China's pediatrician shortage to worsen with two child policy

by MICHAEL WOODHEAD

In Guilin's main children's hospital this New Year there were only three doctors on call to cover more than 30 beds for children - and a long waiting list - around the clock. Last year there were seven doctors but four have resigned.

Doctors at the hospital say there is a vicious circle - as more paediatricians resign, the pressure on the remaining doctors gets worse, and the speciality becomes even less attractive to other medical graduates. Speaking to local media, paediatricians say there problem is an increasing one for the whole of China. Paediatrics is an unpopular branch of medicine that finds few takers.

One of the reasons is the low income compared to other branches of medicine - paediatricians don't get the opportunity to make extra bonuses or commissions from surgical operations, prescribing drugs or providing medical devices.

Secondly there is the intolerable pressure from pushy parents of Little Emperors. Children with only minor illness are brought in by neurotic parents who demand attention and excessive or inappropriate treatment for their child. Doctors working with children say their parents and grandparents can be obnoxious - expecting immediate treatment and instant miracles for their spoiled child. This often leads to abuse, disputes, complaints and legal action between doctors and families.

Thirdly, paediatricians also struggle with what they call the "dumb patient" problem - unlike adults, children cannot explain their problem well, and therefore doctors need much greater clinical skills to be able to diagnose their illness.

The low income, high pressure and lack of respect means that paediatricians get little satisfaction from their work. Not surprisingly, many vote with their feet and leave.

The lack of child specialists means that the remaining doctors face 12 hour shifts every day - and have to work as many as 10 night shifts a month. Paediatricians are already exhausted and demoralised  - and they expect the situation to become even worse as two child regulations come into effect in 2016.

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."

Hypertension treatment outdated; Infants hit by Group B Streptococcal infections; Liver disease brings ruinously medical bills; Caesarean sections the norm; Li Keqiang unhappy with pace of health reforms

by MICHAEL WOODHEAD
Treatment of high blood pressure in China is quite backward because it is exactly that - treatment of just the raised blood pressure, with no attention to other cardiovascular risk factors. Cardiologists now emphasise that it is essential to treat a person's overall cardiovascular risk, not just focus on single risk factors such as blood pressure. But a study carried out in 274 hypertensive patients in Zhejiang found that  found that 28% were still smoking, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was above the national recommended level of 6g. The study also found that most patients were taking only one drug for high blood pressure, which was inadequate to control their blood pressure. Many were taking 'herbal' medicines that actually contained out of date and dangerous western antihypertensives such as reserpine. As the authors conclude: "The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management."

In Shenzhen, researchers at the Children's Hospital have shown that invasive group B streptococcal infection is an important pathogen in infants under 90 days old, resulting in in high mortality and neurological sequelae. The streptococcal infection strains showed strong resistance to clindamycin and erythromycin.

Liver disease is an expensive condition that often sees families facing ruinous medical bills in China. A study carried out at a Kunming hospital found that the average yearly cost of medical treatment for hepatitis B was 19,496 RMB, while patients with cirrhosis faced bills of up to 46,061 RMB. While public medical insurance helped pay for some of the costs, catastrophic health expenditure occurred for families affected by all these illnesses.

China's high rate of caesarean sections will be difficult to bring down to more healthy levels, according to researchers. In a  survey of a112,138 women they found the cesarean delivery rate was 55% and as high as 66% in some regions. Two thirds of the cesarean deliveries were scheduled and performed before labour  and about 40%%  were performed without any recognised medical indications. About 57% of the caesareans were done on request of the mother.

Meanwhile, the progress of health reform is obviously too slow for the Premier Li Keqiang. This month he has called for more medical reform measures to overcome 'difficulties' in the healthcare system. In written instructions he identified problems areas that needed attention, such as hospitals should be prevented from being "financed by drug sales" He also said that more effort should be given to reform of county-level hospitals and more serious diseases needed to be covered by medical insurance. His orders came after reform measures were introduced across all county-level hospitals and are now being piloted in 100 city-level hospitals.

CPPCC - what they're saying about health

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

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

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

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

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

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

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

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

• Baidu's CEO Robin Li says Baidu is looking at online appointment systems.

• China's first new advertising law in 20 years is expected to tighten up regulations around advertising of medical products and healthcare services .

• A Fuzhou doctor became a social media viral sensation when he was photographed working while hooked up to an IV infusion. Weibo users praised him for his dedication for working while sick. 

• International medical experts have expressed concern at China's crackdown on ketamine. While the drug is sometimes abused, it is also a very important and safe anaesthetic, and any restriction would be a major blow for safe surgery in poor countries, they say.

