Tuesday, 23 December 2014

Saturday, 20 December 2014

A roundup of the medical news headlines from China

Efforts to establish a primary care system in China are faltering because a lack of qualified doctors entering the specialty, according to the People's Daily.  It says GPs account for about 50% of doctors in western countries but only 5% in China. In addition, few young doctors want to become GPs because of the poor status, lack of career prospects and poor pay. The article says China must increase pay and career prospects for community care doctors if it is to achieve its stated aim of having a gatekeeper system to reduce hospital overcrowding.
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In Sichuan, villagers have petitioned to expel an 8 year old boy because he is HIV positive. Even his own grandfather was among those who signed to get rid of the boy from an un-named village. The villagers said the boy was a 'time bomb' and he should be removed to "protect villagers' health".

The Washington Post has a feature on the new wave of foreign investors  trying to make a buck out of the rapidly changing and deregulating Chinese healthcare system. However, the feature notes that efforts by foreign investors to open hospitals and clinics in China is limited by the lack of medical insurance and the overall shortage of skilled doctors in China.

Chinese ministers are doing the rounds of county-level hospitals, which are the target for the next wave of reforms. The government wants to try stop the decline of county hospitals as patients bypass them and head straight to major city hospitals, which they believe to have more expertise.

One in four patients admitted to rural hospitals in China doesn't need to be there, according to a study from  Tongji Medical University in Wuhan. The study found that 27% of patients at rural hospitals had been admitted inappropriately, with wrongful admission rates as high as 37% for older Chinese. The researchers said the higher reimbursement levels provided in the New Rural Medical Insurance scheme for inpatients than for outpatients encouraged patients to be admitted and treated inappropriately.

Wednesday, 17 December 2014

Baby for sale to pay medical bills | Ambulances misused by non-urgent callers | Avian flu returns more virulent


Rural migrant sells baby to pay medical bills

A rural migrant women from Sichuan has been trying to sell her baby on the street of Fuzhou to raise money to pay medical bills for the baby's father. Police were called when the women displayed a sign saying "Boss fled after industrial accident and we don't have the money for treatment; I'm willing to sell my child to save her father." The woman said she had already paid Y7000 in medical bills for treatment of her husband who had injured himself after falling from a construction site. Some sympathetic passers-by gave the women some money before she was persuaded to end her 'sale.'

Beijing ambulances used for non-urgent cases

Ambulance services in Beijing are overstretched because 80% of cases they transport are non-urgent and do not need to attend the emergency department, a survey has found. Only 20% of the people brought in to hospital by ambulances had life-threatening conditions, according to a report from the Beijing's Health Planning Commission, which found that most of the ambulance patients could be treated in the outpatients department. The commission has suggested that patients are triaged before being taken to hospital as many critically ill patients are left without transport while ambulances are dealing with non-urgent calls.

Avian flu returns more lethal

The severity of H7N9 avian flu in China increased with the "second wave" last winter and the virus may return in an even more virulent and lethal form this winter, researchers have warned. The lethality of the H7N9 virus increased by 48% from the first wave in 2013 to the second wave in 2014, according to Dr Li Feng and colleagues at the Key Laboratory of Surveillance and Early-warning on Infectious Disease at the China CDC, Beijing. In the latter part of the first wave the death rate among hospitalised patients was 17% for young people under 60 and 42% for people over 60. In the second epidemic the death rate was 36% in people under 60 years, and 59% in people aged 60 years or above.
"If another epidemic of human infections with influenza A(H7N9) virus occurs in the winter of 2014/15, proactive control measures on the poultry-human interface may be preferable to reactive measures," the researchers suggested.

Monday, 15 December 2014

Nurses inadequately trained | Child physical abuse common | Coal use causes black lung

Nurses lack adequate training

Only one in seven nurses in China undergoes a three year undergraduate training program, and many lack adequate training, medical educators have complained. In a letter to the Lancet, Liu Fengxia and colleagues at the Fourth Hospital of Hebei Medical University say that they are worried by the fact that most nurses in China not receive standard nursing training. Each year only 30,000 out of 186,000 graduate nurses earned standard bachelor degrees, they noted. Most nurses received only diplomas after brief training. The lack of education and the stressful working conditions mean that poorly trained nurses could make mistakes in patient care - and their lack of training may also be a factor in triggering violence against health staff.
"Nurses are intermediates between doctors and patients. In our practice, we have seen misunderstanding and mistrust between patients and doctors most probably due to of the inadequate training of nurses. A more comprehensive training system for nurses is needed," they write.

Physical punishment of children condemned

China's high rates of physical punishment of children amount to a culturally-accepted high level of child abuse, researchers have said. A major review found that 36% of children in China experienced physical abuse from parents, typically in the form of slapping and spanking for disciplinary reasons. They said the rates of physical punishment in mainland China were significantly higher than in other Asian countries, where the influence of western methods of parenting was stronger. The researchers said physical punishment was "culturally accepted" within Chinese society because the Confucian philosophy of parenting, which endorses parents’ authority and filial piety, is still prevalent in the minds of Chinese parents and children.
"A well-known proverb “gun bang di xia chu xiao zi” (also translated as “spare the rod, spoil the child”) indicates that the filial piety is achieved by strict physical discipline of children," they noted.
They said China's high rates of physical abuse were concerning because of the known associations with poor mental health and harmful behaviors, such as depressive disorders, anxiety disorders, eating disorders, childhood behavioral disorders, suicide attempts, drug use, and risky sexual behaviour.

Coal use leads to black lung

China's high use of coal for fuel has led to high rates of pneumoconiosis and "black lung", researchers say. In a Dow Jones report, clinicians said pneumoconiosis was common in mining workers and other coal-related industries, especially as workplace safety rules were often ignored in China. masks could help prevent pneumoconiosis but were often not provided to workers, they noted. The number of people diagnosed with pneumoconiosis has risen sevenfold from 2005 to 2013 to about 750,000, at an average pace of 35% annually, according to official data. And while treatment is available, it is often unaffordable for many low paid workers, labour activists note.

Sunday, 14 December 2014

Zhejiang hospital runs out of money, can't pay for medicines

by Michael Woodhead
A hospital near Taizhou in Zhejiang is "crying poor" saying that increasing patient burden and rising prices means it does not have enough money to buy essential drugs. The Xianju county hospital has out up a notice on its public LED screen asking for "understanding" because it is no longer able to provide medical supplies such as blood plasma. 

The hospital authorities said their outlays exceeded their income and they no longer had funds to buy drugs and other medical supplies. The director of the hospital, Chen Xiaojun, told Xinhua that the hospital was more than 15 million yuan in debt because the New Rural Medical Insurance Scheme did not cover all the expenses incurred by patients and the insurer was refusing to release further funds. The local health department was also refusing to provide further funding, and the unpaid bills of 11 million yuan meant that pharmaceutical companies were no longer willing to supply drugs to the hospital.

The shortage of drugs was most acute for the high cost drugs for conditions such as bronchitis and anaesthetics and other drugs needed to cover surgery, he said. This meant that operations at the hospital also had to be curtailed. Medical staff said patients were being advised to find another hospital if they had a serious disease, and medical staff were also complaining that their wages had not been paid for some months.

The hospital authorities blamed the 'bankruptcy' on three factors: they said the government reimbursement levels for had been set in 2008 and had not kept up with rising costs or increasing patient numbers. Secondly, the price of drugs had also increased substantially, leaving hospitals out of pockets, especially with new zero markup policies. And most importantly, the rural medical insurance scheme expanded the reimbursement to patients for inpatient costs from 40% to 80% of fees, which meant many patients now wanted to stay as inpatients for longer, driving up costs.

