Sunday, 31 August 2014

China's move to promote private hospitals means health system will go from bad to worse: experts

In a scathing critique in the Lancet's special China-themed issue, health economists from Oxford and Harvard say that the Xi Jinping government's recent swing to favouring private sector involvement in the health system will be a retrograde step with 'dismal' consequences for health in China.

Professor Winnie Yip and Professor William Hsiao say the new target of giving private hospitals a 20% market share by 2015 is misguided and will promote wasteful and inequitable care. And most importantly, it will do little to improve China's already rotten public hospital system, which suffers from the worst of both words - state-controlled but with a user-pays private model of financing.

Their conclusion is that if the private hospital system continues: "population health outcomes would suffer; health-care expenditures would escalate, with patients bearing increasing costs; and a two-tiered system would emerge in which access and quality of care are decided by ability to pay."

They say China made a good start to health reform with the landmark 2009 decision to introduce universal and affordable public health insurance cover for both rural and urban residents. However they warn that the limited improvements achieved so far will be negated if the privatisation of an already profit-driven public hospital sector goes ahead.

The article is worth reading for its detailed dissection of the ills of the current hospital system, in which state-owned institutions are driven to maximise revenue by overservicing on unnecessary prescribing, tests and procedures. This sentence sums it up:

"Because physician staff are the residual claimants of profits in public hospitals, they are de facto shareholders of the public hospitals. Hence, public hospitals have neither the motivation nor the incentive to integrate care with primary health-care providers or make treatment decisions based on cost-effectiveness or population health maximisation criteria."

They warn that adding private hospitals into this already toxic situation will create even more problems as state-owned for-profit hospitals enter a "medical arms race" with private hospitals to provide more services at higher cost to patients - especially as private hospitals are already being planned by pharma companies and medical device companies.

"Overall, our assessment suggests that China's prospect of provision of affordable and equitable access to health care with a primary health-care-centred integrated delivery model approach would be relatively dismal. The for-profit motive of large public hospitals would result in escalation of health-care cost, inefficient use of pharmaceutical and high-tech diagnostic tests, and an absence of incentives for public hospitals to integrate care with primary health-care facilities. Entrance of private investment will further exacerbate these trends."

The Lancet devotes an issue to China

The Lancet this week has China has its theme, and includes many interesting articles on a wide range of topics around medicine and health in China. 

There's a huge amount of material there and I don't really know where to start in reporting it all. The articles cover everything from China's medical education system, the challenge of non-communicable diseases and even a couple of clinical research articles on pulse oximetry for screening newborns for cardiac disease. For me, the most interesting article is one on the recent change of course in China's health reforms to put emphasis on private hospitals. The authors of the review, from Oxford and Harvard universities, say this move is a retrograde and negative step that will run counter to many of the other recent reforms that aim to encourage equity and more efficiency in China's user-pays hospital based system.

The Lancet also includes several articles on the theme of preventing chronic diseases such as obesity - a very timely issue as China becomes more wealthy and starts to see the same lifestyle diseases such as diabetes that are already so common in more developed countries.

For me the other interesting section in this China-themed Lancet is the letters page. There are several letters from doctors in China commending the journal for highlighting the problem of violence against medical staff in China - and all put the blame on the underfunded health system and overworked doctors. On a related theme, doctors in China also lament the drop-off in applications for medical school - few young Chinese want to become doctors these days, as it is seen as a difficult and dangerous job that requires many years of study for little reward.

And any coverage of the medical situation China would not be complete without comment on the difficult status of organ transplantation. Quite a few doctors take issue with a recent Lancet article claiming that 'a new era' in organ donation is about to begin. They point out that China has about 200,000 require an organ transplant but there are only about 2000 donors. Read the full article to find out why.

My only criticism of the Lancet China issue is the too-deferential interview with China's health minister Li Bin, who gets to trot out all the claims of progress with reforms, without really being challenged about the many problems and contradictions with them. Oh, and the omission of any coverage of primary care [or lack thereof] in China ...

Wednesday, 27 August 2014

In China's hospitals, one in three doctors have latent tuberculosis infection

by Michael Woodhead
It's an avoidable occupational hazard that Chinese doctors could well do without: tuberculosis. 

A  study carried out in a general hospital in Henan has found that one in three healthcare staff have latent tuberculosis infection. The figures are even worse for a nearby infectious diseases hospital where almost 60% of doctors had latent tuberculosis infection.

First some clarification: as the CDC points out:

Persons with latent TB infection do not feel sick and do not have any symptoms. They are
infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a
positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection
are not infectious and cannot spread TB infection to others. Overall, without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives.


So, people with latent TB do not pose a serious risk to patients, but they themselves face a high risk of developing active tuberculosis disease.

In the study of 712 healthcare workers at a 1600-bed general hospital and a 600-bed infectious diseases hospital in Zhengzhou, researchers found that the tuberculin skin test-positive prevalence was 34% in the general hospital and 58% in the infectious disease hospital.

Dr Zhou Feng and colleagues who did the study said that health staff faced high risks of tuberculosis if they worked with infected people, such as those with HIV who often have co-infection with tuberculosis. Rates of infection were also highest in staff with longer years of working in the hospitals, presumably due to greater duration of exposure to risk.

Writing in PLOS One they said many staff did not use personal protective equipment such as  face masks and N95 respirators when working with infectious patients, despite this being recommended in guidelines.

Another problem with detecting and treating tuberculosis in healthcare workers was the low rate of tuberculin skin testing for the infection: many healthcare workers refused testing, and the most effective testing kits were too expensive for many Chinese hospitals. The findings also highlighted the limitations of the regular chest X-rays used to screen workers for active tuberculosis disease.

As the authors conclude - more emphasis is needed on observing and adhering to basic infection control and prevention practices in Chinese hospitals:

"Comprehensive guidelines should be developed for different types of medical institutions to reduce tuberculosis transmission and ensure the health of healthcare workers," they suggest.

Tuesday, 26 August 2014

What the Chinese can learn from Tibetans about hypertension


by Michael Woodhead
I've always wondered why Tibetans could be so healthy when they seem to subsist on a diet composed of dairy and meat, perhaps with the odd potato thrown on the fire. 

One of the staples of the Tibetan diet is tsampa - the butter 'tea' which is more like a salty yak butter tea-milkshake. This is not your EasyWay shake - tsampa is made with barley and is often accompanied by a glob of fermented yak milk sometimes known as kurut - similar to the products seen in Xinjiang.

Now it seems there is a hidden healthy component of Tibetan dairy products that has powerful antihypertensive properties, as strong as the drugs prescribed by western cardiologists. The blood pressure lowering effects come from the fermented milks produced by 259 Lactobacillus helveticus - a kind of probiotic ACE inhibitor if you like. Something in the Lactobacillus has potent effects on Angiotensin Converting Enzyme (ACE), the same system that is the target of modern antihypertensives such as enalapril.

In a recent study conducted by dairy technologists at the Inner Mongolia Agricultural University, Huhho, the fermented milk product was found to contain antihypertensive peptides that lower blood pressure by about 12 mmHg for six to 12 hours. That is fairly impressive BP lowering - and would be useful in a typical hypertensive patient with a systolic BP of 140/95mmHg who wanted to get to a target of 120mmHg.

As well as keeping Tibetans healthy, Dr Chen Yongfu and colleagues say the newly-identified probiotic/peptide may have potential as "a valuable resource for future development of functional foods for hypertension management."

