News this Week

Science  01 Feb 2013:
Vol. 339, Issue 6119, pp. 494

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  1. Around the World

    1 - Mount Elizabeth, Antarctica
    No Survivors in Antarctic Plane Crash
    2 - Washington, D.C.
    Sandy Relief for Hurricane Hunters
    3 - Cairo
    Polio Virus Spreads From Pakistan to Egypt
    4 - Taipei
    'Richer-Than-Nobel' Science Prize Comes With a Twist
    5 - Whillans Ice Stream, Antarctica
    U.S. Mission to Whillans Ice Stream a Success

    Mount Elizabeth, Antarctica

    No Survivors in Antarctic Plane Crash


    The wreckage of a Twin Otter aircraft that went missing in the Antarctic was found near the summit of a mountain in the Queen Alexandra mountain range, about 700 kilometers from both the South Pole and the United States' McMurdo Station. The plane, which was to be used as part of Italy's polar research program, crashed on 23 January, but bad weather prevented rescuers from reaching it for several days. The three Canadian crew members that were aboard the plane are all presumed to have died in the crash. Why the plane crashed was still unclear when Science went to press. Citing poor weather conditions, on 28 January officials with the United States Antarctic Program and Antarctica New Zealand jointly chose to recall search-and-rescue teams from the site and delay efforts to recover any remains until the next Antarctic research season.

    Washington, D.C.

    Sandy Relief for Hurricane Hunters

    Hurricane researchers are about to get some new wings. The U.S. Senate on 28 January approved a $50.5 billion bill designed to help people recover from last year's superstorm Sandy. It includes more than $250 million to help the National Oceanic and Atmospheric Administration (NOAA) replace and repair buoys, radars, and other research assets damaged by the storm, as well as to strengthen weather and coastal science programs designed to track future storms. The total includes $111 million to cover an expected data gap when several weather satellites die over the next few years, $50 million for the agency's cooperative research programs in northeastern states, and $44.5 million to put new wings on two of NOAA's aging Orion "hurricane hunter" aircraft.


    Polio Virus Spreads From Pakistan to Egypt


    Egyptian and international health officials are on high alert after poliovirus from Pakistan was discovered in sewage water collected during routine sampling in Cairo in December. Genetic sleuths linked the Cairo poliovirus to one last seen in Sindh Province in Pakistan in September 2012, the World Health Organization (WHO) reported last week. How the virus got to Cairo is unclear—people can carry the virus asymptomatically when they travel—but the analysis, conducted by the U.S. Centers for Disease Control and Prevention, suggests that it made the leap in the past few months. Egypt has not had a case of polio since 2004.

    So far, no polio cases have been detected in Cairo, and there is no evidence that the virus is circulating widely. But the risk that this imported virus could spark an outbreak there is real, says Bruce Aylward, who runs the global polio eradication effort from WHO in Geneva, Switzerland. Emergency vaccination campaigns are slated for Cairo and the rest of the country in the next few weeks. Meanwhile, Pakistan, one of just three countries where polio is still entrenched, is under even more pressure to stamp out the virus within its borders.


    'Richer-Than-Nobel' Science Prize Comes With a Twist

    A Taiwanese tycoon has established a new science prize that will not only pay out more than the Nobel Prize but will support research as well. Individuals or institutions that have demonstrated the most creative and influential research in four fields will receive about $1.36 million, while an additional $341,000 will support a plan proposed by recipients to support research and develop talent in a related area over 5 years. (The Nobel Prize amount for 2012 was about $1.2 million.)

    The Tang Prizes, named after China's Tang Dynasty, will be awarded biennially for work in sustainable development, biopharmaceutical science, sinology (excluding literary works), and rule of law. Samuel Yin, who made a fortune in diversified real estate, financial, and retail investments, is endowing the prize. Academia Sinica, which oversees Taiwan's premier research labs, will be responsible for the nomination and selection process. The first prize announcement is set for July 2014.

    Whillans Ice Stream, Antarctica

    U.S. Mission to Whillans Ice Stream a Success

    A U.S.-based team announced on 28 January that it had successfully retrieved its first samples of sediment and water from the Whillans Ice Stream, a body of water sealed nearly a kilometer below the Antarctic ice. The interdisciplinary project is looking for subglacial microbial life, and also studying the continent's climate history and ice sheet dynamics. The samples of sediment and basal ice from beneath the water are expected to help scientists understand whether subglacial lakes act to stabilize or destabilize the West Antarctic Ice Sheet.

