Hospitals sell off pharmacies to pharma companies

Hospitals are selling off their lucrative pharmacy operations to pharmamaceutical companies as the government pressures them to adopt zero commission policies on drug sales.
Sales of drugs account for as much as 45% of hospital revenue, but the Chinese government is forcing hospitals to separate their pharmacy units and stop profiteering from them. This week Zheng Yang in China Economic Net reports that Kangmei Pharmaceutical has bought up more than 80 hospital pharmacy trusteeships in areas such as Liaoning and Guangdong. Kangmei has signed contracts to operate the pharmacies for periods of up to 20 years, and will be responsible for the supply of all pharmaceuticals within the hospitals. The deal looks to be very lucrative for Kangmei, with revenue from just nine hospital pharmacies reported to be 1.3 billion yuan in 2013. Kangmei says it expects to make about half a billion yuan per year from each hospital, up from about 100 million yuan that it currently makes in drug sales on average to each hospital. In addition to this added revenue, the company hopes to profit from supply chain efficiencies and also from the pricing power its monopoly will bring. The report quotes Liao Xinbo, deputy director of the Health Department of Guangdong Province,  as saying that the importance of the pharmacy to a hospital is diminishing as policy measures like "zero price difference of medicine" are introduced as part of China's health reforms. Pharmacies will soon become a 'cost' rather than a profit centre for hospitals, he predicts.  Hospital pharmacies currently account for 80% of China's pharmaceutical market with a value exceeding 1 trillion yuan. 
Analysts say hospitals may enter profit sharing agreements with pharmacy owners, thus defeating the Chinese government's health reform goal of removing hospital profit incentives from prescribing of drugs. 

Dr Zhong Nanshan: what's wrong with China's health system and why we need to get doctors on board to fix it

by Michael Woodhead
Dr Zhong Nanshan is one of China's most well known and respected doctors. A respiratory physician and former head of the Chinese Medical Association, he is the 'hero' of the 2003 SARS infection outbreak, and his frank advice is respected by the government. At this week's meeting of the National People's Congress in Beijing, Dr Zhong gave a speech on the current problems with the Chinese healthcare system and the direction of health reforms.

"Today when I heard Premier Li Keqiang's announcement I was very excited, as his words provided a lot of inspiration on the difficult problems we are facing with medical reform. In recent years China's reforms of health insurance and the healthcare system have attracted worldwide attention. But from the public's point of view, there is still the problem of 'difficult to see a doctor, expensive to see a doctor'. Doctor-patient relations are still tense (as the China Hospital Association has recently made clear, hospital doctors and staff have often been the victims of violent  attacks) and hospital staff are not showing enthusiasm or initiative in their work.

For these three criteria, when it comes to health reforms there has been no breakthrough in the last five years, and in fact things have become worse in some areas. Where does the blame lie? The answer is in our major (tertiary level) hospitals.  In these institutions, doctors have not become heavily involved in medical reforms, and this problem is becoming more serious. Look at land reform: this was about the relationship between farmers and landlords, and it was based on respecting the position of the farmer, allowing them to make a living. Likewise with education reform - this was about teacher-student relations and when teachers and schools got better pay, resources and conditions, teachers got more respect.

Why are doctors not enthusiastic for health reform?

Similarly, medical reform will depend on the involvement of doctors. America's medical reforms were about respecting medical opinion and allowing the doctor's clinical judgement to drive the direction of the medical system. I remember in 2012 when Li Keqiang was deputy premier and I saw him at a meeting, and I told him that the most important point I wanted to make was that doctors must be the driving force behind medical reform. However, five years have gone by and it seems that under the present reform system medical staff can see no way in which they can change things for the better. On the contrary it seems that many of the reform programs have an adverse affect on the working conditions for doctors. For doctors it is as if society 'discriminates against them'. And under such conditions, where is the enthusiasm for medical reform going to come from?

As any changes are going to affect doctors' interests, let us first analyse the current situation in regard to doctors' incomes. It is a widely held belief among the public and some government departments that doctors' earn a large amount of extra and unjustified income through what we could call unofficial 'grey channels', and this is seen as outrageous, unethical behaviour. Therefore, before the conference I examined the accounts of the Guangzhou tertiary hospitals. These showed that in 2012 the average official annual salary of a doctor was 41,077 yuan, but the actual annual income for a doctor with all allowances, bonuses and subsidies was 176,320 yuan. For 2013, the average official salary for a doctor was 46023 yuan, but their actual annnual income was more than 190,000 yuan.

Of course this level of income is high compared to the average worker or government official, but it is low compared to the incomes of doctors in other countries. It may therefore be said that this level of income for doctors is reasonable, especially when this extra income comes from government policies as they are applied in hospitals. Here is a typical example of how state-owned enterprises operate to improve performance: hospitals want to increase their income so they increase the number of beds to accept more patients and they increase the number of procedures and tests. On my ward rounds I see many patients who are having unnecessary tests and procedures. One of the main reasons for this is that doctor's income is linked to irrational medical practices - this is a major contradiction within our health system.