Monday, 25 August 2014

Beijing introduces private health insurance for primary care

by Michael Woodhead
Beijing has introduced a pilot scheme of private health insurance to cover primary care services such as child health checks, maternal and perinatal care, postoperative rehabilitation and elderly care.
The service, which will be available through 23 community health centres allows those with insurance cover to tailor the type and level of services to suit their family needs.
The program is being offered online through the "Beijing General Practitioner and Family Care Reform Portal" website. The project has been set up jointly by the Beijing Medical Association and  China Life insurance
According to the BMA's Dr Wu Yonghao, Beijing residents will be able to purchase "Community Care Insurance" that will entitle them to various services provided by family doctors.
The service will also be offered as an add-on for patients who have insurance cover for procedures such as surgery, cardiac interventional procedures, orthopedic surgery and childbirth. General practitioners will provide the community care, including assessment, counselling, referrals and follow-up.
Insurance will also allow consumers to gain access to health checks, fast track referrals and personalised care.
The first of the "Family e-sites" is expected to go live in October and cover six districts of the city. By 2016 it is expected that 23 community health centres will cover all districts  of Beijing. Dr Wu said all community GPs will be qualified practitioners with at least five years experience as a specialist in the public system.
The program combines two of the National Health and Family Planning  Committee's health reform priorities: a move to private health provision and the development of primary care and community care services.

Sunday, 24 August 2014

Why Chinese patients are turning against their doctors: contrasting articles by the New Yorker and BMJ

by Michael Woodhead
Two very interesting and very different articles this week on violence against doctors in China: one in the New Yorker and another in the form of a study in the BMJ Open

The New Yorker story is in the usual stylish narrative, but I prefer the BMJ Open article, because it has more facts and more insights, even if it is a dry scientific paper. In the New Yorker, writer Chris Beam uses the example of the murder of a doctor in Harbin to shine some light on the whole fraught situation of violence against doctors in China. The story focuses on the case of a young man from a small town who had debilitating and degenerative back pain (ankylosing spondylitis) and who was unable to get satisfactory treatment from a Harbin hospital. He also had TB, which made treatment with an immunosuppressive drug even more difficult. Frustrated at his patchy and expensive treatment, the young man returned to the hospital and attacked the first doctor he could find, and killed an 'innocent' medical practitioner who had nothing to do with his care.

Chris Beam tells the story well and uses it to give some background on the health system in China and why so many patients and their families turn violent when they are treated so badly. However, I found the article was a bit too focused on the legal side of things (the American obsession with law once again?) The article doesn't really explore the root causes of violence: the built-in pressure in the system to overprescribe and over service, the rising cost of treatment and the hugely overloaded hospital system. Beam does cover China's health reforms, but strangely fails to mention the recent moves to encourage private clinics and the use of primary care clinics.

Another factor not really touched on by the New Yorker article is the patient/family faults: for me some of the key factors in China's medical disputes are rising expectations combined with ignorance (poor health literacy) and readiness to use brute force. This is not just confined to health: see how Chinese travellers behave when flights are cancelled or hotel rooms are overbooked.

That's why I prefer the BMJ Open article by Dr Jiang Yishi and colleagues at the School of Public Health, Fudan University, Shanghai. Their article takes a look at the reality of the complaints systems that exist in Chinese hospitals - and finds them sadly wanting. Dr Jiang and colleagues undertook the first in-depth study of how the complaints system works for patients and for doctors and hospital staff. They conducted interviews with all 'stakeholders' and found that in many cases, the system is broken. In theory, a patient with a grievance has several channels through which they can seek redress. They can make a formal complaint to the hospital complaints office and can also petition via a system of 'letters and visits'. Patients can also go to mediation by a third party office to settle an unresolved dispute with a hospitals. And patients can also take legal action against a hospital via  a lawsuit.

In practice, these systems often do not work. Firstly, many patients are simply unaware of the complaints system and how to use it. Hospitals don't advertise their complaints offices, which are often hidden away in an obscure corner of the building. The staff in these offices are supposed to be able to investigate complaints and arrange mediation - but in practice they are often unqualified to adjudicate on complicated clinical matters, and they are also under great pressure to deflect complaints - or dismiss them quickly. Complaints departments are understaffed and have little sway in the hospital system. Another problem with the 'complaints office' system is that it lacks transparency. Patients make complaints but they get little feedback from complaints office staff who do everything 'behind closed doors'.

On the other hand, hospitals and medical staff also express great frustration about the complaints system. Doctors say any complaints arise because they work under great pressure to see 60 or more patients in a morning and don't have time to put on a 'warm face' or to explain things in detail to patients. This lack of connection and communication leads to many misunderstandings and unhappy patients.  Doctors also say that they become the scapegoat for failings of the system: for example, (just as in the US) they are restricted in what treatments they can offer to patients by the medical insurance rules - but patients don't understand this and often get angry at being denied treatments are given treatments that come with a hefty out of pocket costs.

Another big frustration for doctors and hospitals is the rise in unreasonable complaints and the use of abuse and pressure (extortion) to get a complaint resolved with financial compensation. More than 50 doctors interviewed mentioned this 'chao' (吵, argue) phenomenon. Doctors said many patients and relatives had unrealistic expectations about what could be done by medical staff. And when things didn't have a good outcome, patients and relatives often turned to threats and 'mob tactics' to put pressure on doctors and hospitals. These unruly groups are not interested in facts or a fair settlement but want to cause as much trouble as is needed to get a financial payout.

The BMJ Open article says the whole health complaints system in China is lacking in structure and rigour: there are no standard protocols for investigating complaints, for assessing harm and no data is collected on complaint numbers or how they are followed up - and no system for using complaints to identify weaknesses or errors and give feedback accordingly. Hospitals have no incentive to collect or document complaints because it just gives them more 'black marks'. 

The overall impression of the health complaints system is that it is perfunctory and ineffective: hospital directors want complaints to be managed quickly and made to 'go away', hence the readiness to make a quick financial settlement and avoid trouble and bad publicity, especially when angry mobs are involved.

The article by Jiang concludes by identifying three crucial areas where improvement is needed in the complaints system: organisational support, personal support from hospital managers and political leaders (and patients) - and learning system to ensure that failures are identified and rectified. The solutions put forward are sensible and obvious - and the full paper is well worth a read. 

However, I  would not be optimistic about the prospects for change: many of the problems that plague the health complaints system are common to those of Chinese society in general: there is a lack of trust in institutions (in this case hospitals and health departments) which are not accountable, lack transparency and which combine vested financial interest with political power. The solutions require open-ness, accountability and an independent watchdog with teeth. In the current environment in China, those are not likely to happen. Instead, China has top-down directives to crack down on the symptoms of these failings - the government issues stern warnings and makes some highly public arrests of wrongdoers. Ultimately it will take workable systems to fix the problems of health grievances, not campaigns and punishments.

Friday, 22 August 2014

Nearly 700 dead in Yunnan rabies epidemic - mass culling of dogs needed to stop spread to Lijiang and Dali

by Michael Woodhead
Yunnan is in the midst of a rabies crisis and drastic action is needed to curb the disease in dogs before it spreads to popular tourist towns such as Lijiang and Dali, Chinese researchers say

In the year 2000 there were only three cases of rabies in the whole of Yunnan, but in the following decade there was an epidemic of the disease and 663 people died. The explosion in rabies cases has mostly affected eastern parts of the province adjacent to Guizhou and Sichuan, and the rabies cases are linked to increasing ownership of dogs in rural areas - and better transport links.

In a report published in the journal Emerging Infectious Diseases this week, researchers from the Yunnan Institute of Endemic Diseases Control and Prevention say a mass culling of dogs in the province is urgently needed to curb the ongoing spread of rabies. They say many rural households have dogs that are apparently healthy but harbouring and spreading rabies. Vaccination is not practical for the tens of thousands of poorly supervised dogs in rural towns and villages, and therefore culling is the only realistic option, they say.