    The team is the second of three research groups this season to achieve its goal of retrieving samples from some of the continent's mysterious buried waters. In December, a British Antarctic Survey team seeking to penetrate subglacial Lake Ellsworth was forced to pull the plug on its mission due to technical problems. Last month, a Russian team nabbed its first sample from subglacial Lake Vostok.

  2. Newsmakers

    Three Q's



    Biotechnologist Hayat Sindi received her Ph.D. from the University of Cambridge and was a visiting scholar at Harvard University before returning to Saudi Arabia in 2011 to create an institute to promote science and entrepreneurship. She's one of the first 30 women to be appointed to the country's 150-member Shura Council, which advises the government on science and technology.

    Q:What issues are you hoping to address as a council member?

    H.S.:I'm [geared] toward entrepreneurship and how we can encourage our youth to be innovative. Also, I'm interested in women's issues. So I'm going to concentrate on innovation, scientific research, youth, and women.

    Q:How do you see the role of science in the Middle East and around the world?

    H.S.:Science was born to solve problems, to look at how to improve quality of life. What I'm trying to figure out is how can I make science affordable and accessible to everybody?

    Q:What does having women on the Shura Council mean for women in Saudi Arabia?

    H.S.:This is the best thing to happen [for Saudi women] since women were permitted to study. Women look at different problems with different angles, in terms of economics or science or health or social studies. We cannot ignore [their] contribution.

    Deep-Sea, Semiconductor Research Net Japan Prizes





    Research at the bottom of the sea and wizardry in semiconductor clean rooms have netted this year's Japan Prizes, among the world's top science and technology awards. Each category carries a 50 million yen ($550,000) award, which laureates will receive along with medals at a ceremony in Tokyo in April.

    Marine ecologist J. Frederick Grassle of Rutgers University in New Brunswick, New Jersey, won for his studies of deep-sea hydrothermal vent ecosystems and organisms. He also helped launch the Census of Marine Life, intended to catalog the diversity of marine life, and the Ocean Biogeographic Information System, which is used in marine conservation efforts.

    Chemists Grant Willson, now of the University of Texas, Austin, and Jean Fréchet, of King Abdullah University of Science and Technology in Thuwal, Saudi Arabia, won for developing chemically amplified resists: photosensitive materials that allow semiconductor makers to shrink integrated circuits for microprocessors and memory chips, such as those in personal computers and mobile phones.

    NIH Loses a Senate Champion



    The National Institutes of Health (NIH) will lose one of its longtime champions with the upcoming retirement of Senator Tom Harkin (D–IA). Last week, Harkin announced he would not seek a sixth term, ending a 40-year congressional career.

    Harkin is currently chair of the Senate panel that sets funding levels for NIH, and he also chairs the committee that oversees federal policies in health, education, and labor. He teamed up with his then-Republican counterpart, Arlen Specter of Pennsylvania, to win a doubling of the NIH budget from 1998 to 2003. He and Specter also led an effort to include $10.4 billion for NIH in the 2009 stimulus package.

    With Specter, Harkin also sponsored legislation in the 2000s that would have expanded federal funding for research on human embryonic stem cells. But Harkin didn't always please scientists: In the 1990s, he pushed to create NIH's National Center for Complementary and Alternative Medicine, which critics claim wastes money testing fringe treatments.

  3. Random Sample

    Astrophysics Over Antarctica: Balloon Breaks Flight Record


    Now on its third orbit around the South Pole, a NASA scientific balloon has broken the record for the longest-flying balloon of its size. As it soars at an altitude of 39,000 meters—about the same stratospheric height from which daredevil Felix Baumgartner completed his record-breaking space dive last October—the balloon wields an instrument called the Super Trans-Iron Galactic Element Recorder (more pithily known as Super-TIGER), which measures heavy elements in the flux of high-energy galactic rays that bombard Earth. Super-TIGER, which launched on 8 December 2012 from a site near McMurdo Station, had stayed aloft for 46 days when Science went to press, shattering the previous record of 41 days for a long-duration scientific balloon, set in 2005. The team plans to continue flying it for another week or so to bring it closer to McMurdo before ending its flight.

    Independents Follow Where the Wind Blows


    U.S. voters who straddle the political fence—self-identifying as independents who lean neither left nor right—are most susceptible to short-term temperature fluctuations when it comes to whether they believe humans are causing climate change, according to a new study.

