French health care: vive la difference!

IT’S the best in the world; France’s healthcare system is held up as a model of good practice. It’s where you want to be if you get sick.

But when you look at how the system works, it’s not unlike what Mary Harney wants for Ireland. Except for one thing. 

“What’s important is to make sure that the private sector would not be like a poker player and only interested in the money, and to ensure that they stay focused on the main topic which is healthcare,” says  Gabriel Ko.

Dr Ko has worked in Ireland and in France - he is a biopathologist, formerly the leader of the French junior doctors, and now works for Claymon-Biominis and for the French government.

He admits: “When I saw the salaries of the Irish doctors, I said: ‘Oh my God, I should definitely live in Ireland!’”

French doctors earn, on average, from €50,000 to €100,000 a year. Not a fortune - but a solid income.

From the patient’s point of view, it’s a great system. Everyone over the age of 16 has a ‘treating doctor’ - usually people choose a GP - who coordinates any medical treatment the person needs.

A visit to the doctor costs €23. If your doctor sends you to a specialist, that visit will cost you €25. 

There are three ‘sectors’ of doctors - Sector 1, in which most GPs are; and sectors 2 and 3. Sector 2 docs charge more, with part of your payment covered by social security and part reimbursed by medical insurance. Sector 3 is tiny - about 1.5 per cent of French doctors - and more absolutely private. This includes a lot of alternative medicine practitioners. 

“Sector two  means that you will be allowed to charge whatever you want to charge a patient, but you have to do it with a certain measure,” says Gabriel. 

“You have to ask the patient if he’s got any private insurance, or any kind of money to pay that.

“Roughly, to give you an idea, in Paris for a gynaecologist in the private sector, the average charge for consultation would be €60 or €70.

“But out of that up to €25 will be reimbursed from Social Security, and the difference between €25 and €70 would be more or less reimbursed by your private insurance.”

You can also choose a specialist not recommended by your doctor - but then you’ll have to pay out of your own pocket. 

Hospital is different too. “With regards to hospitals: we don’t have such a definition of consultants like in Ireland,” says Gabriel. 

“What we would have is senior doctors.  and the majority of the senior doctors are not allowed to ask anything more than the hospital will ask of the patient.

“If you’re going to the cardiology department or going to the pathology department you would have a consultation or even full hospitalisation, and then you will be charged directly by the hospital.

“The doctor would charge you exactly the same as any other doctor: this is the price that is fixed by Social Security.”

Professors or heads of service are allowed to work privately within the hospital - but this is limited to around two-and-a-half days a week.

 “But at the end of the year the public service look at how much they asked to the patient in this private activity,” says Gabriel.

“So if you are making  €1 million as a doctor working in the private sector, well that’s something that will not be tolerated.”

If you’re in an accident or taken suddenly ill, you call for help - but what arrives isn’t an ambulance. It’s the SAMU (Service d'Aide Médicale Urgente).

This is a specialist team, led by a doctor, which may include doctors, nurses and a driver, and is qualified to give emergency treatment on the scene or transfer patients to hospital as needed.

“For the French patient I think the system is quite good,” says Gabriel. 

Published in the Evening Herald, Dublin, Ireland, in June 2010

'TIS in Kilkenny, it is reported, the marble hearts are as black as ink - in JJ Toner's noir thriller St Patrick's Day Special, the ancient city is where a gangster tout is being hidden away from his former friends.
At the beginning of this tense story, DI Ben Jordan of the Garda Síochána is on his way to take over babysitting the tout. But when he arrives, there's nothing left to babysit: the supergrass and Jordan's colleague have been wiped out, seemingly by a murderous pizza deliveryman.
Jordan, obsessed as he is by Ireland's most vicious gang leader, Lafferty, is determined that Lafferty will go down for this: it's obviously his handiwork.
Which leads us into an intricate story involving Jordan's troubled daughter and her beaux, his unhelpful bosses in the Gardaí, his own disintegrating personality, his dicey marriage and new life in a seafront mansion in Dublin 4, and myriad twists and turns.
In a dark vision of drug-ridden post-Celtic-Tiger Ireland, Toner's Ben Jordan makes the first appearance; we're going to see more of him.