A spokesman for the Xianju country government said the relevant departments were now having a 'crisis meeting' to solve the problems that had led to the  lack of funding at the hotel. However a spokesman said the Xianju hospital was not the only hospital facing the problems of rising costs and falling income, and the problem had to be tackled on a wider basis by changing the reimbursement system and charges, he said.

The local government also criticised the hospital for making public announcements about its poor financial state and lack of medications, as this would lead to public panic and loss of faith, he said.

Sunday, 7 December 2014

Infusion superstition condemned | Hukou medical reform | Heavy metals found in wheat

Doctors condemn superstitious belief in infusions

A life-threatening incident of allergy to an infusion has lead a Shanghai doctor to criticise parents and grandparents for insisting their children have unnecessary infusions to treat minor illnesses with fever. A 12-year old boy with fever treated at the Ruijin Hospital  nearly died after having a massive allergic reaction to an infusion he was being given for a fever. The boy recovered thanks to the rapid response of medical staff, but doctors said they faced huge pressure from parents to give infusions when they were not needed. Doctors said parents had an almost superstitious belief in infusions and insisted on them to help their children get better quicker so they would have more time to study.

Hukou reform will give rural migrants healthcare rights

Millions of rural migrants may get access to affordable healthcare as China modifies its household registration (hukou) system to give more right to the floating population. In a major shift in policy, reforms to the residence permit system will grant migrants the same access as urban residents to  public services  such as medical treatment  for their children. The plan, which has been released for consultation by by the Legislative Affairs Office of the State Council, would allow migrant workers who stay in a city for half a year with a stable job and residence may apply for the residence permits.

Wheat near Yellow River contains heavy metals

People living near the Yellow River are being poisoned by eating crops containing high levels of heavy metals absorbed from irrigation water drawn from the river, a study shows. Wheat grown in areas around Baotou irrigated by Yellow River water showed high levels of mercury, lead and selenium, researchers from the Inner Mongolia University of Science and Technology showed. Crops also contained high levels of copper, zinc and manganese, they found.

Wednesday, 3 December 2014

Beijing doctor explains on Youku about bribes and commissions

by Michael Woodhead
A video is circulating on Youku of a man purporting to be a former surgeon at a Beijing hospital, explaining how the red envelope bribe and commission system works in China. 
The erstwhile doctor, claimed to be  Li Rui of the Beijing Aerospace Institute Hospital Urology department. He said that during his time working in surgery, doctors would make huge commissions by charging patients exhorbitant sums for ancillary items such as a 1500 yuan gauze pad to stop bleeding, on which they earned a 30% fee. He said surgeons performed many simple operations such as removing appendix in 10 minutes and then adding lots of expenses to the bills. Dr Li said it was best to work in procedural specialties such as orthopaedics, surgery and obstetrics where there were more opportunities to perform operations and use expensive medical supplies and devices. The man was purportedly giving a presentation at the well-known New Orient academy  in Beijing, although the institute denied any knowledge of his working there. In a statement the Beijing Aerospace Institute Hospital denied the man's claims, describing them as baseless and slanderous. The hospital said there had been a Dr Li working at the hospital but he had been absent for six months and thus his contract was terminated. The hospital said the man's statements on video lacked credibility, citing as an example that there was no way a surgeon could do an appendix removal in 10 minutes, even with the most modern equipment.
However, the video has been widely circulated on Chinese social media sites, drawing comments on the greed and corruption of doctors and the profit-seeking nature of public hospitals.

Tuesday, 2 December 2014

Diabetes in China: the numbers are staggering

by Michael Woodhead

The Lancet Diabetes & Endocrinology journal is this month running a series of articles focusing n type 2 diabetes in China.  

The numbers make for grim reading: more than 12% of Chinese are reported to have diabetes (100 million people) according to US criteria (although there is some dispute over whether these  criteria may result in overestimates).  Because of the lack of awareness and lack of adequate screening and intervention programs, many of the Chinese with diabetes are undiagnosed, untreated, or uncontrolled. 

The articles say that Chinese people are especially prone to type 2 diabetes at relatively low levels of overweight, and Chinese people are more susceptible to [insulin producing] beta cell failure and deficits in insulin production. The blame, unsurprisingly, is put on China's rapid development and shift to lifestyle factors such as eating an unhealthy diet and doing less exercise. 

A second article says that there are also problems with provision of prevention and treatment programs for diabetes in China. As well, there is little research on the best forms of drug therapy for Chinese people with diabetes. Newer [and more expensive] anti-diabetes agents such as the gliptins seem ideal, but they are not currently accessible or widely used by most doctors.

The articles conclude by saying that any solution to the diabetes epidemic in China must be based on multiple strategies: there needs to be healthcare reform to make diabetes prevention and treatment more widely available through primary care and through initiatives such as diabetes nurses. There are need to be major preventive health campaigns to promote healthier eating and activity, to reduce the risk factors for diabetes in China. The articles also note that health reforms are needed to provide adequate health insurance cover and reimbursement for treatment of diabetes patients in China

Monday, 1 December 2014

China's best case scenario for an Ebola outbreak: 3000 deaths

by Michael Woodhead

With more than 600,000 annual passenger arrivals from Africa and a poor to non-existent public health infrastructure in most parts of the country, China faces  a very real risk of an Ebola outbreak. That the verdict of infectious disease specialists who have modelled what will happen if a person with Ebola lands in China and is not detected immediately.

Dr Chen Tianmu and colleagues from the Changsha Center for Disease Control and Prevention have used data from previous Ebola outbreaks overseas and also from outbreaks of dengue and HIV viruses in China to model the likely spread of the infection before it can be brought under control. They modelled several different scenarios based on different levels of infectivity of the virus and different levels of detection and containment.

They based their calculation on the fact that there were 524,900 African visitors and 112,966 Chinese returning from Africa each year in China. Based on current distribution of Ebola Virus Disease and the rates of carriage in Africa, they estimated that 0.04%–0.16% of these arriving passengers in China (255–1021 people) may carry Ebola. Even if an optimistic assumption is made that only 1% of them slip through the entry-exit inspection and only 1% of these are not picked up by further reporting and monitoring follow ups, this would still mean 3-10 Ebola virus carriers could be at large in China.

The researchers noted that China lacks a primary care system and most sick patients go direct to hospitals that are overcrowded and where Ebola patients might spread the virus to others. China also has limited public health reporting and surveillance systems for much of the country, and it would therefor be possible that cases of Ebola virus could be misdiagnosed and slip though the net until the patient became symptomatic and infectious.

The researchers then calculated that the likely impact of such 'index cases' spreading the Ebola infection to others would be outbreaks of Ebola in China affecting between 6000-10,000 people. With a likely fatality rate of around 50% this would mean a severe mortality burden for China, they wrote.

Writing in Travel Medicine and Infectious Diseases, they said the lack of Ebola testing facilities in China and poor infection control practices would further encourage the spread of the infection, they predicted. Other factors, such as the lack of quality control on blood transfusions (as seen with outbreaks of HIV and hepatitis) would also increase the risk of spreading Ebola in China, they warned.

"Even if a good surveillance and monitoring system is implemented at immigration, an effective and efficient local medical response system involving primary health care providers and awareness of the general public is necessary to minimise the risk of an Ebola Virus outbreak due to other unknown sources," they suggested.

Sunday, 30 November 2014

Cancer treatment unaffordable | Drug pricing corruption | Premier tackles HIV stigma | Rare diseases not reimbursed | US medical exams popular in China

Public punchbag to pay son's cancer fees
In Beijing a man who cannot afford the Y700,000 ($114,000) medical bills for his son with leukaemia has offered himself as a public punchbag to raise money. The man called Xia Jun stands outside Guomao station and asks for 10 Yuan to be thumped. He says he has collected 10,000 yuan in one day without anyone taking up the opportunity to hit him.

