch than any other form of java, because steam rapidly forced across the ground beans doesn’t extract as much caffeine than water dripping through or soaking or God forbid percolating. For decades coffee was framed for bringing on all kinds of diseases, based on the puritanical conviction that anything pleasant must be bad for you. True, coffee won’t help if your nerves are already on edge (Hag is the brand name for decaf), and it’s hell on heartburn. But I am pleased to be able to report that medical researchers have not only let coffee off the hook from causing heart attacks, but even speculate it might help ward off – hold your hat – blindness, Parkinson's disease, type 2 diabetes, liver disease, atrial fibrillation, heart attacks, stroke, and cancer.

P.S.: If there are Italians in sight, don’t end your meal with a cappuccino. If you insist and the waiter looks at you funny, try telling him it’s for medical reasons.

P.P.S.: How come at Berkeley’s Market Hall they fuss around for ten minutes to produce a mediocre cappuccino when any barista in Rome can produce a great one in 30 seconds flat?

P.P.P.S.: If you ask for a latte in Italy what you’ll get is a plain glass of milk.

In The Beginning: New York To Rome By Way Of Africa

November 1978, eleven at night, five weeks after my then-husband and I had left New York for good, just inside Tanzania. The two soldiers who stopped our truck were so drunk they barely managed to keep their bayonets pointing in our direction. Andrea and I, about to close our six-week African parenthesis before settling in Italy, obediently climbed down to be escorted at riflepoint to the tent of an equally sloshed camp commander, who dressed us down and ordered the protesting driver to haul us back to Kenya. An abrupt closing of the Tanzanian border, due to fighting near Uganda, had dashed our dreams of watching lions stalk wildebeest at Ngorongoro Crater and smelling the cloves in Zanzibar. Public busses between the two countries had been halted, railway lines had never existed, Andrea’s awkward stab at bribing a ship’s captain had fizzled, and our final attempt to cross the border, by hitchhiking, had now met the same fate. The trucker fumed all the way back across 10 miles of no-man’s-land and dumped us at the Kenyan border station.

There were two benches outside, narrow, wooden, and painful, where we got snatches of sleep until a workingman’s bus stopped at dawn, en route to Mombasa, and picked us up. In my dreams that night I said farewell to my American life. That dusty nowhere in Africa seemed to straddle not just the edge between two countries but a watershed between my old world and my new one. Perhaps it was facing those bayonets as a couple that hammered it home: I really had thrown in my lot with my Italian husband and with the unknown. When our plane took off from Nairobi a week later, I was ready to leave all certainties behind and begin a joyful adventure in chaos.

Chaos aplenty awaited us, joy zero. The Rome we touched down in was bewilderingly dark, depressed, menacing, with none of the raucous street life that had seduced me as a tourist a few years back. Just months earlier former Italian Prime Minister Aldo Moro had been kidnapped by the leftist terrorists of the Red Brigades. When he was murdered and his body dumped two blocks from his Christian Democratic party’s headquarters, it made headlines around the world.

The oil crisis was at its peak, forcing restaurants to close at 9 pm when in normal times people would have just been sitting down to eat. Trigger-happy cops manned the intersections, and the few pedestrians scurried like rats from doorway to doorway. My personal gloom deepened when I learned my Italian medical license wasn’t there waiting for me, as a nice but ignorant lady in the New York Consulate had promised.

Fortunately everything came right in the end. Yes, the license took a year and a half to come through, but by 1981 Rome had regained its bustle and I had launched a medical practice that would with time become the envy of my American colleagues. I’ve gotten to play the old-fashioned country doc for decades, treating three and four generations in the same family, while enjoying a clientele – one-third American, one-third Italian, one-third miscellany – that’s included Kenyan diplomats, English nannies, Burmese nuns, Italian auto mechanics, and Nobel laureate poet Joseph Brodsky. I have the world’s best medical secretary. I practice blissfully free from the diagnostic coding and insurance company pre-authorizations and electronic medical record regulations that torture physicians in the US, and I can choose for myself which medical guidelines to follow and which to ignore. OK, I haven’t had the peace of mind that comes from top-notch hospital backup, or accumulated a fat investment portfolio like my colleagues back home, but between the professional plusses and the glorious Italian lifestyle I wouldn’t exchange my Roman career for any other.

