Thursday, 31 July 2014

Doctors pour scorn on China's medical TV shows: point out five most egregious mistakes

by Michael Woodhead
One of China's most popular TV shows is the medical drama "Young Doctors". Modelled on similar hugely popular shows from Korean TV, the show is all about the lives and loves of a handful of beautiful, smart and successful young doctors. 
China's real young doctors are not impressed - but they are laughing. On the medical social media site DXY. net they have been pointing out the many ridiculous factual errors and goofs in the show. The top five are:

1. Hand hygiene howler: Ming Ming has donned sterile gloves but then adjusts her glasses - an obvious no-no from an infection control point of view

2. Scans all wrong: - holding X-ray pictures the wrong way round - pointing to a chest X-ray and and diagnosing a broken leg, looking for pneumonia in a CT scan of the head ...

3. White coat wearing - on the TV show, doctors never button up their white coats, but wear them open and flapping like fashionable casual wear.

4. Novel medical theories: mahjong can prevent Alzheimers, people wake up from prolonged vegetative state.

5. Miracle patients: man with tracheal obstruction on breathing machine can speak quite clearly with beautiful dialogue.

However, China's medics are more impressed with the other medical drama The Obstetrician. Written by a playwright, it is nevertheless quite authentic as it relies on real cases histories and the scriptwriters consulted medical professionals over the technical details.

Wednesday, 30 July 2014

Public warned of fake doctors soliciting bribes

by Michael Woodhead

The families of patients discharged from hospital are being phoned by scammers pretending to be doctors and soliciting 'red envelope' bribes, Guangzhou media report.

The Guangzhou Daily reports the case of a women referred to as "Auntie Chen" whose elderly mother had just come out of hospital for treatment of stomach cancer. Ms Chen received a phone call from a "Dr Wang" at the hospital who seemed to be familiar with Ms Chen's mother's case and said she needed to have her treatment adjusted after her last visit.

The 'doctor' said he could arrange this the next day, but the medical team would require red envelopes containing 2-3000 yuan to speed things up. He put pressure on Ms Chen, asking if she wanted to take up the offer, but time was limited and other might take the free appointment time. Ms Chen  panicked and agreed to come to the hospital the next day to arrange matters.

The next morning when she arrived at the hospital she called the number supplied by Doctor Wang and he told her he would meet her in the foyer, there was no need to go back to the clinic reception. Ms Chen became suspicious and phoned the clinic where her mother had been treated. They said they knew nothing of any changes to the old lady's treatment plan and Dr Wang had not made any calls to patients. When Ms Chen reported what had happened to the hospital security department, she was told that several families had been called by scammers, trying to dupe families to hand over money as bribes for 'special treatment'.

The head of hospital security said families should be aware that doctors and staff at the hospital would never ring patients asking for money. If there were bills to be paid this would be requested in writing and the bills paid at the hospital cashier.

 When asked how the fraudsters knew the details of the doctor and her mother's condition, the security chief said it was possible that criminal gangs had spied on people when they were registering at the hospital reception. He warned patients and families to be careful when filling in details on forms and not to discard any incomplete forms in rubbish bins. He also warned the public not to discuss the details of cases with strangers or in public where others may overhear.

Tuesday, 29 July 2014

Good news on infant mortality rates in China - but have the numbers been exaggerated?

by Michael Woodhead

The Economist [aka 'the Monetarist'] is impressed with China's socialist achievement in reducing rates of maternal and infant mortality over the last decade. 

The magazine this week cites a WHO report that praises China for reducing rates of infant mortality from 61  to 12 deaths per 1,000 live births since 1991 - meaning they are now one fifth of what they were in the time of Deng Xiaoping. Maternal mortality rates have also dropped by about 70% over the same period. The improvements are attributed to the introduction of universal health insurance  schemes that subsidise hospital care for maternity care - and also implementation of infant vaccination programs.

The Economist then raises a lot of questions about whether China's vaccination program is as safe and appropriate as it could be - mentioning the recent scare about hepatitis vaccine quality and the ineffectiveness of measles vaccine programs. It even makes an absurd suggestion that China should step back from blanket immunisation and instead test mothers for immunity to various diseases before vaccinating them accordingly.  The overall message, however, is that China deserves credit for a major improvement in mother and baby health.

Coincidentally this week a letter is published in The Lancet Global Health from Chinese researchers questioning whether the gains are as extensive as they seem. Dr You Hua and colleagues at the School of Public Health, Zhejiang University School of Medicine, Hangzhou, write that recent improvements in infant mortality have been confined to rural areas - with little change in urban areas despite much greater rises in standards of living. 

Like WHO, they also attribute the improvements in rural areas to the introduction of the New Cooperative Medical Scheme in 2003. The coverage of this scheme reached 97% of village hospitals in 2011 and the subsidies allowed pregnant women to access antenatal and postnatal services. The Chinese researchers note that maternal mortality rates fell from 65 to 27 per 100 000 between 2003 and 2011 in rural areas, but remained virtually unchanged in urban areas. They speculate that the lack of change in cities may be due to the influx of uninsured women from rural migrant worker families.

Dr You also questions whether the impressive reductions in maternal mortality reported by the government are authentic. She remarks that health departments are financially rewarded for achieving targets such as maternal and infant mortality - and punished for not meeting them. The officially reported figures may therefore be subject to 'inflation', she suggests.

"These reservations notwithstanding, it is important to call attention to the dramatic reduction in rural maternal mortality in China and the lack of progress in the urban maternal mortality. The levelling out of urban maternal mortality in China in the past decade calls for increased attention," the researchers conclude.

Monday, 28 July 2014

Respectable doctor ran an illegal abortion clinic in Henan, now on the run after women died

by Michael Woodhead

A doctor working for the health department of  Nanyang city in Henan is a fugitive on the run after a 32-year old woman died at an illegal abortion clinic she was running as a sideline from a private apartment in the city.

In a story published in a local newspaper, the family of Ms Cui Hengjuan told of how she died after undergoing an abortion at the clinic run by a doctor who they trusted because she was an official at the local health department.

Ms Cui was the mother of a seven-year old girl and when she was almost three months pregnant with a second child she went to the private clinic run by a Dr Cui (no relation) for an ultrasound scan to determine the sex of the fetus. She trusted the clinic because Dr Cui was an official in the local health department, where she worked as a tuberculosis control officer in the Communicable Disease Centre. She also claimed to have run the clinic for 20 years, and told Ms Cui her experience meant she could offer reliable and safe sex determination and abortion services.

