Monday, 30 June 2014

Cardiologists accused of overusing coronary stents for profit

by Michael Woodhead
One of the top stories in China's national Xinhua news site today concerns the case of a man who had nine coronary stents implanted at a cost of 150,000 yuan (US$24,000) for one operation. 
His family say they were shocked to hear of the number of stents - especially as the 58-year old man with blocked coronary arteries did not feel any better after the operation.  The accused the hospital authorities of Chifeng in Inner Mongolian of blatant 'overtreatment' and profiteering. A Xinhua reporter quoted the family as saying their father went in for an operation and was found to have extensive coronary artery blockage - the surgeons then recommended coronary stents, which they said would be better than a bypass grafting operation. However after the implanted six stents they told the family the man would need three more to complete the procedure, otherwise the first six would be wasted. 
The family agreed. but were amazed when they received the final bill for 150,000 yuan. They said they had not expected such a high bill and would have to borrow a lot of money to pay the medical fees.
The Xinhua reporter quoted other health authorities as saying that some cardiologists were abusing the system and overusing stents  because they got a high commission for each one implanted. Each stent cost up to 20,000 yuan and a doctor might get 2000 commission. An internet search of the term 'stent abuse' revealed that many families were making complaints online about having to pay large sums of money for multiple stent insertions. A spokesman for the hospital said it was sometimes necessary to insert multiple stents for one patient, and this was the clinical decision of the surgeon - there was no set rule or guidelines.  However, other medical experts said it was usual only to have one or two stents in a cardiac operation, and some hospitals had a rule that operations that required more than three stents had to be discussed with other surgeons and informed consent obtained form the patient and the family. The academic said that 12% of stent operations involved overtreatment and 38% of procedures are of questionable necessity.

Sunday, 29 June 2014

One Country, Two Health Systems: or how Hong Kong has a socialist health system while China has a capitalist one


by Michael Woodhead
It is seldom remarked, but capitalist Hong Kong has a socialist health system while 'communist' China has a capitalist one. 
Hong Kong has a British NHS-inspired publicly-funded health service that remains efficient, good value for money and corruption free. China, on the other hand, has ditched its Soviet-era state-run 'health for the masses' system and replaced it with a state-owned user-pays system that is run on private lines. Don't take my word for it - there is an excellent article illustrating this in the obscure medical journal the International Journal of Radiation Oncology. It makes an interesting comparison of the Hong Kong and Chinese health systems through the eyes of oncologists who work in a cross-border co-operation clinic in Shenzhen.

Health systems
The oncologists note that Hong Kong's health system is based on heavily-subsidised public hospitals that provide treatment at no cost or only minor cost to all Hong Kong residents. It is an efficient system that accounts for only a modest 5.2% of GDP (compared to around 9% for many western  countries and 17% for the US). The Hong Kong public health system is perhaps a little too successful for some interest groups, as it means there is a very low uptake (27%) of private health insurance.
In contrast, China has a capitalist health system (where “money follows the patient') that is struggling to meet the needs of many citizens. Although China has a high rate of health insurance (often funded by employers), this does not cover expensive drugs or medical treatments. There is no safety net system provided by the state, and medical bills are a major burden, especially for low-income families. Initial consultation charges are a modest $2-3, but all Chinese hospitals have to be financial sustainable and thus doctors are encouraged to prescribe expensive drugs, order tests and even promote nutritional products, none of which may be justified by the patient's condition. As the oncologists say with some understatement: "there are serious concerns about the cost effectiveness and quality of services." 

Disease trends
In terms of cancer, Hong Kong and China are also poles apart. Due to preventive health and better treatment programs, cancer rates have decreased by 22% in Hong Kong in the last 25 years and cancer death rates have decreased by 29%. In China, however, rates of cancer have increased dramatically in the last decade as Chinese people have become wealthier and adopted unhealthy lifestyles and persist in smoking. In Shenzhen, cancer rates increased  from 37 per 100,000 people to 100 per 100,000 in the last 10 years. Many of the common cancers could have been prevented through screening and early detection- such as cervical cancer in women, rates of which have been decreasing in Hong Kong. Hepatitis B vaccination is another intervention that should reduce liver cancer rates. 

Doctor training
For oncologist training, Hong Kong follows the UK system of requiring several years postgraduate training regulated by peer group 'colleges' during which clinicians must demonstrate practical expertise in medical oncology, radiation oncology and palliative care, rather than being single branch specialists. Thus patients are treated by a team of oncologists in a 'one stop shop' model. In China there is no formal training program for oncologists, most specialise in one branch of oncology by doing written exams and there is no palliative care training. In China the work of oncologists is governed by 'standard operating procedures' in which the emphasis is on compliance rather than quality or outcomes. 

Access to treatment
When it comes to treatment, cancer patients in Hong Kong have access via public hospitals to the latest technology such as linear accelerators, at modest cost (US10 per attendance). Access is based on clinical need, not financial status or connections. Thus a full course of radiotherapy would be about $400 for a public patient, whereas it would cost $36,000 for a private patient. Across the border in Shenzhen, access to the latest radiotherapy equipment is - in the words of the authors - "appalling". There are only a handful of poor-quality liner accelerators and they are scattered across various hospitals - most patients and doctors do not know how to access them, and even those who do are often reluctant to use them because of fears about toxicity, not to mention the high cost. Shenzhen needs at least 16 such machines (Hong Kong has 37) but hospitals find it extremely difficult to buy such major items because of red tape from the Ministry of Health and the inflated costs of middlemen and the 'commissions' needed to import high-tech equipment into China. 

Drugs - if you can afford them
Access to chemotherapy drugs also differs markedly between Hong Kong and China. In Hong Kong, drugs are approved for use if they can be shown to be cost effective. Regulators model their the drug approval processes on those of western countries.
Patients pay US $13 per oncologist consultation and US $1.30 per drug prescribed. Some high cost drugs are not publicly funded but some costs may be covered by the public safety net or by charities.
In China, many chemotherapy drugs are not available or are long delayed in gaining approval from the China FDA. Drugs that are approved are available on a user-pays basis and can be very expensive. Pemetrexed, for example, costs US $1155 for the genuine drug in Shenzhen although a Chinese generic version is available for US $353. However, the quality of generic drugs is often poor. There are no programs for low income patients. 

Opium wars left their mark?
For palliative care, Hong Kong has developed an integrated  multidisciplinary system based in public hospitals and with hospices. In China, palliative care services are limited or non-existent. There are no palliative care specialists, and so treatment is provided - if at all - by anaesthetists. Pain relief is hampered by draconian regulations over the use of opioids. Most doctors are not allowed to prescribe them, and those who are authorised can only provide a week's supply. Many terminally-ill cancer patients are too weak to return to the hospital every week. This means that cancer pain is under-treated in China.

