Sunday, 22 November 2015

Medical news from China: 7 stories that made the headlines this week

1. Nurses in Wuxi are being taught lessons in etiquette by air hostesses. The aim of the program is to make the nurses more customer focused and dispel their image as unfriendly.

2. Acute kidney injury is common in China with 700,000 deaths a year. Researchers from the Medical College of Nantong University found that acute renal impairment went undiagnosed in more than 70% of cases, and was often caused by patients taking nephrotoxic drugs or TCM.

3. A female neurologist in Wuhan is suing a woman for slander and damage to her reputation after the women mounted a four year campaign to blame her for her mother's death. Dr Mei Bin is suing the woman for 5000 yuan in compensation and apology after the woman spread false stories about her and claimed she was unqualified for her post. Dr Mei Bin said she had nothing to do with the care of the women's mother and the allegations against her were false, probably related to a doctor with a similar name in another province.

4. Researchers from Zhejiiang report a case of human to human transmission of H7N9 influenza in hospital from Feb 2015. Both men died, according to a report in the BMJ.

5. Health inequalities: hospital mortality rates are 40% higher in rural areas compared to the cities, a new study shows.

6. About 44% of Chinese women take Traditional Chinese Medicines during pregnancy, the most common being Angelica sinsensis (29%), Ziziphus jujuba (21%) and Dioscorea opposita (13%). Most women used TCM on the advice of their mother or mother-in-la, according to the survey of 700 women in Sichuan. The researchers warned that TCM may cause fatal hepatic and renal effects and some are adulterated with lead or pesticides.

7. A Beijing medical school has started a program to train more psychiatrists to help overcome China's widespread lack of mental health clinicians. The Beijing Huilongguan Hospital Clinical School of Peking University aims to help train several hundred psychiatrists over the next decade. China currently only has 20,000 psychiatrists and needs at least three times that number to match other countries.

Wednesday, 18 November 2015

Antibiotics in China: not quite there yet

Regular readers of this blog will know that antibiotic misuse is one of my real bugbears about medicine in China. Seeing rows of patients in emergency departments routinely hooked up to infusions of broad spectrum antibiotics for fevers is a symbol of everything that is wrong with healthcare in the PRC.

Well it seems that I'm in good company in deploring this unwelcome practice. As part of Antibiotic Resistance Awareness Week, the World Health Organisation has taken China to task for its misuse of antibiotics. In a new global report it singles out China for having particularly poor usage and knowledge of antibacterials. A survey reveals that more than 60% of Chinese think, incorrectly, that colds and flu can be treated by antibiotics. A similar proportion have used antibiotics in the past few months and one in four bought them over the counter rather than obtain them on prescription. And while 67% were aware of the term ‘antibiotic resistance, few realised that cutting down on antibiotic use was the way to tackle it.

The WHO states that China is one of the worst offenders for antibiotic misuse and blames the lack of awareness among the citizenry for this problem. For a country that prides itself on such a good education system, how can Chinese be so badly informed about such an important matter?

The head of the pharmacy department at the Beijing Union Medical College Hospital, Zhang Jichun, says many Chinese demand antibiotics as a "quick fix". At the hospital if doctors say that antibiotics are inappropriate for patients with a fever or a cough they are rebuked with: "my illness so bad, why don't you give me an infusion for it?" Doctors say patients accuse them of not taking their illness seriously and demand "give me an infusion quickly so I will recover quickly and can get back to work!"

The WHO says it hopes the new report will raise awareness about antibiotic overuse and the risk of resistance in China. I'm not holding my breath.

Sunday, 15 November 2015

Top 10 hospitals in China


I'm not a big fan of top 10 lists, and I would approach this one for hospitals in China with caution. The China 2014 Good Hospital Ranking is produced by the Fudan University Institute of Hospital Management.

I'm not quite sure what criteria they use to decide what makes a good hospital but they claim it is based on factors such as clinical competence, scientific research and academic rigour. How they measure that objectively is anyone's guess. The Fudan team also say they consulted many 'national experts' to rank the country's top hospitals. They say the rankings are a good guide to clinical excellence and should be a benchmark that other hospitals strive for.

