Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?

by MICHAEL WOODHEAD

In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

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

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

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

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

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

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

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

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

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

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

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

Today's Top 10 China medical news stories

1. China is to launch a national cervical cancer screening program to test 10 million Chinese women annually, the National Health and Family Planning Commission says. The move follows concerns about increasing rates of cervical cancer, especially in women under 35. China has 130,000 new cervical cancer cases a year and up to 30,000 deaths a year due to the disease.

2. Vaccination rates have fallen as much as 30% since the hepatitis B vaccine safety scare over the deaths of 17 infants, immunisation experts say. They said the drop in vaccination rates could put up to 500,000 infants at risk of serious vaccine-preventable diseases.

3. In a landmark study, Shanghai clinicians have shown that pulse oximetry is a simple and accurate method for detecting major congenital heart disease in newborn babies in China. Writing in the Lancet, they say the method should be used in all maternity hospitals.

4. Salmonella in China is becoming resistant to most antibiotics including ciprofloxacin, ceftriaxone and azithromycin, "posing huge threat to public health and infection control" say clinicians in the journal Antimicrobial Agents and Chemotherapy.

5. A Beijing doctor was punched by the husband of a pregnant woman who said the doctor had pinched her stomach and threatened to kill her. The woman admitted she had first cursed the doctor when she believed she had been ignored by him.

6. Seven leading hospitals in China have signed an alliance agreement to for a National Team to tackle difficult diseases.

7. Kindergartens in Beijing have been struck by the norovirus gastro bug and dozens of children are showing symptoms such as diarrhoea and vomiting.

8. Young Chinese people do not wish to pursue a career in the medical sector, as jobs in medical services were ranked lowest in a survey of desirable careers by recruitment site zhaopin.

9. Complaints about fake drugs and medical devices being sold online are the most frequent calls to the China Food and Drug Administration hotline.

10. Hospital clinics in Shanghai are overflowing with three-four hour waiting times and yet community clinics are sitting almost empty and 'general practitioners see few patients because the public has little confidence in the level of services provided, according to an article in China Daily.

Eight medical stories from China you should read

by Michael Woodhead

1. Beijing will start to enforce new anti-smoking laws with 200 yuan on-the-spot fines (up from 10 yuan) for people who smoke in public indoor shared areas, and institutional fines of 30,000 yuan (up from 5000 yuan). Cameras will be used to compensate for the lack of enforcement officers, especially after hours, the city government says.

2. The Chinese government has been accused of withholding medical care from dissidents. An article by Sophie Richardson in the WSJ says civil rights campaigner Cao Shunli is now in intensive care because she was denied access to medical care while detained for her efforts to promote a civil society.

3. A link has been found between damp housing in Shanghai and rates of asthma in children. Researchers from the University of Shanghai for Science and Technology say asthma symptoms could be reduced by 25% by simply keeping a child's window open at night.

4. A vaccine against enterovirus 71 developed by Sinovac Biotech has proved effective against EV71-associated hand, foot, and mouth disease or herpangina in infants and young children, according to a study in 5000 children done by the Jiangsu Provincial Center for Disease Control and Prevention, published in the New England Journal of Medicine.

5. Eating shark fin is not only cruel and bad for the environment, it is also a health hazard because of high mercury levels in the product, researchers from Zhejiang have shown. After testing samples of shark fin they found that up to 33% contained toxic levels of mercury.

6. Antibiotics are widely overused by parents in rural China, with more than 60% dosing their children with antibiotics bought over the counter, Shanghai researchers have found. Most parents were ignorant about how antibiotics worked and had little idea hat they do not help viral infections.

7. Migrant workers have little access to healthcare and many of them put off seeing a doctor for illness, a survey in Shanghai has found. Two thirds of migrant workers said they had never had a medical check up and nearly 40% said they had ignored symptoms because they couldn't get to see a doctor.

