HPV vaccine delay | Baidu medical fraud | Malaria system success | Gassers in short supply | GSK case won't stop bribery

1. China may be delaying approval of HPV vaccines made by foreign companies until the country has a homegrown competitor, according to Global Times. The HPV vaccines Gardasil and Cervarix are still not available in China despite 30,000 women dying in China every year of HPV-related cervical cancer. Some Chinese doctors and officials claim there are ethnic differences in vaccine responses between Chinese and Europeans, and clinical trials that in Chinese people are needed to ensure of the vaccines' safety and efficiency on Chinese.

2.  Baidu earns its fortune by promoting fraudulent medical information at the cost of health and even lives, critics say. The search engine site is the main avenue used by illegal drug manufacturers and illegal hospitals to advertise in China, they claim. Many drugs that are explicitly banned by the China Food and Drug Administration (CFDA) are still on promotion on Baidu, an article in Daily Kos says.

3. A '1-3-7' system of dealing with malaria cases that is very successful and could be a model for other countries, researchers from the Jiangsu Institute of Parasitic Diseases claim. The system is based on case reporting within one day, case investigation within three days. and focus investigation and action within seven days.Since the system was implemented in 2012 the proportion of cases investigated in 3 days has reached 100%, and seven-day action rates are 50% and rising.

4. China has a shortage of 200,000 anesthesiologists as doctors avoid the speciality due to low salaries, heavy workloads and lack of a strong training system, experts say. A conference was told that China has only 100,000 anesthesiologists but needs 300,000. Eight anesthesiologists died of overwork last year, according to Yu Weifeng, head of the anaesthesiologist branch of the Chinese Medical Doctors Association.

5. A cure for the endemic corruption in China's healthcare system is still far away despite the scare campaign against executives of British pharma company GSK, the online magazine Caixin says. While the crackdown makes the authorities look like they are being tough on bribery for prescribing, the reality is that doctors still accept commissions and there is no fix for the 'demand side' of the bribery equation, the magazine says. The health ministry cannot afford to alienate doctors, who are central to the problem, it concludes.

Six of the best medical stories from China: Wed 14th May

1. Obesity is on the increase in China with new figures showing that men have a 2.8 kg/m2 higher BMI in 2009 compared to their counterparts in 1993, while women have a 1.5 kg/m2 higher BMI . Waistlines have also increased by 9 cm for men and 5cm for women, according to researchers from the National Institute of Nutrition and Food Safety, Beijing.

2. A man with arthritis died while undergoing treatment at an Anhui clinic and was secretly buried by the doctor on nearby waste ground, the Shanghai Daily reports. The 53-year old man went to the Hefei clinic for treatment of shoulder arthritis, but appears to have had an adverse reaction to an injection and started foaming at the mouth. Instead of trying to treat the man, the doctor who owned the clinic locked him in the room until he died and then took the body outside and dug a big hole to bury it in. Dr Li was found out when police examined video surveillance camera footage and was detained on suspicion of severe medical malpractice.

3. The 'Tiger Mom' style of parenting in China is contributing to mental health problems in later life, according to a study from the Department of Clinical Psychology, Beijing Anding Hospital and the Beijing Key Laboratory of Mental Disorders. The study found that parental punishment, rejection and control were key factors in borderline personality disorder (BPD). Paternal punishment, low maternal emotional warmth predicted BPD diagnosis, especially in women. Maternal emotional warmth may be a protective factor against BPD.

4. Noxious gases from sewage treatment plants pose a threat to human health, a study from Tianjin has found. Researchers found that sewage treatment plants emitted toxic levels of hydrogen sulphide and also many classes of organic carcinogens from waste water.

5. China now has 2.78 million nurses, or one for every 500 people, according to new figures. However, many nurses are working in non-traditional roles such as non-communicable disease management, rehab and hospice care.

6. Fudan University in Shanghai has teamed up with local health services to set up an experimental health care unit to explore healthcare reforms and flexible models of care such as patient transfers, medical insurance payments and doctors working at more than one medical facility.

Four-fold rise in chickenpox shows China's one-dose varicella vaccination policy is not enough to prevent outbreaks

by Michael Woodhead
China needs to move from a one-dose to a two-dose varicella vaccination schedule because he current system is not preventing outbreaks of chickenpox, a study from Beijing has shown.
There have been more than 62 outbreaks of chickenpox (varicella) among children in the Fengtai district of Beijing since 2008 despite vaccination rates of over 80%, researchers have reported this month. They found that the number of varicella cases has increased fourfold in the district from
from 167 in 2008 to 622 in 2012. More than 60% of the cases were breakthrough infections in children who had been vaccinated, according to Dr Zhang Xue and colleagues at the Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University.
"These results indicated that in the Beijing Fengtai District, one-dose vaccination could not effectively protect the vaccination recipient from varicella infection or cut off the varicella transmission during the outbreak," they wrote.
Their study suggested that the efficacy of the varicella vaccine wanes after a few years, and in children with varicella, the average time since vaccination was six years, (76% of cases occurred more than five years after vaccination).
Varicella was also more common among children of migrant worker families, presumably because of lower vaccination rates and due to overcrowded living conditions.
The researchers said their findings showed that the single dose vaccine program introduced in 1997 was not sufficient to contain varicella in China.
"In summary, our study provides justification for implementing a two-dose varicella vaccination program in cities in China, such as Beijing, despite the presence of already-high vaccination coverage."

Husband wins 300,000 yuan compensation from Beijing hospital over wife's death from pneumonia

A Beijing man has won Y300,000  in compensation from the Harmony Hospital in Beijing after a four year legal battle over the death of his wife from complications of pneumonia. The man claimed that his wife had died following  a lung biopsy to investigate the cause of her breathing difficulties. He claimed 900,000 yuan in compensation for living expenses and funeral costs, and was initially 25,000 yuan settlement by the hospital, which denied responsibility for the death. However, the man appealed to a higher court and was awarded 300,000 yuan when the court found that hospital in providing follow up care to the 57-year old woman. The court heard that the woman had a chronic lung disease resembling asthma. and was admitted to the hospital for tests in May 2011. However, the tests were carried out by a junior doctor who ordered a biopsy which the husband claimed was not necessary to diagnose pneumonia. The court also accepted his claim that the follow-up care after the biopsy was lacking as the woman received little supervision and developed pneumothorax and died. The court found that the hospital did not make basic precautions such as doing a risk assessment on the patient for the procedure, or managing thoracic drainage competently. It also heard that the hospital had altered medical records to try cover up its malpractice, but the court did not accept the evidence for this.

