Drug price caps abolished | Healthcare staff HIV knowledge lacking | China develops drug for lung cancer

Drug prices to rise as price caps abolished

The Chinese government is to abolish price caps on all medicines in a move to end drug shortages and bring market forces into play on the country's pharmaceutical supply system. Draft rules propose to "cancel government-set prices on drugs, and through insurance price controls and the tendering process, allow the actual transaction price of drugs to be set by market competition,"an official report said. Drug prices will in future be determined by health insurance departments,  tendering processes and negotiations, it said. Analysts said the government would have to strike a balance between keeping essential medicines affordable and ensuring that companies had enough profit to ensure supply of medicines.

HIV ignorance still common in rural China
Healthcare workers in rural China have a poor understanding of HIV and how it is transmitted, a study carried out in Shaanxi has shown. When subject to a knowledge test on HIV, healthcare workers such as nurses and medical technicians scored only about half of questions correctly, and showed a lack of knowledge of about the transmission of HIV, exposure risks and appropriate protection measures. The lack of knowledge about HIV also translated into inappropriate behaviours, said researchers from the Xi’an Jiaotong University School of Public Health.

Lung cancer drug shows promise
China's homegrown epidermal growth factor receptor inhibitor (EGFR) icotinib (Conmana) shows promise for non-small cell lung cancer, researchers say. The targeted anti-cancer molecule has been researched and produced by the Zhejiang-based Beta pharmaceutical company. It has shown good results published in the Lancet and offers a lower cost alternative to western drugs for the disease that is very common in China, say experts.

China's move to a GP-based primary care system: lots of policy, little progress

In China the average salary for a GP is about half that of a hairdresser.

by Michael Woodhead

If you relied on the official Chinese media you could be forgiven for thinking that China's primary care system was the best thing since sliced bread. Hardly a week goes by without an article extolling the virtues of the new networks of general practitioner-based community health clinics.

Many cities such as Beijing and Shanghai are strongly encouraging all residents to enrol with the local community medical centre and to visit the GP for everyday ailments rather than going direct to hospital. The public are enticed to see GP clinics with incentives, such as the free or low cost availability of GP clinic services and ease of getting to see a GP with little need for waiting or queuing up for registration, as is the case with hospitals. Unfortunately, the great Chinese public are not buying it, and they continue to make a beeline for hospitals whenever they are sick.

This week a revealing commentary in the Quarterly Journal of Medicine paints a more realistic picture of China's fledgling GP system. In fact, fledgling isn't the word, foundling might be a better descriptor.

According to the article by Dr Kong Xiangyi and Dr Yang Yi of the Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, the primary care system is in a kind of "Failure to Launch" status. They say the government's stated aim of training 150, 000 GPs by 2015 is pie in the sky. The problem, it seems, is that nobody wants to be a GP and nobody wants to see a GP. In China, to be a doctor in the community health service is a low-status position in an underfunded and unrecognised branch of medicine. As the two doctors point out, "the average annual income of a Chinese GP is less than half of a hairdresser and far lower than a specialist."

Part of the problem is that there isn't really any good local model for the would-be GP to emulate. There is no real definition of a GP, and currently many GPs are little more than barefoot doctors - local clinic practitioners who have received five years of basic training in health and medicine. They are employed to offer the "Six Basics" of health: prevention, health education, women and children’s care, elderly care, immunisations and physical rehabilitation. There is also a three-year postgraduate program for medical graduates to train as GPs, similar to that seen in western countries. However, there are very few takers for these courses and their impact on the national medical workforce has been minimal.

The authors of the article say that there appears to be little real enthusiasm for creating a genuine general practice system in China. As they put it, there is a lot of policy, but very little concrete support for funding and training programs. There are no primary care institutions or programs in China: the speciality is a career dead end, and the cream of China's medical expertise and social status is still centred around the big teaching hospitals.

The solution, according to the authors, is for China to emulate foreign countries that operate well-funded and high status family medicine programs. The aim must be to create a gatekeeper system in which patients are triaged by the GP before being allowed to see a specialist. And conversely, GPs must be enabled to provide follow up care after a patient is discharged from hospital. To do this, the health ministry needs to harness the skills and the prestige of the major hospitals to implement such programs.

Until that happens, patients will continue to avoid the community medical clinics, which are underfunded and have poor quality and outdated equipment. The lack of funding means that GPs have to charge commissions on drugs and medical supplies, further eroding trust in their services.

"China’s current reforms still do not emphasize enough the value of GP led primary care," they conclude.

China's anaesthetists are dying of overwork

by Michael Woodhead
The sudden death of a 40-year old anaesthetist at the Beijing Fuwai hospital this month has put the spotlight on the high work burden of anaesthetists in China and the shortage of doctors in this speciality. 

Colleagues of the doctor who died of a brain haemorrhage after a long shift are not only mourning him but also the dire state of their branch of medicine. Many of the deceased doctor's colleagues said it could have been them, given the amount of strain they are working under. As one doctor told the CCTV news station, anaesthetists were working such long hours that some of them took naps on spare operating tables. And it was well known that there have been more than 15 fatigue- and stress-related sudden deaths among anaesthetists in recent years.

A recent survey carried out by the Chinese Medical Association's anaesthesia branch found that more than half of the doctors were working shifts in excess of 10 hours a day and 80% believed they were working beyond safe limits to do their job properly. In addition, 70% of anaesthetists said they were dissatisfied with their branch of medicine.

These findings were confirmed in an interview with an anaesthetist in her mid 40s who told reporters that it was not unusual to do 12 hours shifts due to the lack of staff and it was even known for doctors to work right through a double shift of 24 hours.

The president of the CMA anaesthetist branch Professor Hou Ren  said the job was highly stressful as they literally had people's lives in their hands every hour of the day. The job was especially taxing because of the high workload and lack of time for preparation, which meant that an anaesthetist might be dealing with a frail elderly person one minute, then a person with cardiovascular problems the next and later a pregnant woman . Each of these situations required very different management and skills, he said and anaesthetist had to make decision and adjustments according to a patient's condition by the minute.

He said the main problem was that the anaesthetist workforce had not kept track with the increasing number of hospital patients and operations. There were 2.8 million doctors in China, of whom only 2.5% were anaesthetists, which meant there was a national shortage of about 70,000 anaesthetists.
And while some hospitals had enough anaesthetists in theory, in practice there were always shortages because anaesthetists were off sick, on study leave or because they had to teach students.

