Wednesday, 30 April 2014

Red envelopes or red tape? Hospital doctors feel insulted by the new 'no bribes' contract they are forced to sign

by Michael Woodhead
In an effort to clean up hospitals and crack down on bribery,  patients and doctors will be required from 1 May to sign mutually-agreed contracts forbidding the giving or receiving of' red envelopes'. The new contracts, ordered by the National Health and Family Planning Commission, will be an extra step of the hospital registration process and are intended to reinforce the message that doctors can no longer rely on 'grey channels' for their income. However, a survey carried out at one Beijing hospital that has trialled the system raises the question of whether it is all just for show - and whether it is perhaps just another bit of bureaucracy to contend with. An anonymous survey carried out at the Meitan Hospital in Beijing asked 122 patients and 55 doctors what they thought about the giving of 'red envelopes' or gifts to medical staff and whether they accepted the new 'no red envelope' contract system - which has been operating at the hospital for two months.  Interestingly, about a quarter of patients said they had been prepared to give a red envelope before signing the contract, whereas two thirds of patients said they hadn't thought about it. The remainder 10% were 'definitely not' prepared to give a red envelope. About 57% of patients said they agreed with the red envelope contract, whereas about 35% said they thought it was not necessary. Of the doctors, 100% said they would not accept a red envelope or gifts from patients. Despite this, 40% of the doctors said they were not happy about signing the new contracts, and 20% said they were strongly opposed to the contracts. When asked why, doctors said they had already agreed to the Hippocratic Oath when they first donned their white coat, and they believed this was already  a contract not to accept bribes.
However, hospital manager Wang Mingxiao said that the new contract system was a visible way of showing patients and their families that the hospital staff were "clean and incorruptible".  Mr Wang said the contract system was an essential step in the hospital's setting up of an 'honest and clean' checking and monitoring mechanism to ensure ethical medical practice.

Tuesday, 29 April 2014

6 clinical stories from China

1. Abuse of prescription and over-the-counter drugs is  common among Chinese high school students, a study from Guangzhou has shown. The survey of more than 20,000 students found that more than one in twenty had abused medical drugs at some time. The most common drugs of abuse were analgesics (4%), followed by cough syrups with codeine (2%) and valium or tramadol (1%). Peer pressure was one of the major influences in illicit use of prescription and OTC drugs, and it was also more common in children who already smoked, according to researcher Dr Wang Hui of the Guangzhou Centre for Disease Control and Prevention, writing in the journal Drug and Alcohol Dependance.

2. The agricultural practice of burning straw is a major overlooked contributor to smog and air pollution in Chinese cities, say respiratory physicians from the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital. Burning straw caused PM2.5 levels to reach 194 μg/m3 in Nanjing, which far exceeded the daily average maximum allowable concentration of 75 μg/m3, they note in the American Journal of Infection Control. The pollution is linked to respiratory illness and infections such as pneumonia, they say, and thus needs to be regulated.

3. China has a north-south divide when it comes to hypertension in children, a new review has found. shows. Children and adolescents in the north China have hypertension rates of  18% (Beijing) or 23% (Shandong) whereas those in South of China including Shanghai and Changsha have hypertension rates ranging from 3% to 11%, according to researchers from School of Public Health, Shandong University, Jinan. The higher prevalence of hypertension in the north might be due to higher dietary salt intake they say in the International Journal of Cardiology. 

4. The inherited condition of highly-elevated cholesterol levels, familial hypercholesterolaemia, occurs in about one in 200 Chinese people but is rarely detected, a study from Jiangsu suggests. In a study of more than 9000 people they found that about 0.5% had the condition, which confers a very high risk of cardiovascular disease and early death. They suggest that screening to aid detection and family tracing is carried out by hospital cardiology departments.

5. Gastric cancers account for a fifth of all cancer deaths in China and are especially common in younger women, a study from Guangzhou has found. The review of more than 2000 cases of gastric cancer found that the malignancy was common in older men but was also frequently seen in women under the age of 40.  Most patients had advanced stage disease at diagnosis, suggesting that better detection and treatment of early gastric cancer  is needed.

6. Chinese children are at risk from inappropriate prescribing of medicines, say paediatricians in a letter to The Lancet this week. Dr Tang Wenchu and colleagues from the First People's Hospital of Huzhou University Medical College, Zhejiang, say about a third of medicines taken by children are indiscriminately prescribed, and children are also at risk because there are few paediatric formulations of medication in China. The lack of a national adverse drug reaction surveillance system also means that children may have side effects that are not acted on, they say.

Monday, 28 April 2014

Why are GP community clinics unpopular in China?

by Michael Woodhead
A recent article about medical services in Shanghai noted that hospital clinics were severely overworked, with patients facing hours in the waiting room to see a doctor for just a few minutes. In contrast, the nearby community clinic was very quiet, with doctors there underemployed. Now an article has been published claiming that community clinics are underused because they are inefficient and the doctors there lack the expertise of hospital medical staff. According to columnist Xin Ya, community clinics need competition from private clinics to lift their game. The writer says the old state service model on which community clinics are based means they provide only the most basic medical facilities and the service levels are poor - due to the unmotivated 'iron rice bowl' mentality of the staff.
Public community clinics in China are characterised as 'gatekeepers' but the writer says the offer little benefit to patients as they stock only the most basic drugs (due to their non-profit model) and they lack investment in equipment. The doctors are unmotivated because they are on a fixed salary and get paid the same regardless of results, with no performance targets or bonuses.
According to the columnist, a recent visit to the gatekeeper provide frustrating because they did not even have the basic equipment such as needles and sample test tubes to collect blood, and so a prson requiring tests had to go to the hospital to get a full examination.
The author say the government should remove the restrictions on private clinics setting up in competition to the current network of community clinics. In this way, 'the survival of the fittest' will occur as privately-invested clinics will have a motive to offer better services and better facilities to win patients. The government also needs to remove restrictions on doctor's employment contracts to allow hospital doctors to provide community clinic services and earn larger salaries there.
"In the future, private clinics should be as free as the restaurant competition ... and let the market decide who can survive," the article says.
"For community clinics, public sector and private medical institutions are like 'the lion and the antelope' - the establishment of a competitive community "gatekeepers" system, will improve the overall quality of medical care for residents, and allow them to enjoy affordable and quality services."

