Sunday, 29 March 2015

Academic fraud in China: 43 medical studies retracted

by Michael Woodhead
Medical research fraud in China - the latest development is the discovery of widespread fake peer review. The open access publisher BioMedCentral has this week announced the retraction of 43 medical journal publications by Chinese researchers after it discovered widespread peer review fraud. Most of the articles were submitted by medical researchers at universities in China, including China Medical University, Sichuan University, Shandong University and Jiaotong University Medical School. A full list is given here.
Here's how fake peer review works: When a scientific paper is submitted for publication to an academic journal, the journal invites authors to suggest potential reviewers for their papers. The authors or their agents can then provide bogus names with e-mail addresses that go directly to them. They fill in their own peer review form, and bingo - satisfy the publisher's requirements, without actually having the article checked by an independent reviewer.  There's a full article on the topic in Nature.

According to Ivan Oransky's Retraction Watch, the BioMedCentral senior editor of scientific integrity Elizabeth Moylan said some of the fake peer reviews "appear to have been conducted by third-party agencies offering language-editing and submission assistance to authors. It is unclear whether the authors of the manuscripts involved were aware that the agencies were proposing fabricated reviewers on their behalf or whether authors proposed fabricated names directly themselves."

On BioMedCentral's blog, she wrote that "During the course of our investigation, authors have shared with us the names of third-party agencies that offer support to authors but also guarantee favourable peer review outcomes in return for a fee. Other services sell authorship on entire papers written by others. Clearly, there is a need to distinguish the characteristics of reputable third-party agencies from those that are dishonest (in much the same way that bona fide open access publishers can be distinguished from those that are predatory)."

To try combat the fake peer review scams, the publishers have deactivated the automatic "suggest peer reviewer" box in the submission forms. Authors will now have to suggest peer reviewers in their covering letter, and provide verifiable email addresses for their institutions. Other journal editors say this is too lenient, and that authors should not be allowed to suggest peer reviewers at all.

The publishers are at pains to suggest this is not just a China problem. Other incidents of fake peer review have been reported recently from other countries, including South Korea and Taiwan (the latter even resulted in the resignation of a government minister whose name had been cited as a co-author on several of the fraudulent publications).

As the BMC publishers point out, peer review is based on trust, and there is only so much that can be done to prevent deliberate fraud. One of the key factors driving the fake peer review in China is the need for Chinese doctors to publish a quota of papers each year in order to retain their posts and qualify for promotion. It is literally publish or perish, career-wise. I've previously blogged about China's  publish-for-promotion system for doctors and the scams it encourages, including the use of agencies and ghostwriters to generate scientific papers. This latest development seems to suggest that there are now ghost reviewers too.

Tuesday, 24 March 2015

Psychiatry in China: ask a few questions, give a lot of pills

by Michael Woodhead

The neglected state of psychiatry in China is highlighted in an article published by Xinhua this week. In essence the article says that psychiatrists are overworked, underpaid and undertrained - and thus seldom have the time or inclination to provide any kind of talk therapy to patients with mental health or psychological problems. Just drugs.

According to the article, the typical psychiatric consultation involves filling in a form that consists of a few questions such as "Do you have trouble sleeping at night?" and "Do you think life has little meaning?" After reviewing the answers to the form, the doctor then hands over a bag of pills - or a prescription  - with little dialogue or questioning between doctor and patient. According to one young woman who sought help for nightmares and severe stress, the process made her think of the doctor as more of a pharmacy clerk than a psychiatrist.

The article then compares the cost of seeing a psychiatrist at a public hospital - about 50 yuan for 10-20 minutes, with the 1000 yuan fee for a similar consultation with a 'counsellor' in a private clinic. One psychiatrist said that psychiatry was a low priority for most hospitals because unlike 'procedural' branches of medicine there was very little profit to be made from seeing patients. He said some irresponsible doctors tried to increase their income by seeing as many as 30 patients in one morning and providing many kinds of expensive psychotropic drug  - all encouraged by pharmaceutical companies as part of the biomedical model of psychiatry. However, many patients said they wanted more time to talk with a doctor and discuss their problems in more depth. To do this, a doctor could not see more than 10 patients in one shift - but this is just not viable for public hospital psychiatric clinics.

Another psychiatrist told Xinhua that China had a mental illness rate of about 17% - which meant there would be 173 million people requiring psychiatric treatment. However, China has only about 10,000 qualified psychiatrists, which is far too few to manage this number of patients. The shortage of psychiatrists is especially bad in rural areas.

