"Three Lows and One Missing" - Is China on target to deploy 700,000 general practitioners? (short answer: no)

by MICHAEL WOODHEAD

Being a medical journalist in Australia, I've come across a few academics and leaders of medical groups who have marvelled at China's stated aim to deploy an additional half a million general practitioners by 2020. In a country where there are 25,000 general practitioners, the numbers are mind boggling and the ambitious target seems laudable. When I say that this may be an unrealistic goal given the current paltry state of primary/community care in China, I am viewed as a something of an overly-negative cynic or even vaguely racist.

It's therefore reassuring to see that my expectations are in line with those of the president of the China Medical Doctor Association, Dr Zhang Yanling. This month the CMDA chief was one of several big potatoes who showed up at the "2016 GP Training Forum and 13th Community Health and General Practice Annual Conference" held in Beijing on 23 April

The main speaker at the meeting was National Health and Family Planning Commission (NHFPC) Deputy Director Liu Qian, who said that creating a primary care system was one of the key aims of China's healthcare reforms. He said the creation of a primary care workforce was seen as an important step by top leaders such as Xi Jinping and Li Keqiang, who sent a message to the conference to make serious efforts to implement the policy.

Director Liu made the usual top bureaucrat exhortations to strengthen/promote/deepen reform of the medical education system to make this so. However, even he was realistic enough to admit that of the current 120,000 medical trainees only 13,000 (about 10%) were training as general practitioners and some of them may be hospital based rather than in community clinics).

He also acknowledged that China's entrenched doctor system was geared towards hospital-based specialists and that there was only weak support for general practitioners. There is no culture of primary care in China and this is reflected in the lack of training opportunities, low social status of community doctors "and the trust of the masses of trust is not high". Unsurprisingly, therefore, being a general practitioner is not a very attractive career option for any would-be doctor.

Director Liu then went on to make more of the usual remarks about strengthening the education system to train more general practitioners and making more efforts in this direction  etc etc

He was followed by Dr Zhang Yanling of the CMDA , who expanded on what the director said by coining the phrase the "Three Lows and One Missing". General practitioners suffer from "Low Pay, Low Motivation, Low Social Status and Missing Education" said Dr Zhang.

He said that in words, China's authorities had expressed strong support for the WHO-expounded principle of primary care and having general practitioners as gatekeepers to the hospital healthcare system. However in practice, general practice was weak, underdeveloped and had only patchy distribution across the country, he noted. While there are some general practitioners in bigger cities and in some regional hospitals, the biggest gap for primary care was in township and smaller county hospitals which were often both understaffed and underused. Dr Zhang used the Chinese saying "Swallows sitting in the doorway" to express the deserted state of China's township hospitals - because patients do not trust the doctors and take their illnesses straight to the bigger hospital "centres of expertise".

Dr Zhang said three things are needed to build a primary care system in China:

1. A commitment to build a large and sustainable primary care workforce based on teams of well trained general practitioners who are well remunerated and have a graded career pathway, similar to hospital doctors, rather than being in a dead end job.

2. A robust training system that ensures the primary care workforce is motivated and highly skilled - including the retraining and upskilling of allied health practitioners and physician assistants to make a primary acre team. Dr Zhang said the current projections were that China should have 1 GP for every 2000 citizens, which would require 700,000 primary care practitioners by 2020. However, based on current training capacity of 172,000 doctors and doctor assistants, there would still be a shortfall of 400-500,000 general practitioners by 2020.

3. Training pathways including residencies will need a partnership between government departments of health and education along with medical professional groups such as the CMDA. Working together they will need to establish a GP training group with well qualified educators that can set standards, plan training place numbers and oversee assessment and accreditation.

Dr Zhang concludes that a general practitioner primary care system is possible so long as there is good policy, clear commitment from government and cooperation from government departments, industry, the profession and good guidance from academics.

The two day conference also heard from a host of academics and experts in primary care from China, Hong Kong and and foreign countries such as Canada and Australia.

We wait in hope to see if the fine words of the conference delegates are actually matched with government funding and backed by policy that is actually implemented.

Heathcare privatisation: China adopts the US model

by MICHAEL WOODHEAD

Prepare for the Mayo Clinic with Chinese Characteristics. This year China is taking the first steps towards creating the equivalent of US group medical practices such as Permanente and the Cleveland Clinic.

The so-called "Doctor Groups" (Yisheng Jituan, 医生集团) are springing up around the country -  mostly in major cities of the affluent Eastern provinces. They are being set up in response to the loosening of the government's rules on how and where doctors can operate - clinicians are no longer tied to the tertiary hospitals and are now being encouraged to be 'fluid' and 'open'. In response, at least fifteen doctor groups have been set up in 2015 and 2016, usually based around one location and with one specialty.

