Monday, 30 March 2015

Putian: from Fujian VD doctors to private healthcare millionaires and Baidu bashers

by Michael Woodhead
The news that an alliance of private healthcare providers have boycotted Baidu over advertising charges this week requires a bit of background.

The basic story is that the Putian chain of 8600 private hospitals has accused China's number one search engine, Baidu, of hiking the costs for  its paid search 'adwords'. Like Google, Baidu auctions off its keywords to the highest bidder. In the US, Google can charge up to $50 per click through for the most lucrative keywords such as 'insurance' 'loan' and 'attorney ('Better call Saul'?). Advertisers are willing to pay these huge fees because of the high returns they get from having these keyword link straight from the search engine to their site. Likewise in China, Baidu operates a "Pay Per Click" (PPC) advertising sales operation. However, it turns out that in China about 60% of the paid search is for healthcare businesses. This means that words and phrases like 'gynecology' and 'cosmetic surgery' attract sky high adword rates on Baidu. According to one article the cost is as much as Y600 per click.

Resentful at having to pay such high fees for search words, the final straw for healthcare companies came when Baidu announced recently that it would be jacking up its prices by 40% (allegedly).
According to Caixin magazine, this price increase prompted the Putian Health Industry Chamber of Commerce to put out an instruction to all its affiliated 8,600 private hospitals across China to halt all paid promotional activities online. It went further, vowing to stop all cooperation with Baidu and close down all the Putian hospitals accounts with Baidu. Putian said that the advertising price increases meant that "many medical facilities have been reduced to almost working for Internet companies."

However, it's worth noting that Putian is only a loose association of healthcare providers and they are bound by clan ties more than business contracts, for whatever that is worth.The chamber of commerce called for 'unity', making them sound more like a trade union (or cartel).

It's worth pausing here and explaining who and what Putian is/are. The Fujian town has become a byword for private hospitals in the same way that Maotai is associated with hard liquor and Jingdezhen is for crockery. According to this article, the town has spawned (pardon the pun) a nationwide network of healthcare entrepreneurs based on local expertise in private VD clinics. The story goes that a former barefoot doctor called Chen Deliang became successful in the 1980s by selling treatments for ailments that the hospital system wasn't interested in - firstly scabies, then later venereal diseases. Other Putian businessmen followed his lead and they have spread out across China starting up clinics and hospitals that cherry-pick the lucrative but low risk medical treatments - fertility treatment, plastic surgery and dental care are said to be favourites.

Putian people are now said to control up to 80% of China's private healthcare clinics. Most of these attract business via online advertising, hence the Baidu connection. Putian people are also said to be extremely shrewd in business, and thus it is not surprising that when Baidu announced they would be putting up the cost of paid search words to as high as Y999, the Putian entrepreneurs spat the dummy.

The result is a standoff between two giants - Baidu the internet search behemoth and Putian, the biggest network of healthcare providers and thus some of Baidu's most important advertisers. Some say that Putian affiliated clinics account for half of Baidu's 26 billion yuan annual advertising revenue (I find that hard to believe - other estimates put it at a more realistic 6-10%, still, not to be sniffed at).

Baidu, however, is saying that the Putian complaints are not about price increases but about the increasingly strict enforcement of advertising rules about dodgy medical advertising. The Xi Jinping government has been making a lot of noises about cleaning up  unethical advertising and promotions - much of which is related to quack health cures and shonky clinics.

According to Caixin, the search engine Baidu is now seeking to distance itself from the disreputable end of the healthcare sector and align itself with more reputable medical providers. In a way it echoes Google's recent moves to tidy up its medical/health search functions and give more ranking to evidence-based treatments. Only in China this comes with a price - Baidu's share price has taken a hit - and Putian's reach to healthcare consumers has been curtailed.

My take on this? Given that the Chinese government is seeking to increase the influx of social capital (aka private investment) in healthcare to about 20% of all hospitals, they must be daft to estrange Putian. Why not find a way of working with them instead?