When the scan revealed the fetus was a girl, Ms Cui requested an abortion as her family wished for a baby boy. Dr Cui arranged for her to take medication to induce an abortion. Ms Cui went home but began to feel uneasy, so she returned to the clinic, where the doctor put her on a drip. However, Ms Cui felt worse and in the middle of the night she went into shock and stopped breathing.

The family were distraught and went to the health department and police station to complain. However, when they returned to the clinic they found that Dr Cui had slipped away and there were strangers taking the ultrasound equipment away.

According to the newspaper, a journalist went round to the illegal clinic and found only a locked apartment in a block opposite the maternity hospital, with nobody at home. The landlady knew a doctor had rented out the apartment but said she was not aware she was running a clinic on the premises. However, neighbours said the clinic was always busy with women coming and going, , especially on the weekend.

The journalist sought comment on the matter from the local health department, the director said they knew Dr Cui only as a doctor employed in disease control. They had no reports or knowledge of her running any private clinic. The health department said they had no idea of Dr Cui's whereabouts. When informed of the death of the woman, the health department said they would suspend Dr Cui pending an investigation into her clinic.

The police told the newspaper that they had opened a file on the case, but had been hampered because the family had refused to consent to an autopsy on the woman who had died. A spokesman for the police said they were seeking Dr Cui, but they currently did not know where she was.

Mental health treatment in China: still in the dark ages?

by Michael Woodhead

Stigma and shame still feature highly in attitudes towards mental illness among the public - and even among family members of patients, a survey carried out at one of China's leading psychiatric hospitals has revealed. 

Guangzhou Psychiatric hospital was the first mental health treatment institution set up in China and is still one of the largest and most 'progressive' units in the country. Last year, researchers surveyed 87 doctors and 162 nurses at the hospital and 137 family members of people with mental illness, as well as 150 members of the public.

They found, unsurprisingly that medical staff tended to have enlightened views about mental illness - that it has biopsychosocial causes and may best be dealt with in community treatment. However, relatives of patients and the public tended to hold the traditional view that mental illness was something that should be treated in institutions and that patients do not belong in the community.

There was also support for involuntary treatment of mental illness. In rural areas there were also more superstitious beliefs that mental illness might be caused by curses, devils or bad luck.

The researchers said the negative attitudes held by family members might arise because they lived in close proximity to people with mental illness and had to cope with them in isolation as there was little community or health service support for mental illness. "Families must should much of the burden of mental illness alone,"they wrote.

"The results draw attention to the crucial issue of what has been called "family burden" the painful, often debilitating and health-endangering experience of caring for seriously mentally ill family members’ day in and day out. These experiences may be especially strong in Asian countries such as China in which the family, rather than the state or society, has a heavy burden of responsibility for mentally ill relatives, extending even to fiscal responsibility for their occasional damage of neighborhood property or criminal conduct."

The findings support provision of respite care for mentally ill people in China, "that gives family members some distance from the problems of their relatives and support in their care," the researchers concluded.

Sunday, 27 July 2014

This week's top eight health stories from China

1. Leptospirosis rates in China have gradually decreased in recent years, but it is still an important zoonotic infectious disease, say researchers. The development of  vaccines is critical for the prevention and control of  the disease that is spread by infected pigs, they say.

2. The popular Chinese habit of napping is associated with higher rates of glycaemia and a higher risk of diabetes, according to endocrinologists from the Ningde Municipal Hospital, Fujian Medical University.

3. China is still harvesting organs from executed prisoners, making a mockery of the recent "Hangzhou Declaration" which signalled intent to give up this unethical practice, say transplant surgeons from the UK, US and Australia in an article in the American Journal of Transplantation.

4. A Changsha man vowed to kill doctors at a hospital where he was diagnosed with hepatitis, but his plot was foiled when his wife found his 'suicide note' and reported him to police before he was able to carry out the attack.

5. The TV medical drama "The Obstericians" was broadcast in Shandong accompanied by an SMS response forum on which members of the public could post questions to real obstetricians who were consultants to the programme makers.

6. Infections with West Nile Virus in Xinjiang may have been greatly underestimated say researchers from the National Institute for Viral Disease Control and Prevention, who found that many  patients might have been given misdiagnoses of the mosquito-borne infection with Japanese encephalitis because of cross-reactivity between the two viruses.

7. Beijing authorities are holding open forums on the scope of new anti-smoking regulations, debating how to extend them in public spaces such as schools, hospitals and workplaces. The Centre for Disease Control has lobbied for strict restrictions and enforcement, noting that 20% of school students have tried smoking.

8. Children at risk of intestinal worm infections caused by helminth parasites responded well to a trial of health education in Hunan schools, which improved knowledge and awareness, and changed hygiene behaviour.

Wednesday, 23 July 2014

Why China's well-meaning rural health reforms are destroying township hospitals

by Michael Woodhead
In the hierarchy of Chinese healthcare, rural township hospitals occupy the second to bottom rung, below country hospitals, but above village clinics.  They are an essential component of the Chinese health system, especially for rural people on low incomes, but they are collapsing because of ill-planned rural healthcare reforms started in 2008.
The big change that is destroying township hospitals is the attempt by the health ministry to make drugs affordable and stop doctors from profiting from commissions on the sale of medications. To do this, the ministry brought in a new system that restricted township hospitals to using medications on an essential drugs list, all of which are sold at zero commission. This made drugs more affordable to rural people, but it also meant that township hospital doctors lost their main source of income. To compensate, doctors were put on fixed salaries equivalent to those of secondary school teachers. The Chinese government also created an affordable rural health insurance scheme that would provide reimbursement for inpatient care - and less so for outpatient care.
In theory, this sounds like a recipe for affordable and equitable healthcare for rural residents. So what went wrong? The first problem was that the health ministry forgot to consult with rural doctors on the likely impact of the scheme. The unintended consequences of the reforms have meant that they have done the exact opposite of what they were intended to do - they have weakened the township hospital system to the point where it is being abandoned by doctors and patients alike, all of whom are fleeing to the larger and better equipped country hospitals. Why is this?

