No Prescription for Antibiotics? No Problem
By HOWARD MARKEL - Contributor to The New York Times
Jose Martinez, a 29-year-old Dominican immigrant who runs a bodega on the Upper West Side of Manhattan, almost always manages to find whatever his customers need on his store's bulging shelves.
When asked for medicine for an infection, Mr. Martinez often reaches for a box of pills called Ampitrex, a brand name for the antibiotic ampicillin.
The pills sell for 50 cents each and are easily bought at bodegas on the Upper West Side and in Washington Heights, East Harlem, Brooklyn, Queens and the Bronx.
Under federal law, ampicillin, like all antibiotics, requires a doctor's prescription. But Ampitrex is made in the Dominican Republic, where it is readily available and smuggled in small quantities into the United States. It is then sold in small markets much like over-the-counter pain relievers.
''In my country you can go into any store and get antibiotics like this one,'' Mr. Martinez said. ''This Ampitrex, it's 500 milligrams and absolutely pure. For throat pain, infections, it works by the next day. One to two days tops. Once you feel better, that's it. You're done taking the pills.''
Carlota Hurtado, 69, of Washington Heights said that getting antibiotics without seeing a physician, or even a pharmacist, was easy. ''Once in a while, when I have been sick with a cold or a sore throat, I have gone into a bodega to buy antibiotics,'' she said. ''I know a lot of people who when they are sick do the same thing. I take them until I feel better. When the cold goes away, I throw the pills away.''
Easy access to antibiotics is now common in certain areas around the nation, especially in border states. Dr. Richard Besser, director of the Campaign for Appropriate Antibiotic Use for the Centers for Disease Control and Prevention, said the sales at bodegas were only part of a much broader problem involving antibiotic overuse in America.
Many health officials are increasingly concerned. Antibiotics are prescribed only for bacterial infections. They are ineffective against viruses. Different antibiotics are used for different types of bacteria, so merely taking one does not mean it will cure an ailment. Taking the wrong antibiotic may cause worsened infections or allergic reactions.
Most antibiotics need to be taken for 7 to 14 days. When taken for only a few days, the likelihood of a mutation in a bacterium's genetic structure is increased. These changes can make the germs resistant to the antibiotics meant to kill them.
Unlike folk remedies, some of which may be toxic but pose a risk only to the person taking them, antibiotic misuse has far wider ramifications. For example, until recently, ampicillin was the drug of choice for infections of bacteria called streptococcus pneumoniae, a common causes of pneumonia and ear infections. But according to the C.D.C. about 35 percent of the strains of this germ across the nation are now resistant to ampicillin.
Dr. Stuart Levy, a microbiologist and the author of ''The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers,'' published this year, described antibiotics as societal drugs. ''Their use by an individual impacts others in the society because of the drug's ability to affect the bacteria in that community and to propagate resistant germs,'' he said.
''Over-the-counter antibiotics are more likely to be misused,'' he added, increasing the likelihood of resistance and the spread of resistant bacteria to others.
This problem often begins as a local phenomenon, he said, but the resistant germs spread as people move from place to place.
Dr. Jaime Lopez-Santini, a physician at Settlement Health, a nonprofit clinic in East Harlem, says his patients tell him they can get any antibiotic they want. ''By the time they come to see me with a sore throat,'' he said, ''they have already treated themselves with antibiotics they purchased at bodegas.''
Pharmacists like Orlando Cueva of Morningside Heights try to warn customers of the dangers of self-prescribed antibiotics, but often with poor results. ''Many people come in and ask for antibiotics, and I tell them that it requires a prescription from a doctor,'' he said. ''But they say: 'No, it doesn't. I can buy them at any bodega.' ''
An East Harlem pharmacist, Godette Wallace, said, ''You have to understand, these are very poor people, and they don't have the money to see a doctor.'' As a result, he added, they have to find other ways to get medicine.
Elissa Maas, vice president of community health for the California Medical Association Foundation, which researches health care for the state, said her agency had seen ''an antibiotic underground,'' extending from the Mexican border to northern California.
''In our focus groups, Chinese and Russian immigrants, as well as Latinos, spoke about the relative ease with which they can obtain antibiotics at small markets, even swap meets,'' Ms. Maas said.
In El Paso, Salvador Balcorta, who directs the Faith Family Health Center, a community health and human services organization, says that many people in the United States are just beginning to experience a phenomenon that is part of daily life on the border. ''When you couple the problems of poor access to health care and poverty with the ease of self-medication, you have a much bigger problem,'' Mr. Balcorta said.
Dr. Jeffrey Brosco, a pediatrician who sees many Cuban and Nicaraguan patients in Miami, said it was not enough to ask what medicines a child was taking or if he was taking home remedies.
''We also ask if the child is already taking antibiotics and, specifically, which antibiotic, and how frequently they are taken,'' Dr. Brosco said. ''Amoxicillin is the most common, but I have seen many others. All are self-prescribed and easily purchased.''
While the practice is illegal, it is extremely difficult to control. Dr. David A. Kessler, the former Food and Drug Administration commissioner, who is now dean of Yale Medical School, said: ''F.D.A. 101 tells us that this is illegal. No question. It is being sold illegally and shipped into this country in ways that don't comply with our laws.''
But practically, he added, the agency cannot go to every bodega, although it can go after the company that makes these antibiotics if they are involved in their distribution.
In New York, the sale of Ampitrex and other antibiotics without prescription goes largely unchecked. Spokesmen for the State Health Department, the New York City Health Department, the Drug Enforcement Administration, the State Board of Pharmacy and the State Education Department's Office of Professional Discipline all said that while they occasionally reported complaints to the state attorney general's office, they neither seized the antibiotics nor apprehended those selling them.
The New York City Police Department said it rarely, if ever, arrested people for the sale of antibiotics.
Dennis Murphy, a spokesman for the Customs Service, said seizing antibiotics at the borders was not a high priority.
Dennis Baker of the office for regulatory affairs of the F.D.A. said:
''Even when a local or state regulatory authority moves in to close down these operations, they tend to move to another location. It's very difficult to get our hands around this.''
No Prescription for Antibiotics? No Problem