*******

A slightly modified version of this post is being published simultaneously in The American In Italia as the first entry in my new column, Bedside Manners.

Abortion, Birth Rates, The New York Times

As the Italians say, it’s been raining on wet ground. Following my recent blog entry on contraception in Italy I received several emails from readers asking whether the rock-bottom Italian birth rate might be the result of a sky-high abortion rate. By amazing coincidence, two days later the New York Times published an article about abortions in Italy and how hard it can be to get one. So the subject matter of this post is overdetermined – I get to write a wonky post about abortions in Italy at the same time as firing off a Letter to the Editor.

Amazingly, the Italian Parliament legalized first-trimester abortion in public hospitals back in 1978, making it available on demand and free of charge on the National Health Service. Three years later a nominally Catholic electorate roundly scotched a Church-promoted national referendum that tried to re-criminalize it. The Church retreated licking its wounds but eventually hit on an excellent means of sabotage: conscientious objection. The law’s option for gynecologists to refuse to participate was originally intended to remain buried in the fine print but by now 70% of all Italian gynecologists are registered as conscientious objectors. So waiting lists, despite shrinking due to the increasing use of pills rather than surgery, are still scandalously long. One out of three women seeking a legal abortion is given an appointment more than two weeks away, which drives many (20%, it’s estimated) to get one illegally instead.

As the Times article points out, it’s obvious that conscientious objection and Catholicism are related. But the Church uses stronger weapons than mere moral persuasion in its promotion. I explain in the letter I submitted (in vain) to The Times:

To The Editor,

In her otherwise excellent article, “Abortion in Italy, a Right Wronged,” Ilaria Maria Sala omits one crucial element in why so many Italian gynecologists register as conscientious objectors. In addition to the genuine religious convictions of some, and the fear of others that performing abortions would tarnish their reputation, there are more practical threats to their livelihoods. Abortions are performed only in public hospitals, by gynecologists employed by the National Health Service. Many public system gynecologists, however, want also to be able to treat their own patients, after hours, within a large network of private hospitals which in Italy are mostly owned and/or run by the Catholic Church. Any physician who performs abortions – supposedly, any physician who even just counsels patients about them – is barred from operating, delivering babies, or hospitalizing patients in any Church-run institution. Thus a gynecologist who wants to be able to work privately in Italy is virtually obliged to declare him- or herself a conscientious objector to abortion.

So to get back to our original question, do abortions have a big influence on Italian birth rates? Nope. Italy has one of the lowest abortion rates in western Europe. In proportion to the number of babies born alive Swedish women have 40% more abortions than Italians, French women 35%, English and Spanish about 18%. And only one in five abortions performed on Italian women is a repeat procedure.

Since legalization there have been fewer and fewer abortions in Italy, especially among citizens – non-Italians, many of them immigrants from developing countries, now account for one in three.

The bottom line is that the Church has indeed succeeded in mounting barriers to abortion, especially in southern Italy, but those barriers can be overcome. And women here don’t have to run the gauntlet of demonstrators you find screaming abuse outside the entrances to abortion clinics in the USA. And no one has ever shot an Italian abortionist.

Scorecard: Babies

        United States  Italy

Women age 15-44 using modern contraception          70%     36%

Birth rate per woman                                                  1.8       1.4

What’s Their Secret?

When it comes to birth control Italians have a preference for the “natural” you can trace to the Catholic Church, which long since banished the contraceptive diaphragm and persuaded most people not to use IUDs, Pills, patches, rings, implants, Depo-Provera shots, or sterilization. Condoms, which Italians usually call preservativi – watch out what word you use for jam or you’ll get snickers – are fairly popular. But what most people do to avoid pregnancy is what they call stare attenti or being careful: watching the calendar, and using withdrawal on days they think (rightly or wrongly) that they’re fertile.