Sunday, 27 April 2014

China has the highest rate of caesarean births in the world: time to act

by Michael Woodhead
Almost half of Chinese women give birth by caesarean section, a rate that is three times higher than the 15% recommended by WHO, according to two Chinese clinicians writing in The Lancet this week.
Dr Mi Jie and Dr Liu Fangchao of the Capital Institute for Paediatrics in Beijing say China has an urgent need to reduce the number of caesarean births because they have a high risk of related complications or death, and because babies delivered by caesarean section are more likely to have respiratory problems, obesity, and other metabolic diseases.
The doctors list five non-medical reasons why China has a 42% rate of caesareans:

1. Women fear pain and loss of vaginal tone after natural birth. They see caesareans as safer faster and less painful.
2. Women wrongly believe that they will regain their pre-pregnany figure better after caesarean birth.
3. Chinese women like to choose a 'lucky' date to have their baby by caesarean.
4. Doctors prefer to schedule the caesarean for convenience and to avoid medicolegal disputes with vaginal birth
5. Caesareans are more profitable for hospitals (12000 yuan vs 6000 yuan for natural birth).
The authors of the letter to the lancet call on the government to take control the rate of caesarean section in China,
"The Chinese government should develop specific policies and measures, such as use of rate of caesarean section without medical necessities as one of the hospital’s overall rating components, and popularising of natural childbirth," they write.
Hospitals and communities should promote health education in women of reproductive age to provide a more accurate idea of delivery," they conclude.

Saturday, 26 April 2014

Today's Top 10 China medical news stories

1. China is to launch a national cervical cancer screening program to test 10 million Chinese women annually, the National Health and Family Planning Commission says. The move follows concerns about increasing rates of cervical cancer, especially in women under 35. China has 130,000 new cervical cancer cases a year and up to 30,000 deaths a year due to the disease.

2. Vaccination rates have fallen as much as 30% since the hepatitis B vaccine safety scare over the deaths of 17 infants, immunisation experts say. They said the drop in vaccination rates could put up to 500,000 infants at risk of serious vaccine-preventable diseases.

3. In a landmark study, Shanghai clinicians have shown that pulse oximetry is a simple and accurate method for detecting major congenital heart disease in newborn babies in China. Writing in the Lancet, they say the method should be used in all maternity hospitals.

4. Salmonella in China is becoming resistant to most antibiotics including ciprofloxacin, ceftriaxone and azithromycin, "posing huge threat to public health and infection control" say clinicians in the journal Antimicrobial Agents and Chemotherapy.

5. A Beijing doctor was punched by the husband of a pregnant woman who said the doctor had pinched her stomach and threatened to kill her. The woman admitted she had first cursed the doctor when she believed she had been ignored by him.

6. Seven leading hospitals in China have signed an alliance agreement to for a National Team to tackle difficult diseases.

7. Kindergartens in Beijing have been struck by the norovirus gastro bug and dozens of children are showing symptoms such as diarrhoea and vomiting.

8. Young Chinese people do not wish to pursue a career in the medical sector, as jobs in medical services were ranked lowest in a survey of desirable careers by recruitment site zhaopin.

9. Complaints about fake drugs and medical devices being sold online are the most frequent calls to the China Food and Drug Administration hotline.

10. Hospital clinics in Shanghai are overflowing with three-four hour waiting times and yet community clinics are sitting almost empty and 'general practitioners see few patients because the public has little confidence in the level of services provided, according to an article in China Daily.

Friday, 25 April 2014

Six sick crimes: Supreme Court issues guidelines on how to manage violent medical disputes

by Michael Woodhead  
In response to a wave of attacks on doctors and nurses, China's Supreme Court has released a list of six illegal activities that will be targeted as part of guidelines on how to manage violent disputes in healthcare settings.
 The criminal activities highlighted are:

1. Attacking doctors and damaging hospital property,
2. Setting up shrines and burning paper money in medical institutions [Ed note: this is done to disrupt hospitals and extort money],
3. Restricting doctors' freedom (eg harassing doctors, blocking their movement)
4. Insulting medical workers,
5. Bringing weapons into medical institutions,
6. Instigating others (including family members) to commit crimes against medical staff.

Any violations of these guidelines will result in serious consequences, and offenders will be convicted and punished under criminal law, the Supreme Court has announced. The list is part of a new 'opinion" position statement drawn up by the Supreme People's Procurate, Ministry of Public Security, Ministry of Justice, National Health and Family Planning Commission jointly entitled "On the punishment of crimes involving medical advice, medical order and maintaining normal law". The new guidelines also call on medical institutions to prevent medical disputes by ensuring a good standard of medical care, enhance medical ethics, improve service attitudes, focus on humane care and to maintain good communication with patients. They also call on institutions to set up dispute mediation protocols to handle complaints and to offer adequate security to medical staff. "The Supreme People's Court will uphold the law while handling cases involving medical disputes and severely punish those who seriously harm or even kill doctors over groundless assumptions," said Sun Jungong, the spokesman of the Supreme Court. China had more than 50,000 serious medical disputes last year and two doctors were killed by disgruntled patients, drawing the death penalty for the offenders. The Supreme Court said disputes must be handled in a timely way and resolved by arbitration or through fast track medicolegal channels if necessary.

Thursday, 24 April 2014

Rabies rise reversed in China

by Michael Woodhead
The resurgence in rabies in China that started in the 1990s is slowly being curbed, but the infection still causes more than a thousand deaths a year, a new report shows.
After a peak of almost 3500 cases in 2007, the incidence of rabies in China has since declined by about 50%, with around 1500 reported cases in 2012, according to a study from the State Key Laboratory for Infectious Disease Prevention and Control and the Chinese Center for Disease Control and Prevention, Beijing.
Most of the cases of rabies were caused by dogs and occurred in rural areas in the south west of China. In most cases of rabies infection the disease was fatal because few people received post-exposure prophylaxis treatment, the authors of the report noted. They said there was complacency and lack of awareness about rabies in China as the disease was thought to be under control and few hospitals or clinics stocked vaccine or were aware of the need to monitor for the disease.
The study found there had been almost 20,000 cases of rabies since 2005, mostly in provinces such as Yunnan, Guangxi, Guizhou, Guangdong, Hunan and Sichuan. However, while authorities had managed to curb the re-emergence in rabies with new control programs in those provinces there were signs that the disease was spreading to northern and western provinces, including Beijing.
Writing in BMC Infectious Diseases, the researchers said rabies was on the increase because of the increasing ownership of dogs and domestic animals in China.
They said there was a need for greater rabies control efforts, including inoculation of domestic animals such as dogs in high risk areas.