Image systems

Having slept through the TV showing of Forbrydelsen 2 (the Danish original of The Killing, season 2), I went back to watch the first episode again, and was pleased to see that they've got a big image system thing going. 

Image systems, for those not familiar with the minutiae of fiction, are used, often unconsciously by writers, more often as a conscious part of the storytelling by filmmakers, to hint at secrets, and to express the theme and to make a coherent emotional whole of the story.
Hitchcock was the boy for image systems - if you look at his Psycho, Vertigo, Rear Window, etc, each one has its own image system - dank in Psycho, vertiginous in Vertigo, sneaky in Rear Window. The Psycho image system is cogged to some extent from Henri-Georges Clouzot's spectacularly nasty Les Diaboliques, in which the plan to murder a woman gradually seeps up through the chinks in the audience's subconscious through the use of endless watery images: a dripping tap, an emptying swimming pool, a murderous bath.
But probably the most famous image system is that in Casablanca, which Robert McKee uses as his illustration in his useful seminar Story. Casablanca is riddled with subtext, both in the text and in the visuals: it's full of arches, the costumes of the lovers Rick and Ilsa grow closer in design as they grow closer to each other; a conversation about clothes in the market is a coded love scene.
Time is also a constant image - even the theme of the song is As Time Goes By. Ratcheting up the tension of the fast-approaching Nazi victory (as it seems in the film), an adorable old couple who are supposed to leave for America the next day explain that they are speaking only English now, to practise. "Sweetness heart, what watch?" the gentleman asks, and the lady answers: "Ten watch." "Such much!" he exclaims. Knowing as we do that these, as with millions of their like, are more likely to be murdered, the conversation has an extraordinary bittersweet horror.

And when the Germans in Rick's Café Americain strike up a pugnaciously anti-French Die Wacht am Rhein, and having stood it for long enough, Ilse's Resistance hero husband tells the band to strike up the Marsellaise and every liberty-lover in the café sings along - even, in the end, the girl who's getting off with the Nazis - you'd need a heart of stone not to be moved.

So it's pleasing to see that Forbrydelsen II is riddled with an image system whose meaning will become clearer as the episodes go on. So far, it involves a particularly bloody colour of red, in curtains, in heroine Sara Lund's blood-red jumper, on the walls, in hints of the blood-red Danish flag with its Crusader's cross, in a disturbing spiral staircase filmed from above, and in the curtains of rooms, in rectangles or squares in the background of many scenes.

The rain pours and pours down out of the heavens - or rather, it seems as if the world is just full of rain without it actually coming from anywhere. No one wears a hat or a hood or puts a newspaper over their head, they just stand stoically in it like cows in a field. (Why don't cows get shelters in fields, by the way? Surely they're just as miserable as the rest of us in the fleeping rain?)

There's also another dominant image: big wedge-shaped buildings, seen first from the outside, then entered to find that some organisation is leaning down on a fragile human; or big wedge-shaped tunnels down which the heroes must venture. And there's another rectangle that joins both systems: the military dogtags, sheared in half so that the numerals on them echo the slit windows of those buildings. 

It's also full of roads, bridges, railways, slick with rain, dividing one part of the story from another. 

And last, there's a forest glade with brutally broken-off stumps: we see it first at the very beginning, with the corpse of the first victim tied to one of these stumps, in a memorial garden - to Resistance fighters, the underground army that fought the Nazis who occupied Denmark, a powerful image, since the Danish army and its deployment in Afghanistan is already making itself clear as a large part of the story. This glade is echoed in the visiting room of the prison, where a psychologically scarred ex-soldier has, first, a conjugal visit with his wife, then a visit with a friend who is fleeing back to Helmand to escape whatever's going on; in that innocent-looking room with its mural of forest trees, he tells Raben - the ex-soldier that "it's not over". But soon he will be dangling like a blood sacrifice too.

There are the books, like the cowboy novel by Stetson Cody slapped on the desk by the pudgy but hardass new justice minister; the Chagall coffee-table book, the meaningful (I assume) Danish titles briefly lingered on in the bookshelves of various characters. 

