Monday, 6 May 2019

Who will protect the health of rural residents in China if village doctors run out?

By Le Yang and Hongman Wang
Abstract: This paper discusses the current situation of Chinese village doctors and highlights the importance of increasing the number of village doctors for better health service and a stronger health system. This study reviewed relevant health policies and data from the Chinese Statistic Year Book 2016 to assess the current status of Chinese village doctors and clinics. The Chinese government has launched a set of healthcare reforms to strengthen primary health care (PHC), especially in rural areas. However, the recruitment and retention of village doctors has not been successful. The analysis of available data suggests that fewer doctors or graduated medical students want to work in village clinics and provide services for rural residents. It is widely recognised in China and other countries that a good PHC system protects the population’s health at low cost. To achieve a better health system, the Chinese government should strengthen PHC, expanding the village clinics’ coverage to improve access to PHC and basic public health, and introduce more sustainable policies to attract more PHC practitioners to Chinese villages.

Friday, 26 April 2019

Tencent-backed online healthcare platform Trusted Doctor secures $250m

China's Tencent Trusted Doctor, a venture backed by tech giant Tencent Holdings, announced that it had raised $250M in a fundraising round. The investment was led by Country Garden Holdings, Tencent Holdings and Sequoia Capital, Tencent Trusted Doctor said in a statement.
The fundraising marked the first investment since the entity was formed through a merger of Tencent Doctorwork and Trusted Doctors last year.
Tencent Trusted Doctor said it connects 440,000 certified doctors with more than 10 million patients online, offering services from online consulting to e-commerce to physical checks.
Source: Mobihealthnews

Tuesday, 1 November 2016

China's primary care sector suffers from "Just a GP" syndrome

by Michael Woodhead

While the Chinese government aims to promote primary care and reduce the hospital-centred approach to healthcare, the situation at the coalface suggests this is going to be an uphill struggle. A report from Henan shows that while the city of Zhengzhou has 54 primary care centres, they are unpopular with both patients and doctors. According to an article in the local newspaper, the main problem is 'lack of talent'. The community medical centres fail to attract talented doctors because they are seen as a career dead end with low pay, low status and few if any opportunities for training or promotion.

A former respiratory physician who now works at one of the clinics says the failure to attract and retain reputable doctors to work a primary care centres is a vicious circle. With salaries of only 2-3000 yuan (US$300-400) a month for doctors working in community medical centres, the hospital based staff would rather switch to a remote rural branch of the hospital rather than work in one of the city-based community clinics, says Dr Song Gang, who became a primary care practitioner in 2008.

But it's not just the low wages that deter would-be general practitioners. Dr Song says doctors fear that in community practices they will only see minor problems and will therefore become de-skilled. This in turn will mean that they no longer qualify for promotion and career advancement, he says.
Another problem with the lack of 'medical talent' in community centres is that the few doctors who do work there are overworked, facing long hours for little reward. This again leads to a high rate of burnout and high staff turnover, as well as lack of continuity of care for patients.

Professor  Cui Liuxin, a specialist in public health at Zhengzhou University says the key to building up primary care is investing in talent, and making community centres more attractive to high level doctors. However, he says this is not going to happen overnight. In the meantime, local clinics and village hospitals are shunned by patients and represent a waste of resources and workforce. At the same time, city hospitals are overused by people with minor ailments, leaving them swamped and unable to cope with the high demand.

The Zhengzhou city planning commission says it aims to create a stronger primary care workforce as part of a six year plan  based on training and recruitment for community clinics. However critics say that a six year time schedule is unrealistic, and it will take even longer than this to build up a well-qualified and capable primary care medical workforce.

The workforce planning committee said that pilot programs had shown that doctors could be attracted to work in primary care community clinics with financial bonuses, investment in medical hardware and also with extra support support for ongoing doctor training and education.

It remains to be seen whether local clinics will be able to attract and retain high quality healthcare staff.

Monday, 11 July 2016

Blog is resting for a while

Sorry no posts for  month - I have been in China and unable to blog from behind the GFW. Hope to get tarted again soon.

Monday, 6 June 2016

China's healthcare system - my article from Australian Doctor magazine

by Michael Woodhead


The Chinese have a saying: "Kan bing nan, kan bing gui," which roughly translates as "It's difficult and expensive to see a doctor".
This is evident at 8am in the foyer of a hospital in Kunming, the largest city in Yunnan Province, south-west China. There are lengthy queues to obtain one of the coveted ‘registration tickets' necessary to see a doctor, and arguments are breaking out among those who have been lining up for hours.
This is the frontline of healthcare in China because there is no primary care gatekeeper system to filter and triage.
Since the early hours, scores of people with minor ailments have arrived, hoping to claim a place in one of the outpatient clinics. Many of them are poor families from rural areas, who have come to the city because they have little faith in their primitive township clinics and under-trained barefoot doctors.
To see a doctor at a Chinese hospital, you first have to register and pay a cash deposit. However, the unrest in this morning's hospital queue has been triggered for another reason.
Because of the value of the registration tickets, scalpers exploit the economic possibilities and are brazenly working the queue, reselling tickets for many times their face value. And faced with long and often unsuccessful waits to get a clinic appointment, there is no shortage of willing buyers.
This is the reality for China's creaking healthcare system, which, through a mixture of underfunding and half-baked reforms, embodies the worst of both communist and capitalist healthcare models — long waits combined with high cost.
Hospitals are state-owned enterprises that receive meagre funding from government following the market reforms of the 1990s. The basic cost of a medical consultation is pegged by law at round 20 yuan ($4).
To cover their operating costs, hospitals resort to a wide range of surcharges that inflate medical bills. They have also come to rely on the commissions they charge on medicines, tests and procedures.
While most Chinese citizens are, in theory, covered by a national health insurance system, in practice, the caps, exclusions and lack of portability of these policies means that most people still face high out-of-pocket fees. Healthcare in China is strictly user-pays: no cash, no care.