Nurses inadequately trained | Child physical abuse common | Coal use causes black lung

Nurses lack adequate training

Only one in seven nurses in China undergoes a three year undergraduate training program, and many lack adequate training, medical educators have complained. In a letter to the Lancet, Liu Fengxia and colleagues at the Fourth Hospital of Hebei Medical University say that they are worried by the fact that most nurses in China not receive standard nursing training. Each year only 30,000 out of 186,000 graduate nurses earned standard bachelor degrees, they noted. Most nurses received only diplomas after brief training. The lack of education and the stressful working conditions mean that poorly trained nurses could make mistakes in patient care - and their lack of training may also be a factor in triggering violence against health staff.
"Nurses are intermediates between doctors and patients. In our practice, we have seen misunderstanding and mistrust between patients and doctors most probably due to of the inadequate training of nurses. A more comprehensive training system for nurses is needed," they write.

Physical punishment of children condemned

China's high rates of physical punishment of children amount to a culturally-accepted high level of child abuse, researchers have said. A major review found that 36% of children in China experienced physical abuse from parents, typically in the form of slapping and spanking for disciplinary reasons. They said the rates of physical punishment in mainland China were significantly higher than in other Asian countries, where the influence of western methods of parenting was stronger. The researchers said physical punishment was "culturally accepted" within Chinese society because the Confucian philosophy of parenting, which endorses parents’ authority and filial piety, is still prevalent in the minds of Chinese parents and children.
"A well-known proverb “gun bang di xia chu xiao zi” (also translated as “spare the rod, spoil the child”) indicates that the filial piety is achieved by strict physical discipline of children," they noted.
They said China's high rates of physical abuse were concerning because of the known associations with poor mental health and harmful behaviors, such as depressive disorders, anxiety disorders, eating disorders, childhood behavioral disorders, suicide attempts, drug use, and risky sexual behaviour.

Coal use leads to black lung

China's high use of coal for fuel has led to high rates of pneumoconiosis and "black lung", researchers say. In a Dow Jones report, clinicians said pneumoconiosis was common in mining workers and other coal-related industries, especially as workplace safety rules were often ignored in China. masks could help prevent pneumoconiosis but were often not provided to workers, they noted. The number of people diagnosed with pneumoconiosis has risen sevenfold from 2005 to 2013 to about 750,000, at an average pace of 35% annually, according to official data. And while treatment is available, it is often unaffordable for many low paid workers, labour activists note.

Cancer treatment unaffordable | Drug pricing corruption | Premier tackles HIV stigma | Rare diseases not reimbursed | US medical exams popular in China

Public punchbag to pay son's cancer fees
In Beijing a man who cannot afford the Y700,000 ($114,000) medical bills for his son with leukaemia has offered himself as a public punchbag to raise money. The man called Xia Jun stands outside Guomao station and asks for 10 Yuan to be thumped. He says he has collected 10,000 yuan in one day without anyone taking up the opportunity to hit him.

Corruption on drug price setting cited as reason for abolition
The recent move to abolish price caps for prescription medicines was triggered by corruption in the agency charged with setting drug prices. Critics said officials in the National Development and Reform Commission (NDRC) were under investigation by the anti-corruption and bribery bureau under the Supreme People's Procurate for taking bribes. Pharma company executives said the current pricing system forced them to pay bribes to regulators to set higher procurement prices.

Premier lends support to ending HIV stigma
Premier Li Keqiang has shown public support for people with HIV and aimed to dispel prejudice and ignorance about the infection by visiting  a HIV clinic at the inspected Beijing You'an Hospital.
 For World AIDS Day, the Premier met HIV patients and healthcare workers and said the old attitudes of fear surrounding the topic of HIV must be abandoned and HIV patients need more care.

Rare diseases slip through the health insurance cracks
China's health system is not working for children with rare diseases, as their families face high treatment costs and no access to medical fee reimbursement, according to an article in the SCMP. One mother of a 3-year old boy with Langerhans cell histiocytosis (LCH) said his bills for diagnosis and treatment had reached nearly 200,000 yuan ($33,000), of which just 4,800 yuan ($780) had been reimbursed by the rural medical insurance scheme.

US medical exams popular in China
Thousands of China's medical students and young doctors are studying for the US Medical Licensing Examination (USMLE) that will allow them to practice medicine in the US. However, despite studying for up to 1500 hours for the exam, many of them say they are taking it to improve their medical skill rather than just to get a better paying job. Many Chinese students said the US medical exams taught them a more patient-centred approach and put more emphasis on communication and empathy rather than just rote-learning of medical facts. The test is also taken by many of the 60,000 foreign students studying medicine in China.