In their article they says that rabies had been all but eliminated from Yunnan by the late 1990s after serious outbreaks in the 1980s. In the year 2000 there were just 3 cases in one county, but since then the disease has spread to 77 counties within the province and the epidemic shows no sign of abating. The problems has become so bad that Yunnan is now the focal point for the spread of rabies not just within China but also for neighbouring counties such as Laos and Burma, they claim.

Rural families often own two to three dogs and there is little legislation to enforce vaccination, they note. In addition, better road links and increased ownership of vans and cars means that dogs are now traded over a much wider area and they are also sold to restaurants for dog meat.

They propose a four point plan for the most severely affected regions of Yunnan, which include Wenshan, Zhaotong, Qujing, and Honghe counties.

1 Domestic dogs should be confined in the household at all times.
2. All unsupervised dogs and domestic dogs within the affected villages to be killed.
3. Vaccination of all  dogs in neighboring villages as an emergency and temporary measure.
4. Provide free rabies vaccination to all susceptible people and educate local inhabitants regarding the
risk of rabies.

If these measures are not adopted immediately, rabies can be expected to spread to the tourists towns of Lijiang and Dali, they warn. In the longer term, compulsory vaccination programs for all dogs will be needed to curb rabies. However, they are pessimistic about the prospects for such a campaign.

"The greatest obstacle to removing the threat of rabies is the low level of political commitment because dogs are not regarded as economically useful animals in Yunnan Province," they conclude.

Thursday, 21 August 2014

Hunan: 200 hospital staff strike and stage protest over attack


by Michael Woodhead
More than 200 hospital staff staged a sudden strike and protest at the Yueyang Second Hospital after medical staff were attacked, held hostage and forced to kneel in front of the body of a patient.

The incident arose after a young man was brought into the hospital emergency department on August 20th with stab wounds. The patient, a 31-year old male called Chen Qiming, was critically ill and did not survive for long. After his death, dozens of relatives of the dead man came into the hospital and created havoc, seizing and beating medical staff and forcing them to kneel in front of the body of their dead relative in the mortuary. The family members also ran riot in the hospital, smashing up offices and blocking entrances, disrupting normal working of the hospital for eight hours.


The next morning hospital staff said they would refuse to work until those responsible for the attacks had been brought to justice and they were provided with adequate safety protection in the workplace.
They carried placards saying "Expecting fairness, give us respect". The protest attracted a large crowd of onlookers, and the strikers said they demanded that their legal rights be respected.

A staff member at the hospital said the mood of staff was indignant and emotional.  Hospital managers had advised them not to stage a protest but to instead take their grievances to the local government office. However, the staff opted for a spontaneous strike and could not be blocked.


Doctors said the dead man had suffered critical injuries including deep penetrating knife wounds to the chest that caused heavy blood loss and which were not survivable. They had done everything they could to save him when he was brought into the hospital, but despite their best efforts the man died.
When the staff were attacked many other staff members including doctors and ambulance drivers came to their help, and police were called. However, despite trying to mediate, the more than 150 police were unable to settle the situation for eight hours.

A spokesman for the Yueyang City Health Bureau said an investigation had been launched into the incident. Local police said they were also investigating the incident but had not yet contacted the families said to have been involved in the attacks.

According to sources at the hospital this is the second violent attack on staff this year and the third violent medical dispute in Hunan in in the last two months.

Wednesday, 20 August 2014

How an uneducated migrant worker became a successful medical journal editor: the publish-for-promotion swindle

 by Michael Woodhead
An amazing and hilarious story in the Chinese Legal Daily this week about how a rural migrant came to Beijing and set up a fake medical journal to publish scholarly articles for senior doctors wanting to boost their promotion prospects.

The young man ran a highly successful publishing operation and made almost two million yuan ($325,000) between 2009 and 2013 when his operation was busted by police. The man called Liu Yang was only 23 years old when he came to Beijing and started working on the reception desk of a hotel in 2009. It was while he was talking to a doctor at the hotel that he hit on his money-spinning idea. The doctor was complaining about how difficult it was to get promotion because of the requirement to have a quota of articles published in medical journals. The problem, he said, was simply that there were too many doctors trying to get published and not enough journals.

Liu Yang had the obvious idea of inventing a medical journal to meet that demand. Despite having only a middle school education and knowing nothing about medicine, he quit his job at the hotel and borrowed  money to buy some basic publishing equipment such as a scanner and large printer. He installed this at his apartment, which would become his editorial office. However, his most important investment was 200 yuan for copies of the leading medical journals, whose style he copied. He also bought a list of top doctors and top hospitals around China.

Awarding himself a doctorate and appointing himself editor and publisher, Liu Yang then wrote to the hospitals on his list and offered the services of his medical journal for publishing. He was immediately inundated with manuscripts from mid-career doctors. As a police investigator later explained to the reporter, the medical career pathway in China is based on publication of scholarly articles for advancement. Promotion from hospital resident onwards is dependent on having a list of articles that have been published in journals. No publication, no promotion.

"Dr" Liu Yang received so many submissions he was rushed off his feet publishing his journals every month, and soon had to call in his wife and other family members to help out. The journals were only circulated to the doctors who had articles published in them. It was essentially vanity publishing. And yet, to maintain some credibility, Liu Yang even started to reject some manuscripts. The fake journal published articles from doctors all over China: the most frequent users were doctors seeking elevation to 'deputy director of department' level, a career step which required many published articles.

At first, the fake journal was a print operation, but doctors then started asking 'Editor' Liu Yang why their articles were not being published online. The fake editor then expanded his shanzai operation online and hired a web designer to copy the website  of a leading medical journal and set up a website for his own fake journal. Now Liu Yang offered digital journal publishing to his hundreds of clients.
In total he published articles by more than 800 doctors, and most were senior doctors at major hospitals, including military hospitals. Most did not realise the journal was a fake operation. A few suspected things were not quite above board, but still paid Liu Yang to publish their efforts because they believed others would not notice.

And for four years they didn't. As a police investigator remarked, there are hundreds of such medical articles and theses published every year and nobody is much interested in what they say - they are simply published to impress hospital administrators. And so until recently nobody was auditing these medical articles or the journals that published them.

However, somebody must have eventually twigged to Liu Yang's ruse. In September 2013 police came calling at the new expanded Chaoyang offices that Liu Yang had expanded into. As cops banged on the door, his wife tried to throw plastic bags of money out of the window, whereas Liu was more interested in trying to save the raw materials for his publishing operation. The police gained entry to the premises and shut down the publishing business, confiscating equipment and 600,000 yuan. Liu Yang and his wife were arrested by police and charged with fraud.

Commenting on the case, a senior doctor at a Beijing Hospital said the fake journal saga highlighted a major fault of the medical career system in China, namely the reliance on having papers published. The doctor said there was enormous pressure on doctors to publish, because promotion offered higher income through access to prescribing a wider variety of drugs. Doctors who were good clinicians but did not publish remained stuck on the lower rung of the hospital ranking and only treated large numbers of patients. Some hospitals even fined their doctors if they did not achieve a quota of published article, he said. And the doctor said the busted operation was not the only fake journal -  he still regularly received emails from dubious sources offering journal publishing services and also ghostwriting services.

Liu Yang's fake publishing operation is now smashed, but the publish-for-promotion system is still intact in China. And while doctors are under enormous pressure to publish, other loopholes will be exploited, corners cut and more scams like those of Liu Yang can be expected to occur.

Tuesday, 19 August 2014

Antibiotics overused | More SFDA managers in trouble | Cloud medical records | Forced blood donation


Antibiotics overused in hospitals
Up to 90% of hospitalised patients are given antibiotics, regardless of whether they need the, a snapshot of antibiotic usage at one hospital in  has shown. The study carried out at Taihe Hospital, Hubei University of Medicine, found that 56% of inpatients were receiving antibiotic therapy, with the highest rate  in the ICU (90%), and the lowest in the medical wards (39%). The most commonly used antibiotics were β-lactam antibiotics, including cephalosporins (40%) and piperacillin (19%), followed by fluoroquinolones (14%).

