The power of the medical lobby in reversing China's medical negligence law reforms

This week I came across a very revealing legal article (no, don't go away!)  that illustrates the power of the medical lobby in China - and also how the Chinese government is no longer a monolithic closed entity where laws are rubber stamped. 
The article by two leading law professors from China and Hong Kong describes how China medical negligence laws were overhauled by judges in 2002 because they were widely viewed as favouring doctors and hospitals over patients who had suffered from medical negligence. Until 2002 the burden of proof in any medical negligence case lay with the patient - in other words, they had to prove that the doctor had made an error that had resulted in harm.

As the article notes: "In practice, it was not uncommon that medical care providers, during the course of dispute resolution (court proceedings), denied patients ready access to their own health records.
Many medical care providers have reportedly submitted false or falsified medical records. In extreme cases, hospitals went as far as destroying the original records that evidenced the medical staff’s breach of standard of care and replaced them with fake ones."

In a radical move, the burden of proof requirement was reversed - medical providers had to prove that they had NOT made a mistake. This boosted the chances of patients successfully suing their doctor or hospital and not surprisingly led to a large rise in the number of medical negligence cases.
Doctors and hospitals hated the new law, and they claimed that it led them to practice defensive medicine and that it exposed them to a high financial burden.
The courts then decided to try adopt a "Third Way" compromise and developed amendments including a so-called "Article 59" that would balance the burden of proof requirement. The medical profession and hospitals, were not satisfied with this compromise, however, and wanted to veto Article 59 and revert to the former protections they had. It's worth quoting the article on this to give some background to the lobbying power:

"The most vocal advocates for removing Article 59 were two national-level medicine professional associations, that is, the Chinese Medical Doctor Association (CMDA) and the Chinese Hospital Association (CHA). The CMDA is the statutory self-regulatory body of all practicing physicians in China.64 The CMDA is also resourceful in terms of its government connections. Its president is a former vice minister of the MoH, and many of its vice-presidents are incumbent senior officials of the MoH and local BoHs. More notably, one of its two honorary presidents is a vice-chairman of the National People’s Congress Standing Committee (NPCSC). Renamed from the China Hospital Management Association, the CHA is the self-regulatory body of medical care providers (exclusive of rural medical clinics) in China, and is affiliated to the MoH. Its president is also a former MoH vice-minister."

In the end, the doctors won the day. When the medical negligence law was released for consultation they lobbied hard. When the amendment was debated at the NPCSC, the offending clause was dropped altogether. As the authors of the article conclude:
"The associations representing medical practitioners and medical care institutions exhibited remarkable ability to mobilize and lobby the national legislature. The outcome of the legislative process was thus unsurprisingly the removal of Article 59, a rule that the medical profession strongly disfavored."

Two conclusions from this article:
1. The medical profession and medical institutions have remarkable influence and lobbying power in China.
2. The process of  lawmaking in China is no longer behind-closed-door rubber stamping, but is subject to more open consultation and interest group lobbying. .

The article by Professor Yang Lixin of Renmin University and Professor Xi Chao of the Chinese University of HK is published in The China Review and can be downloaded here.

Men make better doctors | Respiratory physicians criticise tobacco policy | Bogus intern | Children dumped in hospitals

Men make better gynaecologists than women because they are better surgeons and are 'more sensible and calm', according to Beijing hospital authorities. Hospitals have defended their continuing use of male gynaecologists against complaints from women, saying there is a shortage in the speciality due to the government's two child policy.

Respiratory physicians have published strong criticism of the Chinese government's conflict of interest in opposing tobacco companies. Writing in The Lancet, Dr Dan Xiao and colleagues at the Beijing Chaoyang Hospital says smoking cessation campaigns are meaningless when the government plans for tobacco production increases through its State Tobacco Monopoly Administration.

A bogus female doctor managed to work as a medical intern at a Chongqing hospital for 6 months before being unmasked. The woman used fake medical qualifications and a fake ID to get the job at the Jiangbei district hospital.

Children with serious diseases are being dumped in hospitals by their parents, according to the Shanghai Daily. Eight children were abandoned at the Shanghai Children's Hospitals and two are still there as police are unable to trace their parents.

A group of female medical students in Guangzhou have developed a wearable G-string condom that has a detachable sheath. They now have attracted investors to put in 2 million yuan to market the first 10,000 condoms.

Foreign doctors working illegally in China should be reported and deported, says a leading Chinese plastic surgeon. He says China's boom in cosmetic surgery had attracted many Korean surgeons to take advantage of 'academic exchange" visas and abuse them to work for prolonged periods in China.

Despite government investment of three trillion yuan over the last five years, China's health reforms have failed to have any effect on the incomes of medical staff, Caixin reports. The next phase of reforms must de-couple doctors' income from drug sales and reward them with higher salaries commensurate with their skills, analysts say.

China's new reality TV show is "Miracle Detective Doctor"

by Michael Woodhead
Launching this weekend, China's latest reality TV show "Miracle Detective Doctor" has the lofty aim of entertaining and educating the masses in medical matters and also easing the ongoing crisis in violent disputes between patients and medical staff.
Starting on prime time tonight (13 June) on the Travel Satellite channel, the show  (also translatable as 'Super Sleuth Doctor') will feature two teams of three medical students who will compete to find the correct diagnosis in a series of simulated medical cases. The teams of would-be doctors will go through three rounds of 'work up'. The first will be video clips that give background of the fictional illness. The second round will feature simulated patients who can be questioned by the contestants about their condition. In the third round the medics are given a fictional 'health budget' gold coin that they can choose to spend on various tests and investigations such as x-rays or pathology tests.
If that sounds a bit dull, director Tang Li says the show will be livened up with appearances by 'poison tongue' reality TV show hosts such as Ma Ding He and also the beautiful female celeb star of medical dramas, Yu Ying Dan. The show has also modelled it's look on Korean TV medical dramas, and the contestants will be given makeovers to look like the popular Korean soap opera stars.
However, the director says the show will not just be celebrity fluff. In China's current climate of frequent medical disputes, he says the 'medical tournament' will help improve relations between medical staff and the public. He says there is a lack of communication and trust between medical staff and the public that is a major cause of disputes, and the show aims to build up mutual understanding.
He says the reality TV show will highlight the difficulties of deciding on diagnosis and treatment from a doctor's point of view and show the public that it is a difficult process. It will also educate the public about expensive scans and tests, showing that they are not routinely needed to diagnose illness, and that doctors usually rely more on a detailed history.
Tang Li says the "Super Sleuth Doctor' will also feature top medical experts who will give their advice and pronounce their opinion. The cases are based on real life, and the pursuit of the correct diagnosis will be full of suspense, as the consequences of a wrong decision will be spelled out by the experts, he says.
The show will also be like real life hospital in that the doctors will have to make their diagnosis under time pressure, and the effects of their decisions on the lives of the patients and their families can be very moving, the director says.