    Sociologist Lawrence Hamilton of the University of New Hampshire (UNH), Durham, used data from some 5000 random telephone interviews of New Hampshire voters conducted over a 2.5-year span. The interviewers asked voters about their political affiliations and views on climate change—whether it's happening and, if so, whether it is "caused mainly by human activities." The poll also asked the voters to rate their political affiliation (on a scale of one to seven, with four representing independents).

    Then, Hamilton and UNH geographer Mary Stampone compared the answers to temperature and precipitation data collected across the state. They found no pattern associated with precipitation. Temperature was another story. Whereas Democrats and Republicans tended to stick to their beliefs regardless of how hot or cold it was, independents were strongly influenced by temperature (see graph). When interviewed on unseasonably warm days, independents tended to agree that humans are causing climate change. On unseasonably cool days, they tended to think the opposite, the team reported last month in Weather, Climate, and Society.

    It's a striking graph, Hamilton notes. "If ever a logia regression plot could go viral, that might be the one." But the pattern is not totally unexpected, he says. Past studies have shown that "minor experiential things," such as room temperature, can alter how subjects answer a question.


    Join us on Thursday, 7 February, at 3 p.m. EST for a live chat with experts about a hot topic in science.

  4. A Worm Vaccine, Coming at a Snail's Pace

    1. Kai Kupferschmidt

    The long struggle to develop a schistosomiasis vaccine badly needs new money.

    Eyes on the target.

    Miriam Tendler's vaccine candidate is based on Sm14, a crucial Schistosoma protein.


    RIO DE JANEIRO, BRAZIL—Miriam Tendler has not moved her lab in more than 20 years. Her office is cramped and filled with stacks of paper, and the hallways are lined with big filing cabinets. Yet Tendler has stayed in this old, low building on the campus of the Oswaldo Cruz Foundation, she explains, because she is afraid of doing anything that could disturb the life cycle of the microscopic worm that she has carefully nurtured in her lab all these years. Tendler has devoted her career to developing a vaccine against this worm, a pernicious parasite that is a scourge of people in eastern Brazil: Schistosoma mansoni.

    Her target is one of at least six flatworms that cause a debilitating human disease called schistosomiasis. The worms can live for decades in blood vessels, shedding eggs that cause pain, severe blood loss, and malnutrition and that can damage the liver, kidneys, and spleen. Half of their unusual life cycle takes place in freshwater snails, which is why one room in Tendler's lab houses dozens of aquariums.

    According to the World Health Organization (WHO), schistosomiasis, also known as bilharzia, is the second most devastating parasitic disease in the world, after malaria. Some 200 million people are estimated to be infected, most of them children, and another 600 million are at risk. Mortality estimates vary widely, but Lester Chitsulo, who heads WHO's Schistosomiasis Control Programme in Geneva, Switzerland, says that there are probably almost 300,000 deaths a year in sub-Saharan Africa alone.

    Vaccines could be powerful weapons against schistosomiasis, but a lack of interest and money, combined with the fact that a cheap, effective drug is available, has hampered research. "We have limped along with small amounts of money," says Alex Loukas of James Cook University, Cairns, in Australia. That could change if, as researchers hope, the Bill & Melinda Gates Foundation joins the fight. Next month, the foundation will bring experts to Seattle for a 2-day meeting to discuss schistosomiasis vaccines. If it decides to fund the research, everything could change, Loukas says.

    There has been some progress; two vaccines are now in clinical trials. But there are questions about both. Bilhvax, developed at the Pasteur Institute in Lille, France, targets S. haematobium, a species that causes urogenital schistosomiasis and is common in Africa and the Middle East. But despite extensive trials, very little has been published so far, leading other scientists to wonder what's going on.

    The other is Tendler's candidate against S. mansoni, backed by the Brazilian government through a public-private partnership. The vaccine, the only one from a country where Schistosoma is endemic, may enter phase II trials this year. (It's based on a protein called Sm14, which a worm uses to ferry a host's fatty acids into its own cells.) But some groups have been unable to replicate the high level of protection that Tendler has shown in mouse studies.

    What's more, vaccines are needed for other Schistosoma species as well, as there is no one-size-fits-all vaccine. "We need to develop a pipeline," says Peter Hotez, dean of Baylor College of Medicine's National School of Tropical Medicine in Houston, Texas. Hotez is working on a vaccine candidate named Sm-TSP-2 that has yet to reach the clinic; another candidate, Sm-p80, is also being developed in the United States.