The crisis in paediatrics in China

by Michael Wodhead
In the US medical journal Pediatrics this month is an extraordinary editorial about the workforce crisis affecting the discipline of paediatrics in China.

The article written by Dr Zhang Shu-Cheng and colleagues at the Shengjing Hospital of China Medical University, Shenyang, says that few doctors in China want to be paediatricians because of the low pay and high pressure from pushy parents. Dr Zhang says there is a recruitment crisis affecting paediatrics in China, with many hospitals unable to fill positions.

The country has a shortage of 200,000 paediatricians, and this creates a vicious circle by creating additional pressure on those who do choose to work in this field. Because paediatricians are in short supply, they have to see high volumes of patients, leading to more errors and more dissatisfaction from families who feel their child's medical complaints are being rushed and ignored. This in turn leads to conflicts between families and doctors - especially as Chinese culture and the one child policy puts a lot of focus on the health and wellbeing of the child.

According to Dr Zhang and colleagues, much of the problem stems from the low pay and low status of paediatricians. They receive about 70% of the base pay of other doctors, and even less when it comes to the 'grey income' based on sales of drugs and income from procedures and other items. And yet despite these problems - and their causes - being well known to the government, nothing is being done, they lament. Many paediatricians are voting with their feet - moving into better paid or less stressful positions within hospitals, such as lab work or as administrators. Others change to different branches of medicine or leave clinical medicine altogether.

"Despite this crisis, little is being done by the Chinese government to stop the loss of pediatricians, by either increasing their pay, decreasing their job intensity, or attempting to prosecute the violence
committed against pediatricians. The government needs to play a leading role in dealing with this crisis by writing and implementing appropriate laws and establishing fair and objective third party
accreditation bodies. Increasing the investment in pediatrics from public finances, easing the pressure on pediatricians, eliminating the practice of physicians supplementing their income by selling medicines, and increasing pediatricians’ salary levels are possible steps that will lead to
more pediatricians willing to stay in the profession," they conclude.

Good news on infant mortality rates in China - but have the numbers been exaggerated?

by Michael Woodhead

The Economist [aka 'the Monetarist'] is impressed with China's socialist achievement in reducing rates of maternal and infant mortality over the last decade. 

The magazine this week cites a WHO report that praises China for reducing rates of infant mortality from 61  to 12 deaths per 1,000 live births since 1991 - meaning they are now one fifth of what they were in the time of Deng Xiaoping. Maternal mortality rates have also dropped by about 70% over the same period. The improvements are attributed to the introduction of universal health insurance  schemes that subsidise hospital care for maternity care - and also implementation of infant vaccination programs.

The Economist then raises a lot of questions about whether China's vaccination program is as safe and appropriate as it could be - mentioning the recent scare about hepatitis vaccine quality and the ineffectiveness of measles vaccine programs. It even makes an absurd suggestion that China should step back from blanket immunisation and instead test mothers for immunity to various diseases before vaccinating them accordingly.  The overall message, however, is that China deserves credit for a major improvement in mother and baby health.

Coincidentally this week a letter is published in The Lancet Global Health from Chinese researchers questioning whether the gains are as extensive as they seem. Dr You Hua and colleagues at the School of Public Health, Zhejiang University School of Medicine, Hangzhou, write that recent improvements in infant mortality have been confined to rural areas - with little change in urban areas despite much greater rises in standards of living. 

Like WHO, they also attribute the improvements in rural areas to the introduction of the New Cooperative Medical Scheme in 2003. The coverage of this scheme reached 97% of village hospitals in 2011 and the subsidies allowed pregnant women to access antenatal and postnatal services. The Chinese researchers note that maternal mortality rates fell from 65 to 27 per 100 000 between 2003 and 2011 in rural areas, but remained virtually unchanged in urban areas. They speculate that the lack of change in cities may be due to the influx of uninsured women from rural migrant worker families.

Dr You also questions whether the impressive reductions in maternal mortality reported by the government are authentic. She remarks that health departments are financially rewarded for achieving targets such as maternal and infant mortality - and punished for not meeting them. The officially reported figures may therefore be subject to 'inflation', she suggests.

"These reservations notwithstanding, it is important to call attention to the dramatic reduction in rural maternal mortality in China and the lack of progress in the urban maternal mortality. The levelling out of urban maternal mortality in China in the past decade calls for increased attention," the researchers conclude.

