IN LAND OF CHAMPAGNE AND CROISSANTS, PILLS ARE KING

French lead the world in use of medications

On Easter Sunday, when Marie-Claude Monnet began slurring her words after a
single glass of wine and fell asleep midway through the holiday roast lamb,
the Monnet family realized that it had a problem.

Her daughter Jeanne found more than 100 open boxes of tranquilizers,
narcotic painkillers and antibiotics in the 79-year-old woman's Paris
apartment. ``We had to face the facts,'' Jeanne said. ``Maman is a
droguee'' -- ``a junkie.''

The family's name has been changed, at their request. But the details are
all too real. In a nation that has become the runaway world leader in
pill-popping, Marie-Claude Monnet's pharmaceutical hoard is as typically
French as a well-stocked wine cellar. With less than 1 percent of the
world's population, France now accounts for almost 10 percent of all
expenditures on drugs worldwide.

In 1995, the Organization for Economic Co-operation and Development (OECD)
reported that the average citizen of France purchased 52 containers of
medication -- more than the total combined figure for the United States,
Great Britain, Germany and Italy.

The average French woman in Madame Monnet's age group took home 99
containers of medication, while the average 80-year-old man purchased 91.

French doctors ``prescribe four times more than the British, Irish,
Italians or Greeks, and six times more than Danish, Belgian and German
doctors,'' said pharmaceutical researcher Berthod Wurmser, an expert on
European health issues.

According to the pharmaceutical industry's own figures, purchases of
medications in France rose by 518 percent between 1970 and 1995.

A similar jump has been registered in the United States, where the national
medication bill soared from less than $10 billion in 1970 to nearly $50
billion in 1995. But adjusted for purchasing power parity, French annual
drug spending per person still remains No. 1 on Earth, at more than $300,
with the United States a close second at $290.

Lest Americans feel smug, they might take note of the fact that U.S.
suppliers aggressively feed the French habit. Marketed and purchased on the
Internet, increasing numbers of drugs are being shipped illegally to Europe
from the United States, postal authorities say.

But the main sources remain overwhelmingly French. In 1991, a government
report found that almost a third of French women were being prescribed
tranquilizers or anti-depressants at every doctor's visit. By 1996, 30
percent of all women over 60 were regular consumers of such drugs, as were
57 percent of the unemployed.

In one extreme case in central France, a doctor prescribed 38 separate
medications for the same patient. In another, a retiree was found to be
taking 116 pills per day.

``If more than three chemical compounds are ingested by a patient, it is
almost impossible to predict what the effects of their interactions might
be,'' warns Dr. Jean- Pierre Poullier, director of health policy studies at
the Paris-based OECD.

Like the family of Madame Monnet, France knows it has a serious problem.
But solving it, as one pharmacologist put it, ``would require a cultural
revolution.''

As in the United States, the problem stems from a complex series of
relationships between doctors, patients, the pharmaceutical industry and
the larger medical system that unites them.

It is also a classic example of a once-model social welfare program that
has defied the best of intentions and wandered into disaster.

A nonscientific survey of experts on both sides of the Atlantic found
universal agreement that loopholes in the world's most comprehensive
government-subsidized health care system are chiefly responsible for the
catastrophic explosion in drug use.

``Catastrophe'' is no exaggeration. France ``holds the world record for
deaths due to medication,'' notes Wurmser. Its prescription drug-related
mortality rate is 10 times higher than in neighboring countries and an
astounding 20-to-50 times higher for those older than 75.

Put simply, drug prices are kept so low that pharmaceutical manufacturers
must sell enormous amounts of their products to fund research and
development.

In the United States and Great Britain, the annual profit margin of drug
manufacturers is nearly 20 percent. By contrast, French firms average just
over 3 percent, according to Professor Denis Richard, chief of
pharmacological services at the Henri-Laborit Medical School in Poitiers.

``In France, the government controls drug prices, and the pharmaceutical
industry can't do much about its income except to emphasize volume,'' says
the OECD'S Dr. Poullier.

``French (drug) prices have long been less than 50 percent of the
corresponding German prices,'' notes Dr. Anne-Laurence Le Faou, author of a
book on the economics of public health in Europe.

Pharmaceuticals are the only sector of French industry in which prices are
set by the state, a policy that involves 80 percent of all medications on
the market.

To achieve volume sales, the $20 billion-a-year French pharmaceutical
industry runs giant marketing campaigns, papering city walls with posters
for drugs and inflating mass-circulation magazines with slick full-page
ads. It besieges doctors with more than 17,000 sales representatives.

The costs are effectively passed on to the government.

National health insurance covers 99 percent of the French public. Patients
are directly reimbursed for 65 percent of most drug purchases, and 100
percent for medications regarded as indispensable for the treatment of
serious illness.

Much of the remaining cost is absorbed by ``la mutuelle,'' a supplementary
private insurance policy, usually paid for by employers, that covers 87
percent of the population.

``For individuals, there are no financial inhibitions on consumption,''
said Professor Mike Dixon of the University of South Carolina, who spent a
year in Paris researching comparative levels of pharmaceutical use.

