tags: cultural observation, expat life, Life in Germany, Apotheken, Drogerien
Expats, immigrants, and people who travel internationally often are impressed with differences between their home country and the country they are visiting or living in. I thought I'd write about some of the daily features of my life in Germany that are different from my former life in Seattle and in NYC; sometimes amusing, other times annoying. If you also have similar experiences, I'd sure like to read about your experiences and observations in the comments thread. Because I only recently found a "drug store," I'll start by comparing drug stores -- Drogerien -- and pharmacies -- Apotheken.
If you need to purchasing any sort of drug, whether you need an aspirin or you are filling a prescription from a doctor (something I've not done yet), you go to an Apotheke. Unlike in the US, where pharmacies are typically found in the larger drug stores (often in the back), the German Apotheke is a separate destination altogether. They are denoted in Germany by the symbol that you see on the right.
To my eye, German Apotheken closely resemble an overpriced upscale NYC spa, because the walls are covered with clear glass shelves that are sparsely stocked with overpriced skin and hair cremes, shampoos, hair tints and other items that I cannot identify (thanks to my crappy German). Oddly, they also stock a fair amount of herbal "remedies" in these places.
If you wish to purchase aspirin, over-the-counter allergy meds or hydrocortisone creme (for example), you have to stand in one of a dozen or so lines and wait to ask the female clerk (it's almost never a man) behind the counter for the item(s) you seek. Often, they want me to describe my symptoms before they will allow me to purchase the item I am asking for. After the clerk has figured out what I need (thanks to my crappy German, this might take a few minutes), I get to wait while they fetch whatever it is that I am asking for. Unfortunately, because I have no idea what brands are available in Germany, nor their prices, I am stuck with whatever the woman gives me after she's deciphered what it is I am seeking. Why won't they allow me to choose my own over-the-counter items?
While standing in line, waiting, waiting, waiting for the customers in front of me to finish their business and just leave already, I've also found that many people view this interaction with the pharmaceutical clerk as a social event of sorts, instead of a business transaction. I suppose that my perspective results from numerous relocations, my general impatience and my crappy German, but I find it to be rather annoying to be stuck in line, suffering from a nasty headache or eyes and nose streaming due to an allergic reaction, while families brag about their babies and whatnot.
Because I despise shopping, especially for pharmaceuticals, I tend to purchase as much as I can when I finally do go into the Apotheke. Unfortunately, the German system is not set up for this. "Pill" medications are sold in very small quantities (generally one dozen per package), so when I ask for more than one box to avoid having to return the following week for, say, allergy meds, the clerk "counsels" me about how to avoid overdose and occasionally asks about my suicide risk. Honestly, I find this annoying and extremely offensive since my state of mind is no one's business but my own.
Another difference is that medications in pill form are heavily packaged -- even more so than in the US. Individual pills are packaged inside their own compartment in a plastic blister pack which is then packed inside a box containing a paper insert describing the properties of the medication and its side effects. Why don't Germans put pills into bottles instead? Wouldn't that be less labor-intensive and produce less packaging waste?
There are drug stores in Germany too -- Drogerien -- although why they are known as Drogerien is beyond me since they don't sell over-the-counter medications like they do in the US. Instead, these Drogerien sell all sorts of other householdy items items, such as cleaning and bathroom supplies, skin and hair care products, cosmetics, baby supplies, toys, candles, "travel sizes" of various products, condoms, pet food and litter, snacks and a variety of "Bio" (natural) fruit juices -- that sort of thing. Of course, as a reward (bribe?) for shopping there, they also sell candy and wine. Yes, Germans sell wine -- and even hard liquor -- "over the counter" while they subject people to questioning before allowing them to buy one week's worth of allergy medications.
My American perspective, tempered by a fair amount of international travel and 1-3 month stays in various countries, of German Apotheken/Drogeriemärkte is they are enormously labor-intensive for the staff and are annoyingly time-consuming for the customer who might just wish to go into the store, get some aspirin and leave as quickly as possible. I am sure there's a reason for the way things are, but those reasons are not obvious to me. Can anyone enlighten me?
