In my previous editorial for the July issue, I boasted about the smooth entry into Beijing without any delays from the reportedly stringent H1N1 quarantine measures. But our luck ran out quickly and in the two weeks following our arrival, members of my family had to be separated and went through China’s H1N1 quarantine and treatment procedures one after another. 

Despite plenty of anxieties, frustrations and systemic failures throughout the process, I am convinced the Chinese government has made considerable efforts to accommodate the needs of those under quarantine and provide treatments for the flu. 

Through the ordeal, however, I gained valuable first-hand experience of the Chinese public health and healthcare systems from the perspective of a patient, who is often weak and helpless. As it was a rare opportunity to experience personally the China healthcare as a patient, I’ve decied to share my story and observations with readers here.

Public health in the age of globalization

Once again I was reminded how small our world has become and how healthcare decisions in one country can seriously impact  countries on the other side of the globe.

At one end, the U.S. authorities decided to minimize its response to the H1N1 flu outbreak in the country due to its mild symptoms so far and for fear of further disturbing the beaten economy.  The U.S. quickly became the place with highest prevalence of the H1N1 flu and its infected population is estimated by experts to be over 1 million, if not more. Schools became the hotbeds for spreading the flu due to lax control measures and negligence of school administrators. Although fatalities from the flu have been low thus far, the ultimate global public health impacts and consequences of the U.S. approach for H1N1 flu are yet to be determined.

At the other end,, the Chinese government decided to bet on tough quarantine measures for H1N1 flu in order to avoid mistakes it made at the SARS outbreak in 2003.

Obviously, international travelers are not going to be happy with China’s stern response to what seems to be a mild seasonal flu and few would appreciate the efforts of the Chinese government after being locked up in a hotel room for a week. It is almost hilarious to read about some Westerners confronting guards of quarantine facilities to request steaks from designated luxury restaurants in central Shanghai, but raising their criticisms of the quarantine measures to a level of “freedom and democracy” is simply too much for my appetite – I doubt if anyone would have the freedom to walk away if the U.S. government decided on a quarantine deemed necessary for public health reasons, not to mention the democracy to confront U.S. guards, which is far more dangerous to your life than any flu.

The price China has to pay for acting tough against H1N1, however, is well above just discontent expressed by foreign travelers. While the Chinese government budgeted CNY billions to pay for the quarantine and treatments, unknown hidden costs beyond quarantine facilities and hospitals are abound.  

In the absence of any global consensus over the prevention approach and with some countries like the U.S. not controlling the disease at all, the questions China needs to ask itself are if its quarantine measures will be actually effective in containing the flu at all and if all these efforts and costs are worthwhile.

The decision making process for public health response

It’s obvious to see the goodwill and political motivations of the Chinese government to do a better job in containing H1N1 flu than it did with SARS. It is nevertheless intriguing to find out how such decisions were made this time - what were the weights of public health experts, government bureaucrats and senior leaders respectively in the decision making process and if any risk/benefit analysis was conducted before the decisions were made during the process.

There is limited transparency on this subject, but I am inclined to think that among decision makers and public health experts this time, there was a consensus that overkill was better than inadvertent miss. In addition, the rather strong WHO stand on H1N1 pandemic also strengthened China’s confidence in its strategy. Nevertheless, it seems China has seriously underestimated the importance of synchronized global epidemic control.

Very recently, China announced its decision to withdraw quarantine of those who had close contacts with H1N1 flu patients and to start allowing some patients with mild symptoms to stay home for treatment.  This almost equals to an admission of defeat or failure for its previously-adopted policies. In fact, I already predicted this outcome when I saw how over-capacitated Chinese hospitals were two weeks ago while I was there.  

If the objective of the original Chinese policies for H1N1 flu was to prevent an outbreak of the epidemic, in the absence of any concerted efforts globally, the Chinese government took onto itself a mission impossible from the beginning. 

If the objective was to delay the outbreak in China in order to earn time for a massive scale vaccination nationwide, it also failed because China is still at least two months from having the capability to deliver commercial quantities of H1N1 vaccine. 

My H1N1 experience exposes structural flaws, inefficiencies and poor execution of the Chinese public health and healthcare system

It was unfortunate that my family had to travel even in times of such public health tension due to compelling personal reasons. But we made a conscious decision to self-quarantine upon arrival in Beijing to be responsible for others. 