Then there are the pictures: the new Minister for Justice's office is decked with black-and-white photos of his predecessors; his greeting present from his party is a framed photo; he finds in a briefing document the police stills of the murdered woman in the memorial park. It turns out that her killer has videotaped her. The strong and fierce and solitary Raben, alone in his cell, has covered the wall with his little son's pictures of dragons, strong and fierce, blu-tacked on the cement. 

What do the images mean? Already the heart knows; as you watch, your heartbeat speeds up when certain colours or shapes appear, your mood sinks at others. Ten episodes to the end of this series; the story will have borne out the warning of the images.

Fucked-up folks

Raymond Chandler and his buddies gave us a dark model of the crime investigator: impoverished, silent outsiders whose knowledge that the world is a corrupt place allows them to speed straight to the centre of the ill doing they've been hired, ostensibly to probe, in reality to cover up and obfuscate.
Philip Marlowe (the hero Chandler (left) called after a house in Dulwich College in London, which he attended at the same time as PG Wodehouse) is a pulp fiction detective, but like Wodehouse's Bertie Wooster, is a wisecracker; you'd have to assume that both honed their knives of wit under the tutelage of a master, the headmaster AH Gilkes, known for his "quality of merciless chaff". It is his savage wit that distinguishes Chandler's Marlowe from the creations of his mentors, Dashiell Hammett and the other writers of the literary detective story magazine Black Mask, in whose pages the genre came to maturity.
The detectives of this mid-century version of the genre are fucked-up folks, but they are working-class heroes, alone with their honour and taking arms against vicious upper-class criminals protected by the law that the criminals have bought and paid for.
In a series of these formal tilts, which spread from books into films, battle is joined between the cynically honest working detective and the cruel and wealthy: The Big Sleep, The Maltese Falcon and the ultimate iteration, Chinatown.
It's part of the understanding with the readers that the brave representative of the working classes fights the rich, but never wins. The basset-faced Humphrey Bogart played both Chandler's Marlowe and Hammett's Sam Spade with sepulchral decency; keeping to the contract, he's beaten down by the rich swines, but wins out morally, keeping the rotten contract between wealth and exploitation with all the indignant sorrow of the beaten wife who stays with her abusive husband.
Chinatown is the ultimate because not only is the rich swine about to become a multi-bulti-hulti-smulti-gazillionaire by cheating poor farmers out of their water rights to supply the new town of Los Angeles, but he is a child rapist who fathered a child on his own daughter. At the end of the book the old moneybags is preparing to repeat history as he takes control of this child, now an attractive teenager.
Is it - was it - a sign of a changed world when Donna Leon produced a very different type of detective. Commisario Guido Brunetti of the Venice police also investigates the crimes of the rich. But he is no sole trader in decency.
Brunetti is a policeman, for a start: he is within the system, and he has allies - good people, all prepared to bend the rules - within that system. Elettra, the beautifully named hacker, arrives first as PA to Brunetti's ambitious and vicious boss, Vice-Quaestore Patta, a Sicilian who is quite obviously destined for great political power. Elettra finds her way into every computer system with the innocent amorality of a visiting angel; she is a creature of glamour (in both the old sense of illusion and the new sense of being a fashionista), sitting in her office surrounded by expensive flowers and dressed in the loveliest garments the Italian couturiers can provide. Her formal amorality is a coating on absolute morality: she will come to the rescue of any oppressed creature.
His loyal constable, Vianello, is Brunetti's reflection, a decent man in an indecent world. Yet in Leon's hands, he is not a cut-out; somehow his baffled honesty deepens the picture.
Brunetti walks home for lunch and dinner, described mouthwateringly; his wife, Paola, is a university lecturer in English (Leon's own second trade), and the daughter of immensely rich aristocrats with a pedigree stretching back to ancient Rome, people Brunetti regards with deep caution. Their two children, typical teenagers, add to the deliciously uxorious vision of a happy home.
Brunetti's world, although there are corrupt wealthy people here too, and they act with the same cavalier spitting upon the rights of anyone not richer or more influential than themselves, is a world where there is an approach to equality.
I think that it's a vision that comes out of a brief blossoming of egalitarian values - values which swiftly gave way to the idea now gaining currency that only those who can express their greed and gather all the gold to themselves are worthy.
The times are changing, and the next generation of investigators will, I suspect, return to the bleak cynicism of Chandler and Hammet, as the food queues grow and the wealthy jet in to gift buildings to universities starved of municipal cash. We can look forward to a new Marlowe, and forget about Brunetti.