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this reminds me somewhat of when I lived in italy.
if only that it took equally long to get what I needed explained to the pharmacist, and just about the same amount of time to recover after finding out that what I was looking for was sold as over-the-counter at one tenth the price of the chemically identical, from the same manufacturer, medication...
I'm curious to know if germany has similar differences of what is and isn't OTC that italy had. as well as the price differences between germany and the US in prices for perscription medications.
Pharmacists in Germany are requirred to warn/educate people about the pills they sell, simply because something is OTC (nicht verschreibungspflichtig) it doesn't mean it's harmless. Buying several packs of pills is rare in Germany, most pharmacists will ask questions if you do that. Pharmacists rank in public perception almost as high as a doctor, so a German wouldn't consider questions about your state of mind very intrusive or offensive. I certainly didn't mind the warning about nose spray addiction when I had to buy some for my cold.
Each pharmacy has to have an university trained pharmacist on staff, the other people on staff have a special vocational 3 year training.
I think you are right about the packaging overkill, and I'd prefer bottles. German (and I think european) laws require a printed explanation about the medical properties, possible side effects and dose, that might make counting out pills and selling them in bottles difficult.
When you buy your pharmaceuticals, don't hesitate to ask for the cheapest. (Das Billigste, bitte.) And for most things you can ask for a bigger pack of pills, those are cheaper per pill too.
The official reason for the lack of various pills in drugstores is a division of the substances in roughly 4 classes:
(1) Harmless stuff, in drugstores ("Drogerien") - e.g. vitamins in low doses.
(2) "Moderately dangerous stuff", only in pharmacies. These things are labeled "apothekenpflichtig", the idea is that they should be sold manually so that the pharmacist can speak to the customer. Only substances which are harmless when used properly even without a doctor's supervision are in this group.
(3) Prescription-only substances ("rezeptpflichtig") - the idea is that the effects need to be supervised by the prescribing doctor anyway.
(4) narcotics - this needs a special prescription on centrally issued special forms with serial numbers and the prescribing doctor is held accountable for every single sheet.
In Germany, it seems both pharmacies and drugstores make lots of money with so-called "Dekorative Kosmetik" (superfluous stuff people smear onto themselves in order to be colorful and stinky) which fills most of the area of those shops.
peter: when did you live in italy? do you still live there?
thanks ralf and monika for the explanations! this makes sense, although the packaging aspect still does not .. in the US, bottles of pills are usually placed in a box that has a paper "insert" (as the situation in Germany) explaining the medical properties, possible side effects and dose, etc.
thanks monika for the "Das Billigste, bitte" advice! i will be adding it to my book of useful German phrases (as a reminder) and practicing my pronunciation of this phrase.
i am curious to know .. if i do manage to get rezeptpflichtig allergy and asthma meds, does this mean i have to be visiting the doctor often so i can use them?
As you may know in the U.S. we have HUGE mega drugstores on every corner of every town and city. They are becoming more common than liquor stores. Our compelling need for drugs is disgusting and our feeling that a pill or lotion can fix every little normal change in how we fill shows our immaturity. I think Germany has got it right.
"Often, they want me to describe my symptoms before they will allow me to purchase the item I am asking for."
Yes. They are educated pharmacists - not just sales clerks. They are not just there to sell you whatever crap they can persuade you to buy, but to take care of your health. Someone may have persuaded you that you really-really need to take these drugs (as you know happens in the US) - but drugs are not and should not be a commodity that people with a profit incentive will make you want to take. You should take it only when you need to. Pharmacists are part of the health-system, like doctors and nurses. Therefore they may want to make sure that this is the right drug for you. I'm not saying it works perfectly, but this is the theory.
"Why won't they allow me to choose my own over-the-counter items?"
