China medical news headlines - the week in focus

Health authorities in Kunming have ordered a school to stop forcing kids to have daily "antiseptic" vinegar throat washes to prevent infections. The order follows a series of revelations of kindergartens giving children unauthorised and often dangerous drugs to prevent infections. 

Pregnant women in coastal areas of China have been advised to avoid seafood because of high mercury levels, which have been linked child developmental problems.

A new 60mcg hepatitis B vaccine is effective in the 10% of Chinese people who do not respond to the standard hepatitis B vaccine, a viologist says. 

Chinese villagers have high rates of COPD because of cooking with coal in unventilated kitchens, a study from Guangdong has found. However, switching to biofuels and increasing ventilation can substantially cut rates of lung disease, the research showed.

Children in China suffer physical abuse from harsh parental discipline, a study has shown. Researchers from Shandong Normal University surveyed 2518 families and found that 15% of Chinese children experienced severe physical abuse such as being kicked, beaten with a stick, fist or belt or being knocked down by a parent. The study found that 80% of Chinese parents used verbal aggression to punish their children and 50% used corporal punishment. 

A careless patient left behind more than 30,000 yuan in a bag at the outpatients clinic of the Kunming Hospital Dermatology Department. Doctors say they were shocked to find the bag containing wads of 100 Yuan notes and handed it over to the police. Authorities have not revealed exactly how much money was left, but have asked the rightful owner to contact them with more details in order to claim the cash

Malaria is still a risk in Yunnan border areas with Burma especially between April and July, with new figures showing there are more than 10,000 cases reported.

The deaths of four hospital patients given intravenous drips this month are being investigated by authorities in Jiangsu. Yizheng People’s Hospital said three of the four patients had been given the same medicine, which wasn’t identified, but from different batches. The medicine had been withdrawn from use across the city and its producers are being investigated, yesterday’s Modern Express newspaper reported.

New non-interferon antivirals will not eliminate hepatitis C overnight, say Chinese experts

by Michael Woodhead
New antiviral drugs offer the chance to eliminate hepatitis C from China, but over-optimistic predictions need a reality check, says a leading Chinese virologist.
In an article in Gastroenterology, Dr Lai Wei of the Peking University People’s Hospital and the Beijing Key Laboratory for Hepatitis C and Liver Disease Immunotherapy says there has been a lot of hype about new pipeline drugs bringing about a "hepatitis C revolution". It is claimed that a whole new range of drugs soon to be released will be able to treat the intractable blood-borne viral disease much more effectively and quickly than current treatments - and most importantly without the debilitating side effects of current drug regimens based on interferon. It is said that drugs such as simeprevir and sofosbuvir will be able to cure hepatitis C infection in 95% of people after a single 12-week course of treatment. If this is true then these drugs could potentially have a major impact in China, which has one of the highest rates of hepatitis C in the world.
It is estimated at least 2% of the Chinese population - about 30 million people - have chronic hepatitis C infection. The disease burden for China in terms of hepatitis C-related cirrhosis, liver failure and liver cancer is huge.
Hepatitis C is a chronic disease, and many of those with the infection remain undiagnosed and untreated until it progresses and the severe consequences such as cirrhosis and liver cancer become apparent. In China fewer than 3% of people with the infection are diagnosed, and only half of those diagnosed get any treatment. And the treatment itself is not very effective or tolerable. The best available agents are peg-interferon and ribavarin, which can produce a 'sustained viral response' in about 70% of patients with a 24-week course - but only in people with certain types of HCV (genotypes 2 or 3). Treatment success rates are much lower for people who have HCY type 1, even with much longer treatment courses. The side effects of treatment resemble a very bad case of flu, and many patients simply cannot or will not tolerate these effects and stop treatment.
The appeal of the new anti-hepatitis C drugs is therefore obvious. They are more effective and bettwr tolerated. Within five years it is theoretically possible for all types of hepatitis C to be cured with a single course of treatment lasting as little as eight weeks.
The reality for China, however, is not so simple. There are three major barriers to eliminating hepatitis C from China.

1. First and foremost is the problem of identifying the 97% of people in China who have hepatitis C infection but are not diagnosed. This will require some kind of screening program - and this may be very expensive unless there is an accurate and affordable test available. Identification of hepatitis C also requires the public to be aware of the disease and that it can be treated.

2.If patients with hepatitis C are identified they then need to be able and willing to access treatment. Many people with hepatitis C live in rural areas. Even in cities, China does not have a sufficiently large medical workforce with the skills to accurately diagnose hepatitis C and provide appropriate tailored treatment and follow up. A major medical workforce expansion and education program would be needed.

3. The new hepatitis C treatments are not affordable for a developing country like China . The costs of the new anti-hepatitis treatments are enormous. In the US a single course of sofosbuvir costs $84,000. Some countries such as India and Egypt have planned low cost programs for antiviral drugs for hepatitis C. But even if low cost versions of these new drugs are produced generically, the costs of treating 30 million people will still be huge. There is also a question of whether the new drug treatments can be used in sub-groups of patients with hepatitis C such as those with co-morbidities, cirrhosis the elderly and most importantly, in children

In summary, China has potentially much to gain from the new era of hepatitis C treatment - but huge practical problems lay ahead in identifying people with the infection and getting them into treatment.

Chinese hospitals offer millions to poach doctors from Taiwan

Top medical specialists in Taiwan are reportedly being offered millions of yuan to work in mainland China, and scores of doctors are already taking up the offer to "moonlight" at the weekend.
The Focus Taiwan news channel makes the claim that doctors are being offered as much as 100 million yuan to relocate to the mainland, and there are already 50-60 "holiday knife jugglers" flying from Taiwan to China at weekends to perform surgery or give consultations at hospitals there.
Cardiac transplant surgeon Dr Wei Jeng (left), who is head of the Heart Center at Cheng Hsin General Hospital in Taipei said several Chinese hospitals had made him high-paying job offers in recent times but he had turned them all down.
However, he said many of his colleagues had taken up the offers of  mainland work and the current joke among local physicians that "if you try calling on doctor friends on the weekends, you'll find they are all on the mainland."
While the 100 million yuan claim may be hype, the reality is that doctors in Taiwan earn about NT$8,000 per clinic but can make up to NT$50,000 per clinic in China. And many are doing so. A doctor who used to be a senior manager at a Taiwanese-funded hospital in China said he knew of many Taiwanese doctors earning hundreds of thousands of Taiwan dollars a month by doing weekend moonlighting shifts in China. This has lead to fears of a medical brain drain. Dr Wei said the lucrative offers from China were taken up because the Taiwan national health insurance system paid doctors relatively poorly.
A spokesman for the health ministry acknowledged that 90% of doctors in Taiwan earned their main income from the national insurance scheme and it would be impossible for the health ministry to match the huge pay offers made by Chinese hospitals to Taiwanese medical professionals.
To try retain doctors, the the Taiwan government was planning to set up special medical tourism zones to attract private paying patients from overseas, he said.
Local doctors urged the Taiwan government to make the medical system more attractive to doctors by cutting down on paperwork and improving benefits.