8. Health workers in Guangdong have completed a successful pilot trial of a cervical cancer screening program using the ThinPrep cytological system. The program offered Pap test cancer screening to more than 40,000 women, and found that improvements are needed in basic education regarding cervical cancer screening for young and poorly educated women.

What hope for preventing cervical cancer in China with no access to Pap tests or HPV vaccine?

An inflatable uterus in a Shanghai park aims to raise awareness of women's health

by Xuyang Jingjing
As World Cancer Day is celebrated on February 4, it is a sad reality that potentially life-saving cervical cancer vaccines are being kept from the Chinese mainland due to tight import restrictions and testing requirements. 


HPV types 16 and 18 are responsible for about 70 percent of cervical cancer cases. 

HPV vaccines have been available in Hong Kong, Macao and Taiwan since late 2006. But for vaccines, or any new imported drugs, to be sold in the mainland, new clinical trials have to be performed on mainland residents. Then the drugs are re-evaluated and reviewed by the State Food and Drug Administration before they can be imported, according to regulations.

 Some women who are aware of the vaccines and have the means to do so choose to get inoculated in Hong Kong. There are also many agencies that help mainland women book appointments in Hong Kong hospitals. Such procedures usually come in at around HK$3,000.

 Both Gardasil and Cervarix are given in a series of three shots over the span of six months, which means women have to travel back and forth. They could also take the other two shots back home and get injected at a local clinic, but strictly speaking this is illegal since the vaccines are not yet approved for the mainland. 


Zhou Zijun, professor with the School of Public Health of Peking University, said the purpose of such barriers is to protect the Chinese people while noting that every country has its own set of standards and procedures when approving imported drugs. This also serves to protect domestic pharmaceutical companies. 

But many doctors argue that these regulations are too stringent and may be keeping some good medicines out. The tests done in Hong Kong and Taiwan should have been sufficient, said Gong Xiaoming, a gynecologist at Beijing Union Medical College Hospital.

 He gave another example of an overseas pharmaceutical company that estimated it would cost around 100 million yuan ($16 million) to do all the clinical trials and evaluations to introduce a drug for ovarian cancer to the mainland, ultimately deciding it wasn't worth it and shelving the launch. 


"We should have standards when importing new drugs, but right now it seems the threshold is too high and is preventing us from using some good drugs," said Gong.

 The two vaccines started clinical trials in China around 2007. The first two stages of clinical trials have been concluded and have proven the safety of the vaccine. The third stage has been going since 2009, aiming to test the efficacy of the vaccines. But it could still take years, experts say.

 In the meantime, Chinese pharmaceutical companies have also started clinical trials for domestically-produced HPV vaccines. But it is unclear when any of these will start to be sold on the mainland.
Statistics from the Ministry of Health in 2011 showed over 130,000 new cases of cervical cancer in China each year, accounting for about one-fifth of all new cases worldwide. This translates to about 30,000 women in China dying of cervical cancer each year.

 n China, cervical cancer usually occurs among women over 35 years old, especially between the ages of 45 and 49, according to research carried out by Qiao Youlin, a leading oncologist and a professor at the Cancer Institute and Hospital of the Chinese Academy of Medical Sciences.

 Worryingly, recent years have seen reports indicating that the disease is becoming increasingly prevalent among women in their 20s.

 Most cervical cancer cases occur in central and western areas such as Shanxi, Shaanxi and Hunan, and more so in rural areas than in cities, according to a report released by the Center for Cancer Registry in January.


Besides vaccination, regular screenings are crucial for the early detection and treatment of cervical cancer. However, the biggest problem at the moment is that the general public, especially those in rural or poverty-stricken areas, lack awareness about the disease and the importance of getting regularly tested, said Gong. 


Chinese authorities have also been trying to raise awareness of breast and cervical cancer and have launched programs to promote screening. 

