Liguria, November
I am sitting in a cavern. More accurately in a vaulted room deep in a medieval building, the walls washed white. A doctor’s waiting room that feels like the ante-room to a crypt. Or Plato’s Cave populated by shadows of our former selves. I am next in line. This is Italy. I come here for a few months every year because the climate suits me. It eases my bones. And I am here in this cave because Italy has legalised cannabis for medical purposes and I want to try it.
When the doctor emerges from what looks like another cavern, several people at once stand up and hand him scraps of paper, like medieval petitioners. He takes them, nods to some, then gestures for me to come in. He shakes my hand. In his office I explain that I’ve suffered from rheumatoid arthritis since childhood, that the drugs all cause me problems, that these problems are worsening and the number of drugs I can take is now approaching zero, that I’ve discovered that cannabis is legal in Italy and I’m hoping he is prepared to prescribe it. I feel absurdly guilty. But although it is not quite a matter of life and death, it comes near to it. One of these legally prescribed drugs that I am so reluctant to continue with is associated with cardiac arrest. Each time I take one I imagine myself choosing a set of random numbers in a lottery whose prize is oblivion. The odds are about the same as for the Irish lottery, but people do win.
After a long and interesting discussion he tells me he has never prescribed cannabis. The government legalised it, he says, but provided no guidance for doctors. This is followed by a string of complaints about how Italy is governed. Then he turns to his computer and begins to research it on the internet. I know what he’ll find. I’ve done it myself so often. So I give him the email I have received from the friendly pharmacist in Bologna who first advised me on cannabis. He puts the names of the drugs into Google, his glasses tipped back onto his head. He is completely bald, a slightly square head full of undulations, bright intelligent eyes under the high brow. He says he needs to speak to the pharmacist to understand the dosage. He will call me. He stands up and shakes my hand again.
I ask how much I owe.
Nothing, he says, we had a good chat.
He calls me the next day to say I need to see a pain specialist in Recco. I have an appointment for the following Saturday. This in itself is shocking. Such appointments in Ireland take months or years. Once the pain specialist prescribes the dosage, he says, he will know what to do. So I take the bus on a day of downpours. It wakes me at four a.m., rain pouring from the gutters. It falls on the path outside like continuously breaking glass. It continues off and on through the morning. This is the worst kind of weather for me. Ruefully I note that the weather at home in Ireland is crisp and dry, full sun all day. I am, at least, properly pained up for the specialist. Touch me and I’ll break in a million pieces.
The little bus is almost empty. The driver returns my buongiorno with a cynical smile and a shrug that indicates the windscreen wipers working hard to clear the rain from the glass. It’s true; it is not a buon giorno. I validate my ticket and make my way to the back and watch the sea and the rainswept gardens as we career along the winding road and drop down into the next valley. Nobody else gets on or off.
The town of Recco puzzled me for a long time. It lies in a steep valley. Almost every building in the town is post-1945, and this is something I couldn’t understand because it is clearly situated on a medieval site. Then I discovered that the viaduct which runs across the valley high above the town was an important target for Allied bombing raids; 97 per cent of the medieval town was destroyed during the raids of 1943. After that I began to notice photographs of the old city on plaques on street corners. Melancholy monochrome loss. Despite the massive bombing, the principal festive day is the Festival of Fire (La Sagra Del Fuoco) in honour of the Madonna. The fireworks are famous. So much for collective memory.
The doctor explains to me that my GP has filled her in on the details and we discuss my condition and the level of pain I suffer. Then she tells me that she doesn’t know how to prescribe cannabis, it was legalised by the government without proper information, the government is terrible, et cetera. She thinks that to gain access to therapeutic cannabis I need a ricetta rossa (equivalent to a consultant’s prescription) which can only be obtained from a specialist working in a hospital. She writes out the address of the hospital in Genoa and tells me she will contact me once she has spoken to her colleague there. Instead of writing a prescription for cannabis, she gives me one for oxycodone, which I remember my mother-in-law being given in the final stages of her cancer. I think of it as an end-of-life analgesic, a semi-synthetic opioid of the type responsible for the spiralling prescription opioid epidemic in the USA. I am not enthusiastic.