    Into the groove

    Different Schistosoma species cause different patterns of symptoms, but the parasites essentially follow the same lifecycle. They reproduce in freshwater snails that release large numbers of free-swimming larvae, called cercariae, into the water. When these find a human, for instance a child playing in the water, they burrow through that person's skin with their head. The larvae then lose their tail and migrate through the blood vessels and the lung into the liver, where they mature into adult worms and mate. The larger male worm forms a groove, which the thinner female slips into.

    Together, the couple moves into veins in different parts of the body, depending on the species: S. mansoni and S. japonicum reside in the bowel and rectum, for instance, whereas S. haematobium migrates to the bladder. The females start producing hundreds of eggs daily, sometimes for many years. Most of them are shed in urine and feces, and they can infect new snails if they end up in lakes or rivers. But some get trapped in the liver or other organs, causing an immune response that leads to the typical symptoms and sometimes death.

    Public health officials tried for decades to get rid of schistosomiasis by targeting the snails. Despite sporadic successes, that strategy has proved too daunting in rivers like the Nile and the big lakes in Africa. Since the 1980s, a drug called praziquantel, which kills the worms in a person's body, has been the weapon of choice. In many endemic areas, all schoolchildren get the drug annually; Merck has provided praziquantel to WHO for free since 2007 and recently pledged to increase its annual donation to 250 million tablets.

    Circle of life.

    Schistosoma's life cycle takes it from freshwater snails to human blood vessels and back.

    But scientists worry that such widespread use will fuel resistance against praziquantel, the only drug available. Moreover, people in endemic areas usually get reinfected within months of treatment, so there is little long-term progress. "I think people are finally realizing that drugs alone are unlikely to control schistosomiasis," Loukas says.

    Vaccines would probably not prevent human infections, but they could reduce the number of eggs that female worms produce, which in turn would reduce symptoms and slow transmission, says Maria Yazdanbakhsh of Leiden University Medical Center in the Netherlands, who heads a European project to find a vaccine against S. mansoni. "If the worms produce fewer eggs, the water will be less infested, and that will slowly reduce transmission." Studies suggest this is possible. Adults in endemic areas have been found to be partially immune to reinfection, and in animals, vaccines were shown to reduce the number of eggs by about half.

    Hotez thinks support for a vaccine is now growing, in part because of schistosomiasis's role in the HIV epidemic: Female genital schistosomiasis increases the risk of contracting HIV three- or fourfold. If the Gates Foundation steps in, it would raise the disease's profile, Yazdanbakhsh says, and that could encourage national governments to donate as well. So far, the foundation has made no commitment, and it would not comment to Science.

    Painful rashes

    Even if more money becomes available, there are obstacles to a successful vaccine. One of them emerged in 2007 during a trial of a vaccine against a different group of parasites called hookworms. Healthy U.S. volunteers tolerated the shots well, but a study conducted in an area of Brazil where hookworm infection is common had to be suspended when three of the first seven volunteers developed painful rashes on their head, neck, and shoulders. The rash was caused by a class of antibodies called IgE, which the volunteers had developed during prior hookworm infections, says Loukas, who was involved in the trial.

    To prevent such nasty surprises with Schistosoma, Loukas says, any new vaccine candidate needs to be screened to see whether people in endemic areas might have IgE in their blood that reacts with it. "If they do, we immediately throw the candidate out," he says. For some of the candidates already in development—including the two in clinical trials—such data have yet to be presented.

    Another difficulty is that the results of several promising studies in mice—including Tendler's Sm14 vaccine—have not been replicated by researchers in other labs, for reasons that aren't clear. "This is a problem that has plagued the schistosomiasis field for many years and it has done the field an enormous amount of harm," Loukas says. How well results in mice translate to humans is also unclear. Although S. mansoni infects mice readily, the rodent is not a natural host; in terms of sheer size, one pair of worms in a mouse is equivalent to a very heavy infection in humans. Some researchers have switched to other animal models, such as baboons, which require special facilities and are more expensive.

    The French vaccine, meanwhile, is a bit of a dark horse. A phase I trial, done in 1998 and 1999 in France, was not published until July 2012; phase II and phase III studies, both completed, have yet to appear. The team's original strategy was to go through all the phases before publishing anything, Gilles Riveau of the Pasteur Institute writes in an e-mail to Science. "I think today that we were wrong," he adds, saying that results on phase II may be out soon.

