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China News Service. Chen Zhu: most of 86 million doctors are good in China. http:// www.chinanews.com/jk/2012/0314/3744342.shtml (accessed July 25, 2012). Yin D. Law-regulated practice and evidence-based self-protection. Chinese J Evidence-Based Med 2005; 5: 12.

Absence of humanities in Chinas medical education system

The crisis of trust between doctors and patients in China has been denounced widely.1 An online news story2 on June 5, 2012, described an astonishing scandal at a hospital in Hangzhou, Zhejiang province, in which a female nurse abused an infant and uploaded several photos of the process to her Weibo page (a Chinese social network). The public reacted angrily towards the scandal, and accused the medical sta of having no medical ethics or humanitarianism.2 There are many possible reasons why Chinese doctors are mistrusted by patients. We believe that the primary reason is the absence of humanities education for medical studentsa view shared by former president of the Chinese Medical Association, Zhong Nanshan.3 A study of 80 years of medical curricula at the Peking Union Medical College4 revealed that, since 1990, students total hours spent on medical humanities have comprised only about 1% of the total; 4% is spent on historical and political courses, and 95% on basic science and biomedical courses (36% basic medicine, 29% basic science, and 30% clinical medicine). Other medical colleges in China do not seem to be much dierent. As medical students, we have found that most school curricula consist of professional medical courses, but there are few courses on medical humanities and social science. Fortunately, on May 7, 2012, the Chinese Government issued a new policy5the distinguished physician
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education programmedeclaring that the proportion of medical humanities and social science courses should be increased in medical universities and colleges to reverse the situation. The eort is worth encouraging, and we look forward to a medical curriculum in China that aims to produce doctors whose empathy and ethics equal their clinical skills.
We declare that we have no conicts of interest.

*Jie Li, Feng Qi, Shanshan Guo, Ping Peng, Ming Zhang
jetlidoctor@foxmail.com
College of Medicine, Ningbo University, Ningbo, Zhejiang 315211, China (JL, SG, PP); and Department of Orthopedics, Ningbo Medical Center and Li Huili Hospital, Ningbo, Zhejiang, China (FQ, MZ) 1 Tang S, Meng Q, Chen L, Bekedam H, Evans T, Whitehead M. Tackling the challenges to health equity in China. Lancet 2008; 372: 1493501. xkb.com.cn. Hangzhou: practice nurse abuses infant takes photos with single hand holding infant. http://news.xkb.com.cn/ zhongguo/2012/0605/204222.html (accessed June 17, 2012). Yuan JZ. Zhong Nanshan: the education of medical and humanistic spirit in the fall. http://informationtimes.dayoo.com/ html/2011-11/13/content_1528200.htm (accessed June 17, 2012). Lin P. Peking Union Medical College, the comparison of 80 years to clinical medicine courses. Chinese J Med Educ 1999; 6: 2527. Ministry of Health and Ministry of Education. The implementation of distinguished doctor education and training plan. http://www.moe. edu.cn/publicles/business/htmlles/moe/ s3864/201205/135805.html (accessed June 17, 2012).

Embargo on publication of scientic papers by Iranian authors

Iran and western countries have had an unstable political relationship since the Islamic revolution in 1979. Despite this, fruitful academic relationships have occurred during the same period. Scientists from Iranian institutions have published joint papers with scientists from 107 other countries in the past three decades, most commonly from the USA and UK.1 Iran has also experienced a rapid increase in the publication of scientic papers in indexed journals.1,2

Iranian researchers have traditionally placed great emphasis on the importance of publication, a tradition that dates back to the era of Avicenna and before. The number of papers published in non-Persian journals has increased strikingly in the past decade, and in some disciplines eg, medicinemost Iranian papers are now published in English. This desire of Iranian scientists to share their ndings with the world has fostered many international scientic collaborations in which Iranian scientists were usually the initiators. Recently the political environment has become more dicult, with more restrictive embargoes against Irana situation that has occurred on several occasions in the past. But a new event is that a few academic publishers have embargoed scientic publications from Iran, irrespective of the subject matter. The basis of, and rationale for, these restrictions is unclear. This type of discrimination is not in concordance with scientic publication ethics. Decisions like these only ll the academic environment with feelings of injustice and unfairness. We urge international scientists to voice their objections to journals that have adopted this discriminatory practice against scientists from Iranian institutions. We hope to see a world in which we do not have double standards in any area, including publishing, and all people are treated in the same way irrespective of their nationality. The sharing of knowledge is the heritage of mankind.
We declare that we have no conicts of interest.