Communist health minister quotes Adam Smith to support privatisation of China's hospitals

by Michael Woodhead
In its inimitable way, the Chinese government is dressing up a very capitalist idea in socialist clothing and presenting it as "a Chinese solution to a Chinese problem". The problem in question being the mismatch between supply and demand in medicine - too many patients and not enough doctors. Or put more simply, overcrowded hospitals. In the Peoples Daily, the former health minister Chen Zhu and leading Communist Party member Chen Zhu is quoting Adam Smith and talking about market solutions to the Chinese healthcare system. He speaks a lot of jargon but the take home message is that doctors deserve to be paid a lot more - they work hard to qualify as doctors, they do a demanding job and work long hours, but get paid a pittance and get no respect. And thus his conclusion is that medical reform must "move into the deep water zone" and tackle doctors' income. Doctors need a high income to be motivated, he says, and the income must not come from sales of drugs - as it does at the moment. Therefore to rebuild trust in the medical system and to put it on a more sustainable path, doctors must earn more - and therefore must charge more. An accompanying article notes that itcosts only 5 yuan to register for treatment at a public hospital, whereas it costs a few hundred yuan for a woman to get her hair done. Why does a hairdresser charge a higher fee than a doctor? [Misleading question - the 5 yuan fee is only to register for treatment - actual out of pocket costs can be astronomical, running to thousands per day for inpateint treatment].
Chen Zhu says "we entrust our health and our lives to doctors but expect them to accept only 5 yuan."
The article says that like many other aspects of Chinese life, healthcare has become a market - and people want the best. The big improvements in roads - and expectations means that people i regional areas are no longer satisfied to go to their local community clinic or county hospital for treatment. When they get sick they get i the car and drive to the big city hospital. Chen Zhu says people have rights to access healthcare, but they also have responsibilities to use the system properly and not to abuse it. He says legislation alone cannot force people to go to community clinics, but there needs to be a more orderly gatekeeper system to stop the overloading of major hospitals - and also the drain of talent from local hospitals and clinics to big city medical markets. His article is short on specifics when it comes to answers - but hints at the usual privatisation slogans of using 'social capital' (ie private investment) and greater flexibility in medical models (ie deregulation) as the way forward. As with so many other areas of Chinese reforms, it's state-directed capitalism decorated with a  few socialist-sounding phrases.

Contaminated food | Induced abortion rates | Blueprint for healthcare | Doctor shortages

In Beijing markets, 20% of vegetables have excessive levels of arsenic and 25% of fish have excess levels of lead, according to tests carried out by researchers from the Chinese Research Academy of Environmental Sciences, Beijing.

The limits of China's public medical insurance coverage are illustrated by the case of a 12-year-old boy with bone cancer whose parents have already had to spend 400,000 yuan ($64,000).

A hospital in Shanghai has set up what it claims is China's first patient representative council to represent the interests of patients and improve services at the hospital.

China's rates of induced abortion peaked at about 60% in the early 1980s, and fell sharply in the mid 1990s to the current level of about 20%, a study shows. However rates are still high in rural areas where family planning policies are rigidly enforced, according to researchers from the Central University of Finance and Economics, Beijing. 

A blueprint for China's healthcare system by former health minister Chen Zhu will be published in English translation by the Anglo-Dutch publishing house Elsevier.  The "Healthy China 2020 Strategic Research Report", will be published in conjunction with People's Medical Publishing House (PMPH), China, said Dr Chen, who is now Vice-Chairman of the National People's Congress.

Methadone programs in China have proved very effective in cutting crime, reducing needle sharing and keeping users off drugs, a preliminary study has found. However most drugs users have little or no chance of accessing methadone programs, according to researchers from the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing.

Anhui province is suffering from a major doctor shortage despite offering salaries of 60,000 yuan, and there are now 220 unfilled medical posts, according to the provincial health department.

Gaokao madness: hospital works overnight to do myopia surgery to help kids meet college entrance criteria

by Michael Woodhead
As if the phenomenal pressure of the gaokao ((高考) college exams was not enough, students in Liaoning are also putting themselves through last minute laser eye surgery to meet college eyesight entrance criteria.
A report from Dalien describes the plight of students wanting to get into the city's law schools, which are run by the PSB and lay down strict criteria on having good eyesight. After several days of exams, students than had 48 hours in which to undergo surgery before having an eye exam to assess their vision. Explaining the last minute rush, families said they were unaware of the college entrance criteria or were not willing to have their children undergo eye surgery while preparing for the all important gaokao exams. However, on learning that perfect eyesight was a requirement for entrance, many students went straight from their final exam to the eye clinic to have corrective eye surgery. One clinic in Dalian reported staying open all night and having eye surgeons on overtime into the early hours to perform a string of last minute operations on desperate students. A surgeon reassured parents that it usually took only 8-12 hours to recuperate from laser eye surgery, and their children should have perfect eyesight in time for taking their eye exam in nearby Jinzhou 48 hours later.

What does Beijing's air pollution do to your lungs?

by Michael Woodhead
Breathing the polluted air in Beijing has the same effect on the lungs as being a heavy smoker, a study carried out before and after the 2008 Olympic Games has shown.
Researchers from Peking University have shown that residents of Beijing have impaired lung function – but that their lungs can revert to normal during clean air periods such as during the Olympic Games, when air pollution was artificially curbed for a few weeks.
The findings come from a novel series of lung function tests done on 200 Beijing residents before, during and after the 2008 Olympics.
Dr Lina Mu of School of Public Health at the University at Buffalo, New York, carried out the research in conjunction with colleagues at the School of Public Health, Peking University,
They found that ordinarily in Beijing, the mean PM2.5 (83 µg/m3) is more than three times higher than the WHO׳s safe limit of 25 µg/m3. At the same time, lung function of Beijing residents (as measured by peak expiratory flow or PEF) was well below the normal range for healthy lungs.  Lung function was impaired by 16-40% for men (PEF of 418 vs a healthy range of 500-700 L/min) and by 23-42% (PEF of 292 vs a norm of 380–500 L/min) for women.
During the Olympic Games the closure of factories and curbs on use of vehicles resulted in air pollution levels falling and particulate matter levels were reduced up to 60%. During this brief ‘clean air’ window lung function was observed to increase by 17% in females and 13% in males, “suggesting an improved airway status after 40 days of lowered exposure to air pollution.” The researchers said.
Interestingly, lung function improved more in non-smokers than smokers and in younger, female residents compared to male and older Beijing residents.
The clean air period in Beijing also saw a reduction in the number of Beijingers with rapid breathing (more than 20 breaths per minute) – a typical response to pollution and impaired lung function.
Lung function deteriorated back to unhealthy levels after the Olympics when factories were re-opened and pollution levels returned to their usual levels.
The researchers said their findings confirmed the adverse effect of particulate matter in the atmosphere on lung function.
“Deposition of particulate matter induces increased oxidative stress that not only results in DNA, lipid and protein damage, but also leads to the inflammatory responses,” they noted.
They said the pollution curbs implemented by the Chinese government during the 2008 Olympics had created conditions for a natural experiment that showed the impact of air pollution on Beijingers’ lung health.
They said the findings confirmed the adverse effects on lung health but showed that these cold be reversed – at least in some sections of the population. However, they also noted that long term exposure to air pollution in Beijing was likely to have more severe ongoing effects on lung health.
The study is published in Environmental Research.