New code of medical ethics released – and why it is meaningless

by Michael Woodhead
The most surprising thing about China’s new code of medical ethics released this week is how unsurprising it is.
The 39-item code of practice developed for medical practitioners by the Chinese Medical Doctors Association is a long list of banalities and the bleeding obvious.
It includes basic standards on doctor-patient communication and interactions that you would think should not need spelling out.
“The doctor should respect the patient and revere life,” the code states.
“The doctor should listen attentively to the patient and pay attention to their concerns and questions ... the doctor should ensure good communication with the patient, and respect the patient’s rational requests and choices” it says.
According to the CMDA, the code should be regarded as the 'Doctor’s Bible' and deserves to be studied continually.
The CMDA says doctors should understand that doctors and patients look at things from different angles, and doctors should try put themselves in patient’s position when in the consultation.
"The doctor is thinking about the diagnosis and the course of treatment. The patient however, is worrying about the cause of their illness, how long it will last, what effect it will have on their life and how much the treatment will cost," says CMDA director Li Feng.
If the patient does not listen to the doctor’s advice or does not agree with the doctor’s diagnosis, the doctor should ask questions to clarify the patient’s doubts and worries, she says. Patients should be asked to ensure they understand what is happening and asked if thy have further questions, she suggests.
Li Feng says doctors have a duty to show compassion to the patient and provide them with appropriate care.
Medical ethics means having 'charitable feelings of compassion and solicitude in the heart'. Doctors should have 'great love and warmth for patients in their hearts', she says.
This is all very well, and who would disagree with notions that doctors should respect the patient, listen to their concerns, care for them as best they can and maintain good communication? The real question is how doctors can be expected to do this in an environment where they have to see 60 patients in a single shift and can only spend a maximum of three minutes with each one? And how can the code address situations where doctors have a financial conflict of interest, such as when doctors work for hospitals where their employment contracts link  salary to the number of patients seen?
The code may useful in setting out the basic expectations of a doctor in black and white. But many of the 'standards' it sets are not only related to medical ethics or morality, but also to the health environment in which a doctor works. Respect, communication and attention to the patient are not only determined by a doctor's personal ethics - they are also dictated by the system in which they work. Perhaps China also needs a code of practice for the health system as well as the health provider.

Seven doctors jailed for accepting drug company commissions

by Michael Woodhead
Seven doctors from Baotou in Inner Mongolia have been found guilty and jailed for accepting sales commissions from pharmaceutical companies and other bribes.
The seven doctors are  heads of various medical departments at the Baotou No 6 Hospital and also include the chief physician for the hospital. They are accused of accepting commissions from pharmaceutical company representatives for amounts between 80,000 yuan and 710,000 yuan. The commissions were illegal and constituted bribes according to the law, the court heard.
Five of the doctors are also accused of accepting bribes for providing favourable medical and psychiatric reports in legal cases to help people get lighter sentences or avoid financial penalties in court cases.
The doctors were found guilty and sentenced to terms of imprisonment ranging from  18 months to seven and a half years, suspended for two years.
The doctors have appealed the severity of their sentences, disputing the amount of prescribing that was claimed in court.
A representative from Jiangsu Enhua pharmaceuticals was also tried for giving bribes of more than 240,000 yuan to doctors at the hospital in return for writing prescriptions. He was sentenced to three years in prison, suspended for four years, and fined 10,000 yuan.

Schistosomiasis test | Cancer snapshot | Stroke survival: six medical news stories from China

A simple and accurate test for schistosomiasis developed by Shanghai researchers could help in the eradication of the disease in China. The rSP13-ELISA method is an affordable serology test for markers proteins of Schistosoma japonicum. The test is highly specific, sensitive and affordable, according to researchers from Tongji University, Shanghai, in an article in Lancet Infectious Diseases this week.

 One in five Chinese people will develop cancer and 13% will die of cancer before the age of 74, data from the nation's cancer registries show.  The most common cancers in China are lung cancer, gastric cancer, liver cancer, oesophageal cancer, colorectal cancer, pancreatic cancer, breast cancer, leukemia and lymphoma, which account for 80% of all cancer deaths.

Chinese people with stroke are more likely to survive now than they would have five years ago, say researchers from the Second Military Medical University, Shanghai. A decrease in mortality from stroke probably reflects advancements in stroke care and prevention. With better survival rates, we should pay more attention to rehabilitation and quality of life for stroke patients. 

Two children in Shanghai have died from hand foot and mouth disease, the infection caused by EV71 enterovirus. The children were from migrant worker families and attended a Jinshan District care center blacklisted over hygiene issues.

Hospital are making large profits from mortuary services, the Global Times reports. Morgues are changing huge markups for services such as preparing corpses for burial and families typically pay 10,000 yuan for cremation and burying services. 

Cardiologists have dismissed internet claims that rubbing inside the elbow is  an effective way to treat people who have had a heart attack. The advice being circulated on social media sites claims that thromboses can be dislodge by  massaging blood vessel near the elbow.

Breast cancer is different in China:  women get it  at a younger age, are  less likely to have breast- conserving surgery and less likely to have positive oestrogen receptor cancers.

Undercover patients reveal poor standards of care in rural clinics

by Michael Woodhead
Rural health clinics provide poor medical care because the clinicians working in them have inadequate training, little equipment and poor working practices, a study based on sending 'undercover' patients has revealed.
Researchers at Shaanxi Normal University tested the quality of  care provided at village and township health clinics by measuring the responses to undercover patients who had been trained to mimic patients with angina or dysentery.
In an analysis of the content of  72 patient visits to 36 different clinics, the quality of the consulation was found to be very poor. The average length of each consultation was seven minutes, but only one and a half minutes was spent interacting with the patients - most of the time was spent writing prescriptions.
The village doctors made a correct diagnosis in only 26% of the consultations and were completely wrong in 41% of interactions. The most common incorrect diagnoses were ‘indigestion’ for the dysentery patients and ‘sprain’ for the angina patients.
Village clinicians asked less than 20% of the recommended questions for the health condition and  performed only 15% of the necessary examinations for the condition. Most of the questions were focused on prescribing a medicine. For the patients with chest pain, clinicians did not ask the crucial question about whether pain was radiating, and only 11% measured blood pressure.
Rural clinicians were poorly equipped to deal with conditions such as heart attack. For heart problems,  less than half said  they had the necessary equipment to treat moderate cases. Most had a stethoscope and blood pressure measuring equipment, but few clinics had an ECG monitor.
Medications were prescribed in 75% of consultations, but they were either unnecessary or harmful 64% of the time. The village clinicians often failed to refer serious cases, even when they got the diagnosis right.
The average cost to the patient was between 10 and 15 yuan, with most of this cost being for medicines prescribed.
Only 20% of the village clinicians had completed high school and most had only a rural physician certificate as a qualification. Most of their income was made from selling drugs or devices, with only only 351 yuan per their monthly income of 1355 yuan not coming from sales.
The researchers said it was clear that rural clinicians were not yet ready to act as the front line fighters in China’s primary care system.
"If recent reforms that expand access to rural health care are to lead to actual gains in population health, more attention should be paid to improving the quality of care delivered by the rural health system," they said.
"China has recently made enormous strides in providing access to health care for rural residents; however, efforts focused on improving the quality of care delivered by grassroots providers will be essential for reforms to lead to actual gains in health."
The findings are published in Health Policy and Planning.

New organ transplant network launched, transplants for foreigners banned

by Michael Woodhead
China's leading organ transplant specialist Professor Huang Jiefu has launched a new national network of  Organ Procurment Organisations to try clean up the organ transplant system in China.
Professor Huang also launched a new national voluntary organ donation registry, in a bid to move away from the corrupt 'organs for sale' system that has operated in the past.
Under the new system, organs will be assigned according to clinical need rather than according to payment or connections, and there will be severe penalties for doctors and transplant clinics that are found to be flouting the rules.
At an official launch by the National Health and Family Planning Commission in Beijing attended by representatives from WHO and the Red Cross, Professor Huang said that about 160 hospitals had now been approved to carry out organ transplants. In the past about 600 clinics had offered transplants for money, but under the new system any clinic that operates outside the official donor network will lose its license and doctors will be suspended. There is a ban on private organ donations for money and also a ban on procuring and giving organs from Chinese to foreigners.
However, Professor Huang said some provinces had been slow to join the new network and to play an active role in the new organ donor sharing system. He urged them to work more closely with the new system, noting that there were about 30,000 critically ill people in China who urgently needed an organ transplant. He also encouraged Chinese people to sign up for the new national organ donor registry, saying it was possible to amend or withdraw from the scheme at any time.

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.