To remedy the problem some general physicians were being re-trained as temporary anaesthetists, but this was only a short term solution, he said. Another way of addressing the problem was to learn from foreign countries which had managed to use anaesthetists more efficiently through the use of technology and better staff management, he added. In the meantime, anaesthetists faced high levels of pressure and there would continue to be overwork, stress and potentially unsafe work situations.

County hospitals under scrutiny | iKang CEO gets award | Mass General expands into China

China sends in hit squads to fix unpopular country hospitals
Authorities in China have decided to take action to tackle the growing problem of Chinese patients leapfrogging their local hospitals and making a beeline for the big city hospitals (which makes them hopelessly overcrowded).  County hospitals are seen by many Chinese as second rate and over priced, and hence they willing to travel long distances to be seen by a doctor in a major hospital in a big city. Now the State Council has decided to send teams to inspect improvements at county-level public hospitals around the country.The teams will conduct onsite inspections to ensure that reforms are being implemented, including overhauls of financing to eliminate commissions and profiteering in commissioning and contracts.


Healthcare tycoon wins entrepreneur award
The head of medical centre operator iKang has won an international award for being Entrepreneur of the Year. Zhang Ligang, who is CEO of iKang, has been named as the EY Entrepreneur of the Year in the 2014 National Life Science Awards. Mr Zhang is the founder of iKang, which now owns 50 private medical clinics and has contract arrangements with a further 300 medical facilities and hospitals.

Prejudice against leprosy patients triggers riots in Hainan over new medical centre

by Michael Woodhead
Deeply felt cultural phobias and prejudices about infectious diseases have triggered mass riots in the southern province of Hainan, where local residents in Haikou violently opposed the construction of a leprosy recovery centre.
According to local reports, thousands of local residents in Hainan clashed with riot police over the construction of a new dermatology clinic in the Sanjiang district for  patients recovering from infections including leprosy and STDs.
Although authorities explained that patients who had recovered from leprosy were no longer infectious, this was not enough to assuage the fears of local residents, who strongly opposed the building of the clinic and rest facilities in their neighbourhood. Authorities said the clinic was a rehab centre for elderly people who had recovered from the disease and who were no longer contagious, but local people violently opposed the building of the clinic.
According to Chinese state media, local people clashed with police and overturned police vehicles. Several police and local residents were injured in the riot.
Local authorities were reported to have ceased construction of the clinic until a consensus could be achieved with local residents.

9 scary health stories from China that might put you off working there

1. Six nurses have been murdered and a hospital janitor killed in a knife attack on a hospital dormitory in Hebei. The attack at the No. 281 Hospital in Qinhuangdao was thought to be the work of a 27-year old male from Tangshan, who has been detained by police.

2. Outdoor pollution can't be escaped by staying indoors in China because it is also a major cause of sick building syndrome, according to researchers at the Institute of Environmental Science, Shanxi University, Taiyuan. In a study of 2134 school students they found that many suffered from skin and mucosal problems that were exacerbated by high levels of outdoor air  pollutants such as SO2, NO2, O3 and PM10 particles.

3. A quack doctor in Henan has been jailed for 15 years after he killed a student with what he claimed to be a traditional Chinese medicine cure based on soy sauce, sugar and vinegar. The 65-year  old bogus healer had only just been released from jail after serving an 11-year sentence for the same offence - his previous quack remedies had killed as several people in Luoyang.

4. Make no bones about it - China has about a quarter of a billion osteoporotic fractures every year due to brittle bones. A study from Anhui Medical University and Nanjing Medical University estimated that in 2010 there were more than 2.3 million osteoporosis-related hip, clinical vertebral and wrist fractures in Chinese people aged 50 years and over, costing the Chinese healthcare system US$9.61 billion.

 5. An outbreak of scrub typhus that originated in a Guangzhou park killed four people and caused serious disease in 29 people, according to local researchers. The outbreak at the Xiaogang Park in May 2012 seemed to affect people who sat on the grass or who were near rat burrows.

6. One in seven young Chinese are Weibo addicts, findings from a study in Anhui suggest. In a study of more than 3000 college students between 4% and 15% of students showed signs of addiction to Weibo-like microblogs, including cravings, dependence, withdrawal and disruption to everyday activities, according to researchers at the Laboratory of Brain Function and Disease, and School of Life Science, University of Science and Technology of China, Hefei.

7. Extreme weather triggers heart attacks, according to a Jiangsu study. Heart attacks were found to be more common following changes in atmospheric pressure and variations in temperature, according to a study by Dr Jia Enzhi of the Department of Cardiovascular Medicine, First Affiliated Hospital of Nanjing Medical University. The findings suggested that climate change could have a major impact on cardiovascular disease rates, he concluded.

8. Superbugs are already a major problem in China and now it has been shown that the use of animal manure as fertiliser is spreading the problem of antibiotic resistance even further. A study of agricultural soil in Jiangsu found that fertiliser was responsible for the high prevalence of sulfonamide-resistant bacteria and their resistance genes.

9. A previously unrecognised tick disease may be endemic in several parts of China inlcuding Yunnan and Zhejiang, say parasitologists.After a recent epidemic of babesiosis in malarial areas of Yunnan they carried out a review that suggests the diseases carried by ticks and rodents may have caused many more  cases of disease and outbreaks in recent years that were mischaracterised as other tick-borne fevers.

Doctors refuse red envelope pledge | Online pharmacies to be allowed | Chinese diabetes patients don't adjust diet

Famous doctor won't sign bribe pledge
One of China's leading doctors has refused to sign the government's anti-bribery pledge against accepting red envelopes, saying it is an ineffective and damaging document. SARS hero Professor Zhong Nanshan said the no red envelopes pledge was not a legally-binding document and its ethical pledges were already contained in the Hippocratic Oath that doctors already swore when they graduated from medical school. He said that if doctors signed the pledge it would be a tacit admission of guilt that all doctors were accepting bribes for preferential treatment, which was not the case. He added that signing the pledge also sent the wrong signal that doctors were to blame for the high costs of medical bills, which he said were actually driven by systemic problems such as the linking of hospital doctors incomes to overservicing and the lack of government funding for government hospitals.

Online pharmacies permitted from 2015
Online sales of prescription medicines in China may begin within months, according to the China Food and Drug Administration. The regulatory agency is expected to announce new policies that will allow  online prescription medicine sales as early as January 2015. Pharmaceutical retailers have said the opening up of online medicine sales will open up a potential 10 billion yuan market for drugs. However, the expected increase in  online pharmacies will have a major impact on bricks and mortar pharmacies, they have warned.

