My January news blog ...

Regrettably, I am cutting back on my blogging about China medical news this year. I've been doing this for more than a year now, out of enthusiasm and my own personal interest in the area, but it's becoming too much of a burden on my time. And of course it is all unpaid. Unless there is a sponsor out there who wishes a regular stream of China medical news? After my day job doing much the same thing about Australian medical news I find it hard to sit down at home and do the writing for this blog. So from now on I shall probably only update the site about once a week. That is not enough to cover the many things happening in healthcare in China, but that's your lot. As they say in Yorkshire, you don't get owt for nowt.

This week I have been reading about how patients in Shanghai with chronic diseases will now be able to pick up their repeat prescriptions from community clinics instead of the big hospitals. It's a move intended to relieve the overcrowding at the tertiary hospitals and sounds like an obvious and sensible idea. Whether it will work or not depends on whether China's hospital-obsessed patients can be persuaded to show up at the low-status community clinics.

There are also moves to try curb China's high levels (approaching 50%) of caesarean section intervention in pregnancy. A feature article by Yang Wanli describes how some obstetricians in China are trying to persuade women to opt for natural birth. However, the barriers are a lack of available analgesia for women in labour and the industrial production-line mentality of China's hospitals.

Rural health is a major issue in China this month, with the State Council approving a plan to boost the rural medical workforce. The Council wants to see rural areas of China have qualified doctors replace the current 'barefoot' practitioners. However, well-meaning intentions will not fix the huge rural medical workforce problem in China. The simple problem is that university qualified doctors do not want to work in rural villages. The pay is pathetic, there is no status and the workload is high. As this article shows, the current rural medical workforce is mostly unqualified and often dangerously lacking in skills.

That's not to say that rural health is completely hopeless in China. There have been great achievements in some areas of public health such as immunisation and basic child health. However, as a major article by Chinese paediatricians the Archives of Diseases in Childhood shows, the next step for China is to try reduce the incidence of more complex diseases in children. China has done well in tackling the easily preventable causes of child disease, now it must turn its attention to the difficult stuff - the consequences of preterm birth, and the many congenital and metabolic diseases.

One problem with monitoring China's progress in child health is knowing whether or not the official  figures are true. Take measles vaccination for example. According to official reports, China has 95% measles vaccine coverage of infants. But when researchers analysed the causes of measles outbreaks in Hunan and Jiangsu that affected hundreds of children they found that the actual rates of measles immunisation more like 80%.

And finally, for those who put their faith in western healthcare companies helping improve the health of China, take a cautionary look at the sorry tale of GSK. A well regarded company in the west, GSK was the subject of high profile bribery allegations and a court case that jailed one of its British executives for  his role in the bribes to doctors and hospitals. Now the company is reported to be cutting the jobs of 1000 employees in China following the downturn in its business there (including a 60% drop in revenue).

Lost post

I just spent an hour writing a great article about the Chinese government's moves to encourage public hospital doctors to work in private practice. But my internet browser crashed and I lost it.

Short version: there is little enthusiasm for this move by doctors because of the practical barriers: pensions, medical indemnity insurance and new contracts on working hours/remuneration. Also barriers because public hospitals don't want to lose their 'talent' and see the same doctors working in 'competition' against them (not to mention the conflict of interest this creates). And importantly for doctors, their careers are determined by the public hospital system, from which they get their experience, evaluations, academic training and status.

Conclusion: Moving to more flexible public/private working arrangements in healthcare is an immense challenge for China and won't happen overnight.

Fertility clinics drive thriving black market in eggs

Young Chinese women are risking their fertility by selling off their eggs to unscrupulous fertiliy clinics, a CCTV program has claimed.

As part of an investigation into the "human egg black market" CCTV found that high school students and university students were selling their eggs to agents for a few thousand yuan. The clinics then offer these eggs to infertile women who pay 30,000- 100,000 yuan (US$5000-$15,000).

The report said young girls were picked because of their looks, education and health and had to endure a series of injections with fertility hormones to stimulate ovulation so their eggs could be harvested by clinics. The young women said they used the cash to pay off credit card debts, but most were unaware of the serious risks of the procedures, including infertility.