Sunday, 29 March 2015

Academic fraud in China: 43 medical studies retracted

by Michael Woodhead
Medical research fraud in China - the latest development is the discovery of widespread fake peer review. The open access publisher BioMedCentral has this week announced the retraction of 43 medical journal publications by Chinese researchers after it discovered widespread peer review fraud. Most of the articles were submitted by medical researchers at universities in China, including China Medical University, Sichuan University, Shandong University and Jiaotong University Medical School. A full list is given here.
Here's how fake peer review works: When a scientific paper is submitted for publication to an academic journal, the journal invites authors to suggest potential reviewers for their papers. The authors or their agents can then provide bogus names with e-mail addresses that go directly to them. They fill in their own peer review form, and bingo - satisfy the publisher's requirements, without actually having the article checked by an independent reviewer.  There's a full article on the topic in Nature.

According to Ivan Oransky's Retraction Watch, the BioMedCentral senior editor of scientific integrity Elizabeth Moylan said some of the fake peer reviews "appear to have been conducted by third-party agencies offering language-editing and submission assistance to authors. It is unclear whether the authors of the manuscripts involved were aware that the agencies were proposing fabricated reviewers on their behalf or whether authors proposed fabricated names directly themselves."

On BioMedCentral's blog, she wrote that "During the course of our investigation, authors have shared with us the names of third-party agencies that offer support to authors but also guarantee favourable peer review outcomes in return for a fee. Other services sell authorship on entire papers written by others. Clearly, there is a need to distinguish the characteristics of reputable third-party agencies from those that are dishonest (in much the same way that bona fide open access publishers can be distinguished from those that are predatory)."

To try combat the fake peer review scams, the publishers have deactivated the automatic "suggest peer reviewer" box in the submission forms. Authors will now have to suggest peer reviewers in their covering letter, and provide verifiable email addresses for their institutions. Other journal editors say this is too lenient, and that authors should not be allowed to suggest peer reviewers at all.

The publishers are at pains to suggest this is not just a China problem. Other incidents of fake peer review have been reported recently from other countries, including South Korea and Taiwan (the latter even resulted in the resignation of a government minister whose name had been cited as a co-author on several of the fraudulent publications).

As the BMC publishers point out, peer review is based on trust, and there is only so much that can be done to prevent deliberate fraud. One of the key factors driving the fake peer review in China is the need for Chinese doctors to publish a quota of papers each year in order to retain their posts and qualify for promotion. It is literally publish or perish, career-wise. I've previously blogged about China's  publish-for-promotion system for doctors and the scams it encourages, including the use of agencies and ghostwriters to generate scientific papers. This latest development seems to suggest that there are now ghost reviewers too.

Tuesday, 24 March 2015

Psychiatry in China: ask a few questions, give a lot of pills

by Michael Woodhead

The neglected state of psychiatry in China is highlighted in an article published by Xinhua this week. In essence the article says that psychiatrists are overworked, underpaid and undertrained - and thus seldom have the time or inclination to provide any kind of talk therapy to patients with mental health or psychological problems. Just drugs.

According to the article, the typical psychiatric consultation involves filling in a form that consists of a few questions such as "Do you have trouble sleeping at night?" and "Do you think life has little meaning?" After reviewing the answers to the form, the doctor then hands over a bag of pills - or a prescription  - with little dialogue or questioning between doctor and patient. According to one young woman who sought help for nightmares and severe stress, the process made her think of the doctor as more of a pharmacy clerk than a psychiatrist.

The article then compares the cost of seeing a psychiatrist at a public hospital - about 50 yuan for 10-20 minutes, with the 1000 yuan fee for a similar consultation with a 'counsellor' in a private clinic. One psychiatrist said that psychiatry was a low priority for most hospitals because unlike 'procedural' branches of medicine there was very little profit to be made from seeing patients. He said some irresponsible doctors tried to increase their income by seeing as many as 30 patients in one morning and providing many kinds of expensive psychotropic drug  - all encouraged by pharmaceutical companies as part of the biomedical model of psychiatry. However, many patients said they wanted more time to talk with a doctor and discuss their problems in more depth. To do this, a doctor could not see more than 10 patients in one shift - but this is just not viable for public hospital psychiatric clinics.

Another psychiatrist told Xinhua that China had a mental illness rate of about 17% - which meant there would be 173 million people requiring psychiatric treatment. However, China has only about 10,000 qualified psychiatrists, which is far too few to manage this number of patients. The shortage of psychiatrists is especially bad in rural areas.