‘Infusion room' syndrome
All this can create perverse incentives. For instance, the reliance of hospitals' budgets on drug mark-ups means that there is widespread overprescribing and overtreatment.
This is evident in the ‘infusion parlour' of the general medical outpatients clinic of the Kunming hospital.
The large room is filled with rows of seats, along which sit patients hooked up to IV drips delivering antibiotics or ‘tonics'. This is the routine first-line treatment for any patient with a fever, cough, cold or gastro complaint in China.
The hospital charges about 100 yuan ($20) per infusion — a healthy profit for them but unhealthy for patients who need only simple analgesics, fluids and rest.
"Hospitals giving infusions for minor illness has become a long-established bad habit, which is one of the important factors for antibiotic drug misuse," according to Professor Wu Yunming of Xuzhou Medical College in Jiangsu Province.
"Hospitals are businesses, and infusions represent a significant source of revenue for them."
To be fair to China's doctors, it is not individual greed or ignorance on their part that drives this poor practice.
Chinese doctors know antibiotic infusions are not best practice for minor illnesses, but infusions have become embedded in routine care because doctors depend on commissions for about a quarter of their monthly income.
The basic salary of a hospital resident is about 4000 yuan ($800) a month, equivalent to that of an entry-level public servant or teacher.
However, their contract includes performance bonuses of a further 1500 yuan ($300) — the so-called ‘grey income' — which doctors receive if they meet prescribing quotas in line with the hospital's revenue targets.
Senior doctors, especially those working in procedural specialities such as orthopaedics, can make considerably larger sums of money from commissions.
The government is trying to tackle this well-recognised cause of overservicing by banning drug commissions and allowing hospitals to charge higher consultation fees.
However, the early signs from pilot programs carried out in regional and rural healthcare facilities suggest that hospitals simply shift from drug mark-ups to additional fees for services.

Violence against doctors
Unsurprisingly, this mix of overservicing and overcharging is a source of widespread public distrust of doctors and hospitals. The feelings of being short-changed extend to the short consultation times.
The 80/20 rule, which prohibits GPs from billing 80 or more services on 20 or more days a year, is used by Medicare in Australia as a benchmark of poor care. But not so in China, where doctors working in clinics routinely see 80-100 patients during a four-hour shift.
"I'm so busy I don't even have time for toilet breaks, let alone lunch. I eat at my desk," one doctor told me during my visit to the hospital in Kunming last year.
A patient can expect to be with the doctor for about three minutes — six minutes if they are lucky. The perfunctory nature of such medical consultations means some patients resort to verbal and physical aggression to vent their frustration over perceived mistakes or miscommunication. Violent attacks against medical staff are commonplace.
In a survey by the Chinese Medical Doctor Association, more than 60% of doctors said they had been subjected to physical abuse and 13% had been physically assaulted in 2015. That year, there were 115,000 reported disputes in hospitals with 4600 serious "security incidents" leading to 1425 arrests.
There have also been several widely reported fatal attacks against doctors by disgruntled patients or their family members.
The most recent, in early May 2016, saw an emergency surgeon bludgeoned to death at a Hunan hospital by relatives of a traffic accident victim. After they were arrested, the assailants claimed the doctor had "not been vigorous enough" in treating their relative and had told them to wait their turn, according to Xinhua News Agency.
Such attacks have led to walkouts and public demonstrations by medical staff calling for authorities to crack down on violence.
On each occasion, the government has vowed to "strike hard" against offenders, but aside from ordering hospitals to hire more security guards, little has been done in reality.
Some doctors have taken to wearing personal protective gear such as stab-proof vests to work.

Primary care the solution?
China's health ministry is well aware of these problems and has two strategies to relieve the burden on hospitals: privatisation and primary care.
One of the key healthcare reforms underway in China at present is a move to bring "social capital" (namely, private investors) into the hospital sector. To encourage this, the Chinese government has relaxed laws to allow private operators to set up hospitals, with pharmaceutical companies taking a lead in the sector.
Just as importantly, China's health ministry has also eased employment regulations for doctors so that they are no longer tied to state-owned hospitals and have the freedom to work where they please.
In the past year, there has been a rapid increase in the number of ‘independent doctor groups' being set up to run private clinic services — the Chinese equivalent of US groupings such as the Mayo Clinic.
China's second major healthcare reform is a plan to boost the primary care system. This is a much tougher challenge. The current ‘community clinic' sector is very much an underdeveloped and under-resourced poor cousin to the culturally prestigious hospital system.
Some of the reasons may sound familiar. Few of China's doctors are willing to work in community clinics because the pay is poor, the clinics have little equipment and, unlike the hospital system, there is little prospect for promotion or career advancement.
China's health ministry has set itself a goal of having one family practitioner for every 2000 citizens by 2020 (the GP-patient ratio in Australia is around one FTE GP for every 1080 people).
But to meet this target, China would have to train an additional 400,000 medical practitioners. The scale of this task can be grasped by the fact that there are only 170,000 doctors in training, of whom 13,000 are in the generalist community practitioner training stream.
Primary care pilot projects have been trialled in China's major cities such as Shanghai and Shenzhen, but with mixed results.
They are declared a success by their proponents, on the basis of achieving 90% enrolments in their areas. However, there is still a marked reluctance among the Chinese public to actually use community clinics as the first port of call. Most still make a beeline for the major hospitals, which are still seen as the ‘centres of excellence' for medical care.
China's health ministry — like so many Australian governments — is nevertheless proclaiming that primary care is the way of the future for healthcare. They have also been mixing carrot-and-stick approaches to encourage the public to use primary care clinics, such as offering free consultations, but also making it mandatory to get a GP referral for a hospital appointment.
The ministry has also ordered that GP training pathways be set up and requires medical schools to introduce ‘primary care pathway' training quotas.
Meanwhile, the effects of a medical system that has embraced the alleged wonders of hospital-based care, can be seen.
Back in the Kunming hospital, by mid-afternoon the corridors are crammed with patients, hanging about at the doors of the clinics in the hope that a doctor will "squeeze them in" at the end of their official list.
But as one doctor told me, "It's too much. I'm supposed to finish at 5pm but most days I'm here for an extra hour or more. I am always late for dinner. I studied medicine for eight years and yet I work longer hours and earn less than a hairdresser."
He adds: "My parents are doctors but I wouldn't want my child to be a doctor."

Michael Woodhead is Australian Doctor's clinical editor.

Sunday, 15 May 2016

Putian hospital surgeon spills the beans on dodgy practices


Dr Qiu Jianqin is a plastic surgeon turned cosmetic surgeon from Fujian province who has a few unkind things to say about Putian hospitals. In an 'exposure' aired in the Chinese media this week, Dr Qiu talks of his four years working in a Xiamen hospital run by the Putian network - and portrays it as rife with corrupt practices, overcharging, health insurance fraud and substandard clinical practices.

