Sunday, 26 April 2015

Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?


In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

Monday, 20 April 2015

Are Chinese hospitals safe? Fear of blame and shame is common, but the overall safety climate is good


China may not have as many ambulance-chasing lawyers as the US, but healthcare staff live in fear of making mistakes because of a culture of blame and shame. Not so much "Better Call Saul" as "Better Keep Quiet".

While in the west there is now an attempt to make healthcare staff be more open and transparent in reporting medical mistakes, it seems like China has a long way to go in overcoming cultural barriers to admitting to errors. In a survey of 1272 healthcare staff at Shanghai hospitals, researchers found that there was a high level of fear of being blamed and fear of being subject to shame. Almost three quarters of staff said they would be disciplined if found making a mistake and 42% thought that asking for help was a sign of incompetence. A similar proportion of staff - 42% - thought that telling others about mistakes was embarrassing, and 40% of thought that it was better to not report errors in the hope that nobody would notice the mistake.

Worryingly, work pressure was also a major factor in mistakes - and covering them up - with about 60% of staff saying that with higher workloads, management forced them to work faster and taking shortcuts that might negatively affect patient safety. About 40% of hospital staff said they had witnessed a coworker do something that appeared to be unsafe in patient care in the last year and one in three staff admitted they had done something that was unsafe for patient car.

The fear of blame and shame phenomenon appears to be an Asian and Chinese concept. The 40-70% levels of 'blame and shame' fears seen in the study were much higher than the 5% rates seen in U.S. hospitals. As the authors note:

"Chinese society tends to be more collective than the Western society, which is called “familial collectivism” People admitting mistakes do not only embarrass themselves but also embarrass the team. Thus, [healthcare] workers may be reluctant to admit to making mistakes in China."

Interestingly, doctors had the highest levels of  “fear of shame” and the researchers said this chimed with the finding that Chinese doctors do not believe that “human error is inevitable”,  - in other words, Chinese doctors feel they must act like gods and be seen to be infallible - whereas admitting a mistake would be a sign of incompetence. This is consistent with “fear of shame” being particularly high among physicians. The Confucian ethic was also seen in the high levels of fear about reporting mistakes made by more senior staff that endanger patient safety.

Nevertheless, the overall safety climate in hospitals was no worse than that seen in the US, with 15% of staff giving 'problematic' responses to safety questions. As the authors said, Chinese healthcare workers are only likely to report mistakes and safety issue when they feel psychologically safe and do not have to fear being blamed and shamed.

The findings are published in BioMed Central.

Sunday, 19 April 2015

Alibaba Health, iKang, Online consultations, Tobacco advertising ban, Antibiotics in food, HIV discrimination


Hello and welcome to another week of China Healthcare. As China makes headlines around the world for its slowing economy, few have remarked that China's entrepreneurs are taking a different and more rosy view by re-focusing on healthcare. This week the Alibaba internet billionaire Jack Ma has issued a $2.5 billion vote of confidence in the prospect for online pharmacy in China by transferring his pharmacy e-commerce section to Alibaba Health ("Ali Jiankan" or  According to the WSJ, "Alibaba said the deal would position it to sell prescription pharmaceuticals should China’s reforms allow retailers to move in that direction".

At the same time, Forbes has profiled another internet millionaire who has made his fortune by turning to health. Zhang Ligang made his first fortune by founding the travel booking site e-Long, but he is more famous for building a chain of private clinics under the banner iKang. And if China really does shift to a more private healthcare system, companies like iKang should be at the forefront of the wave.

The NHFPC has banned online medical diagnosis. In a statement this week the health ministry said medical consultations cannot be conducted online as there have been too many cases of unqualified people offering medical advice, purporting to be experts. The ban does not seem to apply to accredited hospitals that have approved programs. What this means for online doctor apps such as Spring Rain ( remains to be seen.

Children in China are exposed to a wide variety of antibiotics in food, which may promote resistance. A study in Shanghai that tested the urine of more than a 1000 children aged between 8 and 11 years of age found that as most had traces of at least one antibiotic and many had several antibiotics in their system.  Altogether 18 different antibiotics were found in the urine of Shanghai children, reflecting the high levels of antibiotics used in food production in China. This was confirmed by another report out this week which noted that the Chinese food and livestock industries use 100,000 tons of antibiotics  a year to promote growth in animals reared for their meat.