These are not socialist collectives nor are they not-for-profit groups. Instead they are privately financed businesses that are being set up with large investments from major industrial players such as pharmaceutical companies. These are groups that are seeking profits and market share as a return for their investment. Not sure how PRC's Marxist theorists will explain this away.

A typical example is the Yibai Pharmaceutical Anhui Oncology Group. This covers ten leading cancer specialists and their staff, as well as specialist treatment facilities in the Anhui and Shanghai area - services that include diagnostic imaging, radiotherapy, microsurgery and chemotherapy. The pharmaceutical backer has invested hundreds of millions of dollars already and is hoping to use its industry experience and connections to package other services such as pharmacy, supply chain and IT services. According to an investment analyst, the Yibai group is hoping to make 500 million RMB profits within two years.

Yibai is just one example: others include the Medical Imaging Group - an alliance of imaging facilities covering 27 hospitals including the Beijing Union Medical College Hospital, and Beijing PLA General Hospital.

Another doctor group is United Lige, which has a looser structure covering many cities and provinces including Beijing, Tianjin, Shanghai, Chongqing, Jiangsu and Zhejiang. It aims to bring smaller groups of doctors together in private clinics under the Lige banner.

Others Doctor Groups include

• Sanjia (Mobile phone referral, liaison etc services)
• Mingyi Hui (a multi-speciaity consortium that aims to offer family care from children to the elderly, with an online/telehealth emphasis)
• Song Dong Lei Neurosurgery Group (Shanghai)
• Pumai Doctors Group (collaboration with Chow Tai Fook to set up polyclinics in Shanghai)
• Yongchun Male PLastic Surgery Group ( Shanghai Woxin Hospital)
• Fenlan/Huaxia Pathology Group (Set up with more than 120 pathologists in conjunction with the China Medical Association Pathology Society, this group has received 30 million investment and will provide specialist pathology services via a network of 60 hospitals).
• Famous Doctor Fertility Group (Shenzhen based, set up by veteran Obstetrics and Gynaecology specialist Gong Xiaoming)

Most of the private doctor groups are financed by domestic companies, many with little healthcare experience. But rather than doing joint ventures with western healthcare companies to get foreign know-how, Chinese newcomers to private healthcare are simply buying up foreign healthcare providers. The Luye Medical Group recently bought the Australian private hospital consortium Healthe Care for $938 million. Luye's Charles Wang says the new doctor groups aiming to do business outside the big hospital environment lack operational expertise, and they are hoping to transfer such skills from the Australian outfit to the Chinese market.

This is what he told the Australian Financial Review:

"When things change in China, they tend to happen very fast. Doctors and practitioners forming their own doctor groups is something that never would have happened until last year. They are now leaving the public sector and forming their own groups, and once that gains momentum, you will see it rapidly become more westernised."

According to the AFR, the idea is not to parachute Australian executives into China, but to export the way Australians manage their hospitals, including finances, procurement, risk and clinical control.

"I expect you'll see, in time, structured medical programs, and we'll go up to China and do training and bring middle managers down here in Australia. In clinical areas there will be doctor mentoring and nursing programs,"  says Healthe Care's CEO Steve Atkins.

My own view is that it will take a lot to break up the power of the big hospitals. There are a lot of vested interests involved. The move to private doctor groups also raises the question of what impact this will have on the capacity of the existing public hospital system. If the most talented doctors can work outside the system, who will replace them? If top surgeons take two-three days a week doing private work, who will fill their positions in the public hospitals for clinical work and training?

There are many unknowns, but with official backing from the health minister and the Premier, expect to hear a lot more about Doctor Groups from 2016 onwards.

Why Beijing's war on hospital ticket scalpers is doomed to fail: top cardiologist says jail sentences won't fix supply & demand problem

by MICHAEL WOODHEAD
This week a Beijing court sentenced 15 hospital ticket scalpers to prison sentences varying from 19 months to two years in jail. It's all part of a very public crackdown on the practice of 'entrepreneurs' buying up the hospital clinic reservation numbers (guahao, 挂号) that are needed to gain access to see a doctor. Typically, these hospital tickets cost 20 yuan at the front desk but are bought up and sold for ten or more times their face value by scalpers (piao fanzi, 票贩子) who operate in gangs around the foyers of public hospitals.

In theory, China's hospital clinics operate on a first come, first served basis. Whoever is prepared to queue up early at the hospital ticket window in the morning gets the tickets. In practice, the scalper gangs either send their agents to stand in line and book an appointment - or they have inside connections with hospital staff to procure the tickets through the back door. The corrupt practice has been going on for years, but made headlines in January when a video emerged showing a young rural migrant woman ranting about the scalpers at a Beijing obstetrics hospital. The video went viral on China's social media channels and there was soon public pressure for 'something to be done'.