The Chinese Dream? A Hangzhou children's hospital tries to help poor families who can't afford to keep their children alive

by Michael Woodhead
An amazing article from a Hangzhou hospital reveals the appalling Dickensian situation that now exists in one of China's wealthiest cities, where sick children of the poorest rural migrant workers literally die in the streets from neglect. 
Dr Zhang Weifang of the Children’s Hospital, Zhejiang University School of Medicine writes about the efforts the hospital puts in to try provide medical treatment for seriously ill children of rural migrant families, most of whom are not covered by urban medical insurance cover. The situation arises because migrant families living in cities are uninsured or only covered by rural medical insurance policies that have meagre payouts and are not 'portable' to the city. The creates a problem when children become seriously ill with conditions such as leukaemia, congenital heart disease and oddly, scalds (the third most common serious problem they treat at the hospital). The hospital tries to treat such children and makes ad-hoc public appeals through the media and relies on donations from 'warm-hearted people'. It also seeks one-off funding from the government and from a handful of medical charities such as "Love Without Borders". The hospital has been modestly successful in soliciting funds in this way - bringing in almost 4 million yuan in donations in 2011. But to put that in perspective, that amount is only about 0.6% of the hospital's budget. And this did not cover the treatment costs of the most seriously ill children - the hospital also waived half a million in unpaid medical bills for the most severe cases. Nevertheless, most poor families are asked to medical fees pay upfront, in advance of treatment, and many simply can't afford this and "abandoned treatment".
As Dr Zhang writes: "At times, the hospital will reduce or remit the treatment cost for these patients. However, the hospital cannot afford to provide all the uncompensated care these children need ... We try to establish a long-term relationship with media and solicit contributions for low-income families. However, the situation is still far from perfect."
This, then, is the stark reality of China's lack of a health and social security safety net for its most vulnerable citizens. It also explains the huge disparities in health outcomes between China's wealthiest and poorest residents - a six-fold difference in child death rates. President Xi Jinping is often quoted in the Chinese media talking about the "Chinese dream". Martin Luther King had a dream of all Americans being equal, in which "the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood." Perhaps Xi Jinping could try realise the dream of all sick Chinese children being equal when it comes to getting hospital treatment.

Jumping the queue at Beijing hospital costs 200-600 yuan

by Michael Woodhead
Faced with the prospect of queuing for hours - or even overnight - for a registration ticket for admission to the Beijing Children's Hospital, parents are prepared to fork out up to 600 yuan to a scalper.
The going rate for a 5 yuan (80 US cents) registration ticket is 200 yuan ($32) for a general appointment and 500-600 yuan ($80-95) for a specialist appointment, according to the Beijing Daily newspaper.
To investigate the scalper situation a reporter from the paper went to the children's hospital foyer and posed as  parent seeking admission of their child for acute illness.  He didn't have to look far - in fact he didn't have to look at all, as he was surrounded by a group of three scalpers all shouting out offers of a variety of 'appointments' and proferring their business cards. They said they could supply registration tickets for appointments on any time and also for any department .
The conversation went like this:

Scalper: What department do you want - general or specialist?
Reporter: How much is a general ticket?
Scalper:  200 yuan. Can arrange any date within the next three months or next week. We have today, tomorrow ... you get the idea. Every day, every department.
Reporter: What about the 'named user ticket system' [similar to train ticketing, in which tickets are only valid for the user ID]?
Scalper:  No problem. We've been doing this for eight years. Just use my ID to get in the clinic, then switch when you get to see the doctor.

On the electronic screen in the hospital foyer there were almost 70 different clinical departments listed, and the screen showed that 90% were 'sold out' - no appointments available. Despite this, long lines stretched back from the registration ticket office window. One father from Shaanxi told the reporter he had been waiting all night without success, and so had turned to the scalpers to get a registration ticket for his sick child. He said he had seen at least ten scalpers operating at the hospital. Several of them were openly touting for business along the line for the registration office. Sometimes they helped each other out and 'swapped' tickets, sometimes they strove to undermine or 'outbid' their competitors. It was a very chaotic situation.
According to a spokesman for the nearby Yuetan Police Station, there were more than a hundred hospital scalpers operating in the area of the hospitals. Although they operated quite openly trying to 'recruit' customers in the queue, arresting them was not easy. This was because they had to be caught 'in the act' exchanging tickets and their illegal sale of tickets had to be confirmed by the person buying them - but most refused and fled. And even when caught, they scalpers faced a maximum of five days in detention and a 50 yuan fine. This was only a fraction of a single 'sale' of a ticket for 200-600 yuan, and thus was no deterrent, the police spokesman said. With no effective law this meant "social order is disturbed", he concluded.