A total ban on tobacco advertising n China has been urged by the WHO. The head of the China office of WHO said China had a treaty obligation to phase out tobacco advertising, and should start to do so at retail points of sale. However, the powerful state-owned tobacco industry might baulk at that. The relative power of the health and tobacco industry was shown this week when health minister Li Bin noted that new graduates could earn twice as much in the tobacco industry compared to medical graduates working in hospitals. She made the point that the basic salary for a university graduate working in the tobacco industry was 4571 yuan a month compared to only 2100 yuan a month for a junior doctor. Li Bin said there was a need to learn from Adam Smith and pay the market rate for medical graduates - and this would mean patients being prepared to pay higher medical fees.

And finally the question arises of whether anti-HIV discrimination still exists in the China's hospitals. A patient at the Sichuan University Huaxi Hospital says he was refused surgery when doctors discovered his HIV positive status. The man said he had been scheduled to have surgery for haemangioma but it was cancelled and he was told that he would instead be kept 'under observation' instead. The hospital rejected the discrimination claim, saying that it was standard practice to keep patients under observation before going ahead with surgery for this condition.

Private health insurance in China: expansion blocked by hospitals

One of the key elements of the Chinese government's health reforms is to increase the role of private health. One way in which they are doing this is to encourage Chinese citizens to take out private health insurance to supplement the meagre coverage provided by government. The government is expected to offer policy support - including tax breaks - to encourage commercial health insurance providers such as PICC. However, according to Caixin, the growth of private health insurance is being stymied by the entrenched power of state-owned hospitals. Insurers are unable to offer a viable insurance product when they have no control over hospital costs or procedures - in other words, insurer-dictated managed care is essential for health insurance to make a profit. In addition, insurers need access to data and social security system figures if they are to manage their risks adequately - and they have been denied access to this information by local governments who fear losing control over their social security arrangements. Some Chinese health insurers have tried to partner with foreign insurers to build on their experience and technical know-how, but a joint venture between China Pacific Insurance Group C. (CPIC) and Germany's Allianz SE in Shanghai collapsed after less than a year when the European partners found that the insurer had no sway over hospitals.
We have already heard how doctors are unwilling to work in the private sector  - despite official encouragement - because they fear being 'excommunicated' by their main employers, the all-powerful state hospital system. The entrenched power of the big hospitals also appears to be another major barrier to any evolution towards private provision of healthcare in China.

Tuesday, 14 April 2015

How much does it cost to go to the doctor in China?

by Michael Woodhead
How much does it cost to see a doctor in China? Well the basic consultation fees may be cheap at just 20 yuan or so, but figures released by the health department of Dongguan in Guangdong show that the average cost of a hospital clinic visit is about 155 yuan (US$25).
The average cost of clinic visits per person in a year was 530 yuan ($85). Bear in mind that most people with an illness in China go direct to hospital, where they will register and wait several hours to see a doctor for just a few minutes. No wonder they call it kan bing nan, kan bing gui (看病, 看病Difficult to see a Doctor, Expensive to see a Doctor).
The figures released by the Dongguan health department also show how much you might expect to pay for inpatient treatment. At this medium level city in an affluent part of China a public hospital bed will cost you 910 yuan a day (US147). The report says that the average costs per person per year of hospital treatment overall were 7820 yuan ($1260).
These costs were lower than the average for larger hospitals in cities such as Guangzhou, where a hospital clinic treatment would cost 250 yuan ($40) and an average hospital stay might be as much as 14,000 yuan ($2250).
These are the upfront costs for hospital treatment. Many people will be covered by some kind of basic national health insurance. Typically this might cover 30% of outpatient clinic costs and up to 70% of inpatient costs.
This means that a patient might face a 'gap fee' of 100 yuan per clinic visit and 300 yuan per day in hospital. However, like health insurance schemes everywhere there are major restrictions on eligibility,  procedures covered and 'caps' on reimbursement.
Some people questioned the high costs put out by the health department, saying they were not the fees they expected to pay for visiting a clinic for a cold or fever. However, the department said they were average costs, based on hospital finance department figures, and included costs of medicines and other services. For some patients undergoing procedures such as surgery, they could be much higher, raising the average.  They said they fees were higher at tertiary level hospitals and they had released the figures to show that it would be much cheaper for people to seek treatment for minor illnesses at community level "general practitioner" clinics.
For comparison, a mainland Chinese reporter went to Hong Kong to see how much it cost to see a doctor there. They found that in public hospitals the doctor consultation fees were a nominal 50HKD (40 yuan) and the costs of an inpatient stay was 100 HKD per day (80 yuan), including all food. There were very few queues. Locals said they preferred to go to local GP clinics for minor illnesses, or a private GP clinic, where the cost of a consultation was a modest 100HKD, rather than hospitals, which were for more serious illness.