Diabetes patients don't adjust diet
Chinese people with diabetes have little idea how to manage their diet so as to better control their condition, a new study shows. A survey of 100 people with type 1 diabetes by researchers at Peking University People's Hospital found that less than half had ever seen a dietician and few monitored or adjusted their diet to help control their blood glucose levels. The study found that while 64% were aware of carbohydrate counting', only 12% ever used the technique

China's public hospitals and breastfeeding mums are the losers with latest free trade deal

by Michael Woodhead
China's private hospitals are the winners and breastfeeding mums are the  losers under the Free Trade Agreement Xi Jinping agreed with Australia today.

The FTA gives Australian companies unprecedented access to China's healthcare system, allowing Aussie  health providers to build and ­operate hospitals in China without the current restrictions that apply to other foreign health companies.

Until recently foreign companies have only been allowed to set up joint venture hospitals, although rules have recently been eased to permit foreign hospitals to be buy or set up hospitals and clinics in Shanghai, Beijing and Tianjin.

One of Australia's leading private hospital operators, Ramsay Health, has already announced a move to buy into a Chengdu private hospital group  that operates five hospitals. However, it remains to be seen whether other Australian companies follow suit, especially given that Australia has only a limited number of private hospital operators. Australian healthcare companies may also find it difficult to work in the cut-throat China healthcare environment as they are  accustomed to working in a heavily protected and subsidised market. Private health companies receive $5 billion in Australian government handouts a year in a support scheme introduced in the 1990s to prop up the uncompetitive industry when Australians abandoned private hospitals in favour of the public hospital system funded by Medicare.

Australians are more accustomed to dealing with China over resources than services, though one mining tycoon  has been quick off the mark to cash in on the free trade agreement to sell milk formula to anxious Chinese mothers. Billionaire Gina Rinehart, whose fortune come from iron ore mines she inherited from her father, has announced she will set up a massive dairy operation to produce milk formula for the China market. Australia's richest woman will acquire about 5,000 hectares of farmland in Queensland to that is expected to produce an estimated 30,000 tonnes of infant formula for export to China every year.

However, the move is unlikely to be welcomed by China's child health specialists, who are already struggling to raise China's pitiful 28% breastfeeding rate to somewhere near to the global average of 40%. Groups such as the World Health Organisation and UNICEF have called for urgent action to boost China's breast feeding rates, but they struggle against aggressive and unethical promotions by milk formula companies, who are also known to bribe hospitals and clinicians to promote their products.

Leukaemia donations missing | Asthma rates soar | Syphilis rates as high as 44% in sex workers

Leukaemia boy misses out on donations

One of the top stories in the Xinhua news this weekend is the story of a boy from Leshan in Sichuan with leukaemia who has missed out on most of the funds donated by wellwishers for his treatment. The family of the 8-year-oldcalled Lin Zhouzheng appealed for help in paying several hundred thousand yuan in medical bills after they ran out of money and even sold their house to pay for chemotherapy for their son. They were approached by a local man called Xu Ping who mounted a major publicity drive to raise money, and this netted more than 100,000 yuan. However, to date the boy's family have only received 7,000 in money from all the fundraising despite taking part in many media interviews, publicity appearances and having an army of volunteers working under Xu Ping. However, Xu Ping told reporters that the 110,000 yuan raised had only been pledges rather than actual donations - and he was still working to get companies and individuals to make good on their pledges.

Asthma rates soar in Shanghai

Asthma rates in Shanghai have increased four-fold over the last 15 years, with pollution being given much of the blame. A study of more than 27,000 residents of Pudong found that the prevalence of asthma was 1.4%, markedly higher than the 0.4% rate seen in the last major study carried out in 1997. Researchers from the Department of Respiratory Medicine at the Shanghai Putuo District People's Hospital carried out further pulmonary tests on 428 people with asthma and found that 53% had an FEV below 80% of normal and the severity of impaired lung function increased with age. The main triggers for asthma were dust exposure, cold air and respiratory tract infections.


STDs rates high in Jiangxi sex workers

More than 40% of female sex workers in Jiangxi have syphilis, a study has found. Researchers from the Department of Dermatology and STDs at the Affiliated Hospital of Nanchang University tested 361 street-based female sex workers and found that 44% had syphilis infection. About half of the sex workers had little education, a high proportion had been sex workers for several years and many failed to use condoms consistently. "Comprehensive interventions targeting this high-risk group, especially scaling up screening and ensuring consistent use of condoms during sex are needed," the researchers suggested.

China's first mental health law - 27 years in the making, but will it change negative attitudes?

by Michael Woodhead
There is a very severe stigma about mental health in China - just try calling someone "shenjingbing" (神经病, mentally ill)  and watch the reaction. This cultural taboo about mental health  is just as strong for doctors in China - a 2012 survey found that even Chinese psychiatrists had negative and unscientific views about mental illness. Most worryingly, many psychiatrists believed that the best approach for someone with mental illness was to institutionalise them, by force, if necessary. There is still a strong belief in involuntary treatment of mental health conditions in China.

It is therefore interesting to see the reactions to the Mental Health Law that was enacted more than a year ago, in May 2013. This law had originally been proposed by the Ministry of Health back in 1985. Such was the lack of interest in change and the entrenched attitudes, it took more than 20 years to get even as far as the draft stage, when it was submitted to the State Council in 2007. After much more negotiation and consultation, the law was approved and came into effect on 1 May 2013.

To westerners, much of the law would appear unremarkable. It states that mental illness must be treated according to basic clinical guidelines, with an emphasis on prevention, treatment and rehabilitation. Where the law has proved controversial (in China at least) is on the matter of involuntary treatment. The new law states that for people with mental illness, "voluntary admission and treatment should be the priority".  It also states that involuntary admission should be based on “risk criteria", but this is a grey area that is untested in China.

In an article published this month by three psychiatrists from Shanghai's Jiaotong University School of Medicine, it is argued that the new law is flawed and will still allow mentally ill patients to be inappropriately 'committed' to an institution on flimsy pretenses. They argue that the risk criteria are too broad and open to interpretation. They say the regulations put too much weight on the opinions and wishes of the families of mentally ill people. In reality this will mean that families with 'backward' attitudes and knowledge about mental health will be able to 'get rid' of the stigma of mentally ill person in their family by having them admitted involuntarily.