As in the past, the hospitals and the Beijing health department announced yet another "get tough" campaign on scalpers. They sent in the PSB to round up the usual suspects. They also issued a series of "Five Musts" measures that included real name registration procedures and an end to collusion between hospital staff and scalpers. And as usual, an example has been made of a few offenders in the media. The Party has listened to the masses and taken action. Never mind that the 15 offenders sent to jail weren't actually scalpers, but fraudsters. They had hired hospital rooms in which they used bogus doctors to swindle unsuspecting out-of-towners into jumping the queue and paying for dodgy TCM treatments.

But even if the authorities had enacted a serious and enduring action against hospital ticket scalpers, it still would not make any difference, according to one leading cardiologist.

Professor Yang Qing, has worked at the cardiology department at the Sichuan University Huaxi Hospital for 20 years. He says the problem is not due to the scalpers, who are only the symptoms of a monopolistic system. Professor Yang says it is important also not to blame doctors, who are also constrained by the system.

According to Professor Yang, every day his hospital cardiology clinic in Chengdu is besieged by patients from far and wide, seeking a consultation. Patients come not only from Chengdu, but also from across the province and even from overseas. A typical clinic has 20 allocated slots to see patients with an average consult duration of 6 minutes - but most will actually fit in 30 patients by running over time. Every day at the front desk he is mobbed by people saying: "Professor Yang can you add an extra place for me?" Some are very deserving patients who have traveled a long distance to see him - even renting rooms near the hospital. Others are former patients who want continuity of care and to be followed up by the same treating doctor. And there are also 'insiders' - acquaintances, connections and people who work in the hospital who seek an appointment with him.

Professor Yang says the demand for 'tickets' is inexhaustible and he only has a finite amount of time in a working day. On a typical day he works right through an after noon clinic without a break even to go to the bathroom. He is supposed to finish at 5pm, but usually does not actually finish until at least 6pm. If there is a chance he will add a few extra places, but he says he feels bad for not being able to accept all the requests. And his colleagues all feel the same way. They are not heartless, but they have other responsibilities and things to do - not to mention family life. Professor Yang says that in addition to attending to patients in the outpatient clinic he must also do surgery, supervise junior staff, take part in research and write reports. He must attend medical conferences and teach students.

Professor Yang says that the demand for hospital tickets is high, but the price is low and does not reflect the 'economic value' of the doctors' skill and experience. The scalpers are simply selling the doctor's appointment at a price the market is prepared to pay, he says. And the 'profit' is going to criminal gangs instead of to the hospitals.

Professor Yang says that what the scalpers do is an unsatisfactory and unfair situation, but he believes it is inevitable under a monopoly system. It would be unrealistic to expect them to be stamped out - and even if all the ticket scalpers were removed there would still be an imbalance between supply and demand of medical appointments, he says.

"When a resource is scarce, and when everyone wants to have this resource, the authorities' fight against ticket brokers is meaningless," he says.


Professor Yang says that in theory a system that guarantees low prices is good because it makes treatment affordable for everyone. However, in practice he says low prices enforced within a monopoly lead to low quality care and also to the 'detestable' practice of scalping.
 
Professor Yang's solution is a free market one - free up the doctors to set their own prices and let them manage their own patients. In this way, there will be competition between doctors that will keep prices low and affordable while raising levels of service and quality, he believes.

[Editor's note: Given that they have been given prominent place in the state media, Professor Yang's pro-market comments are presumably endorsed by the government and China's minister for health. It's notable that the learned professor suggests a new model based on the US free market healthcare system, and makes no mention of other more successful models such as the gatekeeper' system of Britain's NHS. 

The kind of problems that Professor Yang describes do not occur in the UK  because that country (like many others) has an efficient primary care gatekeeper system that ensure that patients do not go straight to hospital. To see a hospital specialist, patients in countries such as the UK and Australia must first go to see a community-based general practitioner, who decides if and where they should be referred. This means that patients with minor illness and chronic disease can be managed in the community' rather than clogging up the overloaded hospital system. It also means that patients are sent to the most appropriate specialist. 

Of course the system isn't perfect because financial restraints mean that public hospital patients often have to wait months for an appointment to see the doctor. In countries such as Australia, patients can jump this queue if they have private health insurance (but they still need a GP referral) But if any patient needs urgent care, they can receive it. 

Interestingly, China is pursuing both these options. It is loosening the monopoly of public (actually state-owned for-profit monopoly) hospitals. China is also moving towards a community/family doctor system. However the progress is glacial because of the entrenched financial interests of local governments [and managers] in their local hospital monopoly. So is the solution to hospital scalpers a crackdown, free-market healthcare or a gatekeeper system? You decide ...]