Looking to the future, on the positive side, health services in China are now evolving rapidly and there is a huge demand for good-quality clinical services. The authors say their Hong Kong-Shenzhen hospital has been operating for only a year but is already providing valuable lessons and experience. It has established a strict 'no-bribery' rule and has also become the first hospital in China to gain international certification for quality of management.

[Editor's note: This story is based on an article by Drs Anne Lee, Henry Sze, Lam Ka-On and Chen Xian of the Clinical Oncology Center, University of Hong Kong – Shenzhen Hospital.]

Survey reveals the bad antibiotic habits of Mainland Chinese

by Michael Woodhead
Chinese people have developed bad habits of antibiotic misuse such as self medicating with OTC products, not finishing the course and hoarding leftover antibiotics for later use, a new study shows.
Doctors at the University of Hong Kong made the worrying findings when they surveyed recent Chinese immigrants on their knowledge and attitudes towards antibiotic use.  They conducted focus group interviews with 56 recent migrants from mainland China and also conducted phone surveys with 134 Chinese and 1600 Hong Kong residents.
The survey showed that both Chinese and Hong Kong-born Chinese had many erroneous beliefs about antibiotics, including the belief that they were effective against viruses and the common cold. One in ten Chinese patients had never heard of antibiotic resistance and most believed that antibiotic would weaken the immune system. A significant minority of Chinese believed antibiotics had significant side effects such as drowsiness or loss of appetite, and said they would stop taking antibiotics when the symptoms had cleared up rather than finishing the full course. About one in seven said they would  keep leftover antibiotics and store them in the fridge to 'recycle' them for later use. A similar proportion said they would seek to self medicate with antibiotics bought over the counter  - sometimes for 'prevention' of infections - even though OTC sale is illegal in Hong Kong.
In the focus groups, many mainland Chinese said they were accustomed to the IV antibiotic infusions that are routinely given to feverish patients in China, and they believed that the oral antibiotics prescribed by doctors in Hong Kong were less effective and led to the infection persisting for longer. However, some respondents said they trusted doctors in Hong Kong more than those in China, and tended to accept their advice on antibiotics and would not ask for antibiotics if they were not recommended.
The researchers from the University of Hong Kong said their survey dispelled the myth that mainland Chinese demanded more antibiotics from doctors. It showed that many recent mainland Chinese migrants had acquired some knowledge of appropriate antibiotic usage during their stay in Hong Kong, but the knowledge was not always translated into practice. They suggested that antibiotic education campaigns were needed for both Hong Kong Chinese and their mainland counterparts.

Saturday, 28 June 2014

Official media says Lancet editor backs China's health reforms

[file pic from 2013]
by Michael Woodhead
The Chinese media is reporting that The Lancet editor Dr Richard Horton has praised China's health reforms and urged them to go further, during a meeting he had with health minister, Li Bin.
According to China Daily, Dr Horton met with Li Bin in Beijing on 26 June and had an interview with her. Li Bin is said to have explained China's unique health situation to Dr Horton, including how the country has a large population and many differences between regions. She said China's health system was in transition, and the work of health and family planning services faced huge challenges. She described China's healthcare reform as a long-term systematic project that faced many difficulties. Reforms should adopt the lessons from the experiences of foreign countries but adapt them for China's unique circumstances and  select methods that are suitable for China, Li Bin said. She added that public hospital reform must be based on a high level plan and start with pilot schemes before being gradually adopted nationally.
According to Chinese language reports, Richard Horton praised China's reforms of public hospitals and said China's progress in health reforms was acknowledged around the world. He is quoted as urging China to strengthen cost-benefit analyses for  pharmaceuticals and medical procedures, adopt pay-for-performance funding mechanisms, attach importance to community-based non-communicable chronic disease programs and enlist healthcare staff to support and implement reforms. Richard Horton is said to have committed The Lancet to focus on China's health system reforms and to work in closer cooperation with China's medical organisations.
Editor's note: Lost in translation, perhaps, but compared to the dry English language article in China Daily, the Chinese-language reports of this meeting put much more emphasis on The Lancet editor's support for China's health reforms.

Thursday, 26 June 2014

Three reasons why you shouldn't have a heart attack in China

by Michael Woodhead
This week's major new research findings on heart attack in China have been reported as showing a four-old increase - as if China is simply catching up with the west in terms of heart disease. The media reports missed the more important message from this study, which is that treatment of heart attack in China still has a long way to go.
To understand the findings of the Chinese research you need to know a bit of context. In western countries such as the UK and the US there has been a real revolution in the way that heart attacks are treated - and some very real progress in surviving a heart attack. Just a few decades ago, a heart attack was a death sentence - few people survived them, and those who did often were crippled by the ongoing coronary disease or killed off by recurrent attacks. These days, all that has changed because coronary arteries can be unblocked. With early recognition of the signs, and swift transport to hospital (with early rescue treatment started in a cardiac-equipped ambulance), a heart attack can be a survivable event with a reasonably good prognosis for the person who has their blocked coronary arteries cleared and kept open with a stent and or a 'clotbuster' (thrombolytic). Long term prospects are also improved for those who take the right medical therapies such as anti-platelet drugs, beta-blockers and statins - and of course for those who make the necessary lifestyle changes of stopping smoking, doing more activity and eating healthily.
What the report in the Lancet shows is that China is still decades behind the west when it comes to these basic steps - and the survival rates for heart attacks reflect this. The report from the so-called 'China PEACE—Retrospective Acute Myocardial Infarction Study' is one of the first national snapshots of heart attack treatment to come out of China. It sampled about 4% of all coronary treatment units, and found that  - as reported, rates of ST-segment Elevation Myocardial Infarction (STEMI) heart attack rose about four-fold (from 4 per 100 000 in 2001 to 16 in 2011). It also showed that in many aspects there had been little progress in treatment of heart attack over the last decade. Firstly, most people who have a heart attack in China take far too long to get to hospital - averaging about 12 hours. Compare that to western countries, where the average time from the onset of coronary symptoms to actually going under the knife is now as little as three to four hours (remember there can be delays of hours between being admitted to hospital and getting into the catheter lab, the so-called 'door to balloon time').
These long delays in getting to hospital mean that Chinese people with heart attacks are missing out on the 'treatment window' for re-opening those blocked coronary arteries - this is best done within the first few hours of a heart attack before cardiac tissue starved of oxygen dies. The study results showed that less than half of Chinese patients qualified for treatment, and only about a quarter got reperfusion procedures, whereas in western countries about 80% of heart attack patients have treatment such as angioplasty and stenting to re-open occluded coronary vessels.
And in terms of additional medical treatments, Chinese patients also miss out. While most now are prescribed blood-thinning aspirin and a statin (lipid lowering) drug, only about 60% get the recommended cardiovascular drug treatments such as beta-blockers and ACE inhibitors. With these continuing 'treatment deficits' it's not surprising that survival rates for heart attack have improved little in China over the last decade.
The Lancet commentary thus concludes by saying:
"Major emphasis must be placed on early patient presentation (requiring public education of acute myocardial infarction symptoms and prompt response), followed by rapid diagnosis and reperfusion therapy in all appropriate patients (ultimately with primary percutaneous coronary intervention or a pharmacoinvasive strategy). Equally important is establishment of high-quality continuity of care and efforts at secondary prevention after hospital discharge."
In other words, Chinese patients need three things:
1 To recognise signs of a heart attack and get to a hospital immediately.
2. To get early coronary reperfusion treatment from a cardiac unit.
3. To be prescribed the basic drugs to preserve and maintain coronary function.
(I haven't even touched on things like the lack of cardiac rehab and the sky-high smoking rates in China).
The question is: does China have the paramedics, cardiologists and hospital facilities to achieve a Great Leap Forward in coronary care?

