China is crazy for medical apps

The latest medical app craze in China is iBaby, developed by an entrepreneur from Harbin to provide antenatal, childbirth and childcare advice to Chinese women. The creator Lu Guotao featured on a recent Apprentice-style TV show on which he demonstrated how his app can link women up to advice via video and online help from obstetricians. Lu turned down offers from investors and went it alone to market the app, which he says now has tens of thousands of users in 31 provinces. Lu says he has had 10,000 obstetricians sign up to provide medical advice online via the app. The one stop platform for pregnancy advice also links women up with local clinics and offers links with merchandisers for pregnancy wares.

Lu says he was already a successful businessman when his wife became pregnant, but they were so busy attending to their work that she lost the baby through a miscarriage. Lu turned his grief into an energetic mission to help avoid such incidents again, by providing accessible information, advice and contacts for prospective parents.

He says the huge success of the app is not surprising given China's move towards relaxing the one child policy and also the opening up of the healthcare system to private investment and more flexibility in doctor roles.

The app has received backing from national obstetric experts including Professor Liu Xinghui, director of the West China Second Hospital, Sichuan University, Chengdu. Professor Liu offers weekly online lectures via the app. She says women can access a wide range of obstetric experience via the app.

China healthcare's "Sunshine Act" and the journalist who exposed corruption: common cause?

[Banner outside Beijing court says: Support Journalist Chai Huiqun!]

by MICHAEL WOODHEAD 

With China's media often containing significant items of "managed opinion" it's hard to tell whether common themes that emerge in coverage are coincidence or not. Take this week's high profile case of a health journalist involved in legal action over an article in which he exposed corruption in purchasing at a Sichuan hospital. Is this a case of censorship by litigation - or is the government trying to use this case to back its own policy of reforming hospital purchasing?

The legal action in question is between the China Medical Doctor's Association and Southern Weekend journalist Chai Huiqun. The CDMA has lodged an official complaint against Chai to authorities over his reports about corruption in purchasing of medical equipment at the Mianyang Hospital following the major earthquake there in 2008. Chai wrote articles exposing inflated prices claimed for old equipment. The scam was based around the hospital claiming generous funding was spent on expensive ultrasound scanners but actually buying cheap second hand ones.

As reported by RFA, the CMDA put in a complaint to the All-China Journalists Association (ACJA), claiming that the stories were fabricated, and offered as evidence receipts proving that the hospital equipment was genuine. The ACJA accepted the complaint, which was a major blow to Chai's reputation and which effectively blacklisted him.

Now Chai has counterattacked with a legal action in a Beijing court, claiming 20,000 yuan damages and demanding that the statements and articles issued by the CMDA are retracted. In his claim, Chai points out that the receipts are for the wrong kind of scanners, new models which weren't even available in 2008. The court has yet to announce its verdict.

Chai is one of China's leading investigative journalists, working for the relatively liberal Southern Weekend (while it is relatively 'open' its contents cannot be syndicated). He specialises in exposing the dark side of the healthcare industry in China - and has made many enemies. If he is stymied, this will be a major blow for open-ness in the healthcare system in China.

However, Chai may be working in the right direction. Local governments and health departments are being ordered by the central government to clean up their acts and be more transparent and accountable in their purchasing of healthcare supplies.

In Beijing this week the Municipal Health and Family Planning Commission has launched a "Sunshine Program" to reveal the true value and scope of healthcare purchasing. Hospital and health institutions must publish comprehensive 'shopping lists' of all their purchasing and tenders, including all items and prices. This is to encourage and genuine free and open market for hospital supplies and to avoid dodgy backroom deals, the health department says.

If this kind of system had been operating in Mianyang in 2008, perhaps Chai would not have had anything to report.

Alibaba Health, iKang, Online consultations, Tobacco advertising ban, Antibiotics in food, HIV discrimination

by MICHAEL WOODHEAD

Hello and welcome to another week of China Healthcare. As China makes headlines around the world for its slowing economy, few have remarked that China's entrepreneurs are taking a different and more rosy view by re-focusing on healthcare. This week the Alibaba internet billionaire Jack Ma has issued a $2.5 billion vote of confidence in the prospect for online pharmacy in China by transferring his pharmacy e-commerce section to Alibaba Health ("Ali Jiankan" or alijk.com).  According to the WSJ, "Alibaba said the deal would position it to sell prescription pharmaceuticals should China’s reforms allow retailers to move in that direction".