Before I describe these in more detail I should point out that Dr Qiu may well be an aggrieved ex-employee because he has been sacked by the hospital over claims that he was treating patients privately, in an unauthorised way, in his own premises. Dr Qiu and the hospital are now in litigation over unpaid wages, broken contracts etc etc.

The expose comes from the Southern Weekend - based in Guangzhou, which has a reputation for relatively bold investigative journalism.

Dr Qiu says he made the move to the Xiamen New Century hospital in 2011 after becoming burnt out and disillusioned working in the public hospital system. Despite being a senior plastic surgeon, (he is a representative of the Chinese Medical Association Standing Committee of Fujian plastic and cosmetic branch) Dr Qiu says his workload was excessive and the rewards small. The market reforms in the public sector meant that many burns units became more oriented towards lucrative cosmetic surgery, and gave staff commissions and quotas to generate more income for the hospital. And yet at the same time, the hospital still had an iron rice bowl mentality in which they were overstaffed by bureaucrats, says Dr Qiu. The last straw was when his assistant surgeon left over low pay, and Dr Qiu allowed himself to be lured by the promise of the New Century Hospital. He was personally invited by the manager, Su Qincan, who he said spouted a lot of hype but promised a lot of benefits and good facilities.

Su Qincan
Dr Qiu joined the New Century Hospital along with his wife, a senior nurse, but was disappointed to find that the private facility was lacking in many basic facilities such as as resuscitation equipment that are standard in public hospitals.  He wasn't aware initially that it was part of the Putian network, and he had a poor impression of that group. His negative impressions were confirmed when he found that the hospital was now what it purported to be. While claiming to have many different departments, it actually concentrated only on four areas: cosmetic medicine, STDs, obstetrics and dentistry. The other departments - required by health department regulations were 'Potemkin villages' - they were there in name only and were only staffed when health department inspectors visited, at which time they 'borrowed' clinical staff from sister hospitals. The New Century even paid 10,000-30,000 RMB to 'rent' the name plaques of several senior doctors, to make it appear as if they had many eminent consultant physicians and surgeons.

Dr Qiu found that the doctors and managers working at the hospital were unscrupulous profiteers. They would lure in patients, overdiagnose and overtreat their illnesses. In the cosmetic filed, a simple skin fold operation that would typically cost 50 RMB in a public hospital was being billed at 1000 RMB at New Century. If patients complained about costs or about botched procedures the hospital's policy was to engage them with obstructive and expensive legal actions.

The hospital also engaged in routine health insurance fraud - doing extensive cosmetic work such as liposuction and claiming it as appendix removal was one  common example. The hospital accountants became skilled at 'swiping' the health insurance cards of patients, using all their family credit balance on the card even if just one person was being treated at the hospital.

Dr Qiu said this practice was so widespread that the local health authorities must have known but they were also bribed by the hospital. The hospital managers had a well organised system of what Dr Qiu termed "Feeding Putian Cake" - taking officials out to dinner on a monthly basis and allowing them to win 'prizes' of department store spending vouchers worth 1000RMB.

Dr Qiu said that at first he believed this widespread corruption and malpractice was a passing phases as part of the transition to a market-based healthcare system - and he believed he could help improve standards and bring change from within. However, after a couple of years he realised things were getting worse, not better and he started to look for ways out of his five year contract. He was working on commission and described it as being "like forced prostitute"

His managers told his he could not leave and warned him that he would not be able to work anywhere else because his name would be blacklisted if he broke his contract. Things came to a head in 2015 when Dr Qiu kept making complaints and demands for improvements in the hospital. He was told he had been fired - along with his wife. The given reason for his sacking was that he was 'sneaking work home' - seeing patients privately without payment through the hospital. Dr Qiu disputes this. And now he has entered into a litigation with the Putian hospital and its manager Su over unpaid wages and the refusal to hand over his documents and medical licence.

Sunday, 8 May 2016

After the vaccine scandal, now a cancer treatment scandal

Wei Zexi's parents

For someone ostensibly responsible for healthcare, China's health minister Li Bin is keeping a very low profile throughout a string of healthcare scandals. She was invisible during the recent scandal over 2 million doses of out-of-date vaccines that were widely distributed by dodgy wholesalers. Now she is also missing in action during the national uproar over the death of a 21-year old cancer patient Wei Zexi, who was duped into having an expensive and unproven cancer treatment at Beijing's Armed Police Corps Second Hospital.

As has already been widely reported, the hapless Wei found the hospital through its paid search results coming top in the search engine Baidu. Much of the commentary so far has been around the responsibility (or lack thereof) of Baidu and its dependence on shonky medical clinics for much of its paid search advertising revenue. There has also been a lot of adverse commentary about the role of the Putian network of private hospitals. As has been mentioned several times before on this blog, the Putian 'network' is a loose association of entrepreneurial clinics and hospitals offering healthcare services on the fringe of mainstream medicine - they specialise in 'monetiseable' services such as cosmetic surgery and fertility clinics. It therefore comes as little surprise to find they are implicated in the latest scandal.

With a synovial sarcoma, Wei Zexi is said to have paid 200,000 RMB (about US$30,000) for a novel "biological immunotherapy" treatment from the Putian-affiliated oncology unit at the Beijing Armed Police Corps Second Hospital. As a medical journalist who has been reporting on oncology for more than a decade I have to say I had never heard of the so called "DC-CIK immunotherapy" offered by the hospital. I did a bit of googling (not Baidu-ing) and looking through the peer-reviewed literature, and it soon became apparent that this is an experimental therapy that sounds impressively technical but has virtually no evidence or clinical trials to support its use.

The Beijing clinic claimed that the DC-CIK technique had been invented by Stanford university in California, but it didn't take Chinese reporters long to discover that the procedure is not being used at many reputable hospitals or institution in the US. A phone call to the developer of the technique at Stanford revealed that it is being used as an adjunctive (back up) treatment for some rare kinds of myeloproliferative diseases, but it is not a mainstream therapy. DC-CIK has also been reported in the Chinese/Hong Kong media as being used as a pseudoscientific and discredited cosmetic treatment.