Doctor taken hostage after patient dies of lung cancer

by Michael Woodhead
An oncologist was taken hostage by a knife-wielding man at a Dongguan hospital after the man's father died from lung cancer, Guangdong media have reported.
The doctor, surnamed Chang, was able to escape from his captor during negotiations with police, but two police were injured while trying to apprehend the hijacker. Doctors say the man was the son of a patient who died after an operation for lung cancer on 9th May. Doctors said the patient had been unco-operative throughout his treatment and had refused to follow doctor's advice, even refusing to stay in bed when he was sick. When the man got out of bed and started moving round, he had breathing difficulties and his condition deteriorated and he collapsed. After the man died, his son left and returned with a knife, which he used to threaten staff, and he took Dr Chang hostage and locked the door. He called for Dr Wen to come over, believing him to be the one responsible for his father's death and said he would kill him and then himself. Dr Chang told the man that he was the one who operated on his father and only he was responsible. When he tried calling for Dr Wen three times without success, the man got more agitated.
A police hostage squad with shields came to the hospital and started negotiations with the attacker, who had Dr Chen held with a knife at his neck. When the hostage negotiator asked the man to approach to talk, Dr Chen was able to suddenly break away and escape from the room. The attacker chased after the doctor but was stopped by police who used their shields to press him to the wall. When the attacker was trapped he lashed out at police with the knife, stabbing two of them around the ear and the hand, injuring them.
The 28-year old man was then arrested by police. Dr Chang said it was the first time in his career that he had ever come across such an extreme situation.

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

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

My top 7 medical news stories from China for Sunday 11th May

1. An intensive control program has helped to reduce the incidence of schistosomiasis in China over the last decade, according to Dr Li Shizhu of the National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai. However, nine 'hotspots' still exist, mostly in the marsh and lakes areas of the the middle and lower Yangtze River basin.

2. Japanese researchers have developed a vaccine that is effective against the H7N9 avian influenza that has killed more than x people in China since it first emerged in 2013. The researchers from Hokkaido University developed an inactivated whole virus particle  vaccine from a Duck/Mongolia/119/08 (H7N9) strain that is antigenically similar to Anhui/1/13 (H7N9) that has been circulating in China. In an animal tests, the vaccine induces protective immunity against the challenge with Anhui/1/13 and the researchers say their vaccine could only be mass produced within six months to be used in case of a H7N9 pandemic.

3. About 75% of foreign medicines bought by Chinese from internet sources are counterfeit, according to the China FDA. The agency says Chinese cancer patients often turn to online agents to buy foreign new drugs that are not available or not approved in China and are very expensive to buy in China. However, an investigation found that drug bought on the internet such as Gleevec are typically counterfeit and contain no active ingredient.

4. New clinical guidelines on the management of COPD have been published for China by Professor Cai Baiqiang and colleagues at the Department of Pulmonary Medicine, Peking Union Medical College Hospital

5. The city of Beijing wants to divert people with minor illness from overcrowded hospitals to local 'family doctor' clinics. It is promoting the availability of family doctor clincis, saying these will be available in most areas of the city from this year. The advantages of family doctor clincis are that pateints can easily make appointments to see the doctor - and the services are aso open to people without a Beijing hukou. 

6. Price controls have been lifted for 280 essential drugs in China because reputable pharmaceutical companies found it unprofitable to manufacture them. The  National Development and Reform Commission (NDRC) recommended lifting price caps on the basic drugs which had been designed to make them affordable to the less well off. The price caps meant that basic drugs were often made by dodgy companies that cut corners on quality to try make a profit on the low prices.

7. Many Chinese patients with type 2 diabetes have poor control of their glycaemia through inappropriate use of hypolgycaemic drugs. A survey of almost 10,000 patients found that those using metformin as monotherapy had better control, whereas those using insulin secretagogues often had poor control and had to make frequent changes to therapy. The study found that 70% of patients used insulin secretagogues such as sulfonylureas or glinides (28%), 54% used metformin and 17% used thiazolidinediones. Dual-drug combination therapy was more common (45%) than monotherapy (36%.

Measles resurgent in China as migrant children miss vaccinations

by Michael Woodhead
China looked like it was on track to eliminate measles until two years ago, but now the infection is making a comeback among unvaccinated young children, the World Health Organisation has warned.
In a report of the progress towards measles elimination in China a WHO surveillance study notes that China has seen dramatic reductions in rates of measles since it implemented and expanded childhood vaccination campaigns in the 1980s  and 1990s. Rates of the infection fell from 572 per 100,000 in the 1960s to below 10 per 100,000 since the 1990s. Since then, further reductions in measles have been seen as children have been given two doses of measles vaccine with uptake rates of more than 90%. There have also been additional 'catch up' measles vaccination campaigns in provinces where continuing outbreaks of measles have occurred. This resulted in the annual number of cases coming down from 140,000 per year in 2008 to under 10,000 in 2012. However, as the WHO Bulletin report notes, there has been a resurgence in 2013, with the number of cases bouncing back to around 24,000 in that year. The report says most of the measles cases occurred in young children who had missed one or all of their scheduled vaccination doses, although a few also occurred in adults. It says the resurgence is disappointing, especially as it follows intensive 'catch up' campaigns. In their report, the WHO researchers say it is likely that many of the unvaccinated children spreading measles will belong to migrant worker families who have left their hometown and thus drop out of the measles vaccination and reporting programs based in schools and local health centres.
"The resurgence of measles seen among young unvaccinated Chinese children in 2013 indicates a weakness in routine immunisation that allows some children to miss one or both of their scheduled doses of measles vaccine. Such weakness must be eliminated if a further resurgence in the next few years is to be avoided and measles is ever to be eliminated in China," they conclude.
"Improvements in the identification and location of children who are new to an area may permit marked improvements in vaccine coverage" they note.