Reward doctors for their skills, not for how much they prescribe

My second major point is that a doctor's economic labour value is not reflected in medical fees in China, which are far too low. A doctor's economic value should be related to their ability to diagnose and treat and their ability to give individual attention to a patient based on their skill and knowledge. Unfortunately, in China this is not the case. In the rest of the world a doctor's income depends on their clinical skills, whereas in China a doctor's income is linked to how many drugs they prescribe and how many tests and treatments they order. It is not surprising then, that in China doctors' credibility is called into question. But rather than blame this on a doctor's ethical flaws, we should recognise that this is due to hospital policies that prioritise income and profit and skew the doctor's working patterns.

Too many patients, not enough time

My third point is related to the tense situation in doctor-patient relations. I believe this is 80% due to the difficulty that patients have in accessing a doctor. Owing to the way hospitals operate, doctors are given quotas of numbers of patients to be seen each day. If they do not meet the targets for numbers of patients treated, they miss out on their financial bonus. In other words, the more patients they see, the better. Thinks about this: in half a day a single doctor must see fifty or sixty patients. What does this say about patient access to a doctor and the doctor's 'space' to practice good medicine? The reality for patients is "wait for three hours to see a doctor for three minutes". That just isn't enough time for a proper consultation, and as the consultation time shrinks, the strained relations between doctors and patients increase.

These days in a bid to exploit 'resources' to the full, hospitals are always seeking to increase their bed numbers and they open 'branch hospitals' to increase capacity. While in theory this increases the opportunities for the population to get treatment, the reality is that this increases the hospital income. And the other aspect is that doctors are 'running to exhaustion' trying to treat ever higher numbers of patients. This is not a sustainable model for providing for a community's medical needs.

So we have doctors who see that the government health system cannot provide them with a basic income in proportion to their work and skills. They thus see no benefit from medical reforms so far: they have a negative view, show little enthusiasm and no initiative towards medical reforms. Therefore, as the public should be the target for healthcare reforms, I could set the theme of my speech today as: "Discard doctors as driver of health reform: don't let the medics change the medical reform."

Principles: the need to put more value on health

The way to solve these problems is to change our principles. Today I especially appreciated hearing Premier Li Keqiang's remarks that: "For existing problems the government should look within itself for the causes." I think for health reform we need to look within the health system for the causes of the problems.

Firstly, within both government and society we need to develop a respect for life, to treasure life and health. And if we are to attach importance to preserving life and health we must invest in the health system. From 2005 to 2012 our country made great efforts in health and increased funding for health from 3% to 5% of GDP. However, this is still a lower level of health funding compared to developed countries - in fact we spend less on health by GDP than Afghanistan does. Developed countries spend between 8% to 15% of GDP on health, and we need to aim for that.

But we can't just think of health in economic terms. Health reform must start by putting health and life as a first priority for society. At present in Chinese hospitals the economic value of the healthcare staff is very low compared to other countries. The incomes  of public hospital medical staff are very low and should be higher. Other countries have managed to create good public hospitals systems, why can't we?

Use public insurance funds to improve health services

Of course China has a huge population, and we can't expect our public hospitals to immediately become public welfare providers for everyone. We have to look to the health insurance system for the potential to do that. Since 2011, the national health insurance scheme has been meant to guarantee access to medical treatment and medicines. However the system is fractured and un-coordinated, and those benefits have not been realised. Since 2009, the rural medical insurance scheme has shown good results but these have not been seen with urban insurance schemes, which still have major problems.

Health departments lack the management skills to oversee these schemes, and although the public have paid a lot into these public insurance schemes, the benefits have not been taken out. We should look to these accumulated health funds as resources to fund health reforms. We need to focus on the supply side, not just on patient input and demand. If doctors show good performance they should be rewarded for providing more services. Hospitals should be able to use this insurance funding as a lever to deliver more and better services - but currently the health insurance funds are out of their control and managed by the social welfare department.

The social welfare department does not accept responsibility for health reform and this is a major obstacle to reform of public hospitals and the way that funding is raised, dispersed and linked to performance of the public hospital system. In 2010 there was something like a 7 billion yuan surplus in health insurance contributions - why is this surplus not being used to boost the public hospital provision of services? The health department does not have funding for hospitals - this system needs to be changed - as in 70% of foreign countries where health departments manage public hospitals.

Hospitals should be centres of excellence

Finally we need to improve the education and culture of healthcare staff. We need to have a system based on merit. In most countries, large hospitals are centres for medical expertise and do not deal so much with common, everyday problems. These are dealt with by family doctors or community clinics. Last year the government's health working group made the creation of community clinics and hospitals a priority. I strongly approve of this. Through investment the government should improve the skills and the remuneration and conditions for community clinics and local hospitals. I think the technical and management skills of small hospitals and clinics should be nurtured and overseen by tertiary hospitals, which take responsibility for community clinics. In this way the standard of local clinics could be increased to allow them to cover the same scope of basic care as tertiary hospitals within 3-5 years.