In a new paper in the journal Social Science and Medicine, China health experts including Dr Theresa Hesketh from the University of London report on a series of interviews with rural health workers and patients, who describe the impact of the health reforms.

1. Essential Drugs List
The main complaint of rural health workers is that the essential drugs list is too narrow, and it prevents them from doing their job properly. Many doctors have found that the drugs they need are simply not available, and as a result patients have to go to a country hospital, where the essential drugs lists (and capped prices) are not enforced. Thus patients end up having to travel long distances for treatment and also have to pay more for their drugs. Another problem with the essential drugs list is that drugs are often not in stock because the low prices mean that drug companies have little incentive to produce them to a good quality standard.

2. Doctor Incomes
A second problem with rural health reforms relates to the switch to fixed salaries of doctors - a return to the 'iron rice bowl' of the Mao years. This means that doctors no longer have an incentive to see more patients or work more flexible hours, such as night shifts or in mornings and evenings when rural residents may be free from farmwork. Doctors now get paid regardless of how hard they work, which is a disincentive. The low level of the fixed salaries is also demoralising because doctors see themselves (rightly or wrongly) as more highly qualified and skilled than secondary school teachers, whose salaries are used as a benchmark.

3. Inadequate health insurance
One of the main anomalies of the New Rural Cooperative Medical Scheme is that patients get more reimbursement for inpatient treatment fees (70%) than outpatient treatment fees (30%). This creates a perverse incentive for patients to get admitted to hospitals, even for minor illness. However, the low ceiling of the health insurance cover (about 200 yuan a year) means that it fails to protect patients who have catastrophic health costs due to serious or chronic illness.

The net result of the reforms has been the demoralisation and de-skilling of rural doctors because they have seen their income drop and their ability to treat patients curtailed. Not surprisingly, many doctors have joined a brain drain from township to county hospitals, where they can earn higher incomes (from drug sales) and have more clinical freedom to prescribe what they want.

Dr Hesketh says the reforms have done some good in the poorest rural areas of China, such as those in Yunnan. There they have made drugs more affordable and guaranteed doctors some income. But in more mainstream parts of China such as Zhejiang the reforms have had a negative impact. The problems might have been averted or minimised if doctors had been consulted about the reform before they were implemented. She suggests that the way forward will have to involve raising doctor's incomes and also expanding the scope of the essential drugs list. Giving rural doctors a 'gatekeeper role' - like primary care physicians may also help, but will prove unpopular with Chinese patients who are used to going direct to the hospital. Dr Hesketh says there is also a need to improve insurance cover and the 'supply side' problems such as overservicing and price gouging.

In the meantime, China is left with a broken health system in need of repair to fix the damage caused by early reforms. Let's hope Health Minister Li Bin is paying attention.

Tuesday, 22 July 2014

Ask me no questions .... a bland press conference hosted by the NHFPC

by Michael Woodhead
For some reason, Chinese state media is running a transcript of a press conference convened by the National health and Family Planning Commission. It contains very little new or newsy, but does show how these events differ from those in countries with a free(er) media. Given the long and detailed replies, it's obvious that the questions and answers are pre-prepared. And it's all a bit of a whitewash from the start. The un-named 'journalist' first asks about the health of China's women and children. The reply is filled with the usual numbers and statistics to back up [genuine] improvements in maternal and child health. It avoids any discussion of 'sensitive' subjects such as abortion rates, female suicide, sex-selective fertility clinics and gender disparities in health.
The journo than asks a more pertinent question about the health of China's huge floating population of rural migrant workers and their families. This is one of China's most disadvantaged groups, as they lack health insurance cover in their place of residence - their rural insurance (if any) is not potrtable to cities and offers only paltry levels of reimbursement.
However in the press conference this topic is deflected with a bland reply about how services for rural migrant healthcare have improved in recent years. It also claims that "up to" 92% of migrant families have access to health services such as immunisation. This is incorrect - as I have reported here in recent months, immunisation rates  are very low for children for rural migrants because most are ineligible for urban health services.
The press conference then moves on to preparations for the two child policy and prevention of birth defects through folic acid supplementation. It also touches on the dismal rates of breastfeeding in China, which have collapsed in recent years as newly wealthy Chinese women opt for baby formula. The press spokesman says that breastfeeding will be promoted by policies that 'hope' employers will provide nursing areas in workplaces.
The only point of interest is the pledge that 'VIP wards' (or special medical services as the spokesman euphemistically describes them) will be phased out of China's public hospitals, with new private hospitals expected to take on this role.
All in all, a fairly standard piece of non-news.

Monday, 21 July 2014

Yunnan Baiyao gets the Streisand effect when it sends police to interrogate a doctor who reported a side effect

by Michael Woodhead
A Guangzhou dermatologist got a very rude shock when he posted a report of a possible adverse reaction to one of China's most popular traditional remedies, Yunnan Baiyao (an astringent said to be good for wound healing). 
The remedy is a multi-million yuan bestseller product for its Yunnan manufacturer, and they obviously have a lot of 'guanxi' and clout with the law enforcement authorities. Two years ago a Guangzhou dermatologist Dr Liu Xin posted a report on Weibo about a young girl who had an adverse reaction to some medicine that her family used on an open wound. The post advised caution in using excessive topical antiseptic products on wounds. Dr Liu did not even mention Yunnan Baiyao by name, but it was fairly obvious to readers which product the girl's family had used (in addition to mercurochrome antiseptic). The original post was circulated quite widely and has occasionally resurfaced over the last two year.
Dr Liu had almost forgotten about it, until the police came knocking on his door recently. The police had been sent by Yunnan Baiyao, who wanted the post retracted. They claimed that Dr Liu was trying to damage their corporate reputation and wanted hims charged with being involved in an extortion attempt against the company. They acused Dr Liu of deliberately spreading false and malicious rumours to discredit Baiyao - and they wanted to make an example of him. The police posed questions to him such as - "has the picture of the wound been Photoshopped? ... How come you don't remember this family's exact details?" and "did you verify with proof that these medicines were used and caused the disfigurement?" Dr Liu said he was amazed to be accused of a crime for doing his job - as a licensed dermatologist it is professional duty to treat cases such as this - and his public duty to report on matters where injury may be avoided in future. The police did not press charges against Dr Liu, but he says that even though he was 'exonerated' he has been left with a sense of fear and intimidation. How many others will choose to remain silent in such circumstances by such heavy handed tactics? Fortunately, online commentators have now circulated the latest news about Dr Liu's 'persecution' by Yunnan Baiyao - and exposed their use of police to put pressure on any public criticism of their product that threatens their commercial interest. Commentators say this is a clear case of freedom of speech being suppressed for financial reasons, and abuse of police powers to protect a commercial organisation. They say it is a typical case of s powerful local company relying on police to defeat perceived threats to their interests. They say it also underlines the lack of trust in Chinese society generally and the lack of trust in health products in particular.