Can you legislate to make better doctors?

 
by Michael Woodhead
New draft legislation released by China's National Health and Family Planning Commission seeks to make doctors practise medicine in a more humane and 'patient-centred' way. The new regulations will make it a criminal offence for a doctor to neglect to treat a patient, and will force doctors to take responsibility for the adverse outcomes of any patient that they fail to treat in a reasonable and timely manner.
Released at the behest of the State Council, the "Medical Treatment Quality Management Regulations (Draft)" is a wide ranging document that aims to improve the quality of medical treatment by spelling out the doctor's duties and also highlighting prohibited practices.
The new rules state that it will be a criminal offence for medical staff to refuse to take responsibility for patients in need or treatment, and staff must bear the consequences of any damage or injury that results from failing to provide treatment. The NHFPC says the new legislation also requires health providers to have mechanisms in place to accept and respond to medical complaints in a timely manner. It says medical staff must act in a humane and patient-centred way to carry out the core responsibility of "healing the wounded and rescue the dying". Staff must show respect to the patient and uphold their rights. The new rules also require medical personnel to use medications responsibly and to have a good knowledge of how they work and their efficacy. They also make it a criminal offence to use non-approved drugs, medical procedures, equipment.

China's latest medical soap - a bit too sudsy?

"The Male Obstetrician" (产科男医生) is China' new medical soap opera, and its first episode has met with mixed reviews. It stars the real life recently-wed celeb couple Li Xiaolu and Jia Nailiang as the two doctors in the obstetrics department of a major hospital. Viewers have praised the medical details of the show, saying it may educate and enlighten people about the realities of what really goes on in an obstetrics department. However, they have also ridiculed the storylines, such as a scene in which a pregnant woman in a coma hears the sound of mahjong and is brought back to consciousness and is then able to deliver her baby. Critics say the new show is not as heavy as previous medical shows that focus on the dramas of heroic doctors and the tensions they face in diagnosing cases and struggles between patients and doctors. The new show is said to be lighter and more humorous, with much petty squabbling between the male and female leads.

My top 5 medical stories from China for Thursday 8th May

1. Malnutrition is still a significant problem in rural China, with 27% rates of stunting and 13% rates of severe stunting seen in a survey of 84 villages in mid-western provinces in 2010. Researchers from the Chinese Center for Disease Control and Prevention, Beijing, looked at 1260 children under 3 years old, and recommended that the Chinese government should implement appropriate nutritional intervention strategies to help reduce the prevalence of malnutrition in children.

2. Two million Chinese people die of a heart attack each year and the treatment of survivors is very poor, cardiologist Professor Wu Yangfeng told the World Congress of Cardiology in Melbourne this week. Professor Wu said there was very little use of proven treatments such as aspirin, statins and antihypertenisves in China for secondary prevention of acute coronary syndromes.

3. Resistance is a rapidly growing problems for the aminoglycoside antibiotics that are routinely used for the treatment of severe infections due to Klebsiella pneumoniae, Beijing researchers have shown. In a new study they found high rates of 16S rRNA methylase genes among 43 K. pneumoniae isolates found in nine tertiary hospitals in China.

4. The angiotensin system may play a key role in H7N9 influenza morbidity and mortality, according to researchers from Hangzhou. In a study published this week they showed that blood plasma levels of angiotensin II are higher in H7N9 patients and could be used to predict their physical deterioration.

5. The first death of a human due to the H5N6 strain of avian flu, has been reported in a 49-year-old man, from Nanchong in Sichuan, Xinhua says the man had been exposed to dead poultry and was initially diagnosed as having pneumonia.

My top 7 medical stories from China for Monday 5th May

1. Epidemics of haemorrhagic fever with renal syndrome are likely unless rat populations are controlled, say researchers from the Shaanxi Provincial Centre for Disease Control and Prevention, Xi'an. Rats provide the reservoir for hantavirus which causes the disease, and outbreaks are linked to the size and density of the rodent population, they found.

2. Gene mutations that increase the risk of rheumatoid arthritis have been identified by clinicians at the Second Military Medical University, Shanghai. 

3. The average length of a Chinese man's penis is 6.5cm, according to a survey of more than 5000 men carried out by urologists at the Renji Hospital, School of Medicine, Shanghai Jiaotong University. They say their findings "established a reference range for penile dimensions, which will help when counseling patients worried about their penile size or seeking penis enlargement surgery."

4. A 12-year old boy in Beijing has received a heart transplant from a 21-year old donor who died of brain tumour.

5. Healthcare for Tibetan nomads is improving but still underdeveloped, as healthcare staff are often unwilling to work in remote areas, according to one clinicians in Yushu, Qinghai. The most common medical problems are back and knee problems, hepatitis and cancer, the medic said.

6. Working long hours puts men at higher risk of developing type 2 diabetes, the 'Karoshi' study of more than 2200 people in Shanghai has found.

7. Women in China with pre-cancerous changes of the cervix show high rates of spontaneous regression, suggesting that cervical prevention may need to be modified to reflect this, according to researchers at the Chinese Academy of Medical Sciences and Peking Union Medical College.

Academic fraud doctors swindled out of 5600 yuan by ghostwriters

by Michael Woodhead
Two doctors from Suzhou who tried to publish fake articles in medical journals found themselves to be the subject of fraud when their 'ghostwriters' pocketed 5600 yuan. 
The two doctors attempted to cheat on medical publishing requirements for promotion by getting an online 'writing agency' to write an article in their names and have it published in the "China Medicine" journal. The deception arose because in China it is necessary for doctors to get work published in journals in order to obtain advancement in their careers. The two Suzhou doctors felt they didn't have the time or the inspiration to do an article of their own, so they turned to an internet ghostwriting agency website that offered writing services for such situations. The website promised that an article could be written on a topic of their choice and published in the "China Medicine" journal. The doctors paid  2800 yuan and sent a list of suggestions for the article content.
At first the writing agency seemed very competent, and sent them a manuscript for their comments and revisions. The agency then asked them for a further 2800 yuan for publication fees. However, when the doctors sent the money, they never heard anything more from the online agency. When they checked the website of the China Medicine journal they found their article had not been published. They later found that the agency had a fake address and the phone had been disconnected. The  doctors reported the fraud to the police, but they were unable to track down the fraudsters. The police advised anyone thinking of publishing to check the publisher credentials.