    Others are betting on new targets, and the genomes of S. mansoni and S. haematobium, both now sequenced, have given them a wealth of choices. Yazdanbakhsh and colleagues are aiming at the earliest form of the worm that the immune system encounters: the larvae passing through the skin. Scientists in the consortium have identified genes that are turned on only in this stage; by targeting these proteins, they hope to catch the worm before it has its defenses up. Such a vaccine, they hope, might prevent infection altogether.

    Loukas's group, meanwhile, has developed an array of Schistosoma's surface proteins, which they have screened against the blood of resistant individuals to see which antigens are recognized by their immune system. A new vaccine candidate will be published soon, he says.

    With so much new technology available, developing a vaccine is now primarily a question of political will, Tendler argues. "This is not a bet, this is not a game, this is not magic. It is just work."

  5. Space

    Tight Budgets Squeeze European Earth Observation

    1. Daniel Clery

    The Europe-wide financial crisis and uncertainty over the European Union's future funding are casting shadows over Earth monitoring and science missions.

    On the face of it, the European Space Agency's (ESA's) Earth-observation program came out of last November's budget-setting council meeting pretty well: With €1.9 billion over the next 5 years (20% of ESA's total budget), it is the agency's biggest program. But to make room in the budget for new launchers and the International Space Station, member states have put the squeeze on Earth-observing science missions (Science, 30 November 2012, p. 1135). And, with the funding of the European Union still in doubt, questions hang over the future of a groundbreaking environmental monitoring system, an ESA-E.U. collaboration called Global Monitoring for Environment and Security (GMES, recently renamed Copernicus by the European Union). "This is far too important for Europe not to get its act together," says Alan O'Neill, director of the United Kingdom's National Centre for Earth Observation.


    Monitoring topography, temperature, and color of land and sea.


    GMES is an unprecedented attempt to create an operational environmental monitoring system akin to the meteorological systems that have been in place for decades. GMES involves a whole fleet of spacecraft with different sensors—built and paid for by ESA—along with duplicate backup craft and operations and user facilities provided by the European Union. The aim is to provide steady, reliable data of use to European governments, industry, emergency services, and citizens. "There is no program like GMES. It's an Earth management system," O'Neill says.

    European researchers got a taste for long-term, high quality data from Envisat, ESA's bus-sized satellite that operated for 10 years until ended by an unidentified failure in April 2012. The idea of GMES "emerged out of the Envisat decade. People could see what you can do with long-term data," says John Remedios, head of Earth observation science at the University of Leicester in the United Kingdom. Envisat carried nine instruments that gathered data about land, water, ice, and the atmosphere. Most will be replicated or upgraded in GMES.

    ESA is close to completing the first three GMES spacecraft, known as Sentinels, which are due to launch this year. But the European Union's funding beyond the end of this year is not yet secure as the European Commission (the European Union's executive arm), the 27 member states, and the European Parliament debate the union's budget for the next 7 years (Science, 16 November 2012, p. 872).

    The next round of the E.U. budget negotiations will take place on 7 to 8 February. Because of the faltering economies across Europe, the commission is under enormous pressure to curb its ambitions; some states even want to cut E.U. funding below current levels. In 2011, the commission proposed €5.8 billion for GMES over 7 years. The member states countered with a suggestion of €3.8 billion, a figure that alarmed ESA, researchers, and other potential users.

    At that level of funding, "there will be cuts," says ESA's head of Earth observation, Volker Liebig. "If they can't finance the recurrent [duplicate] satellites, there is a danger that we might have data gaps," he says. If the European Union has not confirmed the budget for the operations infrastructure by the time of the Sentinel-1 launch in August, Liebig says, the ESA member states could decide it is too risky to launch the satellite. "We have delivered; I hope the commission can also deliver," Liebig says.

    Because of the continuing uncertainty over the E.U. contribution to GMES, at the ESA council meeting in November some ESA member states were reluctant to commit the full amount for the next round of GMES satellite building. ESA secured only 80% of the required funds at the meeting.

    Much of ESA's Earth observation budget goes toward meteorological satellites. But another area also came up short on funding: a series of science missions known as Earth Explorers, which seek to observe Earth and its atmosphere in new ways using innovative technology. Three have been launched so far—looking at soil moisture and ocean salinity, ice cover, and ocean circulation—and another three are under construction. A further three proposals are vying to start construction as Earth Explorer 7. A choice will be made sometime in the next few months.