Daily Mail fake miscarriage | 120 seconds per patient | Dogs a hepatitis risk | Atrial fibrillation untreated

The Daily Mail has been running a fake story claiming that a pregnant Changsha nurse had 'lost her baby' after being attacked by relatives of a cancer patient who died. Chinese media reported the attack but said she was fortunate to have avoided a miscarriage.

A doctor at a Guangzhou hospital could only spend an average of one and a half minutes per patient when he was the only clinician on duty and had a waiting room of 100 patients to see in one morning.

About 20% of dogs and 6% of cats in Guangzhou are infected with hepatitis E, a new study has shown. The high rates of hepatitis infection should raise concern about the eating of dogs, warn researchers from the South China Agricultural University.

China should not copy the US private model of healthcare according to Nobel prize winning economist Daniel McFadden, of the University of Southern California. Professor McFadden said that when looking at healthcare systems around the world, the most efficient are those where the community medical providers are either employed by the government or employed by companies that are largely contracting to the government and not operating as private businesses.

Hospital staff in the Muslim Xinjiang province have been told not to fast during Ramadan. The request was made at a meeting on upholding ethnic minority unity, “in order not to affect normal work and life." Muslim hospital staff members were requested to sign their pledge of compliance in a “responsibility book.”

One in ten emergency department patients leave without being seen by a doctor, according to a study carried out in Chengdu hospitals. Those who left tended to be families who arrived on foot with children who had less serious problems.

Most Chinese people with atrial fibrillation go untreated, with only 40% receiving anticoagulants, according to a study from Fuwai Hospital and Peking Union Medical College, Beijing.The study also showed that only 26% of people treated for  atrial fibrillation received adequate treatment.

Reform of the medical school curriculum is needed in China as many medical schools are still using outdated and ineffective teaching methods that fail to keep pace with developments in medicine, according to a study from Tongji University, Shanghai.

Iron deficiency anaemia is common in rural parts of central China, where only about 40% of infants have an adequate diet, a study by the UNICEF Office for China, Beijing, shows. Malnutrition and anaemia was more of a risk for ethnic minorities and for those living in poor mountainous areas.

Lack of unions in China’s healthcare system leads to corruption

by Michael Woodhead
One of the main aims of the current wave of health reforms in China is to curb corruption by de-linking doctors’ income from sales of drugs and the numbers of tests they order.
It is widely acknowledged by Chinese authorities that many of the problems in the current Chinese healthcare system stem from overservicing. Hospitals obtain about half their income from sales of drugs and also rely for income on the use of expensive and often unnecessary tests and procedures. Doctors in turn are given incentives in the form of bonuses and quotas to prescribe more drugs and more expensive drugs. The end result is waste, inappropriate treatment and high costs to the patient. The widespread and institutionalised bribery and corruption also means that the public mistrust doctors and the healthcare system - and they often turn to violence when they believe they have been cheated or not received adequate treatment.
One of the main reasons why doctors in China are so amenable to accepting commissions/bribes to prescribe drugs is their low income. The basic income of a Chinese doctor is less than that of a teacher or a civil servant. As I have previously reported, this encourages doctors to look to ‘grey channels’ for income – including the infamous red envelopes (bribes) and sales commissions. One of China’s leading physicians Professor Zhong Nanshan highlighted this problem earlier this year when he reported the huge discrepancies between official and actual incomes of doctors at his hospital in Guangzhou.
This week sees the publication of an interesting analysis of Chinese doctors’ incomes by Chinese healthcare analyst, Cao Xuebing.
He says that despite hospitals being opened up to the market, the ‘market has failed’ China’s doctors, who remain underpaid for their services. As a result, they turn to ‘informal’ income streams to make up for that. His paper also highlights the discrepancies - and resentments - between different branches of medicine within a hospital. Surgeons and cardiologists can earn much more than their counterparts in specialties such as paediatrics because they do a lot of procedural work and prescribe more expensive drugs, he notes. The poor income means that China’s doctors are demotivated and have no incentive to be efficient or productive. Income differentials also explain why China has huge shortages of doctors in the poorly paid specialities.
The study shows that most doctors in China are dissatisfied with their income, but unlike doctors in western countries, they have no way of acting on this. There are no medical unions to lobby for pay and conditions and doctors have no power in their relationships with hospital managers, who are backed by local governments. And unlike in other jurisdictions such as Taiwan and Hong Kong, doctors do not have the option of leaving the public system to work for better pay in private practice.
Cao Xuebing observes that if China is to have significant healthcare reform, it will need to tackle the central issue of doctors’ income. And to do that doctors need to have a meaningful voice in such discussions – regardless of whether you call it a union or not. At present the only group speaking on behalf of doctors in China is the China Medical Doctors Association (not to be confused with the official Chinese Medical Association). Currently the CMDA is a weak and unofficial -but tolerated - voice on medical issues such as violence against doctors. The CMDA has the potential to speak on behalf of doctors on remuneration as well as on other issues such as the level of control in doctors' training, education and the supply of the profession. These are the 'bread and butter’ work of medical ‘unions’ such as the AMA and BMA in western counties.
However, Cao Xuebing notes that the Party in China has always aggressively suppressed independent union activity, and exerts strong political control over the tame official unions. If doctors in China see no scope for improving their conditions through official unions they will continue to look to ‘unofficial’ ways of boosting their income. Or as the author puts it:
“If the market opens a window of informal payment that can lead to substantial pay rise, they may not have strong feeling to pursue an empowered professional body or union.”
And he concludes:
“It will … be interesting to follow the development of the CMDA in organising the biggest group of medical practitioners in the world. Professional organisations in China … are important for the party-state to incorporate the interests of key professionals. If regular socialisation can consolidate Chinese doctors with political representation, then these practitioners may be able to gain traction over hospital management issues through leveraging the social capital of their professional body.”