Universal health coverage in China - are we there yet?

by Michael Woodhead
An interesting reference article in The Lancet today comparing the progress to universal health coverage in the BRICS countries (Brazil, Russia, India, China, South Africa ...). The section on China I presume is written by Professor Wang Kongde of the School of Public Health at Peking University.
Some of the useful facts in the article, such as China's health expenditure increasing from ¥75 billion in 1990, to ¥1998 billion in 2010. At the same time, average per-head health expenditure increased from ¥65 to ¥1490.

China has four major health insurance schemes:

1. The New Rural Cooperative Medical Scheme (NRCMS) - started in 2003, now covers 812 million farmers (ie 95% of them), financed mainly by the government, with small contributions from farmers

2. The Urban Employee Basic Health Insurance (UEBHI) - covers 30% of population, jointly funded by employers and employees.

3. The Urban Resident Basic Health Insurance (URBHI) - cover urban residents not enrolled in UEBHI.

4. The Medical Financial Assistance system (MFA) - a relief scheme for China's poorest citizens, (70 million people), providing direct aid for the severely disabled and people with serious illness.

According to the Lancet article, the rural and urban health scheme provide 75% reimbursement for inpatient expenses (but I have heard that it actually cover much less than this and patients face high out of pocket expenses even with insurance).
These three systems, NRCMS, URBHI, and MFA, complement each other and greatly expanded the range of health service benefits.
Professor Wang say the Chinese government aims to expand the insurance schemes to reduce health spending to less than 30%. For example, subsidies to rural residents will increase to ¥360 by 2015.
"Meanwhile, efforts will be made to standardise and improve reimbursement plans, enhance inpatient reimbursement, and undertake broad outpatient pooling fund reimbursement continuously to increase the number of people benefiting from the NRCMS," he writes.
However, he acknowledges that China's publicly-subsidised health insurance schemes face many problems in achieving universal coverage.
Like other countries, China faces an ageing population and increasing rates of chronic diseases, not to mention higher expectancy for health services.
He notes that access to health services and resources varies widely between regions. Cost control is also a major problem. Simply increasing government funding may just trigger overservicing with the use of more inappropriate tests and expensive medicines.
Thus measures on cost control are urgently needed, and also a stronger regulatory system and reform of hospital governance. Professor Wang also notes that China is going through a turbulent period of health reform, and that many in the health ministry and government are inexperienced in this area. Therefore, the road to universal health cover for China remains uncertain.

The top 8 medical news stories from China for Thursday 1 May

1. A person's blood group may influence their survival from cancer according to oncologists in Guangzhou. In a study of patients with oesophageal cancer they found five year survival rates were 50 % for patients with blood type A, 45% for type B, 51% for type O, and 61% for type AB.

2. The incidence rate of type 1 diabetes is increasing at a rate of 14.2 % per year in Shanghai and if present trends continue, the number of new type 1 diabetes cases will double from 2016 to 2020, researchers say.

3. Chinese neurologists say people with atrial fibrillation may be able to avoid the need to take lifelong anticoagulant drugs to prevent stroke by using a minimally invasive surgery procedure called left atrial appendage closure (using a system created by Boston Scientific Corp - could be an advertorial).

4. The introduction of the New Cooperative Medical Scheme (NCMS) has increased access to healthcare for elderly people, but not had any effect on their overall health, a study from Nanjing University shows. The study found that the health cover did not affect overall health status and did not reduce the out-of-pocket spending of elderly people.

5. An outbreak of hand, foot, and mouth disease that hospitalised 1844 children in Central China from 2011 to 2012 was caused by a mixture of co-circulating coxsackievirus A16 (CVA16). and enterovirus I71 (EV71). This may have contributed to the genomic recombination between the pathogens say researchers from Wuhan University.

6. The whistleblower 'Corridor Doctor' doctor of Mianyang who worked in a corridor after being suspended from her job for two years, has now been sacked. Authorities said Dr Lan Yuefeng had been absent for almost two years and had been disruptive and uncooperative. Her colleagues rejected charges of overservicing at the hospital and went on strike claiming she had made false allegations and damaged their reputation.

7. Health authorities in Beijing are urging adults to have measles vaccination after a surge in cases in thecity. They say there has been a spike in cases in the past two months, and more than half of the infected are in adults, probably because protection from childhood vaccination has waned.

8. Radiologists in Sichuan claim that resting-state functional MRI could be useful in providing early and accurate diagnosis of ADHD. In a study published in Radiology, Dr Qiyong Gong of the West China Hospital of Sichuan University, showed that the boys with ADHD had altered structure and function in certain areas of the brain, such as the orbitofrontal cortex and the globus pallidus. that play in executive inhibitory control - the ability to control inappropriate behaviors or responses.

Red envelopes or red tape? Hospital doctors feel insulted by the new 'no bribes' contract they are forced to sign

by Michael Woodhead
In an effort to clean up hospitals and crack down on bribery,  patients and doctors will be required from 1 May to sign mutually-agreed contracts forbidding the giving or receiving of' red envelopes'. The new contracts, ordered by the National Health and Family Planning Commission, will be an extra step of the hospital registration process and are intended to reinforce the message that doctors can no longer rely on 'grey channels' for their income. However, a survey carried out at one Beijing hospital that has trialled the system raises the question of whether it is all just for show - and whether it is perhaps just another bit of bureaucracy to contend with. An anonymous survey carried out at the Meitan Hospital in Beijing asked 122 patients and 55 doctors what they thought about the giving of 'red envelopes' or gifts to medical staff and whether they accepted the new 'no red envelope' contract system - which has been operating at the hospital for two months.  Interestingly, about a quarter of patients said they had been prepared to give a red envelope before signing the contract, whereas two thirds of patients said they hadn't thought about it. The remainder 10% were 'definitely not' prepared to give a red envelope. About 57% of patients said they agreed with the red envelope contract, whereas about 35% said they thought it was not necessary. Of the doctors, 100% said they would not accept a red envelope or gifts from patients. Despite this, 40% of the doctors said they were not happy about signing the new contracts, and 20% said they were strongly opposed to the contracts. When asked why, doctors said they had already agreed to the Hippocratic Oath when they first donned their white coat, and they believed this was already  a contract not to accept bribes.
However, hospital manager Wang Mingxiao said that the new contract system was a visible way of showing patients and their families that the hospital staff were "clean and incorruptible".  Mr Wang said the contract system was an essential step in the hospital's setting up of an 'honest and clean' checking and monitoring mechanism to ensure ethical medical practice.