At the same time, Forbes has profiled another internet millionaire who has made his fortune by turning to health. Zhang Ligang made his first fortune by founding the travel booking site e-Long, but he is more famous for building a chain of private clinics under the banner iKang. And if China really does shift to a more private healthcare system, companies like iKang should be at the forefront of the wave.

The NHFPC has banned online medical diagnosis. In a statement this week the health ministry said medical consultations cannot be conducted online as there have been too many cases of unqualified people offering medical advice, purporting to be experts. The ban does not seem to apply to accredited hospitals that have approved programs. What this means for online doctor apps such as Spring Rain (www.chunyuyisheng.com) remains to be seen.

Children in China are exposed to a wide variety of antibiotics in food, which may promote resistance. A study in Shanghai that tested the urine of more than a 1000 children aged between 8 and 11 years of age found that as most had traces of at least one antibiotic and many had several antibiotics in their system.  Altogether 18 different antibiotics were found in the urine of Shanghai children, reflecting the high levels of antibiotics used in food production in China. This was confirmed by another report out this week which noted that the Chinese food and livestock industries use 100,000 tons of antibiotics  a year to promote growth in animals reared for their meat.

A total ban on tobacco advertising n China has been urged by the WHO. The head of the China office of WHO said China had a treaty obligation to phase out tobacco advertising, and should start to do so at retail points of sale. However, the powerful state-owned tobacco industry might baulk at that. The relative power of the health and tobacco industry was shown this week when health minister Li Bin noted that new graduates could earn twice as much in the tobacco industry compared to medical graduates working in hospitals. She made the point that the basic salary for a university graduate working in the tobacco industry was 4571 yuan a month compared to only 2100 yuan a month for a junior doctor. Li Bin said there was a need to learn from Adam Smith and pay the market rate for medical graduates - and this would mean patients being prepared to pay higher medical fees.

And finally the question arises of whether anti-HIV discrimination still exists in the China's hospitals. A patient at the Sichuan University Huaxi Hospital says he was refused surgery when doctors discovered his HIV positive status. The man said he had been scheduled to have surgery for haemangioma but it was cancelled and he was told that he would instead be kept 'under observation' instead. The hospital rejected the discrimination claim, saying that it was standard practice to keep patients under observation before going ahead with surgery for this condition.

Leukaemia donations missing | Asthma rates soar | Syphilis rates as high as 44% in sex workers

Leukaemia boy misses out on donations

One of the top stories in the Xinhua news this weekend is the story of a boy from Leshan in Sichuan with leukaemia who has missed out on most of the funds donated by wellwishers for his treatment. The family of the 8-year-oldcalled Lin Zhouzheng appealed for help in paying several hundred thousand yuan in medical bills after they ran out of money and even sold their house to pay for chemotherapy for their son. They were approached by a local man called Xu Ping who mounted a major publicity drive to raise money, and this netted more than 100,000 yuan. However, to date the boy's family have only received 7,000 in money from all the fundraising despite taking part in many media interviews, publicity appearances and having an army of volunteers working under Xu Ping. However, Xu Ping told reporters that the 110,000 yuan raised had only been pledges rather than actual donations - and he was still working to get companies and individuals to make good on their pledges.

Asthma rates soar in Shanghai

Asthma rates in Shanghai have increased four-fold over the last 15 years, with pollution being given much of the blame. A study of more than 27,000 residents of Pudong found that the prevalence of asthma was 1.4%, markedly higher than the 0.4% rate seen in the last major study carried out in 1997. Researchers from the Department of Respiratory Medicine at the Shanghai Putuo District People's Hospital carried out further pulmonary tests on 428 people with asthma and found that 53% had an FEV below 80% of normal and the severity of impaired lung function increased with age. The main triggers for asthma were dust exposure, cold air and respiratory tract infections.


STDs rates high in Jiangxi sex workers

More than 40% of female sex workers in Jiangxi have syphilis, a study has found. Researchers from the Department of Dermatology and STDs at the Affiliated Hospital of Nanchang University tested 361 street-based female sex workers and found that 44% had syphilis infection. About half of the sex workers had little education, a high proportion had been sex workers for several years and many failed to use condoms consistently. "Comprehensive interventions targeting this high-risk group, especially scaling up screening and ensuring consistent use of condoms during sex are needed," the researchers suggested.