Wednesday, 25 June 2014

Most Chinese unwilling to pay for vaccines

by Michael Woodhead
Most Chinese people are unwilling to pay for vaccines to prevent common infections such as influenza and pneumonia, a study has found.
In a survey of more than 2600 people in three provinces, researchers from the China Center for Health Development Studies, Peking University asked whether people would be willing to pay the market price for influenza vaccine that costs 80 yuan ($12) and for a course of pneumococcal conjugate vaccine that costs 860 yuan ($138). Only 8% of people surveyed said they would pay for pneumococcal vaccine while 45% said they were willing to pay for influenza vaccine. The average price people were willing to pay was 60 yuan for influenza vaccine and 200 yuan for pneumococcal vaccine, according to the study in Vaccine.
Put another way, the number of people willing to have pneumococcal vaccine would increase from 8% to 25% if the price reduced from 860 to 400 yuan. The demand for influenza vaccine would increase from 45% to 70% if the price reduced from 80 to 40 yuan.
The researchers said the widespread unwillingness to pay for vaccines reflected their high price in China and the lack of any government subsidy. They said profit mark-ups on vaccines mark ups were high in China (as much as 43%) and they generally cost much more than in other countries.
"Our results suggest that both innovative vaccine pricing mechanism and expansion of financing sources are needed to alleviate economic barriers to self-paid vaccines," they concluded.

Tuesday, 24 June 2014

Downton Abbey? No, Beijing: domestic servants have fake health ceritficates, risk passing on infections to kids

by Michael Woodhead
For a newspaper that is supposed to be upholding the spirit of socialism, the Beijing Daily is sounding uncannily like the bourgeois Daily Mail these days. 
In today's issue there is a lengthy feature dedicated to investigating the question of whether domestic staff can be trusted when it comes to health and hygiene. More specifically, the paper has an in-depth report on the bona fides of the health certificates that nannnies, cleaners and other domestic ayi-style servants present to their employers as evidence of their suitability for working in the household. The Beijing Daily reports the case of a female obstetrician, Zhao Li, who spent months and more than 10,000 yuan looking for a suitable nanny for her 2-year old daughter. When she found the right nanny, she was assured by the domestic staffing agency that the woman was of good character and had a health inspection certificate. However, being a meticulous medical mother, Zhao Li was concerned about the possible risks to her daughter's health and decided to double check the nanny's health status by having her undergo a health checkup at her own hospital. She was shocked to discover that the young nanny was hepatitis B positive and also had a fungal skin infection. "My daughter could have been exposed to many infectious diseases. These health certificates they present are worthless," she told the paper.
When reporters from the Beijing Daily inquired further they found that  nannies and other domestic staff are not required by law to have the state-monitored health checks that are required by other employment sectors such as hotel and food preparation staff - and yet they do much the same work. Domestic staff are certified by the employment agencies, which have a vested financial interest in showing that their 'workers' are in excellent condition. The health checks for domestic staff are done by private clinics and there is no supervision of their standards or identity checks - it was reported that some would-be employees sent a healthy 'impersonator' in to have their tests done for them. A spokesman for a reputable public hospital (the PLA 302 Hospital) that has  a clinic for employment health certification said that many domestic servants were migrant workers and often had been exposed to many infectious diseases. As well as hepatitis they frequently detected diseases such as tuberculosis, measles, intestinal and skin diseases. Females they tested sometimes had vaginal thrush and other sexually transmitted diseases (STDs), the spokesman said.
A doctor at the hospital said domestic servants might pass on viral, bacterial and fungal disease to household members via washing facilities, eating utensils and if they were in contact with the bathroom. The Beijing Daily report concludes that it is an anomaly that domestic helpers are not covered by regulations related to employment health checks. They advise that anyone employing a nanny or domestic cleaner/cook should have them checked for a wide range of diseases including respiratory infections (eg tuberculosis), STIs, intestinal diseases (eg amoebic dysentery), hepatitis, skin diseases and also have up to date vaccinations for childhood infections.

Monday, 23 June 2014

Beijingers still unprepared for influenza pandemics

by Michael Woodhead
Despite the many deaths from H7N9 influenza over the last year, most Beijingers lack basic knowledge about influenza prevention and do not use basic hygiene practices to avoid spread of the infection, a study has found.
In a survey of more than 13,000 Beijing residents found that only 7% had the minimum standard of knowledge and behaviour in relation to influenza prevention.
When asked to complete a survey on influenza, only 24% had adequate influenza-related knowledge, 12% showed influenza prevention behaviour although 43% possessed influenza prevention skills,
The survey tested Beijingers on their knowledge about the disease and its symptoms; and also assessed practices towards influenza and people with influenza-like-illness such as cough etiquette, use of masks, hand washing, and the need to seek medical care for influenza.
The survey also measured skills necessary to avoid and manage influenza such as use of a thermometer, attitudes towards flu vaccine and understanding of information materials related to influenza such as medication instructions.
The low levels of "health literacy" showed that more work was needed to encourage Chinese
"Improvements are needed in terms of certain aspects [of health literacy], particularly for the elderly and the population of rural districts," said Dr Zhang Li and colleagues from the Beijing Centre for Disease Prevention and Control. 
Update: A study from Guangzhou has also shown widespread misunderstanding about the threat of H7N9 infection. In a survey of more than 1000 city residents, more than 80% did not believe they would be at risk of H7N9 infection from live poultry markets. Resident wrongly believed that poor hygiene practices in markets were responsible for the disease risk, and the vast majority opposed permanent closure of live poultry markets, instead favouring 'rest days' when trading is suspended for cleaning and disinfection.