Corruption on drug price setting cited as reason for abolition
The recent move to abolish price caps for prescription medicines was triggered by corruption in the agency charged with setting drug prices. Critics said officials in the National Development and Reform Commission (NDRC) were under investigation by the anti-corruption and bribery bureau under the Supreme People's Procurate for taking bribes. Pharma company executives said the current pricing system forced them to pay bribes to regulators to set higher procurement prices.

Premier lends support to ending HIV stigma
Premier Li Keqiang has shown public support for people with HIV and aimed to dispel prejudice and ignorance about the infection by visiting  a HIV clinic at the inspected Beijing You'an Hospital.
 For World AIDS Day, the Premier met HIV patients and healthcare workers and said the old attitudes of fear surrounding the topic of HIV must be abandoned and HIV patients need more care.

Rare diseases slip through the health insurance cracks
China's health system is not working for children with rare diseases, as their families face high treatment costs and no access to medical fee reimbursement, according to an article in the SCMP. One mother of a 3-year old boy with Langerhans cell histiocytosis (LCH) said his bills for diagnosis and treatment had reached nearly 200,000 yuan ($33,000), of which just 4,800 yuan ($780) had been reimbursed by the rural medical insurance scheme.

US medical exams popular in China
Thousands of China's medical students and young doctors are studying for the US Medical Licensing Examination (USMLE) that will allow them to practice medicine in the US. However, despite studying for up to 1500 hours for the exam, many of them say they are taking it to improve their medical skill rather than just to get a better paying job. Many Chinese students said the US medical exams taught them a more patient-centred approach and put more emphasis on communication and empathy rather than just rote-learning of medical facts. The test is also taken by many of the 60,000 foreign students studying medicine in China.

Survivors of Mao's 1959 Great Famine now in poor health

by Michael Woodhead
The Great Famine of 1959-61 triggered by Mao Zedong's disastrous  agricultural policies is estimated to have caused 16-30 million deaths.  But its effects are still being felt among the survivors - especially the children who were born around that time and who are now reaching retirement age. 
In a major national survey two Chinese researchers Fan Wen and Qian Yue have found that the "59-61" generation have significantly worse physical and self rated health than a similar cohort of unaffected people. The poor health is not unexpected given the malnutrition experienced by the children growing up in that era. Previous studies have shown major effects on growth retardation and development. Interestingly, the researchers found that those currently in the worst health tended to be people from families who had Communist Party connections. This was presumably a 'weak survivor' effect because people with Party connection had better access to food during the famine, whereas   families without Party connections would simply have starved, killing off the weaker children. Writing in Social Science Research, the  researchers say there are millions of Chinese in their fifties and sixties who in poor health because of the early life effects of the famine.
They conclude: "Having experienced one of the largest famines in human history, these individuals are now moving through their retirement years. Our study suggests the necessity of paying special attention to this cohort, with programs designed specifically to meet their special needs."

Thursday, 27 November 2014

Drug price caps abolished | Healthcare staff HIV knowledge lacking | China develops drug for lung cancer

Drug prices to rise as price caps abolished

The Chinese government is to abolish price caps on all medicines in a move to end drug shortages and bring market forces into play on the country's pharmaceutical supply system. Draft rules propose to "cancel government-set prices on drugs, and through insurance price controls and the tendering process, allow the actual transaction price of drugs to be set by market competition,"an official report said. Drug prices will in future be determined by health insurance departments,  tendering processes and negotiations, it said. Analysts said the government would have to strike a balance between keeping essential medicines affordable and ensuring that companies had enough profit to ensure supply of medicines.

HIV ignorance still common in rural China
Healthcare workers in rural China have a poor understanding of HIV and how it is transmitted, a study carried out in Shaanxi has shown. When subject to a knowledge test on HIV, healthcare workers such as nurses and medical technicians scored only about half of questions correctly, and showed a lack of knowledge of about the transmission of HIV, exposure risks and appropriate protection measures. The lack of knowledge about HIV also translated into inappropriate behaviours, said researchers from the Xi’an Jiaotong University School of Public Health.

Lung cancer drug shows promise
China's homegrown epidermal growth factor receptor inhibitor (EGFR) icotinib (Conmana) shows promise for non-small cell lung cancer, researchers say. The targeted anti-cancer molecule has been researched and produced by the Zhejiang-based Beta pharmaceutical company. It has shown good results published in the Lancet and offers a lower cost alternative to western drugs for the disease that is very common in China, say experts.

Monday, 24 November 2014

China's move to a GP-based primary care system: lots of policy, little progress

In China the average salary for a GP is about half that of a hairdresser.
by Michael Woodhead

If you relied on the official Chinese media you could be forgiven for thinking that China's primary care system was the best thing since sliced bread. Hardly a week goes by without an article extolling the virtues of the new networks of general practitioner-based community health clinics.

Many cities such as Beijing and Shanghai are strongly encouraging all residents to enrol with the local community medical centre and to visit the GP for everyday ailments rather than going direct to hospital. The public are enticed to see GP clinics with incentives, such as the free or low cost availability of GP clinic services and ease of getting to see a GP with little need for waiting or queuing up for registration, as is the case with hospitals. Unfortunately, the great Chinese public are not buying it, and they continue to make a beeline for hospitals whenever they are sick.

This week a revealing commentary in the Quarterly Journal of Medicine paints a more realistic picture of China's fledgling GP system. In fact, fledgling isn't the word, foundling might be a better descriptor.

According to the article by Dr Kong Xiangyi and Dr Yang Yi of the Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, the primary care system is in a kind of "Failure to Launch" status. They say the government's stated aim of training 150, 000 GPs by 2015 is pie in the sky. The problem, it seems, is that nobody wants to be a GP and nobody wants to see a GP. In China, to be a doctor in the community health service is a low-status position in an underfunded and unrecognised branch of medicine. As the two doctors point out, "the average annual income of a Chinese GP is less than half of a hairdresser and far lower than a specialist."

Part of the problem is that there isn't really any good local model for the would-be GP to emulate. There is no real definition of a GP, and currently many GPs are little more than barefoot doctors - local clinic practitioners who have received five years of basic training in health and medicine. They are employed to offer the "Six Basics" of health: prevention, health education, women and children’s care, elderly care, immunisations and physical rehabilitation. There is also a three-year postgraduate program for medical graduates to train as GPs, similar to that seen in western countries. However, there are very few takers for these courses and their impact on the national medical workforce has been minimal.

The authors of the article say that there appears to be little real enthusiasm for creating a genuine general practice system in China. As they put it, there is a lot of policy, but very little concrete support for funding and training programs. There are no primary care institutions or programs in China: the speciality is a career dead end, and the cream of China's medical expertise and social status is still centred around the big teaching hospitals.

The solution, according to the authors, is for China to emulate foreign countries that operate well-funded and high status family medicine programs. The aim must be to create a gatekeeper system in which patients are triaged by the GP before being allowed to see a specialist. And conversely, GPs must be enabled to provide follow up care after a patient is discharged from hospital. To do this, the health ministry needs to harness the skills and the prestige of the major hospitals to implement such programs.

Until that happens, patients will continue to avoid the community medical clinics, which are underfunded and have poor quality and outdated equipment. The lack of funding means that GPs have to charge commissions on drugs and medical supplies, further eroding trust in their services.

"China’s current reforms still do not emphasize enough the value of GP led primary care," they conclude.