Heavy rainfall and floods to blame for resurgence in leptospirosis in China

by Michael Woodhead
An outbreak of leptospirosis in Sichuan in which six people died shows that the disease spread by water contaminated with rat urine is far from eliminated in China.
The 26 cases of leptospirosis reported in Lezhi country east of Chegdu in 2010 were analysed by researchers from the Department of Medical Microbiology and Parasitology, Institutes of Medical Sciences, Shanghai Jiaotong University School of Medicine.
They found that the cases were caused by the parasite that is typically spread from rats to humans via the urine and other hosts such as domestic dog and cattle. The researchers noted that local farmers in Lezhi collect rainwater in the farm land for rice plant. And in the harvest season, men and women, old and young all work barefooted in the farm land. 
The infection is caused  by a spirochaete bacterium and signs of the disease may vary from mild fever and jaundice to very severe and often fatal kidney, liver, and heart failure.
The leptospirosis outbreak coincided with periods of heavy rainfall and flooding they noted.
"This outbreak has reminded us that leptospirosis should not be neglected, especially during flood season," they concluded.
They reported their findings in the Biomedical and Environmental Sciences journal.

Mianyang hospital doctors strike in protest against 'Corridor doctor' whistleblower

The long running saga of the Sichuan 'whistleblower doctor' took another twist this week as her colleagues staged a stop work meeting and mounted a noisy demonstration in Mianyang. They complained that the doctor's widely-aired allegations of overservicing and bad medical practice at the hospital were untrue and had besmirched their reputation. Police were called to the demonstration by medical staff as they became angry and shouted for her to be expelled from the hospital. They said the doctor's allegations had ruined the reputation of the hospital and resulted in it being downgraded, despite an official investigation finding no wrongdoing. Her allegations had also resulted in doctors at the hospital being abused and ridiculed, they said. Her claims of poor medical practice had stuck to individual members of staff who now found it hard to work because patients no longer trusted them, they added.  Dr Lan Yuefeng claimed to have been stood down from her position in the ultrasound department after she refused to agree to overtreatment of patients. She became a media star when she carried on working in a corridor for almost two years after being turned out of her office.

Woman needs six stitches after argument with doctor

[Editor's note: there are three shocking things about this story, not just the alleged violence against the woman].

A woman in the Sichuan town of Yibin has needed six stitches for a wound sustained after a fight with a doctor over a dirty cushion. The woman named Chen says she got into an argument with a doctor in the X-ray department after she asked him to swap the cushion on the bench because it had  a bloodstain on it. The woman said that she took her 20-month old son to the hospital for a checkup when he had a cough and cold. When she took him into the X-ray room for a scan, she noticed the bloodstain on the cushion and asked the doctor to change it. However, the doctor refused and said "get on with it". When the woman took out some paper towels and started to clean the cushion, she says the doctor disappeared into  side room. She admitted she swore at him in frustration and then the doctor came back and swore back at her. The argument erupted and she said the doctor struck her on the head, cutting it open and causing bleeding, for which she needed six stitches. The woman said she was eventually faced with a bill for 3000 yuan in medical costs and she is demanding compensation from the hospital.
When the Dr Li was contacted at the Huaxi city Renmin Hospital he gave a different story. he said there were some bloodstains from a traffic accident on the cushion  that he had been trying to clean off, but the clinic was extremely busy and he was under a lot of pressure to examine a waiting room full of patients.  He said the woman called Li had been in an argumentative and volatile mood and had shouted and swore at him before chasing him into the side room. He said he had not hit the woman but had pushed her away after she started brawling with him, and she had fallen and hit her head.
 A hospital spokesman said he could not comment on the matter until a police investigation was completed.

Three things shock me about this story:

1. A dispute over a dirty cushion could result in a violent argument between a female and a male doctor.

2.  A woman would  take her infant with a minor illness like a cough and cold to a hospital and have the child exposed to high doses of radiation with needless chest X-rays.