We shake hands and part company.
The rain has stopped when I emerge onto the street. The forecast is for rain again tomorrow, and low temperatures. I go into the butcher shop and buy a steak, not exactly dreaming of home.
The next day is Sunday and the sky clears for a cool, windy day. So much for forecasts. By mid-afternoon a huge sea is falling on the pier and the beach, waves breaking against the church wall and the old citadel, driving up the stony foreshore, ferocious growlers, white foam as far as the eye can see. They come in higher than the pier and shatter on the rocky breakwater outside it. They explode like bombs. The noise is deafening. In the houses along the lungomare, the promenade, it is like continuous war. Pity anyone at sea tonight, pity the child in a rubber boat with a fake lifejacket between Libya and Lampedusa.
Ships anchor in the Genoa roadstead waiting for space at the wharf or waiting for the price of their cargo to improve. They’ll have a rough night of it tonight. Their lights illuminate nothing but they announce their presence and punctuate the darkness. Sometimes a belated cruise ship goes by. A friend who once worked on the cruises told me that after dinner they steam around in a wide circle offshore so that the passengers can be surprised to find the next port of call coming up just exactly at dawn. If they just steamed from port to port the entire cruise would be over in thirty-six hours. Tonight is a half moon, so bright it looks artificial. They say it will be a super-moon when it grows up.
Genoa was where Christopher Columbus was born. His name appears on many streets and public buildings. The nautical school in Camogli is the Cristoforo Colombo. Other names that appear frequently include Garibaldi, whose statue appears in every town of note, and who appears to have slept in an alarming number of houses in Liguria, to judge by the plaques. Although he had a poor grasp of theory, to say the least of it, he did at least once say that socialism was the sun of the future. I revere him for that. The other players in the unification process figure too, Mazzini, Cavour, Victor Emmanuel, but mainly out of civic duty. Of all of them, only Garibaldi still commands public affection.
The hospital of San Martino is really a small town. The original buildings, constructed between 1907 and 1920, are in the ‘liberty’ or ‘belle-epoque’ style, with a central administrative unit and the specialities housed in individual ‘pavilions’, each in itself a bourgeois villa, with fine windows and doors, some with porticoes, Greek-style columns and even balconies. In the sixties, a magnificent new, curved modernist building (called the Monoblocco), of fourteen floors, was added, making Ospedale San Martino one of the largest in Europe.
I meet my pain doctor in one of the pavilions. He is a genial man who is keen to point out that all the internet research I might have done counts for absolutely nothing. In scientific terms there is virtually no serious research on cannabis and therefore any possible benefits I might have read about are mere hypotheses. He takes a dim view of hypotheses. Or at least a reserved view. In his gentle determination I read my fate. There will be no cannabis.
He tells me that he cannot legally prescribe cannabis for me until he has exhausted all other therapies. He writes me a note for a rheumatologist colleague and, for the meantime, prescribes a form of liquid Tramadol. I can titrate my own dosage with the liquid, he tells me, ten drops should be enough. I now have Tramadol under both species and oxycodone. These doctors are prepared to prescribe any kind of drug except a humble weed that has been used for thousands of years. Behind it all I sense a moral distaste. When I tell the doctor that I know I’m not allergic to it because I used to enjoy a spliff at college, he is uncomfortable.