Experts said that typically a psychiatric patient might need at least four sessions of psychological treatment lasting one hour each. However this was not possible when hospitals could only charge 30-50 yuan per doctor visit. Therefore, some patients turn to private clinics which charge 500-1000 yuan for a single consultation, even though some of these are run by unqualified practitioners and offer unscientific therapies.

Patients often required non-drug therapies such as psychotherapy or even physical therapy, but these were not profitable for state-owned hospitals, the expert said. According to analysts, psychiatric clinics in China are underfunded and there are far too few psychiatrists and psychologists. The answer, they say, is to encourage the investment with 'social capital' (ie private business and corporations) and also to increase the awarenes of mental health problems and their treatment in China

Sunday, 22 March 2015

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.

And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

Sunday, 15 March 2015

When it comes to health, for China the numbers are staggering

by Michael Woodhead
In western countries hardly a week goes by without some disease condition being put in the spotlight in a press release saying "Condition X affects Y million people a year and costs Z million dollars". 
If industry has a stake in the matter then this is usually followed by a statement saying that the Condition X is underdiagnosed and undertreated and if only we used Drug A or Test B then we would avoid prevent much suffering and save the health budget in the the long run.
This sort of thing is now happening with health conditions in China, except the numbers are bigger by a factor of ten or even a hundred. Take osteoporosis, for example. An analysis published this week shows that there are about 2.3 million osteoporotic fractures a year in China, costing $10 billion in health costs. And if you think that's bad, wait until you see their projection for 2050 - the researchers estimate that with the ageing population there will be 6 million fractures a year costing $25 billion. And as predicted, the report's authors say that "screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget."

A similar dire warning was made this week for hypertension and diabetes in China. An article in the Journal of the American College of Cardiology said that China was facing a cardiovascular disease epidemic as three out of four Chinese people are in poor cardiovascular shape due unhealthy eating, smoking and obesity. On a similar note, a study from Shenyang showed that 50% of older adults had hypertension and poor cholesterol levels. And a report in The Lancet this week shows that China has 300 million smokers and that tobacco causes 1 million premature deaths a year. The numbers are so big they are incomprehensible. And yet at least the Lancet offers a workable solution: cigarette taxes. It says that if cigarette taxes were raised by 50% this would result in 231 million years of life gained over 50 years and also produce an additional US$703 billion in extra tax revenues from the excise tax. The overall effect would be to relieve financial burden on the poor by avoiding diseases such as lung cancer and the consequent medical bills and time off work. But does Xi Jinping have the gumption to increase cigarette taxes?

For yet another set of mind boggling numbers turn to the example of cervical cancer. With no Pap test screening program, tens of thousands of Chinese women develop this disease and die of it each year, even though it is preventable. Western countries have long had screening programs and are now tackling cervical cancer with the HPV vaccine for young women. Some health economists have crunched the numbers for China and estimated that a national vaccination program of HPV vaccine for 9-15 year old girls, between 2006 and 2012 would have prevented 381,000 cervical cancer cases and 212,000 related deaths. They say that a HPV vaccination program could be implemented in China at a cost of about $50 per girl for the whole set of vaccinations and program costs. In total this would cost China about $160 million, but would ultimately prevent hundreds of thousands of deaths from cervical cancer - and also be cost effective.

A final example: stomach cancer. This causes  hundreds of thousands of deaths in China every year. And yet researchers have found that regular use of low dose aspirin could reduce the risk of stomach cancer (and other common cancers such as colorectal cancer) by as much as 40%. In other words, if Chinese people took a regular dose of aspirin they could avoid many fatal cancers, not to mention the protective cardiovascular benefits against stroke and heart attack. Whether these would be outweihed by increased bleeding risk remains to be seen.

I think what I am trying to say here is that when it comes to ill health in China, the numbers are often too large to be imagined. But that also means that measures that produce only modest reductions in rates of disease can also have major impacts on the absolute numbers of illness.

And while talking of high rates, let's return to my favourite bugbear about healthcare in China - the infusion. I have been guilty in the past of blaming backward thinking among the Chinese masses for insisting on having an infusion for every ailment. I hope I haven't hurt the feelings of the Chinese people and perhaps I owe them an apology. A study from a bog standard Hubei hospital shows that a staggering 96% of antibiotics used in the hospital wee given parenterally (ie by injection or infusion rather than orally). The authors of the report contrast this with the rates of about 30% of IV antibiotic use seen in European hospitals.