Sunday, 20 July 2014

Sunday snippets: health reformer sidelined, Hong Kong-style hospital fails, HIV activist banned

Three stories stand out this week: firstly, the  'open' reporting of Caixin is a refreshing change from the routinely stultified, narcissistic column fodder of the official English language publications such as China Daily. This week they have an interesting profile of Guangdong doctor-turned-health bureaucrat Dr Liao Xinbo. He is portrayed in Caixin as an outspoken critic of the system, who has put a few noses out of joint. One incident in particular seems to have seen him sidelined for not toe-ing the Party line - when he made promises to some pregnant women who were protesting about the one child policy. However, on closer reading Dr Liao doesn't seem to be that much of  maverick. His outspoken-ness relates to his advocacy of two policies that are already at the forefront of NHFPC reforms, namely allowing doctors more flexibility to work in the private sector and promoting 'social capital' (ie private investment) in medical facilities. Perhaps Dr Liao's real crime is to have highlighted the fact that the NHFPC is a relatively weak government ministry, and the real decisions are being made by ministers for finance and social security and the he National Development and Reform Commission. To the embarrassment of the NHFPC he also points out that local governments are a major barrier to real reforms - because they have a huge financial vested interest in running local hospitals (and the profits from drug sales).
On a related note it is interesting to see a model health reform project faltering. Shenzhen has set up a joint venture hospital with Hong Kong, in an attempt to bring in Hong Kong-style health systems - most importantly a 'gatekeeper' system in which patients are triaged by a generalist practitioner before going to see a specialist. Unfortunately for the project, mainland Chinese residents do not seem to be taking to this new model of care. Despite huge overcrowding in Shenzhen hospitals, they are staying away in droves from the Hong Kong-China hospital. And it's not because of the cost - fees are subsidised by the Shenzhen government to an embarrassingly generous  extent. According to one report, the HK joint venture hospital is costing a billion yuan a year - almost all of the Shenzhen city budget for supporting city hospitals. And yet it is operating at only a quarter of its capacity. The hospital management are pinning their hopes on the opening of a VIP section of the hospital to bring in some much-needed revenue - and yet VIP medical wards are exactly the opposite of what China's health reforms are supposed to achieve, and other hospitals have been ordered to phase them out. It looks like China health reforms have a rocky road ahead of them.
And finally, just when you think China is opening up and showing a more enlightened approach to health, the government shows that its repressive, authoritarian ways extend to advocates for appropriate HIV treatment.  Ms Ye Haiyan, a Hubei-based advocate for sex worker health, was banned from attending the International AIDS Conference in Melbourne. Her crime, it seems, has been to criticise Xi Jinping's crackdown on the sex trade, pushing brothels and sex workers further underground.Ye says this will inevitably make it harder to detect and treat HIV. Another more high profile HIV activist, Hu Jia, was assaulted by plainclothes police in Beijing. We can only hope that these regressive actions by the Xi Jinping administration  are raised at the International AIDS Conference.

Saturday, 19 July 2014

Why do some Chinese patients with HIV refuse lifesaving antiviral treatment?

by Michael Woodhead
[UPDATED] China has a huge number of people with HIV, though fortunately there are now effective antiretroviral drugs that can prevent progression of the infection and allow people to live with HIV rather than die from it. However, for some reason some Chinese people refuse antiretroviral treatment and become victims of AIDS.
According to Dr Lu Hongzhou an infectious diseases specialist at Fudan University, this is because some Chinese still have 'traditional thinking' and believe they can overcome the disease through traditional methods such as Chinese medicine rather than with 'superficial'  western medicine. Writing in Bioscience Trends this week, Dr Lu describes a typical such case involving a man called Zhang Shan who was diagnosed with HIV in 2010. At that time he was already quite unwell with a CD4 cell count of 49/μL and he also had tuberculosis.  His prognosis was poor and he was advised to immediately start antiretroviral therapy. However, Zhang refused, citing his belief that he did not believe in  western medicine and that he could conquer the infection by finding out more about the virus and seeking Chinese remedies. For the next year he did a lot of reading and travelled to visit several famous "monks and Taoist priests" who claimed that they could cure him of his disease. Zhang's HIV infection deteriorated and he eventually decided to seek medical help again when he was extremely sick with a CD4 cell count of just only 8/μL. He was persuaded to start on anti-retroviral medications and made some recovery, but by that time he had left treatment very late and had already experienced some disability. After several months of antiviral treatment Zhang was still alive, but his doctors told him that he had missed his best opportunity because the earlier treatment begins, the better.
Dr Lu said the case highlighted the barriers that Chinese beliefs represented to delivering effective treatment for HIV. He characterised these barriers as including "society, history, morality and ideology, family, education" (- and most of all,the patient’s mindset).
"The daunting task is to transform or change traditional or inculcated beliefs of potential AIDS patients so that they are open to antiretroviral therapy, which is a product of modern science, to help their plight," he concludes.
Update: A newly published study shows that only about half of patients with HIV were still taking their antiviral medication after six months. One significant finding in this study was that many patients had depressison, which may have affected their motivation to continue with treatment.