Xian parents say government has suppressed findings of side effect damage from kindergarten antivirals

by Michael Woodhead
One of the top Xinhua stories this week is a report from Xian claiming that the local government in the city has suppressed or manipulated the results of health checks on children dosed with antivirals by kindergartens.
The report is a follow up on the shock discovery that two local kindergartens had been routinely dosing children with antiviral medication. The so-called "Yao Er Yuan" [药儿园] scandal (a pun on the Chinese name for kindergarten - You Er Yuan 幼儿园 - replacing one character with that for drug) was supposedly about schools dosing kids with antivirals to prevent them getting colds and to improve their attendance (and performance) at the schools. The practice was strongly condemned by health authorities, with the National Health and Family Planning Commission (NHFPC) issuing a warning that this kind of practice was strictly prohibited, and calling on all local authorities to conduct checks on kindergartens. 
The children attending the kindergartens involved were referred to local hospitals to undergo checks to ensure that there had been no untoward effects from having being exposed to the antivirals. However, some parents are now saying that the checks have been a sham and the results of health checks have either been fabricated or suppressed. One parent quoted by Xinhua is a Mr Zhu, who says that his five year old daughter had suffered from renal impairment and haematuria from the antivirals, but this had not been picked up by the official hospital checks. He took his daughter to another hospital for a check up and they found significant kidney damage, but this was not reported by the official hospital. Further investigation by Xinhua reporters found that there were several hundred children whose tests showed that had experienced adverse health effects from the antivirals, but the official government figure was just 65. Further investigation revealed other anomalies. Many of the tests results were identical, suggesting they were not genuine but just copies. Discrepancies were also seen in ultrasound scans of children, which experts again said were not genuine. One parent reported that when he took his child for a scan he was given the 'result report' even before she had undergone a scan.
A Xinhua reporter put these claims to the local government in Xian, which responded by saying that the investigation into adverse effects had not been concluded and any figures released were premature. They said the concerns raised by parents and the media would be referred to higher authorities, which would take the feedback as part of its ongoing investigation into the antiviral dosing of kindergarten children.
[Editor's note: it might seem odd that a Chinese government newspaper is highlighting apparent government malpractice ... there may be more than this than meets the eye, or perhaps it is genuine attempt to expose wrongdoing as part of Xi Jingping's campaign against 'formalism' and 'poor working styles'].

6 clinical stories from China

1. Abuse of prescription and over-the-counter drugs is  common among Chinese high school students, a study from Guangzhou has shown. The survey of more than 20,000 students found that more than one in twenty had abused medical drugs at some time. The most common drugs of abuse were analgesics (4%), followed by cough syrups with codeine (2%) and valium or tramadol (1%). Peer pressure was one of the major influences in illicit use of prescription and OTC drugs, and it was also more common in children who already smoked, according to researcher Dr Wang Hui of the Guangzhou Centre for Disease Control and Prevention, writing in the journal Drug and Alcohol Dependance.


2. The agricultural practice of burning straw is a major overlooked contributor to smog and air pollution in Chinese cities, say respiratory physicians from the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital. Burning straw caused PM2.5 levels to reach 194 μg/m3 in Nanjing, which far exceeded the daily average maximum allowable concentration of 75 μg/m3, they note in the American Journal of Infection Control. The pollution is linked to respiratory illness and infections such as pneumonia, they say, and thus needs to be regulated.

3. China has a north-south divide when it comes to hypertension in children, a new review has found. shows. Children and adolescents in the north China have hypertension rates of  18% (Beijing) or 23% (Shandong) whereas those in South of China including Shanghai and Changsha have hypertension rates ranging from 3% to 11%, according to researchers from School of Public Health, Shandong University, Jinan. The higher prevalence of hypertension in the north might be due to higher dietary salt intake they say in the International Journal of Cardiology. 

4. The inherited condition of highly-elevated cholesterol levels, familial hypercholesterolaemia, occurs in about one in 200 Chinese people but is rarely detected, a study from Jiangsu suggests. In a study of more than 9000 people they found that about 0.5% had the condition, which confers a very high risk of cardiovascular disease and early death. They suggest that screening to aid detection and family tracing is carried out by hospital cardiology departments.

5. Gastric cancers account for a fifth of all cancer deaths in China and are especially common in younger women, a study from Guangzhou has found. The review of more than 2000 cases of gastric cancer found that the malignancy was common in older men but was also frequently seen in women under the age of 40.  Most patients had advanced stage disease at diagnosis, suggesting that better detection and treatment of early gastric cancer  is needed.

6. Chinese children are at risk from inappropriate prescribing of medicines, say paediatricians in a letter to The Lancet this week. Dr Tang Wenchu and colleagues from the First People's Hospital of Huzhou University Medical College, Zhejiang, say about a third of medicines taken by children are indiscriminately prescribed, and children are also at risk because there are few paediatric formulations of medication in China. The lack of a national adverse drug reaction surveillance system also means that children may have side effects that are not acted on, they say.