Experts said that typically a psychiatric patient might need at least four sessions of psychological treatment lasting one hour each. However this was not possible when hospitals could only charge 30-50 yuan per doctor visit. Therefore, some patients turn to private clinics which charge 500-1000 yuan for a single consultation, even though some of these are run by unqualified practitioners and offer unscientific therapies.

Patients often required non-drug therapies such as psychotherapy or even physical therapy, but these were not profitable for state-owned hospitals, the expert said. According to analysts, psychiatric clinics in China are underfunded and there are far too few psychiatrists and psychologists. The answer, they say, is to encourage the investment with 'social capital' (ie private business and corporations) and also to increase the awarenes of mental health problems and their treatment in China

Sunday, 22 March 2015

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.

And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

Sunday, 15 March 2015

When it comes to health, for China the numbers are staggering

by Michael Woodhead
In western countries hardly a week goes by without some disease condition being put in the spotlight in a press release saying "Condition X affects Y million people a year and costs Z million dollars". 
If industry has a stake in the matter then this is usually followed by a statement saying that the Condition X is underdiagnosed and undertreated and if only we used Drug A or Test B then we would avoid prevent much suffering and save the health budget in the the long run.
This sort of thing is now happening with health conditions in China, except the numbers are bigger by a factor of ten or even a hundred. Take osteoporosis, for example. An analysis published this week shows that there are about 2.3 million osteoporotic fractures a year in China, costing $10 billion in health costs. And if you think that's bad, wait until you see their projection for 2050 - the researchers estimate that with the ageing population there will be 6 million fractures a year costing $25 billion. And as predicted, the report's authors say that "screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget."

A similar dire warning was made this week for hypertension and diabetes in China. An article in the Journal of the American College of Cardiology said that China was facing a cardiovascular disease epidemic as three out of four Chinese people are in poor cardiovascular shape due unhealthy eating, smoking and obesity. On a similar note, a study from Shenyang showed that 50% of older adults had hypertension and poor cholesterol levels. And a report in The Lancet this week shows that China has 300 million smokers and that tobacco causes 1 million premature deaths a year. The numbers are so big they are incomprehensible. And yet at least the Lancet offers a workable solution: cigarette taxes. It says that if cigarette taxes were raised by 50% this would result in 231 million years of life gained over 50 years and also produce an additional US$703 billion in extra tax revenues from the excise tax. The overall effect would be to relieve financial burden on the poor by avoiding diseases such as lung cancer and the consequent medical bills and time off work. But does Xi Jinping have the gumption to increase cigarette taxes?

For yet another set of mind boggling numbers turn to the example of cervical cancer. With no Pap test screening program, tens of thousands of Chinese women develop this disease and die of it each year, even though it is preventable. Western countries have long had screening programs and are now tackling cervical cancer with the HPV vaccine for young women. Some health economists have crunched the numbers for China and estimated that a national vaccination program of HPV vaccine for 9-15 year old girls, between 2006 and 2012 would have prevented 381,000 cervical cancer cases and 212,000 related deaths. They say that a HPV vaccination program could be implemented in China at a cost of about $50 per girl for the whole set of vaccinations and program costs. In total this would cost China about $160 million, but would ultimately prevent hundreds of thousands of deaths from cervical cancer - and also be cost effective.

A final example: stomach cancer. This causes  hundreds of thousands of deaths in China every year. And yet researchers have found that regular use of low dose aspirin could reduce the risk of stomach cancer (and other common cancers such as colorectal cancer) by as much as 40%. In other words, if Chinese people took a regular dose of aspirin they could avoid many fatal cancers, not to mention the protective cardiovascular benefits against stroke and heart attack. Whether these would be outweihed by increased bleeding risk remains to be seen.

I think what I am trying to say here is that when it comes to ill health in China, the numbers are often too large to be imagined. But that also means that measures that produce only modest reductions in rates of disease can also have major impacts on the absolute numbers of illness.

And while talking of high rates, let's return to my favourite bugbear about healthcare in China - the infusion. I have been guilty in the past of blaming backward thinking among the Chinese masses for insisting on having an infusion for every ailment. I hope I haven't hurt the feelings of the Chinese people and perhaps I owe them an apology. A study from a bog standard Hubei hospital shows that a staggering 96% of antibiotics used in the hospital wee given parenterally (ie by injection or infusion rather than orally). The authors of the report contrast this with the rates of about 30% of IV antibiotic use seen in European hospitals.