However, they blame the profit motive among hospital managers for the widespread use of antibiotic infusions - noting that hospitals depend on drug sales for a major part of their income. Therefore it will be interesting to see what happens when the Chinese government tries to eliminate this source of income for hospital by introducing cost price pharmaceutical billing this year (ie not charging a markup).  How will hospitals  fund their services? The government only covers about 20% of their running costs. There are already predictions that costs will be shifted to medical procedures - and trigger even more overservicing.

At least there is some discussion taking place of these kinds of problems and some in the government are acknowledging that there is still a long way to go in health reform. This week a very frank and bleak account of the ills of rural Chinese health system was published. Doctors and hospital managers said quite bluntly that the rural healthcare system in China is being hollowed out - older doctors are retiring, and nobody is taking their place. Young doctors do not want to work in rural hospitals, partly because the ban on commissions from pharmaceuticals means they can make only a tiny income. And patients do not want to be treated in them. And so the county and township hospitals are becoming ghost hospitals - deserted compared to the overcrowded city hospitals, where rural Chinese flock when they have a serious health problem.

Fact of the week: Chinese primary care (community health centre) doctors earn only 3000-4000 yuan a month. Primary care doctors account for only 4% of doctors in China.

Sunday, 8 March 2015

CPPCC - what they're saying about health

It's that time of the year again - the Chinese People’s Political Consultative Conference (CPPCC). The toothless talking shop cum fancy dress parade as deputies from around China meet to chinwag and talk up the government's policies. It's an occasionally interesting forum - some grievances are allowed to be aired, but usually only to justify measures that are already being taken.
There has been quite a bit of talk about healthcare this year. Most of the problems discussed are ones that have been given a regular airing on this blog: doctors' income linked to overservicing, excessive workload of doctors and the issue of publish for promotion. On the last point, Prime minister Li Keqiang attended one meeting that heard about the problem of junior doctors having to publish academic papers in order to qualify for promotion. He was told that more than a quarter of doctors had their articles written for them by ghostwriters and agencies. The PM said this was a bad situation and doctor's should be rated on their practical skills, not writing skills.

Our old friend Professor Zhong Nanshan made an appearance at one People's Conference, at which he re-stated his concerns about doctors' pay being linked to sales of drugs and number of procedures and devices provided. He cited the case of one cardiologist who implanted several expensive cardiac stents for a patients who was not even seriously ill. Zhong Nanshan said the problem of doctors' ethic arose because up to 80% of their income was tied to hospital profits. This meant doctors were given quotas to meet and the 'profit-driven' mentality meant that hospitals were more like department stores than public health facilities, he said. Zhong Nanshan said that to end the problem of overservicing there was a need to de-link doctors' incomes from prescribing and servicing levels. Doctors should be paid a higher basic salary that reflected their worth, he said - and he stressed this did not mean a return to the 'iron rice bowl' mentality.

The problems caused by pharmaceutical commission were highlighted this week by the news that GSK is to sack 110 of its employees in China in the wake of last year's massive bribery scandal that resulted in the company being fined  $450 million. The widespread use of bribes, commissions and backhanders caused a lot of pain for the multinational pharma company when exposed. The staff who have lost their jobs may well be scapegoats. The man at the top, CEO Andrew Whitty, kept his job but had his salary package halved to a measly $6 million. Whitty said  “substantial changes” had been made at GSK China, including training for managers in anti-bribery and corruption practices.

Other 'unhealthy tendencies' raised at the CPPCC include the hospital VIP suites reserved for officials and local bigwigs. Professor Huang Zemin of East China Normal University said hospitals had two different worlds, with the VIP outpatient wards reserved for officials being quiet and luxurious whereas the outpatient room for the general public was crowded and noisy. A fair point, but the VIP suites have already been slated for abolition, so he's hardly breaking new ground there.

And also from the CPPCC, a cry for help from the paediatricians.  One of the country's top paediatricians, Professor Shu Xiaomei, told the CPPCC that there was a crisis in paediatrics as very few doctors go into this branch of medicine in China. The reasons are that paediatricians earn very little compared to other doctors, again because they don't prescribe so many drugs or do many procedures). Another reason for the unpopularity of paediatrics is the high workload and the huge pressure from pushy parents - often leading to violence when things go wrong. Professor Shu said there was also no formal training program for paediatrics, unlike other specialties and therefore the speciality was a 'tree without roots'.