I don't think anyone is going to see any surprises in the list - all the top hospitals are the 'usual suspects' in the major cities such as Shanghai and Beijing and Guangzhou. I'm also not sure what the point of league tables for hospitals is - if you asked me to name the top 10 hospitals in Australia I could tell you quite easily without having to do a ton of homework - just based on location and whether they are teaching hospitals with a good research culture.

The rankings actually extend to 100 top hospitals, but I've only listed the top 10 here for brevity. I'm also not sure what the point of doing these survey on an annual basis is - it's not as if hospitals will move up and down the list very much and whether that is significant anyway. Any doctor will tell you that some good hospitals can have very bad departments and vice versa - some hospitals have a good reputation in certain specialities and can be terrible for others. Much of it is down to personalities and medical politics. I can also think of some 'good' hospitals that are over-rated and charge exhorbitant fees based on their reputation and "closed shop" monopoly status.

But what do I know. Here's the list:

  1. Beijing Union Medical College Hospital
  2. Sichuan University, West China Hospital
  3. People's Liberation Army General Hospital (aka 301 Hospital, Beijing)
  4. Shanghai Jiaotong University Affiliated Ruijin Hospital
  5. Xijing Hospital (No 4 Military Hospital) Xian
  6. Zhongshan Hospital, Fudan University, Shanghai
  7. Huashan Hospital, Fudan University, Shanghai
  8. Zhongshan Hospital, Guangzhou (First Affiliated Hospital of Sun Yat-sen Univeristy)
  9. Tongji Medical College Hospital, Shanghai (Huazhong University of Science and Technology)
  10. Peking University First Hospital

Wednesday, 11 November 2015

Dodgy hospital uses call centres to lure bumpkin victims

A backstreet private clinic in Beijing is using call centre staff posing as doctors to lure unsuspecting victims to have expensive and often unnecessary medical procedures. In an expose, a Beijing Times reporter spoke to call centre staff for the Beijing Sande Weiye (三德伟业) clinic, who described their high-pressure sales tactics to bring patients in for high tech and often unproven treatments such as 'stem cell' technology for arthritis.

The call centre staff said they were given a script and a template to respond to phone inquiries coming from people who had been deceived by fake websites and Baidu advertisements that claimed their 'hospital' was affiliated with prestigious major hospitals in the capital. When answering calls, the sales staff said they were doctors but in reality they were unqualified and just ran through a script whose aim was to convince callers that they could jump the queue and get access to top specialists at the city hospitals. Most of the callers tended to be gullible out-of-towners who were seeking treatment in the capital rather than rely on the more basic and underfunded rural hospitals.

Sales staff told the reporter that they were pressured to get the caller's mobile, after which they would make a series of promises and phone calls to establish a relationship with the prospective customer. They were paid on commission: 2 yuan for getting a call, 20 yuan for getting a registration (ie phone number and verbal contract) with the 'network' and 60 yuan for a hospital visit. The sales person also got a cut of the treatment fees and drug fees. A successful telesales operator could make 5000 yuan in this way. The treatments offered were often high technology - such as joint replacement - and were offered regardless of whether they were really appropriate for that patient.

When the reporter visited the 'hospital' he found it to be just a standard clinic with unscrupulous doctors offering treatments that were much higher in price than the same treatment in public hospitals. A knee replacement, for example was priced at 60,000 yuan.

When the reporter informed the top three hospitals that their name (and reputation) was being hijacked to promote a bogus clinic they said they did not have the staff or resources to chase up the many such cases they heard about from complaints. They suggested the fraud be reported to the Public Security Bureau, but the PSB said they would only follow up complaint from people who had been swindled and who had evidence to show criminal behaviour. They instead suggested that the reporter called the consumer affairs bureau.

The Beijing Industry and Commerce Bureau  told reporters that any company making false propaganda, should be reported to the bureau's hotline and would be investigated, with fines and business license suspensions for offenders..

