COVER: A VIEW TO A PILL
Penicillin fought bacterial infection for 50 years, but today's antibiotics are lucky to be effective for 10 years. It is not only pollution, overeating, and stress that is diminishing Taiwan's health, the island is now breeding tougher bugs and our arsenal is diminishing.
By Jeniffer K. Lin
Penicillin was once hailed as a "miracle pill."This first antibiotic saved soldiers from having to amputate infected limbs, cured pneumonia, and sent tuberculosis to the history books for almost a generation. By the 1960s, the U.S. Surgeon General foresaw infectious diseases to be a thing of the past. But as modern medical practices spread around the world, antibiotics have now become too easily accessible, leaving strains of resistant bacteria in its wake. The worldwide overuse and misuse of antibiotic drugs is rapidly weakening our ability to fight infectious diseases. Antibiotic-resistance is a natural phenomenon of biology. As an organism's existence is challenged, natural selection and development of countermeasures are nature's assurance of a fair fight. But while antibiotic resistance is occurring globally, those prescribing and using these powerful weapons carelessly are triggering bacteria to evolve faster. Factor in a culture that neglects health education and believes taking medication will cure everything, and Taiwan is a major culprit in the breeding of "superbugs."
A Bug's Life
Bacteria is everywhere. Human beings have bacteria in the stomach, mouth, and skin, but the majority is harmless. When you take an antibiotic, all the bacteria on and in your body is affected. That means, any exposure to an antibiotic initiates a selection process. The weaker ones will be killed off, leaving the resistant strains behind, whether or not they were harmful. "The situation is especially bad when you're doing nothing but selecting resistant strains," says Dr. Monto Ho, distinguished investigator and director, Division of Clinical Research, National Health Research Institutes (NHRI). Ho has conducted extensive research finding Taiwan doctors administering antibiotics for unfounded reasons. Ho was a professor and chairman emeritus of the Department of Infectious Diseases and Microbiology at the University of Pittsburgh for 38 years before coming to Taiwan in 1998 to head a study on the antibiotic-resistance problem here. Ho established the Microbial Infections Reference Laboratory to begin surveillance of antibiotic usage. After Ho's alarming findings were published in the Journal of Microbiology, Immunology and Infection, in a paper entitled "Surveillance of Antibiotic Resistance in Taiwan, 1998," the results prompted a series of evaluations throughout the healthcare system. Dr. Kow-Tong Chen, director of the Division of Surveillance, Center for Disease Control (CDC) in Taiwan calls Ho's findings "very severe."
Drug Culture
Taiwan -- as well as Japan -- believes in taking medicine. If someone is sick, that person goes to the doctor, gets some pills or a shot, and feels confident that he or she will get better. "Patients go to the doctor to get relief," says Ho. "They don't go for a precise diagnosis." As a result, local waiting rooms are overcrowded, doctors see patients for only a matter of minutes, and most prescribe a diverse cocktail of pills. The latest Taiwan government figures show that the average Taiwanese visits the doctor 14.7 times annually, returning home with four to five different medicines in each prescription. But the problem with antibiotics-overuse does not stem from how often patients see doctors. Trouble starts when doctors prescribe antibiotics irresponsibly, especially when they do so to a large number of patients. And this is the case in Taiwan. "Physicians like to give antibiotics to [fight] the common cold," says Chen. "It is a custom. Patients will change doctors just to get antibiotics." Since 90 percent of colds are viruses, and antibiotics fight bacteria, such prescriptions are not only reckless but simply incorrect. Sadly, since patients and doctors both see improvement after taking the drugs, they assume the medicine cured the cold. In reality, the cold virus simply ran its course naturally, and in the meantime, the antibiotics taken helped to build resistance on a host of bacteria strains it encountered on the patient. Chen blames these ignorant ?or misinformed ?doctors for the widespread misconceptions about antibiotics in Taiwan. Far more damage occurs than wasted fees when drugs are prescribed and there is no infection to fight. As in the case of a common cold, natural selection occurs with or without an infection. Oftentimes, resistant bacteria strains are small in population and would not otherwise thrive due to competition with other strains. But thanks to the inappropriate and overuse of antibiotics, the resistant strain dominates and multiplies, creating a population of bugs resistant to that particular antibiotic. "[Taiwan's] drug culture makes for an overuse of antibiotics," says Ho. His findings uncovered huge problems with the way in which the Bureau of National Health Insurance (BNHI) was regulating antibiotic use. The restrictions were proving largely ineffective given loopholes in the system that allowed for misuse by doctors and healthcare practitioners. Worst of all, the efforts to protect second and third-line antibiotics ?stronger and more widely effective ?have allowed first line drugs in Taiwan to become almost completely useless. The BNHI recognized the need to control the administering of antibiotic drugs, but it also understood the locals' plea for the wonder pills. As a compromise, the bureau allotted for the reimbursement of three days-worth of antibiotic prescriptions. This, they hoped, would satisfy the public demand for antibiotics without breaking the bank. Unfortunately, such short-term prescriptions are the surest way to breed resistance. Three days-worth of antibiotics is not a full cycle ?not enough to kill off all of the culprit bacteria causing an infection. So, assuming the doctor did prescribe the right antibiotics for the right type of infection, the medication would fight the bugs only long enough to help them to build up immunity, much like a vaccination. Equally hazardous is the problem of over-the-counter medication in Taiwan's pharmacies and drugstores. Although only licensed pharmacists may legally dispense antibiotic drugs with a prescription, Chen says antibiotics are actually "easy to get over the counter." And that spells bad news. Pharmacy and drugstore owners do not diagnose whether the customer needs an antibiotic; they simply sell them if requested. To make matters worse, they will sell antibiotics by the pill, and without explaining the importance of taking a full cycle. The Bureau of Pharmaceutical Affairs is struggling to control this, but in the meantime, antibiotic resistance mounts.