Milk formula propaganda pushes Chinese women’s breast feeding rates down to 16%

by Michael Woodhead
Breast feeding rates among Chinese women have declined dramatically in the last decade, and are now as low as 16% for women living in urban areas, official figures show.
The proportion of women in China breast feeding up to six months declined from 67% in 1998 to 28%, according to an article in China Youth Daily.
Data from the National Health and Family Planning Commission show that breast feeding rates are now 16% for urban women and 30% is for rural women.
The dramatic reduction in breast feeding rates has been blamed on society attitudes, pressure from workplaces and extensive promotion of milk formulas to new mothers.
In theory, Chinese women are encouraged to breast feed with protections written into law that guarantee them two 30 minute breast feeding breaks at work without being penalized in their income. Breast feeding mothers are also guaranteed an additional one month of maternity leave by law.
However, although many women start breast feeding in hospital they soon stop because the reality of the workplace is that there is no encouragement to breast feed and often many obstacles. Most workplaces do not have places where mothers can breast feed and many women feel under pressure from employers against breast feeding.
The other major factor in deterring breastfeeding is the promotion of milk formula, experts say. Despite the introduction of milk formula advertising regulations in 2006, milk formula is still promoted aggressively and misleadingly to women in China. Claims are made that milk formula is ‘just as good’ as breast milk and more convenient.
Experts say it is difficult for public hospital maternity nurses and doctors to counter the extensive and well-funded ‘propaganda’ of the milk formula companies, which lead to many women being misinformed about the relative benefits of breast feeding and formula feeding. They recommend that breastfeeding should continue for at least for six months and up to the first birthday if possible.
Professor Zheng Lu of the department of community health at Tsinghua University said there was a need for more societal support for breast feeding. He said there was a need for nursing rooms in workplaces and other positive incentives for women to encourage breastfeeding.

Essential medicines for children not available in China

by Michael Woodhead
Essential paediatric medicines such as amoxicillin and salbutamol are often not available in Chinese hospitals or private sector pharmacies, and those that are stocked come with hefty markups, a survey from Shaanxi has found.
When researchers from Xi'an Jiaotong University surveyed a sample of pharmacies and hospital dispensaries to check the availability of 28 common paediatric medicines they found that less than 30% of the drugs on their list were available. The list included basic medicines such as antibiotics, analgesics, antihistamines and vitamins. Drugs that were not available included amoxycillin-clavulanic acid, ibuprofen, morphine and vitamin B6.
Writing in PLOS One, the researchers said this was a concern because when paediatric drugs are not available, doctors   may try adapt adult versions of the drug by using lower doses, which is dangerous. Or if the recommended drug is not available, doctors may substitute a less appropriate drug, they added.
They also found that the paediatric drugs that were available often had huge markup over and above the manufacturers selling price. Amxoycillin, for example, had a manufacturer's price of 6.20 yuan but was sold to the patient for 11 yuan,  a markup of 77%. Salbutamol had a manufacturer's list rice of 13 yuan but sold for 37 yuan to the public. The recommended treatment for chronic asthma,  beclomethasone, cost about 1.6 days’ wages, which made it unaffordable in the public sector hospitals especially as it is needed for ongoing treatment of a chronic condition.
Most of the high markups was due to  public hospital pharmacy profit margins.
The researchers concluded: "We recommend that relevant measures should be taken to enable children to obtain sufficient medicines and effective treatment at affordable prices. The government should adjust the prices of originator brands and lowest-priced generics and improve the efficiency of centralised medicine purchasing systems.
"We recommend urgently that the government should substantially improve public drug procurement and price management, making the procurement system more efficient and the pricing system more scientific, rational and transparent."

My top10 medical stories from China for Saturday 22 February

1. Smoking with a water pipe confers a 'profound' risk of chronic obstructive pulmonary disease (COPD) among people in south west China and also carries a high risk from passive smoking, researchers have shown.

2. Patients with pneumonia of unexplained origin should be promptly investigated for H7N9 risk factors such as exposure to poultry and they should also be given pre-emptive antiviral treatment such as Tamiflu, the Beijing health department has ordered.

3. About 85% of Chinese doctors experience burnout, with those who are younger, unmarried and working in emergcncy medicine having the highest risk of serious burnout, a study shows.

4. Fertility clinics in China need to become more patient-friendly as they are perceived as too impersonal and lacking in transparency and respect for patient informed consent, researchers say.

