The Chinese government’s antibiotics crackdown

SHANGHAI, China — The outpatient waiting room at Shanghai’s Putuo District Hospital on a weekday evening resembles a bubbling cauldron. Faces are flushed with fever, and bodies are sweating through thick layers. Many of the hundred or so patients are accompanied by a family member running back and forth to the buzzing nurses’ station to check on their spot in line.

Inside the office, two young doctors sit at wooden desks, examining patients at a brisk pace. Obviously outnumbered, they take about two minutes with each case before ordering tests or dashing off prescriptions. Most patients are here because of a fever, and when they get up to the doctor’s desk, what they want — and expect — is a dose of antibiotics to speed recovery.

“I had a fever for three days, and no other cold symptoms. They did all sorts of tests on me — a chest X-ray, cardiogram, two blood tests — for fear that it was H1N1. My nose wasn’t even running. And after all those tests, the doctor sent me home to rest with nothing,” a corporate driver named Zhang said. “I went back and begged him for an antibiotic IV.”

But Zhang found that his doctor had become unusually unwilling to dispense from the arsenal of “cure-all” meds that even elderly patients can request by name. China has high rates of antibiotic resistance and a health care system that provides strong financial incentives for over-prescribing antibiotics. Now the central government is taking measures to change that.

Stockpiling antibiotics at home is a common practice among Chinese households. Those who are sick will often go to the hospital and pressure doctors to dole out prescriptions, then take a couple and hold the rest in reserve until they get worse or for the next time they’re sick.

According to the Chinese Pharmaceutical Association, last year 22 hospitals in China’s major cities prescribed more than RMB53 billion ($7.75 billion) worth of cephalosporin — one of the most popular groups of antibiotics prescribed in China — a record. Coughs and diarrhea are almost universally treated with antibiotics, according to a study published in Health Policy in April 2009.

During the height of the SARS epidemic in 2003, many Chinese rushed into pharmacies to stock up on powerful antibiotics, which were available over the counter. Some even took them daily as a preventative measure against getting ill.

“It was a wake-up call,” said Dr. Ding Zhao, who treated SARS patients in Shenyang, China, and is now practicing traditional Chinese medicine in Shanghai. “Patients were eating all kinds of antibiotics before coming to the hospital, and then they were prescribed even more pills.”

According to Art Reingold, a professor and head of the epidemiology division at University of California, Berkeley: "Before it was discovered that SARS was a coronavirus, people were treating it wtih anything they could come up with."

Though there’s no evidence that antibiotics abuse contributed to the development of SARS, the World Health Organization has warned that efforts to control infectious diseases have been jeopardized by widespread drug resistance, a consequence of poor medical treatment and the misuse of antibiotics.

China’s Ministry of Health banned over-the-counter sales of antibiotics in 2004 and imposed price limits on hundreds of prescription drugs to reduce the incentive for hospitals to over-prescribe. After state-run media reported in January 2009 that misuse of antibiotics kills 80,000 people in China a year due to adverse reactions, the ministry launched a program to train 40,000 Chinese medical staff in the proper use of antibiotics.

With public fear about the spread of the swine flu virus at a high this winter, patients are eager to stamp out any flu-related symptoms. But antibiotics have become a prickly subject with doctors and pharmacists. In early December the central government issued a revised edition of the national Medication Catalog, including for the first time guidance for physicians on the use of antibiotics. Of the 2,151 drugs in the catalog, 843 are restricted, up by 12 percent from the 2004 edition.

In the new Medication Catalog, antibiotics are sorted into specific categories, such as those that can only be used after all other antibiotics are proven ineffective, those requiring a bacterial culture analysis, or the supervision of a managerial level doctor, and so on, “to prevent their abuse,” Yao Hong, chief of the Medical Insurance Bureau of the Ministry of Human Resources and Social Security, told the People’s Daily newspaper.

One physician at Shanghai’s Minhang District Hospital said that he could not discuss the subject without permission from the Ministry of Health.

These sweeping regulations are difficult to enforce in a nation where gentamicin sulfate, a cheap but potent antibiotic for treating stomach bacteria, is dispensed as freely as antacids in local pharmacies. Its use is limited in Western countries due to a potentially devastating side effect that damages the inner ear.

A businessman named Chen said his wife went out and bought cephalosporin “just in case” at a small local pharmacy after spending some time cajoling the pharmacist.

“If you have the guanxi (good connections), then you can still get them,” he said.