They usually will (but you might have a harder time insisting of course, with your broken German). But here's the reason why they don't just automatically give you the brand you ask for. Medicine and drugs is something you take when you have health-reasons to do so. It is not a fad or a fashion-thing, it is not something you do because of brand-loyalty or because some company has made a convincing advertisment. You take it because you need it and what you need is the active ingredients - not the brand or the logo.
We all know that there is corruption in medicine. For one, you may be wanting to buy a certain brand, not knowing that there are other products with the same (or maybe better) active ingredients. But also, your doctor may have prescribed you some brand-medicine because a company gave him a nice holiday. The German (and Scandinavian) health system has some build in checks-and-balances. One of them being that pharmacists are required to inform you about other products with the same or similar active ingredients, and they also have to tell you if there are some that are cheaper than the one you had prescribed. Again, the system is not perfect, but that's what checks-and-balances are for: to make sure that if one part of the system goes corrupt then others will balance it out a little.
All in all there are good reasons for these things - all though you may want to prioritize things differently. Except the thing about them selling crap like new-age lifestyle products and stuff. There's no excuse for that.
About packaging - I'm not entirely sure about this, but I think the point of the blister-pack is that one can keep track of how many pills one has used already. Not much of a big deal for Aspirin, but useful for other drugs (or patients with bad memory)...
AH! yes, muhor, your suggestions regarding blister packs makes perfect sense now that you mention it.
ole: i can understand the corruption part of medicine due to big pharma! i like to think i am mostly immune to it since (in the US) i didn't have health insurance, and so almost never saw a doctor except in the hospital emergency room, and i also never had a TV, so was not exposed to pharma advertizing, either.
when i noticed herbal "remedies" being sold in the Apotheke, i immediately became suspicious about the sort of advice i was getting from the pharmacy clerks. i wish the Apotheken would ditch the overpriced leaves and other "natural" junk items and just provide the over-the-counter and prescription meds that they seemingly are supposed to sell. providing the appearance of authority by questioning customers about their symptoms while selling real medications alongside herbal "remedies", it really creates a real conflict regarding the "seriousness" and quality of advice i am getting ..
Drug packaging in Australia is similar to how you have described it in Germany. Along with Muhor's comments regarding keeping track (my blood pressure pills have days marked on the non blister side) I was also told another reason. Some years ago on a first aid course the presenter, an older experienced paramedic, claimed that it was also to deter suicides. Strange as it sounds, the effort to open a bunch of the blisters in one go was enough of a deterent that it had a measurable effect on reducing successful attempts. FWIW
The traditional split between 'Drogerie' and 'Apotheke' you describe actually seems to be breaking down at least slightly - there is now a new chain called 'wir leben', which is more of a 'Boots' (UK) or Walgreens-type store. And I'm with you on the herbal stuff - it's supposedly more regulated here, but even doctors are way too happy to prescribe it, and in my experience most of the stuff doesn't really help...
A difference between UK pharmacies and French ones (not sure about Germany, Italy etc) is that dosages are by weight, rather than by age. Sensible, once you think about it. So I was asked my daughter's weight, rather than her age, when I wanted painkillers in France.
I got some funny looks when I said I didn't know her weight. We weren't a family with scales in the bathroom - we are now!
Penny
steffi: the thing that bothers me about herbal "remedies" is they have been demonstrated repeatedly to be ineffective, or dangerous, either because they contain so little of the active ingredients or because the "remedy" is truly not effective (beyond the placebo effect) such that prescribing it amounts to nothing more than an institutionalized rip-off of the consumer. worse, this (American?) bias that "all natural remedies are superior to pharmaceuticals" attitude is truly dangerous because (1) at least a few of us are allergic to the impurities present in herbal "remedies" or (2) these so-called "remedies" are just as likely to worsen our illnesses as relieve them in those rare cases when herbal "remedies" actually do anything at all.