Big changes seen in Chinese women's reproductive health

by Michael Woodhead
Chinese women reach puberty earlier, have children later, have more abortions and are much less likely to breastfeed than their mother's and grandmother's generations, a major new study has shown.
The generational changes in Chinese women's reproductive factors have been shown in data the China Kadoorie Biobank cohort study that recruited 300 000 women born between 1930 and 1974 from 10  urban and rural regions of China
The findings showed that the average age that women started menstruating declined from 16.1 years of age to 14.3 years. Not surprisingly given the one child policy, the average number of children Chinese women had fell from five to one (from six to one in rural areas). The average age at first birth increased from 19 years to 26 years in cities and from 18 to 24 in rural areas.
Breastfeeding rates and duration of breastfeeding also showed major declines in both urban and rural women.
The proportion of women having an abortion increased so that 68% of urban and 48% of rural women had a  pregnancy terminated after 1980.
The average age for onset of menopause increased from 48 to 49.3 years.
The researchers said the changes not only affected women's reproductive health but also may have an influence on their risk of breast cancer and cardiovascular disease rates.
The findings are published in the International Journal of Epidemiology.

Tuberculosis in China - the good news and the bad news

by Michael Woodhead
China has succeeded in more than halving its tuberculosis prevalence with a major campaign launched in the 1990s, according to a new report from the Chinese Ministry of Health.
The campaign produced dramatic reductions in tuberculosis because it shifted treatment out of hospitals and into the community via public health centre TB dispensaries, according to an article published in The Lancet this week.
The report assesses the impact of China's tuberculosis control program based on the directly observed treatment, short-course [DOTS] strategy which was scaled up to cover half the population during the 1990s, and to the entire population after 2000.
Between 1990 and 2009 the prevalence of tuberculosis fell from 170 cases to 59 cases per 100 000 population. The decreases were attributable to the program because declines were only seen in areas where it was operating in the 1990s. The reduction in tuberculosis was greater after 2000 than the 90s (57% vs 19%), with 70% of the total reduction in tuberculosis seen in the last decade.
The proportion treated by the public health system using the DOTS strategy increased from 15% of cases in 2000 to 66% of cases in 2010.
The health ministry said China had shown that it was possible to achieve ambitious targets in reducing tuberculosis, which had not been achieved in other developing countries. However, despite this success, China still had an estimated 1 million new tuberculosis cases in 2010.
China now faces the problems of a widening urban-rural gap in tuberculosis prevalence and tuberculosis not being picked up in hospitals. Also, further reductions in tuberculosis prevalence are likely to be less impressive because the DOTS program is more effective in reducing the prevalence of tuberculosis in known cases than in new cases, and the number of known cases is now low.
Therefore other control efforts in addition to the DOTS strategy need to be implemented, the report authors say.
Another problem is that the cost of treating tuberculosis is becoming prohibitively expensive for patients due to hospital profiteering, according to another report released this week. The study by Chinese and international researchers found that many patients are being treated at hospitals with second-line drugs when they should have been treated with first-line drugs in community TB dispensaries. The reason for this seems to be because hospitals want to retain patients to make more profits, the researchers surmised.
The study also found that patients faced crippling costs for treatment despite China's supposedly free TB treatment policy and despite most patients being covered by medical insurance. Insurance coverage for outpatient care generally reimbursed only a small percentage of fees and the free TB treatment policy does not cover costs on auxiliary examinations, drugs and hospitalisation, the report notes.
"A large proportion of patients borrowed money for TB care, and incurred catastrophic expenditure due to TB care," the researchers said.

SFDA begins "five rectifications" campaign against dodgy medical devices

The China State Food and Drug Administration has embarked on a "five rectifications" campaign against sub-standard and fake medical devices such as catheters, condoms and contact lenses.
After a half year investigation into the medical devices sector, the SFDA has launched a campaign to crack down on illegal manufacture of medical devices, illegal sales, false claims and misuse of five kinds of medical products.
The "special action" will focus on areas such as disposable infusion equipment that is re-used such as single use catheters. It will also focus on the manufacture and sale of fake and sub-standard condoms, which is a major pirate industry in China. Other areas where illegal activity is rife include the sale of unlicensed cosmetic contact lenses, hearing aids, and diagnostic aids for diabetes and hypertension. Devices that claim to cure back pain and myopia will also be included.
Th SFDA says its crackdown will apply the severest penalties for anyone involved in manufacturing, selling and promotion of fake and substandard medical devices and also for those making false claims including the use of medical 'experts' and those who use the names of famous institutes to endorse such products.

What's in the budget for health? Highlights from China's NPC budget announcements

by Michael Woodhead
Unlike political parties in the west, China's ruling Communist Party does not have to publish an election manifesto with budget commitments or account for where it has allocated its budget spending. However, following the recent National People's Congress meeting in Beijing, the Party has released some 'budget statements'. They're pretty vague and there isn't anyone or any agency to check on the figures, but this is what they had to say about health:

The background:

1. Spending on medical and health care last year amounted to 259 billion yuan, 99.4% of the budgeted figure and a 26.4% increase.

2. We raised government subsidies for the new rural cooperative medical care system and basic medical insurance for nonworking urban residents to 280 yuan per person per year.

3. Most provincial-level administrative areas unveiled plans to introduce serious illness insurance for their rural and nonworking urban residents.

4. We increased the standard of funding for basic public health services to 30 yuan per person per year, and continued to support major public health service projects.

5. We made steady progress in the pilot reform of county-level public hospitals and the comprehensive reform of community medical and health care centers, and launched a pilot program for posting general practitioners in such institutions.

6. We moved ahead with developing a system for providing assistance in dealing with medical emergencies.

What's next?

- First, we must facilitate the reform of the medical and health care systems. In line with the requirements for each year's work set forth in the plan for deepening the reform of the medical and health care systems during the Twelfth Five-Year Plan period, we will increase government subsidies for the new rural cooperative medical care system and basic medical insurance for nonworking urban residents from 280 yuan to 320 yuan per person per year and accordingly increase the annual individual contribution from 70 to 90 yuan per person.

- We will more quickly push ahead the work of insuring rural and nonworking urban residents against serious illnesses to further reduce their burden of medical expenses.

- We will increase input in medical assistance in urban and rural areas, expand access to such assistance, and provide assistance to those suffering from serious mental illness.

- We will increase financial input in public health, continue to implement basic and major public health services projects, and raise annual per capita spending on basic public health services to 35 yuan.

- We will continue with the trials on comprehensive reform in county-level public hospitals, and develop better policies of subsidizing community medical and health care centers to motivate them and their staff to enhance their services in terms of both quantity and quality.

But wait, there's more:

* We will abolish the practice of compensating for low medical service charges with high drug prices, adjust the prices of medical care and drugs, and create a mechanism for running hospitals by nongovernmental capital.

* We will consolidate and improve the system of using basic medicines and the new mechanisms for operating community-level clinics.

* We will improve the system of tiered medical services, strengthen training of general practitioners, and allow doctors to work in more than one medical institution so that people have easy access to quality medical services.

* We will build harmonious relations between doctors and patients.

* We will improve our capacity to prevent and treat major communicable and chronic diseases and occupational and endemic diseases. The government subsidy for basic public health services will be increased to 35 yuan per person.

* We will support the development of traditional Chinese medicine and the traditional medicine of ethnic minorities.

* We will unwaveringly adhere to the basic state policy of family planning and will implement the policy that allows married couples to have two children if one parent is a single child.

* We must resolutely press ahead with medical reform and work out a Chinese solution to this global problem so that the Chinese people can enjoy a happier and healthier life.

So there you have it ....

Illegal ambulances in Beijing ... dogs spread H7N9 ... new vaccines for EV71: eight medical news stories from China

by Michael Woodhead

1. Illegal ambulances in Beijing
One of the most bizarre stories of the week is that of the 'fake' ambulances plying their trade around Beijing hospitals. After hearing about fake drugs and fake doctors being widespread in China it should not come as any surprise to hear that shanzhai (山寨) unofficial ambulances are also operating. According to the Beijing Times the illegal ambulances park near major hospitals in the city and offer their transport services to patients. It is said that the poorly-equipped unofficial ambulances work in collusion with the hospital staff (who receive commissions) to charge patients exorbitant prices for transporting patients to and from hospitals and as transfers between hospitals. "Security guards at many hospitals have tried to stop these illegal ambulances from operating in and around their facilities, but they are afraid of being sued by patients and family members for delaying medical treatment," the article says.The unofficial ambulances have found a gap in the market because there is an insufficient number of genuine ambulances, the article says.

