Defiant words of a doctor killer: Lian Enqing has no regrets for murdering surgeon he blamed for botched rhinoplasty

by Michael Woodhead
The 33-year man Lian Enqing found guilty of killing a Zhejiang doctor over failed nasal surgery has had his appeal against a death sentence turned down, but seems to have no regrets about what he did.
A lengthy article in Guangming Daily portrays faults throughout the system, including sub-standard medical treatment, shoddy hospital record keeping, a flawed medical dispute resolution system and a harsh legal system that condemns a mentally ill man to death. The article includes a few words from a CCTV interview with the murderer, Lian Enqing, from which it is apparent he is delusional and convinced that his victim got what he deserved.

The tragic case originated in March 2012 when the man sought medical help for a chronic sinusitis and nasal obstruction. He had ENT surgery for his problem at a Wenling hospital with surgeon Wang Yunjie, but after a few weeks it became obvious to the patient that the surgery had not relieved his problem - if anything, his symptoms became worse. He went back to the hospital and sought a review, but was not satisfied with the results of the tests. he went back many times to several different hospitals - including some in Shanghai - and underwent many investigations, including CT scans, all of which could find no explanation for his ongoing nasal symptoms and discomfort.

Lian Enqing refused to believe the results of the tests and became convinced that there was a conspiracy, and that doctors were covering up their mistakes. His belief was bolstered by shoddy record keeping at the hospitals, with some hospitals giving his the wrong results or imaging scans. Lian became more angry and assaulted members of his family. In July 2013 he scrawled a message about his surgeon on his wall saying "Wang Yunjie must die". He was taken by his family to a psychiatric hospital in Shanghai and diagnosed as having depression and delusional disorder and he spent some weeks in treatment.

However, his basic belief and resentment against the doctors did not change, and in October 25 2013 he went back to the hospital and attacked his surgeon Wang Yunjie with a knife, stabbing him to death and injuring other doctors. Eyewitnesses say this was no spur of the moment killing -Lian was determined, and even prevented other doctors from getting to the injured surgeon to try and save him.
 An interview aired on CCTV showed that Lian still believed there was a cover up of mistake,

Journalist: Most people would believe the results of multiple repeated tests - what was your reason for not believing them?

Lian: Because doctors feared being exposed. It would harm their image and their reputation to be shown to be wrong.

Journalist: Do you think doctors need to create such a big and complex set of lies over one pateint and one operation?

Lian: Yes

Q: But this would mean collusion on a grand scale, not just within the hospital but withing the region and even with doctors in the Fudan University Hospital in Shanghai Why would they all do that?

Journalist: Because it is a stain on the medical community, a dark stain.

The judge in the case said that he sympathised with Lian a little as his frustration and sense of injustice was justified because he had received sub-standard treatment and his complaint had not been handled properly. Nevertheless, nothing could excuse the extreme violent reaction to the unfortunate events that befell him, he added. Lian still did not acknowledge his crime or show any remorse.
In this situation, given what he did, the court had no alternative but to follow the law and conform the death sentence, he said.

The judge said that if doctors weren't so busy and if the hospital system wasn't under so much pressure, then such a tragic event may not have occurred. He urged doctors to improve the system
and be more understanding of the patients situation.

Daqing strikes gold with diabetes prevention study

by Michael Woodhead
The oil town of Daqing in north China is now becoming famous for something quite different - preventing diabetes. 
Results from a 23-year study conducted in the city have show that people at risk of diabetes can avoid progressing to the disease and almost halve their risk of death by adopting a healthier diet and doing more exercise.
The findings from the study, published in the Lancet Diabetes & Endocrinology this week have been hailed as a breakthough by international experts because they answer many of the difficult questions about how diabetes may be prevented and its harms minimised.
The study started in 1986, when 577 people with impaired glucose tolerance were assigned to either an intervention group that received advice on diet and/or exercise, or a control group. The lifestyle coaching sessions lasted for six years during which participants received regular encouragement to eat more vegetables and consume less sugar and alcohol, and encouraged them to do more physical activity in their spare time.
Now after more than 20 years of follow up, researchers have found that the people who received the lifestyle advice had a cardiovascular death rate of 1% compared to 20% in the control group. The overall death rate was 28% in the lifestyle group compared to 38% in the control group. Rates of progression to diabetes were 73% in the lifestyle group and 90% in the control group.
"These findings emphasise the long-term clinical benefits of lifestyle intervention for patients with impaired glucose tolerance and provide further justification for adoption of lifestyle interventions as public health measures to control the consequences of diabetes," said lead study author Professor Li Guangwei of the Department of Endocrinology at the China-Japan Friendship Hospital, Beijing.
Commenting on the findings, Professor Nicholas Wareham of Cambridge University said the study was a "real breakthrough, showing that lifestyle intervention can reduce the risk of long-term cardiovascular consequences of diabetes." He said the study showed that lifestyle change could be achieved in the real world and it was notable that the effects were particularly strong in women.