So what is DC-CIK immunotherapy? It stands for "Dendritic Cells and Cytokine-Induced Killer" cell immunotherapy. Dendritic cells (DC) are basically part of the body's defence system against tumour cells - they present the antigen and activate the defensive T lymphocytes that kill tumor cells. Cytokine-induced killer cells (CIK),are the body's way of killing tumour cells - but they are non specific and need guidance to recognise the tumour cell as different from a healthy cells. In theory the coupling of these two systems should create the perfect tumour fighting team. But in practice... well, look at the fate of poor Wei Zexi. There have been no clinical trials of DC-CIK, so its use is essentially just guesswork.

Putian affiliate Chen Xinxian
Meanwhile back in the murky world of Putian clinics the journalists at Caixin have been doing some detective work and found that the dodgy hospital that milked Wei Zexi out of $30,000 for a useless pseudoscientific treatment is linked to a well known Putian duo called Chen Xinxian and Chen Xinxi and their company Shanghai Kangxin Hospital Investment Inc. Matching up business and internet records, Caixin found that the Chen brothers were involved in the running of 134 military hospitals around China. The PLA has basically subcontracted out its clinics to the Chen company

Caixin went further and tracked down about 20 other hospitals that are offering the DC-CIK procedure. When contacted by Caixin, many of the hospitals denied it or refused to comment, but Caixin found evidence that they were offering DC-CIK in the form of adverts and recruitment ads that sought staff to offer the treatment.

We thus have a situation in which many Chinese hospitals are exploiting cancer patients by charging them hundreds of thousands of RMB for unproven and dangerous treatments. Many of these hospitals are linked to the military and are thus out of the usual health department jurisdiction. It's notable, then, that this week has seen the Chinese central government declaring that the PLA will have to completely divest itself of commercial ventures such as its hospitals.

In the meantime, it's worth asking how - within a month of the vaccine scandal - China again find itself with having to address a major and widespread breakdown in the quality of its healthcare services. In a developed society such as Australia or Hong Kong, shonky medical practices are kept at bay by a series of checks and balances. Why would the DC-CIK scandal not have panned out in these societies?

1. If a clinic in Sydney or Hong Kong started advertising and offering DC-CIK to cancer patients, it would quickly come to the attention of the media, possibly by whistleblowers. Lack of press freedom in China - and fear of retribution against whistleblowers - means that this check is weak or missing.

2. Medical practitioners in developed countries also face scrutiny from their peers in the form of medical boards and general 'collegiate' links that make it clear what is accepted practice and what is not. An oncologist in Hong Kong or Sydney would be guided by professional guidelines on 'best practice' - and the use of DC-CIK would certainly not be construed as acceptable practice by a reasonable practitioner. The doctor would first warned by his peers and then brought before the medical board and struck off if he/she offered shonky treatments such as DC-CIK. This is obviously not happening in China, despite reports that the clinicians offering DC-CIK are retired or part time senior doctors.

3. There is obviously a problem with clinical governance in China - it is not identifying and addressing bad practice. In developed countries, bad doctors are also kept at bay by a mix of accreditation - having to meet defined professional standards - and also the threat of medicolegal action. This basically means that a doctor or clinic in Sydney or Hong Kong that offered a dodgy treatment like DC-CIK would have its ass sued off - and face a big compensation payout. But in China the jails are now full of lawyers who made the mistake of standing up for the rule of law.

4. And of course dodgy medical therapies are also kept at bay by advertising standards. If Google or a media outlet pushed a dodgy treatment like DC-CIK they would be prosecuted and fined for  deceptive advertising - or for promoting therapeutic claims that are not backed up by evidence. In China, however, Baidu is quick to censor words such as Dalai Lama, but is is given official blessing to rake in millions from advertising dodgy Putian clinics.

One final comment on the whole Wei Zexi/Putian/Baidu saga: it's worth noting that the President Xi Jinping is a former governor of Fujian and has close links to the region that includes Putian. He has gone on record as saying he considers the area his second home. Do the dodgy operators of Putian hospitals gain some degree of patronage and protection from their former provincial boss?

UPDATE: 14/5/2016

A search of PubMed shows there are virtually no clinical trials of DC-CIK published in major peer reviewed journals outside of China. Virtually all the studies are from Chinese centres and they are published in obscure Chinese-language publications. That's not to say there aren't any studies worth looking at. However, even one of the most reputable studies I was able to find showed only  a minimal effect of DC-CIK on cancer outcomes: in a two year study in lung cancer patients, the mortality difference at two years was 5%. In other words only one in 20 patients would still be alive as a result of treatment after two years. Put another way, for every 100 patients treated with DC-CIK, after two years 75 would be alive, whereas 70 would be alive if they received standard chemotherapy. Did the doctors treating Wei Zexi tell him that 19/20 patients would get no benefit for their 300,000 RMB?

Monday, 2 May 2016

A tale of medical murder and extortion

It sounds like the plot of a TV detective thriller but this is real life. A 41-year old man is brought by a friend into a Chengdu hospital suffering from diarrhoea. They both appear to be respectable middle class citizens. The illness is not serious, and the man is treated in the usual way for acute gastroenteritis. He is given intravenous antibiotics including clindamycin, and usually his symptoms would be expected to resolve within 24 hours. 

However, an hour after the antibiotics have been given, the man loses consciousness, turns blue and dies. All attempts to resuscitate him by hospital staff fail. He appears to have died from cardiac arrest. The victim's companion becomes indignant, agitated and blames the hospital staff for negligence. He says the clindamycin may have triggered the cardiac arrest and should not have been used. He demands compensation otherwise he will commence an expensive lawsuit against the hospital for damages.

At this point some of the medical staff find something suspicious about the behaviour of the 'respectable' man, his certain knowledge knowledge of clindamycin's rare side effects, and advise that the body undergo an autopsy. The victim's friend becomes more agitated at this suggestion, but the body is taken away for examination.

A detailed physical examination reveals a small puncture in the back of the victim's left hand. This was the intravenous line where a catheter had been inserted to give the antibiotics. To rule out the possibility that a nurse had given the wrong drug, the pathologist orders tests run on the victim's blood sample, and these come back with surprising results. The victim appears to have been sedated and anaesthetised, because the blood contains high levels of propofol - the anesthetic that killed Michael Jackson. It also contains the sedative midazolam and the muscle relaxant vercuronium. Combined, these three drugs would be sufficient to cause rapid respiratory failure and cardiac arrest. That's why they are used to execute prisoners in the US.