    The future of Earth Explorer 8, however, looks less certain after November's council meeting awarded the program only 80% of its expected €1.25 billion budget. "A variety of solutions are now being considered," says O'Neill, who is the chair of ESA's Earth Science Advisory Committee. Heinrich Bovensmann of the University of Bremen in Germany, who heads one of the teams competing to build Earth Explorer 8, says he expects ESA to adopt "the classical way space agencies deal with budget problems: delay things."

    If selected, Bovensmann's CarbonSat will use absorption spectroscopy to image sources of carbon dioxide and methane—the main greenhouse gases—in high resolution. "It's the first time we'll be able to make a distinction between natural and anthropogenic sources," he says. The other contender for the mission, the Fluorescence Explorer or FLEX, aims to measure the carbon balance of plant life by detecting chlorophyll fluorescence, a sensitive marker for photosynthetic efficiency. "The signal is very small, and this is the first time it will be measured from space," says José Moreno of the University of Valencia in Spain.

    There is now no guarantee that either mission will get off the ground any time soon. Moreno says: "The situation is rather difficult at the moment, and no one knows how well it will evolve in the future."

  6. China

    World's Biggest Health Care System Goes Under the Knife

    1. Mara Hvistendahl

    Ambitious reforms of the Chinese medical system aim to expand infrastructure, cover the poor, and combat chronic diseases.

    Hard to bear.

    High out-of-pocket costs have plunged many Chinese, including the family of this badly burned boy in Hefei, deep into debt.


    SHENZHEN, CHINA—In most Chinese hospitals, teeming waiting rooms and forlorn patients wheeling intravenous drips through dingy, ill-lit halls are troubling but typical sights. University of Hong Kong (HKU)-Shenzhen Hospital, however, is anything but typical. Its gleaming wards and labs, opened to outpatients last July, are at the vanguard of China's health care reforms.

    The hospital here in Shenzhen, the crucible of China's economic rebirth, is the brainchild of China's health ministry, which convinced the local government to put up $56.2 million for the 350,000-square-meter complex across the border from Hong Kong. HKU's stewardship is meant to separate the venture from the rest of the pack for more than its looks. "They don't need us to teach them how to stitch up wounds," says Sum-ping Lee, dean of HKU's medical school. The health ministry envisions the institution as "an important model in the process of reforming public hospitals," says a spokesperson. One prong of that strategy is to boost medical research: HKU professors will apply their expertise to a planned research arm of the hospital that will focus on oncology, orthopedics, liver disease, and infectious diseases.

    HKU-Shenzhen Hospital is part of a Chinese spending spree on health care, with total outlays predicted to triple from $357 billion in 2011 to $1 trillion in 2020, when the government hopes to have implemented universal coverage. (Only 15% of the population was insured in 2000, according to the health ministry.) The investment is largely directed at improving basic health care. In 2000, the World Health Organization (WHO) ranked China 144th out of 191 national health systems. Al though some scholars dispute WHO's methodology, which is no longer used, few deny that China's health care system is ailing. Gaps in hospital capacity and quality of care have fueled rising discontent, culminating in a recent spate of murders of doctors and nurses. According to China Daily, Chinese hospitals reported more than 17,000 violent incidents in 2010—mostly involving disgruntled patients.

    A white paper released by China's State Council last December outlines the basic tenets of the reforms, which include expanding insurance coverage, reconfiguring drug pricing, and promoting primary care. The reform drive also includes money for research into traditional Chinese medicines and an overhaul of the drug pricing system—a move that could affect pharmaceutical research. The health ministry, meanwhile, is pushing the training of more medical professionals, updating China's mental health infrastructure (see sidebar, p. 506), and backing the development of hospitals like HKU-Shenzhen.

    Health care in China today bears little resemblance to the system in place during its socialist heyday. In the 1970s, agricultural communes featured rural health care centers staffed by about 1.8 million "barefoot doctors": health workers with basic training who provided primary care. Among them was Chen Zhu, China's current health minister. As the Chinese government began instituting market reforms in the 1980s, it pulled funding from hospitals and clinics. The barefoot doctor system disintegrated. By the 1990s, the government was contributing less than 20% of total health care costs—the low end of developing countries, says Gordon Liu, an economist at Peking University in Beijing who served on a health care reform taskforce under China's State Council.

    To recoup lost funds, hospitals charged a 15% markup on prescription drugs. Doctors began prescribing antibiotics indiscriminately, sparking an uptick in drug-resistant bacterial strains (Science, 18 May 2012, p. 795). As China's health infrastructure frayed, diseases like syphilis, once on the ropes, reemerged with a vengeance (Science, 27 January 2012, p. 390). Then came the debilitating SARS outbreak in late 2002: "It was a wake-up call for the Chinese government," says Yanzhong Huang, a global health fellow at the Council on Foreign Relations in New York City.