Snake bites in China: the medical consequences

by Michael Woodhead
Living in Australia, I am naturally extremely wary of snakes, given that this continent has many of the world's most venomous and aggressive varieties - often living in your back yard. Aussies know that if you get bitten by a snake you need to use pressure immobilisation and get help - quick. But what about China? What are the chances of being bitten by a snake and how dangerous are they?
A new report of snake bites from  Hainan gives some idea of what might happen. In a review of more than 1000 cases of snake bites, Dr Shuang Jiebo and colleagues from the 425 PLA Hospital in Sanya, found that the vast majority were caused by pit vipers (46% - aka Trimeresurus stejnegeri) or cobras (40%). Most of the bites occurred in summer (April-Sept) in young males, typically farmers or fishermen, and the bites were mostly on the legs or arms. According to the article the pit viper venom contains a potent haemotoxin, but is not usually fatal:
"The wound usually feels extremely painful, as if it had been branded with a hot iron, and the pain does not subside until about 24 hours after being bitten. Within a few minutes of being bitten, the surrounding flesh dies and turns black, highlighting the puncture wounds. The wound site quickly swells, and the skin and muscle become black due to necrosis."
The Hainan doctors found that most of the wound sites of pit viper bite victims showed swelling, and the skin and muscle became black due to necrosis. In contrast, the cobra venoms are mainly neurotoxic, hemotoxic and cardiotoxic. "The cobra bite is extremely painful and the swelling appears immediately. Other symptoms may include drowsiness, nausea, vomiting, abdominal pain, mental alertness and respiratory failure. "
In their review, about a third of snake bites caused mild envenomation, and only 11% resulted in severe envenomation, which meant a longer hospital stay - often a week or more. Only 1% of patients died, and these tended to be due to bites by sea snakes or King Cobras.
Treatment outcomes were better when patients received prompt treatment - and the researchers also claimed that "Sheyao" traditional medicine was a good remedy for snake bites. This is said to contain  toad skin, centipede, and 'humifuse euphorbia' herb as well as paris polyphylla.
"Prevention, pre-hospital management (first aid) and the importance of the early transfer to the hospital should be emphasized," they concluded. 

Shenzhen prescriber kickbacks | Residency training failures | Snoring and heart attack | HIV tests for students

Doctors in Shenzhen continue to prescribe expensive quack remedies to patients to make high commissions from sales, according to reports which said a pregnant woman was told to use fish oil and other supplements to improve her unborn child's intelligence.

Breast cancer survival rates (10 years) for women have improved  from 43% in 1972 to 61% in 1998-2002, according to a cancer registry study from Qidong, Jiangsu.

Tick-borne diseases are a major threat in rural parts of central China, with a new study showing that ticks are common and carry a wide range of human pathogen. The ticks found on animals carried five different kinds of pathogens including Rickettsia and humans were at a high risk of exposure to piroplasmosis, researchers said.

Failings in residency training programs in medical-school-affiliated hospitals in  China have been identified in a national study. The survey of 15 teaching hospitals found that they failed to reach the basic standard of 70% in six basic areas of training, and thus more effort is needed to boost postgraduate medical education (PGME).

Chinese people who snore three or more times per week have a higher risk of heart attack, cardiologists have found.  Their case control study of almost 3000 patients who had a heart attack also found that lack of sleep was a risk factor for heart attack.

A female doctor and a pregnant nurse were attacked  by angry family members of a patient with lung cancer at a Hunan hospital. The attackers forced the doctor to kneel and beat her around the head, before being tackled by security guards.

College students in Henan are being forced to undergo HIV tests. The government says the policy will help early detection and treatment of the inefection.

Dysentery in China - the good news and the bad news

by Michael Woodhead
Dysentery is one of those disease most westerners associate with 'the olden days' - or the Third World. 
Bacillary dysentery, also known as Shigellosis, is the severe gastro disease of poor hygiene, spread by faecal contamination. Ten years ago dysentery was still relatively common in Guangzhou, but a new report shows the city has brought rates of the disease down with a co-ordinated campaign to detect and manage cases and prevent further outbreaks. In 2006 the city had about 12 cases of dysentery per 100,000 population - so for a city of 8.5 million people that's more than a thousand cases a year. To tackle the infection, the city health department implemented the "Intestinal Infectious Disease Surveillance, Prevention and Control Program" (IIDSPCP). This means that once a patient is suspected as having Bacillary dysentery, public health workers target their household with preventive measures such as quarantine, disinfection, and good personal hygiene practices mandatorily implemented by local government. This program has seen the rate of dysentery cut to around 2 per 100,000. Good news so far. However, public health staff say dysentery still remains a problem in the poorest families - as judged by the high rates among children who do not attend school. They now account for the largest group of patients with dysentery.
This social group - usually migrant workers from the poor inland provinces - is China's new underclass. As the report notes: "They are usually lacking in adequate sanitation, with low health risk awareness, and more likely to have exposure to contaminated food or water. It has been reported that compared to the other group, the school-age children not attending school have higher incidence in many infectious diseases such as hand-food-mouth disease, infectious diarrhea, and hepatitis A."
Interestingly, the other high risk group for dysentery is young people aged the people aged 20-44 years - perhaps because they take part in more social activities, have more chance to contact with Shigella patients or carriers, and have more leisure time, and finance to travel and thus more likely to have exposure to Shigellosis.
As the report authors conclude: "more effort should be made to enhance health education about dysentery and monitoring/targeting at school-age children not attending school ... .as well as establish strategies for prevention of the disease in China."

Breast cancer with Chinese characteristics

by Michael Woodhead
Breast cancer rates in Chinese women are only one sixth those of their American counterparts, but China is catching up quickly, a new report says.
A review of breast cancer in China published in the Lancet Oncology this week shows that breast cancer has traditionally been an uncommon disease in China but rates are increasingly rapidly as the country adopts more affluent lifestyles.
The report by researchers at the National Office for Cancer Prevention and Control, Chinese Academy of Medical Sciences, Beijing shows that more than 1·6 million Chinese people are diagnosed with breast cancer and 1·2 million die of the disease each year. Breast cancer is now the most common cancer in Chinese women, accounting for cases 12% of all newly diagnosed breast cancers. Annual incidence rates are about 22 per 100,000, compared to rates of around 120 per 100,000 in the US.
The reviewers say breast cancer occurs at a younger age in Chinese women compared to their western counterparts, and for this reason screening programs such as mammography would probably not be appropriate. Rates have increased in recent years due to reproductive factors such as the single child policy and later age of first birth increasing exposure to sex hormones.
For these reasons, and because of the low awareness and delays in diagnosis, Chinese women with breast cancer tend to have more advanced stages of disease when diagnosed.
Another major disparity with breast cancer in China is the lack of adequate treatment. Most women cannot afford the more expensive advanced drugs for breast cancer now recommended in international guidelines. Paradoxically, treatment of breast cancer by Chinese doctors tends to be over-aggressive, with excessive surgery and chemotherapy. Many women have unnecessary mastectomy and axillary lymph node dissection and also chemotherapy. Under-treatment is also common, with some women receiving inadequate therapy for treatable cancers. The reviewers say palliative-care programs probably represent the best way forward to manage quality of life for patients with advanced disease and their families.
They conclude by saying there is a need for more public  awareness of breast cancer and promotion of early detection.
"Because the disparity of access to treatment for breast cancer will remain for some time, great effort is needed to expand insurance benefits and cancer-care infrastructure to underserved women in China," they conclude.