Sunday, 22 June 2014

Doctor shortage forces anaesthetists to work 12-hour days

In Shanghai's hospitals the anaesthetists start work at 8am and don't finish until as late as 8pm on many working days, doctors say. Medical groups are warning that anaesthetists are becoming dangerously overworked as they try to make up for a huge national workforce shortage in this medical speciality. According to official figures, China needs 300,000 to 350,000 anaesthetists to meet the need of surgical operations, but there are currently only 100,000 anaesthetists nationally. The lack of anaesthetists is not only leading to overwork but is restricting the capacity if hospitals to do surgery in many other areas such as orthopaedics and heart surgery, medical groups say.
In Shanghai thee are 376 anaesthetists to cover the 10 major hospitals, and they have to handle about a quarter of a million surgical operations a year. This means that each anaesthetists is responsible for two or three operating theatres, and it is not unusual for anaesthetists to be on duty for 24 hours and sometimes even 48 hours, working overnight on 10 operations. The Chinese Medical Association says there is a urgent need to train and recruit more anaesthetists to meet the workforce needs.
According to the Shanghai Daily,  one of the reasons for the shortage in Shanghai is due to elitism - as local health authorities refuse to recruit anesthetists from outside the city unless they have the rank of associate professor or higher.
“We want the authority to lower its standards, because we are in urgent need of skilled anesthetists,” said Dr Wang Xiangrui, director of anesthesiology at Renji Hospital.
“As people get wealthier, so demand is increasing for procedures that require a general anesthetic,” he said.

Saturday, 21 June 2014

Antibiotic misuse | Iron deficiency | Medical tourism from Taiwan | Tuberculosis resurgence | Autocratic hospitals

Inappropriate use of antibiotics has declined in hospitals after a national antibiotic stewardship was run in 2011-12. A survey of 100 hospitals showed that antibiotic use decreased  from 39.4 to 26.5 defined daily doses/100 inpatient days while the percentage of antibiotic use in outpatient prescriptions fell from 24% to 19%.

Students in China are ignorant about the correct use of antibiotics, with about 57% self medicating frequently and 30% using them for common colds. About half of the antibiotic users also preferred to have them given as intravenous infusions, a study at a Xian university found.
 
Iron and zinc deficiency are common in Chinese children, affecting 36% and 40% of children aged three to 12 years of age, a study carried out in 1800 children in seven cities has found.

Medical tourism from Taiwan to China is booming, with more than 100,000 insurance claims being made by Taiwanese for treatment in China, at a total cost of US$7.83 million last year.

Hospitals are allowing patients to make appointments via Weixin (WeChat) to avoid the long queues for a doctor registration.  The YueBei Peoples Hospital in Guangdong has posted WeChat QR codes around the hospital for patients to connect with its public account, view information about specialist doctors, make an appointment and even monitor where they are in the queue.

Of the 11,000 private hospitals  operating in China about 8,000 are run by healthcare tycoons from Putian in Fujian, where thousands of locals are engaged in the medical and healthcare industries, according to the National Health and Family Planning Commission.

China is seeing a dangerous resurgence in tuberculosis, with more than 1.3 million new cases of  a year, and many patients with Multiple Drug Resistant Tuberculosis (MDR-TB) or Extremely Resistant Drug Tuberculosis (XDR-TB), says the Chinese Center for Disease Control.

Hospital management in China is characterised by a top-down, autocratic model in which departmental heads have little autonomy and there is little 'talent management' a new study suggests.

Children in Beijing are suffering from an outbreak of mouth sores caused by enterovirus, similar to hand foot and mouth disease. One hospital treated about a thousand cases of herpangina over the past week, according to the Capital Institute of Pediatrics.

Friday, 20 June 2014

Chinese media ramps up attacks on hospital managers and profiteering

China's state controlled media is this week focusing a lot of attention on hospital profiteering and mismanagement. In one story, a financial reporter asks why patients with a health insurance card are charged 300 yuan for a medicine while patients without insurance are charged 20 yuan for a similar drug that they have to pay for out of their own pockets. An anonymous pharmacist interviewed by the reporter said the two drugs were similar in efficacy, but one was a newer and more expensive brand. She said the reason why the doctor prescribed the more expensive drug was because the insurance company would cover the additional cost, and the doctor and hospital would gain a much higher commission. This was a prime example of  the "Yi Yao Yang Yi" ("relying on drugs to nourish doctors") phenomenon that the government is hoping to stamp out. In another article, state media outlet Xinhua has highlighted the top heavy management of local hospitals. One if it's top stories today is about a country hospital that had 12 staff, of whom 4 were managers. The article asks why hospitals have so many bureaucrats when there is a shortage of doctors in many areas. It also questions how hospital managers are appointed, saying that many are unqualified for the task of efficiently managing healthcare resources.

Tuesday, 17 June 2014

The power of the medical lobby in reversing China's medical negligence law reforms

This week I came across a very revealing legal article (no, don't go away!)  that illustrates the power of the medical lobby in China - and also how the Chinese government is no longer a monolithic closed entity where laws are rubber stamped. 
The article by two leading law professors from China and Hong Kong describes how China medical negligence laws were overhauled by judges in 2002 because they were widely viewed as favouring doctors and hospitals over patients who had suffered from medical negligence. Until 2002 the burden of proof in any medical negligence case lay with the patient - in other words, they had to prove that the doctor had made an error that had resulted in harm.

As the article notes: "In practice, it was not uncommon that medical care providers, during the course of dispute resolution (court proceedings), denied patients ready access to their own health records.
Many medical care providers have reportedly submitted false or falsified medical records. In extreme cases, hospitals went as far as destroying the original records that evidenced the medical staff’s breach of standard of care and replaced them with fake ones."


In a radical move, the burden of proof requirement was reversed - medical providers had to prove that they had NOT made a mistake. This boosted the chances of patients successfully suing their doctor or hospital and not surprisingly led to a large rise in the number of medical negligence cases.
Doctors and hospitals hated the new law, and they claimed that it led them to practice defensive medicine and that it exposed them to a high financial burden.
The courts then decided to try adopt a "Third Way" compromise and developed amendments including a so-called "Article 59" that would balance the burden of proof requirement. The medical profession and hospitals, were not satisfied with this compromise, however, and wanted to veto Article 59 and revert to the former protections they had. It's worth quoting the article on this to give some background to the lobbying power:

"The most vocal advocates for removing Article 59 were two national-level medicine professional associations, that is, the Chinese Medical Doctor Association (CMDA) and the Chinese Hospital Association (CHA). The CMDA is the statutory self-regulatory body of all practicing physicians in China.64 The CMDA is also resourceful in terms of its government connections. Its president is a former vice minister of the MoH, and many of its vice-presidents are incumbent senior officials of the MoH and local BoHs. More notably, one of its two honorary presidents is a vice-chairman of the National People’s Congress Standing Committee (NPCSC). Renamed from the China Hospital Management Association, the CHA is the self-regulatory body of medical care providers (exclusive of rural medical clinics) in China, and is affiliated to the MoH. Its president is also a former MoH vice-minister."

In the end, the doctors won the day. When the medical negligence law was released for consultation they lobbied hard. When the amendment was debated at the NPCSC, the offending clause was dropped altogether. As the authors of the article conclude:
"The associations representing medical practitioners and medical care institutions exhibited remarkable ability to mobilize and lobby the national legislature. The outcome of the legislative process was thus unsurprisingly the removal of Article 59, a rule that the medical profession strongly disfavored."

