As a physician in the Department of Intensive Care Medicine at Chi-Mei Medical Center, Dr. Che-kim Tan is nothing if not meticulous, doing everything in his power to save critically ill patients.

"Intensivist physicians are like guardians of the gates of hell. Oftentimes we only get one chance at saving a life," says the doctor, a man with the muscular physique of a rugby player.

But lately his confusion has grown as, despite their obvious youth and good chances for survival, some patients have been unable to outrun the Grim Reaper.

At first Dr. Tan chalked it up to the nature of illness, until one day when he happened upon a paper in an international medical journal that compared an original branded manufacturer's antibiotics against 23 generic products. The study found that, with the exception of one generic medicine that had the same ex vivo efficacy as the branded medicine, the other 23 medicines were only 60 to 90 percent as effective.

Among the medicines shown to have only 80 percent efficacy, two of them were vital weapons he frequently relied on to save patients' lives.

"Could that have been one of the reasons?" a shocked Dr. Tan wondered.

Though he was aware of the difficulty of proving that the efficacy of a single medicine was compromised or had any connection to whether his patients lived or died, the question still gnawed at him.

With a heavy heart, in an entry on his personal blog entitled "Please Give Intensivist Doctors Life-saving Weapons," he wrote the following: "With the constant downward adjustment of medicine prices by (Taiwan's) National Healthcare Insurance system, a considerable number of original pharmaceutical manufacturers have abandoned Taiwan, citing nonexistent profits. Meanwhile, those sticking around are taking action in response to the excessively low rates. So the question is, when the price of a pill is less than a piece of candy, how can we expect vendors to care about safety and quality?"

In his interview with CommonWealth, Dr. Tan stressed that he does not insist on using only drugs from branded original manufacturers, nor does he dismiss generic drugs out of hand, insisting, "I just care about being able to use good quality medicine."

Over the past year, in his dual capacity as an intensive care department physician and his hospital's director of patient safety, he has delivered a series of talks at a number of medical conventions. At them, he has encouraged doctors to inform hospital authorities and conduct further evaluations if they suspect that the clinical efficacy of drugs their hospitals have switched over to could be lacking.

"Doctors believe that the medicine they prescribe has the same efficacy as it says in the book. However, they are unaware just how many different brands are out there, as well as all of the business jostling that goes on before they get their hands on it, let alone the fact that there are differences in the quality of different drugs. That's scary!" exclaims Dr. Tan.

Cheaper in Taiwan than China

Taiwan's National Health Insurance system is world-renowned for its cost controls; from new drugs to old drugs, the cost of drugs in Taiwan is famously low.

Janice Chen, chief of the Center of Education of Comprehensive Drug Utilization at the Sun Yat-Sen Cancer Center in Taipei, has been a member of the NHI's Pharmaceutical Benefits Advisory Committee since the scheme's inception two decades ago. As such, she has long observed the artificially low prices for new drugs in Taiwan.

Her investigations have found that the approved pricing for new drugs under the NHI system is a fraction of what new drugs cost in the top 10 most advanced countries, greatly dampening the big global pharmaceutical companies' interest in introducing new drugs to Taiwan.

"Our new drugs reach the market here four or five years after the first country that gets them, and the situation appears to be worsening," says Professor Weng-Foung Huang of the Institute of Health and Welfare Policy at National Yang-Ming University.

And never mind the low prices; Taiwan even further slaps a ton of restrictions on the use of new drugs.

One of Professor Huang's Ph.D. students is writing a doctoral thesis comparing new drugs for preventing osteoporosis. Overseas, patients use the drugs as a preventative measure before they break their bones, whereas in Taiwan they only take it once they have suffered bone breakage – an absurd practice.

In addition, average annual outpatient visit drug costs in Taiwan are lower than the international trend, hitting US$322 (NT$10,000), which is around 70 percent of that of South Korea, less than half of that of Japan, and only one-third of U.S. prices.

One hematology and oncology doctor confided that when it came time to settle the bill of a Chinese cancer patient seeking out-of-pocket radiation therapy in Taiwan, the patient was astounded to find that the price for target drugs was only one-third of that in China.