Thursday, 17 July 2014

The Chinese midday nap causes high blood pressure

by Michael Woodhead
The common Chinese habit of having a midday nap - or wujiao (午觉)- is bad for blood pressure, researchers from Wuhan have shown.
In a study of blood pressure levels in more than 27,000 people, Dr Wang Youjie and colleagues from the School of Public Health, Tongji Medical College, Wuhan found that those taking daytime naps had significantly higher blood pressure than non-nappers. The risk of hypertension was directly related to the length of the midday nap, with those napping for more than 30 minutes being at significantly higher risk.
Writing in the Journal of Hypertension, Dr Wang said taking daytime naps could result in the elevation of evening cortisol levels, which may lead to high levels of blood pressure. The increased risk of hypertension in people who nap might also be related to sleep apnoea, the researchers suggested. They noted that midday napping is a also a risk factor for diabetes mellitus
"We postulate that midday napping might increase the risk of diabetes and hypertension
through the mediation of pathophysiological pathway(s) underlying metabolic syndrome, such as insulin resistance or increased inflammation," they said.
Dr Wang noted that napping is a common habit in China, ingrained from childhood, and practised by 80% of Chinese college students, even though it is "more a habit than a
physiological need", according to a recent survey.
"Considering that midday napping is a common practice, these findings have important implications for further investigation of the potential health consequences of napping and of the optimum nap regimen for elderly people," they concluded

Wednesday, 16 July 2014

Baby formula illegal marketing | Rural insurance scheme | Dengue fever warning scheme | Shigella resistance

Infant formula manufacturers are defying codes of practice to defeat efforts to encourage Chinese women to breastfeed. A study of almost 300 new mothers in Beijing found that 40% reported receiving free formula samples in or near the maternity hospital an 69% fed their infant with commercial formula. Among  stores surveyed, 46% were found promoting products in a way that violates the International Code of Marketing Breast-Milk Substitutes.
The rural New Cooperative Medical Scheme has reduced the prevalence of households falling into poverty with catastrophic health expenditure due to out-of-pocket medical fee payment, a study shows. However, the scheme is still failing to prevent households being afflicted with high medical expenses and there is a need for provisions to be widened while also reining in abuse and overservicing by health providers.
Two men with a grudge terrorised medical staff at Xinhua Hospital for three years because they claimed the hospital misdiagnosed one of the men's son in 2011. The two men were arrested after they blocked the hospital entrance with their scooters, fired water pistols at medical staff and struck a doctor with an electric stun baton.

An Anhui police officer has been sacked for refusing to drive a dying infant boy to hospital after he was injured in a hit and run incident. The boy's father asked the policeman for assistance but he claimed he was too busy.

Despite being made illegal in 1998, the illegal blood donation trade is still thriving in China, a report suggests. A Shanghai man has been arrested for taking money to organise a circle of 20 blood donors, while the Shanghai Daily reports that fliers offer up to 900 yuan to blood donors.

Guangzhou needs an early warning system for dengue fever as cases of the serious ilnes increase infectious disease experts say. A study of almost 700 dengue fever cases in the city found that one in ten were attributable to imported disease, mostly from SE Asia.

Further outbreaks of H7N9 avian influenza are likely say public health specialists after they found that H7N9 virus infection rates as high as 22% in birds at a re-opened live poultry markets in Huzhou, Zhejiang.

There has been a dramatic increase of antibiotic resistance in dysentery-causing Shigella bacteria in Beijing, a new study shows. An eight study by the Beijing Centre for Disease Prevention and Control found that over 90% of Shigella bacteria strains showed resistance to at least three wide spectrum antibiotics.

Sunday, 13 July 2014

Sex workers misled on vaginal douching | Online gambling leads to rise in suicides | Scrub typhus in Guangzhou

Many prostitutes in China's cities use vaginal douching in the mistaken belief this will prevent STIs, researchers from the National Center for STD Control in Nanjing. In a study of sex workers in three cities they found that as many as one in three used vaginal douching with disinfectant to prevent sexually-transmitted infections, without realising this may actually make infections more likely.

The threat of mutated influenza viruses will persist in the animal markets of Guangdong unless more far-reaching systematic measures are taken, infectious disease specialists say. In a new paper they say the Cantonese practice of having many different animals in close proximity in markets promotes virus mixing and reassortment much more than in poultry markets elsewhere in China.

China's recent legalisation of online gambling in the form of football  'lotteries' has resulted in a spike in suicides among people who have lost money.

There has been a resurgence in epidemics of the fatal disease scrub typhus in Guangzhou with rates increasing three-fold between 2006 and 201, according to researchers from the Guangzhou Center for Disease Control and Prevention.

An outbreak of anthrax in Jiangsu that affected four people in 2012 has been traced to consumption of meat from a diseased cow.

Shanghai is suffering from a major shortage of emergency medicine clinicians willing to as part of ambulance crews. The shortage means that ambulances are often cannot be despatched when local residents call 120. The shortage is due to arduous and stressful 12-hour shift and poor pay, authorities say.

Doctors' pay needs to be increased so that their income reflects their technical skills and experience, health analysts says. There will continue to be an imbalance and black market for doctors while their income is kept artificially low, they argue.

Cloud-based hospital information systems could be the key to revitalisting rural health services, with county hospitals and village clinics accessing and managing medical information and data via the cloud, according to experts from the Electronic Medical Record and Intelligent Expert System Engineering Research Center, Zhejiang University.

Saturday, 12 July 2014

The anti-corruption crackdown gets serious in Guangdong's health system, yields 7 million yuan

by Michael Woodhead  
The effects of Xi Jinping's anti-corruption crackdown are being seen in Guangdong's health system, with health department leaders using stern words and making grave threats against wrongdoers. A report in Guangming Daily says the crackdown on Hong Bao (red envelope bribes) and commissions has already uncovered 7 million yuan and exposed thousands of corrupt staff. The provincial health department head Chen Yuanshang has made dire threats of punishment to any health staff who continue to accept bribes or kickbacks for services. He told the newspaper that Discipline Inspection teams would be renewing their efforts to expose corruption in the health services and would be making unannounced visits to health institutions and looking into the books. He made a speech using all the most stern warnings typically used by officials such as "severe punishment without exceptions" for malpractice and unethical behaviour by public hospital staff. He also noted that many health managers and clinical staff were not taking the anti-corruption drive seriously and were only paying lip service to it. He singled out the relatives of high officials and doctors, saying they would not escape punishment if found to be involved in financial irregularities such as receiving bribes and commissions or overservicing. He reeled off some figures of corrupt practices exposed already including 1362 cases of kickbacks/commissions to the value of 3.4 million yuan involving 3142 individuals. There have also been 5248 cases of bribery (red envelopes) involving 3.74 million yuan. Chen vowed there would be 40 teams of 'secret shoppers' visiting hospitals and health departments to see if staff were still accepting bribes. He also expected all health units to organise their own inspections and to report back on the findings and the disciplinary action taken. He reminded health staff of the "Nine Forbiddens" - the nine kinds of corrupt and inappropriate behaviour (such as overservicing) that should be avoided by health service institutions.