6 clinical stories from China

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


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

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

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

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

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

Why are GP community clinics unpopular in China?

by Michael Woodhead
A recent article about medical services in Shanghai noted that hospital clinics were severely overworked, with patients facing hours in the waiting room to see a doctor for just a few minutes. In contrast, the nearby community clinic was very quiet, with doctors there underemployed. Now an article has been published claiming that community clinics are underused because they are inefficient and the doctors there lack the expertise of hospital medical staff. According to columnist Xin Ya, community clinics need competition from private clinics to lift their game. The writer says the old state service model on which community clinics are based means they provide only the most basic medical facilities and the service levels are poor - due to the unmotivated 'iron rice bowl' mentality of the staff.
Public community clinics in China are characterised as 'gatekeepers' but the writer says the offer little benefit to patients as they stock only the most basic drugs (due to their non-profit model) and they lack investment in equipment. The doctors are unmotivated because they are on a fixed salary and get paid the same regardless of results, with no performance targets or bonuses.
According to the columnist, a recent visit to the gatekeeper provide frustrating because they did not even have the basic equipment such as needles and sample test tubes to collect blood, and so a prson requiring tests had to go to the hospital to get a full examination.
The author say the government should remove the restrictions on private clinics setting up in competition to the current network of community clinics. In this way, 'the survival of the fittest' will occur as privately-invested clinics will have a motive to offer better services and better facilities to win patients. The government also needs to remove restrictions on doctor's employment contracts to allow hospital doctors to provide community clinic services and earn larger salaries there.
"In the future, private clinics should be as free as the restaurant competition ... and let the market decide who can survive," the article says.
"For community clinics, public sector and private medical institutions are like 'the lion and the antelope' - the establishment of a competitive community "gatekeepers" system, will improve the overall quality of medical care for residents, and allow them to enjoy affordable and quality services."

China has the highest rate of caesarean births in the world: time to act

by Michael Woodhead
Almost half of Chinese women give birth by caesarean section, a rate that is three times higher than the 15% recommended by WHO, according to two Chinese clinicians writing in The Lancet this week.
Dr Mi Jie and Dr Liu Fangchao of the Capital Institute for Paediatrics in Beijing say China has an urgent need to reduce the number of caesarean births because they have a high risk of related complications or death, and because babies delivered by caesarean section are more likely to have respiratory problems, obesity, and other metabolic diseases.
The doctors list five non-medical reasons why China has a 42% rate of caesareans:

1. Women fear pain and loss of vaginal tone after natural birth. They see caesareans as safer faster and less painful.
2. Women wrongly believe that they will regain their pre-pregnany figure better after caesarean birth.
3. Chinese women like to choose a 'lucky' date to have their baby by caesarean.
4. Doctors prefer to schedule the caesarean for convenience and to avoid medicolegal disputes with vaginal birth
5. Caesareans are more profitable for hospitals (12000 yuan vs 6000 yuan for natural birth).
The authors of the letter to the lancet call on the government to take control the rate of caesarean section in China,
"The Chinese government should develop specific policies and measures, such as use of rate of caesarean section without medical necessities as one of the hospital’s overall rating components, and popularising of natural childbirth," they write.
Hospitals and communities should promote health education in women of reproductive age to provide a more accurate idea of delivery," they conclude.

Today's Top 10 China medical news stories

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

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

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

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

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

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

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

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

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

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

Six sick crimes: Supreme Court issues guidelines on how to manage violent medical disputes

by Michael Woodhead  
In response to a wave of attacks on doctors and nurses, China's Supreme Court has released a list of six illegal activities that will be targeted as part of guidelines on how to manage violent disputes in healthcare settings.
 The criminal activities highlighted are:

1. Attacking doctors and damaging hospital property,
2. Setting up shrines and burning paper money in medical institutions [Ed note: this is done to disrupt hospitals and extort money],
3. Restricting doctors' freedom (eg harassing doctors, blocking their movement)
4. Insulting medical workers,
5. Bringing weapons into medical institutions,
6. Instigating others (including family members) to commit crimes against medical staff.

Any violations of these guidelines will result in serious consequences, and offenders will be convicted and punished under criminal law, the Supreme Court has announced. The list is part of a new 'opinion" position statement drawn up by the Supreme People's Procurate, Ministry of Public Security, Ministry of Justice, National Health and Family Planning Commission jointly entitled "On the punishment of crimes involving medical advice, medical order and maintaining normal law". The new guidelines also call on medical institutions to prevent medical disputes by ensuring a good standard of medical care, enhance medical ethics, improve service attitudes, focus on humane care and to maintain good communication with patients. They also call on institutions to set up dispute mediation protocols to handle complaints and to offer adequate security to medical staff. "The Supreme People's Court will uphold the law while handling cases involving medical disputes and severely punish those who seriously harm or even kill doctors over groundless assumptions," said Sun Jungong, the spokesman of the Supreme Court. China had more than 50,000 serious medical disputes last year and two doctors were killed by disgruntled patients, drawing the death penalty for the offenders. The Supreme Court said disputes must be handled in a timely way and resolved by arbitration or through fast track medicolegal channels if necessary.

Rabies rise reversed in China

by Michael Woodhead
The resurgence in rabies in China that started in the 1990s is slowly being curbed, but the infection still causes more than a thousand deaths a year, a new report shows.
After a peak of almost 3500 cases in 2007, the incidence of rabies in China has since declined by about 50%, with around 1500 reported cases in 2012, according to a study from the State Key Laboratory for Infectious Disease Prevention and Control and the Chinese Center for Disease Control and Prevention, Beijing.
Most of the cases of rabies were caused by dogs and occurred in rural areas in the south west of China. In most cases of rabies infection the disease was fatal because few people received post-exposure prophylaxis treatment, the authors of the report noted. They said there was complacency and lack of awareness about rabies in China as the disease was thought to be under control and few hospitals or clinics stocked vaccine or were aware of the need to monitor for the disease.
The study found there had been almost 20,000 cases of rabies since 2005, mostly in provinces such as Yunnan, Guangxi, Guizhou, Guangdong, Hunan and Sichuan. However, while authorities had managed to curb the re-emergence in rabies with new control programs in those provinces there were signs that the disease was spreading to northern and western provinces, including Beijing.
Writing in BMC Infectious Diseases, the researchers said rabies was on the increase because of the increasing ownership of dogs and domestic animals in China.
They said there was a need for greater rabies control efforts, including inoculation of domestic animals such as dogs in high risk areas.