[example: a well-meaning person once gave me st john's wart as a "treatment" for my bipolar disorder and then was annoyingly determined that i take it as a "cure." i decided to take it to prove to this person that st john's wart, and all herbals "remedies," are nothing more than a bunch of woo. i ended up experiencing a persistent and nasty migraine headache along with hallucinations. it did however "cure" my manic phase by triggering a very deep and potentially dangerous depression that lasted a few months. lesson learned: in the rare situations when an herbal "remedy" does actually do something, the identity and nature of its effective ingredients are so poorly known that taking such "remedies" triggers more problems than they supposedly treat.]
I strongly have to contradict that herbal remmedies being sold in an "Apotheke" are undermining the seriousness of these institutions. On the contrary, as a German having lived in the UK and the US (and now in Angola), I believe that the fact that in Germany a trained professional (in fact a Pharmacist in Germany has to have a PhD in order to run his/her own Apotheke and is a central part of the German Health care system as the first point of contact for simple health questions, which do not warrant a doctor's visit) advises people not only on standard drugs, but also on "alternative" drugs is part of why Germans overall have a very healthy approach to the question of alternative vs. standard medicine. I have not yet heard about a scandal story in Germany, where people refuse standard medical therapy for cancer and "chose" alternative medicine instead. In Germany, most people have a very healthy understanding of where alternative medicine might be appropriate (such as herbal teas to alleviate the symptoms of a common cold) and where standard medicine is absolutely necesary (such as cancer therapy). The "side effect" of this rational approach to alternative vs. standard medicine are standard drugs based on herbal ingredients, which are available in Germany and which I have found to be much more effective than the over-the-counter equivalent (based on standard drug chemistry) in the US or UK.
...as I said, I'm with you. But out of curiosity, I now looked up the regulation on 'natural remedies' on the 'Bundesinstitut fuer Arzneimittel und Medizinprodukte' (the German FDA). A quick search brings up an old press release from 2005 talking about the first official registration of a natural remedy after the ratification of (then) new EU regulations. From that press release (second paragraph):
"The registration of traditional herbal remedies offers the opportunity to get products for patients that have been traditionally used for decades. While the quality assurance and safety of traditional herbal remedies corresponds to the demands made on other pharmaceuticals, the proof of effectiveness has been simplified and can be plausibly deduced from the traditional use. This is reflected by the statement "traditionally used for..." on the package insert ('Packungsbeilage')."
Hmmm....
@grrrl: a regrettably long time ago, (the eighties) and we met at your scienceblog party in Seattle last year. (where I am for the forseeable future... (think funny socks.)
But I was getting a medication that at the time was costing me $30 a month in the States, that went for @2200 lire (around $1.50 at the time.) This was when I started to learn about profiteering, as the pharmaceutical companies would charge more in the US where cost was hidden by insurance company co-pays, claiming that it had to defray R&D cost solely in the US.
I am German myself and have lived there all my life (...22 years by now), and I never felt as annoyed as you did. I do agree that the not selling pills in bottles makes things more complicated and that they should change that. But I never had the clerks wanting to know my symptoms before they would serve me, if I clearly state that I wanted Iboprufen, they will ask me whether I want the strong ones or the weak ones and then they'll get it for me, usually a matter of about 45 seconds. So maybe you were just unlucky with your pharmacy.
When it comes to the selling of wine in drug stores, I guess that this is due to our in general way less stric alcohol laws than in the state (our legal drinking age is 16).
I, on the other hand, find it confusing that in the US you can buy cigarettes and alcohol at pharmacies (like Walgreens, CVS and all that), where you are supposed to find stuff that helps your health - I have traveled a lot, and so far the US seems to be the only country that does that.
Not saying that one system is better than the other, but just wanted to add my experieces to it.
... the female clerk (it's almost never a man) behind the counter ...
Monika @ # 2: Pharmacists rank in public perception almost as high as a doctor...
A high-prestige position occupied almost entirely by women?