"The patient said he didn't want to leave, and even asked if he could buy some drugs to take back with him to China," the oncology specialist said.

Tainted Dietary Oil Fears

Not only are high-end medicines relatively inexpensive in Taiwan, popular drugs also cost less per unit than a bottle of water or a chocolate bar, even going for less than one NT dollar (about three cents in U.S. dollar terms).

For instance, one tablet of the major international painkiller brand Panadol typically sells for NT$13.5, and members of the public must buy it at their own expense. However, in order to grab the market of hospitals and clinics using locally made analgesic pain relievers, some suppliers have slashed prices to less than NT$0.2 per tablet.

One physician admits that when he gets a cold, instead of using the Panadol tablet that he can get at his own hospital for just a few cents per dose, he prefers to head to a pharmacy and pay over 10 times higher the price for a brand he trusts.

At a meeting of the Legislative Yuan's Social Welfare and Environmental Hygiene Committee, Legislator Lin Shu-fen questioned whether pharmaceutical manufacturers could source inexpensive and sub-par raw materials because the price of drugs is too low to profit otherwise. Lin's line of questioning resulted in Food and Drug Administration Director-General Chiang Yu-mei promising to undertake an audit of low-cost drugs. When cheap is the rule, whether drug safety follows food safety and leads to the uncovering of a series of troublesome issues is a palpable fear hanging over the healthcare field.

"Will the healthcare field have its version of tainted cooking oil?" worries Jay C.J. Jeng, Director of the International Medical Service Center at Kaohsiung Medical University Hospital. Low drug prices could not only drive major international drug makers away and leave the Taiwanese public without decent drugs, he warns, it could even force drug makers to use substandard raw materials or cut corners.

Ten Times the Price

Low drug prices have resulted in medical suppliers ceasing manufacturing or no longer importing certain drugs, resulting in shortages, so that the NHIA has even been forced to pay more for some drugs, such as long-acting penicillin.

One doctor of infectious disease at a medical center in northern Taiwan relates that this drug is the first treatment option for syphilis, and is also used as a preventative drug for breast and cervical cancer patients to guard against cellulitis caused by post-operative lymphedema.

In the past, National Health Insurance paid NT$79 for a dose of penicillin, but medical suppliers stopped importing it after several rounds of price cuts by the NHIA, resulting in an island-wide shortage.

But patients still need medicine, and the NHIA eventually arranged a special order for suppliers to import penicillin at over 10 times the price, paying out NT$800 per dose.

"The Control Yuan should conduct an investigation!" the doctor says.

Moreover, the front-line penicillin shortage forced doctors to resort to treating patients with back-line antibiotics like cephalosporin. "Won't this raise the risk of bacterial resistance, so that a super bacterium could show up in Taiwan? What a crazy policy!" another doctor said, shaking his head.

Shortages Expected to Worsen

Taiwan's generic drug makers are also concerned about medicine shortages.

In an effort to institute drug regulation at the source, Taiwan's Food and Drug Administration has mandated that allopathic pharmaceuticals manufactured domestically must be produced from GMP-approved raw materials (the active ingredient used in manufacturing drugs).

However well-intentioned the policy may be, international GMP drug suppliers have recently hiked prices en masse, and with the prices the NHIA pays for medicine remaining low, some local pharmaceutical suppliers have given up on some drugs due to cost considerations.

"According to the prevailing ground rules, drug shortages will only continue to get worse, becoming a trend," relates Chi Sheng Chemical Corporation chairman Tung-mao Su.

Apart from the NHIA, hospitals have also been keeping a watchful eye on costs, aiding and abetting low drug prices. A seasoned observer of the pharmaceutical industry and former director of the Department of Health's Pharmaceutical Affairs Bureau, Professor Weng-foung Huang points out that Taiwan has never had a real pharmaceutical policy, only a drug pricing policy, which is like losing sight of the forest for the trees. "The Ministry of Health and Welfare, National Health Insurance Administration, medical community, and pharmaceutical industry are all in on it," he charges.

And patients' rights are being sacrificed.

Translated from the Chinese by David Toman