Doctor's income must not be linked to drug sales or patient quotas, health ministry says

by Michael Woodhead
Doctor's income must not be linked to sales of drugs or other profit-linked activities such as the numbers of tests done or patients seen, the National Health and Family Planning Commission has decreed.
Under the new health reforms for county-level hospitals, any bonus schemes for doctors must be 'scientific' and related to appropriate performance measures such as efficiency and patient satisfaction, the NHFPC has decreed.
It is forbidden for hospitals to set up schemes in which doctors are given quotas or rewards for use of drugs, tests or patients treated, and appraisal must be based on public good and work efficiency.
The rules apply to country-level hospitals, and are an extension of the reforms that were initiated in a trial basis in a 311 hospitals, now extended to more than 1000 hospitals. From now on, county hospitals that serve populations of more than 30,000 people will be graded as second level hospitals.
The new proclamation "Concerning the reform of County Level Hospitals" is made on behalf of the NHFPC in conjunction with the Ministry of Finance, Ministry of Social Security and the State Council.
The aim of the new rules is to break the dependence of hospitals on income from drug sales, the so-called "drug dependence" system. The aim is to establish a new and sustainable model of hospital funding.
The new 'white paper' also contains new guidelines for hospital drug purchasing mechanisms: country level hospitals will now be expected to rely on the provincial level purchasing systems for the drug supplies. Quality will take precedence over price in purchasing, but prices are still expected to be reasonable and fair, based on tendering systems.  Suppliers will be expected to guarantee drug supply and will manage logistics, to cut out the 'middleman' wholesalers role in drug delivery to hospitals.

Hospital ticket scalpers fight outside Beijing hospital gate

by Michael Woodhead
A gang knife fight that erupted outside the door of Beijing University Hospital in February has been revealed as a turf war between hospital ticket scalpers.
Twelve people have been arrested and seven charged with gang-related activities after a police investigation into the scuffle found that it was related to the re-sale of hospital registration slips.
In China, patients face long waits in queues at a counter to 'register' and get a number before they can make an appointment to see a doctor. In a way similar to tickets for trains and entertainment events, criminal scalper gangs obtain these tickets and re-sell them at a markup to people who want to jump the queue.
On the 25th February Xicheng police were called out to a mass fight with knives at the Beijing University Hopistal door. When they arrived they found tow injured men and a women, but the culprits had fled. The injured trio told police it was a fight between friends that had got out of hand - and they refused to co-operate or say any more. Police suspected there was more to the incident and set up a task force to investigate. They subsequently found that the fight was over protection money demanded by a local gang from a group of ticket scalpers working around the gates and doors of the hospital. The gang regarded the hospital as their territory and demanded payment from the scalpers. When there was a dispute about payment, the fight broke out. The police arrested twelve people who now face charges of assault as well as gang-related illegal financial activity.