Thursday, 29 October 2015

Doctors tempted by offers from private hospitals

As China tries to develop its private healthcare sector, some doctors are contemplating a move from their high workload, low paid public hospital positions to the private sector. One Shanghai obstetrician with 10 years' experience was interviewed by Caijing and said he was tempted to make the move to the widening private sector, but not for financial reasons. He said he could already earn 300,000Y (US$47,000) a year in the public hospital, counting bonuses, which was comparable to the private hospital salary. What attracted him to private work was the lower workload and the opportunity to have more patient continuity.

"In public hospitals every day you need to see hundreds of patients, and you have no energy left to do academic work, research and innovative practice. In the private hospitals there is reduced patient throughput and often the patient will follow you from start to finish - and this is a more valuable medical experience," said Dr Liu. "None of my friends who have switched to a private hospital have shown any regrets," he added.

Another reason for moving into the private sector is independence, say doctors. One said that private hospitals offered more clinical and financial autonomy than a public hospital where you worked under the authority of a 'big medical leader' and were also subject to the rigid career path and control of hospital management. In a private hospital there was more opportunity to select your patients, treatments and also have an equity stake in the business, he said.

However the doctor noted that there was less job security and often questionable quality of care and backup in private hospitals compared to the public system. He noted a clear divide between domestic and foreign-funded private hospitals. Foreign joint ventures tended to have little interaction with public hospitals as the quality of care was generally good. However he saw many 'referrals' of patients from private hospitals where patients had not been properly assessed or had spent tens of thousands of yuan for minor ailments. Most of the doctors in the tertiary public hospitals would opt for foreign-invested hospitals, he suggested.

Sunday, 25 October 2015

Plans for online pharmacies hit a roadblock in China


It was pitched as the great disrupter of the Chinese healthcare system: online sales of prescription drugs would reduce distribution costs, improve efficiency of the supply chain of medicines and be great for consumer choice, convenience and affordability. Unfortunately, despite a lot of official hot air, nothing has actually happened.

In May 2014 the Ministry of Commerce released a draft plan to 'open up' the pharmaceutical market to allow online sales. But since then there has been nothing heard from official sources about when and how online sales of prescription drugs will be permitted. While some of the big players such as Alibaba are positioning themselves to be online pharmaceutical vendors, it is still just talk: selling drug online is still illegal and insiders say the government is now dragging its feet on plan to open up the market. The pressure is coming from vested interests in the pharmaceutical industry and also from the powerful hospital lobby.

According to the Commerce Department, online sales of drugs are growing at a phenomenal rate. They say revenue has increased 50% in the last year and there are now 425 companies competing to sell pharmaceuticals online in a 4 billion yuan market. However, at present only non-prescription drugs can be sold online - that market is worth 200 billion yuan and only 2% of it is online. The much bigger market - the 800 million yuan prescription drug market - is still out of bounds. Analysts predict that up to 30% of drugs sales could move online - so there are huge stakes involved for those who win and lose on online pharmaceuticals.

According to Caixin magazine, plans for online sales of pharmaceutical are being opposed by those who say government-run hospitals will lose one of their main sources of revenue if this goes ahead. The China Pharmaceutical Association warns that prescription drugs must be dispensed under the supervision of a pharmacist to ensure quality of the product and also to ensure that it is going i the right for to the right patient.There is no guarantee that this will happen online, they say. They also point to the fact that online purchases of drugs will not qualify for heath insurance rebates - a crucial factor for most patients, who expect to get some or all of the cost of their medications reimbursed by their health insurance.

Hospital-based pharmacists have also attacked the proposals for having little real-world benefit. They say there is no clear evidence for the benefit of online sales of drugs from a clinical perspective. Are online sales of drugs being promoted to improve patient's health, or just as a trend or a money-making venture, they ask. They have called for a responsible "opening up" policy towards online pharmaceuticals from the government.

In the meantime, it seems China has stalled on the issue of online pharmacies.

Wednesday, 21 October 2015

Uber Doctor? China's version of the taxi app just launched a home doctor visit service.

The company that runs China's answer to the Uber app - DiDi, has just launched a home doctor service, called DiDi Doctor. 
A pilot program of the doctor-hailing app is being run out in four cities: Beijing, Shanghai, Hangzhou, Nanjing. The services promotes itself as offering a renowned surgeon for private consultations. In its first few days it got 20,000 calls - but only treated 40 patients. The service is being run in cooperation with Ali Health, and is currently being offered for free - for those who can get through. However, feedback on the service has been mixed, with consumers doubting the experience of the doctors involved, and questioning whether they are even entitled to treat patients outside of hospital.