Sunday, 23 November 2014

China's anaesthetists are dying of overwork

by Michael Woodhead
The sudden death of a 40-year old anaesthetist at the Beijing Fuwai hospital this month has put the spotlight on the high work burden of anaesthetists in China and the shortage of doctors in this speciality. 

Colleagues of the doctor who died of a brain haemorrhage after a long shift are not only mourning him but also the dire state of their branch of medicine. Many of the deceased doctor's colleagues said it could have been them, given the amount of strain they are working under. As one doctor told the CCTV news station, anaesthetists were working such long hours that some of them took naps on spare operating tables. And it was well known that there have been more than 15 fatigue- and stress-related sudden deaths among anaesthetists in recent years.

A recent survey carried out by the Chinese Medical Association's anaesthesia branch found that more than half of the doctors were working shifts in excess of 10 hours a day and 80% believed they were working beyond safe limits to do their job properly. In addition, 70% of anaesthetists said they were dissatisfied with their branch of medicine.

These findings were confirmed in an interview with an anaesthetist in her mid 40s who told reporters that it was not unusual to do 12 hours shifts due to the lack of staff and it was even known for doctors to work right through a double shift of 24 hours.

The president of the CMA anaesthetist branch Professor Hou Ren  said the job was highly stressful as they literally had people's lives in their hands every hour of the day. The job was especially taxing because of the high workload and lack of time for preparation, which meant that an anaesthetist might be dealing with a frail elderly person one minute, then a person with cardiovascular problems the next and later a pregnant woman . Each of these situations required very different management and skills, he said and anaesthetist had to make decision and adjustments according to a patient's condition by the minute.

He said the main problem was that the anaesthetist workforce had not kept track with the increasing number of hospital patients and operations. There were 2.8 million doctors in China, of whom only 2.5% were anaesthetists, which meant there was a national shortage of about 70,000 anaesthetists.
And while some hospitals had enough anaesthetists in theory, in practice there were always shortages because anaesthetists were off sick, on study leave or because they had to teach students.

To remedy the problem some general physicians were being re-trained as temporary anaesthetists, but this was only a short term solution, he said. Another way of addressing the problem was to learn from foreign countries which had managed to use anaesthetists more efficiently through the use of technology and better staff management, he added. In the meantime, anaesthetists faced high levels of pressure and there would continue to be overwork, stress and potentially unsafe work situations.

Saturday, 22 November 2014

County hospitals under scrutiny | iKang CEO gets award | Mass General expands into China

China sends in hit squads to fix unpopular country hospitals
Authorities in China have decided to take action to tackle the growing problem of Chinese patients leapfrogging their local hospitals and making a beeline for the big city hospitals (which makes them hopelessly overcrowded).  County hospitals are seen by many Chinese as second rate and over priced, and hence they willing to travel long distances to be seen by a doctor in a major hospital in a big city. Now the State Council has decided to send teams to inspect improvements at county-level public hospitals around the country.The teams will conduct onsite inspections to ensure that reforms are being implemented, including overhauls of financing to eliminate commissions and profiteering in commissioning and contracts.

Healthcare tycoon wins entrepreneur award
The head of medical centre operator iKang has won an international award for being Entrepreneur of the Year. Zhang Ligang, who is CEO of iKang, has been named as the EY Entrepreneur of the Year in the 2014 National Life Science Awards. Mr Zhang is the founder of iKang, which now owns 50 private medical clinics and has contract arrangements with a further 300 medical facilities and hospitals.

Friday, 21 November 2014

Prejudice against leprosy patients triggers riots in Hainan over new medical centre

by Michael Woodhead
Deeply felt cultural phobias and prejudices about infectious diseases have triggered mass riots in the southern province of Hainan, where local residents in Haikou violently opposed the construction of a leprosy recovery centre.
According to local reports, thousands of local residents in Hainan clashed with riot police over the construction of a new dermatology clinic in the Sanjiang district for  patients recovering from infections including leprosy and STDs.
Although authorities explained that patients who had recovered from leprosy were no longer infectious, this was not enough to assuage the fears of local residents, who strongly opposed the building of the clinic and rest facilities in their neighbourhood. Authorities said the clinic was a rehab centre for elderly people who had recovered from the disease and who were no longer contagious, but local people violently opposed the building of the clinic.
According to Chinese state media, local people clashed with police and overturned police vehicles. Several police and local residents were injured in the riot.
Local authorities were reported to have ceased construction of the clinic until a consensus could be achieved with local residents.

Thursday, 20 November 2014

9 scary health stories from China that might put you off working there

1. Six nurses have been murdered and a hospital janitor killed in a knife attack on a hospital dormitory in Hebei. The attack at the No. 281 Hospital in Qinhuangdao was thought to be the work of a 27-year old male from Tangshan, who has been detained by police.

2. Outdoor pollution can't be escaped by staying indoors in China because it is also a major cause of sick building syndrome, according to researchers at the Institute of Environmental Science, Shanxi University, Taiyuan. In a study of 2134 school students they found that many suffered from skin and mucosal problems that were exacerbated by high levels of outdoor air  pollutants such as SO2, NO2, O3 and PM10 particles.

3. A quack doctor in Henan has been jailed for 15 years after he killed a student with what he claimed to be a traditional Chinese medicine cure based on soy sauce, sugar and vinegar. The 65-year  old bogus healer had only just been released from jail after serving an 11-year sentence for the same offence - his previous quack remedies had killed as several people in Luoyang.

4. Make no bones about it - China has about a quarter of a billion osteoporotic fractures every year due to brittle bones. A study from Anhui Medical University and Nanjing Medical University estimated that in 2010 there were more than 2.3 million osteoporosis-related hip, clinical vertebral and wrist fractures in Chinese people aged 50 years and over, costing the Chinese healthcare system US$9.61 billion.

 5. An outbreak of scrub typhus that originated in a Guangzhou park killed four people and caused serious disease in 29 people, according to local researchers. The outbreak at the Xiaogang Park in May 2012 seemed to affect people who sat on the grass or who were near rat burrows.

6. One in seven young Chinese are Weibo addicts, findings from a study in Anhui suggest. In a study of more than 3000 college students between 4% and 15% of students showed signs of addiction to Weibo-like microblogs, including cravings, dependence, withdrawal and disruption to everyday activities, according to researchers at the Laboratory of Brain Function and Disease, and School of Life Science, University of Science and Technology of China, Hefei.

7. Extreme weather triggers heart attacks, according to a Jiangsu study. Heart attacks were found to be more common following changes in atmospheric pressure and variations in temperature, according to a study by Dr Jia Enzhi of the Department of Cardiovascular Medicine, First Affiliated Hospital of Nanjing Medical University. The findings suggested that climate change could have a major impact on cardiovascular disease rates, he concluded.

8. Superbugs are already a major problem in China and now it has been shown that the use of animal manure as fertiliser is spreading the problem of antibiotic resistance even further. A study of agricultural soil in Jiangsu found that fertiliser was responsible for the high prevalence of sulfonamide-resistant bacteria and their resistance genes.

9. A previously unrecognised tick disease may be endemic in several parts of China inlcuding Yunnan and Zhejiang, say parasitologists.After a recent epidemic of babesiosis in malarial areas of Yunnan they carried out a review that suggests the diseases carried by ticks and rodents may have caused many more  cases of disease and outbreaks in recent years that were mischaracterised as other tick-borne fevers.

