Note: China Labour Bulletin recently published our healthcare workers' report: Unprotected yet Unyielding: The Decade-Long Protest of China’s Healthcare Workers (2013-2023).
The Strike Map includes 17 cases involving safety at work, seven of which were protests against patient violence and happened between 2013 and 2017. The other 10 cases happened in 2022 and are related to pandemic control arrangements and the safety of resident students. The Calls-for-Help Map also collected five work safety cases in 2022 with similar worker concerns.
Causes of patient violence
Medical disputes and patient violence are not only triggered by patients’ irrationality but also caused by patient triage arrangements of the hospital system, funding and management problems.
All seven protests against patient violence occurred in secondary or tertiary public hospitals. Patients generally prefer public hospitals (especially tertiary and secondary ones), which have a better reputation and receive comparatively more resources. This is shown in higher patient visits per doctor in these hospitals (see tables below). The staff in these hospitals will likely experience longer hours, fatigue and more tense relationships with patients.
Source: Statistical Bulletin on Health Development in China 2022
The Survey Report on the Working Conditions of Medical Staff in China (中国医务人员从业状 况调查报告) (hereafter “the 2013 survey”) points out that due to China’s failure to implement “gatekeeper system” and “two-way referral system”7 , overcrowding is common in secondary and tertiary public hospitals. Healthcare staff there have long working hours and heavy workloads. Out of the doctors surveyed, 76.1 per cent worked more than eight hours a day, 36.8 per cent worked 9-10 hours, and 30.3 per cent worked more than 10 hours. Those who worked more than 8 hours a day were more likely to suffer from physical discomfort, anxiety, depression, and other adverse health symptoms.
These long hours also worsen the doctor-patient relationship. According to the survey, about 75 per cent of staff felt that the doctor-patient relationship was tense. The three leading causes of doctorpatient disputes were “inadequate communication with patients”, “shortage of staff and heavy workload”, and “poor service attitude.” These are interrelated. Particularly in overcrowded tertiary hospitals, the fact that patients queue up at five in the morning to see a doctor for only three to five minutes, while the doctor has no time to consult the patient, creates dissatisfaction and the feeling that the doctor is perfunctory.
A doctor in a tertiary general hospital in Xinjiang said:
“We wish to see only ten patients every morning, calmly and properly communicating with them, but if we do that, we cannot meet the outpatient volume target, and the hospital and the department’s income generating goal cannot be accomplished. What can be done?”
A doctor at a tertiary hospital in Shanghai said: “Many problems cannot be solved by doctors, but the conflicts and pressures are shifted to them.”
Also, as mentioned in Chapter 1, the need to generate revenue in public hospitals creates pressure to give patients additional and unnecessary prescriptions and tests. This results in excessive medical care, which is prone to conflicts between doctors and patients and hence threatens the safety of healthcare workers.
In addition, healthcare workers usually get dissatisfied with hospitals and government departments' negligence on cases of patient violence and the lack of support and safety protection. Workers’ mourning sessions and protests are also repressed.
Protests against patient violence
A protest in Jinan, Shandong
On 4 and 5 October 2016, the paediatrics department at Laigang Hospital (莱钢医院) in Jinan, Shandong province, went on strike to mourn the death of a colleague, Dr. Li Baohua, who had died from knife wounds inflicted by a patient’s relatives. The hospital director asked the head of the paediatrics department to bring the staff back to work, but workers refused. The department head, who was the deceased doctor’s mentor, had already tendered his verbal resignation at the time and refused to schedule shifts for the department staff on 5 October. The hospital tried repeatedly to deter the staff who had organised the memorial service, including a nurse who was seven months pregnant but still insisted on attending the memorial service.
Photo: Mourning session on 4 October Photo credit: Weibo post by “A reporter with a slight ideal”, China Labour Bulletin archive
In the morning of 6 October, Li Baohua’s colleagues defied the hospital and set up a simple mourning hall at the nurses’ station. That afternoon, the union at Laigang Hospital issued an article organizing a fund-raising campaign and said that all the heads of the hospital expressed their “deepest remembrances” of Li Baohua and “deepest condolences” to his family.
On 7 October, after the requests from multiple sides, the hospital set up a mourning hall in its funeral parlour, allowing medical staff and students to pay tribute to Li Baohua, but refused the entry of non-hospital employees and forbade employees to take pictures, hold banners, shout slogans, or release information to the public. The employees’ WeChat records show messages saying that inside the hall, “whoever wears plain clothes is a cop”, and “We were sad and were crying, then the hospital board decided that we had problems in controlling our emotions and drove us all away.”
In some cases, in addition to the dissatisfaction at the hospital board, the medical staff also suspected the local government’s intention to play down an incident.