A pregnant woman called Chen who used the service in Shanghai, said she thought it would offer a way to avoid the long waits at the tertiary hospital. However she found that the doctor dispatched was a cardiologist with no experience in obstetrics and gynaecology. The doctor also told her that he was only allowed to give general advice and could not write prescriptions for pharmaceuticals - only minor medications and supplements. It seems the DiDi Doctor staff are on secondment from private hospitals, but they do not have authority to practice medicine beyond their registered place of work. Users also questioned the calibre of he doctors involved, saying that good doctors were already in high demand, seeing 30+ patients in a morning - why would they spend a day driving round seeing only four or five patients. Users also questioned the business model, saying they would pay about 200-300 yuan to see a doctor in a public hospital - how much will DiDi Doctor charge when the service is beyond the test stage?

Tuesday, 20 October 2015

Inequality in China healthcare - fixing it isn't easy

The Chinese government acknowledges that serious inequalities exist in the country's healthcare provision - rural areas are seriously under-serviced compared to the cities. 

More than a decade ago the government announced a grand plan to try address some of these inequalities - by sharing the expertise of big city hospitals with rural areas. The plan was for medical personnel from tertiary hospitals in prosperous eastern China to spend time in placements and long-term exchanges in disadvantaged rural hospitals and clinics in poorer parts of western China.

However, the so-called "Myriad Doctors Supporting Rural Health Care Project" has not been a complete success (to put it mildly), according to a letter in the Lancet this month from Dr Wang Tao of the Shanghai Jiaotong University Sixth Affiliated Hospital.

After touring western districts to see the progress of the project in its 10th year, Dr Wang found that it had helped bring medical personnel and technology to some poorer areas. However, the project was also under-resourced for such a major undertaking. Lack of funding meant that hospitals struggled to pay their seconded medical workers an adequate wage. The transfer of five senior doctors from each supporting [eastern China] hospital to a disadvantaged hospital on six-month shifts also proved impractical.

"These long-term arrangements create a huge burden for hospitals in eastern provinces and can cause personal difficulties for medical staff," he writes.

Another problem was that medical resources were allocated by government bureaucrats rather than determined by need.

"Coordinating this huge project that involves thousands of hospitals and medical workers according to strict policy guidelines is extremely tough, and inefficiencies and repetitive allocation of resources inevitably arise," says Dr Wang.

The project has not done much to address inequalities in healthcare, he reports. Latest figures show that eastern China areas have average annual healthcare funding levels of 1067 yuan per person, whereas in western China hospitals have only half that level of resources (about 500 yuan per person). Inequalities also exist in the numbers of hospitals, doctors, nurses and beds between eastern and western China.

"Healthcare inequalities remain a serious problem and necessitate support projects for the foreseeable future," Dr Wang suggests.

He asks whether market forces could succeed by encouraging hospitals in eastern provinces to open public or private amenities in the western provinces.

"New sources of income might provide sufficient motivation to create efficient, high-quality services. The fear is that new sources of income might cause new problems, counteracting the government's attempts to reduce inequality. Nevertheless, the consistent provision of an excellent level of health care in China, particularly in less developed areas, still has a long way to go."

Sunday, 18 October 2015

Why is there so much violence against doctors in China?

As I've said many times on this site, the level of violence against medical staff in China is extraordinary. In one province, Guangdong, there were 25,000 recorded incidents last year alone. Many reasons have been put forward by academics and politicians to explain the epidemic of violence - but there has been little actual study of the contributing factors. Now researchers have interviewed patients and medical staff in seven Guangdong hospitals to get some feedback from the grassroots.

The results of the survey are published in the BMJ this month and one theme emerges: mistrust.

The survey found that there was widespread mistrust of doctors and healthcare staff by the public, based on well-grounded beliefs that there was widespread injustice and commercial bias in the Chinese healthcare system. Patients believed that decisions on their treatment were based more on hospital revenue than need, while at the same feeling resentment that they had to wait for hours to see a doctor for just a few minutes. Costs and financial injustice were a major source of anger: people cited examples of patients being refused treatment - or having treatment terminated due to inability to pay fees.