Freelance "Doctor Groups" - the first sign of workforce reforms in China

by MICHAEL WOODHEAD

The creation of some 30 independent "physician groups" (Yisheng Shoutuan, 医生集团) is the first sign of the Chinese government's 2015 relaxation of working regulations for the hospital system. The rules have been relaxed to allow "workforce fluidity" - in other words to allow doctors to work where they wish rather than being bound to a single hospital ( a legacy of the old danwei work unit system).
 he Chinese Nationa Health and Family Planning Commission (NHFPC) wishes to create a more flexible workforce and to allow doctors to work in a more more market-oriented system, supposedly to free up medical talent and overcome the current mismatch in supply and demand for medical services.

It is still early days for these doctor groups, which face problems such as how to engage with hospitals, how ensure high quality medical standards and how to take on medicolegal risk (and insurance). These are things that are usually the responsibility of hospitals and something that doctors have not had to worry about in the past.

To try tackle these issue the Beijing Henghe Hospital has set up a "doctor group collaboration model platform" to try work with doctors towards new ways of working. The group has already started to look towards the US for business and working models for doctors. Initial discussions have revealed that 55% of hospitals have doctors doing some form of 'moonlighting' - and therefore the doctor groups may formalise this working model.

Another survey found that many talented young doctors were leaving the hospital system because of the long hours, high pressure and low pay. A new freelance model may help retain the skills of these doctors, the collaboration discussion group said.

However, other doctors have pointed to the fact that the vast majority of doctors continue to work  in the public hospital system, and they say this system (and its workforce) is already stretched to breaking point. They ask how the public system will cope if many of its 'backbone' doctors reduce their commitment to practising in the hospitals - and also the reduced input in areas such as teaching and mentoring.

The group heard from some leading doctors saying there now had to be a pragmatic approach to developing Doctor-Hospital Partnerships to ensure optimum allocation of medical resources and also recognise the true value of doctors.

In one Doctor Group forum, vascular surgeon Dr Zhang Qiang said there were 10 issues facing doctor groups:
1. Doctor groups are a very vaguely defined concept.
2. Policies have to be open, pragmatic and work with the health ministry and hospitals.
3. What size should doctor groups be? How much will they be worth? And what disciplines will the consist of?
4. How will doctor groups be organised? As private companies? Co-operatives/ Joint ventures?
5. Where will doctor groups be located? In private hospitals? In large institutions or be in stand-alone clinics? Or as flexible visiting doctors?
6. If doctors join freelance groups [how] will they maintain their participation in academia, teaching and research?
7. How will doctor hierarchy and work assignments/responsibilities be arranged in private groups? In the public system there is a clear structure and system of rosters, promotion and responsibility - how will this translate in private groups?
8. How will private doctors interact and communicate online and digitally, if they do not have the support of the government and hospital system? Will there be referrals and shared care?
9. How will freelance doctor groups be financed and where will they find their start up capital from? If there is a share ownership, who will own the shares and control the doctors?
10. Will private doctor groups have clout? For example, in medical insurance will doctor groups have enough buying power and negotiating strength to be able to arrange medicolegal cover, settle medical disputes and influence policy?

Antibiotics in China: not quite there yet

by MICHAEL WOODHEAD
Regular readers of this blog will know that antibiotic misuse is one of my real bugbears about medicine in China. Seeing rows of patients in emergency departments routinely hooked up to infusions of broad spectrum antibiotics for fevers is a symbol of everything that is wrong with healthcare in the PRC.

Well it seems that I'm in good company in deploring this unwelcome practice. As part of Antibiotic Resistance Awareness Week, the World Health Organisation has taken China to task for its misuse of antibiotics. In a new global report it singles out China for having particularly poor usage and knowledge of antibacterials. A survey reveals that more than 60% of Chinese think, incorrectly, that colds and flu can be treated by antibiotics. A similar proportion have used antibiotics in the past few months and one in four bought them over the counter rather than obtain them on prescription. And while 67% were aware of the term ‘antibiotic resistance, few realised that cutting down on antibiotic use was the way to tackle it.

The WHO states that China is one of the worst offenders for antibiotic misuse and blames the lack of awareness among the citizenry for this problem. For a country that prides itself on such a good education system, how can Chinese be so badly informed about such an important matter?

The head of the pharmacy department at the Beijing Union Medical College Hospital, Zhang Jichun, says many Chinese demand antibiotics as a "quick fix". At the hospital if doctors say that antibiotics are inappropriate for patients with a fever or a cough they are rebuked with: "my illness so bad, why don't you give me an infusion for it?" Doctors say patients accuse them of not taking their illness seriously and demand "give me an infusion quickly so I will recover quickly and can get back to work!"

The WHO says it hopes the new report will raise awareness about antibiotic overuse and the risk of resistance in China. I'm not holding my breath.

Top 10 hospitals in China

by MICHAEL WOODHEAD

I'm not a big fan of top 10 lists, and I would approach this one for hospitals in China with caution. The China 2014 Good Hospital Ranking is produced by the Fudan University Institute of Hospital Management.

