Correspondence

Health and Development, Queen Margaret University, Edinburgh, UK (GZ, BM); and School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China (XW) 1

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Wanga K, Gimbela S, Malikb E, Hassenc S, Hagopiana A. The experience of Chinese physicians in the national health diplomacy programme deployed to Sudan. Glob Public Health 2012; 7: 2. Chan L-H, Chen L, Xu J. China’s engagement with global health diplomacy: was SARS a watershed? PLoS Med 2010; 7: e1000266. Ministry of Health China. Beijing Declaration of the ministerial forum of China–Africa health and development, 2013 (in Chinese). http:// www.moh.gov.cn/gjhzs/s3590/201308/ d331f487fa304e11b86a856df7f4eee8.shtml (accessed Nov 18, 2013). Han Q, Chen L, Evans T, Horton R. China and global health. Lancet 2008; 372: 1439–41. Ministry of Health China. Call for expression of interest, 2013. http://cps.moh.gov.cn/flo/c/ main?fid=open&fun=show_news&from= view&nid=1599 (accessed Nov 18, 2013). Walley J, Khan M, Shah S, Witter S, Wei X. How to get research into practice: first get practice into research. Bull World Health Organ 2007; 85: 424.

Medication safety for children in China Despite years of promotion of medication safety for children by WHO,1 the situation remains difficult in China. Recently, two kindergartens in northwest China were accused of having given unauthorised antiviral moroxydine hydrochloride tablets to children since 2008—1455 children reported constipation, stomach aches, leg pain, loss of appetite, and night sweat after taking the pills.2 Later, more kindergartens were closed for issues of irrational medication.3 According to the Southern Medical Economy Institute of China Food and Drug Administration (CFDA) about a third of the medicines given to children are indiscriminately prescribed by doctors and non-medical personnel, sometimes unnecessarily or on parents’ request, with little regard for their potential hazards. The number of annual paediatric outpatient visits exceeds 300 million in China. 4 Nowadays, medication safety for children is a recognised issue and increased pressure has generated widespread social concern in China. 1462

A scarcity of national adverse drug reaction surveillance systems among children and weak national drug policies are the major issues. Although CFDA has achieved a lot in improving medicine administration, it is not enough. CFDA should increase collaborations with health officials and health institutions to create a comprehensive national paediatric drug administration network. The restricted availability of paediatric drugs is another important issue. Only 5% of the pharmaceutical companies produce paediatric drugs, and 90% of medications on the market do not have a child-specific dosage on packages in China. Paediatricians are forced to prescribe adult drugs, which can threaten children’s safety.5 China should encourage paediatric drug research and production, and support safety and effectiveness of drugs used in children. Moreover, the tense doctor–patient relationship in China can also lead to irrational medication. Indeed, when the treatment does not work as quickly as the parents would expect, doctors are under pressure and can be threatened by parents; doctors might then favour strong and fast-acting medicines. To ensure drug safety for children in China, efforts are needed at all levels: governments, drug regulatory agencies, pharmaceutical industries, health-care professionals, and parents. Collaborative regulatory initiatives, such as the use of common warnings, can also contribute to a more rational use of medications for children. We declare that we have no competing interests.

*Cheng Wu Tang, Wen Ming Feng, Ying Bao, Yan Zhu [email protected] Department of Pediatric Surgery, First People’s Hospital affiliated to Huzhou University Medical College, Huzhou, Zhejiang Province, China (CWT, WMF, YB); and Department of Pediatrics, First People’s Hospital affiliated to Huzhou University Medical College, Huzhou, Zhejiang Province, China (YZ) 1

WHO. Promoting safety of medicines for children. Geneva: WHO Press, 2007.

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Ma L. Kindergarten probed over pill claims. China Daily, March 13, 2014. http://www. chinadaily.com.cn/china/2014-03/13/ content_17343004.htm (accessed March 13, 2014). Luo WS. Medicine scandal shows child-care mismanagement. China Daily, March 18, 2014. http://www.chinadaily.com.cn/ china/2014-03/18/content_17354289.htm (accessed March 18, 2014). Southern Medical Economy Research Institute of China Food and Drug Administration. China report of medication safety for children in 2013 (in Chinese). http://web.yyjjb.com:8080/ html/2013-06/03/content_192971.htm (accessed June 3, 2013). Liu ZH. Children forced to take adult medication. China Daily, Dec 25, 2013. http://www.chinadaily. com.cn/life/2013-12/25/content_17195142. htm (accessed Dec 25, 2013).

Reviving medicine as the art of humanity in China “Medicine is the art of humanity” (yi nai ren shu, in Chinese). Yet, the art of medicine in modern China is in profound disarray. Mistrust between patients and physicians has become endemic, and stories of patients killing the physicians entrusted to heal them are increasingly common.1 A tenprovince survey in China showed that more than half of physicians had been verbally abused, a third of physicians were threatened, and 3·4% were physically assaulted by patients.2 This widespread patient–physician mistrust has affected medical education in China. More than three-quarters of physicians in China would not advise their children to follow their footsteps into medicine.3 At the same time, the medical education system importantly shapes the values of modern medicine and could be a fulcrum for change. Reforming preclinical and clinical education in China can help begin to rebuild patient–physician trust. First, enhancing of preclinical ethics, humanities, and social science training that directly relate to medicine could promote doctors’ empathy for patients and crucial reflection skills that nurture professionalism.4 Many medical schools in China incorporate www.thelancet.com Vol 383 April 26, 2014

Correspondence

We declare that we have no competing interests.