Friday, 11 July 2014

US anti-abortion campaigners set up groups in China's hospitals

by Michael Woodhead
American Christian groups are working discreetly in China to spread an anti-abortion message through unofficial churches and to set up groups of activists to "save" women from abortion clinics.
According to the conservative Christian website, American sponsored groups are spreading the message that abortion is wrong among Chinese Christian congregations and encouraging Chinese converts to go to into abortion clinics to talk women out of having abortions.
According to an article on their website, an American under the pseudonym "Jim Peters" has been preaching the anti-abortion message to "packed  congregations" including at official Protestant 'Three Self' churches. They also claim to have appealed successfully to Christian medical staff at one hospital to have women who seek abortions first undergo anti-abortion advice. The activities are co-ordinated by the groups such as  "All Girls Allowed" set up by former Tiananmen student leader Chai Ling, and a network known as the China Life Alliance (CLA).
"By linking resources from the experienced American pro-life movement to the leaders of the Chinese church, CLA was able to equip local believers quickly to start their own ministries," an article on the website claims. "The group has launched a network of safe houses for pregnant women, abortion rescue teams, a Christian legal aid ministry, a Chinese resource website, and a pregnancy help center ... so far about 20,000 churches have heard of the pro-life message, and each church that hears the message goes on to save two to five babies a year."
As well as being "pro-life", the World News website propagates the pro-gun ownership policies of other US Christian conservative groups, and it is strongly opposed to the Affordable Care  ('Obamacare') policies that aim to provide wider access to healthcare for US citizens.
The US group say they are encouraging Chinese Christians to respect life and spread the anti-abortion message in various ways, and describe how one young member of a Chengdu congregation was arrested by police for passing out anti-abortion flyers.
It claims that there are now about 8,200 preachers campaigning against abortion in their churches in China.
“I do this because I see China’s rate of abortion is growing too fast; it’s frightening,” one Chinese convert is quoted as saying. “This is what I believe: We cannot murder. But Chinese people have sinned in this way. I don’t want to let the next generation live in an environment like this.”

Thursday, 10 July 2014

The Chinese Dream? A Hangzhou children's hospital tries to help poor families who can't afford to keep their children alive

by Michael Woodhead
An amazing article from a Hangzhou hospital reveals the appalling Dickensian situation that now exists in one of China's wealthiest cities, where sick children of the poorest rural migrant workers literally die in the streets from neglect. 
Dr Zhang Weifang of the Children’s Hospital, Zhejiang University School of Medicine writes about the efforts the hospital puts in to try provide medical treatment for seriously ill children of rural migrant families, most of whom are not covered by urban medical insurance cover. The situation arises because migrant families living in cities are uninsured or only covered by rural medical insurance policies that have meagre payouts and are not 'portable' to the city. The creates a problem when children become seriously ill with conditions such as leukaemia, congenital heart disease and oddly, scalds (the third most common serious problem they treat at the hospital). The hospital tries to treat such children and makes ad-hoc public appeals through the media and relies on donations from 'warm-hearted people'. It also seeks one-off funding from the government and from a handful of medical charities such as "Love Without Borders". The hospital has been modestly successful in soliciting funds in this way - bringing in almost 4 million yuan in donations in 2011. But to put that in perspective, that amount is only about 0.6% of the hospital's budget. And this did not cover the treatment costs of the most seriously ill children - the hospital also waived half a million in unpaid medical bills for the most severe cases. Nevertheless, most poor families are asked to medical fees pay upfront, in advance of treatment, and many simply can't afford this and "abandoned treatment".
As Dr Zhang writes: "At times, the hospital will reduce or remit the treatment cost for these patients. However, the hospital cannot afford to provide all the uncompensated care these children need ... We try to establish a long-term relationship with media and solicit contributions for low-income families. However, the situation is still far from perfect."
This, then, is the stark reality of China's lack of a health and social security safety net for its most vulnerable citizens. It also explains the huge disparities in health outcomes between China's wealthiest and poorest residents - a six-fold difference in child death rates. President Xi Jinping is often quoted in the Chinese media talking about the "Chinese dream". Martin Luther King had a dream of all Americans being equal, in which "the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood." Perhaps Xi Jinping could try realise the dream of all sick Chinese children being equal when it comes to getting hospital treatment.

Wednesday, 9 July 2014

Emergency care for all | World Bank on health reform | Social capital for private hospitals | Coronary reperfusion sexism

Hospitals have been ordered to provide emergency care to all patients regardless of their ability to pay, with the National Health and Family Planning Commission saying the new rules will help eradicate the social problem of "waiting for money before saving lives."

The World Bank will work with China on a study to investigate "bold, sustainable options for health sector reforms, including in the private sector," according to bank president Jim Yong Kim.

The Chinese government will increase its input into the healthcare system and encourage "social capital" (ie private investment) to enter the industry, Premier Li Keqiang told WHO leader Margaret Chan, but health economists  say commercial health insurance must be improved if this is to work.

In China women hold up half the sky, but only a quarter receive reperfusion therapy for acute coronary syndrome, cardiologists have said.

The Chinese cultural aversion to darker skin means most Chinese avoid the sun and many in northern China are at risk of vitamin deficiency, a new study from the School of Public Health, China Medical University, Shenyang shows.

Despite spending more than 800 billion yuan on health services,  China has only 200 qualified health managers, according to researchers from Shandong University.

One in four blood donors are infected with hepatitis E, many of them seemingly contracting the infection from previous episodes of blood donation, according to researchers from Lianyungang Second People's Hospital, Bengbu Medical College, Lianyungang.

Dysentery is ten times more common during periods of flooding in Hunan and is especially bad after sudden heavy floods, a study from the National Institute for Communicable Disease Control and Prevention, Beijing.