Commentators said the commercial transactions of human eggs were illegal and banned, but there was little enforcement of the rules in practice. They said illegal clinics and the doctors who worked in them made large amounts of money, offering infertile women the chance to select a donor egg based on looks, intelligence and other personal characteristics of the donor. Despite being illegal, the egg black market was a thriving market and barely concealed  with advertisements by agents common on the internet.

The report said the fertility agents and their networks also offered infertile women other services such as surrogate mothers, as part of packages that could cost as much as 400,000 yuan.The trade was very lucrative and many young women saw nothing ethically wrong with what they were doing, it said.
The commentators said there was a need for a widespread crackdown to enforce the regulations on artificial reproductive technology. There was also a need to better regulate reproductive clinics and promote legitimate egg donation rather than the commercial practices, they added.

Statin therapy has disappointing results in Chinese patients

by Michael Woodhead
Only about one in four Chinese patients taking a statin have their cholesterol levels under control, according to a new study.

A review of the effects of statin therapy in 8965 outpatients with cardiovascular disease from 200 clinical departments of 122 hospitals across China found that about 75% of patients still had poorly controlled lipid levels.

The findings, published in the International Journal of Cardiology showed that despite taking long term statin therapy in medium to high doses, about 75% of patients had an above-target LDL-cholesterol level. In a similar manner elevated levels of total cholesterol and triglycerides as well as low HDL-cholesterol persisted in 34–43% of patients despite statin therapy, according to Professor Wei Yidong and colleagues at the Department of Cardiology, Shanghai Tenth People’s Hospital and Tongji University School of Medicine.

Only about 10% of patients overall had optimal levels of all lipid measures (LDL, HDL and triglycerides) despite taking statins. Patients with diabetes had slightly better control of lipid levels (43%) compared to those without diabetes (39%).

The study authors said it was not clear why patients taking statins did not have good control of their lipid levels. Oddly, there appeared to be no relationship between the potency of the statin doses and the degree of lipid level control.

About 77% of patients taking low doses of statins had LDL-C not at goal, compared to 72% of patients taking medium potency regimens and 74% of patients taking high potency courses of statins.
Chinese patients may need more intensive lipid-lowering therapy with additional agents other than statins, to improve their lipid levels. Patients may also need more attention on lifestyle factors such as diet and exercise before starting statin therapy, they added.

However, they could not rule out poor adherence to treatment a a possible cause of the poor lipid control.

China's doctors now officially encouraged to moonlight in the private sector

China's 'health ministry', the National Health and Family Planning Commission, has told doctors in the public hospital system that they should seek additional work in  private hospitals.
Health minister Li Bin told a conference this week that the registration regulations for doctors had been changed to encourage practitioners to work outside of the public hospital system.
"Limited resources of talent will be optimized among hospitals of various types under the initiative, which helps with the sustainable and healthy development of privately funded medical institutions," she said.
Doctors will no longer 'belong' to public hospitals and will be encouraged to work for market-set fees in private hospitals.
According to the China Daily, one senior doctor said he hoped his patients would 'follow' him to the better environment of the private hospital where he intends to practice, despite him charging much higher fees there.
The health minister told a NHFPC conference this week that she was urging private health institutions to provide a range of healthcare services, both treatment and prevention, to help divert patients from public hospitals, which are usually overloaded with work.

Inequity in access to healthcare: China has the worst record of any major country

by Michael Woodhead
Despite claiming to have health insurance coverage of more than 90%, China has some of the highest levels of inequity in access to healthcare in the world, a new study shows. 

A review of socioeconomic inequities in healthcare utilisation carried by by Dr Zhang Xin and colleagues at Harbin Medical University found that China fared very poorly compared to its neighbours such as Japan, South Korea and Thailand.

The study based on data from 2008, found huge differences in access to outpatient care based on income and even greater inequities for in-patient care. Chinese on low incomes were much less likely to be able to get hospital treatment compared to their compatriots on higher incomes, according to the findings published in the Asia-Pacific Journal of Public Health.

The researchers said their findings confirmed previous work that had shown that one in four poorer Chinese had been unable to get hospital treatment when they needed it because they could not afford it. Low income Chinese people with chronic and serious diseases were particularly badly affected by income disparities and lack of access to healthcare, they said.