The victim's friend was apprehended and questioned by police and the true story emerged.
He confessed to secretly added mannitol - a liquid laxative - to the victim's drink, which caused diarrhea. Next, the man brought his apparently sick friend to the hospital for treatment. When the victim fell asleep and no other people were present, the man injected 10 mg of midazolam into the victim's vein through the path established for fluid infusion. Next, the companion twice injected 200 mg of propofol and 4 mg of vecuronium into the victim's vein. A few minutes later, the victim's breath and heartbeat stopped.

The perpetrator was revealed a surgeon with four years' experience who had gained access to the drugs from a former colleague at the hospital. He would have got away with the crime - and perhaps received a large sum in compensation if his behaviour had not raised suspicions of the vigilant medical staff.

This case is reported in the Journal of Forensic Sciences by Dr Ye Yi and colleagues of the Department of Forensic Analytical Toxicology, West China School of Basic Science and Forensic Medicine, Sichuan University, Chengdu. The fate of the perpetrator is not given, but it can be presumed he was tried for homicide - and if found guilty, received the death penalty.

Monday, 25 April 2016

"Three Lows and One Missing" - Is China on target to deploy 700,000 general practitioners? (short answer: no)


Being a medical journalist in Australia, I've come across a few academics and leaders of medical groups who have marvelled at China's stated aim to deploy an additional half a million general practitioners by 2020. In a country where there are 25,000 general practitioners, the numbers are mind boggling and the ambitious target seems laudable. When I say that this may be an unrealistic goal given the current paltry state of primary/community care in China, I am viewed as a something of an overly-negative cynic or even vaguely racist.

It's therefore reassuring to see that my expectations are in line with those of the president of the China Medical Doctor Association, Dr Zhang Yanling. This month the CMDA chief was one of several big potatoes who showed up at the "2016 GP Training Forum and 13th Community Health and General Practice Annual Conference" held in Beijing on 23 April

The main speaker at the meeting was National Health and Family Planning Commission (NHFPC) Deputy Director Liu Qian, who said that creating a primary care system was one of the key aims of China's healthcare reforms. He said the creation of a primary care workforce was seen as an important step by top leaders such as Xi Jinping and Li Keqiang, who sent a message to the conference to make serious efforts to implement the policy.

Director Liu made the usual top bureaucrat exhortations to strengthen/promote/deepen reform of the medical education system to make this so. However, even he was realistic enough to admit that of the current 120,000 medical trainees only 13,000 (about 10%) were training as general practitioners and some of them may be hospital based rather than in community clinics).

He also acknowledged that China's entrenched doctor system was geared towards hospital-based specialists and that there was only weak support for general practitioners. There is no culture of primary care in China and this is reflected in the lack of training opportunities, low social status of community doctors "and the trust of the masses of trust is not high". Unsurprisingly, therefore, being a general practitioner is not a very attractive career option for any would-be doctor.

Director Liu then went on to make more of the usual remarks about strengthening the education system to train more general practitioners and making more efforts in this direction  etc etc

He was followed by Dr Zhang Yanling of the CMDA , who expanded on what the director said by coining the phrase the "Three Lows and One Missing". General practitioners suffer from "Low Pay, Low Motivation, Low Social Status and Missing Education" said Dr Zhang.

He said that in words, China's authorities had expressed strong support for the WHO-expounded principle of primary care and having general practitioners as gatekeepers to the hospital healthcare system. However in practice, general practice was weak, underdeveloped and had only patchy distribution across the country, he noted. While there are some general practitioners in bigger cities and in some regional hospitals, the biggest gap for primary care was in township and smaller county hospitals which were often both understaffed and underused. Dr Zhang used the Chinese saying "Swallows sitting in the doorway" to express the deserted state of China's township hospitals - because patients do not trust the doctors and take their illnesses straight to the bigger hospital "centres of expertise".

Dr Zhang said three things are needed to build a primary care system in China:

1. A commitment to build a large and sustainable primary care workforce based on teams of well trained general practitioners who are well remunerated and have a graded career pathway, similar to hospital doctors, rather than being in a dead end job.

2. A robust training system that ensures the primary care workforce is motivated and highly skilled - including the retraining and upskilling of allied health practitioners and physician assistants to make a primary acre team. Dr Zhang said the current projections were that China should have 1 GP for every 2000 citizens, which would require 700,000 primary care practitioners by 2020. However, based on current training capacity of 172,000 doctors and doctor assistants, there would still be a shortfall of 400-500,000 general practitioners by 2020.

3. Training pathways including residencies will need a partnership between government departments of health and education along with medical professional groups such as the CMDA. Working together they will need to establish a GP training group with well qualified educators that can set standards, plan training place numbers and oversee assessment and accreditation.

Dr Zhang concludes that a general practitioner primary care system is possible so long as there is good policy, clear commitment from government and cooperation from government departments, industry, the profession and good guidance from academics.

The two day conference also heard from a host of academics and experts in primary care from China, Hong Kong and and foreign countries such as Canada and Australia.

We wait in hope to see if the fine words of the conference delegates are actually matched with government funding and backed by policy that is actually implemented.

Sunday, 17 April 2016

Heathcare privatisation: China adopts the US model


Prepare for the Mayo Clinic with Chinese Characteristics. This year China is taking the first steps towards creating the equivalent of US group medical practices such as Permanente and the Cleveland Clinic.

The so-called "Doctor Groups" (Yisheng Jituan, 医生集团) are springing up around the country -  mostly in major cities of the affluent Eastern provinces. They are being set up in response to the loosening of the government's rules on how and where doctors can operate - clinicians are no longer tied to the tertiary hospitals and are now being encouraged to be 'fluid' and 'open'. In response, at least fifteen doctor groups have been set up in 2015 and 2016, usually based around one location and with one specialty.

These are not socialist collectives nor are they not-for-profit groups. Instead they are privately financed businesses that are being set up with large investments from major industrial players such as pharmaceutical companies. These are groups that are seeking profits and market share as a return for their investment. Not sure how PRC's Marxist theorists will explain this away.

A typical example is the Yibai Pharmaceutical Anhui Oncology Group. This covers ten leading cancer specialists and their staff, as well as specialist treatment facilities in the Anhui and Shanghai area - services that include diagnostic imaging, radiotherapy, microsurgery and chemotherapy. The pharmaceutical backer has invested hundreds of millions of dollars already and is hoping to use its industry experience and connections to package other services such as pharmacy, supply chain and IT services. According to an investment analyst, the Yibai group is hoping to make 500 million RMB profits within two years.