Medical news headlines from China

Wenzhou clinic operators have been arrested for offering sex selection blood tests to pregnant women. Couples were charged thousands of yuan for having blood samples that were sent to Hong Kong for fetal DNA testing.

Scabies mites are commonly found on dogs especially the Pekingese breeds, of which more than 20% were found to have the parasite that can infect humans and cause intense itching, a Guangzhou study has found.

Beijing hospitals have been inundated with applications from more than 5000 volunteers to act as 'guardian angels' to protect medical staff against angry patients in medical disputes.

Angry relatives have assaulted and beaten a 24-year old junior doctor into a coma at a Jiangsu obstetrics department.

A massive drug counterfeiting operation that made 100 million yuan by offering cut-price cancer chemotherapy drugs supposedly imported from the US has been broken up by police in Shanghai.

The Beijing University Renmin Hospital has started a male erectile dysfunction clinic but doctors says many men are too stigmatised by the condition to seek help.

A court in Guangzhou has jailed 12 hospital staff after they protested about their wages and working conditions.

Public hospitals should use private investment to improve efficiency and "let the market play a decisive role", the National Health and Family Planning Commission says.

Shanghai hospitals are to use middlemen to act as mediators in disputes between patients and doctors.

A Wuhan couple who were unable to have children after being married for seven years didn't know how to have sex, a doctor found. He prescribed them a pornographic movie.

Hospital VIP suites: going, going, but not yet gone

by Michael Woodhead
Most major hospitals in China have a VIP suite or 'special treatment' section that offers hospital beds with 'first class service - these are typically single rooms with extra nursing cover, and their own TVs and fridges. Naturally, the cost is much more than for a typical hospital bed, and hospitals have been expanding their 'special treatment' sections to make more money. However, the National Health and Family Planning Commission has now decreed that things have gone too far and ruled that hospitals may only use 10% of their bed capacity for special treatment beds. The NHFPC says hospitals must focus on providing services that have a public benefit and not seek profits from expensive special services.
The Beijing Daily this week visited several hospitals to find out what the situation was with VIP areas of hospitals. They found that many hospitals have developed these areas in addition to the existing cadre (ganbu) sections that offer preferential treatment for government officials. Some VIP sections were developed initially to service foreigners such as consular and diplomatic staff, but have now become more focused on domestic patients.
According to the article, the official fee for a standard hospitals bed is 20 yuan per night, and for a government official section the fee is 100 yuan per night. However, the fee for a bed in the VIP section can cost 1000 yuan per day or more -  ten times the cost of the most expensive official bed. And yet there is no shortage of takers. In fact, the Beijing Daily found that at some hospitals there were waiting lists of up to 3 months for VIP beds.
Hospital managers said the beds were popular because people believed that they would get better treatment from the best doctors and face less inconvenience such as waiting times in hospital.  However, insiders said that some VIP sections were really just 'hardware' and that patients there received exactly the same treatment from the same staff as the standard hospital bed patients.
When asked how long it would take to scale back the VIP sections to the 10% limit, managers were cautious. Some said that hospital had invested substantial amounts of money in their VIP sections and were reluctant to give them up. Others said they relied on the VIP sections for hospital income, and would not be able to make major changes until the government reformed the hospital funding and staff salary arrangements for pubic hospitals. In theory the role of the VIP sections should be taken over by private hospitals and clinics that are now being encouraged to develop by the government. However, insiders said private hospitals were still in the early stages of development and they simply did not have the capacity to take on all the VIP bed clients that currently use public hospitals. Therefore they believed that the government would take a 'relaxed' approach to the scaling back of VIP sections and would not be 'rigid' in enforcement of the 10% limits.

Medical news in brief

Prostate cancer rates have increased as much as five fold over the decade up to 2010, a study from the Jiading area of Shanghai suggests.However, prostate cancer mortality declined slightly and the five-year prostate cancer survival rate was 51%.

An outbreak of enterovirus 71 (EV71) infection in Shanghai resulted in severe disease in hundreds of children. Of 220 children admitted to hospital, , 11% needed pediatric intensive care unit care and 3% (seven) died. Severe disease tended to occur more in children who were younger and male gender.

Almost one in five medical staff are suffering from excessive workload and burnout, a study carried out at a Beijing hospital has found.

A herbal remedy, called Triptergium wilfordii is more effective against rheumatoid arthritis than the conventional medicine methotrexate, according to a trial in 207 patients carried out by Peking University Medical College.

Gastric lap banding is being used successfully in severely obese Chinese people to help them lose weight and avoid diabetes, clinicians from the First Affiliated Hospital of Jinan University, Guangzhou report.

Asthma and rhinitis symptoms are common in Chinese children, research from Chongqing has shown. A study of 4530  children under eight found that 47% had recent rhinitis symptoms, 1.6% reported a history of allergic asthma . Risk factors for respiratory disease included living near a main road and having a damp or mouldy room.

Patients from around China are flocking to Beijing and overloading its hospitals, according to the city's Health and Family Planning Commission. Officials said the capital was taking on more than its fair shareof the medical burden because patients came to the city for treatment from other provinces where hospital services were poor.

A joint venture medical school set up by Duke University and Wuhan University will enrol 100 students for postgraduate medical degrees costing up to 300,000 yuan.

Local residents living near a mine in Guangdong have been found to have toxic levels of cadmium and lead in their bodies, because they eat rice that is contaminated with these metals from pollution, researchers have shown.

Fish caught in Lake Taihu near Suzhou contain high levels of arsenic, mercury and the insecticide DDT that pose risks to human health, a study has found.