They said that the New Rural Cooperative Medical Scheme introduced in 2003 had made a slight improvement to access to healthcare, but poor patients still missed out on needed treatment because of  high gap fees, limits to insurance cover eligibility and high insurance fees.

Dr Zhang said most OECD countries had a relatively little inequity for healthcare access, especially those that had good primary care systems and free-at-the-point-of-care treatment.

"Despite growth in health insurance coverage, the challenge of perusing equitable pathways toward universal health coverage is still truly daunting task in China," they concluded.

"Being poor and lacking the ability to pay additional out-of-pocket charges remains a significant barrier to access [to healthcare]."

Plague debrief: what really happened in the July 2014 Gansu case of pneumonic plague?

by Michael Woodhead
In July 2014 a case of pneumonic plague was widely reported in the media.

The victim was a 38-year old shepherd who caught the infection from a marmot (the usual carriers of the infection) after it was caught by his dog. At the time it was widely reported that the town of Yumen (near Jiayuguan) where he was treated, had been put into lockdown. None of the 30,000 residents were allowed to leave town and more than 150 close contacts were kept under observation in quarantine. It looks like Chinese authorities did the right thing - but only after a fatal delay in the initial diagnosis. A new report published by the local infection control team gives more details of the case.

Dr Ge Pengfei and colleagues say that the man contracted the Yersinia pestis infection from an infected marmot after it was caught by his dog on 11 July. He skinned the marmot for its pelt and fed the meat to his dogs. Two days later the shepherd started to develop respiratory symptoms and went into a nearby village to seek treatment. However, when he first went to the local clinic on 15 July he was mis-diagnosed as having a simple respiratory tract infection and given just a prescription for an antibiotic (clindamycin) and some anti-inflammatories. When his condition worsened later that day he was seen by doctors at the hospital in Yuman, who diagnosed pneumonia on x-ray and they gave him an ineffective antibiotic, cefoperazone, and more anti-inflammatory treatment.

It was only later that night when the man's condition deteriorated further and he started coughing up blood that throat swabs were taken, which showed the presence of the characteristic Yersinia bacilli when tested. Doctors then gave the man the recommended treatment of IV streptomycin, but this was too late and probably did more harm than good in the rapidly advancing conditions of the infection. Streptomycin must be used with great care in advanced plague because it cases the Y. pestis bacteria to burst (lysis) and release large amounts of the endotoxin that causes septic shock. This is what happened in the case of the Gansu shepherd, whose quickly deteriorated in the early hours of 16 July and he died at 5am.

The infection control team said they also detected Yersinia infection in the man's sister in law and in two patients who had been in close contact with him at the hospital. These people were among the 150 close contacts subject to quarantine and to preventive treatment with streptomycin. This containment strategy worked, as none of the close contacts developed full blown pneumonic plague.

The infection control team said them man may have survived if his infection has been detected earlier. However, the village clinic and hospital had only limited medical facilities, and the plague was only picked up when cultures were examined under a microscope.

They said that local clinics in areas such as Gansu where plague is present (on average there is one case per year in the region) should be alert for the early signs of the infection - and be prepared to take a careful history to see if there has been any contact with potential sources such as marmots and infected dogs. Despite the death of the patient, they said the incident had shown that quarantine and antibiotic prophylaxis procedures for contacts were effective.

"Doctors need to improve awareness and ask about contact history for the possibility of plague infection to avoid misdiagnosis," they recommended.

International Journal of Infectious Diseases.

Drug resistant bacteria - just how much of a problem are they in a typical Chinese hospital?

by Michael Woodhead
With broad spectrum antibiotics easily available over the counter in China  - and the Chinese cultural expectation of an antibiotic as the magic bullet for every viral fever - it's not surprising that drug resistance is a major problem in the PRC. 
But just how common is the problem for a typical provincial hospital? The rather worrying answer is quite a big problem. A study carried out in the Liaocheng People's Hospital in Shandong has found that one in three bacteria samples obtained from around the hospital were multi-drug resistant. Researchers at the hospital took almost 10,600 microbial samples from around the hospital and found that  33.4% were multi-drug resistant pathogens such as ESBLs producing E. coli and A. baumannii. The blackspots for resistant bacteria were in surgical departments and the intensive care department. Samples obtained from respiratory and secretions were the greatest source of resistant bacteria. The obvious consequences of these multi-drug resistant bacteria are treatment failure, longer hospital stays, increased mortality, and higher hospitalisation costs. As the authors conclude, their findings show the need for much greater attention to antibiotic resistance, especially from respiratory cases and surgical wounds.