Nonetheless, the Italian birth rate hovers between the lowest and the next-to-lowest on the planet. How come? The main explanation is that – contrary to what I was taught in medical school – withdrawal works. It helps that Italy has a surprising culture of shared responsibility between men and women in this particular realm, so guys are more willing to use condoms, and more skilled at pulling out.

Ripping Off The System

Fraud is a worldwide sport but in Italy, land of Verdi and Puccini, it may get embellished by melodrama. Some years back the administrators at Rome’s Jewish Hospital figured out a solution for their hospital’s unbalanced budget and their own empty pockets: soak the National Health Service. In 2014, after some 20 million dollars had been siphoned off, their scheme hit the headlines with a bang. At first the conspirators had just been overcharging dental fillings as implants, or outpatient procedures as though the patient had spent the night. Poca roba, small stuff, as the Italians say.

The Jewish Hospital staff gradually escalated to shameless double billing and to inventing “ghost operations,” until one day the authorities planned a surprise inspection. That was when the plotters found themselves having to call on their native theatrical flair. A mole inside the regional National Health Service office tipped them off about the upcoming raid, giving them time to dress up an orthopedic ward as though it belonged to dentistry (don’t ask) and a private ward as though it were public. Phony medical charts were fabricated, complete with temperature readings and lab tests, and flocks of patients were shuttled between one ward and another. One hospital chief was caught on a wire tap telling a crony: “The inspectors are coming, it’s time for us to put our little piece of Hollywood into motion. You empty out the patients on the fifth floor, and we’ll cross our fingers.”

Now don’t be shocked, but even in the USA public medicine loses billions every year to greedy cheats. There are macroscams where clinics bill for medications that were never given or buy used equipment as though it were new. Middling scams where doctors and opiate pushers collude. And microscams – the only Medicare bill I’ve happened to see with my own eyes, related to a 3-minute visit for a non-smoker’s athlete’s foot, tossed in a charge for “Tobacco counseling.” All effective in their way, but sadly lacking in pizzazz.

So who’s worse? According to reports commissioned by the European Union, 13% of all the money spent on health in Italy gets lost through corruption, whereas outright medical fraud in the US is said to add up to only 3%. But if you join me in considering obscene overpricing to be tantamount to fraud – mebendazole pills for deworming your kids, two for a buck at your local Italian pharmacy, cost $442 per pill wholesale in the USA, and many American Emergency Rooms charge patients $1000 just to walk in the door before even seeing a nurse – maybe we can charitably call the contest a draw.

The Perils Of Fast Food

Italy has a perfectly fine public health system, but it doesn’t encourage audience participation. Here’s Ralph’s story. One year ago he wobbled into my office barely on the mend from food poisoning, the sitting-on-the-toilet-holding-a-bucket-to-barf-in kind, that had started 10 hours after having a burger and shake at one of Rome’s forty-one McDonald’s. Obvious food poisoning, and a menace to other customers.

Being a good citizen I set out to make a formal report so an investigator could be dispatched to start testing those Big Macs. After dialing a dozen health department numbers trying to find out how, I finally found someone who knew the correct answer: forget it, Dottoressa. In the UK a physician who suspects restaurant-acquired gastroenteritis is legally obliged to report it, and in the US it’s strongly advised. In Italy, the physician can’t do a thing – by law, I was told, only the injured person him- or herself can do the reporting.

When I passed this information on to Ralph, he proved to be an even better citizen than me. He tracked down the address of the proper office and trotted over there the next day. The man behind the desk heard him out then said, “OK, before we start our investigation we need your receipt for that meal.” My patient made the Italian both-palms-up gesture of astonishment: “You must be kidding. There's no way I'd have held onto the receipt for a fast-food hamburger I ate a week ago.” Employee: “What, no receipt? You threw it away on your way home? Sorry,” he said, tossing the report in the trash. “We can’t take your complaint if we don’t first have proof you ate that night at McDonald’s.”