In summary, across the world, the medical profession is regarded with respect in most countries, but China is the exception. The economic value of medical personnel has been degraded, and until this is restored they will not be at the front of driving health reform. The medical staff of Guangzhou University Hospital have great underlying enthusiasm for health reform - it just needs to be shown that reforms will bring them benefits and respect, for them to be positive and actively support them, I believe. I think that in this respect Guangdong doctors will be at the forefront of reforms. We will work together to fulfill what Li Keqiang described as "a solution with Chinese characteristics to the difficult problem of health reform."

Editor's note: This is my translation of Dr Zhong Nanshan's speech that was made at the NPC meeting in Beijing on 5th March, 2014 and published in the People's Daily. It is not a perfect translation, but I have covered the main points as best I can. If you see any errors I will be happy to correct them. The original can be seen in Chinese here.

Why Beijing's plans to privatise medical services get a lukewam reaction from China's doctors

by Michael Woodhead
Beijing is one of several cities that has recently announced plans to encourage doctors working in public hospitals to set up private clinics. The government used the socialism-friendly euphemism "social capital" for the private capital investment it wishes to attract for establishing new medical facilities. 
However, the plans come with a few strings attached, which will deter most doctors from even thinking about setting up private clinics. Firstly, the city also announced that Beijing already has enough medical clinics in the central area, and it will only permit new clinics to be set up outside the fifth ring road. It also stipulated that only experienced doctors who hold the grade equivalent to 'associate professor' would be able to set up the new private clinics.
The reaction from doctors has been underwhelming and many have questioned how such a monumental change in the current system will be implemented. In theory, the new proposals will "free up" doctors to better serve patients in more flexible ways. Doctors however, have described these predictions as wishful thinking.
Firstly, the number of senior doctors who qualify to set up new clinics is only a small proportion of the total number of working doctors. These senior doctors are in short supply and they are the backbone of the current public hospital and medical school teaching system. How will the system cope if these doctors leave to devote their time to private clinics?
Doctors say that if a new layer of private clinics is to be established, there needs to be a plan for how patients will be managed in public hospitals. If the privatisation plan is to succeed there will need to be a move away from large hospitals treating minor illness, and these functions being taken over by local clinics. Big hospitals will have to become specialist centres with expertise in treating serious diseases, they say.
In places such as Hong Kong and the US, there is a long tradition of doctors working in private clinics as well as in public hospitals. How will China manage this balance? In the US, for example, patients can only get their medical fees reimbursed if they go to a  doctor approved by the insurer or government, and the doctor and clinic must have acceptable quality and safety standards - how will China manage such a system? In addition there needs to be safeguards that private clinics will operate in an ethical manner. In western countries there are a range of professional associations and health department systems to define and oversee standards. With new private clinics in China there is also a danger that they will inherit the 'prescribing for profit' and overservicing practices of some existing hospitals in an effort to increase revenue, doctors warn
In reality, there is also a big difference between the government 'permitting' and 'encouraging' doctors to set up private undertakings. As anyone in China knows, running a private enterprise can involve a lot of 'mafan' (trouble) - and that 'mafan' can also mean paying out a lot of money. How many experienced doctors will be prepared to take on this risk?
These are just a few of the doubts that doctors have expressed about the new proposals for private clinics in China. They say "jumping into the sea" of private enterprise is a huge step for a doctor to take - there are so may unanswered questions and risks that it will need more than just "permission' from the government to make them do it.

All health departments to undergo financial audits

The National Health and Family Planning Commission (NHFPC) has announced that all health departments will undergo more stringent financial audits to promote a healthy organisational climate. The NHFPC said the audits will look at financial management and also at areas such as personnel in health departments and their subsidiary agencies. The NHFPC warned that any departments that resisted or obstructed auditors, covered up or provided false or misleading information would be severely punished.

Infusion madness: patients in Nanchang hospitals consuming gallons of IV antibiotics