The workforce theme was raised by another delegate at the CPPCC, who said that China simply does not have enough qualified doctors to do everything that the public expected of them. His succinct appraisal was that "without more doctors, all discussion about health reforms is empty talk. "
Other CPPCC delegates said that the push to create a primary care system based around community clinics was commendable but facing the major problem of neither doctors nor patients wanting to go anywhere near primary health clinics. Dr Zhao Ping, of the Chinese Academy of Medical Sciences, said patients did not go to local clinics because they had poor equipment and poorly trained staff and could not refer to the best specialists.
"People don't trust these clinics and hospitals. The thing is, people want to go to better and larger hospitals, and so do healthcare workers. We don't have a mechanism in-place to keep our best healthcare workers at community clinics," he said.

But it's not just the CPPCC, here are some other major medical news stories from China this week:

  • Two doctors in their 20s have died suddenly of 'overwork' in the last few weeks, prompting some doctors to say that the pressure of work is too high.

Sunday, 1 March 2015

A violent week for attacks on medical staff in China: My weekly blog of medical news from China

by Michael Woodhead
Who would be a doctor in China? There's something about Chinese New Year that makes people a bit more bonkers than the rest of the year. Maybe it's the social pressure, the expectation - who knows. But this week has seen an unprecedented number of attacks on medical staff in China. First there was the "hostage siege" at a Henan hospital at which doctors were bailed up by patients and forced to drink urine. The incident occurred after doctors failed to save the life of a drunk man who had killed himself by drinking insecticide. The man's relatives became angry when he died and accused emergency department staff of not doing enough to save him. The staff said they did all they could but he was already beyond help when brought in. The family became enraged and summoned more people to blockade the hospital entrance. They then barricaded the doctors in their office and tried to force them to drink urine. The situation was only defused when riot police arrived.
Sometimes violence is more random. At a Jiangsu hospital a cardiologist was attacked suddenly by the son of an 82-year old woman who died. The man became angry when requesting a death certificate, grabbed the doctor's stethoscope and used it to hit the doctor on the head, causing a major wound that bled. Police are investigating.
And in another similar incident in Hubei, a young female doctor had her skull fractured (see picture) when she was attacked by relatives of a women who died of a heart attack. Witnesses say the female doctor had been trying to resuscitate the women but was unsuccessful. She had not even taken her gloves off when she was attacked by a male relative of the dead women who hit her so hard it fractured her skull around the eye.
And finally in Hangzhou a female psychiatrist was stabbed by a 16 year old patient at the city's Jingdu hospital. The doctor is in a stable condition, and there is no stated reason for the attack.
And even if the patients don't physically attack you, thy may take to the courts instead. This week there was a report of a female obstetrician who is facing a three year jail sentence for manslaughter after being prosecuted over the death of a baby during childbirth. However, colleagues of the doctor say she is being made a scapegoat and there should be no criminal case made against doctors in medical situations such as this.

In other news head lines ...

Chinese doctors don't read English medical journals
A survey of 910 doctors in from teaching hospitals found that two thirds only read medical journals in Chinese. Only 44% were aware of major English-language journals in their speciality and  17% said they had never read a single English paper or textbook in English.

Hospitals banned from buying expensive drugs for commission
In an attempt to cut down on pharmaceutical corruption and bribery, China's hospitals  have been told they must buy their drugs only from approved pharma companies and wholesalers. The move is intended to cut out the system of commissions and kickbacks that currently exists, and which encourages hospitals to buy and use more expensive drugs.

Hangzhou eliminates hepatitis B with vaccination
Health authorities in Hangzhou have achieved dramatic reductions in hepatitis B thanks to a long term vaccination campaign. In a comparison with 1990 a recent survey found that the hepatitis B incidence and mortality of Hangzhou had declined dramatically since the introduction of universal childhood vaccination against the infection.

Alarm over resistant tuberculosis
Rates of drug resistant tuberculosis are "alarmingly high" according to researchers from Beijing. A study by the China CDC of Mycobacterium tuberculosis strains from children and teens between  2005 and 2012 found that  levels of drug resistance and multi-drug resistance (MDR) rates were 55% and 22%  respectively. In children with multi-drug resistance, new cases accounted for 41.

Sunday, 22 February 2015

Gong Xi Fa Cai! Medical news in the Year of the Sheep

Chinese New Year is upon us, with businesses closing up for a long holiday and most Chinese families looking forward to a reunion. But of course people still get sick at Spring Festival and the Chinese media has been full of stories praising the heroic and dedicated doctors and nurses who forego the holiday and put duty ahead of family to stay at work.  There are stories of doctors working solo for 24 hours to keep up with all the demand during the Spring Festival. From Hubei there is the story of the man bitten by his rabid pet dog who went to the hospital and was hugely relieved to find that the infectious diseases doctor was on duty to give him a rabies injection. At Fuzhou Hospital on New Years Eve the medical and nursing staff gather together to have the "big family banquet" that they would normally have with their families at home.  And there is even a story of the doctor at a Zhejiang leper colony who was urged by his ailing patients to go home and see his family rather than spend New Year on duty at the sanatorium.