It seems clear that cannabis as a medical preparation partakes of the reputation of cannabis the recreational drug. I suspect that many doctors retain a dislike or resentment of hippies, who perhaps had a better time than them at university. To be fair, most of the research on the drug has concentrated on proving that the recreational form is bad for you. Quite possibly it is, though I doubt it. In any case, it is a different drug, the result of a long process of selection for the ‘high’, rather than for any therapeutic benefit. The history of cannabis has led to a kind of unconscious conspiracy involving the resolute and secretive opposition of the pharmaceutical industry to a drug that can be grown in your back garden, and is therefore difficult to charge a fortune for, together with the natural moralising of politicians and the desire to police the pleasures of sick people who, after all, really should suffer if we’re to believe in them at all. But why, I ask my doctor, should a medical system privilege the ‘high’ caused by opioids like Tramadol over the ‘high’ caused by cannabis? Again that sympathetic shrug. The words ‘evidence’, ‘data’ and ‘hypothesis’ occur in his answer. I can see no way to break through this barrier. I try to argue that whatever the evidence as to its efficacy, there are clearly appalling side effects to a drug such as oxycodone, which has caused the American epidemic. Nevertheless, he says, I must first see a rheumatologist who will confirm that the wide variety of arthritis medications available are either ineffective or contra-indicated. He passes me the letter of referral and shakes my hand.
I feel as if I am caught in an infinite regression tending towards the President and the Pope, perhaps even God. I need some sort of breakthrough.
Sure enough it comes.
The following day I have to travel to Milan to give a reading. Afterwards I will fly home for Christmas. As always when I travel the Plain of the Po (the Pianura Padana), fog sets in early. I have never yet been in Milan on a clear day. From the window of the train the distance is obscured. There are occasional glimpses of hills, animals. We twice cross a river I assume to be the Po, which loops and meanders all over northern Italy actually beginning on the western Alps, and emptying into the sea close to Venice. It is near Voghera – flattened by Allied bombing during World War Two; but home to the museum that houses the weapon that killed Mussolini – that I am contacted by my pharmacist friend in Bologna whom I have kept apprised of my travails. She tells me that there are two doctors there that prescribe cannabis and I could simply make an appointment with one of them. However, I would have to come to Bologna to be examined. She gives me their numbers.
I tell her that I am flying home to Ireland after my reading. I will contact her again in February.
Bologna, February
Gloomy days in Bologna. The temperature varies between 2°C and 8°C, the sky never breaks. I realise the weather of this essay is more West Kerry than Italy. Think of Dunquin with better wine.
The doctor’s house is outside the Porta Vitale, the ancient gate on the road to Ravenna built in 1286. It is, essentially, a large private house or palazzo containing eight apartments one of which is the studio of Dr C. The garden is full of bicycles. Bologna is almost completely flat, as is most of the region of Emila Romagna. The bicycle is king here.
Something is wrong with me that morning, but I can’t quite put my finger on it. I blame the risotto ai funghi porcini I had the night before. Mushrooms and I do not always agree.
Dr C is a woman of about fifty with a mane of blue, black and grey hair. Her waiting room and office are hung with posters about naturopathy, the Bologna Festival of Good Health, acupuncture, homeopathy and even a message from the Dali Lama, in both English and Italian, on The True Meaning of Peace: ‘The most important factor in maintaining peace within oneself, in the face of any difficulty, is one’s mental attitude.’ Perhaps it sounds better to an Italian. Behind her desk is a map of India and a chart which explains how to read the iris. The sector around nine o’clock in the right and left irises, for example, denote the lungs. Dr C explains to me that the healthy iris has a good regular structure. Mine is weak in the half-past six area of the left iris, which means my kidneys need a boost. I was not aware of the fact but I take the information like a man. The rest of my iris indicates a strong constitution. I do not have sufficient colloquial Italian to pull it off, but I would like to say that I should think I have a strong one, considering how many legitimate chemicals I have ingested in fifty or so years of surviving my body and surviving the pharmaceutical industry.
She persuades me to drink half a litre of water while she interrogates me gently about the things my ancestors died of (we pass swiftly over the wartime experiences of my uncles, one of whom died in an Italian minefield), known flaws in my pedigree and moving on to whether I am happy in my married life, my work life, the kind of life I lead in general, my relations with my children and grandchildren. Alas, for purposes of karma, I have been lucky in love and life with the small exception of the disease for which I am in pursuit of cannabis.