Monday, 21 April 2014

Medical news headlines from China

Wenzhou clinic operators have been arrested for offering sex selection blood tests to pregnant women. Couples were charged thousands of yuan for having blood samples that were sent to Hong Kong for fetal DNA testing.

Scabies mites are commonly found on dogs especially the Pekingese breeds, of which more than 20% were found to have the parasite that can infect humans and cause intense itching, a Guangzhou study has found.

Beijing hospitals have been inundated with applications from more than 5000 volunteers to act as 'guardian angels' to protect medical staff against angry patients in medical disputes.

Angry relatives have assaulted and beaten a 24-year old junior doctor into a coma at a Jiangsu obstetrics department.

A massive drug counterfeiting operation that made 100 million yuan by offering cut-price cancer chemotherapy drugs supposedly imported from the US has been broken up by police in Shanghai.

The Beijing University Renmin Hospital has started a male erectile dysfunction clinic but doctors says many men are too stigmatised by the condition to seek help.

A court in Guangzhou has jailed 12 hospital staff after they protested about their wages and working conditions.

Public hospitals should use private investment to improve efficiency and "let the market play a decisive role", the National Health and Family Planning Commission says.

Shanghai hospitals are to use middlemen to act as mediators in disputes between patients and doctors.

A Wuhan couple who were unable to have children after being married for seven years didn't know how to have sex, a doctor found. He prescribed them a pornographic movie.

Friday, 18 April 2014

Hospital VIP suites: going, going, but not yet gone

by Michael Woodhead
Most major hospitals in China have a VIP suite or 'special treatment' section that offers hospital beds with 'first class service - these are typically single rooms with extra nursing cover, and their own TVs and fridges. Naturally, the cost is much more than for a typical hospital bed, and hospitals have been expanding their 'special treatment' sections to make more money. However, the National Health and Family Planning Commission has now decreed that things have gone too far and ruled that hospitals may only use 10% of their bed capacity for special treatment beds. The NHFPC says hospitals must focus on providing services that have a public benefit and not seek profits from expensive special services.
The Beijing Daily this week visited several hospitals to find out what the situation was with VIP areas of hospitals. They found that many hospitals have developed these areas in addition to the existing cadre (ganbu) sections that offer preferential treatment for government officials. Some VIP sections were developed initially to service foreigners such as consular and diplomatic staff, but have now become more focused on domestic patients.
According to the article, the official fee for a standard hospitals bed is 20 yuan per night, and for a government official section the fee is 100 yuan per night. However, the fee for a bed in the VIP section can cost 1000 yuan per day or more -  ten times the cost of the most expensive official bed. And yet there is no shortage of takers. In fact, the Beijing Daily found that at some hospitals there were waiting lists of up to 3 months for VIP beds.
Hospital managers said the beds were popular because people believed that they would get better treatment from the best doctors and face less inconvenience such as waiting times in hospital.  However, insiders said that some VIP sections were really just 'hardware' and that patients there received exactly the same treatment from the same staff as the standard hospital bed patients.
When asked how long it would take to scale back the VIP sections to the 10% limit, managers were cautious. Some said that hospital had invested substantial amounts of money in their VIP sections and were reluctant to give them up. Others said they relied on the VIP sections for hospital income, and would not be able to make major changes until the government reformed the hospital funding and staff salary arrangements for pubic hospitals. In theory the role of the VIP sections should be taken over by private hospitals and clinics that are now being encouraged to develop by the government. However, insiders said private hospitals were still in the early stages of development and they simply did not have the capacity to take on all the VIP bed clients that currently use public hospitals. Therefore they believed that the government would take a 'relaxed' approach to the scaling back of VIP sections and would not be 'rigid' in enforcement of the 10% limits.

Wednesday, 16 April 2014

Medical news in brief

Prostate cancer rates have increased as much as five fold over the decade up to 2010, a study from the Jiading area of Shanghai suggests.However, prostate cancer mortality declined slightly and the five-year prostate cancer survival rate was 51%.

An outbreak of enterovirus 71 (EV71) infection in Shanghai resulted in severe disease in hundreds of children. Of 220 children admitted to hospital, , 11% needed pediatric intensive care unit care and 3% (seven) died. Severe disease tended to occur more in children who were younger and male gender.

Almost one in five medical staff are suffering from excessive workload and burnout, a study carried out at a Beijing hospital has found.

A herbal remedy, called Triptergium wilfordii is more effective against rheumatoid arthritis than the conventional medicine methotrexate, according to a trial in 207 patients carried out by Peking University Medical College.

Gastric lap banding is being used successfully in severely obese Chinese people to help them lose weight and avoid diabetes, clinicians from the First Affiliated Hospital of Jinan University, Guangzhou report.

Asthma and rhinitis symptoms are common in Chinese children, research from Chongqing has shown. A study of 4530  children under eight found that 47% had recent rhinitis symptoms, 1.6% reported a history of allergic asthma . Risk factors for respiratory disease included living near a main road and having a damp or mouldy room.

Patients from around China are flocking to Beijing and overloading its hospitals, according to the city's Health and Family Planning Commission. Officials said the capital was taking on more than its fair shareof the medical burden because patients came to the city for treatment from other provinces where hospital services were poor.

A joint venture medical school set up by Duke University and Wuhan University will enrol 100 students for postgraduate medical degrees costing up to 300,000 yuan.

Local residents living near a mine in Guangdong have been found to have toxic levels of cadmium and lead in their bodies, because they eat rice that is contaminated with these metals from pollution, researchers have shown.

Fish caught in Lake Taihu near Suzhou contain high levels of arsenic, mercury and the insecticide DDT that pose risks to human health, a study has found.