    A more enduring problem is that economic development and an aging population have driven a shift in the disease burden from infectious to chronic diseases, which today account for roughly 85% of deaths in China, up from 53% in the 1970s. "That pushed the demand for health care a lot," Liu says. As the transition took hold, the health care system remained woefully unprepared to handle the surge of patients, with too few doctors and medical facilities. Inadequate insurance, meanwhile, meant that many Chinese could not afford care in catastrophic cases. "Families are suffering from a huge economic burden," said Yao Hong, director of the Ministry of Human Resources and Social Security's health insurance department, at a conference in Beijing in July.

    Dreaming big.

    Sum-ping Lee envisions the University of Hong Kong-Shenzhen Hospital as a trailblazer in research and care.


    To address these issues, in 2009 China unveiled a blueprint for providing basic insurance for 90% of Chinese by 2011, implementing more standardized training for doctors, constructing thousands of new county hospitals, and putting a clinic in every village. The plan also emphasized chronic diseases, which the health ministry says accounted for 69% of costs associated with China's disease burden in 2009. Community health centers must now provide free check-ups for hypertension and diabetes patients four times a year, says Wu Yangfeng, director of The George Institute, China, and a cardiovascular specialist at Peking University Clinical Research Institute in Beijing. The health care reforms are "not just of political significance," he says. "The basic health services will really help to cover a broad range of the population affected by chronic disease." A new requirement to check every patient's blood pressure will help catch the estimated 70% of Chinese with hypertension who are not aware they have it, Wu says. The increased focus on chronic diseases may benefit research. "Our whole conceptualization of noncommunicable diseases is based on data from what is a minority of the global population today," says Gabriel Leung, a public health researcher at HKU. "None of it came from China." Researchers may now start to identify population-specific risk factors in China and other developing countries, he says.

    One potential downside is the effect of reforms on drug development. Until recently, up to 50% of China's total health care spending went toward drugs, Liu says—a sum that "might be the highest drug-to-total-health-care-expenditure ratio in the world." (In Organisation for Economic Co-operation and Development countries, the ratio averaged 18% in 2003.) China aims to bring expenditures down, Liu says, by restricting hospitals to lists of government-approved drugs and by outlawing profiteering on prescriptions. The selection process for the lists has set off bidding wars, with companies rushing to underbid each other. The drop in revenue will shave profit margins—a change that could squeeze research. "Drug companies are of course nervous about the future source of income for their R&D," Liu says. But, he adds, because total health care spending in China is increasing by more than 15% each year, the country will continue to be a profitable market: Even as drug companies' share of the pie decreases, Liu says, "The total pie will increase." The health ministry contends that strong government support of pharmaceutical research will help compensate for any losses.

    Life insurance.

    Hospitals have hired guards following a wave of violence against doctors and nurses.


    A larger economic challenge will be containing costs for patients. Today, 95% of Chinese have basic insurance covering some medical costs, according to the health ministry, which has gradually deepened the coverage to include some catastrophic medical expenses and outpatient treatment as well as routine checkups and tests. But broader coverage has not stemmed soaring costs. A preliminary study from the Institute for the Study of Labor in Bonn, Germany, shows that Urban Resident Basic Medical Insurance, which was launched in 2007, has increased hospital visits without reducing out-of-pocket expenses. "If health expenditure growth is not controlled, then the financial protections on the population are still going to be limited," says Winnie Yip, a health policy expert at the University of Oxford in the United Kingdom. Huang points out that China's roughly 200 million internal migrants—a "bridging" group that spreads HIV and other infectious diseases from high-risk groups like urban sex workers to low-risk groups like rural heterosexual women—are largely insured in their home towns, meaning far less than 95% of the population takes advantage of the new national program.

    The central government has tried to better cover migrant workers by allowing them to enroll in insurance at their urban workplaces. But combating chronic diseases will ultimately require much more than free checkups and treatments. "The most effective control is really prevention," Yip says. At the top of the list, Huang says, should be enforcing the WHO Framework Convention on Tobacco Control—a tough task in a country with an entrenched tobacco lobby (Science, 13 January 2012, p. 153). "We haven't seen any government leaders publicly speak out against smoking," he says.

    "Clearly there is still a long way to go," Wu says. But the emphasis on chronic disease is an important first step, he says: "That is the right direction for China."