More China FDA officials investigated
Three more top managers at the China FDA drug regulatory authority are being investigated for wrongdoing.  The deputy director of China FDA and the deputy director of the regulator’s drug evaluation center, are among managers accused of illegal activity by provincial officials from Henan. The officials say the FDA managers refused to approve some batches of rabies vaccine and did not give detailed explanations why the batches failed. One of he officials is also a director of the vaccine manufacturer. Last week other top managers at the FDA were accused in the media of wrongdoing.

Cloud medical records
The China-Japan Friendship Hospital in Beijing may use cloud computing as part of a digital medical  records network that already covers 17 other hospitals, The network would allow electronic medical record sharing, fee transaction and telemedicine and would cost about 200 million yuan ($32.54 million).

Children forced into blood donation
It is now reported that ten teenagers were forced by a gang to donate blood in Gansu. The group of children under 18 in Wuwei were forced to donate blood every month for six months by a gang including a staff member of a blood centre.The gang led by a man called Huang, who was the deputy chief of a blood center run by Lanzhou Institute of Biological Products illegally collected 10,700 yuan (US$1,742) through more than 48 forced blood donations.

Doctor consults via smartphone
The makers of a health app that allows smartphone users to make online doctor consultations has received $50 million investment. The Chunyu Yiseng app allows users to link up and chat with real doctors in real time and ask questions about their illness. The app also includes a doctor forum and allow users to make appointments to see doctors face to face.
Chunyu Yisheng, the Chinese smartphone app that lets users remotely consult with physicians to diagnose their ailments, has raised a US$50 million series C round of funding from China International Capital Corporation (CICC) and Dunan Holding Group, according to Sina Tech.

Read more: Doctor consultation app gets China’s biggest ever investment in a healthcare startup http://www.techinasia.com/doctor-consultation-app-chinas-biggest-investment-healthcare-startup/
Chunyu Yisheng, the Chinese smartphone app that lets users remotely consult with physicians to diagnose their ailments, has raised a US$50 million series C round of funding from China International Capital Corporation (CICC) and Dunan Holding Group, according to Sina Tech. Previous investors also pitched in, including Temasek and BlueRun ventures, making this the biggest single funding round into a Chinese healthcare startup to date.

Read more: Doctor consultation app gets China’s biggest ever investment in a healthcare startup http://www.techinasia.com/doctor-consultation-app-chinas-biggest-investment-healthcare-startup/

Monday, 18 August 2014

Resisting the Japanese invader: the China success story against Japanese encephalitis

by Michael Woodhead
 As China cranks up its media hate campaign against its former enemy Japan, the country can actually celebrate victory in its war against another 'Japanese' invader from the 1940s: Japanese encephalitis. 

This mosquito borne viral disease used to cause about 200,000 cases of severe neurological illness in China every year at its peak in the 1960s and 70s - with about 30% patients dying and many of the survivors  left with lasting neurological disability as a result of the infection.

The name is misleading - the disease did not originate in Japan, but was first identified there in the 19th century. The infection was first recorded in China in the 1940s and became widespread in the 1960s - partly because of the breakdown in public health preventive activities during the chaos of Mao Zedong's Cultural Revolution.

A vaccine against the virus was developed in Japan in 1965, and China started manufacturing its own vaccine a few years later.  Writing in the journal PLOS Neglected Tropical Diseases, Dr Gao Xiaoyan and colleagues at the Chinese Centre for Disease Control and Prevention, Beijing, describe how Japanese encephalitis was brought under control in China.

The initial Chinese vaccine was only available in limited quantities and required many doses. It was expensive and was only available to privileged cadres and Party members, not to the peasants who were most at risk of the disease. With more than half the cases of Japanese encephalitis in the world, China continued to work on improving the vaccine and eventually developed one in 1988 that was more convenient and could be mass produced at relatively low cost, to make it affordable for public health use.

This vaccine was gradually made available at a cost of 1 yuan to rural residents, and was fully subsidised as a free vaccine after the year 2005. Since it was included in the "Expanded Program of Immunisation" this cheap and effective vaccine had reduced the incidence of Japanese encephalitis in China from 21/100,000 people to just a fraction of 1 per 100,000 - a remarkable achievement.

But the vaccine is not the only reason for the drastic reduction in Japanese encephalitis in China. Other public health measures were implemented by local health authorities to reduce mosquito breeding and transmission:  pig farms were moved away from villages,  sewage disposal was improved to reduce mosquito breeding, and mosquito breeding grounds in areas of static water were eliminated.

The threat from Japanese encephalitis has now been markedly reduced in the more prosperous eastern provinces of China but it remains a problem in the poorer parts of southwest China. Nevertheless, Chinese researchers say other developing countries can copy the Chinese model for eliminating Japanese encephalitis: low cost programs using inexpensive vaccine and anti-mosquito measures.

Sunday, 17 August 2014

Censorship of medical research by retraction? A worrying precedent from China

by Michael Woodhead
A study on Chinese attitudes to organ donation has been retracted by its authors because they object to the journal Transplantation publishing a letter that is critical of their article. This is not just a case of study authors being hypersensitive about their work - rather, the authors object to the 'criticism of the political situation' in China contained in the letter.

The study in question is titled: "Factors Behind Negative Attitudes Toward Cadaveric Organ Donation: A Comparison Between Medical and Non-Medical Students in China". It was published online by Transplantation in May 2014, and seems fairly straightforward. The survey of 400 Chinese university students found they were generally against organ donation. The actual numbers were: 48% of students would refuse to have their organs donated, 37% were not sure and only 15% would agree to organ donation. Attitudes were more positive among medical students: 32% would agree to organ donation and only 27% would definitely refuse: 41% were not sure.

The main factors behind the negative attitudes to organ donation were traditional Chinese culture and family disapproval, mistrust of the medical system and how the organ donations might be used, plus suspicion of premature withdrawal from life support. Religious beliefs and wariness about the nontransparent process of donation were also factors in opposing organ donation for some Chinese students.

The study's lead author is Associate Professor Zhang Lei, a lung transplant surgeon at the Tianjin Medical University Cancer Institute, with various co-authors from other Chinese hospitals and universities. Two of the co-authors are listed as being at Harvard and Indiana universities in the US. The study authors conclude that there is little enthusiasm for organ donation in China, due to the above listed factors - but they end on a positive note, saying the large number of 'don't knows' suggests there is potential for many Chinese to be persuaded about organ donation.

So far, so good. But the Transplantation website now says the article has been retracted at the insistence of the authors. The reason given by the authors: "because the editors [of Transplantation] insist on publishing a Letter to the Editor that is critical of the article and that, in the view of the authors of the article, is unjustified since it extends to criticism of the political situation of organ donation in China and the failure of the article to take this into account."

The offending letter does not yet seem to have been published. I can only guess that it refers to the  controversial and murky area of organ transplantation in China. We're all aware of the stories of organ trafficking and the use of organs from executed prisoners. There are the claims made by a certain quasi-religious meditation group (who I will not name because it will get this blog blocked within the PRC) about organ harvesting. The fact that even mentioning the name of FLG is enough to have a website blocked in China shows the continuing sensitivity around the group in that country - and among the people who work there. Perhaps this is the reason why Dr Zhang has asked for his paper to be retracted: maybe he does not want to get into a debate about 'the group with no name' - or even see his name on the same page as them. The question remains whether Dr Zhang retracted this paper on his own initiative (self censorship) or on advice/orders from others higher up the chain?