Will Beijing's billion yuan "loss leader" private hospital be the model for the future?

by Michael Woodhead
Peking University's flagship new private hospital may lose almost a billion yuan but will still be counted a success if it drives other medical service usage, its backers say.

An article by He Chunmei in the financial magazine Caixin this week heralds the opening of the 1800-bed Peking University International Hospital (PUIH), which is a joint venture by Peking University and the Founder Group. The hospital in the north of the city is expected to lose as much as 800 million yuan but Founder CEO Li You says this is acceptable if the hospital generates revenue in other areas. "It's like a company's advertising department that spends money. We will earn money from other sectors. But the hospital is the foundation," he is quoted in Caixin as saying.

The new hospital is being portrayed as a flagship of China's foray into privately-invested healthcare as an alternative from the current overcrowded and underfunded public system. One of the main barriers to private hospital development in China to date has been the regulations that bar doctors from working outside the official public hospitals. The new hospital will test the recent relaxation of these rules by the government. But employment restrictions have not been the only barrier to private healthcare facilities - many clinicians have been reluctant to work outside the big hospital system for a variety of reasons - fear of stepping off the well-established career pathway, losing peer support groups and moving outside the system that is recognised by health insurance rebates. Doctors have also been unwilling to go it alone and take on the medicolegal risks of operating outside the mainstream system, especially at a time when patients are becoming increasingly distrustful of the healthcare system and prone to taking aggressive action in medical disputes.

The new Peking University International Hospital may overcome many of these reservations because it will 'share' doctors and other healthcare staff from other Peking University-affiliated hospitals, which already enjoy a good reputation for quality care. However the management of the new hospital acknowledge that the new workforce 'sharing' arrangements will require some work and 'adjustments' to coordinate different departments and different hospitals. The hospital says it will lure staff with offers of higher pay, which will be guided by the market rather than the patchy, commission-based remuneration of state-controlled public hospitals. "Head doctors usually earn several hundred of thousands of yuan every year at a public hospital," said Li You. "But if necessary, we'd like to pay more than 1 million yuan. We will fully follow the market."

The private hospital will also differ from public hospitals in being managed by a board of directors representing investors. Public hospitals are often a conglomeration of mini-empires, with directors of departments often having a lot of power and being unaccountable in terms of services, revenue and purchasing.

The Peking University Healthcare groups say they will be able to implement a more efficient system as they will have a controlling interest in the hospital, whereas public hospitals are often controlled by government agencies, business groups and hospital managers that are resistant to reform. Li says his ambition is to pioneer a new model of hospital management based on integrated databases that will create accountability and efficiency in procurement, servicing and supply. The management system will also encourage doctors in departments of larger hospitals to sponsor and support similar departments in smaller branch hospitals.

"We will grow to become China's largest hospital management company," Li told Caixin, "and control the largest medical database."

"Family doctors" refuse to work in community

by Michael Woodhead
Guangdong province has trained more than 50,000 family doctors in the last few years but only 20,000 of them have opted to work as general practitioners in the community, a conference has been told.
Most of the doctors trained to be general practitioners have been put off by the low pay, low status and unattractive career prospects of community medicine and have opted instead to stay in the "more developed" hospital system, according to a speaker at the inaugural Guangdong Provincial Association of Family Physicians. Dr Wang Jiaji, head of the Family Physicians Association said patients should be able to enrol with a community-based family doctors and be offered treatment for minor illnesses and referrals for more serious conditions. However, he said the current environment for family medicine in the province made it unattractive to medical graduates. He said Guangdong had planned to have 2 GPs per 10,000 residents but currently only had one GP per 10,000 people, and this was far behind the level of 5 per 10,000 residents seen in developed countries such as the US. To try change the situation, he said Guangdong had become the first province to set u[ a local family doctor association, to encourage better training and make general practice a more attractive career. He also called on the government to invest more in primary care.

A Merry Christmas to both of my readers

China Medical News will be back after the summer break here in sunny Sydney.