Tuesday, 8 July 2014

Anything on telly? "The Obstetrician"

by Michael Woodhead
Writer Zhang Zuomin is proud of his new TV series "The Obstetrician" which airs tonight on Jiangsu TV.
He says it is different from the usual medical soap operas focused on romantic liaisons in the hospital - this one is authentic and focused on the medical cases and technical details, he says. Zhang isn't a doctor but he says the dialogue is authentic based on his experience of working in a hospital as a security guard before he went to Fudan University to study Chinese.  He says the TV series focuses on real medical cases and is realistic down to the drug doses used and the medical procedures as described in the medical journals. When working in a hospital Zhang said he noticed that doctors have their own jargon, quite unlike the official language used in textbooks. He has adopted this in the script and says he wanted to show the real day-to-day working life of doctors rather than focus on trivial affairs and melodramatics. Zhang says he became frustrated watching other medical TV dramas on TV as they were phoney. To add extra authenticity he got a doctor friend to review each script and make suggestions. The drama and tension comes more from the conflicts in the medical cases, although the relationships between doctors are also important as they often have different approaches and opinions on medical cases, he says.

Monday, 7 July 2014

Web rumour of the day: doctor sued after helping woman give birth on train

by Michael Woodhead
One of Xinhua's top stories today is about a female doctor who helped a woman give birth on a train from Beijing to Nanjing and was then sued by the mother because the baby was injured. 
Amazing story, but it isn't true, according to Xinhua. The news agency says the whole story was concocted by a disaffected young man from Henan who spread the 'baseless rumour'  on Weixin and caused the legal authorities in Nanjing a lot of grief.
The story started on June 29 when a story went viral on Weixin, Weibo and QQ. It described the case of a female doctor called Li Qian of the Beijing Third People's Hospital, who was travelling to Nanjing by train. A woman on the train went into labour and Dr Li helped to deliver her baby and saved its life. However, during the birth the baby aspirated some amniotic fluid and had breathing difficulties which required treatment at a hospital in Nanjing. The mother sued the doctor for the treatment costs and was awarded 15,000 Yuan compensation by the Nanjing Peoples Intermediate Court.
When the story was posted online it was circulated by hundreds of thousands of' 'netizens'  and elicited thousands of negative comments directed at the stupidity of the Nanjing legal authorities. The following day the Nanjing city legal office became aware of the negative and untrue rumour and reported the matter to the police. They acted swiftly and the original post was traced to a young man in Henan called Shang Mo. The Xinhua article doesn't say who Shang Mo is or what he does for a living, but he was presumably a doctor as he was said to be unhappy about the lack of legal protection for doctors against frivolous and false litigation.
 The legal authorities apprehended the man and Xinhua said he would face 'appropriate punishment from the relevant authorities'. They also reminded netizens that they must act within the law when posting things online and must not 'cross the line' and post material that is illegal and untruthful such as baseless rumours.
Update: The SCMP has now covered this story but with a major difference - it says the perpetrator was motivated by frustration over the law that restricts doctors working at only one location. That is quite different from the report by Xinhua which states that he was angry that "the law did not give doctors sufficient protection" . Not sure why the SCMP has reported this way.

Sunday, 6 July 2014

The two H's that cause the most common cancers in China

Pre-cancerous cirrhotic liver
by Michael Woodhead
In western countries we are quite rightly focused on the high profile cancers and how to prevent them. Lung cancer is now in decline due to the very successful campaigns to stop smoking. Likewise in sunny Australia we are starting to see declines in skin cancer thanks to the campaigns that encourage people to cover-up and avoid carcinogenic UV rays. Other common cancers that are the focus of public attention are of course breast cancer, prostate cancer and to a lesser extent cervical and bowel cancer. All of these are the focus of major screening activities - some with official blessing, others (hello prostate cancer) despite a lack of evidence that they reduce cancer deaths.
In China it's a very different story. As you'd expect given the high rates of smoking, lung cancer is the most common malignancy seen in the country, but the other common cancers are those of the liver and digestive tract - hepatic cancer, gastric cancer and oesophageal cancer, in that order. A new review finds that the incidence of these cancers has increased dramatically since the 1980s. Perhaps because Chinese people now live longer or have better access to diagnostic services, but the gastric and liver cancers are now more common than ever. And the causes? It's the "H''s  - hepatitis and H. pylori. The high rates of hepatitis B in China are the reason for the country's huge rates of liver cancer. China has some of the highest rates of hepatitis B in the world (almost one in ten people have been infected) and new infections are still a major problem. The good news is that most children are now being immunised against hepatitis B, and the government believes that there will be far fewer hepatitis cases by 2050, when the current generation of immunised kids are adults.
Gastric cancer is the third most common cancer in China, and much of this may attributable to diet and chronic infection with the carcinogenic H. pylori pathogen. It has been estimated that the number of people in China infected with H. pylori infection rate is still above 50%, and as high as 80% in rural areas. Some hospitals are now implementing a 'test and treat' H. pylori screening approach and providing antibiotic-based eradication therapy to those found to be positive. There have also been some attempts to screen patients with endcoscopy - but is going to be a resource-intensive and logistically impossible approach to adopt nationally. Oesophageal cancer is another common cancer in China. To try prevent more cases, the government is focusing on diet in rural areas, and urging pubic health services to improve nutritional campaigns and avoid agents such as nitrosamines and harmful water contamination.
For the time being, however, China will continue to have high rates of liver and gastric cancers. Eradicating hepatitis and H. pylori will help in the long run, but Chinese people should be aware of the cancers that currently pose the greatest risk to themselves and their families.
[Based on an article by Dr Wang Rui and colleagaes at the Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, published in Clinics and Research in Hepatology and Gastroenterology)

Saturday, 5 July 2014

Looks like Lancet editor Richard Horton was bamboozled by China's health minister Li Bin