The result of the trade-off between controlled retail prices and high sales
volume, however, is heavy public debt. French households spent 126 billion
francs on drugs in 1995 (about $24.7 billion). In comparison, household
expenditures on wine and all alcoholic beverages was 89 billion francs
($17.5 billion).

Medication expenditures helped push the nation's total health bill from 4.2
percent of GDP in 1960 to 10.2 percent in 1994, a level exceeded worldwide
only by the 14.5 percent outlay in the United States.

Health care costs accounted for two-thirds of France's $10.1 billion social
welfare shortfall in 1996, a deficit that threatens the entire system with
bankruptcy.

``What you see in France is a textbook study of a regulatory environment
and its implications,'' said Dixon.

What you also see, Poullier adds, is ``a demonstration of the principle
that medicine is not a science, it is an art -- an art that draws on the
specific peculiarities of a specific culture.''

Few health care professionals have come to understand that principle more
intimately than Anne Pietrasik, a nurse, author and medical interpreter who
has worked with dozens of the world's top pharmaceutical researchers.

Trained in Britain and in France, Pietrasik has served as an intensive care
nurse for the terminally ill in both countries, and as research assistant
to an experimental pharmacologist with offices in California and Paris.

``French people,'' she says, ``have a deep and abiding faith in the
`baguette magique' -- a magic wand -- that can cure any ill with the
ingestion of the `right' pill.''

Indeed, adds Dr. Poullier, ``the French believe that a doctor is no good if
they come away from an examination without a long list of prescriptions.''

There can be ``tremendous variation in cultural assumptions like these,''
he observes.

``Americans are prone to think `surgery' when they fall seriously ill, far
more often than in other nations. For the Dutch, a good doctor is one who
does not load them down with prescriptions, even though Holland is just 300
kilometers (180 miles) from France.''

In the transaction between overprescribing French physicians and their
overconsuming clients, Pietrasik agrees, the problem cuts both ways. ``The
doctor responds to a demand, the insistence of a patient who is always
determined to find that baguette magique.''

It is precisely such determination that fueled Marie-Claude Monnet's
formidable acquisition of drugs.

Troubled by acute asthma and unable to face the rigors of aging after a
lifetime of frenetic activity as a self-employed businesswoman and single
parent, ``Maman is sure that she can find a pill that will give her back
the energy she had a decade ago,'' says Jeanne, ``if only she searches hard
enough.''

The search took her along another well-traveled road in the French health
care system, a journey from clinic to clinic in quest of a cooperative
doctor. Sometimes, says Jeanne, who found wads of appointment slips mixed
in with her mother's drugs, ``she saw as many as two different doctors a
day, every day of the week.''

As with medications, there is little financial disincentive limiting
doctors' appointments in France. Enrollees in the national health care
system can go to any doctor they choose. They are reimbursed for between 70
percent and 100 percent of the fee.

Increasingly confused and already subject to memory loss, Madame Monnet
took to starting several prescriptions at once on her own, then terminating
some before their intended completion date while refilling others.

Convinced that her breathing difficulties were a result of ``all these
infections,'' as she vaguely told her daughter, she persuaded doctors to
prescribe antibiotics for winter colds -- a dangerous abuse of drugs that
have no effect on common colds or viruses.

``To prescribe a nearly useless medication each day for 20 percent of all
patients, even at a moderate per-unit cost, is to divert 5 or 6 billion
francs per year from public resources that might bring appreciable health
gains to the public if that sum was more effectively used,'' concluded a
1996 government report.

Madame Monnet had no trouble filling her endless prescriptions. Within half
a mile of her apartment on the southern edge of Paris there are more than
200 pharmacies. ``They outnumber cafes and grocery stores,'' notes Jeanne.

Across France, there are nearly 53,000 pharmacies, 107.5 per 100,000
people, almost five times the proportion elsewhere in Europe. For
politicians, any legislation aimed at reducing this number would risk the
backlash of a lobby that counts 220,000 pharmacists and drug industry
employees -- and fiercely defends its interests.

``Medication is habitually the favorite target, the troublemaker, the mangy
cur that brings us problems,'' says Professor Jacques Dangoumou, president
of the Administrative Council of the French Medication Agency, a
counterpart to the U.S. Food and Drug Administration.

``Everyone has the idea that too much (medication) is consumed in France,
which is undoubtedly true. But there are also caricatures: every time
health expenses are discussed (in the media), the illustration shows a
little fellow or a little lady with a bag full of drugs.''

Yet the illustration is perilously close to the truth, according to the
pharmaceutical industry's own figures.

The situation can be described as nothing less than ``the medication of
existence,'' says Professor Edouard Zarifian, a leading French health
analyst.

CHART: DRUGSTORE JUNKIES -- Containers of prescribed medication sold
annually per person in 1995: . France 52 Italy 21.1 Germany 13.5 United
Kingdom 9.3 United States 6.1

Prescription drug consumption per 1,000 persons per day (``defined daily
dosage''):

Checked-by: jwjohnson@netmagic.net (Joel W. Johnson)