However, they blame the profit motive among hospital managers for the widespread use of antibiotic infusions - noting that hospitals depend on drug sales for a major part of their income. Therefore it will be interesting to see what happens when the Chinese government tries to eliminate this source of income for hospital by introducing cost price pharmaceutical billing this year (ie not charging a markup).  How will hospitals  fund their services? The government only covers about 20% of their running costs. There are already predictions that costs will be shifted to medical procedures - and trigger even more overservicing.

At least there is some discussion taking place of these kinds of problems and some in the government are acknowledging that there is still a long way to go in health reform. This week a very frank and bleak account of the ills of rural Chinese health system was published. Doctors and hospital managers said quite bluntly that the rural healthcare system in China is being hollowed out - older doctors are retiring, and nobody is taking their place. Young doctors do not want to work in rural hospitals, partly because the ban on commissions from pharmaceuticals means they can make only a tiny income. And patients do not want to be treated in them. And so the county and township hospitals are becoming ghost hospitals - deserted compared to the overcrowded city hospitals, where rural Chinese flock when they have a serious health problem.

Fact of the week: Chinese primary care (community health centre) doctors earn only 3000-4000 yuan a month. Primary care doctors account for only 4% of doctors in China.

Sunday, 8 March 2015

CPPCC - what they're saying about health

It's that time of the year again - the Chinese People’s Political Consultative Conference (CPPCC). The toothless talking shop cum fancy dress parade as deputies from around China meet to chinwag and talk up the government's policies. It's an occasionally interesting forum - some grievances are allowed to be aired, but usually only to justify measures that are already being taken.
There has been quite a bit of talk about healthcare this year. Most of the problems discussed are ones that have been given a regular airing on this blog: doctors' income linked to overservicing, excessive workload of doctors and the issue of publish for promotion. On the last point, Prime minister Li Keqiang attended one meeting that heard about the problem of junior doctors having to publish academic papers in order to qualify for promotion. He was told that more than a quarter of doctors had their articles written for them by ghostwriters and agencies. The PM said this was a bad situation and doctor's should be rated on their practical skills, not writing skills.

Our old friend Professor Zhong Nanshan made an appearance at one People's Conference, at which he re-stated his concerns about doctors' pay being linked to sales of drugs and number of procedures and devices provided. He cited the case of one cardiologist who implanted several expensive cardiac stents for a patients who was not even seriously ill. Zhong Nanshan said the problem of doctors' ethic arose because up to 80% of their income was tied to hospital profits. This meant doctors were given quotas to meet and the 'profit-driven' mentality meant that hospitals were more like department stores than public health facilities, he said. Zhong Nanshan said that to end the problem of overservicing there was a need to de-link doctors' incomes from prescribing and servicing levels. Doctors should be paid a higher basic salary that reflected their worth, he said - and he stressed this did not mean a return to the 'iron rice bowl' mentality.

The problems caused by pharmaceutical commission were highlighted this week by the news that GSK is to sack 110 of its employees in China in the wake of last year's massive bribery scandal that resulted in the company being fined  $450 million. The widespread use of bribes, commissions and backhanders caused a lot of pain for the multinational pharma company when exposed. The staff who have lost their jobs may well be scapegoats. The man at the top, CEO Andrew Whitty, kept his job but had his salary package halved to a measly $6 million. Whitty said  “substantial changes” had been made at GSK China, including training for managers in anti-bribery and corruption practices.

Other 'unhealthy tendencies' raised at the CPPCC include the hospital VIP suites reserved for officials and local bigwigs. Professor Huang Zemin of East China Normal University said hospitals had two different worlds, with the VIP outpatient wards reserved for officials being quiet and luxurious whereas the outpatient room for the general public was crowded and noisy. A fair point, but the VIP suites have already been slated for abolition, so he's hardly breaking new ground there.

And also from the CPPCC, a cry for help from the paediatricians.  One of the country's top paediatricians, Professor Shu Xiaomei, told the CPPCC that there was a crisis in paediatrics as very few doctors go into this branch of medicine in China. The reasons are that paediatricians earn very little compared to other doctors, again because they don't prescribe so many drugs or do many procedures). Another reason for the unpopularity of paediatrics is the high workload and the huge pressure from pushy parents - often leading to violence when things go wrong. Professor Shu said there was also no formal training program for paediatrics, unlike other specialties and therefore the speciality was a 'tree without roots'.