The two unknown tick diseases that are killing many Chinese

by Michael Woodhead
Two virtually unknown tick born rickettsial diseases have become a serious threat to human health in China, health authorities have warned. In just a few years the diseases caused by tick-borne A. phagocytophilum and E. chaffeensis have become common in rural areas and cause disease including multiple organ failure and death, according to Dr Zhang Lijun and colleagues at the Department of Rickettsiology, National Institute for Communicable Disease Control and Prevention, Beijing.
In a new paper they report that the first cases of human granulocytic anaplasmosis (HGA) occurred in Anhui Province in 2006 and then in Shandong. They said human granulocytic anaplasmosis is a serious disease in which about half of patients are hospitalised, 40% of patients have multiple organ dysfunction syndrome, and the fatality rate can be as high as 8%. However, they suspected that in China infections with the two rickettsial diseases were often not recognised, and were misdiagnosed as hemorrhagic fever with renal syndrome (HFRS).
In their own study they analysed 7,322 serum samples from farmers  and found that 10-15% farmers had been exposed and were at substantially increased risk of the diseases. A second analysis of 819 blood samples from urban residents from showed that 4-12% of urban residents had been exposed and were also at high risk of the tick-borne diseases. Worryingly, the infections were carried by a wide range of ticks, not just one species, and the ticks were found on many domestic animals and livestock including dogs, goats, sheep, cattle, horses, rabbits and rodents.
"In China, the free-range feeding of animals is a major part of livestock production, in contrast to livestock production in modern developed countries. Animals roam hills for feeding during daylight and return at sundown. In such a situation, animals can return with many ticks from wild fields. Moreover, most farm families own two to three dogs for guarding their animals and belongings, and these dogs also roam freely in and out of yards. Therefore, it is not surprise that contacting with domestic animals is regarded as a main exposure risk," they noted in Biomed Research International
The researchers concluded that the wide distribution of the tick-borne infections and their serious nature meant that their transmission and risk factors "urgently needed to be further investigated."
[Editor's Note: The risk of tick borne diseases in China is not insignificant: a US student became paralysed after being bitten by a tick during a school trip to China and was awarded $42 million in damages against her school in a US court last year]

Doctor Stranger | Chicken faecal contamination | Plagiarism in medical publications | Generic chemotherapy drugs |

A Korean medical soap opera “Doctor Stranger” has become hugely popular in China, with over 100 million viewers this month. The success is attributed to the star power of the two male leads, Park Hae-jin and Lee Jong-suk.

A major outbreak of hand foot and mouth disease has been reported in Jiangsu, with the Suzhou hospital seeing a three-fold increase this month, and up to 80 children a day with the infection treated at the hospital.

Indian-made generic copies of expensive drugs for conditions such as cancer are becomong popular on the Chinese 'black market'. Chemotherapy agents such as AstraZeneca's Iressa cost 15,000 yuan per pack but can be bought on the generic market for 600 yuan, even though it is unapproved and unregistered in China.

Pregnant women in China have high levels of mercury in their bodies from eating fish, a study from Shenyang has found. The high level pose a risk to their baby's health, say researchers.

China has the dubious distinction of leading the world in the number of medical and scientific academic papers retracted due to plagiarism, according to a new report. A review of retractions from 2008-12 found that China withdrew  24 plagiarised papers (18% of all papers retracted for plagiarism) and 42 duplicate papers (28% of all papers retracted for duplicate publication).

Boys of middle school age are  four times as likely as girls to smoke, a Shanghai survey has found. The Chinese Center for Disease Control and Prevention said 2.2 percent of boys and 0.6 percent of girls said they were regular smokers. A further 11 percent of boys and 6 percent of girls said they “tried” smoking last year.

China's State Council has said it will relax limits on foreign investment in joint-venture hospitals as part of the ongoing healthcare reform process. The move will reduce restrictions on the percentage of foreign ownership in medical joint ventures and increase the number of locations where Hong Kong and Taiwan investors can set up wholly-owned medical centres. Other overseas investors will be allowed to set up wholly-owned hospitals only in areas such as the Shanghai free trade zone.

One of the main barriers to foreign investors setting up new health facilities in China is the high price of  real estate, according to analysts. Investors are instead looking at proposals to take over and run existing hospitals.

James Murdoch, son of the right-wing media owner Rupert Murdoch, was on the board of GSK and gave advice on corporate ethics when the company was  bribing doctors and hospitals in China, according to reports from the UK. He resigned from GSK when he was investigated over the bugging of private citizens by his newspapers.

About a third of chicken meat sold in retail outlets in China is contaminated with faecal campylobacter bacteria due to unclean conditions  the slaughterhouse, a study has found. Another showed that 43% of chicken contained Salmonella.

Dodgy doctors or innocent victims of patient violence?

by Michael Woodhead
In Australia hardly a week goes by without a report in the media of a 'dodgy doctor' - a male medical practitioner who has sexually assaulted a female patient. You don't hear much of this kind of thing from China but coincidentally today there are two reports in which doctors have been accused of inappropriate behavior towards female patients. Are they genuine or are these yet more instances of China's wave of violence against doctors in an overloaded/corrupted system?
In the first case, a doctor in Nanjing was bashed by the drunken husband of a woman who claimed he had acted 'immorally' to lift her clothing to perform a cardiac exam. The doctor had been trying to perform an electrocardiogram test on the women for cardiac function. As anyone who's had an ECG knows, this involves the placing of up to 12 electrodes on the skin of the chest - there's no avoiding contact. The female patient objected to this, called her husband and he hit the male doctor so hard he broke the doctor's nose. The second case is from Gansu, where a woman took exception to a doctor examining her back, despite her seeking help for a suspected fractured coccyx. She accused the doctor of inappropriate manipulation and called her husband - almost identical outcome to the first case - the husband arrived and set about smashing the doctor around the head with a metal stool, leaving him battered and concussed.
 In both cases medical staff say the doctors were behaving appropriately and carrying out the recommended and necessary routine tests on women to investigate their medical problems. If taken at face value, these reports differ from those seen in western countries, where typically a male doctor will perform inappropriate examinations on women in private. It might be that the Chinese medical staff are covering up for their colleague, but personally I doubt it. While I feel sympathy for the women and their sense of being treated inappropriately, it sounds like the system is to blame here rather than lecherous doctors. In western countries like Australia it is now standard operating procedure to have a female chaperone present (or at least available on request) if a male doctor is to perform any kind of sensitive examination of a female patient. Another 'safeguard' with primary care-based systems is that you can see the same personal 'family doctor' or one of a familiar team on each visit, and so trust is built up in the treating doctor. In China's hospital-based system it's often a case of  'wait three hours to see a doctor for three minutes' and the doctors are strangers. The hugely overloaded Chinese healthcare system does not allow women the option of choosing to see a female doctor, and there may not usually be the option of a female chaperone.
As China develops and expectations about healthcare and personal 'human rights' increase, expect more of these kind of complaints and violent reaction to male doctors. And it could become a particular problem in China's western provinces with a high Muslim population. But what of the rights of women who really are being abused by medical staff? With the growing concern about violence against doctors (and the increasing emphasis on punishing those who take matters into their own hands) there is a risk that the bad doctors will get off scot-free.