The Killing II

For some reason, my ability to stay awake, even for the most gripping and heartrending drama, has suddenly lessened. So my understanding of the start of the second series of the Danish thriller The Killing is... well, gappy.
Sarah Lund, detective extraordinaire, miseryguts supreme, is out of her Icelandic gansey. Now she's arrayed in a new jumper, so deep red that it appears blood-soaked. Sarah has lost her nice job investigating brutal murders. Now she's doing some, um, kind of...
Sorry. Fell asleep there. I think Sarah's a kind of security guard or something now, having failed so tragically in her last investigation, the one in the first series of Forbryselden.
Anyaway. Whatsisname, the granite-faced investigator now investigating an orrible murder of a woman found stabbed a zillion times (one fatally) and tied to a pole in a park, comes to Sarah, well known for her spooky insight into murders and murderers, and lures her into the investigation. They reckon it's the woman's husband (why am I not married, remind me?) but they want to check with Sarah's instincts.
Sarah is just sitting there thinkin', and listening to the zeitgeist, when it is revealed that the husband has confessed. So Sarah goes back to boringland, and...
I'm joking. Of course Sarah has realised that it's not the husband.
At least... in the first series everyone became a suspect at some stage, and like others watching I suspected every character, to the point where I couldn't go to Superquinn without suspecting the checkout clerk, and never mind Lidl.
Last time, an unnervingly sexy clean-cut politician on the broad road from idealist to sleazebag was chief suspect. This time he's been replaced by a stocky new justice minister who is facing down the right-wing anti-immigration party's demands for banning of specific groups - a thing which has never been done in the history of the staunchly fair and egalitarian Denmark. No doubt the minister is soon to be implicated in at least one murder.
For the moment (as far as I understood between helpless snoozes - this isn't because of the writing; it's incredibly gripping, I just can't help it; once 8pm comes I'm out cold - the main suspects are a secret group within the Danish armed forces. A second body has immediately been found: Vyg (Myg? Smyg? Styg?) - who was about to be 'deployed' to Helmand.
But as soon as you start to suspect him, Vyg (?) is found hanging upside down, dead as a cabbage, with half a dogtag dripping with his draining blood.
Somewhere in there is a handsome, sad man in jail and longing for his wife and child, but involved with all this Afghanistan stuff. He seems to be a damaged man, perhaps suffering post-traumatic disorder caused by killing plenty of Afghanis.
Oh, and the woman who was stabbed a zillion times: a video has turned up with her giving some kind of Islamic anti-Danish message. In Danish, of course, which sounds as if she's speaking through a mouthful of turnip.
I'm dying to watch the second, or maybe third episode. I just wish they'd sell it on DVD now so I could actually go back and check what really happened.
Oh, and the acting and writing and direction are great. And the sets, with their moody, dark vision of Denmark, itself a character: an honest country under attack by the forces of corruption.