A roundup of the medical news headlines from China

Efforts to establish a primary care system in China are faltering because a lack of qualified doctors entering the specialty, according to the People's Daily.  It says GPs account for about 50% of doctors in western countries but only 5% in China. In addition, few young doctors want to become GPs because of the poor status, lack of career prospects and poor pay. The article says China must increase pay and career prospects for community care doctors if it is to achieve its stated aim of having a gatekeeper system to reduce hospital overcrowding.

edical College,

In Sichuan, villagers have petitioned to expel an 8 year old boy because he is HIV positive. Even his own grandfather was among those who signed to get rid of the boy from an un-named village. The villagers said the boy was a 'time bomb' and he should be removed to "protect villagers' health".

The Washington Post has a feature on the new wave of foreign investors  trying to make a buck out of the rapidly changing and deregulating Chinese healthcare system. However, the feature notes that efforts by foreign investors to open hospitals and clinics in China is limited by the lack of medical insurance and the overall shortage of skilled doctors in China.

Chinese ministers are doing the rounds of county-level hospitals, which are the target for the next wave of reforms. The government wants to try stop the decline of county hospitals as patients bypass them and head straight to major city hospitals, which they believe to have more expertise.

One in four patients admitted to rural hospitals in China doesn't need to be there, according to a study from  Tongji Medical University in Wuhan. The study found that 27% of patients at rural hospitals had been admitted inappropriately, with wrongful admission rates as high as 37% for older Chinese. The researchers said the higher reimbursement levels provided in the New Rural Medical Insurance scheme for inpatients than for outpatients encouraged patients to be admitted and treated inappropriately.

Baby for sale to pay medical bills | Ambulances misused by non-urgent callers | Avian flu returns more virulent

 

Rural migrant sells baby to pay medical bills

A rural migrant women from Sichuan has been trying to sell her baby on the street of Fuzhou to raise money to pay medical bills for the baby's father. Police were called when the women displayed a sign saying "Boss fled after industrial accident and we don't have the money for treatment; I'm willing to sell my child to save her father." The woman said she had already paid Y7000 in medical bills for treatment of her husband who had injured himself after falling from a construction site. Some sympathetic passers-by gave the women some money before she was persuaded to end her 'sale.'

Beijing ambulances used for non-urgent cases

Ambulance services in Beijing are overstretched because 80% of cases they transport are non-urgent and do not need to attend the emergency department, a survey has found. Only 20% of the people brought in to hospital by ambulances had life-threatening conditions, according to a report from the Beijing's Health Planning Commission, which found that most of the ambulance patients could be treated in the outpatients department. The commission has suggested that patients are triaged before being taken to hospital as many critically ill patients are left without transport while ambulances are dealing with non-urgent calls.

Avian flu returns more lethal

The severity of H7N9 avian flu in China increased with the "second wave" last winter and the virus may return in an even more virulent and lethal form this winter, researchers have warned. The lethality of the H7N9 virus increased by 48% from the first wave in 2013 to the second wave in 2014, according to Dr Li Feng and colleagues at the Key Laboratory of Surveillance and Early-warning on Infectious Disease at the China CDC, Beijing. In the latter part of the first wave the death rate among hospitalised patients was 17% for young people under 60 and 42% for people over 60. In the second epidemic the death rate was 36% in people under 60 years, and 59% in people aged 60 years or above.
"If another epidemic of human infections with influenza A(H7N9) virus occurs in the winter of 2014/15, proactive control measures on the poultry-human interface may be preferable to reactive measures," the researchers suggested.

Nurses inadequately trained | Child physical abuse common | Coal use causes black lung

Nurses lack adequate training

Only one in seven nurses in China undergoes a three year undergraduate training program, and many lack adequate training, medical educators have complained. In a letter to the Lancet, Liu Fengxia and colleagues at the Fourth Hospital of Hebei Medical University say that they are worried by the fact that most nurses in China not receive standard nursing training. Each year only 30,000 out of 186,000 graduate nurses earned standard bachelor degrees, they noted. Most nurses received only diplomas after brief training. The lack of education and the stressful working conditions mean that poorly trained nurses could make mistakes in patient care - and their lack of training may also be a factor in triggering violence against health staff.
"Nurses are intermediates between doctors and patients. In our practice, we have seen misunderstanding and mistrust between patients and doctors most probably due to of the inadequate training of nurses. A more comprehensive training system for nurses is needed," they write.