I'm not quite sure what criteria they use to decide what makes a good hospital but they claim it is based on factors such as clinical competence, scientific research and academic rigour. How they measure that objectively is anyone's guess. The Fudan team also say they consulted many 'national experts' to rank the country's top hospitals. They say the rankings are a good guide to clinical excellence and should be a benchmark that other hospitals strive for.

I don't think anyone is going to see any surprises in the list - all the top hospitals are the 'usual suspects' in the major cities such as Shanghai and Beijing and Guangzhou. I'm also not sure what the point of league tables for hospitals is - if you asked me to name the top 10 hospitals in Australia I could tell you quite easily without having to do a ton of homework - just based on location and whether they are teaching hospitals with a good research culture.

The rankings actually extend to 100 top hospitals, but I've only listed the top 10 here for brevity. I'm also not sure what the point of doing these survey on an annual basis is - it's not as if hospitals will move up and down the list very much and whether that is significant anyway. Any doctor will tell you that some good hospitals can have very bad departments and vice versa - some hospitals have a good reputation in certain specialities and can be terrible for others. Much of it is down to personalities and medical politics. I can also think of some 'good' hospitals that are over-rated and charge exhorbitant fees based on their reputation and "closed shop" monopoly status.

But what do I know. Here's the list:

1. Beijing Union Medical College Hospital
2. Sichuan University, West China Hospital
3. People's Liberation Army General Hospital (aka 301 Hospital, Beijing)
4. Shanghai Jiaotong University Affiliated Ruijin Hospital
5. Xijing Hospital (No 4 Military Hospital) Xian
6. Zhongshan Hospital, Fudan University, Shanghai
7. Huashan Hospital, Fudan University, Shanghai
8. Zhongshan Hospital, Guangzhou (First Affiliated Hospital of Sun Yat-sen Univeristy)
9. Tongji Medical College Hospital, Shanghai (Huazhong University of Science and Technology)
10. Peking University First Hospital

Dodgy hospital uses call centres to lure bumpkin victims

by MICHAEL WOODHEAD
A backstreet private clinic in Beijing is using call centre staff posing as doctors to lure unsuspecting victims to have expensive and often unnecessary medical procedures. In an expose, a Beijing Times reporter spoke to call centre staff for the Beijing Sande Weiye (三德伟业) clinic, who described their high-pressure sales tactics to bring patients in for high tech and often unproven treatments such as 'stem cell' technology for arthritis.

The call centre staff said they were given a script and a template to respond to phone inquiries coming from people who had been deceived by fake websites and Baidu advertisements that claimed their 'hospital' was affiliated with prestigious major hospitals in the capital. When answering calls, the sales staff said they were doctors but in reality they were unqualified and just ran through a script whose aim was to convince callers that they could jump the queue and get access to top specialists at the city hospitals. Most of the callers tended to be gullible out-of-towners who were seeking treatment in the capital rather than rely on the more basic and underfunded rural hospitals.

Sales staff told the reporter that they were pressured to get the caller's mobile, after which they would make a series of promises and phone calls to establish a relationship with the prospective customer. They were paid on commission: 2 yuan for getting a call, 20 yuan for getting a registration (ie phone number and verbal contract) with the 'network' and 60 yuan for a hospital visit. The sales person also got a cut of the treatment fees and drug fees. A successful telesales operator could make 5000 yuan in this way. The treatments offered were often high technology - such as joint replacement - and were offered regardless of whether they were really appropriate for that patient.

When the reporter visited the 'hospital' he found it to be just a standard clinic with unscrupulous doctors offering treatments that were much higher in price than the same treatment in public hospitals. A knee replacement, for example was priced at 60,000 yuan.

When the reporter informed the top three hospitals that their name (and reputation) was being hijacked to promote a bogus clinic they said they did not have the staff or resources to chase up the many such cases they heard about from complaints. They suggested the fraud be reported to the Public Security Bureau, but the PSB said they would only follow up complaint from people who had been swindled and who had evidence to show criminal behaviour. They instead suggested that the reporter called the consumer affairs bureau.

The Beijing Industry and Commerce Bureau  told reporters that any company making false propaganda, should be reported to the bureau's hotline and would be investigated, with fines and business license suspensions for offenders..

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year

For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

The medical appointment "add-on" phenomenon - why China's doctors see far more patients than are booked to see them

by MICHAEL WOODHEAD

A fascinating article run by Xinhua this week describes the so-called "add-on" (加号) system in which doctors squeeze in far more patients than are registered to see them. The official reason for this practice is that doctors often feel sympathy for ailing out-of-towner patient who cannot get a booking to see them that day. However, as the article reveals, the add-on patients are often more to do with doctors making informal arrangements seeing patients with guangxi (connections) or to see patients who have bought their booking slips from ticket scalpers.