Tuesday, 15 April 2014

Cancer in China: don't be distracted by the smog

by Michael Woodhead
Forget about the smog scare - if you want to tackle cancer in China, you need to focus on smoking, diet and physical activity. That's the message from the Asian regional representatives for the World Health Organisation in the Lancet this week. Cherian Varghese and Shin Hai-Rim urge China to act on the obvious causes of cancer and implement practical programs that will achieve the greatest change with the least resources.
In their commentary they note that China has a huge burden of cancer, but there is still a lot that is not known about the causes of cancer and the types of cancer in China.  They note  there is a lot of concern about very evident environmental factors such as air pollution, but they say this is a minor contributory factor compared to factors such as infectious diseases, smoking, poor diet, alcohol consumption and lack of physical activity. Therefore they say much could immediately be done to prevent and reduce cancers by implementing policies such as smoking cessation and vaccinating against hepatitis B and HPV. They also stress the need for a more skilled health workforce and system to deal with cancer, such as by identification of early-stage disease, referral, and palliative care. They warn against the temptation to put resources into expensive new cancer drugs, which would probably have only minimal effect on cancer survival rates.
"A set of very cost-effective interventions are provided in the [WHO] Global Action Plan to reduce tobacco and harmful alcohol use, improve unhealthy diets, and increase physical activity. These measures are mostly regulatory, legal, and fiscal interventions, and will affect rates of non-communicable diseases (including cancer) in large populations," they say.

Monday, 14 April 2014

Africans face health discrimination in China | Cochlear implants success | Fake doctor operates on 1500 women | Psychiatrist says 10 words charges 1000 yuan fee

Africans in China face medical discrimination
With the growing economic links between China and Africa there are as many as 100,000 Africans in Guangzhou but they lack access to healthcare, an article in The Lancet this weeks says. Africans in China face racial discrimination, which fuels mental health problems and also is a barrier to them getting access to needed health services and support. Many Chinese people maintain stereotypes toward Africans viewing them as prone to violence and posing risks to public health through spreading diseases, the article says. While China sends medical teams to Africa, it ignores the Africans living within China.
"Providing Africans medical care is consistent with China's health-care reform, but the system has failed to close the treatment gap. Chinese doctors are not trained in culturally adapted care or in the management of specific diseases affecting Africans, and translation services are unavailable," the article concludes.

More Chinese medical tourists
Affluent Chinese are now seeking medical care overseas, according to CCTV. Their report says more Chinese are going to foreign countries for treatment and the trend is blamed on the lack of access to high quality clinics in China.

No takers for dispute insurance
Few people are choosing to take part in a new surgical insurance program that is designed to reduce medical disputes. The new medical insurance scheme pays only in the event of unsatisfactory results caused by medical malpractice not covered by traditional medical indemnity insurance.

Bionic ears work well in China
Cochlear implants have been used successfully in hundreds of Chinese deaf children and have had few complications, according to a new report from Henan. Cochlear implantation is a safe procedure and early postoperative complications are minor, say clinicians from the Department of Otology at the First Affiliated Hospital of Zhengzhou University.

Fake doctor did nearly 1500 operations
A bogus surgeon working at a gynaecology clinic in Henan performed 1485 operations on women and made almost half a million yuan in profit before being caught, Zhengzhou media report. The Pingdangshan court sentenced bogus doctor Ma Juan to nine years in prison and fined him 300,00 yuan for performing minimally invasive surgery on women at the Third Peoples Hospital gynaecology clinic. The manager of the clinic was also jailed for 12 years for employing the fake doctor and encouraging him to exaggerate illness and overtreat women with unnecessary but profitable operations such as cervical cauterisation and nerve blocks.

Psych clinic has few words of comfort
A Chongqing father has complained of extortionate charges and poor doctor-patient communication at a mental health clinic where he took his uncommunicative 'autistic' daughter for treatment. The man told the Chongqing Evening News that he had to pay almost 1000 yuan for antidepressant medicines after a brief consultation with a doctor who did not speak more than ten words to him or his daughter. The father sad the costs for the questionnaire test and brief consultation were excessive. A medical expert said mental health clinics were under a lot of time pressure and were not designed to provide psychotherapy but to treat psychiatric diseases. If patients want to talk more they should visit a psychologist, he suggested.

Saturday, 12 April 2014

The New Rural Cooperative Medical Scheme has failed: families are still impoverished due to ill health

by Michael Woodhead
Despite covering 90% of rural residents, the New Rural Cooperative Medical Scheme is failing to prevent rural families from becoming impoverished due to expensive medical bills.
A new study shows that 14% of rural families have experienced financial ruin due to catastrophic health expenditure, and one in three people have been unable to afford to go see a doctor when sick.
A review of the NRCMS, which was introduced in 2002, found that it only covered a small proportion of a family's medical bills because the insurance fund did not have enough money. Families typically pay 200 yuan a year to become eligible for the NRCMS, but when sick they face thousands of yuan in bills for treatments that are not covered by the scheme, and face high out of pocket expenses.
Dr Li Ye and colleagues from the Department of Social Medicine, Harbin Medical University found that households in rural areas faced a high risk of medical impoverishment, even if they were relatively affluent. The NRCMS only covered 30-40% of medical expenses, and therefore families faced high levels of out-of-pocket costs when a family member became ill. The study found that 28-30% of families did not seek hospital treatment but self treated when they were sick, because of the cost.
The researchers said the NRCMS had failed in its primary function of preventing catastrophic medical expenses because of the limited scope and low level of its reimbursements
They said that unlike urban health insurance schemes, the  pool of insurance funds in the rural scheme was managed  at a local country level and was insufficient to cover even the most basic medical expenses of someone with a serious or chronic illness. Another problem with the scheme was the lack of cost control mechanisms in the fee-for-service medical system, which meant that hospitals and clinics could take advantage of the system and encourage overprescribing and overtreatment to gain money from the insurance scheme.
"In order to offer a better benefit package for NRCMS contributory members, the financing level of the NRCMS needs to be increased. The NRCMS benefit package should align policies across the whole spectrum of health care services, including primary care, hospital care and long-term aged care. The integrated policies are also important for preventing cost shifting games.
Meanwhile, stronger attentions on provider-side measures need to be paid to control cost of health care," they concluded.
The findings are published in the journal PLOS One.

Friday, 11 April 2014

Clinical Friday - news briefs from the medical journals

An outbreak of Hand, Foot, and Mouth Disease in Changchun in 2013 affected more than 1125 children and was caused by Coxsackievirus A6 researchers report. They say the finding of a different causative strain means that vaccination against enterovirus EV71 will not solve the millions of cases of the disease in China every year.