by Michael Woodhead
Health experts in Nanchang, Jiangxi have admitted that their city's hospitals are some of the worst offenders in China when it comes to the practice of allowing patients to unnecessary IV infusions. 
In a country where the average person consumes eight bottles of IV infusion fluid per year, Nanchang is above the national average. Dr Yuan Zhaokang, head of the Nanchang University department of public health, says 90% of people are not aware of the risks and harms of IV infusions and yet between 60-70% of people in outpatient departments are given them. Of these patients, 75% don't need the infusions and could be given oral medicines instead. Dr Yuan says China's rate of IV antibiotic use is10 times higher than the international average, meaning that most intravenous antibiotics given in China are unnecessary.
In theory, the public are told that they should not have an injection when an oral medicine will suffice, but in practice in China this order has been turned on its head, Dr Yuan says.
A Sichuan emergency medicine director, Dr Zhen Tao says he opposes routine use of IV drips for people with colds, but it is hard to change the public mindset.
"People believe that IV infusions are more effective and work faster than oral medicine - but they are wrong," he says. Given a choice, patients always demand "infusion first", and few are aware that this directly contradicts the WHO advice for "never give an IV infusion when an IM injection will suffice, and never given an injection when oral medicine will be sufficient".
While this message is slowly getting across to more educated adults, the situation for children is getting worse, says Dr Zhen. Whenever the weather gets cold or the season changes, the hospital's infusion room is crowded with children who have colds who are attached to IV infusion bottles.
A common cold is a minor viral illness - so why do all Chinese insist on having unnecessary antibiotics by intravenous infusion? Dr Zhen says one reason is the pressure from parents with 'inflexible' thinking and attitudes. Another reason is that hospitals make money from infusions.
"Families want a quick cure-all and hospitals want a quick profit. When these two factors come together the result is bad medicine," says Dr Zhen.
The craze for children to have infusions especially worries Dr Zhen because he says it can weaken their health. Antibiotics not only kill pathogens, they also kill the 'good' bacteria that children need for developing an immune system and digestive health, he says. This is especially so for children who have repeated infusions, which become a vicious circle, where more treatments are requested because the child gets sicker and more prone to infections.
As well as increasing antibiotic resistance, IV infusions of antibiotics often cause many other serious health problems, including life-threatening anaphylaxis and other allergic reactions, phlebitis and injection site reactions, circulatory overload and heart failure as well as pyrexia (high fever), Dr Zhen warns.
The only people who really need IV infusions are those who have swallowing disorders, gastric malabsorption problems and the acutely  critically ill patient, he said.

Eight medical stories from China you should read

by Michael Woodhead

1. Beijing will start to enforce new anti-smoking laws with 200 yuan on-the-spot fines (up from 10 yuan) for people who smoke in public indoor shared areas, and institutional fines of 30,000 yuan (up from 5000 yuan). Cameras will be used to compensate for the lack of enforcement officers, especially after hours, the city government says.

2. The Chinese government has been accused of withholding medical care from dissidents. An article by Sophie Richardson in the WSJ says civil rights campaigner Cao Shunli is now in intensive care because she was denied access to medical care while detained for her efforts to promote a civil society.

3. A link has been found between damp housing in Shanghai and rates of asthma in children. Researchers from the University of Shanghai for Science and Technology say asthma symptoms could be reduced by 25% by simply keeping a child's window open at night.

4. A vaccine against enterovirus 71 developed by Sinovac Biotech has proved effective against EV71-associated hand, foot, and mouth disease or herpangina in infants and young children, according to a study in 5000 children done by the Jiangsu Provincial Center for Disease Control and Prevention, published in the New England Journal of Medicine.

5. Eating shark fin is not only cruel and bad for the environment, it is also a health hazard because of high mercury levels in the product, researchers from Zhejiang have shown. After testing samples of shark fin they found that up to 33% contained toxic levels of mercury.

6. Antibiotics are widely overused by parents in rural China, with more than 60% dosing their children with antibiotics bought over the counter, Shanghai researchers have found. Most parents were ignorant about how antibiotics worked and had little idea hat they do not help viral infections.

7. Migrant workers have little access to healthcare and many of them put off seeing a doctor for illness, a survey in Shanghai has found. Two thirds of migrant workers said they had never had a medical check up and nearly 40% said they had ignored symptoms because they couldn't get to see a doctor.

8. Health workers in Guangdong have completed a successful pilot trial of a cervical cancer screening program using the ThinPrep cytological system. The program offered Pap test cancer screening to more than 40,000 women, and found that improvements are needed in basic education regarding cervical cancer screening for young and poorly educated women.

Poultry industry demands 'avian' be dropped from H7N9 influenza virus description, threatens legal action

More than a thousand poultry breeding and trading companies have signed a petition letter calling on government departments to stop using the term 'avian' in respect to the H7N9 influenza virus, saying the link has caused catastrophic losses to their industry.
The letter organised by the China Animal Husbandry Association says that 'avian flu' is not an official term used by WHO and should not be used by ministries such as the National Health and Family Planning Commission.
The companies said the warnings about live poultry had caused panic among consumers who shunned the products, leading to a billion yuan in economic losses fr the industry. The poultry industry leaders said ther use of the term 'avian' was irresponsible and unscientific and should not be used. They said if ministries did not stop using the term they would take legal action to force them "to safeguard the rights and interests of the industry members".
The industry association also called on the government to take immediate measures to save the poultry  industry.

