Annie Hubert has lived with cancer for 14 years. She was first diagnosed at age 53, received treatment and was declared cancer free. Then, four years ago, it came back, creeping into her bones, liver and lungs.
Hubert goes to the Bergonie Institute, a cancer clinic in Bordeaux, for her chemotherapy and other treatment. On the day we visited her, she came to the clinic for a regular scan to check the size of her tumors.
"For four years, you know, these very regular checkups. I'm used to it," says Hubert. "It's just part of life. If I were 30, I suppose I would see things differently. But I'm 67. So everybody has to die one day. I'll probably die from this disease. I don't know when. I live with it."
Live with it she has, and as normally as possible.
Hubert is an anthropologist. She did her field work in Southeast Asia. But after her cancer, she got a grant from the French government to study how doctors communicate with patients.
"I am a good anthropologist because I am doing what the French call 'observation participant,'" she says with a laugh. "Nothing equals experience to understand things."
Maybe it's Hubert's upbeat attitude that allows her to keep doing the work she loves. But it's also, in no small part, thanks to France's health care system.
Everyone in France gets health insurance. When someone has a difficult disease, such as cancer, the national health system steps in and pays for 100 percent of the care.
Unlike in the United States, insurance in France is not linked to employment, nor is there a lifetime limit on how much treatment a long-term survivor like Hubert can get.
The guarantee of health insurance is the first reason why cancer experts around the world look to France as a model for cancer treatment and care. Another is that cancer care is well organized at the national and hospital levels. To treat patients, a hospital or clinic has to prove it meets national standards for high-level care. It must treat a minimum number of patients a year, and it must use a team of doctors, nurses and others to provide coordinated care.
These standards are found at the best cancer centers in the United States, but they are set in national standards and required of all hospitals and clinics in France.
In Bordeaux, Hubert has one doctor, oncologist Marc Dublet, who has been in charge of all her care since her surgery. She can call Dublet anytime with any question or concern.
French doctors traditionally have simply told patients what to do, but that's changing.
"Now we discuss more and more with (the) patient and we decide together what treatment to do," says Dublet.
Hubert says she appreciates that she's not treated like "an illiterate something" and that her doctors listen to her.
Nor has Hubert had to fight with insurance companies or worry about getting access to her expensive therapies, a third reason why French health care stands out.
"Never ever. For any. Which is incredible," says Hubert. She knows the value of such care because friends in America with cancer have noted the difference. Hubert also has an American son-in-law in California who has multiple sclerosis. He and her daughter have good insurance, Hubert notes. Nonetheless, they spend several hundred dollars a month for his treatment.
France guarantees that every cancer patient can get any drug, including the most expensive and even experimental ones, says Dr. Fabian Calvo, deputy director at the relatively new National Cancer Institute.
"As soon as there is a breakthrough," he says, referring to signs that the drug is safe and effective, "even if the drug has not obtained (government) approval, you can get access for that."
The national health insurance system pays for even the most expensive drugs. Access to any medication is one reason a study this year rated France the best among industrialized nations at preventing avoidable deaths.
The United States came in last.
Room To Improve
Until recently, France lagged in some preventive care. However, four years after the cancer institute started a campaign to increase free screening, the number of women over 40 who get free mammograms has doubled to 60 percent.
The newest government campaign, started this year, urges people 50 and older to get colonoscopies. Calvo, who runs research programs at the institute, estimates that for every million people who get a colonoscopy, doctors will detect about 6,000 tumors.
"As it is early tumors, we could cure the major part of these patients," he says.
Still, that new emphasis on screening came too late for some, such as Brian Coote. Three years ago, Coote and his wife, Julie, retired early and moved from outside London to southwest France. From their old stone farmhouse on a hill, Coote looks across the farms of the gently rolling Dordogne Valley.
He's 57, athletic and an avid hiker. In spring 2007, he started having stomach problems. At first, his rural general practitioner dismissed it as nothing serious.
"The end of June, I'm doing a big walk in the Pyrenees Mountains," he recalls. "And I had to stop after three days and come home. And that sort of said, well, there's something here that's not normal for me. "
It took until mid-September to get the diagnosis that should have come months earlier: He had colon cancer. Coote faults his first doctor. But he says once he got to a surgeon, he has received excellent care.
Now, there's even a nurse who makes home visits. She drives all the way to the farmhouse.
"She knows me well," says Brian. "When I came out of hospital after the operation, she was here every day to check the dressing."
"She also comes to do a blood test just before the chemo," Julie says. "If chemo is on a Monday, she comes on a Saturday to take the blood test."
Coote's care is designed to keep his life as normal as possible. Earlier in the week, Julie drove him to the hospital for his chemotherapy. Some of it is delivered over several days through a small pump — about the size of a lemon — connected through a catheter to his chest. Back home, a few days later, he took a long hike on country roads with the pump in his pocket. When the chemo was over, the nurse arrived to disconnect the pump.
The Cost of Care
In a country that's so generous, it's hard to control rising health care costs. Last year, the National Health Insurance fund ran a deficit of nearly $9 billion. President Nicolas Sarkozy's government looked for ways to cut costs.
Last fall, just as Coote began his treatment, the government announced it no longer would pay for foreign retirees' health care. They would have to buy their own private insurance. But Coote knew that with cancer, he wouldn't find anyone to insure him.
"I didn't want to think about it too much, especially during that October through November period (when) I was doing chemo and radio at the same time," he says. "I did in the back of my head kind of think this is ludicrous. They cannot possibly do it. It means that people are going to die."
Some 200,000 British expatriates live in France, according to the British Embassy there. Their numbers give them power. They petitioned and protested.
In January, the government reversed itself.
Many British expatriates say they live in France, in part, because they don't trust the British health care system. Coote isn't one of them, but he does appreciate the health care he has received since his surgery in France. It allows him to continue to live the life of his choice in this stunning corner of the world — even as he battles a difficult cancer.