2. Dogs spread H7N9
Feral dogs that live around poultry farms and live poultry markets may be a key to spreading of the disease, say researchers from South China Agricultural University, Guangzhou. In a study of 2357 dogs, they found that 4% showed evidence of influenza A infection (though not specifically H7N9). Writing in Clinical Infectious Diseases, they said that feral animals "may increase the risk of the emergence and transmission of novel influenza A viruses and serve as a threat to both veterinary health and human public health ... As man lives in very close contact with dogs in many areas of the world,we posit that surveillance for novel viruses among feral dogs living in close proximity to
live poultry markets or poultry farms could serve as an early warning system of viral threats to man."

3. Zhejiang markets ground zero for avian flu
In the same vein, researchers in Zhejiang have found that poultry kept in local markets carry a veritable cocktail of influenza viruses including H7, H9 and H5 and two NA subtypes (N9 and N2), as well as H7N9-related reassortment intermediates H9N9. "The co-circulation not only reveals that Huzhou is one of the geographic origins of the novel H7N9 virus, but also poses a potential threat to humans in the future," they conclude.

4. Hand foot and mouth vaccine in the pipeline
More optimistic news in relation to another virus, namely EV71 enterovirus, the causative agent fro hand foot and mouth disease. A review article from the Third Military Medical University and National Engineering Research Center for Immunological Products, Chongqing notes that China has developed three promising vaccines against the disease that have passed Phase III trials, and are expected to be available in the near future.

5. Antivirals in more kindergartens
The scandal over the drugging of kindergarten children with antivirals is widening, with claims that a kindergarten in Jilin has also been giving the drugs without parental consent. The initial reports from Shaanxi that children were being given antiviral prophylaxis supposedly to prevent coughs and cold have justifiably caused outrage among parents. The odd thing is why such an obscure antiviral as the biguanide moroxydine was chosen to give children.

6. Ulcers from fat injections
A 38-year old Beijing woman is taking legal action against a Chaoyang health and beauty spa for half a million yuan in compensation after the "fat dissolving injections" she was given resulted in severe ulcers. In a court case the woman said the 'medical' staff at the clinic were unqualified and the "no side effect" lipolysis injections turned out to be albumen that triggered allergies and skin ulceration requiring skin grafts.

7. Gay 'cure' clinics do thriving business
The Economist has a feature on the 'homosexuality cure clinics' in China, where people can pay around $1700 or a three month program of psychological treatments that supposedly deter them from having gay tendencies by giving them unpleasant injections and treatments in while watching sexual imagery. The clinics are said to be encouraged by the Confucian social pressure to be a good child and conform with traditional Chinese values.

8. Fake medical ads still widespread
And while we are on the subject of dodgy treatment Xinhua reports that advertisements for fake and worthless remedies and clinics are as widespread as ever, despite laws intended to crack down on the. In a long article, Xinhua reporters describe how newspapers are still full of ads for fake treatments or treatments for which exaggerated claims are made. Industry insiders said the marketing of fake medical products and services was a high profit, low risk business as there was little enforcement. Government departments said fake products were widespread and it took a lot of time and resources to track them down and prosecute offenders.

Denial of medical treatment to government critics is "callous and calculating" - Amnesty

The Chinese government is using denial of medical treatment as a way of punishing critics, says Amnesty International, following the death of Cao Shunli in Beijing.
Ms Cao was a legal rights activist who was imprisoned for five months after trying to go to Geneva to attend a human rights training course. She died of organ failure on Friday at a hospital in Beijing, shortly after being released from five months in detention.Her family say authorities rejected repeated request for Cao Shunli to receive medical treatment for serious health problems. She had tuberculosis in both her lungs, cirrhosis of the liver and uterine fibroids.
Cao Shunli faced charges of “picking quarrels and making trouble” after organizing a sit-in protest along with other campaigners outside China’s Ministry of Foreign Affairs.
Amnesty said the Chinese government should allow all detainees to access medical care, and the case of denying it to Cao Shuni was reprehensible.
"Cao Shunli's death exposes just how callous and calculating the Chinese authorities are prepared to be to silence critics. The authorities today have blood on their hands." said Anu Kultalahti, China Researcher at Amnesty International.
"Cao Shunli was a courageous woman who paid the ultimate price for the fight for human rights in China.  She should have never been detained in the first place; but to then deny her the medical treatment she desperately needed is a most barbaric act.”
Her death has prompted criticism from the UK and US governments, but has not been reported in Chinese media. The Chinese government has made no comment on her case and blog and social media posts about Cao Shunli have been censored in China.

Chine medical news headlines for Saturday 14 March

Beijing has set up a medicines information service to give patients advice about how to take their medications and what the side effects and interactions may be. The service set up by the Anzhen Hospital claims to be the first in the country, and is needed because only 15% of patients unrest and the information leaflets that come with medications, it's founders say.

Renal cancer is fast becoming one of China's 'silent killers', affecting many otherwise healthy people, oncologists have warned. Rates of the disease are growing by about 6% a year, they say.

A dedicated Guangzhou doctor who has developed leukaemia has received many contributions to his treatment costs from grateful former patients and colleagues. Dr He of the Nanfang Hosputal is known as the 'all weather doctor' for his long shifts.

The northeast city of Changchun will start to implement strict new anti-smoking rules for public areas. Authorities have warned all government departments that they must strictly enforce the rules and fines.

China's shortage of paediatricians can be attributed to three factors, say experts in the Lancet this week.  One reason is the lack of recognition of paediatrics as a specialty branch of medicine, and the other is the strong pressure that paediatricians face from families in consulting rooms. The third reason is that paediatricians prescribe fewer drugs and tests than other branches of medicine, and thus income is much lower than other specialties, the doctors say.

The State Food and Drug Administration has blacklisted 10 companies selling fake medical devices via websites. The companies posed as well known manufacturers to seel devices for high blood pressure, infertility and epilepsy.

In China, the identities of top medical specialists are being ‘pirated’ by imitators

(Pic: genuine doctors from Wuhan)

by Michael Woodhead
In many hospitals in China the “visiting specialist” all too often is a sham. The names and reputations of top specialists in areas such as dermatology and andrology are being hijacked by imitators – including many smaller regional public hospitals.
Leading specialists are complaining that their identities are being ‘borrowed’ by a wide variety of imitators and institutions, ranging from the blatantly fraudulent imposters to the deceptive and misleading government hospitals that wish to enhance their reputation and drawing power.
According to Xinhua, one Beijing dermatologist says he receives many letters of complaint every year from angry patients from all over China who he has never seen. They claim to have been treated by the dermatologist at one of his “visiting clinics” and say his treatments were worthless and demand their money back. Of course, the dermatologist has never conducted any such clinics outside of Beijing, and the patient has been duped by imitators who have stolen his identity. The dermatologist says that some imitators are quite blatant and his students have even seen the fake ‘him’ wearing a white coat and consulting patients at small clinics with his photograph displayed outside.

"China flooded with medical imposters"
The problem of medical identity theft is acknowledged by the Chinese Medical Association and also by skeptics such as Zhong Nanshan, who says the problem is widespread and that China is flooded with false doctors and false clinics. They have called for a crackdown medical fraudsters, but until now this has not had any effect on the problem.
The CMA says medical specialties such as andrology, infertility, obstetrics, gyanaecology and dermatology are the most popular targets for imitators.  Andrologist Professor Lu Guo said his colleagues recently asked him why he was advertising clinics in the newspaper of a nearby city. He told them he had not placed any such adverts. He followed up and actually went to the clinic that was advertised and found a large queue of patients waiting to see the imposter, whom he challenged – but found he was powerless to do anything, as the man was an itinerant who quickly disappeared.
Another well-known medical specialist, Professor Li Furen, found that an imitator had taken out large newspaper advertisements for pills that included his photo and biography. When he complained to the newspaper and the company involved he found he was powerless because the company had trademarked his own name!