Act of Union

I'm very afraid we're about to repeat the worst mistake Ireland ever made. In 1800 the Irish House of Commons voted by a narrow majority to dissolve itself and centre government in London.
This Irish parliament was barred to Catholics and dissenters, open only to Church of Ireland members, and it was famous worldwide for its corruption. The vote was achieved by enormous bribes, which enriched the members, and would impoverish the majority of Irish people.
Almost immediately on its passing, the money left Ireland, as the centre of power went to London. Landlords (the real strongmen then) abandoned their Irish mansions and took London houses, leaving agents to manage their land in the years running up to the coming famine.
Dublin had been a thriving city; it descended rapidly into a mass of slums and a gigantic barracks for British soldiers who were warehoused there. Prosperity declined catastrophically, as virtually all business and manufacture drained away and resited itself in England.
Angela Merkel wants to centre power in Europe now; she wants the Irish people to vote in a referendum that would give this our consent. If we did so, the same would happen; history would repeat itself. Our politicians would move to Brussels, their focus and their values would swiftly become those of Brussels, and they would function only as lobbyists and as constituency patrons, as happened to the Anglo-Irish and Irish-Irish politicians of the British Parliament in the years before independence.
You have only to look at the blogs and tweets of those famous Irish people who have moved to England for work if you'd like an illustration: they write about politics (British politics) and news (British news) and 'celebs' (British TV personalities). They become subsumed into the place where they live. And nothing wrong with that, unless it's of central economic and cultural importance to our country, as is our parliamentary representation.
The bosses in Europe are offering the false bargain of a dual choice. There is never only a choice between two; there are always other options than the two offered. They are pointing to the stupidity of the capitalists and the greedy troika of developers, politicians and bankers, and saying that a centralised power in Europe will prevent this happening again.
They could have prevented it before - not by putting the lámh láidir on the banks, but simply by speaking out about the danger that existed, by speaking out loudly and pointing to the countries whose housing market was not a Ponzi scheme, like Denmark, which legislated that rezoned land could not increase in price; or like Iceland, which has now legislated that no mortgage-holder must pay anything over 110% of the current value of their homes.
They could act for the people who elected them, rather than the businesses that are the most influential lobbies on the continent.
I hope that European politicians will grow bigger than they are now, more creative with their solutions, looking for an alliance of like-minded nations, not a Reich directed from the centre. But if it comes to a vote for their current dream, I'm out to shatter that dream and hold on to an independent Ireland that can achieve President Michael D's promise: "to move past the assumptions which have failed us and to work together for such a different set of values as will enable us to build a sustainable social economy and a society which is profoundly ethical and inclusive".
Michael D - before he was President, a creative politician who founded the best TV station in the country, the Irish-language broadcaster TG4, and who revived a dying film industry when he was Minister for the Arts - called for us "to build together an active, inclusive citizenship; based on participation, equality, respect for all and the flowering of creativity in all its forms".
We're at a turning-point. If we resist the attempt to centralise power in Europe, we can become the nation our founders dreamed of. We can never do that as a peripheral province of an empire. 

First person narrators

Gabriel Rosenstock was on Miriam Meets this morning. This Sunday morning meditation is an interview with two people who are connected by love or friendship or family relationship, or, often, all three.
They talked about how the family came to be - a German doctor met a Galway woman in Jersey when he was in the Wehrmacht; his friends broke his arm to save him from being posted to the Russian front; they returned to Ireland where he set up a practice allied with a chemist's shop so he could import pharmaceuticals from Germany - funny enough, the same plan my grandfather had for my father, then a medical student, and his brother, a plan nuked when my father had a highly-praised student production of Eliot's Murder in the Cathedral and took to the stage.
They talked about the family poker games, played for real money, money that was lost and won and kept by the winner, even when the loser was 13-year-old Mario, losing £90 of the £130 he'd won the night before, a good lesson for a young gambler.
And then Gabriel started talking about reality. In a particularly hideous twist of fate, his uncle had been drowned while a schoolboy in Clongowes, and then his brother was drowned at 17 in Glendalough - it's possible, apparently, that his friends dared him to swim across one of the lakes, which look so narrow between their steep mountain sides, but are so horribly wide and cold.
Curiously, Marian did not ask him about the horror of the two successive drownings of athletic boys in two generations of the family. What she did ask him, from her own pain at the loss of her sister, was about the effect. Gabriel was dismissive of any idea of division from his brother - he was 10 when his brother died, and the death broke his parents' marriage. You are not born, he explained, and so you do not die. His brother - the essence of him, not his age or sex or nationality or intelligence or anything that we consider makes a person himself, but rather the essential core of that person - is still here, he said.
Marian said, in a voice that sounded so bereft: "But you can't touch him", and she leaned to touch Gabriel's hand. All the people living all alone now turned their faces from the radio.
When you write in the first person, you're mining the essential core that Gabriel Rosenstock was talking about. Your character (for some writers always a version of themselves - come to think of it, Jungians would say that for all writers each character is a version of themselves, because they are its creator) may be an observer, like Scout in To Kill a Mockingbird, who sees the action played out from the sidelines, while her growing-up is a subplot reflecting that main action. Or they may be the centre of the story, like Holden Caulfield in The Catcher in the Rye, whose disillusionment and rejection of his upper-class American world is the story.
But in every case, narration in the first person is heavy in subtext. Everything the narrator says has two purposes: to tell the story, and to tell the reader about the person who's telling the story. When Scout observes her father Atticus take off his glasses, draw a measured bead, and shoot dead the rabid dog, she does so from the viewpoint of a thrilled child discovering that her dull old dad is a hero. She's also prefiguring the later action when Atticus shows himself as a true hero, defending humanity. And the lemony regret that underlies her telling is a taste of the failure of that decency, because the man and the values her father defends will die at the end of the book.
In Holden's anger at the phoniness of his society, there is another subtext: Holden has only one spoilt choice in the end - no matter what he does, he is going to become part of his class, the class he hates and derides.
All this sounds mechanical; but a lot of the time a writer is bumbling along telling the story, becoming that core - whatever Gabriel says, we are all myriad people - and knowing nothing about the subtext that's writing itself without the writer realising.