The retraction seems futile, symbolic and self-defeating: futile because the study is still online, but with the word "Retracted" stamped across it, so it is still possible to read the findings. It's symbolic because the authors are not retracting their work due to it being unsound - only because they disagree with criticism of it. And political criticism at that.

Retracting a study because of 'political' criticism is not in the spirit of science or academic discourse. Being willing and able to defend your work from critical review is one of the foundations of good science. What if Darwin had retracted Origin of the Species because he was unwilling to have John Murray publish a critique of it?

And this makes it self defeating - all that Dr Zhang has done is draw attention to an act of anti-scientific self censorship. The attitude seems to be "you may only publish our research if you promise not to publish others who are critical of our government". Compare this refusal to engage with the very robust debate on the sensitive issue of Gaza currently taking place in The Lancet, with views from all sides. It makes Chinese researchers look intolerant of scientific discussion and unable to handle academic debate. Not a good look for a country that aims to catch up with the developed countries in science and technology.

The retraction raises a whole raft of worrying questions. Does this set a precedent for China? Will Chinese researchers only publish in compliant journals that agree not to publish letters that criticise the political situation in China? Will China put pressure on publishers who publish critical comments? This is a real possibility, as scientific publishers such as Elsevier are  keen to expand in China.

The refusal by Chinese researchers to publish articles is a very worrying move and could have enormous repercussions, given the huge growth in publishing in science and medicine by China-based researchers. Suppression of information and discussion shows China still has one foot in the Mao era. Well, all I can do is suggest Dr Zhang follow the advice of Mao Zedong:  
"Let a hundred flowers bloom and a hundred schools of thought contend". Either that, or submit the paper for publication in the North Korea Medical Journal.


[Editor's note: This is a blog, not a media outlet, but if Dr Zhang or any of the co-authors are reading this and want to 'have your say', I'm happy to update this post and include your take on this].

Friday, 15 August 2014

Why don't Chinese bystanders assist in medical emergencies?

by Michael Woodhead

A frail women collapses at a train station but passers by do nothing. She lies there for almost an hour before emergency services arrive, by which time the woman has died. This was a real incident at Shenzhen railway station in February this year. 

Why do mainland Chinese people not act as Good Samaritans? asks Dr Dan Xiuli of the nearby Faculty of Medicine at the Chinese University Hong Kong, Shatin. Writing in the Emergency Medical Journal this week, he asks, is it because would-be helpers in China have a fear of being wrongly blamed by victims as perpetrators and subject to demands for compensation?

A recent survey found that only 14% of mainland Chinese would be willing to provide assistance to a stranger who needed medical assistance. And that reflects what happens in real life: most bystanders don't get involved, they hover and watch or they scuttle past without offering help. This reluctance to help has major implications for the 1.2 million Chinese who have accidents in public and require assistance each year, he says. Heart attacks, sudden illness in public, traffic accidents, natural disasters etc all require people who are willing to step forward and provide first aid skills. Is there any possibility of this happening in the People's Republic?

Groups such as the Red Cross have suggested that a minimum of 30% of the population should have first aid skills training in order to be able to provide assistance in public emergencies. In developed countries such as Norway, more than 85% have skills in First Aid, whereas in the UK only 14% of people profess to have such skills. At the time of the Beijing Olympics in 2008 the Chinese government aimed to have more than 1% of people trained in first aid, but failed to reach this target. For most Chinese the only aid they are able to provide is notifying the 'relevant authorities' such as by dialling 120.

Not surprising then, that studies have estimated that 87% of deaths from accidents in China are due to the lack of first aid. And shockingly, even staff entrusted with the care of the vulnerable, such as infants have no training or skills in first aid - fewer than 4% of kindergarten teachers could achieve even basic knowledge in first aid.

Dr Dan concludes by saying that "First aid is not merely a skill but an act of humanity." He notes that China has a culture of many thousands of years, but most Chinese seem to have forgotten the traditional call to virtue of: ‘To rescue one person from death is better than to build a seven storeyed Buddha pagoda’ .

Update: Some interesting research on Australian bystander reactions to medical emergencies from Flinders University.

Wednesday, 13 August 2014

The previous head of the China FDA was shot for corruption - now his replacement is also in trouble

Former FDA chief Zheng Xiaoyu sentenced to death in 2007
by Michael Woodhead
Strange goings on at the China Food and Drug Administration. The top leaders past and present are facing public criticism for alleged corruption around the national pharmacopeia. 
There is a possibility that this bizarre case is a veiled way for the Xi Jinping administration to remove a senior official. There again, it might all be true.

The allegations relate to changes made to the official classification of the herbal remedy honeysuckle to favour producers in the Shandong hometown region of Shao Mingli, who recently stood down as FDA director. The claims are being made by an obscure provincial Party official from Hunan, who posted on his Weibo account that former FDA director amended the Chinese Pharmacopoeia to favour the use honeysuckle from his hometown area of north China, which resulted in south China producers losing business.

According to Shanghai Daily, the minor official, who is a member of the local disciplinary committee, says he has gone public because his private complaints were ignored. He claims the Pharmacopoeia Commission under the control of Shao Mingli changed the official terminology so that only plants from Shandong Province, where Shao comes from, could be used in herbal remedies.

The 'whistleblower' says he simply wants to see southern honeysuckle restored to official status so that southern China growers could resume their business. However, as well as calling Shao Mingli 'the major culprit', the official has also implicated other senior FDA officials and has called for the current director of the FDA, Zhang Yong, to step down as he has been obstructive and failed to act on the concerns of officials in southern Chinese provinces.

This might all be taken as a minor business dispute but for the fact that reports of the claims are being reportedly prominently in official media. If the whistleblower's claims are accepted as true this would lead to a major purge of the FDA leadership. And as you may know, this isn't the first time that the leadership of the China FDA have been in serious trouble. The accused Shao Mingli's predecessor Zheng Xiaoyu was executed in 2007 after being found guilty of accepting bribes in return for listing medicines.

According to the official FDA website, the current director Zhang Yong has addressed the claims and made a report to the Party Central Commission for Discipline Inspection. Is this a sign of China's greater openness and accountability? Or is it a Machiavellian way for the new Xi Jinping leadership to take out the leadership of the national drug regulator and replace them with their own people? I doubt that anyone will face the firing squad this time. Some powerful FDA figures may lose their positions, or this may simply be a way of putting them on notice and showing them who is the boss. It may all come to nothing.

Whichever is true, it seem that being head of the FDA in China is a very dangerous career move.

Tuesday, 12 August 2014

China has its first non-imported dengue outbreak in a decade

by Michael Woodhead
Last year, Yunnan experienced an explosive outbreak of  dengue fever spread by mosquitoes.

This was a strange and worrying phenomenon because Yunnan has been dengue free for many years. China has had a few outbreaks of dengue in recent years but they tend to have been in south eastern provinces such as Guangdong, and they are usually related to imported dengue fever. The infection is not endemic to Yunnan.

However, in 2013 health workers in Xishuangbanna had to deal with a huge outbreak of this often severe, life-threatening disease. There were 1245 cases of which 136 patients were hospitalised and 70 were classified as severe cases. The symptoms included severe haemorrhage (including massive vaginal and gastrointestinal bleeding), severe plasma leakage (such as pleural effusion, ascites, or hypoproteinaemia), and organ failure. Twenty of the cases  deteriorated to shock.

In an analysis of the outbreak published in the International Journal of Infectious Diseases, Dr Zhang Fuchun of the Guangzhou 8th People's Hospital say the dengue fever was caused by a new virulent strain of the virus known as serotype 3 (DENV-3). But the main reason for the severity of the outbreak was that the infection was spread  more rapidly by a different type of mosquito - Aedes. aegypti. The usual type of mosquito seen in Yunnan is known as Aedes albopictus, and dengue caused by this species tends to be milder and short lived. The researchers say the 'double whammy' of a new strain of dengue and a new strain of mosquito combined to "carries a high risk for a severe epidemic and endemicity" in an area that was until recently dengue free.