More than 80% of elderly people in Beijing are infected with the stomach bug Helicobacter pylori that predisposes to ulcers and gastric cancer, a study has found. The infection rate with the more pathogenic type 1 H. pylori strain was 56%, researchers found.

Patients with H7N9 influenza living in rural areas were more likely to be female and caught the infection from backyard poultry breeding, a study from Zhejiang has shown.

Heart failure has a poor prognosis in China with 40% patients dying within four years if they have chronic heart failure with reduced ejection fraction, a study from the National Center for Cardiovascular Diseases and Peking Union Medical College shows.

More than one in ten patients attending China's overcrowded hospitals leave without being seen, a study has found. Patients who left without waiting for treatment tended to have less serious illness and have arrived on foot, according to researchers from the Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu.

Uric acid may have a role in hypertension, according to researchers from Xinjiang. In a study of 3778 children and adolescents they found that increasing levels of serum uric acid were associated with high blood pressure.

The most common forms of cancer in China are lung cancer (20.5%), stomach (11%), colorectal (10%) and liver cancer (10%) according to new figures from the National Central Cancer Registry.

Thursday, 10 April 2014

Private health is the centrepiece of health reforms in China

A few news items from this week:

Medical tourism project for Hainan

Hainan province is building what it claims to  China's first special zone for medical travel, to try attract elderly people in search of  a cheap and clean place to spend their retirement.
The Boao Lecheng International Medical Travel Zone covers an area of about 20 square km and the provincial government will create preferential policies to attract overseas medical institutions including lower taxes for imported medical instruments and medicines. Medical tourism has been backed by China's health minister, Li Bin, who said  it "will make Chinese medical institutions take steps to adapt to international demand, so that the overall standard of medical service will be enhanced."

Private hospitals given preferential treatment

To encourage private hospitals, the government is to allow them to charge whatever prices they want and also force health insurance providers to cover treatment in private as well as public hospitals. New measures announced by the National Health and Family Planning Commission include relaxing price controls covering non-public hospital services. The decree also states that all private hospitals should be included in the country's public medical insurance schemes - so long as they reach the basic  standard for 'designated' hospitals -  and government departments should implement the same reimbursement policy for both public and private hospitals. Privately-owned hospitals have welcomed the measures, especially the decision to treat all hospitals equally regarding the reimbursement of patients' medical costs.

Foreign private doctors shown favourably on TV

Chinese TV is giving positive publicity to the handful of foreign doctors working in private clinics in China. In a programme this week CNTV says foreign doctors are "flowing" into China and helping to meet the needs of China's healthcare industry.
"Alongside providing advanced treatment for patients who can afford it ... they can contribute with their knowledge and experience, in Chinese hospitals." the programme stated.

Another doctor killed by patient

A doctor has been killed in Jiangsu reportedly by a 45-year-old male patient who was angry about the outcome of a circumcision procedure. Dr Shan Erhui was stabbed to death in the lounge of a hospital in Fengxian county on Tuesday. The suspect, Wang Fangli,  underwent circumcision in the hospital on March 30 and had antibiotic treatment afterwards, and was said to be dissatisfied with the treatment outcome and the medical expenses.

Volunteers sought to protect doctors from violence

Beijing hopes to recruit 1500 "Guardian Angel" volunteers to act as intermediaries between doctors and patients, defusing disagreements and smoothing over tensions, according to Xinhua. The plan seeks to use students and patients who will serve a one-year 'guardian' term in 21 hospitals in the capital.
“Patients will understand doctors better after talking with our volunteers,” said Feng Guosheng, head of the Beijing Municipal Administration of Hospital.

3 trillion yuan invested and doctors still underpaid

The financial journal Caixin has a feature on how doctors in China still have low incomes despite the 3 trillion invested in the health system by the government. The article says that unless reforms are introduced, medical workers will continue to be paid a pittance -  especially in small town and rural hospitals. It quotes a health ministry spokesman as saying that medical reforms will fail if the "key issue" of doctors' incomes is not solved. The government says it needs to fix the problem of low pay and doctors incomes being linked to prescribing of drugs. It aims to do this by allowing doctors to work in private clinics and to charge higher fees.

Public not happy with expensive private clinics

The Chinese government may see private clinics as the way of the future, but few ordinary citizens in Shanghai can afford their fees. There has been strong criticism of a new private hospital in Shanghai that charges patients up to 1,200 yuan to see a doctor, when it costs just 50 yuan to see a doctor in a public hospital. The opening of Shanghai International Medical Center (SIMC) is being criticised as a symbol of the move to cater only to the well-off in a society.

Wednesday, 9 April 2014

Are China's health reforms stalling? Health ministry denies rumours

by Michael Woodhead
In an unusual move, a spokesman for the National Health and Family Planning Commission (NHFPC) this week spent much of a press conference trying to refute rumours that the health reforms were proving "too difficult" for the NHFPC to implement.
The spokesman for  health minister Li Bin specifically rejected media speculation that the State Council had decided  that implementation of health reforms should be transferred back the the National Reform and Development Commission.
The move comes after media reports noted that plans to merge China's urban and rural  health insurance schemes had stalled. A financial article re-published widely on social media site WeChat had also questioned whether the health ministry had the clout to push through necessary reforms of hospital finances to remove the dependence on income from pharmaceuticals. This was a tough task as the reforms face strong opposition from the medical profession, whose income is based on sales on drugs. Some have also questioned the ability of the health ministry to be a reformer "reforming itself"
and say it has shown weakness in co-ordinating reforms.
Spokesman Mao Qunan said the article was just a rumour and there were no plans to return the reforms to the National Reform and development Commission. He said health reforms were progressing steadily and it was expected hat there would be difficulties along the way. He noted that Premier Li Keqiang had put special emphasis on deepening the health reforms and implementing them in public hospitals, and this was now being extended to more than 1000 country level hospitals.
Health economists such as Professor Hu Suanlian of Fudan University, Shanghai have commented that health reforms are difficult to implement and co-ordinate because they involve many departments with different aims and responsibilities - such as finance, social security and health. There is also the problem of different provinces and cities having different health insurance arrangements and different priorities.
[Editor's note: This unusual admission of a rumour - and the concerted effort to quash it suggests  there is real opposition within the health system - and perhaps the political establishment - to China's health reforms. The health ministry spokesman made specific reference to doctors' income and the pharmaceutical procurement system as sensitive areas of the reforms. This suggests that those with financial vested interests in the status quo - the medical profession, hospitals and the pharma industry - may be trying to stall the reforms or turn them to their advantage.]