5. The stigma of mental illness in Chinese culture means that patients with schizophrenia often do not understand their medication and are unwilling to take any anti-psychotic medication, according to a study from the Guangzhou Psychiatric Hospital.

6. H. Pylori infection rates are over 90% among people in their thirties in Jiangsu, which may explain high rates of gastric cancer in the region, say researchers from Nanjing.

7. Babies in Shenyang have increased rates of neurodevelopmental deficits because their mothers were exposed to high levels of organophosphorous pesticides during pregnancy, according to a study in PLOS One.

8. Adenovirus has emerged as a significant cause of serious pneumonia in China, with a study showing that 5% of cases are attributable to the virus.

9.  People with tuberculosis are also at high risk of HIV, with rates of around 3% in groups tested in TB patients from Guangxi, Henan and Sichuan, say Chinese researchers.

10. A mediation service for patients involved in medical disputes with hospitals is to be launched in Shanghai and it will be open to patients where compensation claims exceed 30,000 yuan ($2900) regardless of whether the hospital refers them.

China's 60 million "left behind" children face neglect and poor mental health

by Michael Woodhead
More than 60 million Chinese children have been 'left behind' by rural migrants who move to cities and these children suffer from neglect and mental health problems, a new study has shown.
Research conducted by Dr Zhao Xue of the Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University has found that almost 60% of children in the rural areas were 'left behind'. This was a much higher number than expected and reflected China's "explosive growth" and shift to urban centres.
The survey of almost 1700 'left behind' children in rural Anhui found that they had higher levels of neglect, higher levels of social anxiety,  lower family function and poor quality of life compared to  children who lived with their parents. The problems were worse for girls perhaps because in Chinese society they have lower status than boys and thus get little attention, receive less physical and emotional support and have worse lives than boys, the researchers said.
However, left behind children tended to have lower rates of physical abuse than children who lived with thir parents. This might be becuse the escaped the "education by sticks" beatings from parents, the study authors suggested.
"These findings suggest that "left behind children' are currently in a relatively disadvantaged situation in Changfeng county and require more help from the local government and society to improve their life environment," they concluded.
The findings are published in Acta Paediatrica.

Clinical news in brief - from the journals

In 'grassroots' hospitals, knowledge about Parkinson's disease - its diagnosis and management - is very limited for both neurologists and patients, a study from the West China Hospital in Chengdu has shown. Neurologists lacked knowledge of non-motor symptoms, differential diagnosis, therapeutic strategy and appropriate indications of surgical treatment, although they were familiar with the motor symptoms of the disease.

Adenoviruses cause 10% of cases where children are hospitalised for severe diarrhoea in China, according to a study from the Capital Institute of Pediatrics, Beijing.

More than 95% of people in Jiangsu have inadequate levels of riboflavin in their diet, putting them at risk of anaemia, a study has shown.

High levels of arsenic in seafood - and especially shellfish - pose a risk to human health, researchers from Shandong have warned.

People with epilepsy who have been seizure free for at least two years may be able to come off their anti-epilepsy medication, neurologists in Chengdu has shown. In a study of 162 patents with epilepsy who slowly tapered off their medication, 23% had a recurrent seizure and had to re-commence medication.

Ovarian cancer is relatively uncommon in China and rates are in decline, a review by the Henan Cancer Research and Control Office has concluded.

China medical news for Thursday 30 January

Blood lead levels still hazardous for Chinese children
Blood lead levels for children have decreased in recent years but are still at unhealthy levels, a study carried out in 11 cities has found. The blood sampling survey of 12 000 children under six years of age found that average blood lead levels dropped by 16% (from 46μg/L in 2004 to 39μg/L in 2010). The prevalence of elevated blood lead levels dropped by 87% (from 9.8% in 2004 to 1.3% in 2010). Factors associated with high blood levels included eating popcorn, chewing fingernails, sucking fingers, being cared for at home or at a boarding nursery, the study in the World Journal of Pediatrics found.

Rise in China's caesarean rates 'alarming'
The overuse of cesareans is rising alarmingly in China and has become a real public health problem, a review by researchers in Beijing has concluded. The current national caesarean rate is near 40%, and there has been a rapid rise of cesarean sections in recent years, say researchers from the School of Public Health at Peking University. Nonclinical factors such as financial incentives for hospitals were considered as the main drivers fueling the rise of cesareans. However the change in health services to focus on specialised care and marginalizing primary care have also played a role, they say in the International Journal of Women's Health.  