Sunday, 12 April 2015

Some good news about the chaining of mentally ill patients in China, from the 686 Program

by Michael Woodhead
In recent years there have been several media articles about mentally ill people in China being chained up - usually by families - because there are no mental health services. 

The impression given by the articles is that this is a widespread practice and is going unchallenged. "This is an example of how mental disorders are dealt with in rural China" said The Independent. It is enlightening, therefore, to read that such practices are rare and have been targeted for elimination for more than a decade. In a sobering paper published in PLOS One this week, Dr Lili Guan and colleagues at the Peking University Institute of Mental Health talk abut the so-called 686 program that has been running since 2005 to provide basic mental health services and ensure human rights are upheld for people with severe mental disorders.

In their article they describe how they recruited village health workers across China to seek out and identify mentally ill people who had been chained up by families. Their program found 271 such people - some of whom had been in chains for 28 years, but most had been chained for shorter periods and intermittently as circumstances arose, rather than continuously. Cases of chaining were rare - accounting for only 0.2% of mental health patients reviewed in the program.

Most of the chained people had schizophrenia and none of them were receiving care from mental health institutions, usually because there were no such community services in their area, or the families could not afford it. The patients were restrained mostly because they were violent and abusive, causing harm to people and property.

The program of 'unlocking' was focused on providing free antipsychotic medications. Patients were first admitted to psychiatric units and assessed, and then families were provided with free medications and a treatment plan. The 'unlocked' patients were then returned home to live in the community.
The good news from the program is that regular treatment rates went from 1% to 75% and most patients complied with treatment and showed great improvements. Their functioning improved and the family burden also lightened significantly. Relapse into ''locking' occurred with only 21 patients (8%), with families citing lack of adherence to medication and return to violence or harmful behaviour and lack of caretaker/financial resources to access help.

"The finding that more than 92% of those unlocked and entered into continuous treatment by the 686 Program remained free of restraints by 2012 demonstrates the feasibility of improving the human rights of persons with severe mental illness by increasing access to mental health care in the community, even with limited societal resources," the researchers said.

"Nevertheless, the failure to prevent relocking for 21 individuals suggests that considerable room for improvement of our mental health care practice still exists."

The researchers also noted that their program covered less than 1% of the population of mentally ill people in China, and said it would require more resources to allow it to cover the whole country.

"There is obviously much to be done in China to scale up the 686 Program for the whole nation and to improve quality of care. This will require substantially increased investment in mental health services. However, the success of the program in maintaining the severely ill individuals in treatment over three to seven years, and the benefits of the intervention for those who have lived for years with untreated psychosis and for their families, attests to the feasibility and social value of the “686” model."

Authors note: Restraint for people with mental illness is not uncommon practice in  western countries, particularly for elderly people in nursing homes. Medical groups in countries such as Australia have expressed concern that patients who are agitated and have challenging behaviour are sometimes restrained due to lack of staff and for convenience, rather than for their own wellbeing.

China's Five Year Plan for healthcare: what's what

At the end of March the State Council released a lengthy document outlining the five year plans for various sectors. For health, the only thing that really made the headlines was the announcement that China would double the number of doctors between now and 2020 (actually I don't think they actually said this - they meant they would try increase the number of available doctors per thousand population).