Three kinds of medical identity theft
Experts say there are three basic kinds of medical identity theft. The first is the straightforward imposter, who uses the photo and biography of a well known medical specialist to advertise ‘visiting clinics’, typically in a regional area where people are less well informed and likely to be impressed by a top specialist visiting from a major hospital. These imposters may or may not be genuine doctors, they put adverts in local papers and posters up at the local hospital or clinic. This kind of imposter is very common and difficult to stamp out. They often prescribe inappropriate or fake medicines and charge patients for unnecessary tests.
The second kind of medical identity theft is done by smaller public hospitals wanting to enhance their reputation. These hospitals search the internet for leading specialists and download their photos and details, which they post on their own website, claiming that the specialist is a “visiting professor” (although the doctor never visits). This attracts more patients to the hospital and also makes the hospital appear more authoritative to other doctors.
The third kind of reputation theft is when hospital managers and lesser-known doctors attend conferences and have their photo taken with a top specialist. They then display the photo prominently in their department, saying that this eminent doctor is a ‘consultant’ at the hospital.

Punishment is too light, no deterrent
The top specialists who are affected by this kind of identity theft say it causes harm to patients and themselves. Patients receive poor and inappropriate treatment and are often ripped off and overcharged for fake or substandard treatments. “It is like rubbing salt in the wound” says one doctor. Another uses the Chinese saying “Hanging up a sheep’s head and selling dogmeat”.
The other harm is to the reputation of the genuine doctor. Specialists whose identity is stolen say they are accused of fraud, malpractice and receive legal letters demanding compensation. However, there seem to be no effective action being taken against fraudsters, they say. Offenders found guilty of medical fraud can incur a fine of up to 10,000 yuan, they note – but for many of those involved these fines are rarely imposed and the actual fines are lower and prove little deterrent to this lucrative business.
The other problem is that offenders are often local government departments that control local hospitals, and there is reluctance among their local government colleagues in inspection departments to take action against them, in order to preserve harmonious relations.
Another reason for medical identity fraud to go unpunished is that most patients do not complain – they only do so if they suffer a major adverse event or become very sick. And with ‘visiting specialists’, many patients who are swindled do not know which relevant department to complain to.

Reforms will worsen the problem
One specialist, Lin Xiaobo is urging the public to be wary of medical swindlers and encouraging them to post details of ‘visiting medical experts’ on social media sites such as Weibo and WeChat to expose them. He also wants government departments and legal authorities to take stronger action and impose heavier fines on the fraudsters. However, he worries that the problem will become worse as the government health reforms encourage public hospital doctors to branch out into private clinics.
“As these private clinics proliferate, how will the public know whether the information about their doctors is genuine or not?” he asks.

Seven China medical news snippets for Thursday 13 March

1. Antivirals at kindergarten
Children at a kindergarten in Xian have been treated with an antiviral without the knowledge of their parents. Parents were furious to discover their children were dosed with moroxydine thee days a week supposedly as prophylaxis to prevent viral infections, at the direction of a doctor who was only licensed to practice in Guangdong.

2. Private health eyes China profits
Private healthcare operator Concord Medical says it sees huge potential in the Chinese health system reforms. The group already owns 144 medical centres and the Chang'an Hospital in Xi'an, and is now building three high-end specialty cancer hospitals in Guangzhou, Beijing and Shanghai.

3. Stroke risk with high normal BP
Cardiologists in Guangzhou have shown that pre-hypertension (systolic BP of 120-140mmHg) is a risk factor for stroke. Their research showed that low range hypertension increased stroke risk by 44%, according to the meta-analysis published in the journal Neurology this week.

4. Needlestick risks in Chinese hospitals
Doctors and nurses in Chinese hospitals face high risks of blood-borne infections because of poor needlestick injury prevention practices, a study has found. Doctors faced a high risk of infections from suturing needle accidents while nurses often had needlestick injuries with syringes and IV infusion sets,w ith an average of two injuries per year, a study in the American Journal of Infection Control showed.

5. Medical article fraud
A doctor in Hainan has been jailed for eight years for fraud after it was discovered he wrote 11 medical articles and dissertations for others. The doctor charged about 12,000 yuan for each article.

6. Knee OA undiagnosed
Knee osteoarthritis is common among elderly people in Guangzhou but often goes undiagnosed and untreated. A study of elderly inpatients at a city hospital found the prevalence rate of knee arthritis was 10% in males and 38% in females. Only about half of patients were aware they had arthritis, and among these only 77% had adequate treatment.

7. Dust full of carcinogens
Inhabitants of Guangzhou are exposed to toxic levels of arsenic and chromium in PM2.5 particle in dust, a study has found. Using hair analysis, researchers from Sun Yat-sen University, Guangzhou found that Guangzhou residents had high and carcinogenic levels of accumulated metals and other toxic elements.

Hospital scalpers: where China's health system meets the black market

The southern Chinese city of Nanning in Guangxi province has launched a campaign against 'hospital scalpers' - the touts who offer patients and their families a chance to jump the very long queue for treatment. 
In a proclamation the city authorities said they had started a crackdown in order to "protect the security of the masses seeking healthcare treatment." In its official warning the Nanning City Health Inspection office said that hospital scalpers were swindlers who often hang about outside hospitals, on the periphery of clinics and also in public areas such as bus and train stations - and even in the lobbies of hotels near to major hospitals. The scalpers use deceptive and illegal means to lure victims into 'taking the wrong path' and avoid the long and frustratingly bureaucratic process by which patients must queue to get a registration number and then pay a deposit for a clinic appointment. According to the city health department, scalpers deceive patients and direct them into poor quality services often run from illegal clinics by unlicensed practitioners. Scalpers are also notorious for using threats, extortion and for overcharging, even to the point of robbing their victims. In the Nanning warning advice, city authorities give some examples of the scalpers' typical modus operandi.
Firstly, the scalpers target the busiest clinics and look out for gullible victims who appear to be in a hurry and unfamiliar with the system. The scalper is friendly and solicitous initially, advising the patients and family members that the official clinic is expensive and extremely busy and the service is poor. Sometimes they say the doctor on duty has a poor reputation or that the clinic is dirty and has poor hygiene. They then tell the victim that there is a better clinic nearby where they have connections and can get a quick appointment.
The scalper then personally escorts the victim to the nearby clinic, where the 'doctor' and staff do many unnecessary expensive tests and prescribes some very common and cheap medicine but charges a high price. These clinics often have signs claiming to be affiliated to military hospitals with a good reputation, and the staff say bad things about the genuine hospitals.
The advice from the Nanning health department is for patients to only attend genuine hospital clinics and to be wary of strangers around hospitals who make unsolicited approaches asking about illness and offering unsolicited medical services and personal introductions.

Coal burning and tuberculosis make COPD a common condition for non-smokers in China

In western countries chronic obstructive pulmonary disease is seen as predominantly a disease of smokers - and the only way to halt its progression is to stop smoking. 
In China however, thousands of non-smokers shows signs of non-reversible airways obstruction - and the reasons seem to be the country's ubiquitous use of dirty coal for cooking and heating. A study of 300,000 Chinese adults who have never smoked has found that one in twenty (5%) have COPD, with the condition more common in women than in men.
The main factors associated with COPD were low income, lack of education, living in a rural area and a prior history of tuberculosis.   However, another major factor was cooking with coal.
The study researchers, from the Chinese Academy of Medical Sciences, Beijing, and Oxford university, said the link between low income and lung disease might be due to higher exposure to infections and to air pollution.
The findings are published in the European Respiratory Journal.