The psychiatrists say the national law also lacks detail and may not be implemented at a local level. They point to local programs and treatment pathways for mental illness that have been adopted in advanced cities such as Shanghai and Beijing, and they say these should be the model for other parts of China. 

However, for the time being psychiatric treatment remains out of reach for many people with mental illness in China. There are an estimated 173 million people with psychiatric disorders in China, but only 20,000 psychiatrists and a few hundred mental hospitals and clinics. China has a long way to go in providing appropriate care for its many citizens with mental illness.

The crisis in paediatrics in China

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

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

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

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

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

Health insurance cover for 95% of Chinese? More like 30%.

by Michael Woodhead
For the last few years the official Chinese media have been proudly trumpeting the claim that almost all Chinese are now covered by government-funded basic health insurance. Health minister Li Bin's recent statement that "China's public insurance schemes have achieved over 95% health coverage in urban and rural populations" was accepted and repeated uncritically by Lancet editor Richard Horton  on a recent visit to China.

But wait a minute ... is it true? The Atlantic last year reported Chinese academics saying that the true figure was likely to be much lower. And this week we have further confirmation that health insurance cover is nothing like 95% - especially for the most impoverished and vulnerable of China's citizens, the 250 million 'floating population' of migrant workers

A survey of more than 600 migrant workers carried out by researchers from the National Center for Chronic and Non-communicable Disease Control and Prevention in Beijing found that only a third had health insurance in their place of residence. This is probably because health insurance is provided according to the hukou (residence permit) by the authorities of a citizen's hometown, and that is not the place of residence for most migrant workers. But even in their hometown, only about 60% of migrant workers had health cover. The researchers, including an actuary from the China Life Insurance Group, said the low rates of health insurance cover were likely due to a number of reasons, including lack of awareness and inability to negotiate the system and its paperwork for poorly-educated rural residents.

And as well as having poor coverage, health insurance cover had little depth in the real world - it did not cover most of the expenses for those who had it. The study showed that rural migrant workers faced high out of pocket costs for health - averaging 2000 yuan a year in gross average payouts and more than 1000 yuan per person per year even after upfront costs had been reimbursed.

The authors conclude: "overall the coverage depth of basic insurance is still very limited, and the insured in China still end up paying a high amount of medical cost out of pocket. In addition, the floating population has a lower coverage rate than the general population, which further diminishes the protecting effects of insurance."

My take? China's government deserves credit for trying to bring in universal health insurance. Unfortunately, the implementation has been patchy and has favoured the urban, employed and middle classes. Claiming 95% coverage may sound good at WHO conferences and on the front page of China Daily, but the reality is that effective health coverage is nothing like that level. And the biggest losers are the rural migrants. Somehow, Xi Jinping's "The China Dream" left them behind.

Corruption crackdown targets doctors running clinical trials

by Michael Woodhead
Senior doctors who accept drug company money to run clinical trials are to be reined in by new health ministry regulations that aim to clean up the potentially unethical and corrupt practices and make clinical research more ordered and accountable.
The National Health and Family Planning Commission has released a new position statement entitled "Administrative Measures for the Clinical Study Projects of Medical Institutions" which will force clinical trials to be run under the auspices of hospital research committees rather than individual doctors or their departments.
The new rules stipulate that to clinical trials will be co-ordinated by a Clinical Study Administration Committee in hospitals, and funding  for trials from industry will be channelled through hospitals rather than a particular department or individual doctor.
The study committee will have to set standards and procedures for administering clinical trials and  maintain constant supervision of studies. Each trial will need to have a full record and documentation of its aims, protocols and the researchers involved. There will also be strict rules about the financing of trials and bans on having industry paying for or accepting "expenses".

Dengue crisis worsens as disease spreads north

by Michael Woodhead
China is now experiencing its worse outbreak of dengue fever in two decades, with almost 1000 cases a day being recorded in south China, and the infection spreading as far north as Henan.
Outbreaks of the serious infection spread by the Aedes mosquito are centred around Guangdong, where almost 43,000 cases have been recorded this year.
However, the disease is now affecting other parts of China, including  Zhejiang, Fujian, Yunnan and Guangxi, according to the National Health and Family Planning Commission (NHFPC).
"The outbreak of dengue fever this year is the worst in China since 1995, when 6,812 cases were recorded," according to Qin Chengfeng, a researcher with the Chinese Academy of Military Medical Sciences.
Alarm bells are ringing because the infection has also been reported as far north as Henan, half way between Shanghai and Beijing. Researchers say this is the first time the disease has been seen so far from the traditional areas of south China. Infectious disease experts said there were more than 50 cases of dengue fever reported in Shenhou township, presumably imported by migrant workers who had been in south China and Laos. They said the findings should act as a warning that the disease is spreading rapidly within China.
Other experts have attributed the spread of dengue to changing weather patterns, pointing to high rainfall that encourages the breeding of the Aedes mosquito.

CMA pharma ban | Cancer survival lags | High rates of undiagnosed diabetes

Health ministry curbs CMA's lucrative industry links
The National Health and Family Planning Commission (NHFPC) is taking steps to curb hugely-profitable links between the Chinese Medical Association and the pharmaceutical and medical device industries. Although supposedly a non-profit organisation, the CMA makes 820 million yuan ($133 million) in income from industry-sponsored events such as medical conferences. The NHFPC has ordered the doctor's professional association to put its conference management on a more sound ethical footing and to stop promoting links between industry and the profession.

Cancer survival rates in China lag behind other countries
Cancer researchers have highlighted the huge disparity between cancer survival rates in China and in developed nations. A study of 139,000 Chinese cancer patients found that only about one-third of survived five years after their diagnosis, compared to 70% in counties such as the US. Researchers from the Cancer Prevention and Control Office said the poor survival rates in China ere due to poor levels of medical treatment and research. Another reason was that China had more cases of stomach, lung and liver cancers, which were more difficult to detect and treat than the common cancers in western countries.

High diabetes rates in central China
Diabetes has become a major public health problem in the region around the Three Gorges of the Yangtze, and a large number of the cases are undiagnosed and untreated. A study involving 3721 randomly selected adults found that the prevalence of diabetes and impaired fasting glucose were 7.6% and 9% respectively. About 55% of the cases of diabetes identified in the study were previously undiagnosed. The researchers from the Third Military Medical University, Chongqing said diabetes was linked to age, family history of diabetes, central obesity, educational level and hypertension for both men and women.