Anyway, here is a more in-depth look at what's in store for health, according to the State Council. The main section on health was relegated to part 41:

The overall aim is to to speed up reform and improvements in the basic healthcare system by:

1. Improve basic medical insurance cover for urban and rural residents by increasing subsidies increased from 320 yuan to 380 yuan per person per year,

2. Introduce direct billing of medical expenses.

3. Further develop primary health care by strengthening general practitioner system,
Extend reform of county-level public hospitals,

4. De-link drug profits from doctors' income and reduce drug prices.

5. Increase fees for medical services paid make up for drug price curbs.

 6. Encourage doctors to work in community clinics instead of hospitals

7. Accelerate the setting up of medical dispute resolution mechanisms prevention.

8. Increase funding for basic public health services

9. Pay rises for rural doctors

10. Strengthen the prevention and control of major diseases.

11. Promote use of Chinese Traditional Medicine.

In addition, the State Council said there would be a need for more hospitals, with a target of  six hospital beds for every 1000 people (up from 4.55 beds per 1000 people in 2013). 

Workforce will be expanded, aiming to increase the number primary care doctors from 1 to 2 per 1000 people and increase the number of nurses.

According to the BMJ, the government also aims to retreat from health service provision (almost 90% of China’s hospitals are public) to “policy-making, overall planning and supervising, to make sure the medical system benefits the public, while the market will decide the distribution of medical resources,” the statement said. The plan states that 1.5 in every two beds per 1000 people should be provided by the private sector by 2020.

The current move to reduce restrictions on restrictions on foreign investor involvement in the healthcare market will continue.

Thursday, 9 April 2015

Military hospitals in China: unaccountable and a law to themselves

by Michael Woodhead
It comes as a surprise to many visitors to China to discover that the swish medical facility in the middle of town is called something like the People's Liberation Army 301 Hospital. 

Military hospitals are a major feature of China's healthcare system - most cities have a major hospital run by the military, whether it be the army, navy or airforce. But don't expect to see them staffed by China's answer to Hawkeye or Major Burns. They are, for all intents and purposes, little different to other hospitals in appearance. No uniforms in evidence, they seem to be just state-owned profit-driven operations, like any other Chinese hospital.

However, according to an article by Zhao Han in Caixin this week, the military hospitals are a law unto themselves. The reporter relates the case of a bogus doctor working in Beijing who stole the identity of a real Shanghai doctor. When the Shanghai doctor discovered this, she demanded that the fake doctor return her identity documents and records. However, when reporters made further inquiries, they hit a brick wall of military secrecy because the fake doctor had been working at a clinic affiliated with the military PLA 466 Hospital.

When the matter was taken up with the authorities, they also got short shrift from the army hospital:

"The health bureau that oversees medical facilities in Haidian District, where Beijing No. 466 Hospital is located, said it does not have the authority to supervise military-affiliated hospitals.
Calls to the health division of the People's Liberation Army's General Logistics Department were not answered," Caixin reports.

This case illustrates a common observation about military hospitals in China - they are effectively beyond the control of the health department. What this means for China's health reforms - and the supposed development of private hospitals in the country - remains to be seen.How will the military react to the unpopular proposals to deregulate hospitals and reduce  profit-linked overservicing practices? Will they also support the move to primary care by allowing doctors to work in the community and accepting new referral networks (and thus losing revenue?) I doubt it.

And as we have recently seen with illegal organ transplantation, the military hospitals network is also protected from action against unethical practices. How the military hospitals are treated will be a true test of whether Xi Jinping is serious about health reforms and rule of law in China.

Wednesday, 8 April 2015

Ten questions that raise doubts about the claims of forced organ harvesting in Human Harvest

I saw bits of the film Human Harvest by Leon Lee last night on SBS Dateline. It seemed like fairly blatant Farlun Gong propaganda, and disappointingly there was little questioning of the claims or those who were making them. I'm no apologist for the Chinese government and you can read my previous reporting on the problems with illegal and unethical organ transplantation in China here. However, I think the FarlunGong claims made in the Human Harvest program are more to do with political propaganda and the agenda of the cult rather than reality of organ transplantation in China.

Haven't had time to do a full article on this, but here are some of my nagging doubts raised by this issue:

1. The claims about an Auschwitz-like camp in which 4000 FarlunGong supporters were murdered for their organs have never been supported by any evidence.

2. Claims that widespread forced organ harvesting had taken place in Liaoning were investigated by on-the-spot visits to the prison and refuted by reputable labour camp survivor and campaigners Harry Wu of the Laogai Foundation

3. Why have the Farlun Gong claims not been supported or taken up by reputable human rights organisations such as Amnesty International or Human Rights in China or reputable medical groups such as The Transplantation Society?