The stark reality of Chinese healthcare: pay up or die

by Michael Woodhead
The case of a Wuhan doctor who paid 26,000 yuan (US$4300) in medical expenses for a critically ill young man out of his own pocket has highlighted the grim reality of the 'user pays' medical treatment in China.
The Beijing News reports the case of a doctor called Hou Lixing who paid the medical bills for a 17-year old impoverished youth who needed an urgent blood transfusion and operation for a intestinal  haemorrhage. The report says the youth known as Xiao Zhou was a migrant worker who had come to Wuhan to find a job to help pay for the upkeep of his ailing grandfather. However, at the weekend he was taken ill with severe abdominal pain and taken to a Wuhan Hospital for TCM. Dr Hou treated him there and quickly realised that the illness was critical and that the young man needed to be transferred to a larger hospital for a blood transfusion as he was severely anaemic. The doctor paid 2000 yuan in immediate treatment fees from his own pocket as Xiao Zhou did not have more than a few hundred dollars. Dr Hou then accompanied the youth to the next hospital, where the patient's condition continued to be serious for several more days. When informed that Xiao Zhou needed further urgent treatment to prevent him from dying, Dr Hou signed the forms and eventually paid medical bills for a further 24,000 yuan.
The youth's condition eventually stabilised and he is now said to be recovering.  The case has been widely reported in the media as an example of how doctor-patient relations can be good, in contrast to the many recent episodes of violence against doctors by patients an their families. Dr Hou is said to have a reputation for doing good deeds. He said he felt sorry for the youth as he was a filial son with a good heart, but had no money. Dr Hou is quoted as saying "Being a doctor is a duty, being a human means playing your part."

No benefit from high dose atorvastatin: Hunan study

For people who have had a heart attack, taking a high dose of atorvastatin (up to 40mg/day) has no added benefit over a moderate dose (10mg/day) a study has shown.
In a two year clinical trial involving more than 1300 patients with acute coronary syndromes (ACS), cardiologists from the Second Xiangya Hospital of Central South University, Changsha, found that the dose of statin had no impact on the primary end points of cardiac death, non-fatal acute myocardial infarction, revascularization, ischaemic stroke and unstable angina or severe heart failure requiring emergency hospitalization. The patients' lipid levels were low initially (mean LDL cholesterol level of 2.7mmol/L) and declined by 20% in the moderate dose statin group and 27% in the intensive statin group, respectively.
"For ACS patients with a relatively low baseline LDL cholesterol level who received optimized current medication and interventional therapy, the incremental LDL cholesterol reduction of 6.4% achieved by double-dose statin did not bring significant clinical effectiveness," the researchers concluded.
The findings are published in Atherosclerosis.

Pneumoconiois: China's neglected occupational disease

by Michael Woodhead
Delegates at the National Peoples Congress have called for a compensation fund to be set up for China's leading cause of occupational disease - dust-induced pneumoconiosis. 
Many people were moved recently by the high-profile case of a young Henan man who suffered from the disabling condition, and he was lucky in winning media attention for his case, and securing 30,000 yuan to pay for his treatment costs. However, representatives say that for the vast majority of patients with pneumoconiosis in China there is no such happy ending. Despite being the leading occupational disease, most of the patients are migrant workers, of whom as many as 600,000 are thought to have penumoconiosis. Since most migrant workers are on low wages, few can afford treatment and the disease progresses to the point where they suffer a slow and painful death. For some patients the pain and disability are so much that they commit suicide.
A few local governments have set up schemes to help pay for the treatment of pneumoconiosis, but most patients live in impoverished rural areas where funds are not available for treatment.
At the NPC, one delegate who is the head of the Changsha Hospital, Dr He Binsheng proposed a simple policy that would help end many of the problems with pneumoconiosis patients once and for all. DR He said the answer was to set up a pneumoconiosis treatment fund and also a dust-disease inspection board to supervise high risk industries and prevent further cases from happening. The fund would help pay for the treatment of patients and also provide some social support for their families. Governments could co-operate to set up regional pneumoconiosis treatment and rehab centres for those who are rendered unable to work through pneumoconiosis disability, he said.
Dr He was supported by a Hunan deputy, who said compensation should come from a workplace injury compensation scheme.

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."

Hospitals sell off pharmacies to pharma companies

Hospitals are selling off their lucrative pharmacy operations to pharmamaceutical companies as the government pressures them to adopt zero commission policies on drug sales.
Sales of drugs account for as much as 45% of hospital revenue, but the Chinese government is forcing hospitals to separate their pharmacy units and stop profiteering from them. This week Zheng Yang in China Economic Net reports that Kangmei Pharmaceutical has bought up more than 80 hospital pharmacy trusteeships in areas such as Liaoning and Guangdong. Kangmei has signed contracts to operate the pharmacies for periods of up to 20 years, and will be responsible for the supply of all pharmaceuticals within the hospitals. The deal looks to be very lucrative for Kangmei, with revenue from just nine hospital pharmacies reported to be 1.3 billion yuan in 2013. Kangmei says it expects to make about half a billion yuan per year from each hospital, up from about 100 million yuan that it currently makes in drug sales on average to each hospital. In addition to this added revenue, the company hopes to profit from supply chain efficiencies and also from the pricing power its monopoly will bring. The report quotes Liao Xinbo, deputy director of the Health Department of Guangdong Province,  as saying that the importance of the pharmacy to a hospital is diminishing as policy measures like "zero price difference of medicine" are introduced as part of China's health reforms. Pharmacies will soon become a 'cost' rather than a profit centre for hospitals, he predicts.  Hospital pharmacies currently account for 80% of China's pharmaceutical market with a value exceeding 1 trillion yuan. 
Analysts say hospitals may enter profit sharing agreements with pharmacy owners, thus defeating the Chinese government's health reform goal of removing hospital profit incentives from prescribing of drugs. 

Dr Zhong Nanshan: what's wrong with China's health system and why we need to get doctors on board to fix it

by Michael Woodhead
Dr Zhong Nanshan is one of China's most well known and respected doctors. A respiratory physician and former head of the Chinese Medical Association, he is the 'hero' of the 2003 SARS infection outbreak, and his frank advice is respected by the government. At this week's meeting of the National People's Congress in Beijing, Dr Zhong gave a speech on the current problems with the Chinese healthcare system and the direction of health reforms.

"Today when I heard Premier Li Keqiang's announcement I was very excited, as his words provided a lot of inspiration on the difficult problems we are facing with medical reform. In recent years China's reforms of health insurance and the healthcare system have attracted worldwide attention. But from the public's point of view, there is still the problem of 'difficult to see a doctor, expensive to see a doctor'. Doctor-patient relations are still tense (as the China Hospital Association has recently made clear, hospital doctors and staff have often been the victims of violent  attacks) and hospital staff are not showing enthusiasm or initiative in their work.

For these three criteria, when it comes to health reforms there has been no breakthrough in the last five years, and in fact things have become worse in some areas. Where does the blame lie? The answer is in our major (tertiary level) hospitals.  In these institutions, doctors have not become heavily involved in medical reforms, and this problem is becoming more serious. Look at land reform: this was about the relationship between farmers and landlords, and it was based on respecting the position of the farmer, allowing them to make a living. Likewise with education reform - this was about teacher-student relations and when teachers and schools got better pay, resources and conditions, teachers got more respect.

Why are doctors not enthusiastic for health reform?

Similarly, medical reform will depend on the involvement of doctors. America's medical reforms were about respecting medical opinion and allowing the doctor's clinical judgement to drive the direction of the medical system. I remember in 2012 when Li Keqiang was deputy premier and I saw him at a meeting, and I told him that the most important point I wanted to make was that doctors must be the driving force behind medical reform. However, five years have gone by and it seems that under the present reform system medical staff can see no way in which they can change things for the better. On the contrary it seems that many of the reform programs have an adverse affect on the working conditions for doctors. For doctors it is as if society 'discriminates against them'. And under such conditions, where is the enthusiasm for medical reform going to come from?

As any changes are going to affect doctors' interests, let us first analyse the current situation in regard to doctors' incomes. It is a widely held belief among the public and some government departments that doctors' earn a large amount of extra and unjustified income through what we could call unofficial 'grey channels', and this is seen as outrageous, unethical behaviour. Therefore, before the conference I examined the accounts of the Guangzhou tertiary hospitals. These showed that in 2012 the average official annual salary of a doctor was 41,077 yuan, but the actual annual income for a doctor with all allowances, bonuses and subsidies was 176,320 yuan. For 2013, the average official salary for a doctor was 46023 yuan, but their actual annnual income was more than 190,000 yuan.