*Kamran B Lankarani, Ali Haghdoost, Peter Smith

lankaran@sums.ac.ir
Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Fars 71348, Iran (KBL); Kerman University of Medical Sciences, Kerman, Iran (AH); and London School of Hygiene and Tropical Medicine, London, UK (PS) 1 Mohammadhassanzadeh H, Samadikuchaksaraei A, Shokraneh F, Valinejad A, Abolghasem-Gorji H, Yue C. A bibliometric overview of 30 years of medical sciences productivity in Iran. Arch Iran Med 2010; 13: 31317.

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Archambault E. 30 years in science: secular movements in knowledge creation. http:// www.science-metrix.com/30years-Paper.pdf (accessed March 27, 2012).

196069 China1 India1 UK24 2078* 0482 0019 0020

197079 0090 0091* 0007 0028

198089 0059 0137* 0036 0024

199099 0013 0263* 0059 0036

200009 0009 0032 0074* 0062

Economic growth and better health: the UKs surprising progress

Many assume that further health improvements will be dicult for countries that have entered an era of chronic non-communicable diseases and life expectancies that are already above 70 years. If life expectancy is lower, it is possible to make gigantic strides given modest resources. For example, between 1961 and 1971, Chinas life expectancy gained 20 years while it experienced a rate of growth of gross domestic product (GDP) per head of only 35%. The belief in ceiling eects makes many think that countries with more room for progress in health, such as India and China, will have an advantage in transforming their amassing economic fortunes into better health. We did a simple four-country comparison to identify top performers by decade from 1960 to 2009. We used as a metric the percentage change in life expectancy divided by percentage change in GDP per capita. This metric is called the income elasticity of life expectancy. Our unexpected results indicate the need for some revisions to popular impressions. China did not maintain its lead in transforming wealth into health. India (1970s, 1980s, and 1990s) and most recently the UK (2000s) have been top producers of health relative to economic gains. Although Indias overall level of life expectancy has been disappointing relative to its income, the slope of ascent had been relatively high until 2000 (table).14 Between 2000 and 2009, the USA and the UK outperformed both Asian countries. Surprisingly, these two Anglophone countries with radically dierent health systems were able
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USA1

Income elasticity of life expectancy=(percentage change in life expectancy)/(percentage change in gross domestic product per capita). *Top performers that decade.

Table: Income elasticity of life expectancy at birth, China, India, UK, and USA, 19602009

to achieve growth in already high life expectancies. The vast dierences in medical care spending per head between the UK and USA suggest that the explanation for progress might not be medical care resources. We conjecture that public health and social investments in the control of tobacco, injury, and other non-communicable diseases might be playing a part. The USA and the UK have maintained systems for public health policy making to manage the social determinants of chronic, non-communicable diseases that might be outperforming those in Asia. Richer countries might also have tness advantages accruing to an ageing population that was born and raised in hygienic conditions rather than achieving hygiene in mid-life, as would be the case in Asia. At least for now, countries looking for lessons in success at improving health in an era of noncommunicable diseases would do well to look to the exemplary performance of the UK and study its public health playbook.
We declare that we have no conicts of interest.

Rizzo M. United Kingdom economic accounts Q3, 2011. http://www.ons.gov.uk/ ons/rel/naa1-rd/united-kingdomeconomic-accounts/q3-2011/index.html (accessed April 18, 2012).

Benchmarking in organ donation after brain death in Spain

Spain is widely known to be the only example of a large country (47 million inhabitants) that has seen a continuous increase in deceased organ donation over 20 years (from 143 donors per million population in 1989 to 3335 donors per million population since 1999),1 and a parallel increase in the number of solid organ transplantations (from 1300 per year in 1989 to more than 4200 per year in 2011).1 The sustained increase in deceased donation follows the implementation of a set of measures, mainly of an organisational nature, internationally known as the Spanish model.2 Despite this outstanding activity, our country is still far from satisfying transplant needs. Additionally, the potential for donation after brain death is decreasing owing to a reduction in mortality relevant to organ donation and to changes in patterns of neurocritical care. Moreover, the co-existence of dierent cultures has set a new challenge for family liaison in deceased donation. These common trends in developed countries necessitate a comprehensive strategy to maintain or increase organ availability.
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David Bishai, *Jessica ONeil

joneil25@jhu.edu
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (DB); and Johns Hopkins Krieger School of Arts and Sciences, Baltimore, MD 21218, USA (JON) 1 World Bank. GDP per capita (current US$). http://data.worldbank.org/indicator/NY.GDP. PCAP.CD (accessed April 18, 2012). Antweiler W. Pacic exchange rate service. http://fx.sauder.ubc.ca/ (accessed April 18, 2012). Measuring Worth. UK annual GDP 1836 to present. http://wikiposit. org/w?lter=Economics/MeasuringWorth. com/GDP/ (accessed April 18, 2012).