Low awareness of cervical cancer prevention in China

by Michael Woodhead 
Cervical cancer is not 'on the radar' of even the most health literate Chinese, a new survey suggests.
A study of medical students has found that while most were aware of HPV as a cause of cervical cancer, few were aware of the screening techniques for cervical cancer or the role of a HPV vaccine in preventing the disease.
The survey of 1878 students at Chengdu Medical College found that 79% of females and 54% of males had a positive view of cervical cancer screening, 40% of females and 45% of males were not aware of what it involved. Most had little idea of when cervical screening screening should start or the role of HPV in the development of cervical cancer. Likewise, few Chinese medical students were aware of the ideal intervals for screening, according to the findings published in PLOS One.
When asked about HPV vaccine, only 14% were aware that persistent HPV infection was the necessary cause of cervical cancer and only 29% knew there was an HPV vaccine available. About 50% of males and 65% of females said they would support HPV vaccination, but about 40% said they had concerns about side effects and the cost of the vaccine.
The researchers led by Dr Pan Xiong Fei of the Department of Epidemiology, West China School of Public Health, Sichuan University, said it was a major concern that China's health providers knew little about HPV and prevention of cervical cancer.
"It is important to improve the knowledge of HPV and cervical cancer among medical students in order to supply well-informed health care providers for prevention and control of cervical cancer," they concluded..

Rather busy at the moment ...

Normal service should be resumed shortly.

Taking a break

China Medical News is having a rest until October 20 while I take a holiday in Yunnan. See you on the other side ...

Patients ignore primary care clinics | Decline in Hepatitis A | Online ratings platform launched for hospitals

The government's newly created network of primary care clinics are struggling for recognition in China, according to a new survey carried out in Chengdu. More than 60% of people surveyed had not heard of the primary care clinics and didn't know where they were located, according to local media. Most people surveyed also said they would still prefer to go direct to hospital for treatment rather than go to a local community clinic, the survey showed.

China has seen huge reductions in hepatitis A over the last two decades, with rates of infection falling from 94% to 42%, a study carried out in Hebei has shown. Rising living standards, better hygiene and widespread childhood immunisation have contributed to the drop in hepatitis rates, and also resulted in most infections being delayed until adolescence rather than infancy, according to researchers from Shijiazhuang. However, the lower infection rates mean that many people now have little immunity to the disease and will benefit from immunisation, the researchers say.

A Tripadvisor-like mobile online platform has been developed that allows patients to rate their experience with hospitals and health providers in China. The Care Voice (Kangyu in Chinese) is a Shanghai-based  social platform that enables consumers to share reviews on hospital services, physicians and treatments and connect with other patients and professionals.

How GSK bribed doctors in China: the gory details

GSK's Mark Reilly, given a suspended prison sentence by Chinese court for bribery.

by Michael Woodhead
The main points of GSK's record 3 billion yuan ($500 million) fine for bribery in China have been reported elsewhere - I won't go over the same ground.

Suffice to say that several senior executives (including one from the UK) have been implicated in the giving of massive levels of bribes/kickbacks to institutions and hospitals in China to promote the  use of GSK's drugs. The company was also found guilty of transfer pricing - dodgy accounting to transfer profits out of China via pricing mechanisms that favoured the revenues of the parent company over the China subsidiary.

Most of the western reports have focused on the implications for GSK and for the prospects of western businesses in China. Surprisingly few have questioned the ethics of what GSK was doing - except to suggest that "Chinese companies were all doing it, it's the way of doing business in China."
I have been reading some of the Chinese language media reports, and they give a lot more detail of the practices GSK was found guilty of. Very few western media reports have focused on the actual bribery methods used by GSK or the specifics of the transfer pricing arrangements (which I presume are not confined to China).

Here are a few examples reported in the Chinese media:

1. According to Chinese prosecutors the bribery was systematic and on a huge scale. Drug reps bribed doctors. Area managers bribed hospitals and 'VIP clients'. Country managers bribed officials in charge of distribution and purchasing. Bribery was done via travel agencies, gifts, sponsorship and through entertainment budgets and PR agencies. There were separate promotional teams for different product groups - the cold chain (vaccine) group is said to have spent 130 million yuan bribing officials in the regional Communicable Diseases Centres with everything from cameras and electronic equipment to cars.

2. How were individual doctors bribed? One liver specialist physician in Hunan called Dr Lee told the court how it worked. For every lamivudine prescription he wrote he was paid 20 yuan by GSK rep. For every new patient he got a bonus of 100 yuan. Dr Lee said every month he wrote about 150-200 prescriptions for lamivudine and started 5-8 new patients on the drug. Do the maths - that 12,000 yuan ($2000) a month, or 144,000 yuan ($23,400) a year.  Dr Lee said the GSK rep arranged to pay him his commission every month at a special meeting when he would be paid for 'lecture fees' and travel expenses for the company. He received these fees 12 time a year but only did 3-4 lectures for GSK each year.

3. It wasn't just individual doctors who were bribed - the court heard how professional 'medical associations' also had huge sums of money transferred to their accounts from GSK to promote the endorsement and use of their products. Medical groups also received millions of yuan in material bribes such as non-medical items like fridges, cars and TVs. Hospital managers were also bribed millions to influence their purchasing policies - sales reps were given a 'Great Wall Plan' and a 'Dragon Plan' of incentives to persuade hospitals to abolish their 'Chinese-made generic drugs only' policies.

The end result was that Chinese consumers paid more for their medicines. Drugs such as Contac, Fenbid and lamivudine were overpriced up to seven-fold compared to other countries. The unit cost of lamivudine was said to be 142 yuan in China compared to 18 yuan in South Korea and 30 yuan in the EU, Japan and Hong Kong. Drug prices were padded to pay for kickbacks. About a third of the cost of GSK pharmaceuticals was said to have been to cover 'commissions', according to a financial controller. This meant Chinese consumers paid 30% extra for drugs  just to cover the cost of bribes.

GSK was driven by high pressure sales tactics for pharmaceuticals: GSK's revenue in China rose from 3.9 billion to 7 billion yuan between 2009 and 2012. The sales workforce increased from 1000 to 5500 people over that period, and each rep was given a budget of 3000-5000 yuan per month to influence prescribing - presumably though officials, doctors and health institutions. Sales reps were promised unlimited bonuses and membership of an 'Elite Club' with foreign travel if they met their targets

Cooking the books: from 2009-2013 GSK had almost 22 billion in revenue from drug sales in China and yet recorded a profits of only 100 million yuan. Investigators found this was due to a 'Five Step' transfer pricing system, by which the costs of products such as the antibiotic Zinacef were inflated at various stages of production in Italy and Cyprus until eventually 'sold' to the China subsidiary. This was a way of repatriating profits back to the US, but again meant that Chinese patients paid far more than they needed to for drugs.