Yibai is just one example: others include the Medical Imaging Group - an alliance of imaging facilities covering 27 hospitals including the Beijing Union Medical College Hospital, and Beijing PLA General Hospital.

Another doctor group is United Lige, which has a looser structure covering many cities and provinces including Beijing, Tianjin, Shanghai, Chongqing, Jiangsu and Zhejiang. It aims to bring smaller groups of doctors together in private clinics under the Lige banner.

Others Doctor Groups include
  • Sanjia (Mobile phone referral, liaison etc services)
  • Mingyi Hui (a multi-speciaity consortium that aims to offer family care from children to the elderly, with an online/telehealth emphasis)
  • Song Dong Lei Neurosurgery Group (Shanghai)
  • Pumai Doctors Group (collaboration with Chow Tai Fook to set up polyclinics in Shanghai)
  • Yongchun Male PLastic Surgery Group ( Shanghai Woxin Hospital)
  • Fenlan/Huaxia Pathology Group (Set up with more than 120 pathologists in conjunction with the China Medical Association Pathology Society, this group has received 30 million investment and will provide specialist pathology services via a network of 60 hospitals).
  • Famous Doctor Fertility Group (Shenzhen based, set up by veteran Obstetrics and Gynaecology specialist Gong Xiaoming)
Most of the private doctor groups are financed by domestic companies, many with little healthcare experience. But rather than doing joint ventures with western healthcare companies to get foreign know-how, Chinese newcomers to private healthcare are simply buying up foreign healthcare providers. The Luye Medical Group recently bought the Australian private hospital consortium Healthe Care for $938 million. Luye's Charles Wang says the new doctor groups aiming to do business outside the big hospital environment lack operational expertise, and they are hoping to transfer such skills from the Australian outfit to the Chinese market.

This is what he told the Australian Financial Review:

"When things change in China, they tend to happen very fast. Doctors and practitioners forming their own doctor groups is something that never would have happened until last year. They are now leaving the public sector and forming their own groups, and once that gains momentum, you will see it rapidly become more westernised."

According to the AFR, the idea is not to parachute Australian executives into China, but to export the way Australians manage their hospitals, including finances, procurement, risk and clinical control.

"I expect you'll see, in time, structured medical programs, and we'll go up to China and do training and bring middle managers down here in Australia. In clinical areas there will be doctor mentoring and nursing programs,"  says Healthe Care's CEO Steve Atkins.

My own view is that it will take a lot to break up the power of the big hospitals. There are a lot of vested interests involved. The move to private doctor groups also raises the question of what impact this will have on the capacity of the existing public hospital system. If the most talented doctors can work outside the system, who will replace them? If top surgeons take two-three days a week doing private work, who will fill their positions in the public hospitals for clinical work and training?

There are many unknowns, but with official backing from the health minister and the Premier, expect to hear a lot more about Doctor Groups from 2016 onwards.

Tuesday, 12 April 2016

Health ministry gets serious about promoting TCM

If you have depression take a herbal infusion of daylily. If you have avian flu, use a few capsules of anti-cold Chinese herbs. These are just as effective and much cheaper than using western pharmaceuticals. That's the official advice from the National Health and Family Planning Commission this week.

At a press briefing organised in Beijing, the ministry's propaganda chief Mao Qun'an said that it was important to look at the public health advantages of using Traditional Chinese Medicine for fighting and reducing the burden of disease, as demonstrated by officials from Gansu province. He said the TCM promotion efforts of Gansu's health department were the "correct direction" and should be a model that other provinces can learn from.

He introduced TCM advocate Liu Weizhong from Gansu, who described how daylily was being sold by the ton in Gansu for the treatment of depression.

"Gansu is a poor province but we have harnessed the power of herbs such as daylily as a low cost way to manage disease in the population," he said.

"When Gannan Tibetan country has landslides many of the local people suffered from insomnia, anxiety and depression. We put two tons of day lily in 12 cauldrons, gave every person a paper cup and treated 7000 people at a cost of 1.4 yuan each. The depression was all gone," he said.

[A quick google search shows that daylily aka Hemerocallis is a traditional herbal remedy that contains active ingredients including clonidine - a drug for hypertension that can cause neurospychiatric effects].

Likewise Liu Weizhong claimed that avian flu, which caused many deaths and serious complications in China, could be easily and successfully treated with just three or four capsules of a Gansu TCM remedy that cost less than 200 yuan. This was much better than the regular medical treatment for avian flu that cost ten times as much, he said.

Another TCM panacea was the health prevention kit issued to households which consisted of a bag of salt, scrapers, plates, cupping utensils and a thermometer.

Liu Wenzhong said farmers were told to boil some fennel and pepper leaf and use this with the equipment as a cure for 13 kinds of disease, including cervical spondylosis, thyroid nodules, cough, pharyngitis, lumbar disc prolapse, frozen shoulder, arthritis, stomach pains, and especially senile prostatic hypertrophy.

These folk remedies might sound like old wives' tales. but they have the official backing of the State Council as well as the National Health and Family Planning Commission.

In February the State Council issued a "strategic plan for development of Chinese medicine," which said that with the ageing population "there is an urgent need to develop and make good use of Chinese medicine".

The NHFPC agreed, saying that Gansu was leading the way in developing TCM and putting it at the centre of healthcare.

Sunday, 3 April 2016

Three vastly different articles on medical disputes - which one gets closest to the truth?

Violent and disruptive medical disputes have become so common in China that they barely rate a mention in the media any more. There has to be something quite different about an attack on doctors for it to make the headlines these days. The recent incident in which a mob of disgruntled relatives of a former patient took over a Shenzhen hospital and forced doctors to kowtow to a 'shrine' was one such incident.

In response, the Chinese authorities have said they will now adopt a new zero-tolerance approach to such protests and attacks on healthcare staff.

"Vice Public Security Minister Huang Ming said police will crack down on hospital-related crimes and show zero tolerance to perpetrators who assault and injure medical personnel. He made the remarks at a meeting on safeguarding order at hospitals and promoting harmonious doctor-patient relations on Thursday."

Ho hum - we've heard it all before. Every time there is a violent attack on hospital staff there are pledges to crack down, strike hard etc etc. A few weeks later it is business as usual. As I've written on this blog before, nothing will change until the government addresses underlying reasons for these disputes: under-resourcing of hospitals leading to ridiculously high throughput of patients - 3 minute consultations in which patients are barely listened to and prescribed the most expensive treatments (so that the hospital can get a bigger profit).