Doctors also believed there were major injustices in the healthcare system - saying their workloads were far too high and the salaries did not reflect their years of training, long hours and high pressure. They also said that they did not trust patients to behave in a civilised manner, with many being demanding or suspicious.

Patients had little trust in the official dispute resolution systems. They believed that hospitals and law courts were unlikely to give time or serious attention to patient complaints and felt there was little chance of redress for any deficiencies or mistakes. For this reason, patients said they would be more likely to get a result - an apology and compensation - if they used physical and verbal threats, disruption of the hospital and violence to gain attention.

The survey also heard from doctors that their training had not prepared the for communicating with patients or having a good bedside manner.

Both patients and physicians were critical of the government's response to rising violence - namely increasing levels of security guards at hospitals. They said this just inflamed the situation, creating a siege them-and-us mentality and did little to address sudden violent assaults on staff.

The researchers - including several China-based doctors - are openly scathing about the policy response from Xi Jnping and his administration.

"The moral crisis that our study revealed in Chinese healthcare demands a legal and regulatory response as well as a moral one. The Chinese phrase “zhibiao bu zhiben” means treating the symptoms and not the disease. Cracking down on violence and enhancing security measures are unlikely to fundamentally alter patient–physician mistrust and may inadvertently undermine trust."

They put forward three policy suggestions to tackle the climate of mistrust that is driving the violence in healthcare. Firstly they say hospital 'commissions' and incentives to staff for overservicing must be abolished and financial conflicts of interest must be addressed.

Second, doctors and hospital staff need better training in communication, ethics, professionalism and dispute resolution. Finally, there needs to be an atmosphere of trust in which the public are willing to negotiate and seek non-violent solutions, while doctors must be willing to apologise to patient families and accept reasonable consequences for medical error. st.

Similar findings were made in a separate study of junior doctors in three Nanjing hospitals recently. The study found that junior doctors felt extremely frustrated at having studied for up to a decade but having only a lowly job title and poor pay. The doctors said they worked extremely long hours and had high pressure in their work, but also faced poor prospect for promotion or increasing their income. The other main finding was that most junior doctors had experience of abuse and violence from the public, and this was a major contributor to poor quality of life.

"Although Chinese doctors feel relatively unsafe, the phenomenon does not raise sufficient concern from hospital managers . These violent events negatively affect medical workers; for instance, these workers may develop guilt and self-doubt, and such outcomes can reduce the quality of services," the study authors note.

Sunday, 11 October 2015

Hospitals heed Xi Jinping's call to make use of "social capital", then rip off investors

One of the cornerstones of Xi Jinping's healthcare reforms is the urging of public hospitals to take advantage of "social capital" (ie private investors) for future expansion and development.

Unfortunately, in China's murky and non-transparent climate of investment, things are quickly going wrong in predictable ways. A hospital in Jiangsu now owes its mom and pop investor almost a billion yuan, according to reports in the People's Daily. The Workers Hospital of Suqian asked locals and employees to put their capital into the hospital's investment fund and promised regular interest and dividend payments.

In 2012, a man called Chen heeded the call to invest in the Suqian hospital to help fund the building of a new hospital and to further develop and expand medical services. The hospital guaranteed a fixed income and this was backed by the local government. Mr Chen put in his 2 million yuan retirement savings and was initially  pleased with the interest payments he received on a regular monthly basis. In fact, Mr Chen was so impressed he persuaded his family and friends to invest their money in the hospital as well. In addition, local TV advertising that was aired to promote the fund resulted in more than 2000 small time investors putting close to 900 million yuan into the Worker's Hospital Investment Fund. However, things started to go wrong in April this year when the hospital defaulted on its interest payments. Investors who asked why they hadn't received their usual payments were fobbed off with non-commital replies.

However, as public complaints and protests increased, the local police and authorities have opened a financial investigation into the missing monies. So far they have found that there is not enough money to pay the interest and also not enough to repay the principal sums that were invested and which most investors are now demanding be repaid.