Monday, 11 August 2014

Monday's medical links from China

Illegal kidneys smuggled as seafood
Kidneys harvested from human were disguised as seafood when sent from Nanchang to Guangzhou, by organ traffickers including a military surgeon.
The kidneys were flown in a refrigerated container to Dr Zhu Yunsong at Guangzhou Military Area General Hospital. The trafficker gang removed 23 kidneys for cash before being apprehended and sentenced to up to nine years in prison.
The gang paid the private Nanchang Huazhong Hospital 35,000 yuan for the hire of a room for each operation, and the doctors were paid 10,000 yuan for each operation.
Gang leader Chen Feng, chairman of the Guangzhou Mengjiadi Trading Co, told police he knew many transplant doctors in Guangzhou because the company sold medicines.
He had begun a search for kidney donors after Dr Zhu Yunsong  told him there was a shortage.
they started sourcing kidneys from brain-dead patients in a Jiangxi hospital, but soon began to recruit live donors.

Medical apps boom
Chinese investors are putting their cash into medical apps, according to Caixin. Venture capital and private equity firms have funnelled US$ 100 million for 33 health care-related app developers who have worked on mobile  functions such as making doctor appointments, ordering medicine and tracking a child's temperature.
A typical example is Xiamen Meet You Information Technology Co. Ltd, which is offering a women's health management app Meet You, that helps women keep tabs on their menstrual cycles, provides information about contraception, pregnancy, beauty aids and parenting, and allows women to link-up through an online community.
According to Caixin, app developers want to profit by mining big data, for which there is strong demand. Another app is an appointment-booking service, guahao, which is the Chinese phrase for 'register'. However, many hospitals do not want to offer appointments via apps, and many of those who need most help with appointments  are elderly people with little knowledge of technology.

Ebola False Alarm
Hong Kong's panic over a Nigerian man with suspected Ebola virus disease has turned out to be a false alarm. The man who had recently arrived from Lagos and was staying in Chungking Mansions, had diarrhoea and fever, but tested negative for Ebola virus.

Impatient patient bashes radiologist
A doctor in Hubei was assaulted by a 56-year old man who was angry at being kept waiting for an hour to have  CT scan. The radiologist was assaulted by the man in the waiting room after he told the man to be patient as there were others in line ahead of him. The 56-year old man beat the doctor over the head with a stick and kicked him to the ground.

Pauper paediatricians miss out on kickbacks
Children's hospitals are having trouble recruiting doctors willing to work as paediatricians because the pay is low. A new report says that one childrens' hospital in Wuxi has filled only half the 35 vacancies for doctors. Managers say doctors do not want to work in paediatrics because the volume of prescribing and test ordering is low, and therefore the income from commissions is low.

Sex-selection clinics use Hong Kong labs
Illegal Chinese sex-selection clinics are sending blood samples to Hong Kong for prenatal gender tests, it has been revealed.
The trade came to light when a woman was arrested in Shenzhen after Customs officials found 96 blood samples from expectant mothers inside her bag. The woman was taking them to Hong Kong to test for the sex of the fetus, as such tests are illegal in mainland China.
According to the SCMP, blood samples from more than 10,000 expectant mothers are brought to Hong Kong for testing each month.
Commercial medical agencies in Shenzhen advertise that a couple can find out the sex of a seven-week foetus for only 4,000 yuan by just sampling a few drops of blood from the mother.
The test analyses foetal DNA in a pregnant woman’s blood to identify a child’s sex weeks earlier than other alternatives such as ultrasound. According to Chinese law the Family Planning Association will perform abortions only in the first 10 weeks of pregnancy.

Beijing hospitals abolish 'Quick Clinics" in favour of GPs

by Michael Woodhead

Beijing hospitals have angered many patients by abolishing the so called "Convenience Clinics" that provide prescriptions for outpatients.
A legacy of the early 1980s reforms, the Outpatient Prescription clinics have been cancelled because they represent a poor model of care, according to health authorities. Without a proper diagnosis or review, the clinics are little more than glorified drug dealers, say doctors.

Notices went up to say that the Convenience Clinics will be abolished from September 1, with the main reason being that they are at odds with rational use of medicine and pose a risk of medication-related problems, especially for children. Health authorities said drug prescribing had changed enormously since the 1980s, and it was no longer appropriate to offer prescriptions without a review. Prescriptions might now involved multiple drugs and more complex drug treatments with narrow margins of safety, prescribed by different specialists. It was therefore a hazard to have them re-issued without a check on the patient's condition.

If patients with chronic diseases such as hypertension want a simple repeat of their prescription they should make an appointment with the new "general practitioners" rather than waiting a long time to see a specialist. The doctor can then review their condition to see if it has changed and to tailor therapy according to response. There were also cases where the patient did not even attend the "Convenience Clinic", but sent a family member instead. According to the Beijing Daily, hospitals said they wanted their specialist clinics to be reserved for more severe disease, with simpler ailments and repeat prescriptions handled by general practitioners.

Sunday, 10 August 2014

China's answer to Ebola: a lethal haemorrhagic fever that kills 20,000 people a year


by Michael Woodhead

Like many other countries, China has gone into a hysterical spin about the threat posed by Ebola virus disease.

Authorities have dusted off the useless thermal scanners last used in the avian flu outbreaks, and have started screening passengers arriving at from Africa at Chinese airports. And despite the World Health Organization saying that China does not need to be overly concerned about the disease, authorities have been issuing stern warnings to health workers about being vigilant for Ebola and also looking with suspicion on the African expats living in cities such as Guangzhou. The irony is that China has seen its own counterpart of Ebola virus disease, a killer disease that has been increasing dramatically in the last two years.

But first some background: Ebola is a haemorrhagic fever, caused by the Ebola virus, which belongs to the  Filoviridae family of RNA viruses. The virus comes from apes and bats and is only transmitted between humans by body fluids such as blood and saliva - in Africa it has been spread by hunters cutting up meat from infected animals, and spread to healthcare workers and close relatives to touch the dead bodies of Ebola victims at traditional African funerals. In the latest outbreak there have been 1323 confirmed and suspected cases of Ebola reported, and 729 deaths. That's a mortality rate of 55% according to my calculator.

What to make then of China's recent little remarked but lethal cases of haemorrhagic fever? In April, Dr Du Hong and colleagues from the Center for Infectious Diseases, Tangdu Hospital, Xian, described the horrific symptoms of some of the 356 patients who had been treated at their hospital for  "hemorrhagic fever with renal syndrome" (HFRS),  a disease caused by Hantavirus that is spread by rats (or more specifically in their droppings, which may become aerosolised and spread to anyone working near where rats have been active).

The symptoms are similar to Ebola: fever, circulatory collapse with hypotension, hemorrhage, but also with acute kidney failure (hence the name renal syndrome). The difference between Ebola and HFRS is that the Hantavirus disease has a death rate of 'only' 40%. For China, which has had about 50,000 cases of HFRS annually, that means about there have been, at a conservative estimate, 20,000 deaths from Hanta virus every year. Makes the 730 Ebola deaths in Africa look fairly insignificant doesn't it? And as with Ebola, there is no treatment or vaccine for Hantavirus, only supportive care.