I am confident, from the start, that she is in fact a qualified doctor, and that the advice she gives me about food and exercise is good. I am also confident from very early on that she will prescribe cannabis, but as the interview proceeds, including taking my acupuncture pulse, reading my iris with the kind of machine you see in an ophthalmologist’s, describing the ideal diet in great detail (including recipes), I begin to despair. I begin to wonder idly when the next train to Rome might be, and whether the Pope is seeing patients this afternoon.
In addition I begin to feel seriously ill in some generalised way which has nothing to do with my disease. It may even be some sort of normal disease, like normal people get.
I need not have worried. She begins to write out the prescription and explain the method of ingestion. I am to take it as an oil, to begin with just a few drops sub-lingual and if the pain does not abate within an hour, to take two more and so on, until the pain stops. There is no upper limit, she says. More correctly, I think, I will limit myself, because after a certain point I will be so stoned that all I’ll want to do is sleep. I resolve to begin on the lowest possible dose. I want to be able to work.
I begin to walk home up the long Via San Vitale. It is a difficult journey. Something is radically wrong with my stomach. I am afraid I will throw up on the street and shame myself and my country in the eyes of the elegant Bolognese. I am afraid to go sit in a cafe in case the dizziness makes me fall down. I have no desire to wake up in an Italian ambulance. I hold myself very upright and make no sudden moves. I pass the two famous towers (known, with plain poetry, as The Two Towers) and make my way across Piazza Maggiore. The last time I walked this great square it was full of red shirts and red flags – a general strike. The speakers blared Bella Ciao. Today it is quiet.
Liz is waiting for me in the hotel, all smiles because I have finally found someone to prescribe cannabis. I just walk straight past her into the bathroom. I spend the next eight hours vomiting and cursing Heathrow salads and, unjustly perhaps, the porcini mushrooms that emerge from my interior like something from the film Alien.
Somewhere around the four-hour mark, at about half-time in the game, the thought occurs that cannabis is an ideal anti-emetic. If only I had it, rather than just the prescription.
So what is it like to take medical cannabis? Despite all the anxious arguments emanating from public bodies in Ireland, it is the most gentle painkiller I have ever taken. It is so gentle that I am not aware of it until I discover that the pain is gone. There is none of the hard buzz I get from Tramadol, the feeling of disorientation, the thirst. I detect a very slightly elevated feeling of well-being, which could as easily be ascribed to the ebbing of the pain as to the drug, sometimes also an intense feeling of relaxation. There is no noticeable high, or certainly not at the level of my prescription with only 6 per cent THC. I have begun to sleep the night through, something that has rarely occurred in the fifty years of my disease. It’s been more than a month now and I haven’t had to take any other prescription medication. This counts as a complete success for me. I don’t know if it can continue to hold the prescription drugs off, or whether it will become part of a mixed regime – I suspect the latter – but in any case the game has been worth the candle.
Along the way I have learned a great deal about Italy and the Italian health service. Italians are fond of telling you how bad the system is, and certainly it has suffered incursions of privatisation that have done damage, but it is still largely free and much more efficient than ours in Ireland. The one prescription that I filled at a pharmacy cost me all of €2.70. I don’t think I could buy a packet of aspirin for that in my local pharmacy. I have had to pay highly for my cannabis because I went the private route (I estimate it costs about €60 per month for the level of prescription I need) but had I continued through the hospital process it would have been free. The only medical appointment I was asked to pay for was the private one.
By early March the unseasonal weather has departed and I am swimming. The sea is about as cold as June in Ireland. I swim out beyond the church on its little island and turn to look back at the town climbing the hill, layer upon layer, from the medieval village to the top of the mountain, flashes of mimosa among the grey of olive groves, occasional orange trees with their glowing lanterns. There is snow on the mountains towards France, a rim of milk-white between the land and the blue sky. Tomorrow’s forecast is even better. The spring has come, they say. And I am looking forward to learning more about the little bottle of dark green oil sitting on the bottom shelf of the fridge. ‘What does it taste like?’ a friend asks me, and I reply, ‘It tastes like hash.’