The overall picture is not pretty - call it what you want - commissions, kickbacks, bribes, - GSK was guilty of them but they were by no means the only pharma company in China  doing it. Commissions and kickbacks are obviously widespread in the Chinese health system, and others have been caught out - such as in the Zhangzhou, Fujian case last year where 73 hospitals were found to be guilty of accepting bribes.

In Chinese media reports on the GSK case, most commentators have concluded that the massive fine and the jail sentences will be a lesson to the pharma industry - and the stamping out of bribes will result in lower medicine prices for Chinese consumers.

However, one leading financial commentator has said the GSK case is a prime example of China's tactic of "killing the rooster to scare the monkey"  - but it would not work. Cai Shen Kun says corrupt practices are so entrenched in China's pharmaceutical industry and are so much a part of the healthcare system that even a major case like the GSK one will not put a stop to them. He says kickbacks have become an unwritten rule in the industry that all insiders believe that nobody can ignore if they want to make sales - even a major international company like GSK.

Cai Shen Kun says the long term solution is to reform the health and pharmaceutical system to make it transparent and remove the incentives for commissions. He also says nothing will change until those who accept the bribes are brought to justice - and that means prosecuting the  government officials and senior doctors who accept the 'crazy money'.

What expat nurses tell us about China's healthcare system

by Michael Woodhead
A survey of Chinese-trained nurses working in Australia has revealed some interesting insights into the role of nurses in the Chinese healthcare system. 

Three main themes emerge from the interviews with 28 Chinese nurses working in Australia carried out by Zhou Yunxian from the Zhejiang Chinese Medical University, Hangzhou. In Australia, Chinese nurses found they had more independence and responsibility than they did under China's more regimented and hierarchical hospital system. Chinese nurses said they felt uneasy about having to take the initiative in patient care rather than be given orders by a senior nurse or doctor.
"Generally speaking, nurses here are more independent. They don’t rely on doctors totally. They can have their own thoughts and make decisions on the caring of patients," said one nurse.

Demarcation of roles is obviously stronger in the Chinese system - the nurses working in Australia found it strange that there was open communication and equality between nurses and doctors in a western healthcare system. "I don’t know what they (local colleagues) are doing, chatting with doctors – a waste of time from my perspective," said one, who believed that nurses should concentrate on 'nurses work' and not get involved with doctors.

Another theme that emerged was around the role of the nurse and their scope of practice. In China, nurses often saw themselves more as clerks and technicians fixing up IV lines rather than patient-oriented 'hands on' nurses. Chinese nurses were horrified to find that in Australian hospitals they were expected to do 'dirty' manual work such as bathing patients or helping to feed them. "I feel too embarrassed to tell people (the fact)…If I tell my family that a nurse in Australia needs to shower the patient, I think even my family would find it very hard to accept," said one.

 This revealed that in China, manual work in hospitals is done by unqualified low-status 'care assistants', and personal help with feeding, toileting and bedding is the responsibility of the patient's family, not the nursing staff. Nurses from China also found it hard to adjust to the notion of a family leaving the care of a relative to 'the system' rather than taking personal responsibility - especially with the elderly and the way they are left in nursing homes.

A third theme that emerged was communication. In China, nurses expected to be given clear instructions about tasks from superiors, however they did not feel any obligation to communicate with patients or their families. Chinese nurses were surprised to find that in western hospitals, nurses were expected to be friendly and personal with patients, who they regarded as strangers. "Here every nurse calls everyone 'sweetie', 'love', things like that. It is totally different from us… I have never thought of addressing a patient so intimately. It is hard for us because we don’t feel this way," said one nurse.

Language and cultural differences also meant that Chinese nurses found their usual 'direct' style of communication appeared rude and imperious to westerners. They found it hard to be 'warm' and polite, believing this to be insincere. In contrast, Chinese nurses expected that their colleagues would become their workmates and were disappointed to find that westerners were out of the door at 5pm and not interested in networking. "Anyway, they (local colleagues) come when they are on duty and they leave when they finish the shift. In China, we are colleagues even after the work. We go out together, and then we become very good friends."

Although designed to investigate the problems of Chinese nurses adjusting to the western workplace, the study highlights many of the assumptions that underpin the Chinese health system

Medical comic strips | Anti-smoking laws weakened | No support for Orphan Diseases

A female doctor in Shanghai draws weekly comic strips and posts them on WeChat to try demystify medical jargon and improve doctor-patient relations
Dr Chen Haiyan, a cardiac ultrasonographer at the Shanghai Zhongshan Hospital has used the comic strips to explain conditions such as heart defects and high blood pressure in easy-to-understand ways. She also tries to explain the daily life of medical staff and show they are human in an effort to defuse the major tensions that have triggered many recent violent attacks against hospital staff.

Health experts have expressed disappointment that Beijing's proposed anti-smoking regulations have been watered down. The latest draft legislation only bans smoking in "shared indoor public places," compared to a previous draft that banned smoking in all indoor public areas, said Professor
Wang Qingbin, a legal expert at the China University of Political Science and Law,
"By banning smoking only in 'shared' indoor public areas, the legislators are giving officials with their own offices a chance to smoke, which is against the spirit of equality," Wang said, adding that it will only make law enforcement all the more difficult.

China lacks adequate health systems to deal with rare 'orphan' diseases such as Duchenne Muscular Dystrophy, medical experts say. At a recent conference on rare diseases at the Children's Hospital of Fudan University experts called for legislation and policies on the prevention and treatment of rare diseases that affect more than 10 million people in China."Related regulations should be created to help provide better support to patients with rare diseases and their families," said Li Dingguo, chairman of the rare disease branch of the Shanghai Medical Association.

Intern scheme concerns | Telehealth ban sparks backlash | Rural residents too poor to pay for care

Internship scheme will create bottlenecks and headaches
Doctor training moves to a three-year internship system next year but many medics believe the changes will leave hospitals with even worse staffing shortages. The new system which will see newly-graduated doctors rotate through various hospital departments to gain experience is intended to bring China into line with other countries and to create a uniform high standard of medical practitioners. However, critics warn that the additional three years of being a trainee will mean that doctors earn very little and the low income will deter many from entering the medical profession. Another drawback of the new system is that doctors will serve as interns in tertiary 'teaching hospitals' and will then refuse to be 'downgraded' to work in smaller local country and township hospitals.