Of course this level of income is high compared to the average worker or government official, but it is low compared to the incomes of doctors in other countries. It may therefore be said that this level of income for doctors is reasonable, especially when this extra income comes from government policies as they are applied in hospitals. Here is a typical example of how state-owned enterprises operate to improve performance: hospitals want to increase their income so they increase the number of beds to accept more patients and they increase the number of procedures and tests. On my ward rounds I see many patients who are having unnecessary tests and procedures. One of the main reasons for this is that doctor's income is linked to irrational medical practices - this is a major contradiction within our health system.

Reward doctors for their skills, not for how much they prescribe

My second major point is that a doctor's economic labour value is not reflected in medical fees in China, which are far too low. A doctor's economic value should be related to their ability to diagnose and treat and their ability to give individual attention to a patient based on their skill and knowledge. Unfortunately, in China this is not the case. In the rest of the world a doctor's income depends on their clinical skills, whereas in China a doctor's income is linked to how many drugs they prescribe and how many tests and treatments they order. It is not surprising then, that in China doctors' credibility is called into question. But rather than blame this on a doctor's ethical flaws, we should recognise that this is due to hospital policies that prioritise income and profit and skew the doctor's working patterns.

Too many patients, not enough time

My third point is related to the tense situation in doctor-patient relations. I believe this is 80% due to the difficulty that patients have in accessing a doctor. Owing to the way hospitals operate, doctors are given quotas of numbers of patients to be seen each day. If they do not meet the targets for numbers of patients treated, they miss out on their financial bonus. In other words, the more patients they see, the better. Thinks about this: in half a day a single doctor must see fifty or sixty patients. What does this say about patient access to a doctor and the doctor's 'space' to practice good medicine? The reality for patients is "wait for three hours to see a doctor for three minutes". That just isn't enough time for a proper consultation, and as the consultation time shrinks, the strained relations between doctors and patients increase.

These days in a bid to exploit 'resources' to the full, hospitals are always seeking to increase their bed numbers and they open 'branch hospitals' to increase capacity. While in theory this increases the opportunities for the population to get treatment, the reality is that this increases the hospital income. And the other aspect is that doctors are 'running to exhaustion' trying to treat ever higher numbers of patients. This is not a sustainable model for providing for a community's medical needs.

So we have doctors who see that the government health system cannot provide them with a basic income in proportion to their work and skills. They thus see no benefit from medical reforms so far: they have a negative view, show little enthusiasm and no initiative towards medical reforms. Therefore, as the public should be the target for healthcare reforms, I could set the theme of my speech today as: "Discard doctors as driver of health reform: don't let the medics change the medical reform."

Principles: the need to put more value on health

The way to solve these problems is to change our principles. Today I especially appreciated hearing Premier Li Keqiang's remarks that: "For existing problems the government should look within itself for the causes." I think for health reform we need to look within the health system for the causes of the problems.

Firstly, within both government and society we need to develop a respect for life, to treasure life and health. And if we are to attach importance to preserving life and health we must invest in the health system. From 2005 to 2012 our country made great efforts in health and increased funding for health from 3% to 5% of GDP. However, this is still a lower level of health funding compared to developed countries - in fact we spend less on health by GDP than Afghanistan does. Developed countries spend between 8% to 15% of GDP on health, and we need to aim for that.

But we can't just think of health in economic terms. Health reform must start by putting health and life as a first priority for society. At present in Chinese hospitals the economic value of the healthcare staff is very low compared to other countries. The incomes  of public hospital medical staff are very low and should be higher. Other countries have managed to create good public hospitals systems, why can't we?

Use public insurance funds to improve health services

Of course China has a huge population, and we can't expect our public hospitals to immediately become public welfare providers for everyone. We have to look to the health insurance system for the potential to do that. Since 2011, the national health insurance scheme has been meant to guarantee access to medical treatment and medicines. However the system is fractured and un-coordinated, and those benefits have not been realised. Since 2009, the rural medical insurance scheme has shown good results but these have not been seen with urban insurance schemes, which still have major problems.

Health departments lack the management skills to oversee these schemes, and although the public have paid a lot into these public insurance schemes, the benefits have not been taken out. We should look to these accumulated health funds as resources to fund health reforms. We need to focus on the supply side, not just on patient input and demand. If doctors show good performance they should be rewarded for providing more services. Hospitals should be able to use this insurance funding as a lever to deliver more and better services - but currently the health insurance funds are out of their control and managed by the social welfare department.

The social welfare department does not accept responsibility for health reform and this is a major obstacle to reform of public hospitals and the way that funding is raised, dispersed and linked to performance of the public hospital system. In 2010 there was something like a 7 billion yuan surplus in health insurance contributions - why is this surplus not being used to boost the public hospital provision of services? The health department does not have funding for hospitals - this system needs to be changed - as in 70% of foreign countries where health departments manage public hospitals.

Hospitals should be centres of excellence

Finally we need to improve the education and culture of healthcare staff. We need to have a system based on merit. In most countries, large hospitals are centres for medical expertise and do not deal so much with common, everyday problems. These are dealt with by family doctors or community clinics. Last year the government's health working group made the creation of community clinics and hospitals a priority. I strongly approve of this. Through investment the government should improve the skills and the remuneration and conditions for community clinics and local hospitals. I think the technical and management skills of small hospitals and clinics should be nurtured and overseen by tertiary hospitals, which take responsibility for community clinics. In this way the standard of local clinics could be increased to allow them to cover the same scope of basic care as tertiary hospitals within 3-5 years.

In summary, across the world, the medical profession is regarded with respect in most countries, but China is the exception. The economic value of medical personnel has been degraded, and until this is restored they will not be at the front of driving health reform. The medical staff of Guangzhou University Hospital have great underlying enthusiasm for health reform - it just needs to be shown that reforms will bring them benefits and respect, for them to be positive and actively support them, I believe. I think that in this respect Guangdong doctors will be at the forefront of reforms. We will work together to fulfill what Li Keqiang described as "a solution with Chinese characteristics to the difficult problem of health reform."

Editor's note: This is my translation of Dr Zhong Nanshan's speech that was made at the NPC meeting in Beijing on 5th March, 2014 and published in the People's Daily. It is not a perfect translation, but I have covered the main points as best I can. If you see any errors I will be happy to correct them. The original can be seen in Chinese here.

Why Beijing's plans to privatise medical services get a lukewam reaction from China's doctors

by Michael Woodhead
Beijing is one of several cities that has recently announced plans to encourage doctors working in public hospitals to set up private clinics. The government used the socialism-friendly euphemism "social capital" for the private capital investment it wishes to attract for establishing new medical facilities. 
However, the plans come with a few strings attached, which will deter most doctors from even thinking about setting up private clinics. Firstly, the city also announced that Beijing already has enough medical clinics in the central area, and it will only permit new clinics to be set up outside the fifth ring road. It also stipulated that only experienced doctors who hold the grade equivalent to 'associate professor' would be able to set up the new private clinics.
The reaction from doctors has been underwhelming and many have questioned how such a monumental change in the current system will be implemented. In theory, the new proposals will "free up" doctors to better serve patients in more flexible ways. Doctors however, have described these predictions as wishful thinking.
Firstly, the number of senior doctors who qualify to set up new clinics is only a small proportion of the total number of working doctors. These senior doctors are in short supply and they are the backbone of the current public hospital and medical school teaching system. How will the system cope if these doctors leave to devote their time to private clinics?
Doctors say that if a new layer of private clinics is to be established, there needs to be a plan for how patients will be managed in public hospitals. If the privatisation plan is to succeed there will need to be a move away from large hospitals treating minor illness, and these functions being taken over by local clinics. Big hospitals will have to become specialist centres with expertise in treating serious diseases, they say.
In places such as Hong Kong and the US, there is a long tradition of doctors working in private clinics as well as in public hospitals. How will China manage this balance? In the US, for example, patients can only get their medical fees reimbursed if they go to a  doctor approved by the insurer or government, and the doctor and clinic must have acceptable quality and safety standards - how will China manage such a system? In addition there needs to be safeguards that private clinics will operate in an ethical manner. In western countries there are a range of professional associations and health department systems to define and oversee standards. With new private clinics in China there is also a danger that they will inherit the 'prescribing for profit' and overservicing practices of some existing hospitals in an effort to increase revenue, doctors warn
In reality, there is also a big difference between the government 'permitting' and 'encouraging' doctors to set up private undertakings. As anyone in China knows, running a private enterprise can involve a lot of 'mafan' (trouble) - and that 'mafan' can also mean paying out a lot of money. How many experienced doctors will be prepared to take on this risk?
These are just a few of the doubts that doctors have expressed about the new proposals for private clinics in China. They say "jumping into the sea" of private enterprise is a huge step for a doctor to take - there are so may unanswered questions and risks that it will need more than just "permission' from the government to make them do it.