China has learned the lessons from SARS, praised by WHO for H7N9 reponse

China's response to the H7N9 influenza outbreaks has been praised the World Health Organisation for the sound preparedness, prompt communication and collaboration with international groups. In the latest WHO Bulletin the agency says China has learned the right lessons from the mistakes made with SARS and now has a robust and open system for dealing with infectious disease outbreaks that can be a model for other countries. After SARS, China reformed its systems to improve disease surveillance and make the country’s response to future disease outbreaks both swift and effective, WHO says. The improvements to the system were evident when H7N9 influenza emerged in March 2013. The Chinese surveillance system based on Centres for Disease Control and Prevention allowed the problem to be quickly identified, and there was a good response in terms of follow up testing and identification of new cases. prompt moves were taken to reduce risk by closing poultry markets, and appropriate risk information was disseminated quickly to the public, the report says. It also welcomes the close cooperation between the National Health and Family Planning Commission and WHO in responding to the H7N9 threat. China was praised for being open about the sharing of information about H7N9 to the public and with the wider scientific community, with no barriers to publishing the results of virological and epidemiological investigations in scientific journals "China’s prompt response to the emergence of the A(H7N9) virus as a human pathogen – which spanned multiple governmental departments and ministries at national, provincial and municipal level – was mainly the result of strong leadership in a critical situation." the WHO report concludes.

Harbin hospital charges dead patient for drugs and tests

by Michael Woodhead
The relatives of a 41-year old woman who died of pneumonia at  Harbin University No 2 Hospital are seeking an explanation for why they have been billed for two days of drug treatment and tests after her death. 
The woman spent 13 days in the intensive care unit after she developed pneumonia and kidney failure in February.  She died on 24 February and the family received an initial bill of 197,000 yuan (US$32,000) for her treatment. However when they came to transfer her body to a funeral centre they received an additional bill of 22,000 yuan ($3500) for drug treatment. The family had no option to refuse as they had already paid a deposit of 250,000 yuan as guarantee, and the hospital refused to refund the difference. They listed the additional costs as being for injections, respiratory tests and blood and heart monitoring.
The family disputed the bill, with the older brother pointing out that his sister would not have needed any tests in the 48 hours after her death. However,  the hospital refused to deal with them, so they took their complaint to the local bulletin board of Tianya. Many other local people sympathised with them and told of similar complaints of overcharging by hospitals.
A reporter from the Legal Daily took up the case and brought in accountants to analyse the bills.  They found that the bills for the extra two days were similar in size to those of previous days but they were vague and did not accurately show what treatments and tests were given or at what time.  When approached by the Legal News, the hospital's accounts department said it would review the figures. It later came back and said that after reviewing the billing it found some uncertainties and it was willing refund the family 18,000 yuan.
Other online commenters pointed the the famous case at the Harbin hospital in 2005 when a patient hospitalised for 67 days received a bill for 5 million yuan.
A spokesman for the hospital refused to comment, and the hospital manager was repeatedly said to be in a meeting when reporters sought comment from him on the case.

Pharma bribes and other medical news from China

China pharma bribes explained
A former pharma industry sales rep in Shanghai has described how bribes were given to doctors in various ways. According to the FT ‘big-ticket bribes’ were laundered through travel agents whereas smaller kickbacks were directly paid in cash or in kind to doctors. The former rep said he covered up the bribes using fake tax receipts or with receipts he collected from family and friends for taxis and meals. Drug reps could boost their base salary of 7,500 yuan a month with a quarterly bonus of 17,000 yuan if sales targets were met, plus an additional 5% of sales above the target.
The average industry kickback to doctors was 5-20% of the value of the drug, he said.

And in other news ...

The best treatment for H7N9 influenza is intravenous zanamivir (Relenza) say HK respiratory physicians.

About 15% of children hospitalised with pneumonia have RSV infection and this could be prevented with a vaccine, according to a study from Suzhou.

Suicide rates have fallen substantially in China in the last decade, according to a study from Shandong.

Prescribing of  tuberculosis drug treatment is poor with only one in four drug courses being adequate, a study from Hubei has found.

Cefrtriaxone may cause postrenal acute renal failure in children, doctors from Wuhan report.

A Chinese doctor from Hebei was one of the passengers on the missing Malaysian flight MH370, the Times reports. Dr Bian Liangjing gave up working as a doctor in China because he could earn more money as a labourer in Singapore, his family said.

Osteoporosis imposes a major financial burden on elderly Chinese, with a hip fracture costing an average of 27,000 yuan ($4300) in treatment and other costs.

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

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

Wednesday news: Knife in head | Medevac helicopters | EV71 alert | Left behind parents | DTP boosters | Salt intake

Surgeons in Huashan are to remove  30cm knife embedded in the temple of a young man after a knife throwing game went badly wrong.