According to the latest empty promise to 'take action' the minister Huang "ordered better settlement of medical disputes by taking precautions, conducting risk assessment and spotting and containing disputes at an early stage." Gee thanks.

The article also makes the implausible claim that the number of hospital-related cases of violence continued has fallen four years in a row, and is down 12.7 percent year on year. The reality is quite the opposite.

And while on the subject of propaganda, the Hong Kong based SCMP, always keen to peddle a  more palatable version of Beijing's policies to foreigners, this week has an interview with a doctor who believes the answer to medical disputes is in looking to China's history. In a Q&A article, journalist Zhuang Ping throws a few easy questions to Dr Yang Zhen, a surgeon and deputy chief of the hospital administration office in Shanghai’s Zhongshan Hospital.

Dr Yang says China should take a look at how doctors in China traditionally established good relations with patients. Other than a few glib statements about being nice to patients and showing a more human face, he doesn't explain how doctors will make this happen when they have to rush through 80-120 patients in one short shift ( and prescribe enough drugs to them to hit their salary bonus target). All pretty worthy sounding but meaningless, really.

The article with the greatest insight into China's medical disputes in published in an academic journal (Health Economics, Policy and Law) and is based on interviews with 12 doctors from a multitude of specialties working in Shenzhen.

Interestingly, the article starts off by directly contradicting the claims of the public security minister,  quoting figures from the China Hospital Association showing that the number of medical disputes has increased by about 20% a year.

"Once worshiped as ‘angels in white,’ members of the medical profession in China are facing unprecedented challenges. Due to the deteriorated public trust during the marketisation reforms of the last three decades, Chinese physicians are working in an antagonistic environment. Heavy workload, low remuneration, and tainted social prestige have left millions of physicians feeling undervalued and
made medicine a career to be avoided, a situation rarely seen in other Confucian societies," it notes.

The article makes several points about medical disputes that have been raised before - but also includes one new one that is unique and potentially game changing.

The authors say that whatever the causes, medical disputes are rarely settled through legal channels, despite there being an officially recommended dispute resolution pathway and laws that in theory should cover medicolegal areas of dispute. The reality is that patients and their families have found that they are much more likely to get results - and get them much faster - if they take matters into their own hands. In other words, mob rule. According to the article, aggrieved patients and relatives of those affected by medical misadventure have found that they can get financial compensation and see their grievances gain attention if they take violent and disruptive action against hospitals and their staff. In practice this means staging demonstrations, blockading departments - and even whole hospitals - and threatening staff. They do it because it works.

This is the testimony of one of the doctors interviewed:

"Because the macro political environment attaches paramount importance to the so-called
‘maintenance of social stability,’ hospital managers are very afraid of high-profile incidents because local government may blame them for failing to mitigate the tension. If payment can quench patients’ anger, hospital managers would certainly love to do that, even when the patients are obviously blackmailing them. Patients also know the hospitals’ mentality very well, and actually take advantage of it. Some have chosen to stage farcical protests because doing so best maximized their interests. In fact, they deliberately avoided legal resolution because they knew hospitals would satisfy their monetary demands anyway."

The article goes on to say that hospitals fear high-profile protests because of the detrimental impact on their reputation, (which would inevitably affect their income) and also the political mandate imposed by local government to avoid mass incidents.

"They are also generally reluctant to resort to legal channels as litigation will not only ruin their reputation, but also consume a great deal of energy and time. Many studies have identified private settlement as the most popular means of resolution, even when patients’ complaints are clearly
unreasonable," it says.

In a second part of the study, two thirds of 300 doctors surveyed described relations with patients as 'very tense' and a similar proportion (65%) had been physically assaulted at least in the previous year.

The authors of the study say there are several key lessons for preventing and managing medical disputes in China. First and foremost is the need to reduced doctors' workload to a level where they have time to interact with patients and spend a meaningful amount of time with patients to allow good communication, adequate assessment and diagnosis and explanation of medical matters so that patients can make 'informed choices'.

Secondly, there is an urgent need to remove the profit/bonus incentives for doctors so that they paid according to their performance on good clinical practice rather than on how many drugs they have prescribed.

The study authors have a rather bleak outlook about the possibility of curbing attacks on healthcare staff - at least in the short-to-medium turn:

"For decades, health policy reform proposals have always put financing reforms, realignment of provider incentives, or organizational restructuring first. However, the [medical dispute] crisis in China shows policymakers and advisors the detrimental consequences of hostile interactions between doctors and patients. While it is not unreasonable to expect systemic reforms to restore trust between the two parties, one must bear in mind that it may take much longer than anticipated to see the effects; in the meantime, the dysfunctional doctor–patient relationship continues to deteriorate," they conclude.

Tuesday, 29 March 2016

Illegal vaccine fallout: clinics deserted as public lose confidence; lawyers support patients' rights; failure blamed on 'private market'


The issue of the 2 million substandard vaccines distributed across China continues to make waves in the media and for the government, with some surprising developments.

In a bold move, a group of more than 40 lawyers has written an open letter to the State Council demanding that the government 'protect the public's rights to information and compensation' in regard to the health consequences of the illegal vaccines. In their letter, they pose five questions:
  • How do individuals know if they have received the substandard vaccine?
  • How can people find out whether the vaccine they received was effective, and if necessary the need to re-vaccinate - and who will bear the cost?
  • Why were the public not informed of these risks associated with vaccination?
  • Why did the vaccine quality monitoring system set up in 2006 fail in early warning?
  • For those with vaccine injury, how will this be remedied?
According to Caixin, one of the authors of the letter is Guangdong lawyer and mother of a baby Wang Shengsheng. She herself got one of the suspect vaccines for hepatitis B and was shocked to discover that she may have put her baby at risk.

Wang Shengsheng says she had her baby vaccinated with both essential and non-essential vaccines on the strong recommendation of health authorities and was told they were both necessary and safe. She says she now expects full and prompt disclosure of all results from the investigation, particularly in relation to the batch numbers and locations of the affected vaccines. She says there is also a need for authorities to learn lessons from this scandal so that health consumers can be confident about future treatments and thus have the right to 'informed consent'. This freedom of information should include access to adverse event reports for individual vaccines that are derived from vaccine monitoring programs, she said.

Wang Shengsheng said China also needed a system of compensation for patients with recognised vaccine-related injuries, similar to the system already operating in the US.

