Americans carp about the cost and availability of drugs but rarely reflect on how pharmaceutical systems function elsewhere in the world. As John Inciardi, an associate clinical professor in UCSF's School of Pharmacy, understands, perspective can be instructive.

Imagine for a moment that you are a Dutch citizen. You are assigned a physician and a pharmacist at birth, and when drugs are prescribed, you visit your similarly assigned community pharmacy any day after 2 p.m. without any waiting or any fee (health care expenses having already been deducted from your taxes).

Or imagine living in Japan, where the pharmacy system is so technologically advanced that pharmacists can dispense drugs without error, or Vietnam, where it is so chaotic that 95 percent of the drugs dispensed by pharmacists - who serve as the country's primary health care providers - are ordered by patients themselves.

Inciardi's academic stints in these three countries have given him rare insight into the mechanics and cultural idiosyncrasies of international drug prescribing - insights that he has now turned into a seminar for UCSF pharmacy students, who broaden their practice horizons without leaving their seats.

"It's always an eye-opener for them," Inciardi says. "And it's important to the practice of pharmacy, since pharmacists need to understand cultural context. When I'm done with the Holland part of the seminar," he laughs, "someone invariably asks about getting a job there."

Were that ever to happen, the UCSF pharmacy school graduate would not be working in what Americans casually call a "drugstore." Dutch drugstores specialize in cosmetics and other personal care items and perhaps a few over-the-counter preparations. But as Inciardi explains, there are no druggists. Instead, pharmacists work in community pharmacies to which citizens are assigned and through which pharmacists fill an average of 400 prescriptions per day.

"The Dutch system operates like one big Kaiser," says Inciardi. There is only one drug formulary, which is reviewed during regular pharmacotherapy discussions. Pharmacists also meet monthly with their physician counterparts and carry on an ambitious amount of clinical and epidemiological research, made possible by a vast database that connects community pharmacy and hospital records.

The logic and order of the Dutch system contrasts with what Inciardi describes as the headache-inducing complexity that prevails in the US. "American pharmacists spend a lot of time on the phone. There are dozens of health coverage plans and different approved drug formularies for each." In this world of choice run amok, learning something as simple as which "me-too" - or comparable - drug is allowable can take hours.

Japan's solution creates a different sort of problem; unlike the US, it allows doctors to dispense drugs from their offices. "Is it any wonder that Japan has the highest number of prescriptions per capita in the world? Or that 30 percent of the health care budget goes to drugs?" Inciardi asks. Admittedly, while there is strong incentive to prescribe the most expensive drugs, Japanese pharmacists also offer a degree of "extemporaneous preparation" that is unheard of in the more standardized American system. In short, Japanese pharmacists make drugs on the spot, tailoring their ingredients to the doctor's individualized specifications. "The standard Japanese pharmacy doubles as a drug preparation facility. It is highly mechanized with lots of robotic technology," says Inciardi. "The pharmacists who work there boast of error-free dispensing." That is particularly impressive considering that until recently patients were given only a single month's supply of drugs, with no automatic refills, thereby increasing the opportunity for mistakes.

Japan's other pharmacies - the community pharmacies - operate in much the same way as Holland's drugstores, a bit of nomenclature confusion that UCSF pharmacy students learn to take in stride. The drug-dispensing situation in Vietnam, on the other hand, inspires striding and striving of another sort. "Many of my Vietnamese students want to go back to the mother country to help out," Inciardi explains. The reasons: Vietnam's health ministry has few pharmacy-related regulations and seldom enforces those that exist. Less than 20 percent of Vietnamese have health coverage of any kind. There also is a tradition of self-prescribing, primarily of antibiotics, and the expectation that if hospitalized, patients will provide their own drugs. "It's a total free-for-all," Inciardi says.

But out of disorder, there is hope. In a country where doctors are in short supply, and HIV infection rates are rising rapidly, community pharmacists have become the principal primary care providers. The Vietnamese government, which is interested in exploiting this relationship by creating national standards of good pharmacy practice, has turned to Inciardi and others in the UCSF School of Pharmacy for advice. Inciardi already has one training symposium in Vietnam under his belt. Another is being planned.

The symposia reflect what Steve Kayser, head of international clinical programs, contends is the School of Pharmacy's stellar reputation and its long history of training doctor of pharmacy students from Asia. "We sit on the Pacific Rim. We are considered the world's leading program in clinical pharmacy. And our faculty have many ties to Asia. So it's not surprising that pharmacy schools in Asia want to partner with us. We're now looking at a number of proposals."

With new possibilities layered atop existing ties, Inciardi's future students may one day be learning about the American pharmaceutical system from their desks in Ho Chi Minh City, or Hong Kong, or Shanghai.