All health departments to undergo financial audits

The National Health and Family Planning Commission (NHFPC) has announced that all health departments will undergo more stringent financial audits to promote a healthy organisational climate. The NHFPC said the audits will look at financial management and also at areas such as personnel in health departments and their subsidiary agencies. The NHFPC warned that any departments that resisted or obstructed auditors, covered up or provided false or misleading information would be severely punished.

Infusion madness: patients in Nanchang hospitals consuming gallons of IV antibiotics

by Michael Woodhead
Health experts in Nanchang, Jiangxi have admitted that their city's hospitals are some of the worst offenders in China when it comes to the practice of allowing patients to unnecessary IV infusions. 
In a country where the average person consumes eight bottles of IV infusion fluid per year, Nanchang is above the national average. Dr Yuan Zhaokang, head of the Nanchang University department of public health, says 90% of people are not aware of the risks and harms of IV infusions and yet between 60-70% of people in outpatient departments are given them. Of these patients, 75% don't need the infusions and could be given oral medicines instead. Dr Yuan says China's rate of IV antibiotic use is10 times higher than the international average, meaning that most intravenous antibiotics given in China are unnecessary.
In theory, the public are told that they should not have an injection when an oral medicine will suffice, but in practice in China this order has been turned on its head, Dr Yuan says.
A Sichuan emergency medicine director, Dr Zhen Tao says he opposes routine use of IV drips for people with colds, but it is hard to change the public mindset.
"People believe that IV infusions are more effective and work faster than oral medicine - but they are wrong," he says. Given a choice, patients always demand "infusion first", and few are aware that this directly contradicts the WHO advice for "never give an IV infusion when an IM injection will suffice, and never given an injection when oral medicine will be sufficient".
While this message is slowly getting across to more educated adults, the situation for children is getting worse, says Dr Zhen. Whenever the weather gets cold or the season changes, the hospital's infusion room is crowded with children who have colds who are attached to IV infusion bottles.
A common cold is a minor viral illness - so why do all Chinese insist on having unnecessary antibiotics by intravenous infusion? Dr Zhen says one reason is the pressure from parents with 'inflexible' thinking and attitudes. Another reason is that hospitals make money from infusions.
"Families want a quick cure-all and hospitals want a quick profit. When these two factors come together the result is bad medicine," says Dr Zhen.
The craze for children to have infusions especially worries Dr Zhen because he says it can weaken their health. Antibiotics not only kill pathogens, they also kill the 'good' bacteria that children need for developing an immune system and digestive health, he says. This is especially so for children who have repeated infusions, which become a vicious circle, where more treatments are requested because the child gets sicker and more prone to infections.
As well as increasing antibiotic resistance, IV infusions of antibiotics often cause many other serious health problems, including life-threatening anaphylaxis and other allergic reactions, phlebitis and injection site reactions, circulatory overload and heart failure as well as pyrexia (high fever), Dr Zhen warns.
The only people who really need IV infusions are those who have swallowing disorders, gastric malabsorption problems and the acutely  critically ill patient, he said.

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.

Poultry industry demands 'avian' be dropped from H7N9 influenza virus description, threatens legal action

More than a thousand poultry breeding and trading companies have signed a petition letter calling on government departments to stop using the term 'avian' in respect to the H7N9 influenza virus, saying the link has caused catastrophic losses to their industry.
The letter organised by the China Animal Husbandry Association says that 'avian flu' is not an official term used by WHO and should not be used by ministries such as the National Health and Family Planning Commission.
The companies said the warnings about live poultry had caused panic among consumers who shunned the products, leading to a billion yuan in economic losses fr the industry. The poultry industry leaders said ther use of the term 'avian' was irresponsible and unscientific and should not be used. They said if ministries did not stop using the term they would take legal action to force them "to safeguard the rights and interests of the industry members".
The industry association also called on the government to take immediate measures to save the poultry  industry.

Urgent action needed on alarming rise in HIV rates in gay men in China

by Michael Woodhead
Rates of HIV in gay men in China are increasing dramatically, and many of them are passing on the infection to wives in sham marriages, a study from Beijing has shown.
The prevalence of HIV in the gay community is now as high as 10%, up from only around 6% in 2006, showing that urgent action is needed to contain the infection, according to researchers from the National Center for AIDS/STD Control and Prevention at the Chinese Center for Disease Control.
In a study of HIV rates in samples of 500 gay men from 2009 to 2011 they found that the overall prevalence rate was 8%. The incidence increased from 2009-2010 from 6.8 to 11.2/100 person years and then declined to 5.8/100 person years.
The main risk factors for HIV infection were being bisexual (ie living with a woman in a  marriage of convenience to avoid the family stigma of homosexuality), recently arrived in Beijing, and a negative attitude to safe sex. Between 40-50% of gay men reported having recent unprotected sex but only about a third said they knew the HIV status of their male partners. Up to 20% of gay men had female partners and about 75% of sex with women was unprotected sex
The researchers said the "alarmingly high HIV prevalence" showed that urgent action was needed to stop HIV spreading beyond the gay community.
"The findings from these three consecutive surveys signal the beginning in changing the landscape of the HIV epidemic in China," the researchers said. "HIV transmission has begun to shift from the historically main transmission route, intravenous drug users, to populations at risk through unprotected heterosexual contacts or male homosexual sex."
They added that their findings "underscored the urgency of increasing effective and better-targeted intervention services to stop the rapid spread of the virus, which includes risk reduction education, condom promotion and distribution, encouraging early and frequent HIV testing, and expanding the coverage of HIV prevention measures. These interventions will help curb the spread of HIV infection inside and outside the [gay] population."
The study is published in Biomed Research International.

Crackdown closes 5088 illegal medical clinics

by Michael Woodhead
A national 'strike hard' campaign against illegal medical practices has resulted in more than 5000 'black clinics' being shut down and many fake doctors being unmasked.
The crackdown, which was a collaboration between numerous government agencies including health departments and police, followed up more than 30,000 complaints from the public. It resulted in 964 criminal prosecutions against individuals and the cancelling of clinic licences for 121 child clinics and family planning facilities. The campaign to 'tidy up and restore order' in the medical field also resulted in 760 criminal cases for fake clinics and the breaking up of 22 criminal gangs involved in running them. The clinics included sex-selection abortion clinics, cosmetic surgery practices and health spas. The crackdown also saw the closure of fertility clinics and unmasked foreign-trained doctors operating without authorisation in China. It also closed down 46 clinics and health stations falsely claiming to be run by the PLA and saw the dismissal of 164 bogus PLA medical workers. The campaign resulted in fines of over 63 million being imposed, and a positive feedback from the public.
The six departments involved will continue and widen their investigations into fake medical practices and illegal medical clinics.

Medical sales bribery: offenders to be named and shamed

by Michael Woodhead

Companies and individuals found to be involved in bribery related to the sales or purchasing of medical and pharmaceutical supplies will be banned for two years and their details added to a public blacklist, the National Health and Family Planning Commission has announced.

From this year, all provincial health departments will be required to investigate and take strong action against bribery in the purchasing and sales of medical products the NHFPC says. Offenders must be listed publicly on a 'blacklist' that is made available for the public on the website of the provincial health department. Details must be added within 5 days of  being found guilty, and the offenders will be banned from buying or selling medical goods to public hospitals and clinics for a period of two years, the NHFPC statement says. The national office of the NHFPC must also be notified of any bribery cases within one month, and it will compile a summary at the end of the year.