3. The medical bill for a cough and cold (and stitches) could be as high as 3000 Yuan.

Three medical stories from Chinese language media

Chengdu doctors out of pocket as fundraiser fails to deliver 

Chengdu neurosurgeons are out of pocket to the tune of 60,000 RMB  after they operated on a seriously ill boy whose parents turned to fundraisers to pay the medical bills. The surgeons at the Chengdu Military District Hospital performed an urgent operation on a 9-tear old boy who had inflammation of the cerebral cortex. His parents did not have enough money to pay for the medical bills and they turned to a volunteer fundraiser to help solicit donations. However, at the end of the year the hospital is trying to balance its accounts and has yet to see the funds for the operation. According to the hospital rules, unpaid bills are the responsibility of the doctors who provided the treatment. When contacted by the West China News, the fundraiser Chen Mei said she was  waiting for the paperwork to be done so she could process the donations and provide the funds to the doctors.

Girl in Sichuan has duplicate organs

The People's Daily reports the case of a 13-year old girl who has a congenital disorder that has given her double the number of organs of a normal person. The Guangzhou girl called "Tian Tian" was born with four kidneys, two bladders, two uteruses and four Fallopian tubes. The girl had some fusion surgery when she was an infant but now her kidneys are causing her problems. The excessive organs mean that she has to urinate twenty times a day and she has frequent urethral infections. According to the newspaper report, the girl and her parents have now gone to Chengdu to track down the doctors who did the original operations to ask them to amalgamate the kidney
Her treating doctor Hu Xianliang said the operation would not remove the kidneys but would seek to normalise their function. He said Tian Tian was likely the first such case in the world and was caused by abnormal development of a twin ovum.

 Chinese children can't exercise in smog

A report in the Guangming Daily looks at the warnings from health experts to parents about not letting their children exercise in smoggy conditions. The report quotes a child health expert from the Sports Ministry saying that children should continue to do physical exercise during smoggy periods of bad air pollution but should exercise indoors and avoid heavy aerobic exercise. The long term health risks of inhaling high amounts of pollution during days of heavy pollution should be weighed against the dangers of a sedentary lifestyle, the article says.
Other sports medicine experts have even produced  a manual that shows the best indoor programs for sports and activities for children to do when the weather is smoggy.

Inquiry rejects claims of Mianyang hospital whistleblower

by Michael Woodhead
A local inquiry into a Sichuan doctor's claims of over-servicing and financial irregularities at a Mianyang hospital has concluded that there is no case to answer.
In a story featured prominently in the People's Daily, the claims of Dr Lan Yuefeng have been found to be unsubstantiated by a major investigation conducted by health and disciplinary authorities in Mianyang into affairs at the Renmin Hospital. Dr Lan claimed to have been stood down over her claims that the hospital was driven by income targets that led to overservicing and inappropriate and unethical treatment. Barred from her office in the ultrasound department, she worked in a hospital corridor for almost two years.
However, an investigation by the local health department and party disciplinary and audit committees has refuted all of her allegations, according to the People's Daily.
The investigation found limited evidence of financial performance related targets and income at the hospital, but said these were in accordance with local health department guidelines and were corrected over time.
The investigation found that Dr Lan's claims of inappropriate use of a cardiac pacemaker for profit rather than clinical need were unfounded. The inquiry also rejected claims that there was 'medical chaos' at the hospital and no abnormal growth in servicing or revenue.
The investigator rejected claims by Dr Lan that she had been stood down because she voiced opposition to the inappropriate use of medical procedures such as the use of a cardiac pacemaker.
However, the inquiry did find fault with the hospital in terms of the overall quality of medical treatment, the attitude of staff to patients and the responses to complaints.
The investigation team said staff were lacking in political ideology and more work in this area was needed, especially for Dr Lan, whose political thinking was primitive. Political work needed needed to be strengthened to counsel Dr Lan and also to rectify the problems identified according to the law, it concluded.