Beijing is to get two medical evacuation helicopters the Beijing Red Cross Emergency Rescue Center says, fitted with resuscitation medical equipment such as ECG monitors and defibrillators.

Shanghai parents warned to be vigilant for symptoms of hand foot and mouth disease after two child deaths.

China has millions of 'left behind' elderly people with unmet social, medical and psychological needs, as their children have migrated to cities for work.

Booster vaccinations for diphtheria, tetanus and pertussis  are needed at seven and twelve years of age because of waning vaccine efficacy, researchers in Henan say.

Chinese people eat twice the recommended daily intake of salt and need to cut down on added salt and soy sauce, experts say in the Lancet.

Tuesday news: The US health model best for China | Food and drug police | SARS victims forgotten | HIV medication non-compliance | Womens' wrinkles vary by region

US healthcare model is the answer to China's problems
The answer to China's health problems is to follow the American model and encourage growth of the private health insurance industry, says an American academic. Harvard's Professor Martin Feldstein, a former economics adviser to Ronald Reagan, says China could boost the growth of private health companies by creating tax breaks for employers and people who pay into them. Expansion of health insurance would also lead to an increase in the provision of hospital services as private insurers will enter the market, Professor Feldstein told Jewish Business News. By encouraging the purchase of health insurance by individuals or employers, the Chinese government could reduce the current trend for household saving to pay for medical bills and free up funds to increase consumer spending, he said.

'Health police' to be set up to catch drug and food crooks
"Watch it, here come the health police ..." - may soon become reality in China.  The Ministry of Public Security is planning to set up a new police division to deal with "food and drug safety crimes" in conjunction with the China Food and Drug Administration (CFDA). At present those who break food and drug regulations are supposed to be dealt with by the CFDA, but  the agency has weak powers and not enough staff to deal with the numerous cases of drug and food violations. The new food and drug police would have more powers, but some people are warning that it will lead to duplication and will not deter back street drug factories or sub-standard food manufacturers.

SARS victims abandoned to ill health
Many of the 5000 people in China who were infected with SARS a decade ago are struggling today under a burden of severe long term complications, clinicians say. SARS victims feel forgotten and abandoned, with may having debilitating lung problems that stop them from working and earning a living, according to an article by Professor Xiang Yutao and colleagues of Capital Medical University in Beijing. Many people who had SARS  developed long term problems and disabilities due to the high dose steroid therapy they were given, according to Professor Xiang. However there is no social or financial support for the many people who need ongoing medical treatment, he says.

HIV patients stop taking their medicines
Antiretroviral medicines are provided free of charge to HIV positive people in China but despite this, many stop taking them, leading to high rates of treatment failure. A new study from Guangzhou of 813 HIV-infected adult 19% had recently missed taking their medication and 7% had had stopped their antiretrovirals for at least a month in the past year). Those most likely to stop tended to be male, living alone, poorly educated and to drink alcohol.

The women with the best skin in China live in ...
If you want beautiful skin, go live near the Yangtze - that's the conclusion of a study of women's skin quality in different areas of China. Dermatologists found that skin quality and appearance depended on the local climate - in the cold, dry smoggy climate of Beijing womens' skin tended to be dry and wrinkled, whereas in the hotter sub-tropical humidity Guangzhou women had finer wrinkles - but more greasy skin due to higher sebum content.  Cities such as Shanghai and Wuhan had a combination of high moisture and moderate temperatures and women's skin had more elasticity.

International transplant specialists call on Xi Jinping to end corruption in China's organ transplant system