The workforce theme was raised by another delegate at the CPPCC, who said that China simply does not have enough qualified doctors to do everything that the public expected of them. His succinct appraisal was that "without more doctors, all discussion about health reforms is empty talk. "
Other CPPCC delegates said that the push to create a primary care system based around community clinics was commendable but facing the major problem of neither doctors nor patients wanting to go anywhere near primary health clinics. Dr Zhao Ping, of the Chinese Academy of Medical Sciences, said patients did not go to local clinics because they had poor equipment and poorly trained staff and could not refer to the best specialists.
"People don't trust these clinics and hospitals. The thing is, people want to go to better and larger hospitals, and so do healthcare workers. We don't have a mechanism in-place to keep our best healthcare workers at community clinics," he said.

But it's not just the CPPCC, here are some other major medical news stories from China this week:

  • Two doctors in their 20s have died suddenly of 'overwork' in the last few weeks, prompting some doctors to say that the pressure of work is too high.

Sunday, 1 March 2015

A violent week for attacks on medical staff in China: My weekly blog of medical news from China

by Michael Woodhead
Who would be a doctor in China? There's something about Chinese New Year that makes people a bit more bonkers than the rest of the year. Maybe it's the social pressure, the expectation - who knows. But this week has seen an unprecedented number of attacks on medical staff in China. First there was the "hostage siege" at a Henan hospital at which doctors were bailed up by patients and forced to drink urine. The incident occurred after doctors failed to save the life of a drunk man who had killed himself by drinking insecticide. The man's relatives became angry when he died and accused emergency department staff of not doing enough to save him. The staff said they did all they could but he was already beyond help when brought in. The family became enraged and summoned more people to blockade the hospital entrance. They then barricaded the doctors in their office and tried to force them to drink urine. The situation was only defused when riot police arrived.
Sometimes violence is more random. At a Jiangsu hospital a cardiologist was attacked suddenly by the son of an 82-year old woman who died. The man became angry when requesting a death certificate, grabbed the doctor's stethoscope and used it to hit the doctor on the head, causing a major wound that bled. Police are investigating.
And in another similar incident in Hubei, a young female doctor had her skull fractured (see picture) when she was attacked by relatives of a women who died of a heart attack. Witnesses say the female doctor had been trying to resuscitate the women but was unsuccessful. She had not even taken her gloves off when she was attacked by a male relative of the dead women who hit her so hard it fractured her skull around the eye.
And finally in Hangzhou a female psychiatrist was stabbed by a 16 year old patient at the city's Jingdu hospital. The doctor is in a stable condition, and there is no stated reason for the attack.
And even if the patients don't physically attack you, thy may take to the courts instead. This week there was a report of a female obstetrician who is facing a three year jail sentence for manslaughter after being prosecuted over the death of a baby during childbirth. However, colleagues of the doctor say she is being made a scapegoat and there should be no criminal case made against doctors in medical situations such as this.

In other news head lines ...

Chinese doctors don't read English medical journals
A survey of 910 doctors in from teaching hospitals found that two thirds only read medical journals in Chinese. Only 44% were aware of major English-language journals in their speciality and  17% said they had never read a single English paper or textbook in English.

Hospitals banned from buying expensive drugs for commission
In an attempt to cut down on pharmaceutical corruption and bribery, China's hospitals  have been told they must buy their drugs only from approved pharma companies and wholesalers. The move is intended to cut out the system of commissions and kickbacks that currently exists, and which encourages hospitals to buy and use more expensive drugs.

Hangzhou eliminates hepatitis B with vaccination
Health authorities in Hangzhou have achieved dramatic reductions in hepatitis B thanks to a long term vaccination campaign. In a comparison with 1990 a recent survey found that the hepatitis B incidence and mortality of Hangzhou had declined dramatically since the introduction of universal childhood vaccination against the infection.

Alarm over resistant tuberculosis
Rates of drug resistant tuberculosis are "alarmingly high" according to researchers from Beijing. A study by the China CDC of Mycobacterium tuberculosis strains from children and teens between  2005 and 2012 found that  levels of drug resistance and multi-drug resistance (MDR) rates were 55% and 22%  respectively. In children with multi-drug resistance, new cases accounted for 41.