This is (ahem) somewhat anomalous in western societies - what's going on over there?!?
kate: i actually was asking for the medications by their proper names (cetirizine) and not brand names (zyrtec, for example) and was asked about my symptoms. i suspect it was because the pharmacy clerks were not sure if they understood me correctly.
and thanks for letting me know the legal drinking age in germany .. i had no idea whether/if there was such a thing, especially since i've been seeing some really young people who are belly-up to the bar. even though the legal drinking age is 21 in the US, the alcohol laws do vary quite a bit from one state to another, which i find confusing, so i'd imagine a foreigner would be more confused than i.
i have no idea why alcohol (beer, NOT wine or hard liquor) and cigarettes are sold in american drug stores. i suspect it's a hold-over from the days when the "corner drug store" was the only store that was open late (or all night), so they added these items to their shelves to sell more stuff, especially to households where both parents worked all day long. once begun, the tradition remains unchanged.
The model of a German pharmacy is a store with individual service and goods behind a counter, not a self-service supermarket. As time passes, they might move more non-drug items to self-serve shelves.--
German pharmacies are heavily regulated, they must be run by the German equivalent of a Registered Pharmacist (not necessarily a Ph.D., but passed a 'Staatsexamen'); they must have in stock, at all times, some 10,000 or so items,
and the local pharmacy board must make sure that at least one pharmacy is open in a city or certain area at all times
{normally, except in bigger cities, German shops close at 7:00 or so in the evening, and all Sunday, a big annoyance for foreign visitors, but relief for the shop clerks.)
I found it always annoying in the U.S. that when you hand in a prescription in a drugstore pharmacy, they don't just hand you the stuff, but ask you to wait or come back in 15 minutes, presumably so that they can count out your 15 pills, put them in a little brown plastic vial, print a label with your name on it, stick it on the container, print the instructions, etc.(and so that you - they hope - buy other stuff in the store while waiting).
(Sometimes this waiting period is justified by the pharmacist calling your doctor, to ascertain a continued prescription, or, worse, calling the insurance company, to make sure that they will pay their part of the bill, and what the co-pay is - another way private health insurance imposes costs on other parts of the health-care system).
I'd think it is more labor efficient to have the pills prepackaged in a small box, with 15 pills in a tamper-proof blister pack and the required insert and warnings. This also prevents errors in labeling and counting, from the blister pack you can see clearly what it is you are taking, when you take it. (Certainly, once in a while someone in the U.S. will get a vial with the label for his/her prescription, but different content, as the pharm tech applied the label to the wrong vial.[This happened once in a store where my wife worked, the next customer fortunately noted that his pills were bigger or differently colored than before,and asked about that, so they had to contact and drive to the other guy with the wrong pills, retrieve them, make a report to the Board... very embarrassing, it could have killed the guy with the wrong stuff])
Then, here in California, there is also a legal requirement that patients are 'counseled' by a Registered Pharmacist before being given their prescription, sometimes I had to wait for that here, too, only to be superficially told what I already knew from what the doctor had said (take 3x daily, with water, may cause dryness of mouth, if you get a heart attack, call an ambulance right away.).
I agree that the prevalence of most 'natural' and even homeopathic drugs are a disgrace, and see their value mostly as placebos or for relief of common cold (where any hot liquid may do, with mint or other herbs or whatever).
Disclaimer: Coming from Germany, I may be biased to their procedures.
With the cutting of generic drug prices in the US you begin to see 1 month blister packs, for example at Wal-Mart. If you think about it a machine can count and package the drugs more cheaply than a person. The pharmacy tech can then just count the packages needed, and slap the labels on. I expect to see more of it, because it makes sense, and also allows one to eliminate the pill boxes with days on them,
May I express my mild astonishment at the number of good folks here who somehow expect humans to behave rationally and reasonably?
May I inquire what has led you to these startling expectations?
:-)
Humor aside- having spent time in Austria, Mexico, Canada, Micronesia, China, and Polynesia, I'd suggest the best strategy is to relax and learn to enjoy the cultural variability, regardless of discomforts It ain't going away, in any case.
w/ ref to 12, I think St John's wort is a well established tranquilizer. It take about a month to take effect, probably worse than standing in line for most Americans. This seems to be the time-to-effect of most traditional remedies. You have to eased off of St. John's wort systematically over a period of time or it will result in depression.