To understand the add-on phenomenon you first have to understand how China's medical appointment system works. To see a doctor in China you have to 'register' (gua hao, 挂号) at the front desk of the hospital before you can get to wait at the clinic And with demand for doctor appointments far outstripping supply, this means patients have to queue very early (often overnight) and for a long time to get one of the limited slots available to see a doctor in their chosen department. There are two kinds of bookings: general and specialists.

Typically, a doctor in a  hospital outpatient clinic will work a morning shift from 8am to 1pm. Assuming that he or she works five hours without a break and sees patients for an average of five minutes (far too brief for an adequate consultation), the doctor could be expected to see 12 patients an hour - or 60 patients per shift. However, some doctors are seeing 50% or even 100% more patients per day than their official limit. Why so?

The Xinhua reporter describes the situation in the Chaoyang Hospital dermatology department, where he sees an impoverished family of 'waidiren' (out of towners) sitting with their ailing grandfather in the waiting room late in the afternoon. They are surrounded by their travel luggage and are telling the clerk that they have come from a remote town in a nearby province especially to see the doctor. At 6pm it is time for the doctors to finish their shift, but the doctor agrees to see the old man without a booking as a jia hao (add on).  The patient is given a ticket with the doctor's signature and the clinic chop, and his family are able to take this to the registration desk to get an official registration slip to see the doctor.

The doctor later explains to the reporter that because of his conscience he feels unable to turn away the desperate family who have been waiting there all day. However, he says he nevertheless feels guilty because his 'extended shift' also means that others have to stay behind - the nurses, clerks, pharmacists and security staff.

The doctor says that all departments have 'add-on' patients, some more than others, and each clinic and each doctor has a different policy about how to deal with them. Some doctors and clinics refuse to have 'add-on' patients, even putting up signs saying they are banned, while others reluctantly agree to see some of the more pitiful cases - the elderly and the seriously ill. Some clinics even leave spare room for add-ons and the doctors try to 'triage' their add-on patients to sort out the most deserving and to weed out the tricksters, malingerers and the ones who have paid for their registration.

The situation is complicated because not all 'add-on' patients are genuine. Some are simply putting on an act because they could not or would not wait in line to get a registration ticket. The doctor describes one woman who came to the waiting room with a wheeled suitcase, lamenting that she had  got off the train from a distant town and needed to see the big city specialist. However, an eagle-eyed nurse noted that the woman's suitcase was very light and obviously empty.

The other big problem with add-on patients is that they are exploited by the thriving trade in add-on appointments by scalpers known as 'hao fanzi' (号贩子).  These are the 'black hand' middle men who hang around the hospital lobby pretending to be patients and getting registration tickets which they then sell on illicitly to  patients who have missed out or don't want to line up early in the morning. To combat this, hospitals have introduced a system of ID checks, with registration tickets only valid for the person who has booked them. If the scalpers are unable to get registration tickets directly from the lobby office, they instead try to get bookings by posing as add-on patients. According to Xinhua, the going rate for a scalper-obtained place to see a doctor is 200 yuan for a general appointment and 300 yuan for a specialist booking.

One doctor told the reporter that the fake scalper 'patients' were often convincing or persuasive and he felt too tired at the end of a long day to try work out if an add on patient was genuine or not. The scalpers also cause annoyance to Beijing residents. One local 70 year old man waiting in the rheumatology department told the Xinhua reporter that he had tried to get to see the doctor for three days but had not been able to get a ticket despite queuing for hours each day. He said he resented outsiders and scalpers taking up the appointments that should be prioritised for local patients.

However another doctor hinted that about half the 'add-on' patients were not outsiders or scalpers but connections - guangxi. They would be patients with some connection to an important person, whom the doctor would 'fit in' to repay a favour, build up guangxi 'credit' or perhaps they were just friends or relations. There are also hints that many of the add-on patients use 'hongbao' bribes to be fitted in to see the doctor at the end of his or her clinic. But another doctor said that add-on patients were not a source of extra revenue - quite the opposite. He said doctors were paid a base salary and therefore if they saw more patients they did not increase their income.  He added that it was not uncommon for a doctor to work a five hour shift from 8am to 1pm without a break. He joked that he dare not drink tea while at work as he never even had an opportunity to go to the bathroom because of the number of patients waiting to see him.

For whatever the reason, the problem of add-on patients is obviously a major one - and yet another example of the problems that come from a health system centred on overloaded city hospitals.

The medical side-effects of China's stockmarket crash

by MICHAEL WOODHEAD

Headaches, irritability, depression and most of all insomnia are the most common medical side effects of China's stockmarket crash, doctors say.

Mental health specialists at Guangzhou's prestigious Sun Yat Sen Hospital say they have seen a stream of unwell patients this week suffering from the mental effects of severe stress from the stockmarket collapse.

