Week 2 of the vaccine scandal: latest developments

by MICHAEL WOODHEAD
It is quite remarkable that in the middle of the second week of the scandal around distribution of dud vaccines there has been no comment whatsoever from China's health minister Li Bin. In fact the response from the Chinese government could be summed up as an attitude of "Crisis? What crisis?"

The official line has been to focus on the perpetrators - the illegal wholesalers and distributors in Shandong -  and to avoid any analysis of how things could go so badly wrong - and what the Chinese public should do about it all.

It seems clear that the government has been 'harmonising' (deleting and censoring) media and online articles and social media discussions relating to the vaccine scandal. The media articles that originally drew attention to the crisis have been removed, and instead replaced with bland assurances from officials that the matter is being investigated and all should be well.

Most of the permitted coverage has been along the lines of the WHO China response, namely:

• The dud vaccines are unlikely to cause any adverse effects even if not handled according to the cold chain.
• Most of the vaccines have already been used, and there have been no reports of spikes in adverse events.
• The illegal distribution is being investigated and the perpetrators brought to justice.

That's it.

There has been no response to important questions such as:

• How many people received dud vaccines and have any of them acquired diseases because of poor immune protection?
• What are the most frequent and potentially most severe diseases covered by the dud vaccines?
• What needs to be done to trace/follow up/test and re-vaccinate those who have received dud vaccines?
• How can the public be reassured that vaccines currently in the system are not duds? Batch numbers? Locations?

These are just a few of the fundamental questions that any professional and competent medical regulator such as the FDA would be asking. And yet in China there has been no such response. There have been some vague reassuring statements from the China FDA, but no detailed information about the scale of the problem and how it will be addressed.

Once again the "SARS hero" Dr Zhong Nanshan has been given airtime to comment. Speaking at a national influenza conference in Hainan (unfortunate timing) Dr Zhong said there was no need to doubt the quality of Chinese made vaccines and no reasons for panicked parents to seek foreign vaccines or to go to places such as Hong Kong for vaccinations. He also said (quite rightly) that he hoped the vaccine scare would not undermine China's immunisation program, which has markedly reduced or eradicated diseases such as measles, whooping cough, polio and hepatitis B in China.



Fine words, and not to be disputed, but there is a need for more leadership on this issue if public faith in the public vaccination system is to be restored. As I've said before, trust is not easily won and it is a two-way street. If the government does not trust the public with information - if it closes down the communication channels and deletes articles about the vaccine problems then it will just encourage the public to turn to the rumour network.

On a wider level there is little hope for a robust medical and healthcare safety system when there is a culture of punishing those who speak out. In other countries there has been grudging acceptance by authorities that transparency and accountability are needed in clinical matters to ensure safety. Staff have to feel confident that they can speak out - and also feel that it is their duty to do so, rather than feel intimidated or a false sense of loyalty to persons or organisations. In China under Xi Jinping there is currently a major crackdown on those who are outspoken or who dare to question "the core".

And so at the end of March we find that China is facing its biggest health safety crisis since the melamine in milk saga of 2011. And yet if you turn to the medical forums such as DXY.cn there is no discussion and no advice there. They have presumably also been 'harmonised'. A week ago when the scandal first became public, the Deputy director of the Department of Immunology at Peking University Professor Wang Yue expressed shock at the safety implications of the dud vaccine trading.

"This is murder" he said, referring tho the likelihood of people dying from vaccine preventable diseases.

The article has now been taken down.

It's important for Li Bin to show some leadership and act swiftly to restore the public's faith in China's vaccination system. If not, vaccines may become like China's milk formula industry - untrusted, shunned and encouraging consumers to turn to expensive alternative 'grey market' suppliers.