On the fourth day, however, my elder daughter developed fever so we called the local CDC thinking that they would be well-prepared to deal with the situation. As our calls were transferred many times, more people got involved each time with mounting questions to be repeated. After spending an hour on the phone, I finally realized all they were going to do for us is to send an ambulance to pick us up and drop us at a hospital of our own choice. Well, I should have called an ambulance straight-away and to save me a lot of time and anxiety.

Arriving at the fever clinic of a 3A hospital, we were told to escort my two younger children under 18 on our own to the pediatric department which was quite a distance away in another building and was packed with parents and children. As we ran among those non-affected patients or hospital visitors between the two hospital departments across the compound, I started to question the logic of riding an ambulance to the hospital.

Compared with the “space-suited” CDC (center for disease control) and ambulance staff, I had the feeling that the doctors and nurses in this hospital seemed to be quite relaxed with H1N1 flu – not necessarily because they knew about the mild symptoms of the flu, but rather they were taking the sidelines since CDC was the lead for H1N1 flu prevention and control. Apparently they also seemed to be poorly informed about the flu and were not even familiar with the relevant tests for the flu. The doctors concluded eventually that two of my daughters who had fever should be quarantined at the hospital immediately, and the rest of us were free to go.

On the second day, we were informed by the hospital that my elder daughter was tested positive for H1N1 and would be transferred to Ditan Hospital, a specialized infectious disease hospital, by CDC, which was supposed to transfer us to a quarantine facility too. But my wife started to develop a fever in the morning and I became worried as her temperature went up during the day. As we did not hear anything from the CDC by that evening, I decided to take her to the hospital on my own and this time in my own car (the ambulance was obviously just a show).

When we arrived in the same fever clinic, it was already packed with people this time. We told the nurse at the reception about my wife’s fever and confirmed H1N1 diagnosis of my daughter, but it did not seem to make an impact on her at all.  We waited nearly two hours for the doctor to call on us in a crowded corridor, but then discovered that she was completely overpowered in her room by patients and families who were manipulating the order of patient records (with call numbers) on her table in order to cut the waiting line.  Finally I fought my way into the doctor room and told the doctor that my wife had all the H1N1 flu symptoms and my daughter was already tested positive. I thought both the doctor and the crowd in her room would be startled, but I was terribly wrong. In fact, the crowd even quietly fortified their positions while the doctor simply replied that there was nothing she could do and we just had to wait. I told her that we would be potentially infectious to other patients and maybe we should wait in a separate room, she simply asked us to find a place on your own but said she could not call on us when it was our turn. We went to the nurses, they refused to do anything either. Out of frustration, I told them we would not wait anymore and were returning home. At this, they were still not moved at all. Disappointed by their indifference, we had to return home but I was smart to buy some Tylenol and cough syrup for self-medication.

In the following morning, I called the Office of the President and the Department of Medical Administration of that 3A hospital and threatened them with media exposure and reporting to the Ministry of Health if they refused to arrange for any proper treatment.  The trick worked and the head of the hospital’s respiratory disease department called me to invite us back and promised prompt actions. 

Half way through our third visit to the same fever clinic, the CDC people came to pick us up – my wife had to be hospitalized immediately, but by the time all her symptoms already started to subside as a result of self-medication with OTC medicines. Eventually my elder daughter needed no medication at all, and my wife was given some hospital-formulated traditional Chinese medicines (TCMs) – since her symptoms disappeared quickly, TCMs were credited and she was even in the evening news for it.  

Meanwhile, the CDC decided to quarantine me and my two younger children in a hotel since we had no symptoms at the time. The hotel was rated at four stars though I think it is lucky to be 3 star minus – but generally the facility is better than what you would expect at the time of public health emergency. Staffs there were friendly, food was reasonably good  and internet access was available. But my nightmare was yet to come. 

I started to have a fever and began coughing on the second day after we arrived at the hotel. My temperature rose quickly thereafter (all AC were sealed so the high room temperature was against me too) and coughing was worsening. I began to ask the doctors and the CDC staff for some OTC fever-reduction medicine and cough depressants (I took it for granted unfortunately). They always agreed but never delivered the medicines. After repeated requests, I finally determined that they were purposely withholding the medicines from me. They finally admitted that their quarantine protocol does not allow them to treat or prescribe drugs at the quarantine facility and all treatments need to be done in hospital instead. Meanwhile, I could not be transferred to a hospital because at first my positive H1N1 test result, which was needed for transfer, did not arrive in time and later there was no available patient bed for me at the Ditan Hospital. 