Two conclusions from this article:
1. The medical profession and medical institutions have remarkable influence and lobbying power in China.
2. The process of  lawmaking in China is no longer behind-closed-door rubber stamping, but is subject to more open consultation and interest group lobbying. .

The article by Professor Yang Lixin of Renmin University and Professor Xi Chao of the Chinese University of HK is published in The China Review and can be downloaded here.

Sunday, 15 June 2014

Men make better doctors | Respiratory physicians criticise tobacco policy | Bogus intern | Children dumped in hospitals

Men make better gynaecologists than women because they are better surgeons and are 'more sensible and calm', according to Beijing hospital authorities. Hospitals have defended their continuing use of male gynaecologists against complaints from women, saying there is a shortage in the speciality due to the government's two child policy.

Respiratory physicians have published strong criticism of the Chinese government's conflict of interest in opposing tobacco companies. Writing in The Lancet, Dr Dan Xiao and colleagues at the Beijing Chaoyang Hospital says smoking cessation campaigns are meaningless when the government plans for tobacco production increases through its State Tobacco Monopoly Administration.

A bogus female doctor managed to work as a medical intern at a Chongqing hospital for 6 months before being unmasked. The woman used fake medical qualifications and a fake ID to get the job at the Jiangbei district hospital.

Children with serious diseases are being dumped in hospitals by their parents, according to the Shanghai Daily. Eight children were abandoned at the Shanghai Children's Hospitals and two are still there as police are unable to trace their parents.

A group of female medical students in Guangzhou have developed a wearable G-string condom that has a detachable sheath. They now have attracted investors to put in 2 million yuan to market the first 10,000 condoms.

Foreign doctors working illegally in China should be reported and deported, says a leading Chinese plastic surgeon. He says China's boom in cosmetic surgery had attracted many Korean surgeons to take advantage of 'academic exchange" visas and abuse them to work for prolonged periods in China.

Despite government investment of three trillion yuan over the last five years, China's health reforms have failed to have any effect on the incomes of medical staff, Caixin reports. The next phase of reforms must de-couple doctors' income from drug sales and reward them with higher salaries commensurate with their skills, analysts say.

Friday, 13 June 2014

China's new reality TV show is "Miracle Detective Doctor"

by Michael Woodhead
Launching this weekend, China's latest reality TV show "Miracle Detective Doctor" has the lofty aim of entertaining and educating the masses in medical matters and also easing the ongoing crisis in violent disputes between patients and medical staff.
Starting on prime time tonight (13 June) on the Travel Satellite channel, the show  (also translatable as 'Super Sleuth Doctor') will feature two teams of three medical students who will compete to find the correct diagnosis in a series of simulated medical cases. The teams of would-be doctors will go through three rounds of 'work up'. The first will be video clips that give background of the fictional illness. The second round will feature simulated patients who can be questioned by the contestants about their condition. In the third round the medics are given a fictional 'health budget' gold coin that they can choose to spend on various tests and investigations such as x-rays or pathology tests.
If that sounds a bit dull, director Tang Li says the show will be livened up with appearances by 'poison tongue' reality TV show hosts such as Ma Ding He and also the beautiful female celeb star of medical dramas, Yu Ying Dan. The show has also modelled it's look on Korean TV medical dramas, and the contestants will be given makeovers to look like the popular Korean soap opera stars.
However, the director says the show will not just be celebrity fluff. In China's current climate of frequent medical disputes, he says the 'medical tournament' will help improve relations between medical staff and the public. He says there is a lack of communication and trust between medical staff and the public that is a major cause of disputes, and the show aims to build up mutual understanding.
He says the reality TV show will highlight the difficulties of deciding on diagnosis and treatment from a doctor's point of view and show the public that it is a difficult process. It will also educate the public about expensive scans and tests, showing that they are not routinely needed to diagnose illness, and that doctors usually rely more on a detailed history.
Tang Li says the "Super Sleuth Doctor' will also feature top medical experts who will give their advice and pronounce their opinion. The cases are based on real life, and the pursuit of the correct diagnosis will be full of suspense, as the consequences of a wrong decision will be spelled out by the experts, he says.
The show will also be like real life hospital in that the doctors will have to make their diagnosis under time pressure, and the effects of their decisions on the lives of the patients and their families can be very moving, the director says.

Wednesday, 11 June 2014

Communist health minister quotes Adam Smith to support privatisation of China's hospitals


by Michael Woodhead
In its inimitable way, the Chinese government is dressing up a very capitalist idea in socialist clothing and presenting it as "a Chinese solution to a Chinese problem". The problem in question being the mismatch between supply and demand in medicine - too many patients and not enough doctors. Or put more simply, overcrowded hospitals. In the Peoples Daily, the former health minister Chen Zhu and leading Communist Party member Chen Zhu is quoting Adam Smith and talking about market solutions to the Chinese healthcare system. He speaks a lot of jargon but the take home message is that doctors deserve to be paid a lot more - they work hard to qualify as doctors, they do a demanding job and work long hours, but get paid a pittance and get no respect. And thus his conclusion is that medical reform must "move into the deep water zone" and tackle doctors' income. Doctors need a high income to be motivated, he says, and the income must not come from sales of drugs - as it does at the moment. Therefore to rebuild trust in the medical system and to put it on a more sustainable path, doctors must earn more - and therefore must charge more. An accompanying article notes that itcosts only 5 yuan to register for treatment at a public hospital, whereas it costs a few hundred yuan for a woman to get her hair done. Why does a hairdresser charge a higher fee than a doctor? [Misleading question - the 5 yuan fee is only to register for treatment - actual out of pocket costs can be astronomical, running to thousands per day for inpateint treatment].
Chen Zhu says "we entrust our health and our lives to doctors but expect them to accept only 5 yuan."
The article says that like many other aspects of Chinese life, healthcare has become a market - and people want the best. The big improvements in roads - and expectations means that people i regional areas are no longer satisfied to go to their local community clinic or county hospital for treatment. When they get sick they get i the car and drive to the big city hospital. Chen Zhu says people have rights to access healthcare, but they also have responsibilities to use the system properly and not to abuse it. He says legislation alone cannot force people to go to community clinics, but there needs to be a more orderly gatekeeper system to stop the overloading of major hospitals - and also the drain of talent from local hospitals and clinics to big city medical markets. His article is short on specifics when it comes to answers - but hints at the usual privatisation slogans of using 'social capital' (ie private investment) and greater flexibility in medical models (ie deregulation) as the way forward. As with so many other areas of Chinese reforms, it's state-directed capitalism decorated with a  few socialist-sounding phrases.

Tuesday, 10 June 2014

Contaminated food | Induced abortion rates | Blueprint for healthcare | Doctor shortages

In Beijing markets, 20% of vegetables have excessive levels of arsenic and 25% of fish have excess levels of lead, according to tests carried out by researchers from the Chinese Research Academy of Environmental Sciences, Beijing.