Not all doctors have been heaped with praise at Chinese New Year, however. In Guangzhou there has been an uproar among the medical community after the city authorities sent anti-corruption teams in to raid hospitals just before Spring Festival. The city disciplinary affairs committee said the inspection teams were looking for evidence of bribes and 'hongbao' (red envelopes) given by patients to doctors. The raids have so far turned up little evidence of bribery, and doctors have been indignant at being suspected of corruption. They objected to having their everyday items such as snacks being documented - and also being questioned in detail about the origin of their possessions - and even for receipts for goods. Doctors said the actions of the inspectors went beyond their powers and the actions should have been a matter for the police. One doctor said a public hospital was not a place where bribes could be openly given or solicited among colleagues - and he was also indignant that many doctors had prepared hongbao or gifts for their families which were assumed by inspectors to be bribes from patients.

Chinese New Year is also a peak risk time for influenza in China. In Guangdong it has been reported there have been 53 cases and 13 deaths from  H7N9 avian influenza. In neighbouring Hong Kong there has also been a very severe flu season caused by the regular influenza H3N2 strain which has been causing as many as 18 deaths per day in the city. There have been reports of shortages of antivirals such as Tamiflu in Hong Kong, and the flu vaccine this year has been ineffective because the H3N2 strain of flu is a new mutation that is not covered by the vaccine. Of course influenza does not stop at the border, so we can only assume that the flu toll has been equally high in mainland China.

Another major infectious disease under the microscope this week is the recent outbreak of measles  affecting more than 1200 people in Beijing. Infectious disease specialists in the capital found that most of the cases originated in wholesale clothing markets popular with  locals and international visitors - so an MMR vaccination might be a pre-requisite if you are going to the Silk Market. The analysis found that many of the cases occurred in migrant workers who (unlike Beijing residents and tourists) had low levels of measles vaccination. The researchers recommended that outreach services be set up to vaccinate migrant workers in Beijing and "the offer of measles vaccine to workers as they register to live and work in the commodity markets might be a reasonable strategy to prevent future measles outbreaks."

In other news this week - the high demand for blood products in China is driving  a thriving black market in organised gangs of donors, organised by the so-called "blood heads" who are paid thousands of RMB for supplying blood. In the field of diabetes, some Chinese endocrinologists have been blasted in the pages of the Lancet for writing a review article that recommended the use of expensive new drugs as first line treatment for diabetes. Their critics say the endocrinologists failed to mention the more effective and cheaper drugs such as metformin - and the Chinese doctors also failed to mention their financial conflicts of interest with the Big Pharma makers of the expensive new drugs.

And finally, the quality of medical education in China has been questioned in several articles published this week. The Year of the Sheep is a milestone for China's medical educators in that they are now requiring a standard 5+3 medical degree + internship program be implemented nationally. However, some commentators have said that the new system will be no better than the current haphazard postgraduate 'Masters' programs if medical graduates receive insufficient clinical experience and supervision. They also say that the internship scheme should include 'exit examinations' to ensure that trainees have actually acquired the specialist skills they have trained in. Coincidentally this week Shanghai media report that trainee doctors get little experience in anatomy because there is a national shortage of donated cadavers. Chinese culture prohibits citizens from 'donating their bodies to science' as is done in the west. This means that Chinese medical graduates get all their anatomy learning from textbooks and have very little "hands on" experience. This is worrying for students going into specialties such as surgery - as they may never have practiced techniques such as cervical spine surgery before being asked to do the real thing. Not surprising then that a special anatomy cadaver training class at Shanghai's Fudan University was heavily oversubscribed.


Sunday, 15 February 2015

Research fraud and inappropriate treatment: my blog about medical news from China for Sunday 15 February.