Despite my weak physical condition, I had to educate these doctors and CDC staff about the facts about serious conditions and fatalities of H1N1 flu which were mostly related to complications from the flu. I was left in high temperature and bad coughing without medications for two days by then and was concerned about developing pneumonia or other unwanted health problems.  One sympathetic CDC staff tried calling her superiors about my case and she later informed me regrettably that they were not still authorized to do anything.

As my last resort, I called the U.S. Embassy for assistance. The counselor had to work with the Beijing Municipal Foreign Office (BMFO) to resolve the issue. Eventually a BMFO official had to use his influence to get through directly to the president of Ditan Hospital who personally arranged a patient room for me.

Upon arrival in this brand new facility of Ditan Hospital, I became one of the few people who were given Tamiflu because of my “serious conditions” which were largely related to lack of medical attention at the quarantine facility. Though the nurses and doctors here were very friendly and attentive, they seemed to be only interested in getting rid of the H1N1 virus in me than treating my conditions. They paid little attention to my cough and I had to deal with it after I was discharged.

Before I had a chance to rest after being transferred to the hospital, phone calls from the CDC and the hospital showered in and one CDC guy even called me at 1 AM to investigate about who had delivered food to me when we were in self-quarantine – “forget those guys who had brief contacts with us for a few seconds”, I told him, “go after the brave people in the fever clinic who spent hours with us without fear”.

On a related thought, the paperwork related to the H1N1 flu has exploded to an extent which is unbearable. From the day we were in touch with the CDC to the day I was admitted into the hospital, I had to deal with tens of paperwork requests from different departments and people of the CDC, quarantine facility and hospitals，repeating my personal and other information countless times. Most information was recorded on paper the first time we were in contact with CDC, so judging by the number of times I had to repeat it, there must be barely any connectivity among these personnel or departments through computer networks.

In any event, it was a very nice hospital room with AC and a private shower in Ditan Hospital.  The staffs in the hospital were friendly and accommodating. We were even given the choice of both Western and Chinese food. My high fever disappeared on the second day and what’s left was waiting for two H1N1 consecutive negative test results. I was told the results have to come from the municipal CDC and it would take upto three days due to capacity overload at the CDC laboratories.

Out of boredom, I began poking around my room. I was told there was no internet access but I did see brand new connection points and found that there were password-protected wireless networks too. Following many failed attempts to “break into” the hospital’s wireless networks, I had to admit my poor talents in hacking. So I harassed every nurse and doctor I saw, demanding them to check out the situation. There explained that the wireless network was for preparing wills of dying patients and obviously I was not qualified to use that just yet.

Finally one young doctor agreed to help me and he actually prepared an application letter to the hospital IT department on my behalf. But later the news arrived – they could allow me to have the access but the process for setting up the connection would take two months, I was told. 

The only comforting thing during my eight-day hospital stay was the availability of a modern flat screen TV with 60 cable channels. But it was equally frustrating because there was no remote control for it (despite my repeated protests), which meant a lot of manual labor for a compulsory channel surfer like me. I still can not understand the rationale of installing an excellent TV but taking away the remote control. A friend of mine in the medical industry recently offered a possible clue – the nurses are concerned about patients walking away with the remotes when they check out, so it is better to withhold them! Alas, isn’t it easier to just go without these TVs to avoid the troubles of having to repairing or replacing them one day?

As my problem of coughing was not properly dealt with at the hospital, I had to visit the same 3A hospital again after being discharged. This time, I paid a premium admission fee of CNY 200 (40 times of what locals pay) to be treated at the hospital’s international medical department and indeed had a rather pleasant experience. Compared with the bare and crowded doctor room in the fever clinic and in the pediatric department, this doctor room offered privacy with the door closed during treatment and, most impressively, it had a computer with an advanced hospital IT platform on which the doctor gets patient records, takes notes and prescribes medicines. I asked the doctor if the whole hospital was equipped with the system, she scoffed and told me the system still could not be implemented hospital-wide because there had been far too frequent changes of top management who had vastly different ideas. 