by Michael Woodhead
A very disappointing commentary from Lancet editor Dr Richard Horton about his recent trip to China, where he met (again) health minister Li Bin.
He starts off with a slightly baffled (and disapproving) anecdote about the minister quoting free marketeer Adam Smith on the move to raise doctor's salaries (and presumably pay them according to what the market will bear rather than what patients can afford).  Without analysing this stunning bit of neo-liberal health policy from a Communist Party health minister, Richard Horton then plunges on by saying (without irony) that the west misunderstands China and treats it as a 'threat'. Instead, he says we should see China for the fragile state it really is, with precarious health reforms yet to bring real benefits to many of the people. And the west should provide support for China's health reforms.
Richard Horton says this was his second meeting with Li Bin - the last time she had just been appointed and had little to talk about (after replacing old lag Chen Zhu, who now heads up the influential doctor-lobby in the form of the Chinese Medical Association). On this second meeting, Li Bin apparently gushed about the progress made by her newly created National Health and Family Planing Commission. And Dr Horton repeats these claims uncritically. The expansion of health insurance (yes but it still doesn't cover even the basics), the family planning 'refinement' (revolution, more like, abandoning the one child policy), improvements in hospital management (what improvements?) and strengthening of public health services (again, what exactly? If anything, public health services have weakened with the continuing shift to income-generating activities).
Richard Horton repeats Li Bin's claim that the essential drugs list has been expanded - without mentioning that this has been a failure in making drugs affordable, because reputable manufacturers have simply stopped making drugs whose prices are capped at an unprofitable level ... he notes with approval the minister's remarks that drugs are too expensive (true) but fails to mention that this is due to the big markups imposed by hospital pharmacies, which are controlled by the local governments. The minister says there will be a zero markup policy, but fails to explain how hospitals will then meet the shortfall in funding this will create, as about 40% of hospital income comes from drug sales.
There is also approval for China's new 'zero tolerance' approach to corruption in healthcare, and yet in the same week we have seen a fraud investigator (and a fellow British citizen of Dr Horton's) jailed in China and about to undergo a secret trial for investigating corporate-government fraud in pharmaceutials and hospitals. It seems the Party will decide what is fraud and what it will and won't tolerate.
Richard Horton then praises Li Bin's standardisation of doctor training, again without asking how this will serve the most deprived areas of China that have relied on 'barefoot' village doctors and will be unable to attract and retain the new stream or more highly-qualified medical graduates.  At a time when the west is looking to use more physician assistants, China is phasing them out! And oddly, Richard Horton (or perhaps Li Bin) fails to mention one of the biggest changes in China - the move to create a primary care system and try get people to attend community health centres. This is shaping up to be  a huge reform, but seems to be unpopular with patients, who are still voting with their feet and going direct to hospitals. Perhaps that's why Li Bin kept quiet about it.
All in all, this is a very strange and sub-standard commentary from an international medical thought leader who is renowned for his interest in global health. If the NHS adopted the free market policies now being embraced by China, I'm sure Dr Horton would be penning furious editorials about deregulation and the shift to user-pays private clinics. Perhaps he has sucumbed to the usual Chinese tactic of flattery and self deprecation. The Lancet readers deserve more insightful and more critical reporting of healthcare in China.

Wednesday, 2 July 2014

Hepatitis B vax for adults | Hypervirulent pneumonia | Home smoking bans | Doctor assaulted in Wenzhou

Hepatitis B vaccination should be extended to adults aged 20-40, Jiangsu researchers say, after their study showed it could have a major impact of prevelance of the disease in the population.

An emerging hypervirulent strain of Klebsiella pneumoniae is causing infections in the community and about one in twenty are fatal, according to a report from Beijing Chaoyang hospital.

Paediatricians have been urged to have discussion with parents about not smoking in the house after a survey in Guangxi found most households with children also have at least one adult smoker. Parents said they would heed advice from paediatricians and many were not aware of the dangers of second hand smoke.

A doctor at a Wenzhou hospital was beaten badly by the family of a patient who he had spent half an hour giving stitches for an injury, the local media reports.

High lead levels in the bloodstream of children in China are leading to behavioural problems as well as the well-know effects on intellectual development, researchers have found.

A Shanghai hospital is adopting a doctor's health program, with initiatives to provide healthy food, ban smoking and encourage physical activity in the workplace, and also to provide psychological services to help cope with stress.

Teenage prostitutes in Kunming do not use adequate contraception and about half have had abortions, a new study shows.

Tuesday, 1 July 2014

China's rural doctor crisis: the 'barefoot' doctors are reaching retirement age and there's nobody to replace them

by Michael Woodhead
China is facing a crisis in its rural health workforce on three fronts: firstly, most village doctors are nearing retirement and there is no junior workforce to replace them. Secondly, the migrant worker trend means the rural population of half a billion people increasingly consists of older and poorer people who have higher medical needs due to chronic diseases and co-morbidities. And thirdly, government reforms mean that village clinics can no longer make an income from selling drugs and they are now also expected to provide unprofitable public health services. Consequently, young Chinese health professionals are not interested in being a village doctor. Who will fill this role?
This is the gloomy and alarming picture painted by a new snapshot of the rural health workforce, based on a survey of almost 2000 village doctors in five rural areas of China. Many village doctors are the original barefoot doctors recruited in the 1960s and 1970s, and most have only a minimal training in healthcare. Typically they are secondary school leavers who have completed the 'county health assistant' examination. Only about 20% have passed the national 'assistant doctor' certificate. The survey found that half the village doctors are nearing the age of retirement (60 for men, 55 for women). Also worryingly, the survey showed that the doctors nearing retirement tended to offer a wider range of medical services (including 'after hours') presumably due to their greater clinical experience than younger village healthcare workers. The younger village doctors also appeared to charge more and expected a more generous pension than the current measly level of 55 yuan a month.
Study author Dr Xu Huiwen and colleagues from the Beijing Normal University said the Chinese government now expected rural doctors to have a higher qualification, and in theory there was an ample supply of medical graduates to fill these roles. However, in contrast to the old village doctors, young graduates were often outsiders who were not trusted by the local people and they also made a low income. For this reason, village clinics found it hard to attract and retain new clinicians. In the future, rural patients may flock to township and country-level hospitals instead of seeking primary care locally. This will put an added burden on second-level hospitals and also increase the cost of healthcare to both patient and government.
The researchers said the Chinese government had recognised the rural health workforce problem and  had tried to fund rural health clinics. However, the funds were often not released by local country governments. They said the Chinese government must act urgently to address the recruitment of rural doctors by improving financial conditions, and especially by addressing the lack of a decent pension scheme. There also needs to be 'political' support as well as economic, they added.
"Ageing of village doctors is a serious and imperative issue in China, and will have a complex and profound impact on the rural health system," they concluded.
Update: Another study of village doctors has just been published that has come to the same conclusions. Published in the International Journal of Health Planning and Management, it found that 1) The village doctors are ageing 2) Younger people do not want to take on the job because of the poor salary (especially the pension), high workload and difficult working conditions. 3) Rural doctors are unwilling to take on new public health and e-health roles for little pay. The study authors say the government should improve working conditions, salaries and continuing education opportunities for village doctors. Recruitment should encourage local residents to train as doctors rather than trying to attract outsiders in to work in villages.