Last week I blogged about how so many medical journal articles in China are simply "vanity publications", written by ghostwriters to satisfy the doctor's need to achieve a quota of published articles. However, this week we see that there are also major problems with 'serious' research clinical trials carried out in China. An article in JAMA this week by Charles Seife reveals that the FDA found serious problems with the Chinese clinical trials of apixaban, a novel anticoagulant.
 At one site the FDA concluded that patient records had been altered. When they investigated further the FDA inspectors declared that data from 23 other Chinese clinical trial sites was suspect and should be excluded from their evaluation of apixaban (Eliquis). We often hear that western pharma companies are shifting their R&D from the US and Europe to China. It may be cheaper but with reports like this you have to wonder if it is worth it in the long run.

China is also trying to make a name for itself in high tech areas such as stem cell transplantation. An announcement in the Shanghai media said the city was to build the world's largest hospital for 'blood diseases'. This seems to be a reference to  hematopoietic stem cell transplant procedures for patients with blood diseases such as leukaemia. This is a highly specialised and expensive form of treatment for a small niche of patients (and often of limited benefit), so it is odd that a city that can't even meet demand in its emergency departments  is pushing ahead with a hospital for rare diseases. perhaps the explanation is that the project is being run by the China Stem Cell Group Co Ltd. This may be more about making profits than providing needed health facilities.

China's love of high tech for its own sake is  also manifest in the move by a Guangdong hospital to set up 1000 telehealth stations in pharmacies to provide online consults. The move by the Second People's Hospital of Guangdong to set up the Guangdong Online Hospital will reportedly include 200 doctors providing services via videolink. All sounds very modern, but how exactly does a doctor do a physical exam, order tests and imaging and provide 'hands on' care over a video link? It might be of limited value in follow up counselling consultations and for repeat prescriptions, but it sounds like a gimmick to me.

Online hospitals are supposed to help address the problem of overcrowded hospitals. I'm not sure how they will help the cancer patients who need a bed but can't get one. In places such as Changsha in Hunan the hospital bed shortages are so acute that patients have to make do with 'cancer hotels' instead. Patients with cancer who require treatment but who are on the waiting list pay 1100 yuan a month to stay in hotels adjacent to the cancer hospitals so they can go into outpatients for treatment. Locals say that about half the hotels near the hospital are occupied by patients, who face 1-2 month waits for a bed.

Breast cancer is an increasing concern in China, but rates are still not as high as in the west, perhaps due to dietary and lifestyle factors. Screening for breast cancer is also not part of the Chinese health system, although there has been some use of mammography. However ultrasound has been favoured by some Chinese clinicians, reportedly because it is more suitable to the smaller and more dense breast tissue of Chinese women. Now a study has confirmed that ultrasound is a more effective screening method for breast cancer in Chinese women. A study of more than 12,500 women who underwent either or both found that of the 30 cancers detected, five were in the mammography group and 11 in the ultrasound group, and 14  in the combined group. Ultrasound was more sensitive had the same specificity and positive predictive value as mammography. It was also considerably cheaper, costing $7876 to detect one cancer compared to $45253 for mammography.

In other clinical news, metabolic syndrome (a highly dangerous combination of abnormal cholesterol, high blood pressure and pre-diabetes) was found to occur in 27% of Chinese people. A study of 15,477people in NE China found that 28% of men and 26% of women had metabolic syndrome. The condition was more common in Chinese on high incomes, those who ate more rice and those who did less physical activity - in other words, 'to get rich is glorious' but it also comes at a price of this disease of affluence. 

However, Chinese people might be forgiven for thinking twice about going for a jog, given the terrible air pollution in many cities. This has now been confirmed by Dr Liu Yu of the Key Laboratory of Exercise and Health Sciences at Shanghai University of Sport. This week he published an article in the BMJ which warned that the harms of ambient air pollution on the cardiovascular and respiratory systems might outweigh the benefits of exercise. He estimated that air pollution probably caused more than a thousand deaths a year in the city.

It's not all bad news from China, though. A paper published by the WHO this week shows that Chinese healthcare workers have had great success in reducing deaths from HIV using a simple 50c antibiotic, co-trimoxazole. Their study showed that giving the antibiotic at the same time as antiretroviral reduced HIV deaths by 37% - a staggering achievement. If routinely use in China for HIV patients  this could save thousands of lives among HIV positive people, the researchers sai.d Unfortunately, however, antibiotic use if often missed in this patient group.

Sunday, 8 February 2015

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

Sunday, 1 February 2015

My weekly news blog for 1 Feb

The medical news in China has been dominated this week by the death of a doctor at a Luoyang hospital after a brawl with a drunken patient. Both fell down a lift shaft and were killed. It's just the latest in a long line of violent incidents against medical staff. Each time one occurs there are protest by staff, stern editorials in the media and vows to crack down on such incidents. There have even been gimmicks, including plans to have 'volunteers' or police patrols in hospitals to defend doctors from violence and defuse violent situations And yet still they continue. I can't understand why Chinese hospital don't have 'crash' alarms like they do in western countries, that trigger lockdowns and mutual protection protocols.