Cancer in China: don't be distracted by the smog

by Michael Woodhead
Forget about the smog scare - if you want to tackle cancer in China, you need to focus on smoking, diet and physical activity. That's the message from the Asian regional representatives for the World Health Organisation in the Lancet this week. Cherian Varghese and Shin Hai-Rim urge China to act on the obvious causes of cancer and implement practical programs that will achieve the greatest change with the least resources.
In their commentary they note that China has a huge burden of cancer, but there is still a lot that is not known about the causes of cancer and the types of cancer in China.  They note  there is a lot of concern about very evident environmental factors such as air pollution, but they say this is a minor contributory factor compared to factors such as infectious diseases, smoking, poor diet, alcohol consumption and lack of physical activity. Therefore they say much could immediately be done to prevent and reduce cancers by implementing policies such as smoking cessation and vaccinating against hepatitis B and HPV. They also stress the need for a more skilled health workforce and system to deal with cancer, such as by identification of early-stage disease, referral, and palliative care. They warn against the temptation to put resources into expensive new cancer drugs, which would probably have only minimal effect on cancer survival rates.
"A set of very cost-effective interventions are provided in the [WHO] Global Action Plan to reduce tobacco and harmful alcohol use, improve unhealthy diets, and increase physical activity. These measures are mostly regulatory, legal, and fiscal interventions, and will affect rates of non-communicable diseases (including cancer) in large populations," they say.

Africans face health discrimination in China | Cochlear implants success | Fake doctor operates on 1500 women | Psychiatrist says 10 words charges 1000 yuan fee

Africans in China face medical discrimination
With the growing economic links between China and Africa there are as many as 100,000 Africans in Guangzhou but they lack access to healthcare, an article in The Lancet this weeks says. Africans in China face racial discrimination, which fuels mental health problems and also is a barrier to them getting access to needed health services and support. Many Chinese people maintain stereotypes toward Africans viewing them as prone to violence and posing risks to public health through spreading diseases, the article says. While China sends medical teams to Africa, it ignores the Africans living within China.
"Providing Africans medical care is consistent with China's health-care reform, but the system has failed to close the treatment gap. Chinese doctors are not trained in culturally adapted care or in the management of specific diseases affecting Africans, and translation services are unavailable," the article concludes.

More Chinese medical tourists
Affluent Chinese are now seeking medical care overseas, according to CCTV. Their report says more Chinese are going to foreign countries for treatment and the trend is blamed on the lack of access to high quality clinics in China.

No takers for dispute insurance
Few people are choosing to take part in a new surgical insurance program that is designed to reduce medical disputes. The new medical insurance scheme pays only in the event of unsatisfactory results caused by medical malpractice not covered by traditional medical indemnity insurance.

Bionic ears work well in China
Cochlear implants have been used successfully in hundreds of Chinese deaf children and have had few complications, according to a new report from Henan. Cochlear implantation is a safe procedure and early postoperative complications are minor, say clinicians from the Department of Otology at the First Affiliated Hospital of Zhengzhou University.

Fake doctor did nearly 1500 operations
A bogus surgeon working at a gynaecology clinic in Henan performed 1485 operations on women and made almost half a million yuan in profit before being caught, Zhengzhou media report. The Pingdangshan court sentenced bogus doctor Ma Juan to nine years in prison and fined him 300,00 yuan for performing minimally invasive surgery on women at the Third Peoples Hospital gynaecology clinic. The manager of the clinic was also jailed for 12 years for employing the fake doctor and encouraging him to exaggerate illness and overtreat women with unnecessary but profitable operations such as cervical cauterisation and nerve blocks.

Psych clinic has few words of comfort
A Chongqing father has complained of extortionate charges and poor doctor-patient communication at a mental health clinic where he took his uncommunicative 'autistic' daughter for treatment. The man told the Chongqing Evening News that he had to pay almost 1000 yuan for antidepressant medicines after a brief consultation with a doctor who did not speak more than ten words to him or his daughter. The father sad the costs for the questionnaire test and brief consultation were excessive. A medical expert said mental health clinics were under a lot of time pressure and were not designed to provide psychotherapy but to treat psychiatric diseases. If patients want to talk more they should visit a psychologist, he suggested.

The New Rural Cooperative Medical Scheme has failed: families are still impoverished due to ill health

by Michael Woodhead
Despite covering 90% of rural residents, the New Rural Cooperative Medical Scheme is failing to prevent rural families from becoming impoverished due to expensive medical bills.
A new study shows that 14% of rural families have experienced financial ruin due to catastrophic health expenditure, and one in three people have been unable to afford to go see a doctor when sick.
A review of the NRCMS, which was introduced in 2002, found that it only covered a small proportion of a family's medical bills because the insurance fund did not have enough money. Families typically pay 200 yuan a year to become eligible for the NRCMS, but when sick they face thousands of yuan in bills for treatments that are not covered by the scheme, and face high out of pocket expenses.
Dr Li Ye and colleagues from the Department of Social Medicine, Harbin Medical University found that households in rural areas faced a high risk of medical impoverishment, even if they were relatively affluent. The NRCMS only covered 30-40% of medical expenses, and therefore families faced high levels of out-of-pocket costs when a family member became ill. The study found that 28-30% of families did not seek hospital treatment but self treated when they were sick, because of the cost.
The researchers said the NRCMS had failed in its primary function of preventing catastrophic medical expenses because of the limited scope and low level of its reimbursements
They said that unlike urban health insurance schemes, the  pool of insurance funds in the rural scheme was managed  at a local country level and was insufficient to cover even the most basic medical expenses of someone with a serious or chronic illness. Another problem with the scheme was the lack of cost control mechanisms in the fee-for-service medical system, which meant that hospitals and clinics could take advantage of the system and encourage overprescribing and overtreatment to gain money from the insurance scheme.
"In order to offer a better benefit package for NRCMS contributory members, the financing level of the NRCMS needs to be increased. The NRCMS benefit package should align policies across the whole spectrum of health care services, including primary care, hospital care and long-term aged care. The integrated policies are also important for preventing cost shifting games.
Meanwhile, stronger attentions on provider-side measures need to be paid to control cost of health care," they concluded.
The findings are published in the journal PLOS One.

Clinical Friday - news briefs from the medical journals

An outbreak of Hand, Foot, and Mouth Disease in Changchun in 2013 affected more than 1125 children and was caused by Coxsackievirus A6 researchers report. They say the finding of a different causative strain means that vaccination against enterovirus EV71 will not solve the millions of cases of the disease in China every year.

More than 80% of elderly people in Beijing are infected with the stomach bug Helicobacter pylori that predisposes to ulcers and gastric cancer, a study has found. The infection rate with the more pathogenic type 1 H. pylori strain was 56%, researchers found.