Urgent action needed on alarming rise in HIV rates in gay men in China

by Michael Woodhead
Rates of HIV in gay men in China are increasing dramatically, and many of them are passing on the infection to wives in sham marriages, a study from Beijing has shown.
The prevalence of HIV in the gay community is now as high as 10%, up from only around 6% in 2006, showing that urgent action is needed to contain the infection, according to researchers from the National Center for AIDS/STD Control and Prevention at the Chinese Center for Disease Control.
In a study of HIV rates in samples of 500 gay men from 2009 to 2011 they found that the overall prevalence rate was 8%. The incidence increased from 2009-2010 from 6.8 to 11.2/100 person years and then declined to 5.8/100 person years.
The main risk factors for HIV infection were being bisexual (ie living with a woman in a  marriage of convenience to avoid the family stigma of homosexuality), recently arrived in Beijing, and a negative attitude to safe sex. Between 40-50% of gay men reported having recent unprotected sex but only about a third said they knew the HIV status of their male partners. Up to 20% of gay men had female partners and about 75% of sex with women was unprotected sex
The researchers said the "alarmingly high HIV prevalence" showed that urgent action was needed to stop HIV spreading beyond the gay community.
"The findings from these three consecutive surveys signal the beginning in changing the landscape of the HIV epidemic in China," the researchers said. "HIV transmission has begun to shift from the historically main transmission route, intravenous drug users, to populations at risk through unprotected heterosexual contacts or male homosexual sex."
They added that their findings "underscored the urgency of increasing effective and better-targeted intervention services to stop the rapid spread of the virus, which includes risk reduction education, condom promotion and distribution, encouraging early and frequent HIV testing, and expanding the coverage of HIV prevention measures. These interventions will help curb the spread of HIV infection inside and outside the [gay] population."
The study is published in Biomed Research International.

Crackdown closes 5088 illegal medical clinics

by Michael Woodhead
A national 'strike hard' campaign against illegal medical practices has resulted in more than 5000 'black clinics' being shut down and many fake doctors being unmasked.
The crackdown, which was a collaboration between numerous government agencies including health departments and police, followed up more than 30,000 complaints from the public. It resulted in 964 criminal prosecutions against individuals and the cancelling of clinic licences for 121 child clinics and family planning facilities. The campaign to 'tidy up and restore order' in the medical field also resulted in 760 criminal cases for fake clinics and the breaking up of 22 criminal gangs involved in running them. The clinics included sex-selection abortion clinics, cosmetic surgery practices and health spas. The crackdown also saw the closure of fertility clinics and unmasked foreign-trained doctors operating without authorisation in China. It also closed down 46 clinics and health stations falsely claiming to be run by the PLA and saw the dismissal of 164 bogus PLA medical workers. The campaign resulted in fines of over 63 million being imposed, and a positive feedback from the public.
The six departments involved will continue and widen their investigations into fake medical practices and illegal medical clinics.

Medical sales bribery: offenders to be named and shamed

by Michael Woodhead

Companies and individuals found to be involved in bribery related to the sales or purchasing of medical and pharmaceutical supplies will be banned for two years and their details added to a public blacklist, the National Health and Family Planning Commission has announced.

From this year, all provincial health departments will be required to investigate and take strong action against bribery in the purchasing and sales of medical products the NHFPC says. Offenders must be listed publicly on a 'blacklist' that is made available for the public on the website of the provincial health department. Details must be added within 5 days of  being found guilty, and the offenders will be banned from buying or selling medical goods to public hospitals and clinics for a period of two years, the NHFPC statement says. The national office of the NHFPC must also be notified of any bribery cases within one month, and it will compile a summary at the end of the year.

Doctor defamed online by spurned patient

A well respected ophthalmologist at a Chengdu hospital was slandered online by a patient who claimed that he was unethical and had discriminated against her daughter. In an 'exposure' on an online forum, the female patient said her daughter had been refused treatment by a Professor Liu, who discriminated against her because she was a single mother and yet he consented to treat other patients who were less deserving than her. On a popular social media site the woman said the professor had no ethics and she warned that he discriminated against common local people. The post stirred up a lot of angry debate about the ethics of the doctor.
However, when reporter from Sichuan Online followed up at the hospital he heard a very different story. The staff said the woman was impolite and demanded treatment despite not having registered at the hospital. Also she had no medical records and her case was not urgent. A patient from Yunnan was seen instead as their case was urgent and because they faced extra expenses if the case was delayed until the following morning.
Professor Liu said he personally intervened after the woman  argued with nurses. He said it was reasonable in a busy clinic to ask the woman to return when she had her medical records. The other case was more deserving. A security camera recorded the woman acting aggressively and knocking over billboards and items on a table in rage.
However, this story was not told online, and the social media site was led to believe that Professor Liu was an arrogant and uncaring doctor with no ethics. His name has been blackened. Nurses and staff at the hospital said he was a caring and hard-working doctor who often stayed until 9pm at night to ensure that all patients in the waiting room were treated.

Beijing to allow doctors to set up independent private clinics

The Beijing health department will for the first time allow doctors to set up their own clinics funded by private investors. At its annual work meeting the health department announced that doctors may now apply to set up private clinics. The new policy will require alterations to the current sustem of doctors remueration and the personnel assigment system for the healthcare system, the department said. It will require changes in the way public hospital departments employ doctors and also changes in work contracts

