You can buy antibiotics without a prescription at pharmacies - alongside stalls selling fruit and rice. Industrial farms in the region feed the drug to fish. The result: an invasion of drug-resistant superbugs.
BANGKOK • In a softly-lit suite of Bangkok's Praram 9 Hospital, Mr Songchai (not his real name) slowly scrawls out his thoughts on paper. Five months in coma have left him with throat muscles so weak he needs a breathing tube, which reduces his words to hollow rasps. Just months ago, his heart was straining to pump blood through a body under attack by a strain of severe and drug-resistant bacteria.
"The doctor told my wife to be prepared for my death," says Mr Songchai, who spoke to The Straits Times on condition of anonymity.
To save his life, doctors gave him the strongest antibiotic available. It helped him pull through, but also destroyed his kidneys. The 66-year-old retired marketing director now has to undergo thrice-weekly dialysis for the rest of his life.
Mr Songchai is lucky. An average of two people die every hour from multidrug-resistant bacterial infections in Thailand, according to a landmark study funded by the kingdom's health ministry and Britain's Wellcome Trust, and published in September.
The study used micromicrobiology databases, hospital admission databases and the national death registry to estimate that multidrug-resistant bacterial infections killed 19,122 people in Thailand in 2010. Thailand's population is 68 million.
The death rate is high compared to the United States or Europe. In the US, there were 23,000 deaths in a 316 million population in 2013; and 25,000 deaths a year in the European Union - from a 500 million population in 2007, according to the study's senior author, Dr Direk Limmathurotsakul of Mahidol University in Thailand.
The problem is not confined to these countries. Some call it the "silent tsunami": The improper use of antibiotics for humans and livestock around the world is leading to the proliferation of increasingly drug-resistant microorganisms, creating new strains of "superbugs" that can be defeated only by "last resort" medicine with toxic side effects.
The World Health Organisation (WHO) warns that "improvements in global health over recent decades are under threat". The microorganisms that cause tuberculosis, malaria, urinary tract infections, pneumonia and food poisoning, for example, are becoming increasingly resistant to a wide range of medicines.
"Some cases of tuberculosis and gonorrhoea are now resistant even to antibiotics of the last resort," the WHO said last year.
The problem is particularly stark in Thailand. "(People) feel they can buy stronger and stronger antibiotics," said Dr Direk.
"They feel the problem is confined to them. They don't understand second-hand antibiotic resistance, that it can (affect) friends and family and other people in the hospital."
AMOXICILLIN FOR SORE THROAT
Many developing countries with poor healthcare systems allow antibiotics to be sold without a prescription. In middle-income Thailand, which draws medical tourists from all over the world, antibiotics are freely available in pharmacies and even convenience stores.
The Thai capital is dotted with pharmacies dispensing drugs. Indeed, a particularly popular hub can be found by Victory Monument, a bustling traffic circle in central Bangkok.
There, anyone can easily buy drugs for high blood pressure, diabetes and a whole range of other ailments, alongside guava or chicken rice touted by hawkers crammed by the storefronts. Runners armed with wads of baht and printed photographs of medicine they are tasked to buy jostle for attention at the busiest stores alongside buyers from Myanmar, Cambodia and even Singapore.
Standing on the other side of one of the counters is Ms Nattiya Apisittinantakul, a 25-year-old pharmacist. At the request of The Straits Times, she fishes out a selection of the antibiotics on sale, ranging from generic blue-green capsules of amoxicillin to brand-name ones like Pfizer's Zithromax. Some Thais buy the medicine because the wait to see a doctor is too long, she says. Others bring empty boxes of drugs previously prescribed to them. Many are familiar with amoxicillin.
"If they had a sore throat yesterday, they would come in and say 'I want amoxi'," says Ms Nattiya in exasperation. "Even if I explain that they don't need it, they wouldn't believe it. Or they would say, 'I want to buy it to keep it in my house'."
Many also ask for the smallest available packs of amoxicillin - a 30-baht (S$ 1.20) strip of 10 generic capsules - and need to be persuaded to buy another strip to make it a full course of antibiotics. Taking an inadequate amount of antibiotics can create drug-resistant bacteria.
Some directly request Norfloxacin, which can be used to treat travellers' diarrhoea. "They don't even say they have diarrhoea anymore," Ms Nattiya laments. "They ask, do you have 'norflox'?"
IT'S IN YOUR MEAT TOO
Antibiotics used on livestock is another concern. Drug-resistant bacteria spreads through direct contact between humans and farm animals, ingested meat or the environment.
In many large industrial farms, where cramped conditions allow diseases to spread fast, antibiotics are often used on healthy animals to prevent rather than treat illnesses.
Farmed seafood from the region in particular has been getting red-flagged. Vietnam's Department of Animal Health, for example, found this year that most of the 139 catfish farms it surveyed in the Mekong delta region were using antibiotics. According to a report in Tuoi Tre News portal, one of the antibiotics detected included colistin, which can damage kidneys.
Over the past two years, the US Food and Drug Administration has put several peninsular Malaysian shrimp producers on its "import alert" list for using nitrofurans, a banned antibiotic.
In June this year, one Thai firm, Narong Seafood, was placed on the same US alert list after drug residue was found in its shrimp.
According to Thailand's National Antimicrobial Resistance Surveillance Centre website, the kingdom uses about 10 billion baht worth of antibiotics every year. It is unclear how much is used on animals.
Thailand's Food and Drug Administration as well as the Department of Livestock Development did not respond to requests for interviews.
While farmers in Thailand are banned from using antibiotics as growth promoters, experts say there are still information gaps on how and where the drugs are used on farms. This is something the Food and Agriculture Organisation (FAO) is working with the Thai government to fix, along with raising awareness of the problem.
Dr Wantanee Kalpravidh, an FAO regional manager, thinks the stringent standards set by countries importing Thailand's farmed products motivate companies to rein in antibiotic use. But cutting back on its use may not save money, since farms need to vaccinate the animals and put up biosafety barriers to protect the animals from disease.
She suggests governments consider dangling incentives before conscientious farmers. "Can the government recognise this as corporate social responsibility and reduce their tax?" she said.
After all, the benefits from reducing indiscriminate use of antibiotics extend to the larger society, and go beyond borders.
It will help lower healthcare costs, for one thing. At Bangkok's public Ramathibodi Hospital, staff have to wear a 12-baht, one-time-use protection gown every time they approach a patient infected with a superbug. Staff in one intensive care ward with 20 of these patients go through 10,000 such gowns a month, reveals the hospital's deputy director Kumthorn Malathum.
In conjunction with World Antibiotics Awareness Week starting on Nov 14, the hospital will set up information booths to educate patients about proper use of antibiotics. "People don't often see the long-term effects caused by superbugs," says Dr Kumthorn. "People think patients just die quickly and the (treatment) cost is low. But infection caused by superbugs also affects your long-term quality of life."
Mr Songchai's troubles began earlier this year, when he fell while going down the stairs at home.
His knees hurt so much he resorted to taking an over-the-counter muscle relaxant three times a day, on top of a cocktail of four to five drugs for diabetes, high blood pressure and other ailments.
The combination of drugs proved too much for his kidneys, so he had to undergo temporary dialysis. It was during the treatment that he was felled by the drug-resistant superbug.
The avid golf and billiards player is now reduced to watching such tournaments on television at home.
He scribbles glumly on a piece of paper: "Don't use (antibiotics) by yourself. Ask the doctor first."
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