Tuesday, 8 April 2014

Defiant words of a doctor killer: Lian Enqing has no regrets for murdering surgeon he blamed for botched rhinoplasty

by Michael Woodhead
The 33-year man Lian Enqing found guilty of killing a Zhejiang doctor over failed nasal surgery has had his appeal against a death sentence turned down, but seems to have no regrets about what he did.
A lengthy article in Guangming Daily portrays faults throughout the system, including sub-standard medical treatment, shoddy hospital record keeping, a flawed medical dispute resolution system and a harsh legal system that condemns a mentally ill man to death. The article includes a few words from a CCTV interview with the murderer, Lian Enqing, from which it is apparent he is delusional and convinced that his victim got what he deserved.

The tragic case originated in March 2012 when the man sought medical help for a chronic sinusitis and nasal obstruction. He had ENT surgery for his problem at a Wenling hospital with surgeon Wang Yunjie, but after a few weeks it became obvious to the patient that the surgery had not relieved his problem - if anything, his symptoms became worse. He went back to the hospital and sought a review, but was not satisfied with the results of the tests. he went back many times to several different hospitals - including some in Shanghai - and underwent many investigations, including CT scans, all of which could find no explanation for his ongoing nasal symptoms and discomfort.

Lian Enqing refused to believe the results of the tests and became convinced that there was a conspiracy, and that doctors were covering up their mistakes. His belief was bolstered by shoddy record keeping at the hospitals, with some hospitals giving his the wrong results or imaging scans. Lian became more angry and assaulted members of his family. In July 2013 he scrawled a message about his surgeon on his wall saying "Wang Yunjie must die". He was taken by his family to a psychiatric hospital in Shanghai and diagnosed as having depression and delusional disorder and he spent some weeks in treatment.

However, his basic belief and resentment against the doctors did not change, and in October 25 2013 he went back to the hospital and attacked his surgeon Wang Yunjie with a knife, stabbing him to death and injuring other doctors. Eyewitnesses say this was no spur of the moment killing -Lian was determined, and even prevented other doctors from getting to the injured surgeon to try and save him.
 An interview aired on CCTV showed that Lian still believed there was a cover up of mistake,

Journalist: Most people would believe the results of multiple repeated tests - what was your reason for not believing them?

Lian: Because doctors feared being exposed. It would harm their image and their reputation to be shown to be wrong.

Journalist: Do you think doctors need to create such a big and complex set of lies over one pateint and one operation?

Lian: Yes

Q: But this would mean collusion on a grand scale, not just within the hospital but withing the region and even with doctors in the Fudan University Hospital in Shanghai Why would they all do that?

Journalist: Because it is a stain on the medical community, a dark stain.

The judge in the case said that he sympathised with Lian a little as his frustration and sense of injustice was justified because he had received sub-standard treatment and his complaint had not been handled properly. Nevertheless, nothing could excuse the extreme violent reaction to the unfortunate events that befell him, he added. Lian still did not acknowledge his crime or show any remorse.
In this situation, given what he did, the court had no alternative but to follow the law and conform the death sentence, he said.

The judge said that if doctors weren't so busy and if the hospital system wasn't under so much pressure, then such a tragic event may not have occurred. He urged doctors to improve the system
and be more understanding of the patients situation.

Daqing strikes gold with diabetes prevention study

by Michael Woodhead
The oil town of Daqing in north China is now becoming famous for something quite different - preventing diabetes. 
Results from a 23-year study conducted in the city have show that people at risk of diabetes can avoid progressing to the disease and almost halve their risk of death by adopting a healthier diet and doing more exercise.
The findings from the study, published in the Lancet Diabetes & Endocrinology this week have been hailed as a breakthough by international experts because they answer many of the difficult questions about how diabetes may be prevented and its harms minimised.
The study started in 1986, when 577 people with impaired glucose tolerance were assigned to either an intervention group that received advice on diet and/or exercise, or a control group. The lifestyle coaching sessions lasted for six years during which participants received regular encouragement to eat more vegetables and consume less sugar and alcohol, and encouraged them to do more physical activity in their spare time.
Now after more than 20 years of follow up, researchers have found that the people who received the lifestyle advice had a cardiovascular death rate of 1% compared to 20% in the control group. The overall death rate was 28% in the lifestyle group compared to 38% in the control group. Rates of progression to diabetes were 73% in the lifestyle group and 90% in the control group.
"These findings emphasise the long-term clinical benefits of lifestyle intervention for patients with impaired glucose tolerance and provide further justification for adoption of lifestyle interventions as public health measures to control the consequences of diabetes," said lead study author Professor Li Guangwei of the Department of Endocrinology at the China-Japan Friendship Hospital, Beijing.
Commenting on the findings, Professor Nicholas Wareham of Cambridge University said the study was a "real breakthrough, showing that lifestyle intervention can reduce the risk of long-term cardiovascular consequences of diabetes." He said the study showed that lifestyle change could be achieved in the real world and it was notable that the effects were particularly strong in women.

Monday, 7 April 2014

Doctor's income must not be linked to drug sales or patient quotas, health ministry says

by Michael Woodhead
Doctor's income must not be linked to sales of drugs or other profit-linked activities such as the numbers of tests done or patients seen, the National Health and Family Planning Commission has decreed.
Under the new health reforms for county-level hospitals, any bonus schemes for doctors must be 'scientific' and related to appropriate performance measures such as efficiency and patient satisfaction, the NHFPC has decreed.
It is forbidden for hospitals to set up schemes in which doctors are given quotas or rewards for use of drugs, tests or patients treated, and appraisal must be based on public good and work efficiency.
The rules apply to country-level hospitals, and are an extension of the reforms that were initiated in a trial basis in a 311 hospitals, now extended to more than 1000 hospitals. From now on, county hospitals that serve populations of more than 30,000 people will be graded as second level hospitals.
The new proclamation "Concerning the reform of County Level Hospitals" is made on behalf of the NHFPC in conjunction with the Ministry of Finance, Ministry of Social Security and the State Council.
The aim of the new rules is to break the dependence of hospitals on income from drug sales, the so-called "drug dependence" system. The aim is to establish a new and sustainable model of hospital funding.
The new 'white paper' also contains new guidelines for hospital drug purchasing mechanisms: country level hospitals will now be expected to rely on the provincial level purchasing systems for the drug supplies. Quality will take precedence over price in purchasing, but prices are still expected to be reasonable and fair, based on tendering systems.  Suppliers will be expected to guarantee drug supply and will manage logistics, to cut out the 'middleman' wholesalers role in drug delivery to hospitals.