I was then dispatched to get a chest X-ray where the technician told me the seemingly brand new Kodak machine had just broken down because the weather was too hot. Seeing I was puzzled, he added that the central air conditioning (AC) never worked in the X-ray room. I then pointed out to him there was a stand-alone AC on the wall, which seemed to be a backup. He then sighed and said: "ah, it is useless, I have never seen a remote for it". Another misplaced remote – what is the logic behind this one? The hospital manager did not want the technician walk away with it, I guess. I was then taken to the regular hospital X-ray lab where, I was told, the best X-ray equipment of the hospital was installed. On the way, I learnt from the technician that the international medical department actually charges me three times the regular price for X-ray with second rate equipment. 

Well, enough about my recent personal experience with the Chinese healthcare system and it is time to offer some first-hand observations:

- Chinese public health decisions are likely to be more susceptible to political considerations of the government and senior leadership; risk/benefit analysis was probably not yet well utilized in the process of public health or healthcare decision making; and the latest H1N1 flu prevention policies by China may turn out to be inefficient;

- The country’s CDC system is very young, but has been given tasks which go well beyond its authority, competence, capacity, experience and know-how; and coordination between CDC and medical institutions is poor;

- Public health and disease control awareness and capabilities outside airports are poor, and medical institutions may very well become one of the biggest sources for disease spreading;

- While infrastructure of urban Chinese medical institutions improved significantly in recent years, hospital management and maintenance remain to be drastically improved; and the IT infrastructure building of urban hospitals continue to lag behind; 

- The efficiency of Chinese public health and healthcare systems is generally low with vast wastes of resources due to a variety of systemic flaws, inadequate management, professional incompetence and low morale & poor ethics of healthcare professionals; 

- Although China’s healthcare institutions have made improvements in providing more patient-friendly support services in some areas, healthcare professionals often lack relevant skills and ability to take charge of and effectively manage their workplaces; they need more training in medical ethics, professionalism, responsibility and accountability; and continuing medical education for them is important in updating their professional competence; and

- The existing Chinese hospital system is particularly problematic in dealing with epidemic & acute diseases or medical conditions.  

Developments in the Chinese pharmaceutical sector in the past month

Turning our attention back to the Chinese pharmaceutical industry, the month of July is a rather peaceful one with few waves in the areas of healthcare reform and drug regulation. But many changes and new policies are brewing, and I do see a flurry of new policies coming our way in the next couple of months.

On the front of healthcare reform, a senior NDRC official predicted confidently earlier this year that all relevant policies supporting the near term goals of the healthcare reform plan would be released in June, but this prediction obviously under-estimated the complexity of getting down to details of the healthcare reform.

Although the central government managed to introduce a few policies on less disputed areas like medical assistance, public health and rural healthcare in the past two months, it has been disappointing to many in the pharma industry that the introduction of important policies on essential drugs, public hospital reform and drug pricing were delayed repeatedly as a result of continued disagreements and conflicts of interests among stakeholders, officials and policy experts. 

But the recent delay of the essential drug list might turn out to be good news to MNCs which have been calling for the government’s attention on quality in the selection of essential drugs. Under the pressure of MNCs, I understood from various sources that some officials have propelled the notion that price shouldn’t be the only criteria in choosing essential drugs, thus creating room to consider more expensive but cost effective products. At the same time, the central government is likely to shift some of the heat to local governments by allowing some variances of the essential drug list at the provincial level. This will reduce the pressure at the central level for inclusion of MNC drugs in the national list and preserve potential market opportunities for MNCs at the local level.  Nevertheless, even if some MNC drugs are included in the national or local essential drug lists, they still face the barrier of low government purchase prices, so it could still very well be a “pie in the sky”. Judging by recent maneuvers of some MNCs to step up their generic drug capabilities in China, many are taking the potential opportunities in essential drugs quite seriously.  Before making any major moves, I would still advice MNCs to hold out a bit longer until the official policies are released.

In the area of drug pricing, it seems the NDRC has completed the drafting of its drug pricing reform policy which is being reviewed by other government agencies. Though NDRC said it hoped to introduce the policy in August, the process to reach a consensus on this policy might not be smooth as wished. While full details of the current draft are not yet available, it is expected the government will expand the scope of drug price control and give provincial level local governments more responsibilities in drug pricing. The prior policy supporting individual pricing of premium products including the “innovative category” drugs will most likely stay, but policies on uniform and/or differential margins will be adopted in hospitals. There is no doubt the government will continue to support drug innovation, thus allowing premium pricing for patented new drugs. New approaches in drug pricing, such as pharmaco-economics and some form of drug pricing negotiation mechanism, may be explored.