Wednesday, 19 November 2014

Doctors refuse red envelope pledge | Online pharmacies to be allowed | Chinese diabetes patients don't adjust diet

Famous doctor won't sign bribe pledge
One of China's leading doctors has refused to sign the government's anti-bribery pledge against accepting red envelopes, saying it is an ineffective and damaging document. SARS hero Professor Zhong Nanshan said the no red envelopes pledge was not a legally-binding document and its ethical pledges were already contained in the Hippocratic Oath that doctors already swore when they graduated from medical school. He said that if doctors signed the pledge it would be a tacit admission of guilt that all doctors were accepting bribes for preferential treatment, which was not the case. He added that signing the pledge also sent the wrong signal that doctors were to blame for the high costs of medical bills, which he said were actually driven by systemic problems such as the linking of hospital doctors incomes to overservicing and the lack of government funding for government hospitals.

Online pharmacies permitted from 2015
Online sales of prescription medicines in China may begin within months, according to the China Food and Drug Administration. The regulatory agency is expected to announce new policies that will allow  online prescription medicine sales as early as January 2015. Pharmaceutical retailers have said the opening up of online medicine sales will open up a potential 10 billion yuan market for drugs. However, the expected increase in  online pharmacies will have a major impact on bricks and mortar pharmacies, they have warned.

Diabetes patients don't adjust diet
Chinese people with diabetes have little idea how to manage their diet so as to better control their condition, a new study shows. A survey of 100 people with type 1 diabetes by researchers at Peking University People's Hospital found that less than half had ever seen a dietician and few monitored or adjusted their diet to help control their blood glucose levels. The study found that while 64% were aware of carbohydrate counting', only 12% ever used the technique

Monday, 17 November 2014

China's public hospitals and breastfeeding mums are the losers with latest free trade deal

by Michael Woodhead
China's private hospitals are the winners and breastfeeding mums are the  losers under the Free Trade Agreement Xi Jinping agreed with Australia today.

The FTA gives Australian companies unprecedented access to China's healthcare system, allowing Aussie  health providers to build and ­operate hospitals in China without the current restrictions that apply to other foreign health companies.

Until recently foreign companies have only been allowed to set up joint venture hospitals, although rules have recently been eased to permit foreign hospitals to be buy or set up hospitals and clinics in Shanghai, Beijing and Tianjin.

One of Australia's leading private hospital operators, Ramsay Health, has already announced a move to buy into a Chengdu private hospital group  that operates five hospitals. However, it remains to be seen whether other Australian companies follow suit, especially given that Australia has only a limited number of private hospital operators. Australian healthcare companies may also find it difficult to work in the cut-throat China healthcare environment as they are  accustomed to working in a heavily protected and subsidised market. Private health companies receive $5 billion in Australian government handouts a year in a support scheme introduced in the 1990s to prop up the uncompetitive industry when Australians abandoned private hospitals in favour of the public hospital system funded by Medicare.

Australians are more accustomed to dealing with China over resources than services, though one mining tycoon  has been quick off the mark to cash in on the free trade agreement to sell milk formula to anxious Chinese mothers. Billionaire Gina Rinehart, whose fortune come from iron ore mines she inherited from her father, has announced she will set up a massive dairy operation to produce milk formula for the China market. Australia's richest woman will acquire about 5,000 hectares of farmland in Queensland to that is expected to produce an estimated 30,000 tonnes of infant formula for export to China every year.

However, the move is unlikely to be welcomed by China's child health specialists, who are already struggling to raise China's pitiful 28% breastfeeding rate to somewhere near to the global average of 40%. Groups such as the World Health Organisation and UNICEF have called for urgent action to boost China's breast feeding rates, but they struggle against aggressive and unethical promotions by milk formula companies, who are also known to bribe hospitals and clinicians to promote their products.

Sunday, 16 November 2014

Leukaemia donations missing | Asthma rates soar | Syphilis rates as high as 44% in sex workers

Leukaemia boy misses out on donations

One of the top stories in the Xinhua news this weekend is the story of a boy from Leshan in Sichuan with leukaemia who has missed out on most of the funds donated by wellwishers for his treatment. The family of the 8-year-oldcalled Lin Zhouzheng appealed for help in paying several hundred thousand yuan in medical bills after they ran out of money and even sold their house to pay for chemotherapy for their son. They were approached by a local man called Xu Ping who mounted a major publicity drive to raise money, and this netted more than 100,000 yuan. However, to date the boy's family have only received 7,000 in money from all the fundraising despite taking part in many media interviews, publicity appearances and having an army of volunteers working under Xu Ping. However, Xu Ping told reporters that the 110,000 yuan raised had only been pledges rather than actual donations - and he was still working to get companies and individuals to make good on their pledges.

Asthma rates soar in Shanghai

Asthma rates in Shanghai have increased four-fold over the last 15 years, with pollution being given much of the blame. A study of more than 27,000 residents of Pudong found that the prevalence of asthma was 1.4%, markedly higher than the 0.4% rate seen in the last major study carried out in 1997. Researchers from the Department of Respiratory Medicine at the Shanghai Putuo District People's Hospital carried out further pulmonary tests on 428 people with asthma and found that 53% had an FEV below 80% of normal and the severity of impaired lung function increased with age. The main triggers for asthma were dust exposure, cold air and respiratory tract infections.

STDs rates high in Jiangxi sex workers

More than 40% of female sex workers in Jiangxi have syphilis, a study has found. Researchers from the Department of Dermatology and STDs at the Affiliated Hospital of Nanchang University tested 361 street-based female sex workers and found that 44% had syphilis infection. About half of the sex workers had little education, a high proportion had been sex workers for several years and many failed to use condoms consistently. "Comprehensive interventions targeting this high-risk group, especially scaling up screening and ensuring consistent use of condoms during sex are needed," the researchers suggested.

Saturday, 15 November 2014

China's first mental health law - 27 years in the making, but will it change negative attitudes?

by Michael Woodhead
There is a very severe stigma about mental health in China - just try calling someone "shenjingbing" (神经病, mentally ill)  and watch the reaction. This cultural taboo about mental health  is just as strong for doctors in China - a 2012 survey found that even Chinese psychiatrists had negative and unscientific views about mental illness. Most worryingly, many psychiatrists believed that the best approach for someone with mental illness was to institutionalise them, by force, if necessary. There is still a strong belief in involuntary treatment of mental health conditions in China.

It is therefore interesting to see the reactions to the Mental Health Law that was enacted more than a year ago, in May 2013. This law had originally been proposed by the Ministry of Health back in 1985. Such was the lack of interest in change and the entrenched attitudes, it took more than 20 years to get even as far as the draft stage, when it was submitted to the State Council in 2007. After much more negotiation and consultation, the law was approved and came into effect on 1 May 2013.

To westerners, much of the law would appear unremarkable. It states that mental illness must be treated according to basic clinical guidelines, with an emphasis on prevention, treatment and rehabilitation. Where the law has proved controversial (in China at least) is on the matter of involuntary treatment. The new law states that for people with mental illness, "voluntary admission and treatment should be the priority".  It also states that involuntary admission should be based on “risk criteria", but this is a grey area that is untested in China.

In an article published this month by three psychiatrists from Shanghai's Jiaotong University School of Medicine, it is argued that the new law is flawed and will still allow mentally ill patients to be inappropriately 'committed' to an institution on flimsy pretenses. They argue that the risk criteria are too broad and open to interpretation. They say the regulations put too much weight on the opinions and wishes of the families of mentally ill people. In reality this will mean that families with 'backward' attitudes and knowledge about mental health will be able to 'get rid' of the stigma of mentally ill person in their family by having them admitted involuntarily.

The psychiatrists say the national law also lacks detail and may not be implemented at a local level. They point to local programs and treatment pathways for mental illness that have been adopted in advanced cities such as Shanghai and Beijing, and they say these should be the model for other parts of China. 