Jumping the queue at Beijing hospital costs 200-600 yuan

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

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

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

Tropical diseases in China: one down, ten to go

by Michael Woodhead
China has eliminated one tropical disease - lymphatic filiarisis - but has ten others that are still affecting millions of people and some of which are becoming endemic again, according to a new report.
The good news from a review of China's tropical diseases published in The Lancet Infectious Diseases is that the country is on track to eradicate five major diseases (schistosomiasis, leishmaniasis, leprosy, rabies and trachoma) in the next five to ten years.  However, the not-so-good news is that some diseases are still uncontrolled and affect millions of people in poorer provinces of the south and west. The most problematic diseases are dengue fever, food-borne parasitic diseases such as liver flukes and Echinococcosis, according to the article by researchers at the Wuxi branch of the Ministry of Health. Professor Yang Guo Jing and colleagues from the Key Laboratory for Parasitic Diseases say that lymphatic filiarisis was eliminated from China in 2007 after a long campaign to remove it from 16 provinces by using mass drug administration techniques.
Tropical diseases in the 'near-elimination' stage include schistosomiasis, which has been successfully controlled in most parts of the country and numbers reduced from 12 million to 287,000 in 2011. The disease is spread by cattle and water buffalo, and thus changes in farming techniques are needed to help eliminate the disease. Similar improvements in control have been seen for leishmaniasis, the sandfly-spread protozoal infection which used to be common around the Yangtze river basin but now affects only about 2500 people a year. The bacterial infection trachoma that causes blindness is also close to elimination due to implementation of mass campaigns that apply WHO strategies such as facial cleanliness. Rabies has also been controlled, but still causes 2000-3000 cases a year. Immunisation of 70% of dogs at risk should break the cycle of infection, but currently only about 20% are vaccinated. Leprosy was reported to affect about 6000 people in China in 2010, of which about 1300 were new cases. Better surveillance and multi-drug treatment regimens should help eradicate the infection by 2020, the report suggests.
China has has less success with soil-transmitted helminthiasis, and there are about 85 million Chinese affected by roundworm and whipworm. De-worming of schoolchildren seems to have only modest efficacy, and so new strategies such as curbs on the use of human waste as fertiliser are needed, the report says.
The most problematic tropical diseases for China include dengue fever, with outbreaks of the mosquito-borne infection rapidly emerging as a major public health problem. Climate change is worsening the problem, which requires better monitoring and mosquito management strategies as there is no drug or vaccine for the disease.
Another major problem tropical disease for China are the food-borne parasitic zoonoses, such as liver flukes, lung flukes, and other trematodes that may be transmitted by fish, snails and freshwater plants. There are tens of millions of cases in China, which has the dubious honour of having 80% of the 15 million cases globally. New programs are needed to identify high risk disease areas and to address transmission of infection through occupational risk (eg farmers) and also consumption of high risk foods.
Control of these many tropical diseases will require huge  resources to build and design  programs specific for each disease and the high risk locations and populations they affect, the authors conclude.

A few fibs about healthcare in China's human rights report

by Michael Woodhead
Don't be too cynical about China's rather self-congratulatory human rights review for 2013. 
 It contains some genuine advances as well as the the usual stuff how much more freedom of speech Chinese citizens enjoy. (The fact that I would not be able to read nor write my blog post or tweet about this report in China because blogspot and Twitter are banned sums it up really). Yes, China has improved human rights if you count lifting citizens out of poverty and providing them with an education and not treating the women like horses. I'll give you that.
But when it comes to the human rights aspects of China's healthcare system, the report is notable for what it leaves out. The report says China has developed a social security system "suitable to China' s current social conditions'. More specifically for health it says that China has established a basic national medical insurance system, that covers than 1.3 billion people, or over 90% of the population. Government subsidies for basic medical insurance for have risen from 40 yuan per person in 2007 to 280 yuan in 2013. It also claims that the reimbursement rate for hospitalisation expenses covered by relevant policies has been raised to around 70%. There are many more figures like this that make it sound as if China now has a functioning health insurance system that covers most of the population. As you will know if you have read many of my previous posts, this simply isn't the case.  The reality is that China's medical insurance scheme coverage of expenses is minimal and fragmented. It's a user pays system and most Chinese people still face high out of pocket expenses for even the most basic hospital treatment. Look at this new report from Guangzhou on the impact of health insurance on the burden of medical fees for Chinese patients. Its conclusion:
"social health insurance participation has a weak negative or even no significant association with the out-of-pocket payments of hospitalized patients. This seems to contradict the principles of social health insurance, which aims to reduce people's out-of-pocket payments and enhance their wellbeing."
Or this study released this week entitled: "The impact of expanded health system reform on governmental contributions and individual co-payments in the new Chinese rural cooperative medical system." It concludes that while co-payments in most rural provinces have been reduced, "a greater financial burden for healthcare persists among persons in the poorest rural regions." The WHO recently reported about the devastating effect that a major illness can have on household impoverishment in China - in other words, low income families are being financially ruined by their medical expenses - they simply can't afford to be sick, and become destitute. And it's not just the low income Chinese who are feeling the healthcare crisis: blogger Zhang Lijia tells of the common experience of middle class urban Chinese:
"The doctor took one cursory look and sent me for an allergy test on an imported machine and then prescribed numerous creams and pills. The total bill was US$800 - more than the average monthly salary in Beijing."
These then are just a few examples of the reality of China's healthcare 'human rights record'. China looks foolish when it publishes reports like this which are so obviously misleading. They have many aspects of their healthcare system of which they can be proud - the good public health services that ensure high vaccination levels and control of infectious diseases such as malaria, for example.
However, if you count universal basic healthcare as a human right China has failed to protect the human rights of its citizens. In this it is in good company - the USA is in much the same boat, as healthcare remains unaffordable for those who cannot get insurance.
Xi Jingping often talks about the 'Chinese Dream' - and that's what this human rights report is when it comes to healthcare - more dream than reality.

A dozen medical news stories to start the week ...

1. The Chinese name for dementia should be changed because the characters meaning “insane” and “idiotic” are demeaning and inappropriate, according to a professor of clinical psychiatry who wrote an editorial in the International Psychogeriatrics journal.

2. Professor Ye Shuang from the Renji Hospital in Shanghai has told an international rheumatology conference that the cheap diabetes drug metformin is a simple steroid-sparing agent in lupus, and thus could enhance efficacy and reduce side effects of therapy, according to Rheumatology Update.

3. A clinic in Shandong Province is said to have charged a pregnant women double for an ultrasound scan because she had twins. The hospital defended its charging, saying it it charged 'per organ'.

4. China's New Rural Cooperative Medical System (NCMS) is not working well for the poorest counties, according to health economists. In a new study they say that hospital out-of-pocket payments are higher for the poorest counties of China under the scheme.

5. A hospital in Shanxi has apologised to a man with a rash who was given vaginal pessaries as oral medicine. The man complained when he read the label but the doctor insisted they were the right medication. He later admitted his error and blamed it on the noisy and chaotic working conditions at his clinic.

6. Officials from the National Institutes for Food and Drug Control in Beijing have defended the quality of vaccines manufactured in China after a critical article in Nature raised doubts about the standards of production.

7. A national campaign to prevent neural tube defects has helped increase the rate of periconceptional folic acid supplementation from 15 % to 85 %. However, more than half of the women began taking the supplements too late, only after learning they were pregnant.