The "Corridor Doctor" - whistleblower or crank?

translated by Michael Woodhead
An interesting follow up to last week's story about the female doctor from Mianyang, Sichuan, who ended up working in a corridor of her hospital for two years after being removed from office for raising concerns about overtreatment and profiteering at the hospital.
In a new article, reporter Chen Xi for the Sichuan office of the Peoples Daily describes how he went to the hospital to follow up her claims and find out the background to her sacking and allegations of 'overservicing'. What he heard was a mixture of  good and bad about the would-be whistleblower.
First he spoke to Dr Lan, who said that she had always aimed to be a 'pure' doctor and wanted to be seen as one of  the 'angels in white' (ie female doctors in white coats).
However, when she started working at the Mianyang hospital she found that every activity involved putting generation of income for the hospital first. She said that practicing good medicine was constrained by the pressure to meet income targets. Patients were often admitted for treatment they did not need, and Dr Lan felt this was a breach of medical ethics. When she took her concerns to the director of the hospital, his reply was: "What are you on?"
As we reported last week, Dr Lan was stood down and barred from using her office in the ultrasound department in 2009 after she questioned the use of a cardiac pacemaker in a 53-year-old patient who had varicose veins. She said there was no need for a pacemaker in a patient who had a stable heart rate and who had already been cleared for vascular surgery.
Dr Lan also had another complaint - she said that the hospital had misappropriated thousands of yuan in earthquake relief funds donated in 2008 by Macau to aid survivors from the Wenchuan earthquake. As head of the ultrasound department, Dr Lan learned there was 235,000 Yuan in donations provided to buy a state-of-the-art Colour Doppler ultrasound scanner. However, when the machine was delivered it turned out to be an out-of-date model that was worth only 160,000 Yuan. It was not clear what had happened to the rest of the money donated from Macau. Dr Lan said she was so angry she left the old machine from the warehouse.

When the reporter tried to put these questions to the hospital management, he was told the hospital director Wang Yanming was not available. However, a deputy director, Feng Jianjun, tried to answer some of the questions.
First of all he rejected Dr Lan's claim that a cardiac pacemaker was not needed for the patient with varicose veins. He said it was usual for patients with vascular disease who needed surgery to have an atropine test. If the patient's heart rate was below 90 beats per minute then this indicated that they needed a pacemaker. In the case  raised by Dr Lan, the patient's heart rate was 60 per minute, showing that a pacemaker was clinically indicated, the hospital deputy director said. The pacemaker was needed to prevent the patient from having an adverse outcome during surgery, he said - so how could this be construed as overtreatment or inappropriate treatment?
Dr Lan ridiculed this claim, saying that it didn't make sense for a patient to be sent for tests after they had been deemed as ready for surgery - this was upside down, as pateints were alsways tested before being referred for an operation, she said.

The reporter sought comments on Dr Lan from other doctors at the hospital. An anaesthetist at the hospital said 'overtreatment' was a grey area and even clinical experts often disagreed strongly on what was the most appropriate treatment for a patient. Therefore, Dr Lan could be right or wrong.
Several doctors said Dr Lan was a hardworking and honest doctor, but with a stubborn individualistic streak and an obsessive personality. Some said she was  a loner who did not communicate or consult well with other doctors. One doctor described Dr Lan's self-image as the only 'pure' doctor as naive, while another said she was known to have strong and unbending opinions about subjects outside her area of expertise. A doctor in the obstetrics department said Dr Lan had often seen his patients and made treatment decisions on obstetrics matters that he did not agree with. She did not accept or understand that ultrasound was an ancillary branch of medicine and that it was inappropriate for her to criticise the diagnosis and treatment decisions of doctors outside her area.
Some doctors told the reporter that Dr Lan was the author of her own troubles, and that it was a joke that she chose to 'practice' in a corridor for two years. For this reason she had become know as "Dr Crazy" by some.
In Mianyang, authorities including the local health department said in a statement that they were now mounting multiple inquiries and audits into the claims made by Dr Lan. The inquiries would look in detail at her claims that patients were being overtreated only to generate income and that unnecessary and inappropriate treatments were being regularly used. As part of the investigation, authorities are  to review all CT scans and ultrasounds of patients for the last three years and check whether the treatments matched the diagnosis.