Physical punishment of children condemned

China's high rates of physical punishment of children amount to a culturally-accepted high level of child abuse, researchers have said. A major review found that 36% of children in China experienced physical abuse from parents, typically in the form of slapping and spanking for disciplinary reasons. They said the rates of physical punishment in mainland China were significantly higher than in other Asian countries, where the influence of western methods of parenting was stronger. The researchers said physical punishment was "culturally accepted" within Chinese society because the Confucian philosophy of parenting, which endorses parents’ authority and filial piety, is still prevalent in the minds of Chinese parents and children.
"A well-known proverb “gun bang di xia chu xiao zi” (also translated as “spare the rod, spoil the child”) indicates that the filial piety is achieved by strict physical discipline of children," they noted.
They said China's high rates of physical abuse were concerning because of the known associations with poor mental health and harmful behaviors, such as depressive disorders, anxiety disorders, eating disorders, childhood behavioral disorders, suicide attempts, drug use, and risky sexual behaviour.

Coal use leads to black lung

China's high use of coal for fuel has led to high rates of pneumoconiosis and "black lung", researchers say. In a Dow Jones report, clinicians said pneumoconiosis was common in mining workers and other coal-related industries, especially as workplace safety rules were often ignored in China. masks could help prevent pneumoconiosis but were often not provided to workers, they noted. The number of people diagnosed with pneumoconiosis has risen sevenfold from 2005 to 2013 to about 750,000, at an average pace of 35% annually, according to official data. And while treatment is available, it is often unaffordable for many low paid workers, labour activists note.

Zhejiang hospital runs out of money, can't pay for medicines

by Michael Woodhead
A hospital near Taizhou in Zhejiang is "crying poor" saying that increasing patient burden and rising prices means it does not have enough money to buy essential drugs. The Xianju county hospital has out up a notice on its public LED screen asking for "understanding" because it is no longer able to provide medical supplies such as blood plasma. 

The hospital authorities said their outlays exceeded their income and they no longer had funds to buy drugs and other medical supplies. The director of the hospital, Chen Xiaojun, told Xinhua that the hospital was more than 15 million yuan in debt because the New Rural Medical Insurance Scheme did not cover all the expenses incurred by patients and the insurer was refusing to release further funds. The local health department was also refusing to provide further funding, and the unpaid bills of 11 million yuan meant that pharmaceutical companies were no longer willing to supply drugs to the hospital.

The shortage of drugs was most acute for the high cost drugs for conditions such as bronchitis and anaesthetics and other drugs needed to cover surgery, he said. This meant that operations at the hospital also had to be curtailed. Medical staff said patients were being advised to find another hospital if they had a serious disease, and medical staff were also complaining that their wages had not been paid for some months.

The hospital authorities blamed the 'bankruptcy' on three factors: they said the government reimbursement levels for had been set in 2008 and had not kept up with rising costs or increasing patient numbers. Secondly, the price of drugs had also increased substantially, leaving hospitals out of pockets, especially with new zero markup policies. And most importantly, the rural medical insurance scheme expanded the reimbursement to patients for inpatient costs from 40% to 80% of fees, which meant many patients now wanted to stay as inpatients for longer, driving up costs.

A spokesman for the Xianju country government said the relevant departments were now having a 'crisis meeting' to solve the problems that had led to the  lack of funding at the hotel. However a spokesman said the Xianju hospital was not the only hospital facing the problems of rising costs and falling income, and the problem had to be tackled on a wider basis by changing the reimbursement system and charges, he said.

The local government also criticised the hospital for making public announcements about its poor financial state and lack of medications, as this would lead to public panic and loss of faith, he said.

Infusion superstition condemned | Hukou medical reform | Heavy metals found in wheat

Doctors condemn superstitious belief in infusions

A life-threatening incident of allergy to an infusion has lead a Shanghai doctor to criticise parents and grandparents for insisting their children have unnecessary infusions to treat minor illnesses with fever. A 12-year old boy with fever treated at the Ruijin Hospital  nearly died after having a massive allergic reaction to an infusion he was being given for a fever. The boy recovered thanks to the rapid response of medical staff, but doctors said they faced huge pressure from parents to give infusions when they were not needed. Doctors said parents had an almost superstitious belief in infusions and insisted on them to help their children get better quicker so they would have more time to study.