The limits of China's public medical insurance coverage are illustrated by the case of a 12-year-old boy with bone cancer whose parents have already had to spend 400,000 yuan ($64,000).

A hospital in Shanghai has set up what it claims is China's first patient representative council to represent the interests of patients and improve services at the hospital.

China's rates of induced abortion peaked at about 60% in the early 1980s, and fell sharply in the mid 1990s to the current level of about 20%, a study shows. However rates are still high in rural areas where family planning policies are rigidly enforced, according to researchers from the Central University of Finance and Economics, Beijing. 

A blueprint for China's healthcare system by former health minister Chen Zhu will be published in English translation by the Anglo-Dutch publishing house Elsevier.  The "Healthy China 2020 Strategic Research Report", will be published in conjunction with People's Medical Publishing House (PMPH), China, said Dr Chen, who is now Vice-Chairman of the National People's Congress.

Methadone programs in China have proved very effective in cutting crime, reducing needle sharing and keeping users off drugs, a preliminary study has found. However most drugs users have little or no chance of accessing methadone programs, according to researchers from the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing.

Anhui province is suffering from a major doctor shortage despite offering salaries of 60,000 yuan, and there are now 220 unfilled medical posts, according to the provincial health department.


Monday, 9 June 2014

Gaokao madness: hospital works overnight to do myopia surgery to help kids meet college entrance criteria

by Michael Woodhead
As if the phenomenal pressure of the gaokao ((高考) college exams was not enough, students in Liaoning are also putting themselves through last minute laser eye surgery to meet college eyesight entrance criteria.
A report from Dalien describes the plight of students wanting to get into the city's law schools, which are run by the PSB and lay down strict criteria on having good eyesight. After several days of exams, students than had 48 hours in which to undergo surgery before having an eye exam to assess their vision. Explaining the last minute rush, families said they were unaware of the college entrance criteria or were not willing to have their children undergo eye surgery while preparing for the all important gaokao exams. However, on learning that perfect eyesight was a requirement for entrance, many students went straight from their final exam to the eye clinic to have corrective eye surgery. One clinic in Dalian reported staying open all night and having eye surgeons on overtime into the early hours to perform a string of last minute operations on desperate students. A surgeon reassured parents that it usually took only 8-12 hours to recuperate from laser eye surgery, and their children should have perfect eyesight in time for taking their eye exam in nearby Jinzhou 48 hours later.

Sunday, 8 June 2014

What does Beijing's air pollution do to your lungs?

by Michael Woodhead
Breathing the polluted air in Beijing has the same effect on the lungs as being a heavy smoker, a study carried out before and after the 2008 Olympic Games has shown.
Researchers from Peking University have shown that residents of Beijing have impaired lung function – but that their lungs can revert to normal during clean air periods such as during the Olympic Games, when air pollution was artificially curbed for a few weeks.
The findings come from a novel series of lung function tests done on 200 Beijing residents before, during and after the 2008 Olympics.
Dr Lina Mu of School of Public Health at the University at Buffalo, New York, carried out the research in conjunction with colleagues at the School of Public Health, Peking University,
They found that ordinarily in Beijing, the mean PM2.5 (83 µg/m3) is more than three times higher than the WHO׳s safe limit of 25 µg/m3. At the same time, lung function of Beijing residents (as measured by peak expiratory flow or PEF) was well below the normal range for healthy lungs.  Lung function was impaired by 16-40% for men (PEF of 418 vs a healthy range of 500-700 L/min) and by 23-42% (PEF of 292 vs a norm of 380–500 L/min) for women.
During the Olympic Games the closure of factories and curbs on use of vehicles resulted in air pollution levels falling and particulate matter levels were reduced up to 60%. During this brief ‘clean air’ window lung function was observed to increase by 17% in females and 13% in males, “suggesting an improved airway status after 40 days of lowered exposure to air pollution.” The researchers said.
Interestingly, lung function improved more in non-smokers than smokers and in younger, female residents compared to male and older Beijing residents.
The clean air period in Beijing also saw a reduction in the number of Beijingers with rapid breathing (more than 20 breaths per minute) – a typical response to pollution and impaired lung function.
Lung function deteriorated back to unhealthy levels after the Olympics when factories were re-opened and pollution levels returned to their usual levels.
The researchers said their findings confirmed the adverse effect of particulate matter in the atmosphere on lung function.
“Deposition of particulate matter induces increased oxidative stress that not only results in DNA, lipid and protein damage, but also leads to the inflammatory responses,” they noted.
They said the pollution curbs implemented by the Chinese government during the 2008 Olympics had created conditions for a natural experiment that showed the impact of air pollution on Beijingers’ lung health.
They said the findings confirmed the adverse effects on lung health but showed that these cold be reversed – at least in some sections of the population. However, they also noted that long term exposure to air pollution in Beijing was likely to have more severe ongoing effects on lung health.
The study is published in Environmental Research.

Saturday, 7 June 2014

Daily Mail fake miscarriage | 120 seconds per patient | Dogs a hepatitis risk | Atrial fibrillation untreated

The Daily Mail has been running a fake story claiming that a pregnant Changsha nurse had 'lost her baby' after being attacked by relatives of a cancer patient who died. Chinese media reported the attack but said she was fortunate to have avoided a miscarriage.

A doctor at a Guangzhou hospital could only spend an average of one and a half minutes per patient when he was the only clinician on duty and had a waiting room of 100 patients to see in one morning.

About 20% of dogs and 6% of cats in Guangzhou are infected with hepatitis E, a new study has shown. The high rates of hepatitis infection should raise concern about the eating of dogs, warn researchers from the South China Agricultural University.

China should not copy the US private model of healthcare according to Nobel prize winning economist Daniel McFadden, of the University of Southern California. Professor McFadden said that when looking at healthcare systems around the world, the most efficient are those where the community medical providers are either employed by the government or employed by companies that are largely contracting to the government and not operating as private businesses.

Hospital staff in the Muslim Xinjiang province have been told not to fast during Ramadan. The request was made at a meeting on upholding ethnic minority unity, “in order not to affect normal work and life." Muslim hospital staff members were requested to sign their pledge of compliance in a “responsibility book.”

One in ten emergency department patients leave without being seen by a doctor, according to a study carried out in Chengdu hospitals. Those who left tended to be families who arrived on foot with children who had less serious problems.

Most Chinese people with atrial fibrillation go untreated, with only 40% receiving anticoagulants, according to a study from Fuwai Hospital and Peking Union Medical College, Beijing.The study also showed that only 26% of people treated for  atrial fibrillation received adequate treatment.

Reform of the medical school curriculum is needed in China as many medical schools are still using outdated and ineffective teaching methods that fail to keep pace with developments in medicine, according to a study from Tongji University, Shanghai.