Nanjing Hospital nurse and doctor injured in attack by top official

by MichaelWoodheadA dispute over male and female patients being forced to share the same ward is supposedly the cause of an attack by a senior Nanjing official on medical staff that left a nurse paralysed.
A nurse has been severely injured in what has been described as a vicious attack by a senior female official who is head of the Jiangsu Science and Technology Institute. The incident occurred on 24 Feb at the Nanjing Stoma Hospital when a young man was brought in for emergency surgery for a bleeding cyst. Because the hospital was full and had few vacant beds, the young man was allocated to a female ward to recover from the operation, and was to be moved to a male ward when a bed became available. However, when he woke from the anaesthetic and realised where he was he called his family and they hurried to the hospital to demand that he be moved to a male ward. When a nurse said this was not possible she was beaten by the mother of the young man. The nurse was beaten with the handle of an umbrella and the attack was so violent that the handle snapped. The nurse received severe injuries to her chicest and was left paralysed in her legs and unable to move. A doctor on duty was also assaulted and severely bruised.
The official is now under investigation by local police. However, the incident has been widely reported on social media sites such as Weibo, with many saying that it is typical behaviour from arrogant and privilege officials. The young man's father is an official in the Nanjing procurator's office and many doubt the injured nurse will see justice for those who attacked her.

3 medical tales from China: the good, bad and the fake

by Michael Woodhead

Hospital performance pay system revealed

Hospitals in China are adopting performance-bonus schemes for their staff based on a concept called the balanced scorecard (BSC) according to an academic paper in the Health Policy and Planning. Researchers from Jinan in Shandong did a literature search and found details of 90 hospitals that had adopted the scorecards for staff as a way of improving performance, staff motivation and patient satisfaction. The hospitals typically compiled the score cards on a monthly basis at a department level and the score systems were usually linked to increasing hospital revenue.  A scorecard might also measure parameters such as operations management (eg bed utilisation), patient satisfaction, learning and attitude to work. The score card-based bonuses were generally well accepted and had become an important part of the staff income, the study found.
(Some interesting facts revealed in the study: China has around 20,000 hospitals, but hospitals receive only about 10% of their operating costs through government subsidies. And medical salaries are low, only about 12% above average earnings.)

Shanxi Hospital swindling exposed

A hospital in Taiyuan, Shanxi is under investigation for swindling women through 'special offers' for treatments including abortion. The provincial Price Bureau started an investigation of the Yellow River Hospital after receiving complaints from women who said they had been charged much more than advertised and had not received the services promised. In one case, the hospital held a special 'Women's Health Week', during which time they offered a special price of 480 yuan to perform painless abortion and IUD insertion. However, women who used the hospital services said they were charged 4288 yuan, not 402 yuan. Part of the excess fee was for 'educational materials' that were widely available elsewhere and cost just a few yuan. The hospital also offered ultrasound scans for for 10 yuan, but women said they were forced to pay 120 yuan. One woman was told she needed magnetotherapy and microwave therapy, for which she was charged almost 10,000 yuan, but no doctor had recommended them. A spokesman for the hospital said the women's health price offer was only available during a certain period and the women in question had treatment outside those dates.


Rat poison kebab death: the fake hospital rumour

A story doing the rounds on Weibo claims that a 12-year-boy has died in a Hangzhou hospital after eating a  rat poison-tainted meat kebab bought from a street stall. The post purports to come from a  doctor at the hospital, who said the boy had a massively increased prothrombin time (known as an INR) of 150. The usual range is around 2-3. The post has been widely circulated, with many netizens commenting that it shows yet again that food in China was unsafe. However, when a reporter contacted the hospital he found there had been no such patient. A doctor said he had heard the rumour being attributed to many hospitals in China, most of which proved to be fake. However, he said there had once been a genuine case of rat poison-tainted food ingestion at the 301 PLA Hospital, but had not been fatal. It was true that rat poison could cause bleeding problems because it was based on the blood thinner warfarin. His general advice was that truth or rumour, it was best to be prudent about eating food from street stalls.

Human-to-human transmission of H7N9 reported in Shandong family cluster

by Michael Woodhead
A probable case of human-to-human transmission of H7N9 avian influenza has been reported by researchers in Shandong province investigating a family cluster of the infection.
A 36-year-old man who developed the infection in April last year in Zaozhuang seems to have transmitted the H7N9 virus to his four year old son, according to Dr Liu Ti and colleagues from the Shandong Provincial Center for Disease Control and Prevention. Writing in the journal BMC Infectious Diseases, they describe the case histories of the family cluster, and conclude that the son had no exposure to poultry as a source of infection but had prolonged contact with his sick father.
The father became infected with H7N9 avian influenza in mid April, possibly from being in proximity to poultry markets, they found. He had no close contact with poultry but there were poultry farms and markets in the area where he lived, the found. The "index case" developed a severe fever and sought medical help. His son became infected seven days later, but he had no exposure to poultry as he remained at home with his sick father before the father was hospitalised with pneumonia. The son had prolonged, close contact with his father, including eating together, and he also became infected with H7N9 and was hospitalised. Both father and son eventually recovered from H7N9 infection and were later discharged from hospital.
“The infection of the index case probably resulted from contact with environmentally contaminated material. For the son, the probable infection source was from the index case during unprotected exposure, but the possibility from the environment or other sources could not be completely ruled out,” the researchers said.
“Though it is difficult to ascertain the infectious source for the two cases, the emergence of H7N9 clusters requires urgent attention because of the possibility that a change in the epidemiological character could spread more easily among people,” they concluded.