Meanwhile, Chinese media outlets such as Sohu Health are reporting that parents are staying away from vaccination clinics as they have lost confidence in the safety and quality of the vaccines being offered.

Reporters who visited community health centres in Guangzhou found them almost empty, and with the few families there expressing concerns about the vaccines being used.

A doctor on duty at a clinic in Tongling said: "Usually at this time we should be full of people. But many parents do not dare vaccinate their children at this time. For the last two days we have been calling people telling them that our vaccines are safe but they are still reluctant to come. They say they are waiting for this matter to blow over."

A doctor at the Zhejiang Tonglu Street Community Health Centre told reporters that they had received dozens of calls from concerned parents asking about the quality and safety of the vaccines they had received. He said parents were still bringing in children to have the essential (Class 1, public funded) vaccines that were not part of the scandal, but use of the Class 2 (private market) vaccines had really dropped.

Doctors at other community clinics were emphasising to worried families that their region's vaccine supplies were on the 'safe list' as they were still part of the public centralised system that had always been well supervised and had not been implicated in purchase of substandard vaccines. They said they were now glad that the vaccine supply and distribution had been kept under control of the government disease control bureau and not 'relaxed' and privatised, as had been the case for many rural counties.

An opinion article in Caixin said the substandard vaccine scandal showed the stark contrast between China's successful and safe public vaccine program and the corrupt and unsafe 'private market' vaccine supply system. The article said the 2006 decision to relax controls on the sale and supply of 'optional' vaccines (Class 2) to allow a free market system had backfired with disastrous consequences for public health.

The article describes how local communicable disease control (CDC) bureaus had been encouraged to 'go to market' to generate extra funds for their own running costs. As with hospitals, these local units had been starved of funding and therefore came to rely on commissions from vaccines to boost their income. This resulted in local CDC bureaus buying the cheapest possible vaccines and charging the maximum markup to patients. It also meant that they strongly recommended non-essential vaccines to families, so that they could make extra profit.

Therefore,  any reform to prevent further substandard vaccine incidents will  need to address the "vaccine commission cash cow" phenomenon as well as ensuring the quality of the vaccine distribution system, it concludes.

Monday, 28 March 2016

Week 2 of the vaccine scandal: latest developments

It is quite remarkable that in the middle of the second week of the scandal around distribution of dud vaccines there has been no comment whatsoever from China's health minister Li Bin. In fact the response from the Chinese government could be summed up as an attitude of "Crisis? What crisis?"

The official line has been to focus on the perpetrators - the illegal wholesalers and distributors in Shandong -  and to avoid any analysis of how things could go so badly wrong - and what the Chinese public should do about it all.

It seems clear that the government has been 'harmonising' (deleting and censoring) media and online articles and social media discussions relating to the vaccine scandal. The media articles that originally drew attention to the crisis have been removed, and instead replaced with bland assurances from officials that the matter is being investigated and all should be well.

Most of the permitted coverage has been along the lines of the WHO China response, namely:

  • The dud vaccines are unlikely to cause any adverse effects even if not handled according to the cold chain.
  • Most of the vaccines have already been used, and there have been no reports of spikes in adverse events.
  • The illegal distribution is being investigated and the perpetrators brought to justice.
That's it.

There has been no response to important questions such as:
  • How many people received dud vaccines and have any of them acquired diseases because of poor immune protection?
  • What are the most frequent and potentially most severe diseases covered by the dud vaccines?
  • What needs to be done to trace/follow up/test and re-vaccinate those who have received dud vaccines?
  • How can the public be reassured that vaccines currently in the system are not duds? Batch numbers? Locations?
These are just a few of the fundamental questions that any professional and competent medical regulator such as the FDA would be asking. And yet in China there has been no such response. There have been some vague reassuring statements from the China FDA, but no detailed information about the scale of the problem and how it will be addressed.

Once again the "SARS hero" Dr Zhong Nanshan has been given airtime to comment. Speaking at a national influenza conference in Hainan (unfortunate timing) Dr Zhong said there was no need to doubt the quality of Chinese made vaccines and no reasons for panicked parents to seek foreign vaccines or to go to places such as Hong Kong for vaccinations. He also said (quite rightly) that he hoped the vaccine scare would not undermine China's immunisation program, which has markedly reduced or eradicated diseases such as measles, whooping cough, polio and hepatitis B in China.

Fine words, and not to be disputed, but there is a need for more leadership on this issue if public faith in the public vaccination system is to be restored. As I've said before, trust is not easily won and it is a two-way street. If the government does not trust the public with information - if it closes down the communication channels and deletes articles about the vaccine problems then it will just encourage the public to turn to the rumour network.

On a wider level there is little hope for a robust medical and healthcare safety system when there is a culture of punishing those who speak out. In other countries there has been grudging acceptance by authorities that transparency and accountability are needed in clinical matters to ensure safety. Staff have to feel confident that they can speak out - and also feel that it is their duty to do so, rather than feel intimidated or a false sense of loyalty to persons or organisations. In China under Xi Jinping there is currently a major crackdown on those who are outspoken or who dare to question "the core".

And so at the end of March we find that China is facing its biggest health safety crisis since the melamine in milk saga of 2011. And yet if you turn to the medical forums such as there is no discussion and no advice there. They have presumably also been 'harmonised'. A week ago when the scandal first became public, the Deputy director of the Department of Immunology at Peking University Professor Wang Yue expressed shock at the safety implications of the dud vaccine trading.

"This is murder" he said, referring tho the likelihood of people dying from vaccine preventable diseases.

The article has now been taken down.

It's important for Li Bin to show some leadership and act swiftly to restore the public's faith in China's vaccination system. If not, vaccines may become like China's milk formula industry - untrusted, shunned and encouraging consumers to turn to expensive alternative 'grey market' suppliers.

Meanwhile, here are some links to articles of interest:

SARS hero Zhong Nanshan reassures on the vaccine problem, urges public to maintain faith in China's vaccine program

Propaganda Ministry directive: "Don't hype the news on illegal vaccines"

VOA article on the vaccine articles that have been removed and the vaccine keywords that have been blocked on social media

Netizens claim that China's propaganda ministry is highlighting news about Japan's war crimes as a distraction from discussion about vaccine scandal

Hong Kong media raise fears that vaccines may be the new milk powder - will mainland 'raiders' flood Hong Kong to buy up good quality vaccines?