Meanwhile, there have been also a few regulatory developments in July. Firstly the SFDA is seeking comments on the draft of “Provisions for ADR Reporting and Surveillance”, I will not spend more time on this draft since we have a full summary of it later in this issue. But it is notable that the proposed regulation contains a provision that requires pharmaceutical companies to report serious ADR events of their products outside China, including such events collected by their voluntary ADR reporting systems or such cases discovered through research or literatures.

Also, the SFDA is now under a process of getting internal comments for the draft of its GMP revision, which is expected to be introduced this year.  Local companies are extremely concerned about the revision as its requirements will be much more stringent and therefore increasing investments and costs. But the development might turn out to be positive for MNCs, most of which already enforce higher standards of manufacturing and quality control. The new GMP edition is likely to reduce the gap in manufacturing costs between MNCs and local companies. More importantly, the Chinese government will be under significantly higher pressure to review its existing drug pricing mechanism and raise drug prices accordingly, leading to smaller price gaps between MNC drugs and local drugs.

Finally, in the area of intellectual properties, Pfizer lost its final battle for the Chinese trademark of “Wei Ge” (popular Chinese name for Viagra) against Guangzhou Wellman Pharma.  Compared with legal fights for patents, MNC pharma companies seem to have little luck with trademark disputes in China. The pattern is worth looking into by legal experts of MNCs or law firms and we will be happy to publish any research on this subject.

Final words … glimpse of hope for future improvements

It feels bizarre how Chinese hospitals became almost the center of my life this summer. In the weeks following my discharge from the Ditan Hospital, I had more chances to visit Chinese hospitals of various types and sizes. I was particularly impressed by two hospitals that, in my opinion, represent hope and future direction of Chinese healthcare facilities.

One of them is a prestigious 3A hospital in Tianjin and on that occasion I accompanied a relative to see a specialist there for a second medical opinion.  I was at first overwhelmed by the crowd in the hospital but very soon I discovered it was quite orderly despite the number of people.  It came as a pleasant shock to find that the hospital admission to see a chief doctor and a deputy chief doctor is only CNY 10 and CNY 8 respectively and the fee for a regular doctor is only CNY 0.5. Once the admission fee was paid, we were directed to a waiting room with a huge display screen (like the ones we see in airports) with patient names and assigned doctor rooms on it. We then proceeded to another waiting area outside our doctor room which had a display panel above the door showing names of all patients in the waiting order. The doctor was very experienced and, to my surprise again, he obtained patient records, took notes and prescribed all on his hospital-networked computer. The whole process of this hospital visit took only 25 minutes and costed CNY 8!

On a separate occasion, I took my daughter to a private women hospital in Beijing, which was referred to us by relatives, for her acne problem. She saw a dermatologist in the U.S. earlier but the medications she was prescribed caused adverse reactions. An internet search seems to suggest that there are few western medicine choices for the condition and patient comments for these medicines are not very encouraging at all. This private hospital offers both Western and traditional Chinese medicine treatments and the hospital environment is very patient friendly with no waiting or crowds. At CNY 100 admission fee, we saw a senior physician who was not only experienced but also very generous with her time. Later we learnt that she was just retired from a 3A public hospital. My daughter was put on a traditional Chinese medicine therapy combining the use of boiled herbal medicines and acupuncture. This therapy is supposed to take care of the root cause of the acne. My daughter is now ten days into the therapy and the result has been remarkable.  I am confident the whole problem will be cured with a few more weeks of treatment.

The ongoing healthcare reform aims to rationalize healthcare resources in the country, reduce wastes and improve efficiency through reforming structural flaws of the Chinese hospital system, support the development of multi-layered healthcare service provision by allowing market forces and private investments, encourage freer flow of healthcare professionals, and revamp incentive mechanisms of healthcare personnel and the hospital financing model.

Backed by the reform and sharply rising government investments, these successful cases give me hope and confidence for enormous improvements in every aspects of the Chinese healthcare system in the near future.