Infant health improves after coal power station shuts down

The closure of a polluting coal-fired power plant in Tongliang, Sichuan, resulted in a marked improvement in the health of local babies, researchers have reported.  
The power station was the major pollution source until its shutdown in 2004. Researchers from Chongqing Medical University measured prenatal exposure to polycyclic aromatic hydrocarbons and other pollutants before and after the closure and found that reduced levels were associated with improvements in birth outcomes, neurodevelopment and early childhood growth rates.
“The findings of this study are encouraging in that direct governmental interventions to remove a polluting coal-burning source can have rapid and direct benefits to children's health. This in turn is a strong motivation for China to further invest in renewable and energy- efficient fuels, a necessity for its future.
Full study: Environmental Pollution

Liangshan region of Sichuan ravaged by HIV

by Andrew Lee
The Liangshan region has been ravaged by an AIDS epidemic for the past 25 years. Official numbers show Sichuan as having 50,000 cases of AIDS, but the actual numbers are sure to be much higher. Half of the cases are from Liangshan, home of the Yi people, and our destination.
Zi'er, 74, has had to bury two of her sons, who died of AIDS. Her other two sons are currently infected with HIV. (Andrew Lee/CBC)
In the small isolated villages lives the Yi minority. They lead a rural life, a world removed from China's big, booming cities. Chickens run across roads while cattle amble and heavy blue capes are worn almost like an unofficial uniform. Faces are darkened by sunshine and the elderly are stooped from carrying a lifetime of burden.
A local NGO worker took me to visit a family crushed by the disease, in a village where 10 per cent of the population has AIDS.
A wrinkled 74-year-old matriarch wanted to speak, and clutching a family photo collage, she started to tell me about how all four of her sons had AIDS; two had already died.
They had gone to the big city looking for work and a better life; instead they found hard drugs and an injection habit.

Rabies epidemic spread by pet dogs in China - but it isn't crossing borders

Rabies is being transmitted across China from the south by relocation of domestic pet dogs

by Michael Woodhead
China's increasing affluence is behind an upsurge in rabies, which is being spread from southwestern provinces by wider ownership of pet dogs and longer distance travel, new research shows.
However the "massive resurgence" in rabies seen in China over the last 15 years is not spilling over into neighbouring countries, according to an in-depth  genetic analysis of rabies cases carried out by researchers at the  Chinese Center for Disease Control and Prevention, Beijing and Wuhan Institute of Virology.
The researchers analysed 3275 samples of dog brain tissue collected from dog meat markets across seven provinces of China. They found two main strains of rabies in 84 samples, and the strain appeared to have evolved form those seen in previous smaller Chinese outbreaks from the 1980s and 1990s.
However, apart from a few isolated cases of strains being picked up in neighboring countries such as Vietnam, the major strain responsible for the current Chinese epidemic has not been exported.
"Our observation of a dominant variant strain that is unique to China is significant in that it suggests that neighboring countries have not been seriously impacted by the epidemic. In spite of the increasing trade between China and other countries in South East Asia, it further suggests that current border controls remain effective at restricting the passage of infected animals … national geographical boundaries and border controls are effective at halting the spread of rabies from China into adjacent regions," they conclude.
Their genetic analysis found that the current rabies epidemic is dominated by variant strains of 'type B' rabies lyssavirus that originated in southwestern provinces such as Sichuan, and which were being translocated to provinces in eastern and northern China.
"It is the rapid economical expansion in China over the last twenty years that has probably had the most significant impact on the spread of rabies," they say.
"Prior to the plan for economic reform plan instigated by Deng XiaoPing, travel was more restricted and more commonly at the local level. Long distance travel was generally by train or bus and large scale transportation of goods only began to increase as the industrial infrastructure expanded. As the economy grew and relocation was more straightforward the population became more mobile. This likely facilitated the spread of [rabies virus] as people moved from villages to towns and cities, or between cities, transporting their dogs as part of the relocation process.
They say their theory is also supported by recent reports of rabies cases in Beijing where infected dogs were brought to the capital by migrant workers.
The researchers say dog meat markets are unlikely to be a major factor in the long distance spread of rabies as dogs are confined in living quarters and when transported to market and are not allowed to roam freely,as is the case with domestic pet dogs.
They say that domestic dogs are the main reservoir for rabies in China, and a government goal of eradicating rabies by 2020 will have to rely on widespread vaccination of domestic dogs if it is to be successful. There has already been some success seen with local dog vaccination programs against rabies in rural areas, and such programs should be extended beyond high prevalence areas and implemented nationally, they suggest.
Source: PLOS Neglected Tropical Diseases