Hospital ticket scalpers fight outside Beijing hospital gate

by Michael Woodhead
A gang knife fight that erupted outside the door of Beijing University Hospital in February has been revealed as a turf war between hospital ticket scalpers.
Twelve people have been arrested and seven charged with gang-related activities after a police investigation into the scuffle found that it was related to the re-sale of hospital registration slips.
In China, patients face long waits in queues at a counter to 'register' and get a number before they can make an appointment to see a doctor. In a way similar to tickets for trains and entertainment events, criminal scalper gangs obtain these tickets and re-sell them at a markup to people who want to jump the queue.
On the 25th February Xicheng police were called out to a mass fight with knives at the Beijing University Hopistal door. When they arrived they found tow injured men and a women, but the culprits had fled. The injured trio told police it was a fight between friends that had got out of hand - and they refused to co-operate or say any more. Police suspected there was more to the incident and set up a task force to investigate. They subsequently found that the fight was over protection money demanded by a local gang from a group of ticket scalpers working around the gates and doors of the hospital. The gang regarded the hospital as their territory and demanded payment from the scalpers. When there was a dispute about payment, the fight broke out. The police arrested twelve people who now face charges of assault as well as gang-related illegal financial activity.

Sunday, 6 April 2014

China has learned the lessons from SARS, praised by WHO for H7N9 reponse

China's response to the H7N9 influenza outbreaks has been praised the World Health Organisation for the sound preparedness, prompt communication and collaboration with international groups. In the latest WHO Bulletin the agency says China has learned the right lessons from the mistakes made with SARS and now has a robust and open system for dealing with infectious disease outbreaks that can be a model for other countries. After SARS, China reformed its systems to improve disease surveillance and make the country’s response to future disease outbreaks both swift and effective, WHO says. The improvements to the system were evident when H7N9 influenza emerged in March 2013. The Chinese surveillance system based on Centres for Disease Control and Prevention allowed the problem to be quickly identified, and there was a good response in terms of follow up testing and identification of new cases. prompt moves were taken to reduce risk by closing poultry markets, and appropriate risk information was disseminated quickly to the public, the report says. It also welcomes the close cooperation between the National Health and Family Planning Commission and WHO in responding to the H7N9 threat. China was praised for being open about the sharing of information about H7N9 to the public and with the wider scientific community, with no barriers to publishing the results of virological and epidemiological investigations in scientific journals "China’s prompt response to the emergence of the A(H7N9) virus as a human pathogen – which spanned multiple governmental departments and ministries at national, provincial and municipal level – was mainly the result of strong leadership in a critical situation." the WHO report concludes.

Friday, 4 April 2014

Harbin hospital charges dead patient for drugs and tests

by Michael Woodhead
The relatives of a 41-year old woman who died of pneumonia at  Harbin University No 2 Hospital are seeking an explanation for why they have been billed for two days of drug treatment and tests after her death. 
The woman spent 13 days in the intensive care unit after she developed pneumonia and kidney failure in February.  She died on 24 February and the family received an initial bill of 197,000 yuan (US$32,000) for her treatment. However when they came to transfer her body to a funeral centre they received an additional bill of 22,000 yuan ($3500) for drug treatment. The family had no option to refuse as they had already paid a deposit of 250,000 yuan as guarantee, and the hospital refused to refund the difference. They listed the additional costs as being for injections, respiratory tests and blood and heart monitoring.
The family disputed the bill, with the older brother pointing out that his sister would not have needed any tests in the 48 hours after her death. However,  the hospital refused to deal with them, so they took their complaint to the local bulletin board of Tianya. Many other local people sympathised with them and told of similar complaints of overcharging by hospitals.
A reporter from the Legal Daily took up the case and brought in accountants to analyse the bills.  They found that the bills for the extra two days were similar in size to those of previous days but they were vague and did not accurately show what treatments and tests were given or at what time.  When approached by the Legal News, the hospital's accounts department said it would review the figures. It later came back and said that after reviewing the billing it found some uncertainties and it was willing refund the family 18,000 yuan.
Other online commenters pointed the the famous case at the Harbin hospital in 2005 when a patient hospitalised for 67 days received a bill for 5 million yuan.
A spokesman for the hospital refused to comment, and the hospital manager was repeatedly said to be in a meeting when reporters sought comment from him on the case.

Pharma bribes and other medical news from China

China pharma bribes explained
A former pharma industry sales rep in Shanghai has described how bribes were given to doctors in various ways. According to the FT ‘big-ticket bribes’ were laundered through travel agents whereas smaller kickbacks were directly paid in cash or in kind to doctors. The former rep said he covered up the bribes using fake tax receipts or with receipts he collected from family and friends for taxis and meals. Drug reps could boost their base salary of 7,500 yuan a month with a quarterly bonus of 17,000 yuan if sales targets were met, plus an additional 5% of sales above the target.
The average industry kickback to doctors was 5-20% of the value of the drug, he said.

And in other news ...

The best treatment for H7N9 influenza is intravenous zanamivir (Relenza) say HK respiratory physicians.

About 15% of children hospitalised with pneumonia have RSV infection and this could be prevented with a vaccine, according to a study from Suzhou.

Suicide rates have fallen substantially in China in the last decade, according to a study from Shandong.

Prescribing of  tuberculosis drug treatment is poor with only one in four drug courses being adequate, a study from Hubei has found.

Cefrtriaxone may cause postrenal acute renal failure in children, doctors from Wuhan report.

A Chinese doctor from Hebei was one of the passengers on the missing Malaysian flight MH370, the Times reports. Dr Bian Liangjing gave up working as a doctor in China because he could earn more money as a labourer in Singapore, his family said.

Osteoporosis imposes a major financial burden on elderly Chinese, with a hip fracture costing an average of 27,000 yuan ($4300) in treatment and other costs.