Patients with H7N9 influenza living in rural areas were more likely to be female and caught the infection from backyard poultry breeding, a study from Zhejiang has shown.

Heart failure has a poor prognosis in China with 40% patients dying within four years if they have chronic heart failure with reduced ejection fraction, a study from the National Center for Cardiovascular Diseases and Peking Union Medical College shows.

More than one in ten patients attending China's overcrowded hospitals leave without being seen, a study has found. Patients who left without waiting for treatment tended to have less serious illness and have arrived on foot, according to researchers from the Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu.

Uric acid may have a role in hypertension, according to researchers from Xinjiang. In a study of 3778 children and adolescents they found that increasing levels of serum uric acid were associated with high blood pressure.

The most common forms of cancer in China are lung cancer (20.5%), stomach (11%), colorectal (10%) and liver cancer (10%) according to new figures from the National Central Cancer Registry.

Private health is the centrepiece of health reforms in China

A few news items from this week:

Medical tourism project for Hainan

Hainan province is building what it claims to  China's first special zone for medical travel, to try attract elderly people in search of  a cheap and clean place to spend their retirement.
The Boao Lecheng International Medical Travel Zone covers an area of about 20 square km and the provincial government will create preferential policies to attract overseas medical institutions including lower taxes for imported medical instruments and medicines. Medical tourism has been backed by China's health minister, Li Bin, who said  it "will make Chinese medical institutions take steps to adapt to international demand, so that the overall standard of medical service will be enhanced."

Private hospitals given preferential treatment

To encourage private hospitals, the government is to allow them to charge whatever prices they want and also force health insurance providers to cover treatment in private as well as public hospitals. New measures announced by the National Health and Family Planning Commission include relaxing price controls covering non-public hospital services. The decree also states that all private hospitals should be included in the country's public medical insurance schemes - so long as they reach the basic  standard for 'designated' hospitals -  and government departments should implement the same reimbursement policy for both public and private hospitals. Privately-owned hospitals have welcomed the measures, especially the decision to treat all hospitals equally regarding the reimbursement of patients' medical costs.

Foreign private doctors shown favourably on TV

Chinese TV is giving positive publicity to the handful of foreign doctors working in private clinics in China. In a programme this week CNTV says foreign doctors are "flowing" into China and helping to meet the needs of China's healthcare industry.
"Alongside providing advanced treatment for patients who can afford it ... they can contribute with their knowledge and experience, in Chinese hospitals." the programme stated.

Another doctor killed by patient

A doctor has been killed in Jiangsu reportedly by a 45-year-old male patient who was angry about the outcome of a circumcision procedure. Dr Shan Erhui was stabbed to death in the lounge of a hospital in Fengxian county on Tuesday. The suspect, Wang Fangli,  underwent circumcision in the hospital on March 30 and had antibiotic treatment afterwards, and was said to be dissatisfied with the treatment outcome and the medical expenses.

Volunteers sought to protect doctors from violence

Beijing hopes to recruit 1500 "Guardian Angel" volunteers to act as intermediaries between doctors and patients, defusing disagreements and smoothing over tensions, according to Xinhua. The plan seeks to use students and patients who will serve a one-year 'guardian' term in 21 hospitals in the capital.
“Patients will understand doctors better after talking with our volunteers,” said Feng Guosheng, head of the Beijing Municipal Administration of Hospital.

3 trillion yuan invested and doctors still underpaid

The financial journal Caixin has a feature on how doctors in China still have low incomes despite the 3 trillion invested in the health system by the government. The article says that unless reforms are introduced, medical workers will continue to be paid a pittance -  especially in small town and rural hospitals. It quotes a health ministry spokesman as saying that medical reforms will fail if the "key issue" of doctors' incomes is not solved. The government says it needs to fix the problem of low pay and doctors incomes being linked to prescribing of drugs. It aims to do this by allowing doctors to work in private clinics and to charge higher fees.

Public not happy with expensive private clinics

The Chinese government may see private clinics as the way of the future, but few ordinary citizens in Shanghai can afford their fees. There has been strong criticism of a new private hospital in Shanghai that charges patients up to 1,200 yuan to see a doctor, when it costs just 50 yuan to see a doctor in a public hospital. The opening of Shanghai International Medical Center (SIMC) is being criticised as a symbol of the move to cater only to the well-off in a society.

Are China's health reforms stalling? Health ministry denies rumours

by Michael Woodhead
In an unusual move, a spokesman for the National Health and Family Planning Commission (NHFPC) this week spent much of a press conference trying to refute rumours that the health reforms were proving "too difficult" for the NHFPC to implement.
The spokesman for  health minister Li Bin specifically rejected media speculation that the State Council had decided  that implementation of health reforms should be transferred back the the National Reform and Development Commission.
The move comes after media reports noted that plans to merge China's urban and rural  health insurance schemes had stalled. A financial article re-published widely on social media site WeChat had also questioned whether the health ministry had the clout to push through necessary reforms of hospital finances to remove the dependence on income from pharmaceuticals. This was a tough task as the reforms face strong opposition from the medical profession, whose income is based on sales on drugs. Some have also questioned the ability of the health ministry to be a reformer "reforming itself"
and say it has shown weakness in co-ordinating reforms.
Spokesman Mao Qunan said the article was just a rumour and there were no plans to return the reforms to the National Reform and development Commission. He said health reforms were progressing steadily and it was expected hat there would be difficulties along the way. He noted that Premier Li Keqiang had put special emphasis on deepening the health reforms and implementing them in public hospitals, and this was now being extended to more than 1000 country level hospitals.
Health economists such as Professor Hu Suanlian of Fudan University, Shanghai have commented that health reforms are difficult to implement and co-ordinate because they involve many departments with different aims and responsibilities - such as finance, social security and health. There is also the problem of different provinces and cities having different health insurance arrangements and different priorities.
[Editor's note: This unusual admission of a rumour - and the concerted effort to quash it suggests  there is real opposition within the health system - and perhaps the political establishment - to China's health reforms. The health ministry spokesman made specific reference to doctors' income and the pharmaceutical procurement system as sensitive areas of the reforms. This suggests that those with financial vested interests in the status quo - the medical profession, hospitals and the pharma industry - may be trying to stall the reforms or turn them to their advantage.]