"Some people can not sleep at night, have difficulty falling asleep or wake up in the early hours three or four times a night.
Many people have overt physical symptoms such as palpitations, chest tightness, aches and pains, stupor and confusion," says psychiatrist Dr Wei Qinling.

Dr Wei says the worst affected people are those with a casino mentality towards the stockmarket and those with little mental resilience, who are most at risk of severe depression, mental confusion and possible suicide risk. Other common reactions are despair, alcohol abuse and loss of motivation. Some workers in the finance industry say there is nothing to work for anymore, and they have lost a reason to work. Others have lost their livelihoods altogether. Dr Wei says some have gone on extreme drunken binges to try wipe out the stress.

And in what some are calling "stocks syndrome", people suffers from sever stress from the sudden reversal from riches to destitution. This is a mix of severe anxiety, guilt, frustration and mental paralysis. Dr Wei says some people have symptoms that are so severe they may require hospital admission and antidepressant treatment.

However, at the Beijing Union Medical College Hospital Department of Psychological Medicine, Dr Li Jianzhong says some people are looking for a quick fix for symptoms such as insomnia. Some of the most difficult to treat are those who were most greedy when the market was good and became obsessed with the stockmarket. After making large gains they are now in denial and are unable to accept that they have made losses and cannot adjust to reality. Counselling may be needed, but it requires people to learn about "spiritual wealth" as well as financial wealth, he says.

Dr Li says there are two steps to treating "stock syndrome". Firstly, people must identify the cause of their symptoms and learn to manage the stressors through activities such as deep breathing and findings distractive activities such as walking or sport. Secondly, people must find an alternative to obsession with the stockmarket and focus on that.

In Shanghai, psychologist Dr Chen Gong says there has been an increase in patients with 'financial stress' but it would be an exaggeration to say his department has been overwhelmed. For him, two of the most serious consequences of mental stress from the stockmarket are cardiovascular and cerebrovascular disease. These may be triggered by severe stress, and people must learn to change their habits and behaviour to have a more balanced life, he suggests. Another problem with financial stress is its effect on the family,and relationships, he adds. He recommends that people talk openly with their family and focus more on family activities rather than being preoccupied with speculating on shares.

Dr Wei, however, warns that for some people the stockmarket has become a form of addiction, just like gambling. He warns family members to look out for signs of addiction and to recommend counselling and treatment for those who have become addicted to the stocks - and are at risk of withdrawal symptoms.

Some good news about the chaining of mentally ill patients in China, from the 686 Program

by Michael Woodhead
In recent years there have been several media articles about mentally ill people in China being chained up - usually by families - because there are no mental health services. 

The impression given by the articles is that this is a widespread practice and is going unchallenged. "This is an example of how mental disorders are dealt with in rural China" said The Independent. It is enlightening, therefore, to read that such practices are rare and have been targeted for elimination for more than a decade. In a sobering paper published in PLOS One this week, Dr Lili Guan and colleagues at the Peking University Institute of Mental Health talk abut the so-called 686 program that has been running since 2005 to provide basic mental health services and ensure human rights are upheld for people with severe mental disorders.

In their article they describe how they recruited village health workers across China to seek out and identify mentally ill people who had been chained up by families. Their program found 271 such people - some of whom had been in chains for 28 years, but most had been chained for shorter periods and intermittently as circumstances arose, rather than continuously. Cases of chaining were rare - accounting for only 0.2% of mental health patients reviewed in the program.

Most of the chained people had schizophrenia and none of them were receiving care from mental health institutions, usually because there were no such community services in their area, or the families could not afford it. The patients were restrained mostly because they were violent and abusive, causing harm to people and property.

The program of 'unlocking' was focused on providing free antipsychotic medications. Patients were first admitted to psychiatric units and assessed, and then families were provided with free medications and a treatment plan. The 'unlocked' patients were then returned home to live in the community.
The good news from the program is that regular treatment rates went from 1% to 75% and most patients complied with treatment and showed great improvements. Their functioning improved and the family burden also lightened significantly. Relapse into ''locking' occurred with only 21 patients (8%), with families citing lack of adherence to medication and return to violence or harmful behaviour and lack of caretaker/financial resources to access help.

"The finding that more than 92% of those unlocked and entered into continuous treatment by the 686 Program remained free of restraints by 2012 demonstrates the feasibility of improving the human rights of persons with severe mental illness by increasing access to mental health care in the community, even with limited societal resources," the researchers said.

"Nevertheless, the failure to prevent relocking for 21 individuals suggests that considerable room for improvement of our mental health care practice still exists."

The researchers also noted that their program covered less than 1% of the population of mentally ill people in China, and said it would require more resources to allow it to cover the whole country.