Iron deficiency anaemia is common in rural parts of central China, where only about 40% of infants have an adequate diet, a study by the UNICEF Office for China, Beijing, shows. Malnutrition and anaemia was more of a risk for ethnic minorities and for those living in poor mountainous areas.

Friday, 6 June 2014

Lack of unions in China’s healthcare system leads to corruption


by Michael Woodhead
One of the main aims of the current wave of health reforms in China is to curb corruption by de-linking doctors’ income from sales of drugs and the numbers of tests they order.
It is widely acknowledged by Chinese authorities that many of the problems in the current Chinese healthcare system stem from overservicing. Hospitals obtain about half their income from sales of drugs and also rely for income on the use of expensive and often unnecessary tests and procedures. Doctors in turn are given incentives in the form of bonuses and quotas to prescribe more drugs and more expensive drugs. The end result is waste, inappropriate treatment and high costs to the patient. The widespread and institutionalised bribery and corruption also means that the public mistrust doctors and the healthcare system - and they often turn to violence when they believe they have been cheated or not received adequate treatment.
One of the main reasons why doctors in China are so amenable to accepting commissions/bribes to prescribe drugs is their low income. The basic income of a Chinese doctor is less than that of a teacher or a civil servant. As I have previously reported, this encourages doctors to look to ‘grey channels’ for income – including the infamous red envelopes (bribes) and sales commissions. One of China’s leading physicians Professor Zhong Nanshan highlighted this problem earlier this year when he reported the huge discrepancies between official and actual incomes of doctors at his hospital in Guangzhou.
This week sees the publication of an interesting analysis of Chinese doctors’ incomes by Chinese healthcare analyst, Cao Xuebing.
He says that despite hospitals being opened up to the market, the ‘market has failed’ China’s doctors, who remain underpaid for their services. As a result, they turn to ‘informal’ income streams to make up for that. His paper also highlights the discrepancies - and resentments - between different branches of medicine within a hospital. Surgeons and cardiologists can earn much more than their counterparts in specialties such as paediatrics because they do a lot of procedural work and prescribe more expensive drugs, he notes. The poor income means that China’s doctors are demotivated and have no incentive to be efficient or productive. Income differentials also explain why China has huge shortages of doctors in the poorly paid specialities.
The study shows that most doctors in China are dissatisfied with their income, but unlike doctors in western countries, they have no way of acting on this. There are no medical unions to lobby for pay and conditions and doctors have no power in their relationships with hospital managers, who are backed by local governments. And unlike in other jurisdictions such as Taiwan and Hong Kong, doctors do not have the option of leaving the public system to work for better pay in private practice.
Cao Xuebing observes that if China is to have significant healthcare reform, it will need to tackle the central issue of doctors’ income. And to do that doctors need to have a meaningful voice in such discussions – regardless of whether you call it a union or not. At present the only group speaking on behalf of doctors in China is the China Medical Doctors Association (not to be confused with the official Chinese Medical Association). Currently the CMDA is a weak and unofficial -but tolerated - voice on medical issues such as violence against doctors. The CMDA has the potential to speak on behalf of doctors on remuneration as well as on other issues such as the level of control in doctors' training, education and the supply of the profession. These are the 'bread and butter’ work of medical ‘unions’ such as the AMA and BMA in western counties.
However, Cao Xuebing notes that the Party in China has always aggressively suppressed independent union activity, and exerts strong political control over the tame official unions. If doctors in China see no scope for improving their conditions through official unions they will continue to look to ‘unofficial’ ways of boosting their income. Or as the author puts it:
“If the market opens a window of informal payment that can lead to substantial pay rise, they may not have strong feeling to pursue an empowered professional body or union.”
And he concludes:
“It will … be interesting to follow the development of the CMDA in organising the biggest group of medical practitioners in the world. Professional organisations in China … are important for the party-state to incorporate the interests of key professionals. If regular socialisation can consolidate Chinese doctors with political representation, then these practitioners may be able to gain traction over hospital management issues through leveraging the social capital of their professional body.”

Thursday, 5 June 2014

Snake bites in China: the medical consequences

by Michael Woodhead
Living in Australia, I am naturally extremely wary of snakes, given that this continent has many of the world's most venomous and aggressive varieties - often living in your back yard. Aussies know that if you get bitten by a snake you need to use pressure immobilisation and get help - quick. But what about China? What are the chances of being bitten by a snake and how dangerous are they?
A new report of snake bites from  Hainan gives some idea of what might happen. In a review of more than 1000 cases of snake bites, Dr Shuang Jiebo and colleagues from the 425 PLA Hospital in Sanya, found that the vast majority were caused by pit vipers (46% - aka Trimeresurus stejnegeri) or cobras (40%). Most of the bites occurred in summer (April-Sept) in young males, typically farmers or fishermen, and the bites were mostly on the legs or arms. According to the article the pit viper venom contains a potent haemotoxin, but is not usually fatal:
"The wound usually feels extremely painful, as if it had been branded with a hot iron, and the pain does not subside until about 24 hours after being bitten. Within a few minutes of being bitten, the surrounding flesh dies and turns black, highlighting the puncture wounds. The wound site quickly swells, and the skin and muscle become black due to necrosis."
The Hainan doctors found that most of the wound sites of pit viper bite victims showed swelling, and the skin and muscle became black due to necrosis. In contrast, the cobra venoms are mainly neurotoxic, hemotoxic and cardiotoxic. "The cobra bite is extremely painful and the swelling appears immediately. Other symptoms may include drowsiness, nausea, vomiting, abdominal pain, mental alertness and respiratory failure. "
In their review, about a third of snake bites caused mild envenomation, and only 11% resulted in severe envenomation, which meant a longer hospital stay - often a week or more. Only 1% of patients died, and these tended to be due to bites by sea snakes or King Cobras.
Treatment outcomes were better when patients received prompt treatment - and the researchers also claimed that "Sheyao" traditional medicine was a good remedy for snake bites. This is said to contain  toad skin, centipede, and 'humifuse euphorbia' herb as well as paris polyphylla.
"Prevention, pre-hospital management (first aid) and the importance of the early transfer to the hospital should be emphasized," they concluded. 

Wednesday, 4 June 2014

Shenzhen prescriber kickbacks | Residency training failures | Snoring and heart attack | HIV tests for students


Doctors in Shenzhen continue to prescribe expensive quack remedies to patients to make high commissions from sales, according to reports which said a pregnant woman was told to use fish oil and other supplements to improve her unborn child's intelligence.

Breast cancer survival rates (10 years) for women have improved  from 43% in 1972 to 61% in 1998-2002, according to a cancer registry study from Qidong, Jiangsu.

Tick-borne diseases are a major threat in rural parts of central China, with a new study showing that ticks are common and carry a wide range of human pathogen. The ticks found on animals carried five different kinds of pathogens including Rickettsia and humans were at a high risk of exposure to piroplasmosis, researchers said.

