The shape of the world a generation from now will be influenced far more by how we communicate the values of our society to others than by military or diplomatic superiority. William Fulbright, 1964

Monday, December 15, 2014


Just Say No To (prescribed) Drugs    

Seven years ago The Jakarta Post published a letter from Dutch microbiologist Henri Verbrugh (left) critical of medical prescription practices.  By the normally restrained standards of professional intercourse it was blunt.
“It is perhaps not polite to be critical of my hosts,” he wrote.  “But in the large majority of the cases presented to me antibiotics were used irrationally… doctors in general have only marginal knowledge about antibiotics.
“A study of 4,000 patients and their relatives in Semarang and Surabaya found most of the antibiotics were prescribed without proper indication.”
Jump to the present. “My comments did attract some attention,” he said wryly during a return visit to attend conferences and deliver lectures at medical schools, including Malang’s Brawijaya University.
“There was some blushing, but overall the letter was accepted readily enough.”
Other critics might not have fared so well.  A citizen of a former colonial power jabbing the needle into local nerves? Send him back! Who does he think he is?
Fortunately this fault-finder was well armored against the barbs.  The descendant of an Indonesian grandmother and son of a mining company doctor, young Henri once lived in Belitung, also known as Billiton. 
The islands off Sumatra’s east coast were the lad’s playground from his birth in 1949 till 1958 when President Soekarno ordered the Dutch to begone or become Indonesian citizens.
The family chose option one and left for Holland where Professor Verbrugh is now a leading scientist, head of the Department of Medical Microbiology and Infectious Diseases at Rotterdam’s Erasmus Medical Center.
He is also an advisor to the Scientific Program Indonesia-Netherlands (SPIN), a long-term joint collaboration project to boost scholarly inquiry in the Republic. Indonesia has fallen behind nations like Iran and Egypt in publishing scientific research.
Professor Verbrugh’s words may have wrinkled brows, but there’s no doubt he had the qualifications to comment, a right he’s still exercising.
“Antibiotics are very useful drugs, but they have to be used cautiously,” he said.  “Microbes adjust and adapt quickly and soon produce drug-resistant strains of bacteria.  These are much harder to treat.
“The situation has improved since I wrote that letter, and there are protocols on antibiotic use in the government hospitals, though not all private hospitals follow these.
“There’s still a lack of collaboration among many doctors and administrators who continue doing things their way. Indonesia is an archipelago of medical kingdoms.
“I tell students this has to stop and they should work together.  They also need to be disobedient and not accept what they’re told without questioning.”
His comments are not a lone cry. Last month (November) the World Health Organization urged Southeast Asian nations to boost plans to combat the ‘rapidly increasing prevalence of antibiotic resistance … that will be devastating in this age of emerging infectious diseases.’

So how can we stay well without resorting to antibiotics?
“The problem is not the drugs but the way they are being used; sometimes we need to get back to basics, like washing with disinfectant soap,” Professor Verbrugh said, advice which must send the drug companies feverish.  
“Just screening out patients from surgery if they are carrying heavy loads of bacteria drops hospital infections significantly.  So does nasal cream (the nose harbors bacteria) and antiseptic baths.
“Reducing the use of antibiotics also brings down costs to the health system.”
Apart from educating doctors about the danger of shooting up antibiotics first and asking questions later, the public also has to be alerted, Professor Verbrugh said.

Questioning a treatment is never easy when feeling unwell; in a culture where doctors are often seen as gods it takes a courageous patient to challenge a physician.

Overseas governments, particularly those with national health schemes, restrict the right to authorize certain medicines to specialists  In Indonesia the public can treat themselves by buying antibiotics over the counter.

Professor Verbrugh alleged that some Indonesian doctors routinely include antibiotics as treatment for dengue fever, and for new-borns who appear to be having breathing problems, when these responses were unnecessary. There were also links between doctors and drug companies seeking to promote their products, he said.

Indonesian doctors told him they use antibiotics as a preventative measure because they fear disease, even when patients are suffering from viruses that antibiotics can’t kill.

“Getting out of these habits may take a while, but I have positive feelings,” he said. “We must focus on the next generation of doctors – they have to clean up the mess we’ve made.”

Forgetting to do the dishes
It’s one of the most famous stories of serendipity in modern medical history, and the excuse smart kids use for not washing up after dinner.

On the morning of 28 September 1928, Scottish scientist Alexander Fleming turned up for work as usual at his London laboratory.
He’d been careless.  The night before he’d forgotten to cover a glass dish of the staphylococcus bacteria that he’d been studying.  Unsurprisingly he found the sample spoiled, contaminated by a green mould.
‘Staph’ infections are common as the bacteria are often present on the skin.  Staph usually causes few problems apart from pus in minor wounds, but it can kill if it gets in the blood.
Instead of tossing the dish in a sink and wondering if he was getting too old for the job (he was then 47), Fleming looked more closely at the mess and noticed the bacterial growth around the mould had stopped.
This, he reasoned, meant that the mould could kill bacteria. And so penicillin was born, a drug destined to father a great family of antibiotics.  There are now more than 150.
Professor Verbrugh said that Fleming, who won a Nobel Prize for his discovery, realised penicillin’s limitations.  He cautioned that other diseases could become resistant as the super smart microbes adapted to this new threat. 
But the world, dazzled by the wonder kill-all-bugs medicine was little interested in the early warning. Which is why we have a crisis today.

(First published in The Jakarta Post 10 December 2014)

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