by Michael Woodhead
The international professional group representing organ transplant specialists has written an open letter to Xi Jinping, urging him to take personal action against ongoing corruption in the organ transplant system in China. 
A group of eminent surgeons belonging to the Transplantation Society have written a strongly-worded letter to the Chinese president, saying the latest government moves to overhaul China organ transplant system are not working, with some Chinese hospitals continuing to openly advertise the sale of organs from executed prisoners to private buyers.
Dr Francis Delmonico and seven colleagues say Chinese transplant surgeons have been the subject of a long-running embargo in international academic circles because of their country's practice of selling organs taken from executed prisoners. The Transplantation Society says it welcomed China's latest moves to ban these unethical practices, and the implementation of a new ethical system of organ donation and transplantation based on clinical need. However, the group says the new system is already looking to be a sham and the rules against organ trading a "paper tiger" because of ongoing commercial trading or organs by some Chinese hospitals. Their letter cites the example of a liver transplant for a Saudi teenage girl recently done for a price of $200,000 by a Tianjin hospital. The transplant turned out to be wholly unsuitable because the liver was scarred and diseased and the girl died. The transplant was illegal unethical and should never have been done, but the Tianjin hospital that did it is still advertising organs for international buyers at www.cntransplant.com. The Transplantation Society doctors say this is just one example of how unaccountable and corrupt the organ transplantation system continues to be in China. They also note that many of the Chinese doctors and officials involved in corrupt organ trading in the old system have already taken up positions of responsibility in the new system.
"These centers are both jeopardizing the public trust at home and tarnishing China’s reputation on the international stage," they write.
"Thus, we ask the Chinese government for an immediate and sustained resolve, to monitor compliance by Chinese professionals in performing organ donation and transplantation in accordance with NHFPC and international standards. The fledgling national organ allocation computer system that has been developed must be authorized as the sole distributor of organs to ensure transparency and fairness. Otherwise, the perception will be that one corrupt system of organ donation in China has simply been replaced by another," they conclude.

How much does the average Chinese doctor earn?

by Michael Woodhead
Much of the recent highly-publicised violence against doctors by patients has been triggered by resentment and mistrust of the medical profession, especially in relation to their earnings. 
In theory, doctors have only a modest salary, but everyone in China knows that many doctors make a lot of money through the so-called 'grey channels'. This week the People's Daily mounted an investigation to discover the true earnings of a typical doctor and the sources of their income.

After speaking to doctors off the record and also to other people working at senior levels in hospital management and in industry, it soon became clear that doctors have many additional and unofficial (but often legal) sources of income. The phrase "drug-dependent doctors" describes the reliance of doctors on prescribing for their income. Another well know rhyming phrase in hospitals is 'physicians rely on commissions, surgeons rely on operations' (it sounds better in Chinese - 'Neike kao huikou, waike kao shoushu').
A typical doctor at a large tertiary level hospital in Beijing will officially earn about 46,000 yuan (US$7500) a year. In reality, doctors earn more than three times that - about 180,000 yuan ($29,000) a year. The additional income comes from four areas:

1. Bonuses  - from hospital, for meeting patient number and performance quotas
2. Commissions for prescribing drugs and ordering tests
3. Red envelopes - from patients to get preferential treatment
4. Moonlighting - doing 'outside clinics' at weekends - often in regional cities and towns

One orthopaedic surgeon said that without the 10,000 yuan ($1600) monthly bonus from his hospital, most doctors in his department would leave. The basic monthly income of a doctor is only about 2-3000 yuan ($320-480), and no-one would work for that. The surgeon said all doctors depend on their monthly bonus for much of their income, and also the annual bonus, which can be several thousand yuan. The real income for a hospital specialist is about 180,000 yuan ($29,000) a year, and for a head of a department as much as 250-300,000 yuan ($40,000-48,000) a year. The income varies between departments and specialities. Some areas such as orthopaedics, surgery and cardiology are the highest paying. Others, such as paediatrics, have a lower income because doctors in these specialities prescribe fewer drugs and use fewer tests. A doctor in a  regional hospital would also earn less - maybe only 10,000 yuan ($1600) a month.

Doctors also get commissions from the sales of drugs. It is well known that hospitals rely on commissions on drug sales, which make up 50-60% of their income. Doctors also individually benefit from drug sales, says a drug company representative. Whether they agree or not, doctor's income is related to how many drugs they prescribe. Companies reckon that 10-30% of drug sales income goes to doctor.s for choosing them and prescribing them. Surgeons do not prescribe as many drugs but they make money from 'red envelopes' in prioritising patients. Surgeons along with anaesthetists and theatre nurses also make commissions on the use of disposable medical items and the use of medical devices and tests.