Hukou reform will give rural migrants healthcare rights

Millions of rural migrants may get access to affordable healthcare as China modifies its household registration (hukou) system to give more right to the floating population. In a major shift in policy, reforms to the residence permit system will grant migrants the same access as urban residents to  public services  such as medical treatment  for their children. The plan, which has been released for consultation by by the Legislative Affairs Office of the State Council, would allow migrant workers who stay in a city for half a year with a stable job and residence may apply for the residence permits.

Wheat near Yellow River contains heavy metals

People living near the Yellow River are being poisoned by eating crops containing high levels of heavy metals absorbed from irrigation water drawn from the river, a study shows. Wheat grown in areas around Baotou irrigated by Yellow River water showed high levels of mercury, lead and selenium, researchers from the Inner Mongolia University of Science and Technology showed. Crops also contained high levels of copper, zinc and manganese, they found.

Beijing doctor explains on Youku about bribes and commissions

by Michael Woodhead
A video is circulating on Youku of a man purporting to be a former surgeon at a Beijing hospital, explaining how the red envelope bribe and commission system works in China. 
The erstwhile doctor, claimed to be  Li Rui of the Beijing Aerospace Institute Hospital Urology department. He said that during his time working in surgery, doctors would make huge commissions by charging patients exhorbitant sums for ancillary items such as a 1500 yuan gauze pad to stop bleeding, on which they earned a 30% fee. He said surgeons performed many simple operations such as removing appendix in 10 minutes and then adding lots of expenses to the bills. Dr Li said it was best to work in procedural specialties such as orthopaedics, surgery and obstetrics where there were more opportunities to perform operations and use expensive medical supplies and devices. The man was purportedly giving a presentation at the well-known New Orient academy  in Beijing, although the institute denied any knowledge of his working there. In a statement the Beijing Aerospace Institute Hospital denied the man's claims, describing them as baseless and slanderous. The hospital said there had been a Dr Li working at the hospital but he had been absent for six months and thus his contract was terminated. The hospital said the man's statements on video lacked credibility, citing as an example that there was no way a surgeon could do an appendix removal in 10 minutes, even with the most modern equipment.
However, the video has been widely circulated on Chinese social media sites, drawing comments on the greed and corruption of doctors and the profit-seeking nature of public hospitals.

Diabetes in China: the numbers are staggering

by Michael Woodhead

The Lancet Diabetes & Endocrinology journal is this month running a series of articles focusing n type 2 diabetes in China.  

The numbers make for grim reading: more than 12% of Chinese are reported to have diabetes (100 million people) according to US criteria (although there is some dispute over whether these  criteria may result in overestimates).  Because of the lack of awareness and lack of adequate screening and intervention programs, many of the Chinese with diabetes are undiagnosed, untreated, or uncontrolled. 

The articles say that Chinese people are especially prone to type 2 diabetes at relatively low levels of overweight, and Chinese people are more susceptible to [insulin producing] beta cell failure and deficits in insulin production. The blame, unsurprisingly, is put on China's rapid development and shift to lifestyle factors such as eating an unhealthy diet and doing less exercise. 

A second article says that there are also problems with provision of prevention and treatment programs for diabetes in China. As well, there is little research on the best forms of drug therapy for Chinese people with diabetes. Newer [and more expensive] anti-diabetes agents such as the gliptins seem ideal, but they are not currently accessible or widely used by most doctors.

The articles conclude by saying that any solution to the diabetes epidemic in China must be based on multiple strategies: there needs to be healthcare reform to make diabetes prevention and treatment more widely available through primary care and through initiatives such as diabetes nurses. There are need to be major preventive health campaigns to promote healthier eating and activity, to reduce the risk factors for diabetes in China. The articles also note that health reforms are needed to provide adequate health insurance cover and reimbursement for treatment of diabetes patients in China

China's best case scenario for an Ebola outbreak: 3000 deaths

by Michael Woodhead

With more than 600,000 annual passenger arrivals from Africa and a poor to non-existent public health infrastructure in most parts of the country, China faces  a very real risk of an Ebola outbreak. That the verdict of infectious disease specialists who have modelled what will happen if a person with Ebola lands in China and is not detected immediately.