Italian Public Medicine: Testimony From My Readers

·      I gave birth to my second one at Fatebenefratelli Hospital. I still remember it as an experience from a third world country.

·      I had a protesi inverso [reverse prosthesis] right shoulder done, great young doctor, great 50 days therapy after, all free. I have a young woman base doctor here in my town and she has saved me twice on diagnosis...

·      an email written at 11:39 AM: Here at xxxx Hospital since 8:00am, haven't yet seen the doctor (eye check up). So far 82 patients all in different stages of waiting and all assured we will be seen....

·      My son had a collapsed lung and was immediately operated on for free by a top doctor. That son is now studying medicine, practically for free...

·      I had the personal experience of visiting a friend's father who was in a Firenze hospital with lung cancer. The green tile on the walls of the rooms and hallways harkened back to 50s operating rooms, and the oxygen breathing apparatus he was using was a crude enclosure that sat on his head and covered his face with a plastic mask. He shared the room with another patient who smoked during our visit.

·      I just could not bear to hear one more doctor say "Non si preoccupi signora, ci penso io" [Don’t worry your little head, ma’am, I’ll take care of everything] when I had a question.

·      My experience with the health system in Italy was positive. I had the same GP throughout (22 years), neither of us aged a day, I never paid a penny. My best experience was when I succumbed to a bout of despondency in the doctor's studio, this about 1992, in tears I was, and he poured me a glass of whiskey.

A Mystery Headline In My Inbasket Last Week

“No extenuating circumstances for those who throw mud on the dental profession.”

            - Rome Medical Society Newsletter

Huh? Who was throwing what mud on whom how? I couldn’t resist clicking through. The mudslingers turned out to be . . . real dentists who dishonor the profession by covering for phony ones. This is an old story. Most dentistry in Italy is done privately, not on the National Health Service, which has spawned a whole army of dental imposters – 15,000 or so strong, said to fill a quarter of all the country’s cavities. Usually the pretender is a technician, trained to work on crowns and bridges but dabbling in live teeth on the side, in cahoots with an authentic doc who for a price allows his name to grace the receipts, the prescription forms, and the bronze plaque on the office door. One of my closest friends had a dental technician uncle so she never went to a licensed dentist until she moved to another city at age 35.

The figure of prestanome or name-lender is as deeply rooted in Italian society as that of the Mafia consigliere. Years ago my secretary was inveigled by her first boss into being the official CEO of a shady import-export company, whose shenanigans eventually got her hauled into court. The judge took one look at her neckline and jeans and spat out in disgust, “She’s obviously just a prestanome.”

While name-lender dentists never used to risk more than a slap-on-the-wrist fine, lately the Medical Societies have started upping the ante. Last week’s headline was celebrating the very first time the Rome Medical Society had publically stripped a dentist of his licence, after the courts had found him guilty. This particularly bad actor, charitably left unnamed in the article, had abandoned hand-in-mouth dentistry years earlier in favor of skimming the profits off a chain of quack offices.

But, then, when I was studying medicine in New York it was whispered that patients at my Mount Sinai Hospital had been operated on for years by a neurosurgeon who didn’t have a medical license. As the Italians say, tutto il mondo è paese, everywhere in the world it’s the same village.

Scorecard: Money and Longevity

                                                                   United States      Italy

Gross Domestic Product per capita                $57,467          $30,527

Health spending per capita                             $9,892            $3,391

Life expectancy at birth                                  78.8 years      82.6 years

What’s Their Secret?

The main reason Italians get more bang for their health care buck is that they have a single-payer National Health Service, financed out of taxes. Everyone can see their own primary care doctor and be cared for in the hospital without paying a penny, while medications, testing, and specialist exams require at worst a tiny co-pay. Add in low income inequality and a famously healthy lifestyle, and Italy has more than enough on the plus side to compensate for its medical system’s many flaws.