Today's medical news: an idiot and 'special care' patients

by Michael Woodhead
"Medical staff are incompetent and deserve to be cut with a knife" - that's the opinion of TV personality Wang Mudi who is described as a Guangdong TV finance news presenter and producer. He made the remarks on Weibo after  he took his girlfriend to a hospital to have treatment for a skin allergy. Mr Wang took his "Little Bunny" to have an IV  'infusion' (the Chinese cure for everything - oral drugs are seen as inferior) for the rash on her hands. Unfortunately, the nurse at the hospital took four attempts to find a suitable vein for the IV line, causing the girlfriend much pain and distress. Wang complained online to his 370,000 followers about the nurse's insolent attitude and said he would like to chop someone with a knife. His remarks drew a lot of negative feedback online in light of recent attacks on medical staff - including he killing this month of an ENT surgeon in Heilonjiang. Wang later apologised on Weibo and tried to justify his remarks by saying the nurse had been chatting away to someone else and didn't seem to care - and didn't apologise either. However, doctors and nurses said Wang's remarks encouraged attacks on medical staff and he wasn't fit to be on TV.

From 'red envelopes'  to 'special needs'
Following on from my post about red envelopes and the culture of bribery and connections in Chinese medicine yesterday, the business magazine Caixin has a timely feature on China's "special care patients" - a euphemism for super rich. The article describes how most hospitals have a special wing for the wealthy, in which money can buy you a luxury private room complete with big-screen TV, plump cushions and an attentive nurse - and of course attended by the top surgeons. The VIP medical suites are thriving and they are one of the main ways that public hospitals can make money. A State Council decree in 2009 ordered them to take up no more than 10% of a hospital's beds, but critics say the VIP sections of hospitals are unlikely to be cut back. Caixin quotes Xu Shuo, deputy chairman of the Chinese Medical Doctor Association, as saying the suites are a symbol of the growing wealth inequality in China and will eventually have to close - or become a bridge between public and private medicine. However, critics say the private wings are simply too lucrative for both the hospitals and the doctors who work in them to disappear.

And in other news:

She's back ...
Mianyang's Corridor Doctor whistleblower Lan Yuefeng is featured in ChinaSmack. The site provides some pictures of the strike and public protest by her former colleagues who objected to her criticisms of the hospital from which she was sacked. Interesting comments from Chinese netizens and also western readers, most of whom side with the 'whistleblower', even though the staff say she is an attention seeker.

Smog and superbugs
Meanwhile, the smog continues in Beijing - and a story in the local news says that a Tsinghua University research team has found more than 1,300 species of microbes in it. Most of the bugs are harmless, but a small number are pathogens, according to the report.

Abandoned babies
And in Guangzhou, authorities are to announce new rules to deal with the "malicious abandonment" of babies after a dead baby was left outside a recently constructed "baby hatch" in the city, it is  reported. The baby hatch was set up by authorities to accept abandoned infants.  An autopsy will be carried out on the dead baby and if it is found to have had disease, the parents could be accused of intentional homicide, police say.

Beijing respiratory wards overflow with smog-related illness

by Michael Woodhead
The heavy smog that has hung over Beijing for days has seen many patients turn up at the city's hospitals with respiratory complaints. The Sino-Japanese Friendship Hospital was overflowing with patents on infusions yesterday and respiratory specialists said the worst was yet to come. The infusion room, where patients are given IV infusions was 100% full and there was an overflow 'ward' in the outside corridor where camp beds had been set up to cater for the extra patients and their families. Doctors said most of the patients had conditions such as pneumonia. The director of respiratory medicine at the hospital, Dr Lin Jiangtao said he expected the problem to worsen over the next week as the adverse effects of the smog tended to be delayed. The patients most affected were those with chronic obstructive pulmonary disease, asthma and heart disease, he said. The accumulation of pollution particles in the lungs tended to cause bronchoconstriction and chest tightness and other breathing difficulties, he said. The exact mechanism was not clear but China was now starting studies to investigate this process, he said.
Authorities in China said this week that one seventh of the country was covered in the thick smog and it was expected to last for about five days.