Another overlooked source of doctors' income is moonlighting. At weekends, Beijing Airport is said to be a social meeting place for the medical profession as doctors fly off to do their 'outside clinics' in other parts of the country. For the top specialists in any field this is a lucrative source of additional income and they can make tens of thousands of yuan from just a single session - and millions of yuan a year. However the junior and low level doctors make much less than the top specialists. A doctor at a community clinic, for example, would get only 4-5000 yuan ($640-800) as a basic salary and would not get much income from prescribing or surgical work.

These kinds of grey income are a contradiction in the health system and are the underlying reason for doctor-patient tensions - it is all to easy for misunderstandings to occur and to flare up into trouble - like 'a minor incident sparking a war' as the Chinese saying goes.

One of the fundamental underlying problems is that the doctor's time is undervalued. Take a knee replacement operation, for example. Such an operation will require two surgeons, two theatre nurses and two anaesthetist and last at least an hour - possibly three hours of their time. And yet the 'doctor's fee' for the operation is only a few hundred yuan - where is all the money to come for the doctor's expertise - let alone for the equipment, drugs, gas and blood and dressings?  There are doctors with a conscience who will add a reasonable and standard markup for their time - and yet there are other 'business minded' doctors who add a lot more. And there are some doctors who use foreign disposable equipment which might cost 200 yuan ($32) to buy, but is billed to the patient at several times that amount.

"There are some bold doctors who when it comes to prescribing always choose the most expensive, not the most appropriate drugs," says one pharmaceutical  supplier. "And when a new drug comes out they all rush for it in a show of excessive and unnecessary prescribing," he says. It is the same with tests - patients are told they must have numerous complex and expensive tests that they don't need, because the doctor gets a commission, he says.

The situation in hospitals also has a rhyming slogan: "Getting to see the a doctor is hard (kanbing nan): registering is hard (guahao nan),  waiting is long (houzhen chang), time with the doctor is brief (kanbing duan), doctor's fee is expensive (kanbing gui), tests are many (jiancha duo), prescriptions are many (chufang duo) and drug costs high (yaofei duo). All in all it is a volcano waiting to explode - no wonder 70% of doctors have experienced violent disputes with patients.

It is hoped that the Chinese government's new health reforms - including those on drug pricing and supply arrangements, will help straighten out this situation. What is also needed to 'restore the honour of the doctor's white coat'? According to leading physician Dr Huang Jiefu, the answer is a turn to the free market. By giving doctors the freedom to practice where and as they wish - as set out in new government policy -  doctors will be able to set a true market value for their services. When they do this they will no longer need to rely on unethical and unfair 'grey market' channels to maintain their income.  The People's Daily ends by saying that new health insurance schemes should allow patients to afford private doctors by encouraging the public to pay in premiums and have a policy that they can use when they need it most.

Why China's new anti-smoking campaign will fail

by Michael Woodhead
The Chinese government has recently announced sweeping measures to ban smoking in public areas of government facilities such as offices, schools and sports grounds. Government officials have also been ordered to take the lead in promoting smoking bans. This is a welcome and long overdue move, but without enforcement it won't work. In the past China has enacted many laws and regulations against smoking but they have not been enforced. People smoke with impunity in 'no smoking' areas because there are no inspectors to enforce the rules. There is very little publicity given to the dangers of smoking and the health benefits of quitting - and very little promotion of smoking cessation. China has also lacked smoking cessation services to cater for those who do want to quit.
Tobacco control experts from China and Hong Kong have said that the new measures will require a huge workforce of anti-smoking inspectors to enforce compliance. Take Hong Kong as an example. The city has 650,000 smokers and has needed 100 full-time enforcement officers issuing 8000 fine tickets a year to adequately enforce its 2007 anti-smoking legislation. Based on these figures, with a population of 300,000,000 smokers, China will need 46,000 full-time enforcement officers and about 4 million penalty tickets issued annually to enforce smoking bans. Writing in the American Journal of Epidemiology, Dr Lam Tai Hing and Dr Yao He say China will also need to put funds into publicity and enforcement of anti-smoking campaigns. At present, the ratio of Chinese government expenditure on tobacco control to annual tax revenue is 20 million Yuan to 424 billion Yuan, or 0.005%, which is one of the lowest in the world.
Until more funding and enforcement of anti-smoking measures are implemented, China's smoking cessation clinics will continue to be empty.

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 ....