"There is obviously much to be done in China to scale up the 686 Program for the whole nation and to improve quality of care. This will require substantially increased investment in mental health services. However, the success of the program in maintaining the severely ill individuals in treatment over three to seven years, and the benefits of the intervention for those who have lived for years with untreated psychosis and for their families, attests to the feasibility and social value of the “686” model."

Authors note: Restraint for people with mental illness is not uncommon practice in  western countries, particularly for elderly people in nursing homes. Medical groups in countries such as Australia have expressed concern that patients who are agitated and have challenging behaviour are sometimes restrained due to lack of staff and for convenience, rather than for their own wellbeing.

Will Beijing's billion yuan "loss leader" private hospital be the model for the future?

by Michael Woodhead
Peking University's flagship new private hospital may lose almost a billion yuan but will still be counted a success if it drives other medical service usage, its backers say.

An article by He Chunmei in the financial magazine Caixin this week heralds the opening of the 1800-bed Peking University International Hospital (PUIH), which is a joint venture by Peking University and the Founder Group. The hospital in the north of the city is expected to lose as much as 800 million yuan but Founder CEO Li You says this is acceptable if the hospital generates revenue in other areas. "It's like a company's advertising department that spends money. We will earn money from other sectors. But the hospital is the foundation," he is quoted in Caixin as saying.

The new hospital is being portrayed as a flagship of China's foray into privately-invested healthcare as an alternative from the current overcrowded and underfunded public system. One of the main barriers to private hospital development in China to date has been the regulations that bar doctors from working outside the official public hospitals. The new hospital will test the recent relaxation of these rules by the government. But employment restrictions have not been the only barrier to private healthcare facilities - many clinicians have been reluctant to work outside the big hospital system for a variety of reasons - fear of stepping off the well-established career pathway, losing peer support groups and moving outside the system that is recognised by health insurance rebates. Doctors have also been unwilling to go it alone and take on the medicolegal risks of operating outside the mainstream system, especially at a time when patients are becoming increasingly distrustful of the healthcare system and prone to taking aggressive action in medical disputes.

The new Peking University International Hospital may overcome many of these reservations because it will 'share' doctors and other healthcare staff from other Peking University-affiliated hospitals, which already enjoy a good reputation for quality care. However the management of the new hospital acknowledge that the new workforce 'sharing' arrangements will require some work and 'adjustments' to coordinate different departments and different hospitals. The hospital says it will lure staff with offers of higher pay, which will be guided by the market rather than the patchy, commission-based remuneration of state-controlled public hospitals. "Head doctors usually earn several hundred of thousands of yuan every year at a public hospital," said Li You. "But if necessary, we'd like to pay more than 1 million yuan. We will fully follow the market."

The private hospital will also differ from public hospitals in being managed by a board of directors representing investors. Public hospitals are often a conglomeration of mini-empires, with directors of departments often having a lot of power and being unaccountable in terms of services, revenue and purchasing.

The Peking University Healthcare groups say they will be able to implement a more efficient system as they will have a controlling interest in the hospital, whereas public hospitals are often controlled by government agencies, business groups and hospital managers that are resistant to reform. Li says his ambition is to pioneer a new model of hospital management based on integrated databases that will create accountability and efficiency in procurement, servicing and supply. The management system will also encourage doctors in departments of larger hospitals to sponsor and support similar departments in smaller branch hospitals.

"We will grow to become China's largest hospital management company," Li told Caixin, "and control the largest medical database."

Beijing doctor explains on Youku about bribes and commissions

by Michael Woodhead
A video is circulating on Youku of a man purporting to be a former surgeon at a Beijing hospital, explaining how the red envelope bribe and commission system works in China. 
The erstwhile doctor, claimed to be  Li Rui of the Beijing Aerospace Institute Hospital Urology department. He said that during his time working in surgery, doctors would make huge commissions by charging patients exhorbitant sums for ancillary items such as a 1500 yuan gauze pad to stop bleeding, on which they earned a 30% fee. He said surgeons performed many simple operations such as removing appendix in 10 minutes and then adding lots of expenses to the bills. Dr Li said it was best to work in procedural specialties such as orthopaedics, surgery and obstetrics where there were more opportunities to perform operations and use expensive medical supplies and devices. The man was purportedly giving a presentation at the well-known New Orient academy  in Beijing, although the institute denied any knowledge of his working there. In a statement the Beijing Aerospace Institute Hospital denied the man's claims, describing them as baseless and slanderous. The hospital said there had been a Dr Li working at the hospital but he had been absent for six months and thus his contract was terminated. The hospital said the man's statements on video lacked credibility, citing as an example that there was no way a surgeon could do an appendix removal in 10 minutes, even with the most modern equipment.
However, the video has been widely circulated on Chinese social media sites, drawing comments on the greed and corruption of doctors and the profit-seeking nature of public hospitals.

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.

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.

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.

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.

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

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

Beijingers still unprepared for influenza pandemics

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

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

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