Failings in residency training programs in medical-school-affiliated hospitals in  China have been identified in a national study. The survey of 15 teaching hospitals found that they failed to reach the basic standard of 70% in six basic areas of training, and thus more effort is needed to boost postgraduate medical education (PGME).

Chinese people who snore three or more times per week have a higher risk of heart attack, cardiologists have found.  Their case control study of almost 3000 patients who had a heart attack also found that lack of sleep was a risk factor for heart attack.

A female doctor and a pregnant nurse were attacked  by angry family members of a patient with lung cancer at a Hunan hospital. The attackers forced the doctor to kneel and beat her around the head, before being tackled by security guards.

College students in Henan are being forced to undergo HIV tests. The government says the policy will help early detection and treatment of the inefection.

Tuesday, 3 June 2014

Dysentery in China - the good news and the bad news

by Michael Woodhead
Dysentery is one of those disease most westerners associate with 'the olden days' - or the Third World. 
Bacillary dysentery, also known as Shigellosis, is the severe gastro disease of poor hygiene, spread by faecal contamination. Ten years ago dysentery was still relatively common in Guangzhou, but a new report shows the city has brought rates of the disease down with a co-ordinated campaign to detect and manage cases and prevent further outbreaks. In 2006 the city had about 12 cases of dysentery per 100,000 population - so for a city of 8.5 million people that's more than a thousand cases a year. To tackle the infection, the city health department implemented the "Intestinal Infectious Disease Surveillance, Prevention and Control Program" (IIDSPCP). This means that once a patient is suspected as having Bacillary dysentery, public health workers target their household with preventive measures such as quarantine, disinfection, and good personal hygiene practices mandatorily implemented by local government. This program has seen the rate of dysentery cut to around 2 per 100,000. Good news so far. However, public health staff say dysentery still remains a problem in the poorest families - as judged by the high rates among children who do not attend school. They now account for the largest group of patients with dysentery.
This social group - usually migrant workers from the poor inland provinces - is China's new underclass. As the report notes: "They are usually lacking in adequate sanitation, with low health risk awareness, and more likely to have exposure to contaminated food or water. It has been reported that compared to the other group, the school-age children not attending school have higher incidence in many infectious diseases such as hand-food-mouth disease, infectious diarrhea, and hepatitis A."
Interestingly, the other high risk group for dysentery is young people aged the people aged 20-44 years - perhaps because they take part in more social activities, have more chance to contact with Shigella patients or carriers, and have more leisure time, and finance to travel and thus more likely to have exposure to Shigellosis.
As the report authors conclude: "more effort should be made to enhance health education about dysentery and monitoring/targeting at school-age children not attending school ... .as well as establish strategies for prevention of the disease in China."

Monday, 2 June 2014

Breast cancer with Chinese characteristics

by Michael Woodhead
Breast cancer rates in Chinese women are only one sixth those of their American counterparts, but China is catching up quickly, a new report says.
A review of breast cancer in China published in the Lancet Oncology this week shows that breast cancer has traditionally been an uncommon disease in China but rates are increasingly rapidly as the country adopts more affluent lifestyles.
The report by researchers at the National Office for Cancer Prevention and Control, Chinese Academy of Medical Sciences, Beijing shows that more than 1·6 million Chinese people are diagnosed with breast cancer and 1·2 million die of the disease each year. Breast cancer is now the most common cancer in Chinese women, accounting for cases 12% of all newly diagnosed breast cancers. Annual incidence rates are about 22 per 100,000, compared to rates of around 120 per 100,000 in the US.
The reviewers say breast cancer occurs at a younger age in Chinese women compared to their western counterparts, and for this reason screening programs such as mammography would probably not be appropriate. Rates have increased in recent years due to reproductive factors such as the single child policy and later age of first birth increasing exposure to sex hormones.
For these reasons, and because of the low awareness and delays in diagnosis, Chinese women with breast cancer tend to have more advanced stages of disease when diagnosed.
Another major disparity with breast cancer in China is the lack of adequate treatment. Most women cannot afford the more expensive advanced drugs for breast cancer now recommended in international guidelines. Paradoxically, treatment of breast cancer by Chinese doctors tends to be over-aggressive, with excessive surgery and chemotherapy. Many women have unnecessary mastectomy and axillary lymph node dissection and also chemotherapy. Under-treatment is also common, with some women receiving inadequate therapy for treatable cancers. The reviewers say palliative-care programs probably represent the best way forward to manage quality of life for patients with advanced disease and their families.
They conclude by saying there is a need for more public  awareness of breast cancer and promotion of early detection.
"Because the disparity of access to treatment for breast cancer will remain for some time, great effort is needed to expand insurance benefits and cancer-care infrastructure to underserved women in China," they conclude.

Sunday, 1 June 2014

The two unknown tick diseases that are killing many Chinese

by Michael Woodhead
Two virtually unknown tick born rickettsial diseases have become a serious threat to human health in China, health authorities have warned. In just a few years the diseases caused by tick-borne A. phagocytophilum and E. chaffeensis have become common in rural areas and cause disease including multiple organ failure and death, according to Dr Zhang Lijun and colleagues at the Department of Rickettsiology, National Institute for Communicable Disease Control and Prevention, Beijing.
In a new paper they report that the first cases of human granulocytic anaplasmosis (HGA) occurred in Anhui Province in 2006 and then in Shandong. They said human granulocytic anaplasmosis is a serious disease in which about half of patients are hospitalised, 40% of patients have multiple organ dysfunction syndrome, and the fatality rate can be as high as 8%. However, they suspected that in China infections with the two rickettsial diseases were often not recognised, and were misdiagnosed as hemorrhagic fever with renal syndrome (HFRS).
In their own study they analysed 7,322 serum samples from farmers  and found that 10-15% farmers had been exposed and were at substantially increased risk of the diseases. A second analysis of 819 blood samples from urban residents from showed that 4-12% of urban residents had been exposed and were also at high risk of the tick-borne diseases. Worryingly, the infections were carried by a wide range of ticks, not just one species, and the ticks were found on many domestic animals and livestock including dogs, goats, sheep, cattle, horses, rabbits and rodents.
"In China, the free-range feeding of animals is a major part of livestock production, in contrast to livestock production in modern developed countries. Animals roam hills for feeding during daylight and return at sundown. In such a situation, animals can return with many ticks from wild fields. Moreover, most farm families own two to three dogs for guarding their animals and belongings, and these dogs also roam freely in and out of yards. Therefore, it is not surprise that contacting with domestic animals is regarded as a main exposure risk," they noted in Biomed Research International
The researchers concluded that the wide distribution of the tick-borne infections and their serious nature meant that their transmission and risk factors "urgently needed to be further investigated."
[Editor's Note: The risk of tick borne diseases in China is not insignificant: a US student became paralysed after being bitten by a tick during a school trip to China and was awarded $42 million in damages against her school in a US court last year]