Several of the hospital financial managers have been detained for further investigation and the local authorities say they are now tracking a number of unauthorised financial investments. It looks very much like the Suqian people have had their social capital blown on the roller coaster Chinese stock market that crashed so spectacularly this year.

Putian cartel?

Meanwhile, China's private hospital market has started to take off in a big way with more than 8000 hospitals and clinics in the loose "Putian Network" forming an procurement alliance. The Putian hospitals network is a loose association of healthcare establishments set up from the 1980s onwards by entrepreneurial families from the Fujian town of the same name. Although suffering from a poor reputation for marketing of dodgy services such as fertility clinics and cosmetic centres, many of the Putian hospitals are trying to transition into more respectable establishments. Several of the hospitals have formed groupings and sought investors through IPOs. Now the Putian group hospitals say they are seeking to consolidate and form buyer's groups to give themselves greater purchasing clout. However, Putian hospital are still suffering from a credibility after being banned from Baidu for their dodgy advertising claims.

Tuesday, 8 September 2015

Having a break

No posting until the end of September: I'm cycling in Heilongjiang and Russia.

Monday, 31 August 2015

Science Communication in China

On this blog you'll often see me harking on about the lack of health literacy among otherwise well educated Chinese people. The media in the west are always looking enviously at China's education system for the high marks in subjects such as maths and science. How is it, then, that Chinese people have such backward views on scientific matters such as antibiotic overuse and resistance? Is there no equivalent of Mythbusters in China?

One factor in the lack of scientific literacy in China is the poor level of science communication. There is little real popularisation of science in China, and few science communicators in the public eye. The reasons for this are well illustrated in an excellent - if somewhat academic - article in the journal Public Understanding of Science this week. Written by Zhang Yueyue (currently at the University of Kent, UK), the article entitled "The Credibility Paradox" explores why China's scientists don't connect with the public - and why the public don't listen to them.

The basic answer is that like many things in China, science is heavily politicised and a no-go area for individuals who are not officially approved. Zhang says that what little science communication there is in China is a "top down" process and is mostly concerned with policy. Science has long been seen as an instrument of Party policy in China, and its role is to serve politics. There is no popular participation in science debate, and no debate or discussion about science beyond the most basic principles.

In the west, we are used to seeing science communicators in the media who are independent and who express their own views and theories about scientific matters. Science communicators are often sceptics and are ready to challenge the official line - whether it be government, business interests or popular misconceptions and quackery. In China, it is a very different situation. Commentary on scientific matters is the preserve of a few "Big Experts" who have official blessing. There is little or no role for grassroots or frontline workers in science fields such as the biomedical sphere. There is no tradition of independent or dissenting thought in science, and there is little willingness among scientists to come forward and engage the public to popularise science.

And because science is seen by the public as being part of the political process, there is little trust or interest in what science commentators say. The top-down official model of science communication has little credibility with the ordinary Chinese citizen - they are alienated from science and there is no engagement.

This lack of interaction is a two-way process. Zhang's journal review describes the feedback she got from nine biomedical scientists who were interviewed abut their views on science communication. Most said they had little interest or willingness to get involved in public discourse or engagement around science. They did not see it as their role and would not want to take on the role.

When asked why, the scientists said they did not want to get involved in politics or become labelled as "stirring up trouble" by starting a public debate. Most scientists also said they were not qualified or entitled to talk about science in any official capacity as they were not "Big Experts" only "frontline workers". They would not comment about science in online forums or by writing articles because this would bring pressure from their institutions and have an adverse effect on their careers, they said.

Another reason that scientists cited for not getting involved in science communication was that experience showed them that nobody paid attention to what they had to say. They remarked that there were few good outlets or forums for science communication, and they were kept "out of the loop" by leaders and managers on science policy, so there was little point in discussing it anyway.

Interestingly, many scientists said they did not want to be associated with official science communication because they believed that science spokespeople had little credibility: "Nobody would listen to you or believe you" was one comment made.

However, the scientists said they did love talking about their work and explaining their scientific methods on an individual basis in informal situations. In other words, they were happy to be science communicators so long as they did not have their official hat on.