Thursday, 3 April 2014

Chinese leaders affirm commitment to Hangzhou Resolution on ethical organ donation and transplantation

by Michael Woodhead
Chinese health officials and hospital leaders have committed to upholding the new ethical framework for organ donation and transplantation as outlined in the recently signed Hangzhou Resolution.
In a update statement, officials and transplant surgeons affirmed the new five point plan that will outlaw practices such as use of organs from executed prisoners and the 'sale' of organs to foreign buyers.
The new statement also includes a list of 38 Chinese transplant centres that have already confirmed  to have stopped using organs from prisoners, with others "anticipated in the days ahead".
The statement published in Hepatobiliary Pancreatic Diseases International is co-authored by China's leading transplant specialist Professor Huang Jiefu  and international transplant specialists including Dr Francis Delmonico, President of the Transplantation Society.
It notes that the Hangzhou Declaration commits China to adopting  a new organ transplantation system overseen by the National Health and Family Planning Commission (NHFPC) and the Red Cross. The new system will set up a national voluntary organ donation scheme and a new organ procurement and allocation system that is based on clinical needs and which is "open and transparent". China will set up a human organ transplant clinical network based on 169 authorised transplant centres, an organ registry system and an organ donation regulatory system.
"The NHFPC expressed the resolution of the government of China that the dependence upon organs from executed prisoners must be terminated. The government of China has affirmed its commitment to prohibit transplant tourism and to shut down organ trafficking and transplant commercialism," the statement says.
The move to the new organ donation system will also mean that China is no longer the subject of an academic boycott on organ transplantation.
Health minister Li Bin also pledged her commitment "to bring China back to the international community and to promote an academic exchange based upon the five-point NHFPC plan elaborated."
The next step will be to implement the agreement in all China's provinces. The statement says China will also host a meeting this year with leaders of the major international transplantation societies and WHO representatives.
"The meeting will affirm the new resolution in the practice of organ donation and transplantation in China. The meeting will be a milestone for China transplant professionals to practice according to the international standards set by WHO Guiding Principles."
Meanwhile, in a public show of support for the new organ transplant system, senior Chinese leaders have registered to donate their organs.
Officials including Chen Zhu, vice-chairman of the Standing Committee of the National People's Congress and a former minister of health; and Hua Jianmin, head of the Red Cross Society of China added their names to the new online organ registry at the Beijing Union Medical College Hospital .
The registry, overseen by the society's China Organ Donation Administrative Center, is available for people aged 18 and over who are willing to be organ donors after their death.
In December, the State Council issued a guideline related to funeral reform, encouraging Party members and officials to register to donate their organs after their death, according to China Daily.

Wednesday, 2 April 2014

Wednesday news: Knife in head | Medevac helicopters | EV71 alert | Left behind parents | DTP boosters | Salt intake

Surgeons in Huashan are to remove  30cm knife embedded in the temple of a young man after a knife throwing game went badly wrong.

Beijing is to get two medical evacuation helicopters the Beijing Red Cross Emergency Rescue Center says, fitted with resuscitation medical equipment such as ECG monitors and defibrillators.

Shanghai parents warned to be vigilant for symptoms of hand foot and mouth disease after two child deaths.

China has millions of 'left behind' elderly people with unmet social, medical and psychological needs, as their children have migrated to cities for work.

Booster vaccinations for diphtheria, tetanus and pertussis  are needed at seven and twelve years of age because of waning vaccine efficacy, researchers in Henan say.

Chinese people eat twice the recommended daily intake of salt and need to cut down on added salt and soy sauce, experts say in the Lancet.

Tuesday, 1 April 2014

Tuesday news: The US health model best for China | Food and drug police | SARS victims forgotten | HIV medication non-compliance | Womens' wrinkles vary by region

US healthcare model is the answer to China's problems
The answer to China's health problems is to follow the American model and encourage growth of the private health insurance industry, says an American academic. Harvard's Professor Martin Feldstein, a former economics adviser to Ronald Reagan, says China could boost the growth of private health companies by creating tax breaks for employers and people who pay into them. Expansion of health insurance would also lead to an increase in the provision of hospital services as private insurers will enter the market, Professor Feldstein told Jewish Business News. By encouraging the purchase of health insurance by individuals or employers, the Chinese government could reduce the current trend for household saving to pay for medical bills and free up funds to increase consumer spending, he said.

'Health police' to be set up to catch drug and food crooks
"Watch it, here come the health police ..." - may soon become reality in China.  The Ministry of Public Security is planning to set up a new police division to deal with "food and drug safety crimes" in conjunction with the China Food and Drug Administration (CFDA). At present those who break food and drug regulations are supposed to be dealt with by the CFDA, but  the agency has weak powers and not enough staff to deal with the numerous cases of drug and food violations. The new food and drug police would have more powers, but some people are warning that it will lead to duplication and will not deter back street drug factories or sub-standard food manufacturers.

SARS victims abandoned to ill health
Many of the 5000 people in China who were infected with SARS a decade ago are struggling today under a burden of severe long term complications, clinicians say. SARS victims feel forgotten and abandoned, with may having debilitating lung problems that stop them from working and earning a living, according to an article by Professor Xiang Yutao and colleagues of Capital Medical University in Beijing. Many people who had SARS  developed long term problems and disabilities due to the high dose steroid therapy they were given, according to Professor Xiang. However there is no social or financial support for the many people who need ongoing medical treatment, he says.

HIV patients stop taking their medicines
Antiretroviral medicines are provided free of charge to HIV positive people in China but despite this, many stop taking them, leading to high rates of treatment failure. A new study from Guangzhou of 813 HIV-infected adult 19% had recently missed taking their medication and 7% had had stopped their antiretrovirals for at least a month in the past year). Those most likely to stop tended to be male, living alone, poorly educated and to drink alcohol.

The women with the best skin in China live in ...
If you want beautiful skin, go live near the Yangtze - that's the conclusion of a study of women's skin quality in different areas of China. Dermatologists found that skin quality and appearance depended on the local climate - in the cold, dry smoggy climate of Beijing womens' skin tended to be dry and wrinkled, whereas in the hotter sub-tropical humidity Guangzhou women had finer wrinkles - but more greasy skin due to higher sebum content.  Cities such as Shanghai and Wuhan had a combination of high moisture and moderate temperatures and women's skin had more elasticity.