Joseph D Tucker, Jing-Bao Nie, Yu Cheng, Wei Zhu, Arthur Kleinman [email protected] University of North Carolina Chapel Hill ProjectChina, Guangzhou 510095, China (JDT); University of North Carolina Chapel Hill, Institute of Global Health and Infectious Diseases, Chapel Hill, NC, USA (JDT); Division of Health Sciences, Bioethics Centre, University of Otago, Dunedin, New Zealand (J-BN); School of Sociology and Anthropology, Sun Yat-sen University, Guangzhou, China (YC); Center for Applied Ethics and Department of Social Sciences, Fudan University, Shanghai, China (WZ); and Harvard Asia Center, Harvard University, Cambridge, MA, USA (AK)

www.thelancet.com Vol 383 April 26, 2014

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The Lancet. Ending violence against doctors in China. Lancet 2012; 379: 1764. Zhang X, Sleeboom-Faulkner M. Tensions between medical professionals and patients in mainland China. Camb Q Healthc Ethics 2011; 20: 458–65. Jiang NJ. 70% of doctors would not want their children to be doctors. 2011. http://health. people.com.cn/GB/15471173.html (accessed March 24, 2014; in Chinese). Dossett ML, Kohatsu W, Nunley W, et al. A medical student elective promoting humanism, communication skills, complementary and alternative medicine and physician self-care: an evaluation of the HEART program. Explore 2013; 9: 292–98. Nie J-B. Medical ethics in China: a transcultural interpretation. London: Routledge, 2011.

Rate of caesarean section is alarming in China Data from WHO suggest that nearly half of all births in China were delivered by caesarean section in 2007–08,1 which is three times higher than WHO’s recommended proportion of 15%. Although the rate of caesarean section in China has decreased to about 42% in 2010, it is still the highest worldwide. Many studies have shown that women who have caesarean section without medical necessities are at high risk of related complications or death.2 Additionally, babies delivered by caesarean section are more likely to have respiratory problems, obesity, and other metabolic diseases. 3 These findings show the urgency of controlling the rate of caesarean sections in China. There are five reasons other than medical necessities that might explain the high rate of caesarean section in China. First, some women’s concerns about pain and vaginal tone after vaginal birth: in their opinion, caesarean section is safer, faster, and less painful, and is less likely to affect the quality of sexual life than vaginal birth. Second, some women wrongly believe that they are more likely to regain their prepregnacy shape after caesarean section than vaginal birth.

Third, Chinese mothers like to choose a delivery date on the basis of luck and belief, and it is easier to deliver on a scheduled day by caesarean section than to deliever an unplanned vaginal birth. Fourth, some doctors do recommend caesarean section to women in view of the present uneasy doctor–patient relationship and possible lawsuits. Furthermore, caesarean section is financially profitable for the hospital. For example, in large Chinese cities such as Beijing, the price is about 6000 RMB (US$1000) for vaginal birth, whereas it is at least 12 000 RMB ($2000) for caesarean section in some top-level hospitals. Fifth, increasing numbers of macrosomia in China attributable to the increasing prevalence of diabetes and obesity in women,4 and increasing pregnancies in older women will further increase the rate of caesarean section. To effectively control the rate of caesarean section in China, the Chinese Government should develop specific policies and measures, such as use of rate of caesarean section without medical necessities as one of the hospital’s overall rating components, and popularising of natural childbirth. Hospitals and communities should promote health education in women of reproductive age to provide a more accurate idea of delivery. Additionally, prevention of obesity and diabetes in women of reproductive age, which will reduce the risk of macrosomia, is also important to decrease rates of caesarean section. Women of reproductive age should also be encouraged to give birth before age 35 years.

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ethics in a symbolic manner, but expanding and firmly rooting these fundamental discussions in modern medical disputes would increase student engagement and clinical relevance. Second, clinical instruction to improve communication can provide medical students with a set of techniques to better manage disputes and navigate the health systems issues that underpin mistrust. These thorny topics are rife with tension and deserve increased attention as a core component of medical education. While such reforms can learn from effective programmes outside China, they can also draw on the rich ancient Chinese tradition of humanism in medicine exemplified by Sun Simiao’s “the excellence and sincerity of the great physician”.5 There are inevitably tradeoffs associated with expanding humanistic medical training. Increased humanism within medical education is necessary but not sufficient for ensuring patient– physician trust in China. A wide range of legal, social, and financial changes are also necessary. Present medical curricula are stretched taut and most schools do have enough full-time medical humanists. However, the Chinese crisis of patient–physician mistrust provides a powerful empirical clinical context by which to promote humanistic medical training. Humanistic training to deepen modern patient–physician trust could help revive and safeguard the old Chinese moral ideal of medicine as the art of humanity.

We declare that we have no competing interests.

*Jie Mi, Fangchao Liu [email protected] Department of Epidemiology, Capital Institute of Pediatrics, 2 Ya Bao Road, Beijing, 100020 China (JM); and Fu Wai Hospital and Cardiovascular Institute, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China (FL) 1

Lumbiganon P, Laopaiboon M, Gülmezoglu AM, et al. World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010; 375: 490–99.

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