On a more positive note, Chinese drug makers have registered the world's first Sabin-inactivated poliovirus vaccine (S-IPV). The vaccine, developed by the Chinese Academy of Medical Sciences is being produced by the Institute of Medical Biology within the Kunming Hi-Tech Zone. It is said to be more effective than the current oral polio vaccine and also inexpensive.

Such a vaccine may have a role in remote parts of China such as Xinjiang, which recently reported an outbreak of polio. After more than a decade being polio free, in 2011 there were 23 polio cases reported, 55% of which were in young adults.  The polio was presumably brought in from the neighbouring Muslim state of Pakistan, where polio has not been eradicated due to the Taliban.

Another first for China this week was the first patient to be treated - and survived - a new H5N6 strain of avian influenza. The patient treated by well-known specialist Dr Zhong Nanshan at Guangzhou hospital after contracting the infection from - guess where - a live poultry market (why don't they just shut them down for good?). Dr Zhong said this was the second patient to contract the dangerous infection - the first one died. he said the second patient had been treated with high doses of antivirals and was in a stable condition. China is also struggling with a winter outbreak of H7N9 avian flu, with 30 cases so far around Guangdong.

In the healthcare reforms, some healthcare managers have said that hospital reforms should focus on the model of funding, and switch to an 'activity based funding' system to reward outcomes. At a meeting of the Beijing Chinese Peoples Consultative Committee they said that the funding system based on "diagnosis-related groups" (DRG)  would "break the link between doctors' incomes and prescriptions, thereby preventing excessive medical treatments and over-prescription of drugs." Hospital managers complained that they were underfunded because fees had been fixed at low prices set in 1999 whereas costs (and incomes) had risen considerably since then.

Well, fees may be too low according to hospital managers, but some patients still can't afford them. A woman has made news in Kunming by dressing up in a wedding gown and offering herself for marriage to any man who will pay her brother's medical fees. Her brother has leukaemia and she says he needs 300,000 yuan for treatment. China is supposed to have a public health fund for people with catastrophic illness, but it obviously hasn't trickled don to this young man.

Monday, 26 January 2015

My January news blog ...

Regrettably, I am cutting back on my blogging about China medical news this year. I've been doing this for more than a year now, out of enthusiasm and my own personal interest in the area, but it's becoming too much of a burden on my time. And of course it is all unpaid. Unless there is a sponsor out there who wishes a regular stream of China medical news? After my day job doing much the same thing about Australian medical news I find it hard to sit down at home and do the writing for this blog. So from now on I shall probably only update the site about once a week. That is not enough to cover the many things happening in healthcare in China, but that's your lot. As they say in Yorkshire, you don't get owt for nowt.

This week I have been reading about how patients in Shanghai with chronic diseases will now be able to pick up their repeat prescriptions from community clinics instead of the big hospitals. It's a move intended to relieve the overcrowding at the tertiary hospitals and sounds like an obvious and sensible idea. Whether it will work or not depends on whether China's hospital-obsessed patients can be persuaded to show up at the low-status community clinics.

There are also moves to try curb China's high levels (approaching 50%) of caesarean section intervention in pregnancy. A feature article by Yang Wanli describes how some obstetricians in China are trying to persuade women to opt for natural birth. However, the barriers are a lack of available analgesia for women in labour and the industrial production-line mentality of China's hospitals.

Rural health is a major issue in China this month, with the State Council approving a plan to boost the rural medical workforce. The Council wants to see rural areas of China have qualified doctors replace the current 'barefoot' practitioners. However, well-meaning intentions will not fix the huge rural medical workforce problem in China. The simple problem is that university qualified doctors do not want to work in rural villages. The pay is pathetic, there is no status and the workload is high. As this article shows, the current rural medical workforce is mostly unqualified and often dangerously lacking in skills.

That's not to say that rural health is completely hopeless in China. There have been great achievements in some areas of public health such as immunisation and basic child health. However, as a major article by Chinese paediatricians the Archives of Diseases in Childhood shows, the next step for China is to try reduce the incidence of more complex diseases in children. China has done well in tackling the easily preventable causes of child disease, now it must turn its attention to the difficult stuff - the consequences of preterm birth, and the many congenital and metabolic diseases.