4. Why have claims not been accepted by the United Nations Special Rapporteur on Torture, who sent personal rapporteurs to China to investigate?

5. Why there no independent evidence and no allegations from people or medical staff not connected with Farlun Gong?

6. China has a prison population of 2 million – if it was such a lucrative trade, why would forced organ harvesting only be targeted on a tiny group such as Farlun Gong?

7. Why did Farlun Gong only start making these claims in 2006 despite organ harvesting being apparently widespread since the 1980s

8. Those making claims about forced organ harvesting belong to Neocon think tanks such as “the Foundation for Defense of Democracies” who have previously been accused of peddling "alarmist rhetoric and fear mongering".

9. Why has Farlun Gong put a block on the Wikipedia page relating to their claims on organ harvesting?

10. What has been the role of Farlun Gong cult founder Li Hongzhi in these claims – what is his background in the Party and his agenda in opposing former PRC leader Jiang Zemin?

Monday, 6 April 2015

Well that escalated quickly! Chongqing's 'market price' health reforms abandoned after just six days as dialysis patients take to streets to demonstrate

by Michael Woodhead 

The introduction of 'market prices' for healthcare services - one of the fundamental health reforms being introduced by the Xi Jinping government -  triggered immediate and widespread opposition in Chongqing and was abandoned after just six days.

In what is likely to be a major setback for health minister Li Bin, the centrepiece of her healthcare reforms was publicly shouted down by angry demonstrators who took to the streets of Chongqing last week. The new policy was intended to move hospitals away from the flawed policy of relying too much on drug sales for income. However, by shifting to a 'zero commission' policy for pharmaceuticals the hospitals are then forced to start charging more realistic (ie higher) rates for other medical services.

When introduced in Chongqing on March 25, about a thousand dialysis patients took to the streets, complaining that the cost of their daily treatment had more than doubled from 95 yuan to 200 yuan. This would mean their monthly costs would rise to about 3500yuan, most of which was not covered by their state health insurance.

Dialysis services were just one of 7886 medical items that were 'adjusted' from march 25 by the Chongqing health department. According to official media, the prices of consultations, surgery and other care services rose from 13% to 30%. The health department also said that some fees were reduced by up to 25%.

However, after angry demonstrations, the Chongqing mayor Huang Qifan convened an emergency meeting on April 1 and announced that the hospital fees would return to the 2014 'standard' level until further notice.

The demonstrations have been reported in the media, with patients telling reporters about the actual effect of the price changes on their medical expenses. Haemodialysis patients said their monthly medical bills would increase by thousands of yuan as a result of the price hikes.

Health analysts told Caixin that the market price adjustment policy failed because there was no 'free market' system for health in China. They said the sector-level reform was 'backward' and there was an underlying problem of national health underfunding, with patients being under-insured and cities such as Chongqing lacking the funds to meet the increasing demands of an ageing population's healthcare costs. They said the reforms simply passed on healthcare costs to vulnerable patient groups such as those needing dialysis, who would face impossibly large 'gap fees'.

The reforms have now been put on hold for further public consultation. What this means for the introduction of similar reforms planned for 16 of China's major cities remains to be seen.

Friday, 3 April 2015

Five Easter medical headlines

1. Pornography sent to hospital leaders in extortion attempt
A Fujian man planned to send pornographic pictures to the directors of most major hospitals in China in a  bid to blackmail them. He was caught by polce and confessed to being put up to the mailing by a mystery "Older Brother".

2. Beijing launched anti-corruption drive in top hospitals
The health department in Beijing is launching an inspection tour of the capital's top 12 tertiary hospitals to root out corruption and check whether hospitals are adhering to the Nine Forbidden's directive against accepting commissions and bribes.

3. Lack of nursing homes leads to bed block
The lack of residential aged care facilities in China means that many hospital beds are occupied by ailing elderly people who do not need treatment but who cannot manage in the home environment.

4. Rural children plagued by worms
More than two out of five children living in rural China are infected by soil-borne worms such as hookworm. However, parents rarely seek help due to ignorance or a belief that treatment is not possible.