Ban on telehealth consultations triggers backlash
There has been a major backlash against an announcement that doctors will be banned from conducting online consultations by the National Health and Family Planning Commissioning. The NHFPC said this week that 'remote' consultations are illegal except through accredited medical institutions because all doctor consultations need to be carried out according to the regulations of the NHFPC as currently laid down for hospitals and clinics. The NHFPC said remote consultations should be viewed as no different to any other kind of consultation and therefore all the usual regulations on medical practice apply. However, after a major backlash from health groups and online health providers such as www.haodf.com, the NHFPC said it would look again at the legislation and would 'listen to the opinion of the masses' in interpreting the legislation.

Rural health insurance not working
People who live in remote rural areas of China are so poor they cannot afford to seek medical attention when they are sick,  a study from Hebei has found. More than 50% of people living in the Dabie mountain areas of Hebei said they would not seek medical care if they felt unwell. The main reason (for 38% of people) was financial difficulty. Other reasons included inconvenience and preference to self medicate. Researcher Dr Fang Pengqian and colleagues from the Tongji Medical College, Wuhan said the findings suggested that the universal health coverage from the New Cooperative Medical Scheme (NCMS) was was not working for people in poorer highland areas. They said the locals could not afford to pay the necessary insurance premiums to  cover basic care and the low reimbursement meant they faced high out-of-pocket costs.

Doctors lose, retail pharmacies win as government cuts the hospital monopoly on dispensing

by Michael Woodhead
The Chinese government appears to have side-stepped the influential doctors' lobby and the tame health ministry by using the Ministry of Commerce to tackle the perennial problem of drug sales commissions and the inflated cost of medicines.

Doctors in China rely for much of their income on commissions and bonuses from sales of pharmaceuticals, and previous efforts to curtail the profits have been stymied by medical lobby groups. The Ministry of Health, previously led by a medic Dr Chen Zhu (who now heads the Chinese Medical Association), has managed to block or delay previous efforts to tackle the drug commissions problem.

Now the government has turned to the Ministry of Commerce to introduce new rules that separate medical services and drug sales in 34 pilot cities across the country, in an attempt to lower the high cost of medicines. The National Health and Family Planning Commission (which absorbed the Ministry of Health last year) has been sidelined by the move, a sign that its own efforts at reform have failed.

Under the new Ministry of Commerce plan, major city pharmacies will replace hospital pharmacies as the source of prescription drug dispensing, putting an end to the lucrative 'gold mine' of revenue for hospitals. In theory, this will mean that hospitals should no longer pressure their doctors to prescribe more and reach quotas to boost revenue via the hospital pharmacies. And by breaking the hospital pharmacy monopoly, the new plan will lower drug prices by encouraging competition between pharmacies.

According to Caixin, previous efforts to break the drug sales-hospital income link have failed because of entrenched opposition from the former Ministry of Health. The ministry pushed a plan under which local governments purchased pharmaceuticals on behalf of local hospitals, but this scheme was ineffective in breaking the stranglehold of hospitals on drug demand and also proved to be yet another channel for corruption.

 The new scheme will also permit more pharmacies to become eligible for reimbursement under the various medical insurance system. These moves will further increase diversity and competition and give pharmacies a boost in business, commentators say. However there has been no analysis of how public hospitals will make up for the huge gap in revenue when their lucrative pharmaceutical monopoly is snatched from them.

Robot surgery for Chengdu | Aussies help with primary care | Weibo cancer medical fee man dies

Robotic surgery is now being used by hospitals in China, with the da Vinci surgery robot system completing its first operation at the Provincial People's Hospital in Chengdu. The 30 million yuan ($5 million) system can perform accurate and less invasive surgery in cases such as prostate cancer and gallbladder procedures but has been criticised by some clinicians as being an expensive system with a steep learning curve that does not offer any real improvements in outcomes compared to conventional surgery.

China is turning to Australia for advice and training in how to expand its primary health system. The National health and Family Planing Commission has asked Melbourne-based Professor Shane Thomas of Monash University to help guide the pilot programs of primary care taking place in Shenzhen. Monash is also hosting 24 Chinese health managers who are attending a leadership-training program at the School of Primary Health Care.

A Chinese man with cancer who became famous for using Weibo to solicit donations for his medical bills has died. Noodle shop owner Li Gang of Zhengzhou raised $16,000 to pay for medical treatment which he could not afford in 2012. His message went viral and he had many visitors to his noodle shop, but some commentators said it highlighted the lack of affordable medical care for most Chinese people with cancer.

Medical accidents kill more people than traffic accidents

by Michael Woodhead
In China there are about 8 million unnatural deaths every years and of these about 400,000 are said to be due to medical accidents - often due to unsafe use of medicines. To try and remedy this poor situation, September has been nominated as national medication safety month by the China State Food and Drug Administration.

According to pharmacist Zhang Jichun of the Chinese Pharmaceutical Association, this high rate of accidents and adverse reactions with medications is due to widespread ignorance in the population about appropriate use of medical drugs. A recent survey of more than one million Chinese found that only about one in ten could answer correctly questions about basic drug safe use.

The higher error rate with drug misuse included allergic reactions to antibiotics in babies and infants, misuse of drugs by pregnant women causing birth defects and adverse birth outcomes, accidental drug overdoses, misuse of sleeping tablets causing accidents, using drugs past their shelf life, taking multiple drugs and causing interactions, abuse of weight loss drugs causing cardiac problems and deaths and failing to use cardiac drugs in sufficient doses leading to heart attacks and strokes.

The survey found that there were many problems with the way Chinese people used medications. About 90% bought prescription drugs from pharmacies and self-treated without getting advice or a diagnosis from a doctor. Almost 70% did not read the package insert and a third made major mistakes in dosing while 25% did not take the medicine correctly and failed o get the expected benefit.

 Zhang Jichun said many of the problems with drugs occurred in children and the elderly, who were more susceptible to their effects. A typical and common avoidable serious problem was deafness seen in 300,000 children due to overuse of some classes of antibiotics. This side effect occurred due to parental medication without being aware of the risks.