However, for the time being psychiatric treatment remains out of reach for many people with mental illness in China. There are an estimated 173 million people with psychiatric disorders in China, but only 20,000 psychiatrists and a few hundred mental hospitals and clinics. China has a long way to go in providing appropriate care for its many citizens with mental illness.

Thursday, 13 November 2014

The crisis in paediatrics in China

by Michael Wodhead
In the US medical journal Pediatrics this month is an extraordinary editorial about the workforce crisis affecting the discipline of paediatrics in China.

The article written by Dr Zhang Shu-Cheng and colleagues at the Shengjing Hospital of China Medical University, Shenyang, says that few doctors in China want to be paediatricians because of the low pay and high pressure from pushy parents. Dr Zhang says there is a recruitment crisis affecting paediatrics in China, with many hospitals unable to fill positions.

The country has a shortage of 200,000 paediatricians, and this creates a vicious circle by creating additional pressure on those who do choose to work in this field. Because paediatricians are in short supply, they have to see high volumes of patients, leading to more errors and more dissatisfaction from families who feel their child's medical complaints are being rushed and ignored. This in turn leads to conflicts between families and doctors - especially as Chinese culture and the one child policy puts a lot of focus on the health and wellbeing of the child.

According to Dr Zhang and colleagues, much of the problem stems from the low pay and low status of paediatricians. They receive about 70% of the base pay of other doctors, and even less when it comes to the 'grey income' based on sales of drugs and income from procedures and other items. And yet despite these problems - and their causes - being well known to the government, nothing is being done, they lament. Many paediatricians are voting with their feet - moving into better paid or less stressful positions within hospitals, such as lab work or as administrators. Others change to different branches of medicine or leave clinical medicine altogether.

"Despite this crisis, little is being done by the Chinese government to stop the loss of pediatricians, by either increasing their pay, decreasing their job intensity, or attempting to prosecute the violence
committed against pediatricians. The government needs to play a leading role in dealing with this crisis by writing and implementing appropriate laws and establishing fair and objective third party
accreditation bodies. Increasing the investment in pediatrics from public finances, easing the pressure on pediatricians, eliminating the practice of physicians supplementing their income by selling medicines, and increasing pediatricians’ salary levels are possible steps that will lead to
more pediatricians willing to stay in the profession," they conclude.

Wednesday, 12 November 2014

Health insurance cover for 95% of Chinese? More like 30%.

by Michael Woodhead
For the last few years the official Chinese media have been proudly trumpeting the claim that almost all Chinese are now covered by government-funded basic health insurance. Health minister Li Bin's recent statement that "China's public insurance schemes have achieved over 95% health coverage in urban and rural populations" was accepted and repeated uncritically by Lancet editor Richard Horton  on a recent visit to China.

But wait a minute ... is it true? The Atlantic last year reported Chinese academics saying that the true figure was likely to be much lower. And this week we have further confirmation that health insurance cover is nothing like 95% - especially for the most impoverished and vulnerable of China's citizens, the 250 million 'floating population' of migrant workers

A survey of more than 600 migrant workers carried out by researchers from the National Center for Chronic and Non-communicable Disease Control and Prevention in Beijing found that only a third had health insurance in their place of residence. This is probably because health insurance is provided according to the hukou (residence permit) by the authorities of a citizen's hometown, and that is not the place of residence for most migrant workers. But even in their hometown, only about 60% of migrant workers had health cover. The researchers, including an actuary from the China Life Insurance Group, said the low rates of health insurance cover were likely due to a number of reasons, including lack of awareness and inability to negotiate the system and its paperwork for poorly-educated rural residents.

And as well as having poor coverage, health insurance cover had little depth in the real world - it did not cover most of the expenses for those who had it. The study showed that rural migrant workers faced high out of pocket costs for health - averaging 2000 yuan a year in gross average payouts and more than 1000 yuan per person per year even after upfront costs had been reimbursed.

The authors conclude: "overall the coverage depth of basic insurance is still very limited, and the insured in China still end up paying a high amount of medical cost out of pocket. In addition, the floating population has a lower coverage rate than the general population, which further diminishes the protecting effects of insurance."

My take? China's government deserves credit for trying to bring in universal health insurance. Unfortunately, the implementation has been patchy and has favoured the urban, employed and middle classes. Claiming 95% coverage may sound good at WHO conferences and on the front page of China Daily, but the reality is that effective health coverage is nothing like that level. And the biggest losers are the rural migrants. Somehow, Xi Jinping's "The China Dream" left them behind.

Tuesday, 11 November 2014

Corruption crackdown targets doctors running clinical trials

by Michael Woodhead
Senior doctors who accept drug company money to run clinical trials are to be reined in by new health ministry regulations that aim to clean up the potentially unethical and corrupt practices and make clinical research more ordered and accountable.
The National Health and Family Planning Commission has released a new position statement entitled "Administrative Measures for the Clinical Study Projects of Medical Institutions" which will force clinical trials to be run under the auspices of hospital research committees rather than individual doctors or their departments.
The new rules stipulate that to clinical trials will be co-ordinated by a Clinical Study Administration Committee in hospitals, and funding  for trials from industry will be channelled through hospitals rather than a particular department or individual doctor.
The study committee will have to set standards and procedures for administering clinical trials and  maintain constant supervision of studies. Each trial will need to have a full record and documentation of its aims, protocols and the researchers involved. There will also be strict rules about the financing of trials and bans on having industry paying for or accepting "expenses".

Monday, 10 November 2014

Dengue crisis worsens as disease spreads north

by Michael Woodhead
China is now experiencing its worse outbreak of dengue fever in two decades, with almost 1000 cases a day being recorded in south China, and the infection spreading as far north as Henan.
Outbreaks of the serious infection spread by the Aedes mosquito are centred around Guangdong, where almost 43,000 cases have been recorded this year.
However, the disease is now affecting other parts of China, including  Zhejiang, Fujian, Yunnan and Guangxi, according to the National Health and Family Planning Commission (NHFPC).
"The outbreak of dengue fever this year is the worst in China since 1995, when 6,812 cases were recorded," according to Qin Chengfeng, a researcher with the Chinese Academy of Military Medical Sciences.
Alarm bells are ringing because the infection has also been reported as far north as Henan, half way between Shanghai and Beijing. Researchers say this is the first time the disease has been seen so far from the traditional areas of south China. Infectious disease experts said there were more than 50 cases of dengue fever reported in Shenhou township, presumably imported by migrant workers who had been in south China and Laos. They said the findings should act as a warning that the disease is spreading rapidly within China.
Other experts have attributed the spread of dengue to changing weather patterns, pointing to high rainfall that encourages the breeding of the Aedes mosquito.

Sunday, 9 November 2014

CMA pharma ban | Cancer survival lags | High rates of undiagnosed diabetes

Health ministry curbs CMA's lucrative industry links
The National Health and Family Planning Commission (NHFPC) is taking steps to curb hugely-profitable links between the Chinese Medical Association and the pharmaceutical and medical device industries. Although supposedly a non-profit organisation, the CMA makes 820 million yuan ($133 million) in income from industry-sponsored events such as medical conferences. The NHFPC has ordered the doctor's professional association to put its conference management on a more sound ethical footing and to stop promoting links between industry and the profession.

Cancer survival rates in China lag behind other countries
Cancer researchers have highlighted the huge disparity between cancer survival rates in China and in developed nations. A study of 139,000 Chinese cancer patients found that only about one-third of survived five years after their diagnosis, compared to 70% in counties such as the US. Researchers from the Cancer Prevention and Control Office said the poor survival rates in China ere due to poor levels of medical treatment and research. Another reason was that China had more cases of stomach, lung and liver cancers, which were more difficult to detect and treat than the common cancers in western countries.

