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'.