Why the ban on "red envelopes" for doctors won't work

by Michael Woodhead
China's National Health and Family Planing Commission (NHFPC) this week announced further restrictions on the use of red envelopes or 'hongbao' (bribes) by doctors. 
From May, both patients and doctors will have to sign an official undertaking or contract within 24 hours of hospital admission, stating that neither side will give nor receive red envelopes, money, gifts or other inducements as part of the treatment process. A ministry spokesman emphasised that the doctor-patient agreements are part of a wider contract in which the doctor also pledges to respect the patient's autonomy, privacy and informed consent, and the agreement requires the clinician to do his or her utmost for the patient. Conversely the patient pledges to respect the medical staff, scientific medicine and to act in an orderly and civilised manner. The ministry says phone complaint lines will be set up to allow authorities to be notified of any infringements of the agreements. They say the new contracts are intended to clean up the medical system, create a professional medical system and to build harmonious doctor-patient relationships.
However, the proposals have been met with cynicism and doubt from those working within the healthcare system. A Xinhua journalist interviewed several doctors, nurses and hospital managers and was told that the plans were unrealistic and unworkable.
A manager at a major hospital said that on the surface, public and private hospitals already prohibited the giving or receipt of 'red envelopes' but the use of favours and connections was a common practice under the surface.  "What doctor would dare to say that he had never received favours, especially the surgeons!" he said. "The red envelope system is an invisible system and a piece of paper from the health ministry isn't going to change it," he said.
Some patients said they believed they had to give small tokens of appreciation to be able to get to see a doctor or to see the best doctor - and also to ensure that the doctor did their best. But doctors interviewed by Xinhua dismissed these claims, saying they would do a good job for all patients and were unlikely to do poor work just because gifts had not been received. However, doctors did admit off the record that guangxi - 'connections' - played an important role in getting prompt and good treatment. They said junior doctors worked hard and had many patients to see, and it was unlikely that red envelopes would make a difference to the way they worked. If a doctor actively solicited red envelopes then that was clearly immoral and he deserved to be caught and punished they said. However, in their clinical practice doctors said they observed that patients and families often wanted to give tokens of appreciation after the treatment was successful - was it normal or wrong to accept such gifts if they were given with gratitude? One doctor said such gifts could be anything from 200 yuan to as much as 10,000 yuan, and he had once been offered a car worth 200,000 yuan by an elderly man whose life he saved.
The main influence over doctors was not from strangers giving bribes but from 'acquaintances' who squeezed them for favours, he said.
Top specialists were much in demand, and it was common for them to give priority to 'friends' who had connections, he said. This kind of favouritism didn't mean that doctors literally had money put in red envelopes or even deposited into their bank accounts - it was more subtle than that. Such favours for connections usually were repaid in kind, he said. He knew one example where a surgeon helped a well connected man and in return the doctor's son was able to gain entry to a good university. How would the new ban on red envelopes prevent something like that?
Another common area of favouritism was in private and personal 'extra' treatment. It was not uncommon for doctors to do 'private calls' and give private clinics for those who could afford it - and for those who could do them favours. This kind of 'private practice' meant that those who did not have money or connections missed out, of course.
The doctor said this kind of thing happened because there was simply a shortage of medical specialists and resources. "There are too many patients and not enough highly skilled doctors.  China has 20% of the world's patients but only 2% of the medical resources, and no law about red envelopes will change the situation until that imbalance is fixed. It's the system that is the problem, not corrupt doctors," he said.
A nurse said that the new regulations would stop the visible giving of gifts, but that wasn't a common occurrence anyway. "Who of us in hospital depends on red envelopes?" she laughed. "It's the unwritten rules that need to be changed," she said.

Chinese people with diabetes have poor insulin injection techniques

by Michael Woodhead
People with type 2 diabetes have poor insulin injection techniques that cause bruising, bleeding and lumps in the skin, a Nanjing study has found.
A survey of the injection techniques of 380 patients with diabetes from 20 centres across China found that their injection techniques with insulin pens were poor and they often re-used single use needles.
The survey found that 36% of patients had lipohypertrophy (fatty lumps under the skin) and 57% of patients had bleeding and bruising, and abdominal lipohypertrophy at injection sites. The re-use of single use needles was a major factor in lipohypertrophy, and there was also a link with rolling the insulin pen while pulling out the needle after injection.

"The bleeding and bruising at the injection sites may be associated with suboptimal absorption of injected insulin. Improved education in optimal insulin injection technique, including reducing needle reuse and correct rotation of injection sites should be emphasized, the researchers concluded..

The study was conducted by Lou Qingqing  and Ji Jiajia at the Jiangsu Province Hospital, Nanjing. The findings are published in Current Medical Research and Opinion.

Heavy rainfall and floods to blame for resurgence in leptospirosis in China

by Michael Woodhead
An outbreak of leptospirosis in Sichuan in which six people died shows that the disease spread by water contaminated with rat urine is far from eliminated in China.
The 26 cases of leptospirosis reported in Lezhi country east of Chegdu in 2010 were analysed by researchers from the Department of Medical Microbiology and Parasitology, Institutes of Medical Sciences, Shanghai Jiaotong University School of Medicine.
They found that the cases were caused by the parasite that is typically spread from rats to humans via the urine and other hosts such as domestic dog and cattle. The researchers noted that local farmers in Lezhi collect rainwater in the farm land for rice plant. And in the harvest season, men and women, old and young all work barefooted in the farm land. 
The infection is caused  by a spirochaete bacterium and signs of the disease may vary from mild fever and jaundice to very severe and often fatal kidney, liver, and heart failure.
The leptospirosis outbreak coincided with periods of heavy rainfall and flooding they noted.
"This outbreak has reminded us that leptospirosis should not be neglected, especially during flood season," they concluded.
They reported their findings in the Biomedical and Environmental Sciences journal.