One problem with monitoring China's progress in child health is knowing whether or not the official  figures are true. Take measles vaccination for example. According to official reports, China has 95% measles vaccine coverage of infants. But when researchers analysed the causes of measles outbreaks in Hunan and Jiangsu that affected hundreds of children they found that the actual rates of measles immunisation more like 80%.

And finally, for those who put their faith in western healthcare companies helping improve the health of China, take a cautionary look at the sorry tale of GSK. A well regarded company in the west, GSK was the subject of high profile bribery allegations and a court case that jailed one of its British executives for  his role in the bribes to doctors and hospitals. Now the company is reported to be cutting the jobs of 1000 employees in China following the downturn in its business there (including a 60% drop in revenue).

Tuesday, 13 January 2015

Lost post

I just spent an hour writing a great article about the Chinese government's moves to encourage public hospital doctors to work in private practice. But my internet browser crashed and I lost it.

Short version: there is little enthusiasm for this move by doctors because of the practical barriers: pensions, medical indemnity insurance and new contracts on working hours/remuneration. Also barriers because public hospitals don't want to lose their 'talent' and see the same doctors working in 'competition' against them (not to mention the conflict of interest this creates). And importantly for doctors, their careers are determined by the public hospital system, from which they get their experience, evaluations, academic training and status.

Conclusion: Moving to more flexible public/private working arrangements in healthcare is an immense challenge for China and won't happen overnight.

Monday, 12 January 2015

Fertility clinics drive thriving black market in eggs

Young Chinese women are risking their fertility by selling off their eggs to unscrupulous fertiliy clinics, a CCTV program has claimed.

As part of an investigation into the "human egg black market" CCTV found that high school students and university students were selling their eggs to agents for a few thousand yuan. The clinics then offer these eggs to infertile women who pay 30,000- 100,000 yuan (US$5000-$15,000).

The report said young girls were picked because of their looks, education and health and had to endure a series of injections with fertility hormones to stimulate ovulation so their eggs could be harvested by clinics. The young women said they used the cash to pay off credit card debts, but most were unaware of the serious risks of the procedures, including infertility.

Commentators said the commercial transactions of human eggs were illegal and banned, but there was little enforcement of the rules in practice. They said illegal clinics and the doctors who worked in them made large amounts of money, offering infertile women the chance to select a donor egg based on looks, intelligence and other personal characteristics of the donor. Despite being illegal, the egg black market was a thriving market and barely concealed  with advertisements by agents common on the internet.

The report said the fertility agents and their networks also offered infertile women other services such as surrogate mothers, as part of packages that could cost as much as 400,000 yuan.The trade was very lucrative and many young women saw nothing ethically wrong with what they were doing, it said.
The commentators said there was a need for a widespread crackdown to enforce the regulations on artificial reproductive technology. There was also a need to better regulate reproductive clinics and promote legitimate egg donation rather than the commercial practices, they added.

Sunday, 11 January 2015

Statin therapy has disappointing results in Chinese patients

by Michael Woodhead
Only about one in four Chinese patients taking a statin have their cholesterol levels under control, according to a new study.

A review of the effects of statin therapy in 8965 outpatients with cardiovascular disease from 200 clinical departments of 122 hospitals across China found that about 75% of patients still had poorly controlled lipid levels.

The findings, published in the International Journal of Cardiology showed that despite taking long term statin therapy in medium to high doses, about 75% of patients had an above-target LDL-cholesterol level. In a similar manner elevated levels of total cholesterol and triglycerides as well as low HDL-cholesterol persisted in 34–43% of patients despite statin therapy, according to Professor Wei Yidong and colleagues at the Department of Cardiology, Shanghai Tenth People’s Hospital and Tongji University School of Medicine.

Only about 10% of patients overall had optimal levels of all lipid measures (LDL, HDL and triglycerides) despite taking statins. Patients with diabetes had slightly better control of lipid levels (43%) compared to those without diabetes (39%).

The study authors said it was not clear why patients taking statins did not have good control of their lipid levels. Oddly, there appeared to be no relationship between the potency of the statin doses and the degree of lipid level control.

About 77% of patients taking low doses of statins had LDL-C not at goal, compared to 72% of patients taking medium potency regimens and 74% of patients taking high potency courses of statins.
Chinese patients may need more intensive lipid-lowering therapy with additional agents other than statins, to improve their lipid levels. Patients may also need more attention on lifestyle factors such as diet and exercise before starting statin therapy, they added.

However, they could not rule out poor adherence to treatment a a possible cause of the poor lipid control.