Dr Chen Tianmu and colleagues from the Changsha Center for Disease Control and Prevention have used data from previous Ebola outbreaks overseas and also from outbreaks of dengue and HIV viruses in China to model the likely spread of the infection before it can be brought under control. They modelled several different scenarios based on different levels of infectivity of the virus and different levels of detection and containment.

They based their calculation on the fact that there were 524,900 African visitors and 112,966 Chinese returning from Africa each year in China. Based on current distribution of Ebola Virus Disease and the rates of carriage in Africa, they estimated that 0.04%–0.16% of these arriving passengers in China (255–1021 people) may carry Ebola. Even if an optimistic assumption is made that only 1% of them slip through the entry-exit inspection and only 1% of these are not picked up by further reporting and monitoring follow ups, this would still mean 3-10 Ebola virus carriers could be at large in China.

The researchers noted that China lacks a primary care system and most sick patients go direct to hospitals that are overcrowded and where Ebola patients might spread the virus to others. China also has limited public health reporting and surveillance systems for much of the country, and it would therefor be possible that cases of Ebola virus could be misdiagnosed and slip though the net until the patient became symptomatic and infectious.

The researchers then calculated that the likely impact of such 'index cases' spreading the Ebola infection to others would be outbreaks of Ebola in China affecting between 6000-10,000 people. With a likely fatality rate of around 50% this would mean a severe mortality burden for China, they wrote.

Writing in Travel Medicine and Infectious Diseases, they said the lack of Ebola testing facilities in China and poor infection control practices would further encourage the spread of the infection, they predicted. Other factors, such as the lack of quality control on blood transfusions (as seen with outbreaks of HIV and hepatitis) would also increase the risk of spreading Ebola in China, they warned.

"Even if a good surveillance and monitoring system is implemented at immigration, an effective and efficient local medical response system involving primary health care providers and awareness of the general public is necessary to minimise the risk of an Ebola Virus outbreak due to other unknown sources," they suggested.

Cancer treatment unaffordable | Drug pricing corruption | Premier tackles HIV stigma | Rare diseases not reimbursed | US medical exams popular in China

Public punchbag to pay son's cancer fees
In Beijing a man who cannot afford the Y700,000 ($114,000) medical bills for his son with leukaemia has offered himself as a public punchbag to raise money. The man called Xia Jun stands outside Guomao station and asks for 10 Yuan to be thumped. He says he has collected 10,000 yuan in one day without anyone taking up the opportunity to hit him.

Corruption on drug price setting cited as reason for abolition
The recent move to abolish price caps for prescription medicines was triggered by corruption in the agency charged with setting drug prices. Critics said officials in the National Development and Reform Commission (NDRC) were under investigation by the anti-corruption and bribery bureau under the Supreme People's Procurate for taking bribes. Pharma company executives said the current pricing system forced them to pay bribes to regulators to set higher procurement prices.

Premier lends support to ending HIV stigma
Premier Li Keqiang has shown public support for people with HIV and aimed to dispel prejudice and ignorance about the infection by visiting  a HIV clinic at the inspected Beijing You'an Hospital.
 For World AIDS Day, the Premier met HIV patients and healthcare workers and said the old attitudes of fear surrounding the topic of HIV must be abandoned and HIV patients need more care.

Rare diseases slip through the health insurance cracks
China's health system is not working for children with rare diseases, as their families face high treatment costs and no access to medical fee reimbursement, according to an article in the SCMP. One mother of a 3-year old boy with Langerhans cell histiocytosis (LCH) said his bills for diagnosis and treatment had reached nearly 200,000 yuan ($33,000), of which just 4,800 yuan ($780) had been reimbursed by the rural medical insurance scheme.

US medical exams popular in China
Thousands of China's medical students and young doctors are studying for the US Medical Licensing Examination (USMLE) that will allow them to practice medicine in the US. However, despite studying for up to 1500 hours for the exam, many of them say they are taking it to improve their medical skill rather than just to get a better paying job. Many Chinese students said the US medical exams taught them a more patient-centred approach and put more emphasis on communication and empathy rather than just rote-learning of medical facts. The test is also taken by many of the 60,000 foreign students studying medicine in China.