8. The inflammatory disease of blood vessels, Kawasaki Disease has been traced to wind-born toxins from cropfields of north-eastern China, according to researchers.

9. Cases of 'breakthrough' chickenpox in children who have been immunised under the one-dose schedule of varicella vaccination are milder than cases of chickenpox in unvaccinated children, a study from the Fengtai Center for Disease Control and Prevention; Beijing, shows.

10. The province of Hebei surrounding Beijing is full of 'ghost hospitals' as patients opt to seek healthcare at major hospitals in the capital, according to a new report. Some Hebei hospitals are 70% empty, and the preference for Beijing is putting strain on the city's already overloaded hospitals.

11. A 3-year old girl with a stomach disorder is being fed mouth-to-mouth by her father who chews up her food for her as she cannot digest it. The father says he needs tens of thousand of yuan to pay for the operation to cure his daughter and has already received several thousand yuan in donations.

12. The Chinese craze for IV infusions has claimed another victim, after an 11-year-old boy with a fever died shortly after being put on a drip at a hospital in Foshan, Guangdong. The hospital says it is investigating the case to ascertain the cause of death.

Sichuan polio cases show need for better vaccine coverage

by Michael Woodhead
A small outbreak of polio that occurred in Sichuan was derived from a vaccine-related strain, according to researchers from the WHO Regional Polio Reference Laboratory in Beijing.
In a new report they describe the strains of polio virus isolated from three cases of flaccid paralysis that occurred in an isolated region of Aba, Sichuan in 2011 and 2012.  They say the virus strain was similar to that used in the trivalent (Sabin) oral polio vaccine, but with minor changes that affected its attenuation and temperature sensitivity. The virus was found in the three cases of polio, all of which occurred in unimmunised infants below the age of one. The virus was also found in one close contact. The new strain of polio virus appears to have been circulating in the remote community for about seven months, they said."
"Our findings reinforce the point that circulating vaccine-derived poliovirus can emerge and spread in isolated communities with immunity gaps, and highlight the emergence risks of type 2 circulating vaccine-derived poliovirus accompanying the trivalent OPV used, they said.
"To solve this issue, it is recommended that type 2 OPV should be removed from the trivalent OPV or use of inactivated polio vaccine (IPV) instead.
The findings are reported in Clinical and Vaccine Immunology.

China: medical procedures are now dictated by fortune tellers

by Michael Woodhead 
In the west, patients often do their ‘homework’ by consulting medical books and websites before seeing a doctor – but in China patients are doing their homework with fortune tellers. A new report shows that patients are relying on fortune tellers to decide what date they will have an operation, when to have a caesarean section and even to guide cosmetic surgery for a more ‘fortunate’ face.
At a Liaoning Hospital, head of nursing Ren Yumei says about 80% of women choose to have a caesarean section birth, and many of them are done so they can select the ‘auspicious’ date and time selected for their child’s birth from fortune tellers consulting the books of the “Great Immortals’.
“Many women and their families demand not just the day but the hour of birth according to horoscopes, they won’t accept any deviation,” she says.
In Anshan, head surgeon Wang Yongshen says the same thing is now happening with patients requiring elective surgery. Patients demand a specific time for the operation – sometimes even in the early hours of the morning.
“Even when they know that surgery in the middle of the night is likely to be less safe and effective they opt for it because of the influence of the fortune tellers,” he says. And when hospitals refuse these unscientific requests, patients turn to smaller private clinics that are happy to cash in on the new fad for ‘auspiciously timed medical procedures’, even though their medical standards are often suspect.
Obstetric nurse Ren Yumei says she is concerned to see mothers and families putting their baby’s health at risk by forcing an early delivery just to have a ‘lucky’ birth timing. She says the health risks of premature birth are well known, including respiratory and developmental problems as well as blood and cardiovascular risks.
A surgeon at a cosmetic clinic in Shenyang says he even sees patients who wish to change their appearance based on advice from fortune tellers. He had one young man who insisted on having surgery to give him a bigger chin because this would make him appear more bold and daring, in accordance with his horoscope, according to an adviser. He went ahead with the operation despite medical advice that it would restrict his jaw movement.
Professor Zhang Bao of the Tianjin Institute for Social Sciences says the new trend is anti-scientific and a remnant of ‘old thinking’ superstitious ignorance. He said the two schools of thought could not co-exist and there would be a collision between the two.
He said many ‘fortune tellers’ were in business for personal gain and they made extravagant claims that had no regard for the welfare of the patient. He said such practices should be strictly supervised and exposed for what they are. If they continued to provide harmful advice fortune tellers should be prosecuted and punished, he said.
The original report is published by Xinhua.

Shenzhen takes to family doctors

by Michael Woodhead
On International Family Doctor Day a Shenzhen joint venture clinic with Hong Kong University is claiming that general practitioners are proving popular with patients. 
The HK University Shenzhen Hospital clinic offers a GP service in which patients with chronic diseases can book face to face appointment with their family doctor. The clinic has an 80% return rate and the main diseases treated are cardiovascular disease, diabetes, arthritis and mental health problems, according to GP Dr Liu Ruihong. He said other hospital clinics are not open to external referrals, and only accept internal referrals. However, the GP clinic works on international model in that a GP can refer to the hospital clinic and vice versa. He says that according to WHO criteria, patients with chronic diseases are best treated by a generalist doctor with continuity of care and an emphasis on preventive care. With good GP care, patients with chronic diseases can stay healthy and avoid the need for hospital treatment for decades, he says.
After six months of a pilot program, the clinic is proving popular with patients and an increasing numbering are registering with the clinic and returning to see their personal doctor, he added.

Six of the top medical news stories from China

1. China has a huge shortage of midwives, and would need a further 800,000 to meet the WHO standard of one for every thousand women of child-bearing age, according to a new report. Health officials say the problem will worsen as China adopts a two child policy.

2. Efforts to control pneumococcal disease and Haemophilus influenzae type b (Hib) in children by vaccination are failing due to low immunisation rates and delayed immunisation, a study from Shanghai shows. A review of vaccination records for 28,000 children up to the age of seven found that 51% had one dose of Hib vaccine and 11.4% had one dose of pneumococcal vaccine. Only 8.2% of children had Hib vaccine at the right time and only 0.5% had timely pneumococcal vaccine. Rates were particularly poor for migrant children, the study found.

3. Rates of hypertension have increased in China and yet treatment and control of the condition remain poor, according to researchers from Shandong. In a study of more than 4000 people they found that the incidence of hypertension increased from 2.9 per 100,000 people in 1991–1997 to 5.3 in 2004–2009 Antihypertensive treatment and control rates for hypertension were 5.7% and 1.7% in 1991–1997 and 19.9% and 7.6% in 2004–2009, respectively.

4. The rate of disabilities from road crashes in China has skyrocketed as the number of cars on the road has increased over the last two decades. The incidence rate for road traffic disabilities increased over time from 1.50 per 100,000 people in 1980 to 11.2 per 100 000 persons in 2005, according to Professor Zheng Xiaoying of the Institute of Population Research, Peking University.