And that's not all. China has other types of haemorrhagic fever. This month The Lancet carries a report of the emergence of one, known as "severe haemorrhagic fever with thrombocytopenia". This is a viral disease spread by ticks, caused by the SFTS phlebovirus in the Bunyaviridae family. According to Dr Liu Quan and colleagues from the State Key Laboratory of Veterinary Etiological Biology, Lanzhou, SFTS was first reported in 2010 and has since been found in 11 provinces of China, with about 2500 reported cases, and an average case-fatality rate of 7%. That's about 175 deaths. As the study authors say with some understatement: "The disease has become a substantial risk to public health".

China is the epicentre for Hantavirus haemorrhagic fever in the world, but it is not the only country affected. The disease is also seen in Europe and the US - a Denver man died of the infection just this week. But with tens of thousands of Chinese people dying every year from this terrible haemorrhagic disease, perhaps China ought to worry more about curbing Hantavirus - and the rats that carry it - rather than panicking over the threat from an African outbreak of Ebola.

Thursday, 7 August 2014

4 China medical news links for Thursday ...

China will become one of the largest global markets for prescription drugs, growing to $260 billion in 2020, a University of Kansas study finds. Generic drugs will account for more prescriptions, but there will still be major problems for health providers to meet consumer demand for brand name innovative drugs and also to provide universal access to affordable medicines, the researchers say.

Beijing's air quality has not improved over the last nine years, with air pollution exceeding Grade II of NAAQS levels for Pm2.5  and PM10 on more than 30 % of day, a study has found. The worst levels occurred at dawn and dusk, whereas midday had lower levels of air pollution. The source of air pollution was road vehicles and heavy industry especially to the south of the city, according to Dr Liu Zirui and co-researchers from the State Key Laboratory of Atmospheric Boundary Layer Physics and Atmospheric Chemistry (LAPC), Chinese Academy of Sciences, Beijing.

Treatment of breast cancer in China has improved in the last decade, but many women still miss out on radiotherapy and endocrine therapy, say oncologists at the West China Hospital, Chengdu. IN a review, they found that chemotherapy was the most popular therapy, but the proportion of women receiving radiation therapy increased from 37% in 2001 to 67% in 2011 . At the same time, use of endocrine therapy from 54% to 86%, they found.

Hand foot and mouth disease is a serious and common illness in China, with more than  five million cases reported over a five year period from 2008 to 2012. The disease caused more than 1200 major outbreaks, caused predominantly by enterovirus 71 and cocksackie virus, with most occurring in April–June and a smaller  peak in September–November. The survey was done by researchers at the Key Laboratory of Surveillance and Early-warning on Infectious Disease, Chinese Centre for Disease Control and Prevention, Beijing.

Wednesday, 6 August 2014

China's rural timebomb: half a billion elderly people with chronic diseases and no care

by Michael Woodhead
A survey of elderly villagers in rural parts of China has revealed some of the monumental healthcare problems the country faces.

Simply put, China is on track to have almost half a billion elderly people by 2050 and most of them will have chronic diseases but no treatment. The research carried out in 4400 households in rural areas of nine provinces found that a staggering 58% of elderly people are illiterate and many of them have been 'left behind' by children who have moved to towns or cities in search of work.

For almost 70% of elderly people their annual income was below 5000 yuan ($810).  And worryingly, they had high rates of chronic diseases: 18% had diagnosed hypertension, 3% had diabetes and 6% had asthma. However, these figures are likely to be underestimates because very few elderly people are getting health checks - only 3% had any kind of health preventive check in the past few weeks. Only 2% of patients had their blood pressure checked.

Not surprising then that substantial proportions of those people with chronic diseases are not receiving any kind of treatment - 25% of people with hypertension and a third of those with diabetes were untreated, the study found.

Published in the journal International Health, the findings show that China has huge numbers of vulnerable people with high health needs who are missing out on basic preventive care and treatment, says the author of the study, Dr Dai Baozhen of the Department of Health Policy and Management at Jiangsu University.

Dr Dai says one of the main reasons for this sorry state of affairs is the lack of funding for preventive health in rural China. Most rural residents are covered by the New Cooperative Medical Insurance Scheme, which provides modest reimbursement for inpatient treatment for acute illness. However, the New Cooperative Medical Insurance Scheme does not cover much outpatient treatment and does not reimburse village clinics for preventive health checks such as measurement of blood pressure or diabetes checks. Even if it did, the scheme also fails to cover the basic 'disease management' approaches needed to curb chronic diseases.

What this means in practice is that many people in rural China have chronic diseases such as hypertension and diabetes that are easily detected and which can be prevented and treated by simple and widely-available therapies. However, most elderly people miss out on the basic preventive and disease management approaches and so their chronic diseases are allowed to progress unchecked until patients develop later stages of disease that are more debilitating and more difficult (and expensive) to treat.

But as Dr Dai points out, there is no point in offering health checks if there is no capacity to provide follow up with early treatment and preventive programs.

"Until now, the New Cooperative Medical Insurance Scheme has not been structured to provide payment for prevention, promotion services and disease management for chronic conditions, and no health intervention (e.g. health education and promotion) is provided for groups at high risk of developing chronic conditions," he writes.

Dr Dai concludes that with adequate funding, the New Cooperative Medical Insurance Scheme could provide early identification and management of chronic conditions and thus help prevent a huge burden of disease in some of China's most vulnerable and deprived people.

Tuesday, 5 August 2014

Shenzhen to pioneer clinical-focused medical training in place of faux-research and academic exams

by Michael Woodhead
Shenzhen is to lead the Chinese medical career pathway away from its traditional emphasis on exams and academic research into a system with more focus on clinical medicine. 
Experts say that medical training and career pathways in China have become dominated by academic achievement at the expense of dealing with patients. This has led to a system in which 'academic essay heroes' get ahead, while those with better clinical skills are overlooked and languish at the bottom end of the career ladder and in smaller hospitals. According to doctors in Shenzhen, the system based on research and academic study is suitable for a few doctors but should not be the backbone of the stem. It puts a huge and unnecessary burden on doctors and also leads to the system in which patients say it is impossible to get to see a good doctor. The academic focus means that doctors build up their titles and certificates, but their clinical skills remain weak from lack of attention.
Under the new system, doctors will be graded according to nine levels of clinical skill and on clinical outcomes and performance. This means that doctors with good clinical skills will be able to achieve career advancement and also increase their remuneration, an article in the Guangzhou Daily says.

Monday, 4 August 2014

Beijing's deregulation of doctors' working locations is a dud


by Michael Woodhead
In 2011, in an effort to improve workforce flexibility, Beijing pioneered a deregulation of medical employment rules so as to  allow doctors to work outside their traditional work unit. 

The move was intended to encourage a free flow of doctors and to encourage medical 'talents' to work outside the public hospital system and perhaps even set up their own private clinics. A kind of medical socialism with Chinese characteristics. However, an article in the Beijing Evening News has highlighted the fact that very few doctors have taken the plunge into private practice - or even left the security of their original hospitals to work at other clinics.

An article in the newspaper says the new flexible working rules were welcomed by doctors and received much positive comment on medical social media forums - but few if any doctors have actually changed their working patterns. Most are still working full time in major hospital clinical departments and doctors seem reluctant to break out from that pattern of work. In interviews, senior doctors say there simply isn't an alternative private framework for doctors to work in - and few doctors are willing to branch out on their own.

They cite several reasons: firstly, doctors are worried about the risks of working outside the established system, especially when it comes to liability and patient disputes. In the public hospital system they are covered by liability insurance and also have the backup and expertise of a major hospital to support them. They feel safe working with trusted colleagues and on familiar ground, and are wary of the quality of working in an unknown environment.

Secondly, doctors face financial barriers to working outside the system. Most are employed full time within the public system and would face a major hurdle in start-up costs to work outside the system - not to mention finding new sources of patients. They also face the major problem of restrictions on medical insurance, which would not cover their work in an unrecognised clinic or environment.