Meanwhile, here are some links to articles of interest:

SARS hero Zhong Nanshan reassures on the vaccine problem, urges public to maintain faith in China's vaccine program

Propaganda Ministry directive: "Don't hype the news on illegal vaccines"

VOA article on the vaccine articles that have been removed and the vaccine keywords that have been blocked on social media

Netizens claim that China's propaganda ministry is highlighting news about Japan's war crimes as a distraction from discussion about vaccine scandal

Hong Kong media raise fears that vaccines may be the new milk powder - will mainland 'raiders' flood Hong Kong to buy up good quality vaccines?

China's doctors now officially encouraged to moonlight in the private sector

China's 'health ministry', the National Health and Family Planning Commission, has told doctors in the public hospital system that they should seek additional work in  private hospitals.
Health minister Li Bin told a conference this week that the registration regulations for doctors had been changed to encourage practitioners to work outside of the public hospital system.
"Limited resources of talent will be optimized among hospitals of various types under the initiative, which helps with the sustainable and healthy development of privately funded medical institutions," she said.
Doctors will no longer 'belong' to public hospitals and will be encouraged to work for market-set fees in private hospitals.
According to the China Daily, one senior doctor said he hoped his patients would 'follow' him to the better environment of the private hospital where he intends to practice, despite him charging much higher fees there.
The health minister told a NHFPC conference this week that she was urging private health institutions to provide a range of healthcare services, both treatment and prevention, to help divert patients from public hospitals, which are usually overloaded with work.

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

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

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

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

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

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

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

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

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

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

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

Chinese leaders affirm commitment to Hangzhou Resolution on ethical organ donation and transplantation

by Michael Woodhead
Chinese health officials and hospital leaders have committed to upholding the new ethical framework for organ donation and transplantation as outlined in the recently signed Hangzhou Resolution.
In a update statement, officials and transplant surgeons affirmed the new five point plan that will outlaw practices such as use of organs from executed prisoners and the 'sale' of organs to foreign buyers.
The new statement also includes a list of 38 Chinese transplant centres that have already confirmed  to have stopped using organs from prisoners, with others "anticipated in the days ahead".
The statement published in Hepatobiliary Pancreatic Diseases International is co-authored by China's leading transplant specialist Professor Huang Jiefu  and international transplant specialists including Dr Francis Delmonico, President of the Transplantation Society.
It notes that the Hangzhou Declaration commits China to adopting  a new organ transplantation system overseen by the National Health and Family Planning Commission (NHFPC) and the Red Cross. The new system will set up a national voluntary organ donation scheme and a new organ procurement and allocation system that is based on clinical needs and which is "open and transparent". China will set up a human organ transplant clinical network based on 169 authorised transplant centres, an organ registry system and an organ donation regulatory system.
"The NHFPC expressed the resolution of the government of China that the dependence upon organs from executed prisoners must be terminated. The government of China has affirmed its commitment to prohibit transplant tourism and to shut down organ trafficking and transplant commercialism," the statement says.
The move to the new organ donation system will also mean that China is no longer the subject of an academic boycott on organ transplantation.
Health minister Li Bin also pledged her commitment "to bring China back to the international community and to promote an academic exchange based upon the five-point NHFPC plan elaborated."
The next step will be to implement the agreement in all China's provinces. The statement says China will also host a meeting this year with leaders of the major international transplantation societies and WHO representatives.
"The meeting will affirm the new resolution in the practice of organ donation and transplantation in China. The meeting will be a milestone for China transplant professionals to practice according to the international standards set by WHO Guiding Principles."
Meanwhile, in a public show of support for the new organ transplant system, senior Chinese leaders have registered to donate their organs.
Officials including Chen Zhu, vice-chairman of the Standing Committee of the National People's Congress and a former minister of health; and Hua Jianmin, head of the Red Cross Society of China added their names to the new online organ registry at the Beijing Union Medical College Hospital .
The registry, overseen by the society's China Organ Donation Administrative Center, is available for people aged 18 and over who are willing to be organ donors after their death.
In December, the State Council issued a guideline related to funeral reform, encouraging Party members and officials to register to donate their organs after their death, according to China Daily.