High diabetes rates in central China
Diabetes has become a major public health problem in the region around the Three Gorges of the Yangtze, and a large number of the cases are undiagnosed and untreated. A study involving 3721 randomly selected adults found that the prevalence of diabetes and impaired fasting glucose were 7.6% and 9% respectively. About 55% of the cases of diabetes identified in the study were previously undiagnosed. The researchers from the Third Military Medical University, Chongqing said diabetes was linked to age, family history of diabetes, central obesity, educational level and hypertension for both men and women.

Monday, 3 November 2014

Low awareness of cervical cancer prevention in China

by Michael Woodhead 
Cervical cancer is not 'on the radar' of even the most health literate Chinese, a new survey suggests.
A study of medical students has found that while most were aware of HPV as a cause of cervical cancer, few were aware of the screening techniques for cervical cancer or the role of a HPV vaccine in preventing the disease.
The survey of 1878 students at Chengdu Medical College found that 79% of females and 54% of males had a positive view of cervical cancer screening, 40% of females and 45% of males were not aware of what it involved. Most had little idea of when cervical screening screening should start or the role of HPV in the development of cervical cancer. Likewise, few Chinese medical students were aware of the ideal intervals for screening, according to the findings published in PLOS One.
When asked about HPV vaccine, only 14% were aware that persistent HPV infection was the necessary cause of cervical cancer and only 29% knew there was an HPV vaccine available. About 50% of males and 65% of females said they would support HPV vaccination, but about 40% said they had concerns about side effects and the cost of the vaccine.
The researchers led by Dr Pan Xiong Fei of the Department of Epidemiology, West China School of Public Health, Sichuan University, said it was a major concern that China's health providers knew little about HPV and prevention of cervical cancer.
"It is important to improve the knowledge of HPV and cervical cancer among medical students in order to supply well-informed health care providers for prevention and control of cervical cancer," they concluded..

Friday, 26 September 2014

Taking a break

China Medical News is having a rest until October 20 while I take a holiday in Yunnan. See you on the other side ...

Wednesday, 24 September 2014

Patients ignore primary care clinics | Decline in Hepatitis A | Online ratings platform launched for hospitals

The government's newly created network of primary care clinics are struggling for recognition in China, according to a new survey carried out in Chengdu. More than 60% of people surveyed had not heard of the primary care clinics and didn't know where they were located, according to local media. Most people surveyed also said they would still prefer to go direct to hospital for treatment rather than go to a local community clinic, the survey showed.

China has seen huge reductions in hepatitis A over the last two decades, with rates of infection falling from 94% to 42%, a study carried out in Hebei has shown. Rising living standards, better hygiene and widespread childhood immunisation have contributed to the drop in hepatitis rates, and also resulted in most infections being delayed until adolescence rather than infancy, according to researchers from Shijiazhuang. However, the lower infection rates mean that many people now have little immunity to the disease and will benefit from immunisation, the researchers say.

A Tripadvisor-like mobile online platform has been developed that allows patients to rate their experience with hospitals and health providers in China. The Care Voice (Kangyu in Chinese) is a Shanghai-based  social platform that enables consumers to share reviews on hospital services, physicians and treatments and connect with other patients and professionals.

Sunday, 21 September 2014

How GSK bribed doctors in China: the gory details

GSK's Mark Reilly, given a suspended prison sentence by Chinese court for bribery.

by Michael Woodhead
The main points of GSK's record 3 billion yuan ($500 million) fine for bribery in China have been reported elsewhere - I won't go over the same ground.

Suffice to say that several senior executives (including one from the UK) have been implicated in the giving of massive levels of bribes/kickbacks to institutions and hospitals in China to promote the  use of GSK's drugs. The company was also found guilty of transfer pricing - dodgy accounting to transfer profits out of China via pricing mechanisms that favoured the revenues of the parent company over the China subsidiary.

Most of the western reports have focused on the implications for GSK and for the prospects of western businesses in China. Surprisingly few have questioned the ethics of what GSK was doing - except to suggest that "Chinese companies were all doing it, it's the way of doing business in China."
I have been reading some of the Chinese language media reports, and they give a lot more detail of the practices GSK was found guilty of. Very few western media reports have focused on the actual bribery methods used by GSK or the specifics of the transfer pricing arrangements (which I presume are not confined to China).

Here are a few examples reported in the Chinese media:

1. According to Chinese prosecutors the bribery was systematic and on a huge scale. Drug reps bribed doctors. Area managers bribed hospitals and 'VIP clients'. Country managers bribed officials in charge of distribution and purchasing. Bribery was done via travel agencies, gifts, sponsorship and through entertainment budgets and PR agencies. There were separate promotional teams for different product groups - the cold chain (vaccine) group is said to have spent 130 million yuan bribing officials in the regional Communicable Diseases Centres with everything from cameras and electronic equipment to cars.

2. How were individual doctors bribed? One liver specialist physician in Hunan called Dr Lee told the court how it worked. For every lamivudine prescription he wrote he was paid 20 yuan by GSK rep. For every new patient he got a bonus of 100 yuan. Dr Lee said every month he wrote about 150-200 prescriptions for lamivudine and started 5-8 new patients on the drug. Do the maths - that 12,000 yuan ($2000) a month, or 144,000 yuan ($23,400) a year.  Dr Lee said the GSK rep arranged to pay him his commission every month at a special meeting when he would be paid for 'lecture fees' and travel expenses for the company. He received these fees 12 time a year but only did 3-4 lectures for GSK each year.

3. It wasn't just individual doctors who were bribed - the court heard how professional 'medical associations' also had huge sums of money transferred to their accounts from GSK to promote the endorsement and use of their products. Medical groups also received millions of yuan in material bribes such as non-medical items like fridges, cars and TVs. Hospital managers were also bribed millions to influence their purchasing policies - sales reps were given a 'Great Wall Plan' and a 'Dragon Plan' of incentives to persuade hospitals to abolish their 'Chinese-made generic drugs only' policies.

The end result was that Chinese consumers paid more for their medicines. Drugs such as Contac, Fenbid and lamivudine were overpriced up to seven-fold compared to other countries. The unit cost of lamivudine was said to be 142 yuan in China compared to 18 yuan in South Korea and 30 yuan in the EU, Japan and Hong Kong. Drug prices were padded to pay for kickbacks. About a third of the cost of GSK pharmaceuticals was said to have been to cover 'commissions', according to a financial controller. This meant Chinese consumers paid 30% extra for drugs  just to cover the cost of bribes.

GSK was driven by high pressure sales tactics for pharmaceuticals: GSK's revenue in China rose from 3.9 billion to 7 billion yuan between 2009 and 2012. The sales workforce increased from 1000 to 5500 people over that period, and each rep was given a budget of 3000-5000 yuan per month to influence prescribing - presumably though officials, doctors and health institutions. Sales reps were promised unlimited bonuses and membership of an 'Elite Club' with foreign travel if they met their targets

Cooking the books: from 2009-2013 GSK had almost 22 billion in revenue from drug sales in China and yet recorded a profits of only 100 million yuan. Investigators found this was due to a 'Five Step' transfer pricing system, by which the costs of products such as the antibiotic Zinacef were inflated at various stages of production in Italy and Cyprus until eventually 'sold' to the China subsidiary. This was a way of repatriating profits back to the US, but again meant that Chinese patients paid far more than they needed to for drugs.

