Behind the upsurge in attacks on China’s medical staff

August 13, 2014 by Wei Yang

Violence against doctors and other medical practitioners is a growing problem in China with hospitals suffering an average of one violent attack every two weeks, according to state media. What is behind the upsurge in attacks on hospital staff?

You don’t have to look far to come across examples of the attacks that are now commonplace in Chinese hospitals. In October last year, for example, a Dr Wang Hao was murdered while on duty at the No 1 People’s Hospital in the city of Wenling, in eastern China. His killer, 33-year-old Lian Enqing, walked into his office and attacked him with a hammer and a knife.

The reason? Lian underwent nasal surgery at Wenling hospital in 2012, but later claimed that the operation left him in constant pain and over the course of the following year his life descended into one of deep unhappiness. His bedroom, left as it was on the day of the murder, offers an extraordinary insight in the mind of man tormented by his illness and furious at the Chinese healthcare system. On his bedroom wall you can still make out the Chinese characters that someone has since tried to erase, spelling out the word “death” next to the names of two doctors. One of them is Dr Wang.

Numerous other attacks took place in the following weeks, at least 10 of which received national publicity in China. A nurse was left paralysed in Nanjing, a doctor had his throat slashed in Hebei and another was beaten to death with a pipe in Heilongjiang. In another recent incident in March this year a doctor at a hospital in Guangdong province was surrounded and humiliated by more than 100 people. They dragged and paraded the terrified doctor for failing to save a drunken 37-year-old man from dying of a heart attack.

A survey carried out by the Chinese Hospital Association (CHA) found that 29% of healthcare workers prefer self-protecting medical procedures, 40% are considering changing professions and 78% don’t want their children to become healthcare professionals in the future.

The perpetrators of almost all these attacks were male, poor and paying for their medical treatment. None had a criminal record or a diagnosis of mental illness, but all seem to have had a grievance against the hospital for problems associated with their treatment. The killings are all the more surprising given that the murder rate in China is amongst the lowest in the world.

The murder of Dr Wang Hao particularly unnerved the medical profession and the authorities, partly because of the apparent premeditation, but also because of the public’s reaction to it. Following the murder of a doctor in north-east China in 2012, a People’s Daily online survey, now deleted from its website, asked respondents to express their feelings. Although the 6161 people who responded are unlikely to be representative of the general population (given the readership of the paper and the type of person likely to respond to such polls), more than 60% expressed happiness by clicking on a smiley face, while just 6.7% clicked on the sad face.

National Ministry of Health statistics indicate that the number of seriously violent incidents against hospitals and medical staff increased from about 10,000 in 2005 to more than 17,000 in 2010. A survey by the Chinese Hospital Association reported an average of 27.3 assaults per hospital per year in 2012, up from 20.6 assaults per hospital per year in 2006. They put the total number of violent incidents in China at 620,000. In 2012, an editorial in The Lancet described the situation as a “crisis” for the practice of medicine in China.

At the heart of the problem is a deteriorating doctor-patient relationship, caused by shortcomings in the health system. Since the introduction of market reforms in the early 1980s, healthcare in China has been commodified. Even if people have health insurance, it only partially reimburses the high medical costs – usually 30% of out-patient costs and 50% of in-patient costs – so for many healthcare has become unaffordable.

The average inpatient stay will cost more than three to four months of a normal person’s salary and prices have been rising at more than 10% per year, higher than the rate of inflation. Substantial mark-ups are allowed on drugs and investigations, giving incentives for doctors to profit from tests and treatments that may be unnecessary and leaving patients feeling exploited.

Doctors are also unhappy. Deep dissatisfaction within the health sector is growing among doctors, according to surveys. In a 2011 Chinese Medical Doctor Association survey of 6,000 doctors, 95% describe themselves as overworked and underpaid, and morale is low. One estimate says that in the decade from 2000 and 2011 the number of daily visits received by doctors increased on average by 52%, while number of in-patients served by each doctor increased by 85%. This not only leads to rushed, indifferent, and disrespectful treatment of patients – a major cause of doctor-patient tension – but also increases doctors’ susceptibility to bribes.

Patients who feel aggrieved about treatment are often forced to take matters into their own hands. Existing legal channels for suing for malpractice, which operate through the local medical association, are inefficient, ineffective, and perceived to be weighted in favour of the medical establishment.

Yu Ying, an outspoken doctor who has gained a following of 2.6m on China’s social networking site Sina Weibo, resigned last year from prestigious Peking Union Medical College Hospital, because she said she was unhappy with the state of healthcare in the country. Dr Yu said that the country has built up mega-hospitals in the biggest cities, attracting rural Chinese who travel thousands of miles across the country to get care they believe they can’t get at hospitals back home. Yet the urban facilities have become overcrowded and are now the source of too much unrest, she said.

However, it would be unfair to say that the Chinese government does not care about the situation. In fact, the government is worried about the violence and has already taken some measures. In April 2012, for example, the ministries of health and of public security issued a joint directive about “effectively maintaining law and order at medical institutions.” This criminalises any acts of disruption of the daily operation of hospitals, including carrying dangerous materials and threats or violence against medical staff.

Tighter security has included a police presence in some bigger hospitals. In addition, the ministerial directive encourages hospitals to develop more effective procedures for resolving disputes, though precise mechanisms are not specified.

But it is more important to tackle the underlying systemic problems. First of all, this would include reforming the current healthcare system and prohibiting excessive profits on pharmaceuticals. A ‘zero profit’ policy for drugs is being gradually rolled-out. However, it is unlikely to be popular with doctors or hospital administrators, who will no longer be able to profit from drug sales, even if it removes the perverse incentive long associated with prescribing.

Second, action is needed to create a more effective system of health insurance. Although over 95% of the Chinese population has some form of health insurance coverage, reimbursement rates for care are still low, and out-of-pocket health payments remain a considerable burden. It is probably no coincidence that most of the serious acts of violence reported against doctors are committed by poor people paying out-of-pocket for healthcare at expensive treatment centres.

Finally, a better system of legal redress would also help to reduce acts of retributive violence and reliance on violence to deal with disputes. China needs to establish a system to resolve medical disputes. The process of resolving disputes must be made efficient, transparent, and fair for doctors and patients.

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