And thirdly, many doctors say that careers in medicine are based on the existing system - training, education, research, peer support, promotion and reputation are all based on working within the current hospital system. Doctors feel they would forsake career advancement if they moved outside the system.

The doctors interviewed by the Beijing Evening News said the deregulation of medical working rules had only legitimised what had already been happening in the current system - doctors moonlighting on weekends and 'after hours' at private clinics or at other hospitals outside Bejing.

The article concludes that much more extensive changes in remuneration, insurance and career paths will be needed beyond relaxing the rules, to encourage doctors to work more flexibly.

Police set up 'safe rooms' in 90% of Henan hospitals

Setting up police-supervised safe rooms  has helped curb three major problems in Henan hospitals: violent attacks against staff, organised gangs of scalpers and theft.

The 'independent police service rooms' have been set up primarily to provide a place where frustrated patients can have their grievances attended to without them posing a physical risk of assault to hospital staff. According to CNTV, the rooms are staffed by police with protective gear and the rooms are equipped with panic buttons and camera surveillance equipment in case things get out of hand when emotions run high between doctors and patients.

The police presence also helps to curb the presence of organised gangs of scalpers who lurk around hospitals, selling registration tickets that help those with money jump the queue and avoid waits of many hours to get in to see a doctor. These same gangs also use their 'muscle' to intimidate staff on behalf of aggrieved families in an attempt to extort compensation - from which they take their cut.

"We feel a lot safer now. It provides an open platform for us to communicate with the patients, and it helps us solve medical disputes. Also, there's been less theft,"  said a senior doctor at a hospital in Zhengzhou that had installed a police room.

After a series of high profile assaults and killings of medical staff in recent months, China has increased penalties for violent disputes against health workers. There have also been reports of riot police being brought into hospitals. However, doctors say the root causes of the problem have not been - an overloaded hospital system in which patients wait hours to see a doctor and then only get a few minutes before being over-prescribed medicines with high markups.

In brief: 7 medical stories from China to start the week

1. A Mao Zedong impersonator was the star of the show at a medical exhibition in Kunming, where the 'Chairman' was helping to promote pharmaceutical products.

2. Rates of preterm birth are as high as 10% in less developed areas of China such as Yunnan and are linked to poor pregnancy outcomes

3. Metoclopramide appears to be a promising candidate for the treatment of patients with intractable hiccups,  says neurologists from Harbin.

4. Many cases of avian H7N9 influenza may have slipped under the radar as the infection is often milder and unrecognised in children, according to respiratory specialists in Guangdong.

5. Increases in fine particulate matter pollution (PM2.5) in Beijing smog are linked to a 50% increase in mortality, a study has found.

6. A doctor was assaulted by police when he refused to sign a fake sickness certificate to allow the policeman time off work.

7. Only 17% of Chinese parents with HIV tell their children about their infection status, mostly because they fear the stigma (especially if they have been in a homosexual relationship).

Sunday, 3 August 2014

Hukou reform: what does it mean for health?

by Michael Woodhead  

The announcement by the Chinese government that it will relax some of the restrictions on the hukou (household registration permit) system will have major implications for the healthcare system.
Access to healthcare in Chinese cities is determined by hukou - if a family or person do not have an urban hukou they are not eligible for social services such as education and health insurance in that city - their hukou only entitles them to health services in the location where their hukou is registered. This means that the millions of migrant workers living in China's cities are denied access to healthcare.
   Actually, it's a bit more complicated than that - rural migrants may be able to attend hospitals, but have to pay full price as their rural-based insurance (if any) will not cover treatment at an urban hospital. With millions of rural migrants locked out of urban schools and hospitals, their demand for education and healthcare has meant that a whole host of 'underground' schools and clinics have sprung up in cities to serve them. As you might expect, the quality of these illegal clinics can be very poor.
   The announcement this week says that the hukou system for some cities will be relaxed to allow rural migrants to switch their hukou to a city. However, the new rules only apply to smaller cities of 1-3 million, not the bigger cities like Beijing, Shanghai and Guangzhou. And as has been pointed out, these changes will not take effect immediately, but will be gradually implemented to create an 'orderly' shift in urbanisation. Furthermore, cities that do not believe they can handle an influx of rural migrants will be entitled to maintain the status quo.
   In theory, the hukou changes will potentially give rural migrants access to urban health services - but this means that urban local governments will face greater demands on their services, and city hospitals will face greater demand. The question is where the extra funding and resources will come from to provide these additional healthcare services. Another cautionary note has come from rural migrants themselves - many have said they will not be willing to relinquish their rural registration because they believe this means they will lose entitlements to land and housing that they may one day want to return to.
   So, to sum up - the hukou changes could potentially fix one of the greatest gaps in Chinese healthcare - the lack of provision of services to the 200 million rural migrant families. The reality, however, is that any change will be a long time coming - and other changes (such as health insurance cover) will be needed too.

Saturday, 2 August 2014

Chinese doctors not happy at rating lists made by patients

by Michael Woodhead
Are you on the Medical Honour Roll or the Black List?
That's the question being asked by doctors in Guangzhou over the websites and social media forums that categorise doctors in the city according to a 'red list' (Honour Roll) or black list. The widely circulated lists ask members of the public to rate doctors according to these criteria:

Black List: 
Attitude: cold and aloof
Orders a lot of tests, prescribes a lot of drugs 
Recommends lots of nutritional supplements

Red List
Good demenour, attentive
Patient
Willing to explain
Not an overprescriber

The lists of doctors at 15 of the city's hospitals have been circulated widely on forums such as Weibo and Weixin, but health authorities claim that they are subjective and un-scientific, and will lead to increased tension and disputes between doctors and patients. They are calling on Guangzhou residents not to circulate or contribute such misleading unofficial lists. They have noted that there are many insulting and coarse comments about the doctors on the Black List, but the doctors named have no right to reply or to correct the statements made about them.

The Black and Red lists also allow users to add their own experiences. One women who claimed to be a patient at a maternity hospital said the named doctor did not even let her finish speaking before writing a prescription and asking to see the next patient. Another said the doctor barely listened to her, ordered 1000 yuan of tests and when she said she didn't have the money to pay for them, simply threw the forms in the bin.

A common refrain on the doctor rating forum sites is that it is impossible to find a sympathetic doctor who is easy to see without a long waiting time or guangxi.

However, the deputy director of one of the city hospitals told reporters that these assessments of a doctor's capability were subjective, unverified and often taken out of context. He said the Red List and Black List did not reflect the clinical skills and experience of the doctors named on the lists. All senior doctors working at the city hospitals had to study for many years, pass many exams and were also evaluated by their peers before gaining promotion, he said. Doctors who were incompetent or who practised bad medicine were not tolerated within the public hospitals system, he said.

The hospital director said patients often got a false impression of doctors because their encounters were superficial and they often had to wait for a long time to see them, hence they had a sense of grievance. The comments did not reflect the pressure under which doctors work he said. Also, many of the comments were about the 'service attitude' of the doctors, which did not reflect their medical skills, he said. He compared the 'doctor rating' sites to theatre reviewers - two people can see the same performance and one will hate it while another thinks it is good.

Another deputy director at a vascular hospitals said the lists were meaningless and some even had the same doctors on both red and black lists. Individual opinions varied, he said, and he used the saying "one man's meat is another man's poison" to show that some patients would find a doctor to be 'good' while others would find them to be 'bad'.

Health authorities recommended that consumers use the "Third Party" healthcare service  evaluation site. This invites feedback for healthcare consumers, but the information is checked and verified by independent professional before being added to the website. The Third Party site also follows up claims of problems such as overcharging and overservicing and will contact the patient and the service provider to provide feedback and improve the service, the health authorities said.