The overall picture is not pretty - call it what you want - commissions, kickbacks, bribes, - GSK was guilty of them but they were by no means the only pharma company in China  doing it. Commissions and kickbacks are obviously widespread in the Chinese health system, and others have been caught out - such as in the Zhangzhou, Fujian case last year where 73 hospitals were found to be guilty of accepting bribes.

In Chinese media reports on the GSK case, most commentators have concluded that the massive fine and the jail sentences will be a lesson to the pharma industry - and the stamping out of bribes will result in lower medicine prices for Chinese consumers.

However, one leading financial commentator has said the GSK case is a prime example of China's tactic of "killing the rooster to scare the monkey"  - but it would not work. Cai Shen Kun says corrupt practices are so entrenched in China's pharmaceutical industry and are so much a part of the healthcare system that even a major case like the GSK one will not put a stop to them. He says kickbacks have become an unwritten rule in the industry that all insiders believe that nobody can ignore if they want to make sales - even a major international company like GSK.

Cai Shen Kun says the long term solution is to reform the health and pharmaceutical system to make it transparent and remove the incentives for commissions. He also says nothing will change until those who accept the bribes are brought to justice - and that means prosecuting the  government officials and senior doctors who accept the 'crazy money'.

Friday, 19 September 2014

What expat nurses tell us about China's healthcare system

by Michael Woodhead
A survey of Chinese-trained nurses working in Australia has revealed some interesting insights into the role of nurses in the Chinese healthcare system. 

Three main themes emerge from the interviews with 28 Chinese nurses working in Australia carried out by Zhou Yunxian from the Zhejiang Chinese Medical University, Hangzhou. In Australia, Chinese nurses found they had more independence and responsibility than they did under China's more regimented and hierarchical hospital system. Chinese nurses said they felt uneasy about having to take the initiative in patient care rather than be given orders by a senior nurse or doctor.
"Generally speaking, nurses here are more independent. They don’t rely on doctors totally. They can have their own thoughts and make decisions on the caring of patients," said one nurse.

Demarcation of roles is obviously stronger in the Chinese system - the nurses working in Australia found it strange that there was open communication and equality between nurses and doctors in a western healthcare system. "I don’t know what they (local colleagues) are doing, chatting with doctors – a waste of time from my perspective," said one, who believed that nurses should concentrate on 'nurses work' and not get involved with doctors.

Another theme that emerged was around the role of the nurse and their scope of practice. In China, nurses often saw themselves more as clerks and technicians fixing up IV lines rather than patient-oriented 'hands on' nurses. Chinese nurses were horrified to find that in Australian hospitals they were expected to do 'dirty' manual work such as bathing patients or helping to feed them. "I feel too embarrassed to tell people (the fact)…If I tell my family that a nurse in Australia needs to shower the patient, I think even my family would find it very hard to accept," said one.

 This revealed that in China, manual work in hospitals is done by unqualified low-status 'care assistants', and personal help with feeding, toileting and bedding is the responsibility of the patient's family, not the nursing staff. Nurses from China also found it hard to adjust to the notion of a family leaving the care of a relative to 'the system' rather than taking personal responsibility - especially with the elderly and the way they are left in nursing homes.

A third theme that emerged was communication. In China, nurses expected to be given clear instructions about tasks from superiors, however they did not feel any obligation to communicate with patients or their families. Chinese nurses were surprised to find that in western hospitals, nurses were expected to be friendly and personal with patients, who they regarded as strangers. "Here every nurse calls everyone 'sweetie', 'love', things like that. It is totally different from us… I have never thought of addressing a patient so intimately. It is hard for us because we don’t feel this way," said one nurse.

Language and cultural differences also meant that Chinese nurses found their usual 'direct' style of communication appeared rude and imperious to westerners. They found it hard to be 'warm' and polite, believing this to be insincere. In contrast, Chinese nurses expected that their colleagues would become their workmates and were disappointed to find that westerners were out of the door at 5pm and not interested in networking. "Anyway, they (local colleagues) come when they are on duty and they leave when they finish the shift. In China, we are colleagues even after the work. We go out together, and then we become very good friends."

Although designed to investigate the problems of Chinese nurses adjusting to the western workplace, the study highlights many of the assumptions that underpin the Chinese health system

Wednesday, 17 September 2014

Medical comic strips | Anti-smoking laws weakened | No support for Orphan Diseases

A female doctor in Shanghai draws weekly comic strips and posts them on WeChat to try demystify medical jargon and improve doctor-patient relations
Dr Chen Haiyan, a cardiac ultrasonographer at the Shanghai Zhongshan Hospital has used the comic strips to explain conditions such as heart defects and high blood pressure in easy-to-understand ways. She also tries to explain the daily life of medical staff and show they are human in an effort to defuse the major tensions that have triggered many recent violent attacks against hospital staff.

Health experts have expressed disappointment that Beijing's proposed anti-smoking regulations have been watered down. The latest draft legislation only bans smoking in "shared indoor public places," compared to a previous draft that banned smoking in all indoor public areas, said Professor
Wang Qingbin, a legal expert at the China University of Political Science and Law,
"By banning smoking only in 'shared' indoor public areas, the legislators are giving officials with their own offices a chance to smoke, which is against the spirit of equality," Wang said, adding that it will only make law enforcement all the more difficult.

China lacks adequate health systems to deal with rare 'orphan' diseases such as Duchenne Muscular Dystrophy, medical experts say. At a recent conference on rare diseases at the Children's Hospital of Fudan University experts called for legislation and policies on the prevention and treatment of rare diseases that affect more than 10 million people in China."Related regulations should be created to help provide better support to patients with rare diseases and their families," said Li Dingguo, chairman of the rare disease branch of the Shanghai Medical Association.

Sunday, 14 September 2014

Intern scheme concerns | Telehealth ban sparks backlash | Rural residents too poor to pay for care

Internship scheme will create bottlenecks and headaches
Doctor training moves to a three-year internship system next year but many medics believe the changes will leave hospitals with even worse staffing shortages. The new system which will see newly-graduated doctors rotate through various hospital departments to gain experience is intended to bring China into line with other countries and to create a uniform high standard of medical practitioners. However, critics warn that the additional three years of being a trainee will mean that doctors earn very little and the low income will deter many from entering the medical profession. Another drawback of the new system is that doctors will serve as interns in tertiary 'teaching hospitals' and will then refuse to be 'downgraded' to work in smaller local country and township hospitals.

Ban on telehealth consultations triggers backlash
There has been a major backlash against an announcement that doctors will be banned from conducting online consultations by the National Health and Family Planning Commissioning. The NHFPC said this week that 'remote' consultations are illegal except through accredited medical institutions because all doctor consultations need to be carried out according to the regulations of the NHFPC as currently laid down for hospitals and clinics. The NHFPC said remote consultations should be viewed as no different to any other kind of consultation and therefore all the usual regulations on medical practice apply. However, after a major backlash from health groups and online health providers such as www.haodf.com, the NHFPC said it would look again at the legislation and would 'listen to the opinion of the masses' in interpreting the legislation.

Rural health insurance not working
People who live in remote rural areas of China are so poor they cannot afford to seek medical attention when they are sick,  a study from Hebei has found. More than 50% of people living in the Dabie mountain areas of Hebei said they would not seek medical care if they felt unwell. The main reason (for 38% of people) was financial difficulty. Other reasons included inconvenience and preference to self medicate. Researcher Dr Fang Pengqian and colleagues from the Tongji Medical College, Wuhan said the findings suggested that the universal health coverage from the New Cooperative Medical Scheme (NCMS) was was not working for people in poorer highland areas. They said the locals could not afford to pay the necessary insurance premiums to  cover basic care and the low reimbursement meant they faced high out-of-pocket costs.