5. Government aims to double the number of doctors
The State Councils five year plan for healthcare includes a plan to boost doctor numbers by 100%, with the aim of having two doctors per thousand people by 2020. The 'roadmap' also sets a target of moving away from public hospital provision of healthcare, with 90% of beds currently provided by the public system.

Monday, 30 March 2015

Putian: from Fujian VD doctors to private healthcare millionaires and Baidu bashers

by Michael Woodhead
The news that an alliance of private healthcare providers have boycotted Baidu over advertising charges this week requires a bit of background.

The basic story is that the Putian chain of 8600 private hospitals has accused China's number one search engine, Baidu, of hiking the costs for  its paid search 'adwords'. Like Google, Baidu auctions off its keywords to the highest bidder. In the US, Google can charge up to $50 per click through for the most lucrative keywords such as 'insurance' 'loan' and 'attorney ('Better call Saul'?). Advertisers are willing to pay these huge fees because of the high returns they get from having these keyword link straight from the search engine to their site. Likewise in China, Baidu operates a "Pay Per Click" (PPC) advertising sales operation. However, it turns out that in China about 60% of the paid search is for healthcare businesses. This means that words and phrases like 'gynecology' and 'cosmetic surgery' attract sky high adword rates on Baidu. According to one article the cost is as much as Y600 per click.

Resentful at having to pay such high fees for search words, the final straw for healthcare companies came when Baidu announced recently that it would be jacking up its prices by 40% (allegedly).
According to Caixin magazine, this price increase prompted the Putian Health Industry Chamber of Commerce to put out an instruction to all its affiliated 8,600 private hospitals across China to halt all paid promotional activities online. It went further, vowing to stop all cooperation with Baidu and close down all the Putian hospitals accounts with Baidu. Putian said that the advertising price increases meant that "many medical facilities have been reduced to almost working for Internet companies."

However, it's worth noting that Putian is only a loose association of healthcare providers and they are bound by clan ties more than business contracts, for whatever that is worth.The chamber of commerce called for 'unity', making them sound more like a trade union (or cartel).

It's worth pausing here and explaining who and what Putian is/are. The Fujian town has become a byword for private hospitals in the same way that Maotai is associated with hard liquor and Jingdezhen is for crockery. According to this article, the town has spawned (pardon the pun) a nationwide network of healthcare entrepreneurs based on local expertise in private VD clinics. The story goes that a former barefoot doctor called Chen Deliang became successful in the 1980s by selling treatments for ailments that the hospital system wasn't interested in - firstly scabies, then later venereal diseases. Other Putian businessmen followed his lead and they have spread out across China starting up clinics and hospitals that cherry-pick the lucrative but low risk medical treatments - fertility treatment, plastic surgery and dental care are said to be favourites.

Putian people are now said to control up to 80% of China's private healthcare clinics. Most of these attract business via online advertising, hence the Baidu connection. Putian people are also said to be extremely shrewd in business, and thus it is not surprising that when Baidu announced they would be putting up the cost of paid search words to as high as Y999, the Putian entrepreneurs spat the dummy.

The result is a standoff between two giants - Baidu the internet search behemoth and Putian, the biggest network of healthcare providers and thus some of Baidu's most important advertisers. Some say that Putian affiliated clinics account for half of Baidu's 26 billion yuan annual advertising revenue (I find that hard to believe - other estimates put it at a more realistic 6-10%, still, not to be sniffed at).

Baidu, however, is saying that the Putian complaints are not about price increases but about the increasingly strict enforcement of advertising rules about dodgy medical advertising. The Xi Jinping government has been making a lot of noises about cleaning up  unethical advertising and promotions - much of which is related to quack health cures and shonky clinics.

According to Caixin, the search engine Baidu is now seeking to distance itself from the disreputable end of the healthcare sector and align itself with more reputable medical providers. In a way it echoes Google's recent moves to tidy up its medical/health search functions and give more ranking to evidence-based treatments. Only in China this comes with a price - Baidu's share price has taken a hit - and Putian's reach to healthcare consumers has been curtailed.

My take on this? Given that the Chinese government is seeking to increase the influx of social capital (aka private investment) in healthcare to about 20% of all hospitals, they must be daft to estrange Putian. Why not find a way of working with them instead?

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.