Peace of Mind
A quarter of Taiwan's antibiotic overuse problem stems from improper usage in inpatient cases. Local hospitals are teeming with highly resistant microbes. Hospitals bring together a high concentration of bacteria and constant antibiotic use, a combination that puts the evolution cycle into hyper-drive, making an army of superbugs. As a result, hospital-acquired infections are classified as the worst type of bacterial infections. Chen says the resistance of bacteria found in Taiwan's hospitals is so high that the figures are equivalent to those found in ICUs in other countries. In his study, Monto Ho discovered a key area in which antibiotic "abuse is profusely demonstrated." The industry-accepted method of preventing infection prior to a "clean" surgery (meaning surgery on an area of the body that is not currently infected) is to administer two to three doses of antibiotics prior to surgery. Such a practice is observed, but Ho found that 70 percent of local surgeons were prescribing three times that standard dosage. Moreover, he found that one-third of local surgeons were prescribing antibiotics only after the surgery. "That means, 30 percent of doctors are ignorant. It's useless to give [antibiotics] afterward," he says. To correct the misperceptions, Monto Ho set out to prove that giving antibiotics for infection-prevention is unnecessary. He conducted an experiment showing side-by-side test results, reassuring doctors that antibiotics do not serve any purpose, except to create more resistance problems. The results of these studies have been spread across local medical circles. Kow-Tong Chen was a practicing surgeon prior to joining the CDC. He, too, is guilty of having overused antibiotics. Like other Taiwan doctors, "for safety," he gave patients antibiotics before the operation and then afterward. "We thought it would avoid the risk of infection," admits Chen. "Now I say you don't need to, but when I treated patients, I felt unsafe." He explains that such perceptions are difficult to change. "You work so hard to perform an operation correctly, but if the patient develops an infection, it was all for nothing," he says, and unfortunately, dispensing antibiotics is an easy way to ensure -- momentary -- peace of mind. The End? The good news is, today Ho says he is no longer "a prophet crying in the wilderness" and his work is effecting changes in Taiwan. As of February 1, the Examination Yuan passed directives to reduce the excessive use of antibiotics in Taiwan. In outpatient cases, BNHI will no longer reimburse antibiotic medicine prescribed to patients with upper respiratory infections, a.k.a. the common cold. For inpatients, the BNHI will stop reimbursing antibiotics used before and after clean surgeries, except those given two hours prior to an operation. These two types of mis-prescription accounted for 30 and 25 percent of all antibiotic use, respectively, in Taiwan. Cutting them out will mean a major victory in the fight against antibiotic abuse in Taiwan. But these measures will not address the problem of Taiwan's existing population of antibiotic-resistant bacteria. Most strains of bacteria in Taiwan have already developed an extremely high resistance to first-line (the most widely used and hence abused of all antibiotics) drugs, presenting a dangerous scenario. "I believe the antibiotic resistance problem will be bigger and bigger in the future," says CDC Director Kow-Tong Chen. "I have visited teaching hospitals and seen patients with resistant TB. And we can't do anything," whereas tuberculosis was thought to be nearly eradicated just after World War II. NHRI's Monto Ho maintains a more hopeful perspective. "I don't want to mislead you -- there are other [antibiotics] down the road," he reassures. But he emphasizes that the current usage cannot continue and the principles of proper usage will always apply. Afterall, the laws of nature state that organisms are bound to develop a resistance to challenges. "Human ingenuity is not keeping up with bacteria," says Ho. Drugs are losing their effectiveness after five to ten years on the market, while it currently takes 15 years for a drug to go from the laboratory to patients in the United States, according to the Pharmaceutical Research and Manufacturers of America (PhRMA). The best news is that Taiwan's healthcare community is beginning to understand the seriousness of its own ailment. Ho's study on the abuse of antibiotics has stepped up preventive measures by the Bureau of National Health Insurance, the Examination Yuan, the Center for Disease Control, the Bureau of Medical Affairs, the Bureau of Pharmaceutical Affairs, and the Bureau of Agricultural Affairs. "People are finally joining the bandwagon," he says happily. Because of Taiwan's small size, Ho is optimistic about getting the problem here under control. He says, "I think it can be done. I think we've shown that it can be done."
