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Paule de Noinville is a survivor. She has lived through two world wars and, at 92, knows that death snatches people out of this world without pause. So looking back on the torturous heat wave that baked France in 40C (104F) temperatures in August, she is under no illusions about why she lived when over 10,000 others are thought to have died. It was not merely politics or fate that made the difference, she says. It was also simple human intervention: De Noinville was not left alone. "We in this home are just lucky we had excellent people caring for us," she says. Thirty doctors, nurses and aides at Sainte-Agnès public retirement home in suburban Paris tended to the 80 residents with ice packs, wet towels and fluids to help them survive the suffocating heat in the home, which, like most French retirement homes, is not air-conditioned. Three residents died during the heat wave — deaths sped by high temperatures, not staff negligence. "They knew exactly what to do to make sure [we] came through fine," says De Noinville. "Not everyone was so lucky."

As death toll estimates in France soared from 2,000 on Aug. 14 to as high as 13,400 last week — geometrically higher than anywhere else in sunbaked Europe — the country has been forced to admit that many of its 4.6 million people aged 75 and over do not receive anything like the care of the Sainte-Agnès residents. Often, in fact, they are ignored or forgotten, left to fend for themselves or die alone.

It's a national reckoning that is not coming easily. The immediate flush of media attention last week centered on the sexier political debate over the slow and initially dismissive reaction by the conservative government of Prime Minister Jean-Pierre Raffarin, much of which was on holiday as the death toll mounted. Raffarin has refused to accept any blame, while President Jacques Chirac was bizarrely silent — and on vacation in Canada — for the duration of the heat wave. When he finally addressed the crisis in televised remarks last Thursday, Chirac avoided finger pointing, instead emphasizing that "family solidarity [and] respect for the aged and handicapped" are necessary to avoid future tragedies. Doctors and health experts, the people no one listened to during the heat wave, are telling a larger, darker story. The heat wave only made visible, they say, a crisis that had been under way for years: a chronically under-funded and understaffed elder care system combined with a national habit of shutting senior citizens out of sight and mind.

"The French family structure is more dislocated than elsewhere in Europe, and prevailing social attitudes hold that once older people are closed behind their apartment doors or in nursing homes, they are someone else's problem," laments Stéphane Mantion, an official with the French Red Cross. "These thousands of elderly victims didn't die from a heat wave as such, but from the isolation and insufficient assistance they lived with day in and out, and which almost any crisis situation could render fatal."

It is true that advocates are seizing an opportunity, at long last, to publicize the plight of France's elderly. But it is also true that this problem deserves a response that lasts longer than the summer heat. Other European countries are also struggling to get a fix on their death tolls — Portugal has announced that 1,300 have died, while Italy does not yet have a national total and Spain has reported at least 100 deaths. Though these numbers will likely rise, France is in a league of its own. "Our older population suffered incomparably higher fatalities — and there are reasons for that," says Mantion.

Everywhere, there is a tendency to treat heat-wave deaths as inevitable, a sad by-product of summer or global warming or aging. But the disparate death tolls remind us that heat waves, like earthquakes and cold snaps, do not have to wipe out populations the size of small towns. They only do so when the existing infrastructure is already inadequate.

The majority of this summer's victims were found dead in homes they occupied alone — or were brought to emergency rooms too dehydrated and weak to be saved. The August vacation period had lowered the staffing levels of rescue squads and hospitals. And well before that, many elderly people had already become cut off from regular human contact. "Heat waves reveal conditions that are always present but difficult to perceive," notes sociologist Eric Klinenberg, author of Heat Wave: A Social Autopsy of Disaster in Chicago — a hot spell that killed over 700 in 1995. "Primary among those is the rise of an elderly isolated population that lives at the margins of major cities."

The remainder of the fatalities — between 30% and 50% — came from France's 10,000 rest homes. The homes, once models of good care, have suffered from underfunding and a shortage of employees. Homes in nations like Germany and Switzerland have staffs twice to three times the size of those in France, says Pascal Champvert, president of an association of French retirement-home directors. "I definitely have enough work for an expanded staff, but I can't fill positions," says Catherine Johanet, director of Sainte-Agnès. "Working with the elderly is scorned professionally and culturally."

Elderly people in southern Europe — including the south of France — tend to be more integrated into families than in the north. So the heat wave there was accordingly less deadly. Nice, Marseilles and Toulouse have preserved what Mantion calls "Latin attitudes," which consider older people valued and active members of society. The southeast and southwest had around 46% higher fatalities in the first three weeks of August compared to last year, versus 102% in Paris — a far more private and anonymous place.

For now, though, with funerals still going on, it is easier to focus on the poor performance of the country's leaders than long-term solutions. The government did issue alerts and call staffers back to swamped emergency rooms, but that was 10 days into the heat wave. Raffarin has personally drawn fire for refusing to return from an alpine vacation until Aug. 14 — the day before temperatures began to cool. He has since made a ham-handed attempt to deflect criticism by blaming understaffed hospitals on the 35-hour workweek passed by the previous government — and then scolding detractors for politicizing the tragedy. But at least Raffarin bothered to address the issue; Chirac said nothing until his solemn but less-than-contrite appearance late last week.

Geriatric workers hope the news cycle and cooler temperatures don't distract people from the real issues. Says Champvert: "France needs a veritable Marshall Plan for the elderly." With its baby-boom generation swiftly nearing retirement, redemption will require plenty of money and an even bigger cultural change of heart. "All we can hope is that this terrible, deadly period will remind people that the simple act of checking on your neighbor, or helping someone stay cool, can be the difference between life or death," says Johanet. "It's worth keeping in mind, since we'll all be old and vulnerable one day."

• BRUCE CRUMLEY | Paris
• France faces up to its neglect of the aged