  7. A New Dawn for Mental Health

    1. Mara Hvistendahl

    After long neglecting the field of mental health, China has included it in sweeping heath care reforms.

    SHANGHAI, CHINA—Graduates of Chinese medical schools once steered clear of mental health work. In the 1980s, recalls Michael Phillips, a psychiatrist at Shanghai Mental Health Center and Emory University School of Medicine in Atlanta, "they would do anything to get out of it." The field then was reeling from decades of suppression. After the 1949 revolution, it had been branded a bourgeois science, with drug treatment in many psychiatric hospitals replaced by readings of Mao Zedong's Little Red Book. Today, psychiatry has gained legitimacy, but psychiatrists still complain of a poor mental health infrastructure and measly salaries. Thus, many cheered when China's health ministry announced in 2009 that it was making mental health a key focus area of its sweeping health care reforms (see p. 505).

    That newfound attention culminated last October in the adoption of a mental health law that had been under discussion for 27 years. The law is "a major event for Chinese psychiatry," Phillips says. It emphasizes the expansion of community mental health services, delineates professional duties in psychiatry and psychology, and introduces a more humane protocol for commitment to psychiatric hospitals. (An English translation of the law has been posted to the Web site of the Shanghai Archives of Psychiatry.)

    China has an estimated 173 million people with mental disorders of whom the vast majority—some 158 million—have never received treatment. Psychiatrists have been trying for decades to change that. In 1985, Liu Xiehe, a psychiatrist at Sichuan University's West China Hospital in Chengdu, wrote the first draft of China's mental health law. But bureaucratic intransigence, concerns about the cost of mental health services, and resistance from some psychiatrists stalled the process. By 2005, the draft had been revised 15 times to no avail.

    In the end, studies on the heavy socioeconomic toll of mental illness prodded Chinese officials to act. In 1996, the Global Burden of Disease Study found that mental illness, neuropsychological conditions, and suicide together accounted for 20% of China's illness burden, using a metric called disability-adjusted life years (Science, 1 November 1996, p. 740). The figure remained relatively stable until 2004, the last year for which data is available, Phillips says. In 2010, China committed to remodeling and expanding 550 psychiatric hospitals and wards within 2 years. Another area to benefit was community-based mental health, which has received more than $35.3 million from the central government since 2004. Health care reforms and the new law should bump up funding even further.

    The law divides China's mental health professionals into psychiatrists, psychological counselors, and psychotherapy practitioners, or what observers understand as clinical psychologists. The distinctions are intended to strengthen professionalism. Of China's estimated 20,000 psychiatrists, only about 20% hold a degree in the field, according to a study published in Asia-Pacific Psychiatry in October 2009. Clinical psychology and counseling is even more of a mixed bag. "Some people have psychology degrees, some have education degrees, and some have a background that has nothing to do with psychology," says Xiang Yutao, a psychiatrist at Beijing Anding Hospital and the Chinese University of Hong Kong. A key provision of the new law, designed to limit the reach of unqualified practitioners, states that psychological counselors cannot diagnose or treat mental disorders.

    No more winging it.

    A new law governing psychiatric hospitals aims to strengthen professionalism and curtail involuntary admissions.


    Patients stand to gain leverage: Under the new law, they can no longer be hospitalized against their will, unless deemed a danger to themselves or others. Previously China had a looser policy for committing patients to institutions involuntarily—a loophole exploited in the past to lock up unruly relatives after domestic disputes and, allegedly, political dissidents. "The most important aspect of the law is that it emphasizes the protection of patients' rights," Xiang says. Not all psychiatrists are keen on the voluntary commitment clause, fearing that it will complicate their work and reduce demand for psychiatric beds. Indeed, patients deemed a danger to others now have the right to request a reevaluation by two additional psychiatrists.

    The mental health community has its work cut out for it. A national epidemiological survey on mental health now under way—China's first in 20 years—should help elucidate what services are needed and where. But as needs in rural areas are clarified, convincing psychiatrists to leave cities will be difficult. "The idea is you're going to get all these psychiatrists out in the community. I don't see it," Phillips says. Another stumbling block may be convincing Chinese to seek help. Psychological counseling remains unaffordable for many, and medical insurance in China only partially covers mental health care, says Zhang Jianxin, deputy director of the Chinese Academy of Sciences' Institute of Psychology in Beijing. But, he adds, the law sets an important precedent. "We have a saying in China: It's better to have something than not to have it."