Dengue fever changes in Guangdong
The pattern of dengue fever outbreaks in Guangdong is changing, infectious disease specialists have found. The disease appears to be becoming endemic although outbreaks are caused by the milder types of dengue, researchers report. The prevalance varies between 2-5% and serotypes are now more varied, according to the study in PLOS One.

Puberty arrives earlier for Chinese girls
The age of onset of puberty is now at least a year earlier for Chinese girls compared to those of 1984, a study from the Capital Institute of Pediatrics, Beijing, has found. The research in the World Journal of Pediatrics found that the age of onset of puberty for urban girls had decreased by 4.2 months per decade, and that of rural girls by 9.6 months per decade from 1980 to 2004.

Fish pedicures a hepatitis risk
Aqua pedicures where tiny fish nibble away at dead skin on bathers feet may spread blood diseases such as HIV and hepatitis B, a Ningbo newspaper says. Dr Wang Jiahua, a dermatologist at a local hospital, said there were risks of infection, citing a patient whose legs became hot and swollen days after his first fish pedicure.He suggested a one month interval between fish pedicures and antibiotic ointment to protect skin where wounds are found.

China's paediatrician shortage reaches crisis point

by Michael Woodhead
An article in Dalian's local paper the Peninsula Morning News has highlighted the real world impact of China's chronic shortage of paediatricians.
The paper notes that local children's hospitals have been unable to recruit paediatricians for some time, and currently had no replies to the latest 'situations vacant' ad for child doctors. In addition, many existing staff have resigned.
The "Bandao Chenbao" says the paediatric workforce problem is due to the familiar reasons of low pay, low status, high stress, long and inconvenient working hours  and danger of being assaulted by the public.
With starting salaries of little more than 4000 yuan a month, few are attracted to paediatrics when a similar income can be made from working as a 'baomu' (childminder) in Guangzhou. Insiders ask why would anyone go through 5 years of medical school then another three years of a masters degree and internship to do a job that pays so little and requires so much input in terms of paperwork and bureaucracy? In addition to the long period of study, paediatricians have a heavy burden of exams and also a huge amount of medical file paperwork to keep up with. And dealing with children, they are often the target of assaults and abuse from parents and family members when things don't go according to their expectations. Those who know the job say that it requires a lot of night shift work and working long unsociable hours.
The root cause of the problem is under-investment in the medical system and the low fees charged to patients. This means that there are few resources to support doctors and thus doctors must deal with a high number of patients each day. Inevitably with such as high throughput and scant resources, mistakes occur, and it is the doctor on the front line who gets the blame. It is a vicious circle as more doctors leave, so the remainder face even greater pressures.
The article says the situation is not confined to Dalian, but is a national problem that needs to be addressed by training more doctors but more importantly by putting more resources into the system to support doctors and reduce the number of patients seen per day.

Doctors warn of oestrogen in meat as Henan girl develops puberty at 4 years of age

by Michael Woodhead
Doctors in Henan says the precocious puberty reported in a 4-year-old girl may have been caused by her mother's use of oestrogen-like drugs while breatfeeding or by her intake of foods such as chicken that were high in added hormones.
The girl from  Pingdangshan is reported to have developed breasts and started menstruating at the age of four. She is now undergoing treatment at the local hospital but her family say they cannot afford the 2000 RMB cost of monthly injections that she will need until the age of 12 to counter the condition, according to a report from Xinhua.
The girl comes from a poor farming family in the mountainous and deprived Ruzhou country. Her parents say the puberty effects first started to appear when she was two years old. Her family took her to the local hospital but it was only a very basic clinic and the doctor there did not have the expertise to examine or diagnose a hormonal condition in a small child. She was only diagnosed properly when they took her too the city of Zhengzhou. Even at that early age, doctors said her skeleton resembled one of an 8 or 9 year old. The Zhengzhou hospital clinicians worked out a long term treatment plan for the young girl who was already showing signs of breast development and menstruation. However, her family struggled to find the 30,000 RMB needed to pay for monitoring tests and hormonal treatment.
A doctor involved in the case siad the girl was showing body changes at 3-4 years of age that would normally only start at 8-9 years of age at the very earliest. He feared that f the girl did not get proper inhibitory treatment she would suffer physiological damage and show premature ageing.
As to the cause of the condition, he said it appeared to be due to external factors rather than an inherited or innate disease. he speculated that the premature puberty might have been caused by early exposure of the girl to high levels of sex hormones such as oestrogen. This might have occurred as she was breast fed and her mother had used medicines that contained the hormone. In addition, the precocious puberty may also have been made more likely due to hormones in the food she and her mother consumed.
"We advise families that food such as chicken, beef, soya milk and egg white can all contain high levels of oestrogen and should be eaten in only small amounts by daughters in particular."