A protest in Wenling, Zhejiang
On 25 October 2013, three doctors at the First People’s Hospital in Wenling, Zhejiang province (温岭市第一人民医院), were attacked, with one dead and two injured. A funeral was scheduled for 27 October, but news broke that the family had not agreed to transport the remains. The special force police car was present, and staff believed that the hospital and local officials feared the incident would affect an upcoming political event, so they sent special police to the hospital, forcing the family to cremate the body early. The following day, more than 1,000 of the hospital’s staff went on strike, and staff from a number of nearby hospitals showed up in solidarity. Signs read, “Give me back my life,” “Give me back my dignity,” and “Protect the safety of healthcare staff.” Radio Free Asia (RFA) interviewed a doctor at the time, who said
“Because an innocent doctor was hacked to death, colleagues are worried that similar cases will recur. Those injured or killed are our colleagues. It is too cruel. We want the community to be concerned. Our actions are all rational and peaceful.”
Photo: Healthcare workers protest at the First People's Hospital of Wenling City Photo credit: Radio Free Asia (courtesy of people at the scene)
The local government sent in special police to disperse the protesting workers. A doctor who participated in the protest told RFA:
“We tried to rush to the street to protest, but we were surrounded by the special police. We were forced to retreat to the hospital gate, and then dispersed. ”
According to China News (中国新闻网), the secretary of the Wenling City Party Committee, the deputy mayor, and other officials went to the hospital afterwards to listen to the demands of the workers. The officials said they made compensation arrangements for the deceased doctor’s family. They expressed understanding of the demands of the staff, and said they would make every effort to safeguard the rights and interests of the staff and severely punish the culprits.
The hospital denied that there had been a body-snatching situation and said that there were negotiations with the family. The event was simply due to the family’s emotional breakdown. The hospital also denied that the upcoming polical event affected their decisions and said that the police just happened to be present at the funeral.
The cause of the incident may have been a misunderstanding, but CLB has documented other cases of police officers allegedly snatching bodies of the deceased, such as at the funeral of a murdered doctor at Shaodong County People’s Hospital (邵东县人民医院) in Hunan province in 2016. These cases show the distrust of healthcare staff toward the hospital and local government, which are perceived to be downplaying the incidents rather than seriously dealing with the issues staff are raising.
Suggested solutions
In these protests, the trade union did not reflect to the hospital management and government departments the staff’s concerns and the purpose of the protest, fight for space for the staff to take action, or propose concrete measures to combat patient violence and alleviate the conflict between doctors and patients. According to a White Paper published by the Chinese Physicians Association (中国医师协会), physicians believe that healthcare institutions should provide assistance to staff when dealing with incidents of attacks. The most critical tasks doctors believe medical institutions should do include providing personal safety protection, mediating doctor-patient conflicts, and providing relevant legal support to doctors (see chart below). These are all measures that trade unions can take up.
Conflicts between doctors and patients, and violence experienced by healthcare staff, are longterm, ongoing problems. The CLB Strike Map does not record protests against patient violence from 2018 to 2022, but it does not mean that the problems have disappeared. According to incomplete statistics from Health Sector News (健康界), more than 10 serious injuries to doctors occurred from 2020 to early 2023, while the media reported 295 injuries to doctors and 362 injuries to healthcare workers from 2013 to early 2023. Violent incidents in tertiary hospitals were the most common, accounting for 67.6 per cent of the cases, followed by secondary hospitals at 23.8 per cent and primary hospitals at 4.1 per cent.
In addition to encouraging authorities to take legal action against patient violence, trade unions need to pay attention to the policy of patient triage, of ensuring that hospitals are adequately staffed, and of reducing the pressure on hospitals to generate income, as these are important issues relating to the relationship between doctors and patients.
Protests against the lack of pandemic control in hospitals
In 2022, the CLB Strike Map included 10 cases of protests against the lack of pandemic control arrangements. Two were protests against the hospital’s pandemic control policies, and eight were protests by resident students against return-to-work demands.
In April 2022, employees of Shanghai Putuo District Central Hospital (上海市普陀区中心医院) sought help online during the major COVID-19 outbreak in the city that led to a months-long lockdown. The hospital’s staff worked without protective gowns, and on 3 April, some workers tested positive for COVID-19, but the hospital still sent them out for daily nucleic acid testing in the community. There were no decontamination or pandemic control measures in the hospital. On 6 April, almost all of the healthcare workers in one ward were positive, and the remaining uninfected nurses in that ward had to go on strike to succeed in demanding quarantine and control measures. Another ward had essentially the same issue. For this ward, only testing was done, and it took two days to get a batch of protective gowns, which was insufficient for all the staff, while they were required to take nucleic acid tests for potential patients. Employees noted that if this ward were not sealed off, then positive patients should be moved and properly housed, and healthcare workers in close contact should be quarantined. The incident showed that hospital management was neglecting the welfare of healthcare staff, and it contributed to the spreading of viruses during the pandemic.
In late 2022, as there was a sudden relaxation of pandemic lockdown measures and a surge in positive cases in many areas, a large number of healthcare workers were infected with COVID-19, resulting in a staff shortage. Medical colleges demanded that student residents (规培生) return to their posts and threatened them with a ban on sitting for the final exam, causing a wave of protests. They demanded equal treatment/pay as doctors and the provision of protective equipment and guarantees of work safety. Some students demanded “voluntary return to their hometowns” (自愿返乡), pointing out that university students were allowed to go home, whereas medical students and postgraduates were prevented from doing so (see Chapter 3 for more details).
To be continued.
Download the full report as a pdf here.