Between 2009 and 2011, China invested over 350 million yuan to screen for breast cancer and cervical cancer among women aged between 35 and 59 in rural areas. Over 11 million rural women were tested for cervical cancer and the country aimed to screen another 10 million in 2012. Whether this program was successful remains unknown.

 Despite the government's effort to promote screening, not enough is being done to ensure that the hundreds of millions of women who need the test are all able to receive it.

 The commonly used screening technique, the pap smear test, detects pre-cancerous and cancerous processes in the cervical canal. It requires skilled doctors to analyse cells for cancerous changes and is therefore more suited to developed countries where medical staff have decades of experience. 

It takes over 10 years to train a doctor qualified to diagnose the disease from the test, but China lacks both the training system and qualified doctors, according to Qiao. 

In 2008, Qiao and scientists from other countries announced in a paper published in The Lancet Oncology that they had developed a new test, named careHPV, to detect 14 high-risk types of HPV in about 2.5 hours.

 It took the team five years to develop the new test, which is considerably cheaper and faster than the currently used pap smear or HPV DNA tests. It is also much easier for medical workers to master. The new test, based on the Hybrid Capture 2 technology, is designed for low-resource areas and works in environments that lack water, electricity or modern equipment.

Qiao said that the new test has just been approved by the State Food and Drug Administration last year and will enter mass production soon. 

In 2011, the Cancer Foundation of China launched a research program that aims to prevent cervical cancer in ethnic minority areas. An ethnic minority county would be chosen respectively from Inner Mongolia, Yunnan and Sichuan where about 6,000 girls between 13 and 15 years of age would be inoculated with HPV vaccines.

 Qiao is hoping that the medical community in China could push for the vaccines to get approved as early as possible. "We are already seven years late. Who knows how many people have been affected during that time?" said Qiao.
Source: Global Times

China medical news in brief

Headache and migraine a problem for one in ten Chinese children

A study of 4812 children and adolescents in Shanghai, China has found that 10% experienced a headache in the past three months. Of those who had headache, 45% were classified as having migraine. with the highest rates of migraine found at ages 14 years and 15 years. Tension-type headache accounted for 29% of headaches, while  cluster and other headache were responsible for 6.2% and 20%, respectively.
Source: Clinical Journal of Neuroscience 

Zhejiang prostitutes have high HPV rates and cervical cancer risk

Two out of three sex workers are infected with high risk subtypes of HPV putting them at increased risk of cervical cancer, a Zhejiang study has found.
Cervical samples from almost 300 female sex workers  in Huzhou, Zhejiang, showed that the prevalence of HPV was 67%, compared to 19% in the general population. Among the different types of HPV found,  HPV-16 (29%) was the most prevalent, followed by HPV-58 (24%) and HPV-52 (21%), and these were significantly associated with abnormal cervical cytology. The rate of cervical abnormalities was also higher among female sex workers (21%) than among the general population (5%). Researchers from the Huzhou Central Hospital conclude that female sex workers in the city have a greater probability of being infected with high-risk HPV, and novel vaccines against HPV-58 and HPV-52 should be developed. Using condoms could reduce the risk of infection.
Source: International Journal of Gynecology & Obstetrics 

Jiangsu simplifies medical insurance claims

Medical insurance claims can now be settled on the spot for outpatients in  Jiangsu. Outpatients from 13 cities including Changzhou, Nantong, and Wuxi can immediately settle their medical insurance if they go to see a doctor with their medical insurance cards, according to Jiangsu provincial Human Resources and Social Security Bureau.
Source: Jiangsu China.


Gay men in Yunnan have high HIV risk

More intensive HIV and STD screening and prevention campaigns are needed for gay men in Yunnan, say researchers who found a high incidence of new infections. In an 18 month study of 378 seronegative gay men in Yunnan they found that 11 became infected with HIV and 15 were infected with syphilis. Subgroups at high risk included students, retirees and minority ethnic groups, say the researchers from the No.1 Hospital of China Medical University, Nanjing.
Source: BMC Infectious Diseases.