Radio review - the day of the general election

This was my last radio review, the day after the general election that swept Fianna Fáil and the Greens away and brought in the Fine Gael and Labour coalition last March.
Wonder what the Greeks are saying now, when they go out to riot: "We're not the Irish. We're not like that. We don't use democracy." Democracy in Ireland, though, is different. The politicians stalked the streets like exiled princes in the days before the poll. On the day, white-faced - or unbelieving and delighted - they stood in the count centres while the radio journalists feasted on them. There was a palpable air of schadenfreude as the interviewees - or in some cases, anticipatory schadenfreude, for who knows what the future will bring. Will it be premature coalition, or coalition interruptus, ending in tears and slaps? High points on the day the cleamhnas was set up were Newstalk's breathless early reporting - "Envision the picture: Taoiseach Enda Kenny, and in the seat directly opposite him (pause) Arise, Baron Gerry Adams" - Ivan Yates with a chuckle in his voice at 10am. I don't know who said it, but I choked on my tea, at home in the Dublin South Central Soviet, at "The blue bloods of Dun Laoghaire have turned blue for Fine Gael, while working-class Dublin South Central is red for Labour." By mid-morning Radio 1 was as avid as a cat looking at a bird and making that unnerving chattering noise with its teeth. The noon news reported: "Every Fianna Fail seat in Dublin is in danger.... the Greens are in a fight for their political lives". The most unconsciously telling statement for the fallen princes was from Sinn Fein's Dessie Ellis. Revealing how Fianna Fail's fortunes have changed, he said: "We're not going to be like the three main parties - and I include Fianna Fail in that." Radio 1's was a master feat of reporting, going on through the day, relentlessly circling from constituency to constituency, and Rachael English and Sean O'Rourke finally staggered off to bed at 4am, leaving those last few centres still counting, counting. It's all a dream - could it really be the end of the Tammany Hall fixing that has been the curse of Irish politics since the 18th century? By midweek, Fine Gael and Labour have their match well on the way, and the two stations were reporting Enda, spurning the Enda-pendants for the fine reliable farm of Labour, murmuring "D'you want to be buried with my people?" * A made match can work better, sometimes, than a mating in the full heat of passion; as the Indians say, in a love-match the kettle is boiling and is only going to cool; in a made match the kettle is cold when it's put on the fire and keeps getting hotter. Labour and Fine Gael, though, will have to have the same careful trust that goes into any marriage. They may get help from the book Little White Whys - about why men lie. Brian O'Connell gave David Harvey the skinny on it, having talked to author Ish Major. Everything you want to know about a man is in first three conversations, said Brian. He gave some helpful questions to ask a man if you're interviewing: Have you any legal problems? If you hear "Not that I care to discuss" or "Nothing that affects me now", run a mile. The texters were speaking tough love. "Little white lies will lead to big black eyes," texted Dave. Texter M was indignant: "I don't think that writer's going to have many male friends." David pointed out: "Giving away trade secrets." Listener Marie said bitterly: "Men are animals but some make better pets." And her ideal match, Noel: "Women's place in kitchen cooking - and they shouldn't be allowed on the road." PANEL: Election coverage, Newstalk, Saturday Election coverage, Radio 1, Saturday David Harvey, 4fm, weekdays