5. Malaria is still a major problem in central China especially during floods and rainy periods of the summer. A study from Mengcheng County, Anhui found that there were 3683 malaria were notified during the study period of May to October 2007 Most of the cases occurred a week to a month after flooding and waterlogging. Public health action should be taken to control the potential risk of malaria epidemics after wet weather, the researchers from Shandong University said.

6. The recent outbreaks of H7N9 avian influenza also resulted in many mild and asymptomatic infections as well as severe life threatening cases, researchers from Guangdong have reported. Their surveillance program noted 21 cases of infection in Guangzhou, China in 2013 and 2014, of which several were mild or asymptomatic infection. Family clusters occurred, suggesting limited person-to-person transmission of the H7N9 virus, they said.

Wuhan medical staff on trial for organ trafficking

by Michael Woodhead
A gang of 12 organ traffickers including surgeons, anaesthetists and nurses on on trial in Wuhan accused of selling organs for up to 360,000 yuan ($58,000).
In a case know as the "undergound kidney trafficking network" the 12 are accused of buying and selling kidneys in a million-yuan scheme scheme in which donors were paid 30,000 yuan ($5000). According to the Anhui News, the gang performed six commercial organ transplant operations between 2012 and 2013, for which they charged between 170,000 and 360,000 yuan ($27,000-58,000), which was divided up between the participants. The gang included a surgeon called Dr Chen, an anaesthetist Dr Peng, an assistant surgeon Dr Yao, two surgical nurses, and two follow-up nurses. There was also a group of 'fixers and 'agents who bought medical equipment and drugs and who set up the deals and arranged premises in the Jiangxia district in which to perform the illegal operations.  Other gang members arranged transport and liaised between medical staff and buyers and sellers. Eleven members of the gang have already pleaded guilty to the offences. The ringleaders of the gang were an agent called Deng and Dr Chen. Deng set up the deals through the internet, making contact with people looking for an organ and also contacting people who were willing to sell one of their kidneys. Deng said he received 34,000 yuan ($5500) for each deal. One donor in the court said he could now put his heart at rest. he said he greatly regretted his disastrous decision to sell one of his kidneys when he was deeply in debt. now he said he was easily tired and had lost all his strength after the operation.
Xinhua report does not say at which hospital the doctors worked or who the buyers of the organs were, nor what the outcomes of illegal organ transplant surgery were.

Beijing’s 3-point reform plan for maternity services

by Michael Woodhead
Maternity services are to shift from hospitals to community health centres and women will not be allowed to have routine Caesareans unless there is a valid medical indication, Beijing health officials have announced.
New reforms are needed in maternity policies to cope with the expected increase in births as China moves to a two child policy, according to the city health department.
Under new measures, three new basic policies will be introduced. These are for women to register first with a community health centre rather than a maternity hospital. Following tests at six week of pregnancy, women will be enrolled on the maternity database, and women will then be graded into one of four levels according to risk of pregnancy. Only high-risk pregnancies (such as in older women) will be managed in tertiary level hospitals. Low risk births will be managed in local hospitals and clinics, the new policy states. In addition, women will no longer be offered caesarean section unless there is a good medical indication. The head of Beijing maternity services department says caesareans must be discouraged because China already has a 45% rate, which is much higher than the WHO benchmark of 14%. In addition, caesarean birth mean women spend longer in maternity hospitals, taking up scare resources, she said.
Health officials said the maternity system was already at breaking point with something like 94% occupancy of obstetric beds and thus no additional capacity to cope with a two child policy. Maternity services will be expanded but they also must be used more rationally, the officials said. By managing low risk pregnancies outside the hospital system, this will free up beds to deal with high risk pregnancies, they said.

Smoking deprivation | Suicidal ideation in school students | Obesity surgery | Oestrogen in the environment

About 7% of Chinese people smoke so much their spending on cigarettes deprives the household of essential items like food, a study from Beijing has found. Low-income smokers were more likely to have smoking-induced deprivation.

Suicidal ideation occurs in one in three Chinese high school girls and 20% of boys, a study of 5249 students in Anhui Province of China has found.

Laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy are safe and effective for the treatment of morbid obesity, resulting in 63% and 76% loss of excess weight, a study from Nankai Hospital of Tianjin Medical University has shown.

The waist circumference cut off for high risk of central obesity and metabolic syndrome is 85 cm for women and 90 cm for men, researchers from Shandong have shown.

In Shanghai, almost one-in-five boys are obese and 8% of girls are obese. The prevalence of combined overweight and obesity is 49% for boys and 31% for girls aged 8-15-years, according to a study that found rates of obesity started to increase from age 10 years.

Oestrogen hormones are widely used in animal rearing in China and this leads to high levels of the hormones in excreted manure which is then used on crops, perpetuating the environmental contamination and human exposure, researchers from the State Key Laboratory of Water Environment Simulation, Beijing have shown.

The highly pathogenic strain of H7N9 avian influenza is quite different from other H7N9 strains seen in China and appears to have come about by re-assortment with the H9N2 strain, according to researchers from the Guangdong Provincial Center for Disease Control and Prevention.

Infliximab is safe and effective in Chinese patients with ulcerative colitis, resulting in 85% response rates and 62% remission rates after 30 weeks of treatment. However, relapse rates are high, say researchers from the Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou.

Freaky Friday: nurses now dress as air hostesses at Jiangsu Hospital

by Michael Woodhead
Just when you thought you'd seen it all, here's a Chinese hospital that has come up with a gimmick to promote its service-oriented approach.
The Lianshui Huaian Hospital of Chinese Medicine has sent 12  nurses on an Eastern Airlines-style airline cabin crew training course and now requires them to wear air hostess uniforms on the wards. The aim is to emphasise the personal service aspect of the hospital's care, says hospital manager Bo Haijuan.  He came up with the idea a year ago and has been doing market research about the plan, which was implemented this month. The nurses were recruited from other departments and hospitals based on age, height and appearance, and their etiquette skills were nurtured in a one-month training course.
Bo Haijun says he wanted the 'hostess nurses' to stand out from ordinary nurses, who he said gave patients a 'cold face', lacked manners and had little personal caring spirit. The hostess nurses always have a warm smile and patience, he said. However, they still carry out all the normal patient care and technical functions of regular nurses. A reporter from Yangzi Evening News noted that in the hospital the nurses administered treatment such as moxibustion, but they also dealt with small service matters such as offering coffee and comfortable chairs for waiting patients. Their uniforms resemble those of airline cabin crew although the skirts are slightly longer for modesty reasons.
The new nurses who spoke to the reporter said they felt more pride in their job but now had to be more careful about their lifestyle and appearance. One said she no longer dare stay up past midnight on social media because she feared having dark rings under her eyes and looking tired - now she went to bed at 10pm. Another said she had to avoid fatty food because she must keep her figure. The hospital said the hostess nurses got higher pay, but that was because they did harder work in providing service to patients.