Ultimately, the lack of science communication means there is little understanding of science and thus poor science literacy in China, the scientists concluded.

In practical terms, this means that when biomedical scientists in China comment publicly about health and medical matters they are seen as having little credibility, and are viewed as simply spouting the "official line" or propaganda - and not to be trusted. And even when they are believed, their views and outlook are often not understood or given much attention.

This may explain why China's healthcare system is often dominated by unscientific practices - and why China's "medical experts" have little credibility in the public eye.

Sunday, 23 August 2015

High Noon for dodgy drug trials: China cracks down (again) on pharmaceutical data fraud

Eight years ago, the Chinese government took a rather drastic step to clean up fraud and corruption in its drug regulator - it shot the director of the State Food and Drug Administration. However, this has  now been shown to be just another example of the uselessness of capital punishment as a deterrent, because the Chinese government has now announced ANOTHER crackdown on pharmaceutical drug registration fraud.

Although not spelling it out as such, the Chinese ministry of health has basically admitted that there has been ongoing and widespread clinical trial fraud since 2008. Not exactly a ringing endorsement for the succesors to the hapless Zheng Xiaoyu (above).

Despite efforts to correct the situation, the new director of the China FDA, Bi Jingquan (in office since 2015) has announced that the problems of clinical trial fraud have not been fixed. On 22 July he issued proclamation 117, which states that the China FDA is to review the registration applications for more than 1600 drugs, to verify the data as genuine. In a sign of how bad things are, the China FDA has described this as a "last chance amnesty" for all the naughty companies who have submitted false data to come clean. Leniency for those who confess ... and for those who don't - three years exiled in the wilderness. Yes, the China FDA is going to blacklist the drugs and companies that are found to have acted fraudulently - if they don't put their hands up and admit to it. They will be banned from re-submitting any drug registration applications for at least three years.

Not surprisingly, the pharmaceutical industry is not happy with this situation. In fact, they are shitting bricks and calling it "7-22" - the industry's play on 9-11. They know the government means business this time because of what happened to GSK - the Anglo-US company was fined a whopping 3 billion yuan ($489 million) for dodgy goings on within its sales force.

But to be fair on Big Pharma, it's not all their fault. The real villains are the so-called Clinical Research Organisations (CROs), which are agencies that actually do most of the local clinical trial work on behalf of the pharma companies. According to Caixin magazine, industry insiders acknowledge that the CRO sector in China is riven by fraud and corruption. Pharma companies pay the CROs to obtain the clinical trial data for China and submit it to the regulators. However, it's an open secret that the trials allegedly run in China's hospitals have been fixed or faked,  and the regulators bribed or blindsided.

To use the words of a regulatory agency insider, "the chaos has not been effectively curbed" since 2008 and therefore the CROs are being invited to undergo a period of "self examination" and verification of their results. The China FDA is tearing up its 2001 guidelines for drug registration and is starting afresh with more rigorous rules. The CROs have a chance to correct their irregularities or will be banished for three years. It is hope the shake-up will clean out what it currently a rotten and severely compromised sector - but this remains to be seen.

The last word goes to an insider at a reputable company - he says the short term effect may well be a kick up the arse for the CROs and the pharma industry, but old habits die hard. He says the only way to achieve positive long term change is to overhaul the management of CROs and pharma companies - and build expertise based on technical and scientific ability, not an ability to bend the rules

My article in the BMJ on the medical response to the Tianjin blast

China’s health authorities have activated disaster response plans to send in medical teams to help treat hundreds of casualties from the massive Tianjin chemical explosion on Wednesday 12 August.
Official reports have said that at least 112 people were killed, 95 were missing, and 722 were admitted to hospital for treatment of injuries from the blast, which destroyed a wide area around a container storage area in the northeastern port city of Tianjin.
Many of the dead and wounded people were firefighters sent to tackle the blaze that triggered the huge explosion at around midnight on 12 August.
Doctors treating casualties at the nearby Taida Hospital said that most of the injuries were blast injuries such as burns and fractures, although hundreds of nearby residents were also … 
Read the rest at BMJ 

Sunday, 9 August 2015

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year
For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."