In the elderly one of the main problems was excessive medication, he added. Many elderly people take several different drugs for various ailments without understanding that they can interact to cause severe side effects, he said. Elderly people also made the mistake of taking western medicines with Chinese traditional medications, and this could also cause problems he said.

To try address this problem the China Pharmaceutical Association has set up a "medication safety expert advice hotline” and invites all Chinese to seek advice before using medications.

How many hours a week do Chinese doctors work? Too many.

After featuring many articles from the Lancet's China-themed issue it is only right that I give some attention to an article published by their competitor, the BMJ.

This week a blog post from four Chinese doctors lamenting the long hours they have to work. According to the lead author, Dr Luo Deng (an endocrinologist at the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital) China's doctors work an average of 11 hours a day, six days a week. That's an average - not the maximum. And before you jump in and say that many doctors in other countries work those long hours - remember that Chinese doctors earn about $5000 a year.

The working hours figure comes from a survey of more than 3771 Chinese doctors, which found that 80.5% worked more than eight hours in hospital every day. The exact figures were an average of 11.22 hours per day for 5.62 days a week, with only one day off.

"On top of this, we fear that the increasing number of daily hospital outpatient visits, along with administrative or academic affairs, may further contribute to the imbalance between family and career in doctors’ lives," the doctors write.

The doctors blame the heavy workload on a huge increase in patient consultations in the last decade - up from from 1.21 billion in 2001 to 2.74 billion in 2013. During that time, hospital admissions increased nearly fourfold, but the Chinese government still spends only about 5% of its GDP on health, compared to 8.8% for Brazil and 9.2% for South Africa.

"With a generally high patient to physician ratio in most practices, and near constant patient contact throughout the workday, most physicians find it difficult to take even a short break. Even the public of China has begun to raise concerns about the physical and mental health of physicians; however, these issues probably remain unknown to much of the world," the Chinese doctors write.

They suggest, quite meekly, that the government implement "effective and efficient measures  ... to improve the health of China’s medical staff, and boost their career enthusiasm amid the stressful job atmosphere."

Smoking cessation prospects poor | Bleak outlook for foreign-owned hospitals | 500 children die of rabies every year

Smoking cessation efforts are doomed to fail in rural China unless the culture of  giving cigarettes as gifts can be broken, say researchers from the Ministry of Health in Jinan, Shandong. Their study found that although many people in rural China attempted to quit at the advice of other family members, relapses were common and few were able to quit completely because they were culturally expected to share cigarettes. The study also found that village doctors did not smoking cessation advice to all patients and there were few if any smoking cessation programs in rural areas.

Allowing foreign companies to set up and operate hospitals in China will not make much difference to overstretched health services, a leading health official says in Caxin. Lian Xinbo says the real barriers are in employment and insurance regulations which mean that foreign companies will find it difficult to attract talented doctors and also to offer services that are reimbursed by health insurers.

More than 500 Chinese children die of rabies every year, and tragically most of the deaths could have been avoided if children had received correct treatment, say clinicians from the National Institute for Viral Disease Control and Prevention in Beijing. Most of the rabies cases occur in rural areas and are due to bites by domestic or stray dogs. However, few children with rabies get the recommended treatment of post-exposure rabies injections or even adequate wound care.

Medical schools in China: outdated and unpopular

Some insider views of the Chinese medical education system have been published as part of The Lancet special China-themed issue this week. The rather gloomy conclusion is that China's vast medical education system is failing to attract good students and failing to produce graduates who are able and willing to work as doctors.

A review article notes that China made some major reforms to medical education in 1998, greatly expanding the number of students to produce half a million would-be doctors a year. However, many of these medical graduates do not enter medicine but take up other careers. Why is this? The review authors say there "is a mismatch of health professional education and employment opportunities".

Another article in the same issue of the Lancet throws further light on the lack of enthusiasm for medicine as a career: Dr Yang Pengfei of the Changhai Hospital, Second Military Medical University, Shanghai, says most doctors now advise their children against taking up a career in medicine and only 7% would recommend it. He cites the breakdown in trust and respect between patients and doctors and the tide of violence against medical staff - 30 killings in recent years by disgruntled patients and their families. Dr Yang notes that even the best medical schools such as Peking Union Medical College are now struggling to attract high quality students.

"The national admission score for a graduate student majoring in medicine has also declined for three consecutive years, according to the Chinese Ministry of Education. It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow's doctors?" he asks.

The review article says the problem of poor relations between patients and doctors is due in part to the narrow and inflexible education system that fails to instil students with the values, ethos, and ethics of the medical profession and also fails to produce doctors with good communication skills and characteristics such as empathy.

"The curriculum system still focuses narrowly on biomedicine, medical technology, and clinical practice. Pedagogic methods are rigid: mostly teacher-controlled didactic lecturing, which requires rote memorisation by students. The increase of disputes between doctors and patients, and violence against doctors in China might be associated with these deficiencies in education," it says.

Another problem with medical education in China is that it is still rigidly hospital focused and geared towards producing narrow specialists rather than generalists who can work in the community or in rural health.

"Therefore, it is not surprising that the graduates have limited knowledge about primary care services and prevention of diseases."

Will things improve in the near future? It's hard to see how, as huge class sizes are a barrier to more innovative teaching methods such as problem-based learning, and encouraging interaction and discussion.

China's medical schools may need to take a leaf from the book of China's factories. Instead of mass producing unpopular low quality products they could adapt the best foreign know-how and methods through joint ventures to produce a wider range of higher quality sought-after products.

Schistosomiasis eradication at snail's pace | Medical guinea pigs paid 10,000 yuan | DXY gets $70 million investment boost

Eradication of schistosomiasis in China is being hindered by factors such as lack of political and financial support, praziquantel resistance and climate change, say clinicians from the Jiangsu Institute of Parasitical Diseases in Wuxi. A sense of complacency has set in since the  prevalence of schistosomiasis was reduced to about 1% in animals and humans, they say. Renewed efforts are needed to ensure the final elimination of the parasite by 2020 and avoid its re-emergence, they say.

Young Chinese are signing up to be human guinea pigs in pharmaceutical drug tests and trials, being paid up to 10,000 yuan to be injected with experimental drugs. Medical students are the most popular choice for the first human trials of the 10,000 different trials run by China's 6,000 pharmaceutical firm.

China's leading medical social network site DXY has received $70 million in investment funding from Tencent, which will start to use the doctor networks as part of its services to consumers in the form of online consultations and appointment booking services. DXY will also develop new products in the healthcare area for consumers as well as doctors.