Why Chinese patients are turning against their doctors.
By Christopher Beam
There was still snow on the ground on the day, in late March, 2012, that Li Mengnan, a seventeen-year-old boy, hobbled into the First Affiliated Hospital of Harbin Medical University for the last time. He came from a remote town in Inner Mongolia, a ten-hour train ride away, and this was his sixth trip to the hospital in two years. During that time, his illness, an excruciating inflammation of the spine called ankylosing spondylitis, had got progressively worse. Earlier that day, the doctors at the hospital had sent him across town to a clinic for an X-ray, only to tell him, when he came back, that he should have brought the clinic’s notes with him. When he returned with this paperwork, they told him that they couldn’t treat his spinal problem after all, because he had a history of tuberculosis. Li would have to go back to Inner Mongolia untreated.
Meanwhile, Li Mengnan and his grandfather Li Lu, who had accompanied him to Harbin, walked back to the small hotel where they were staying, across the street from the hospital. Li Lu lay down to take a nap, and Li Mengnan said that he was going out for a walk. Instead, he went to a nearby store that sold household goods and then returned to the hospital carrying a three-inch fruit knife. He took the elevator up five floors to the rheumatology department, where he’d been turned away. He didn’t have a plan, exactly. He later said that he’d been looking for the doctor who had refused to treat him. But when he came out of the elevator he approached the first white coat he saw. Wang Hao was sitting at a computer when Li plunged the blade hilt-deep into his neck. Hospital workers rushed over, and Li turned on them, cutting one doctor’s ear and face and slashing two others. Li then tried to stab himself, but the knife was cheap and he succeeded only in making a surface gash in his neck and injuring his hand. Having failed to kill himself, Li fled.
Li Lu later remembered his grandson coming through the door of the hotel holding his throat, blood running through his fingers and soaking his sweater and jeans. “I don’t want to live anymore,” Li Mengnan said, and lay down on the bed. His grandfather wrapped his neck and hands with tissue paper and bedsheets, and took him back across the street to the hospital’s emergency room. As he was being treated, one of the doctors he’d slashed, who was also in the E.R., identified him and he was quickly arrested. Down the hall, in the intensive-care unit, Wang Hao had been declared dead.
The killing in Harbin was national news. The health minister called for severe punishment. When Li Mengnan went on trial, four months later, the government took the rare step of opening the courtroom to the media. The Chinese business weekly Caixin spoke of the country’s “doctor-patient conflict,” and an editorial in the British journal The Lancet warned that “China’s doctors are in crisis.”
Violence against doctors in China has become a familiar occurrence. In September, 2011, a calligrapher in Beijing, dissatisfied with his throat-cancer treatment, stabbed a doctor seventeen times. In May, 2012, a woman attacked a young nurse in Nanjing with a knife because of complications from an operation performed sixteen years earlier. In a two-week period this February, angry patients paralyzed a nurse in Nanjing, cut the throat of a doctor in Hebei, and beat a Heilongjiang doctor to death with a lead pipe. A survey by the China Hospital Management Association found that violence against medical personnel rose an average of twenty-three per cent each year between 2002 and 2012. By then, Chinese hospitals were reporting an average of twenty-seven attacks a year, per hospital.
As new details emerged in Harbin, the media’s portrait of the killer softened: Li Mengnan wasn’t a lunatic, nor did he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out. Wang Hao’s death came to symbolize the collapse of doctor-patient relations and a fundamental dysfunction in China’s health-care system.
Li Mengnan was represented at his trial by a lawyer named Wei Liangyue. I went to visit him in his office, in downtown Harbin, on the fourth floor of a drab building with heavy front doors and a security guard in the lobby. Wei is a youthful fifty-year-old. For much of his career, he has specialized in human-rights law. He has suffered as a result. At the time of the trial, Wei had only recently returned from a reëducation camp, where he’d been held for twenty-six days. In 2009, he and his wife were detained for a month by police from Harbin’s public-security bureau, owing to his work on behalf of Falun Gong practitioners in Inner Mongolia. Since then, he has been too nervous to take on controversial cases, he told me, but when a colleague asked if he would defend Li Mengnan he accepted immediately. He said that, when he first heard media reports about the case, he thought, Why did the patient resort to this?
The prosecution was calling for life in prison, the maximum punishment for a minor. But the more Wei and his team learned the more Li seemed like a victim in his own right. They decided to construct their case around the argument that the medical system had repeatedly failed him. “Although there is no reasonable ground for Li Mengnan to kill someone,” the written defense plea at the trial stated, “the hospital’s negligence, overprescription, and terrible quality of service are the main reasons this tragedy occurred.”
Li Mengnan was born in 1994 and grew up in Dayangshu, a small town in the Hulunbuir region of Inner Mongolia, known for its grasslands and its coal mines. His parents divorced when he was around a year old, and he lived with his grandparents while his father looked for work in the cities. When Li was three, his father was sent to prison for participating in a botched robbery. Li didn’t do well in school, and his middle-school teacher recommended that he drop out. At the age of fifteen, he went to live with an aunt in Beijing. Borrowing the I.D. of an older friend, he got a job giving rubdowns at a public bathhouse, where he earned, at best, a monthly salary of seven hundred yuan (a little more than a hundred dollars).
After a few months, his legs started to hurt. He went to a hospital but couldn’t afford all the tests necessary for a full diagnosis. He left Beijing and went back to his family, but rural hospitals rarely have specialist care; many can’t afford basic equipment. In September, 2010, Li and his grandfather booked cheap tickets on the ten-hour night train to Harbin, the nearest major city.
Like all top-tier hospitals in China, the one in Harbin was thronged. A doctor diagnosed synovitis, an inflammation of the joint lining, and prescribed a series of shots for Li. This turned out to be a misdiagnosis, and at the trial Wei argued that treatment for the wrong disease worsened Li’s condition.
By the following spring, it was evident that the medicine wasn’t working. Li, still in his mid-teens, walked like an old man. “He couldn’t even squat when he went to the bathroom,” his grandmother told reporters later. In April, his grandfather took him back to Harbin. This time, the diagnosis was the correct one: ankylosing spondylitis, a chronic inflammatory disease that can result in a complete fusion of the vertebrae known as “bamboo spine.”
The condition is incurable, but doctors explained that the symptoms could be treated with an intravenous drug called Remicade. For a poor Chinese family, the cost was daunting—thirty-nine thousand yuan (more than six thousand dollars) for the course of injections. As a migrant worker, Li had some insurance, but the plan covered less than half of the total cost, which eventually came to around eighty thousand yuan. The remainder he and his family had to pay out of pocket. They scraped together the funds using Li’s welfare subsidies and his grandfather’s pension, and borrowing the rest from family and friends.
After the first round of Remicade injections, Li immediately felt better. He trotted around the family’s courtyard, yelling to his grandmother, “Look, I can run!” But a month later doctors found that he had tuberculosis—a likely consequence of the drug’s tendency to weaken the immune system. They’d have to halt the Remicade, they told him, until the t.b. was cured. In his defense brief, Wei argued that the hospital had detected tuberculosis before giving Li the injections, inviting the suggestion that it hadn’t said anything because the medication is so lucrative.
Before he could continue with his back treatment, Li had to spend four months in a hospital in Hulunbuir, taking an anti-tuberculosis drug. According to his grandfather, during this period Li started to act strangely. He would suddenly burst out laughing, and walk around at night shouting. Still, by the time the pair returned to Harbin for the last time, they were feeling optimistic. News that the t.b. still hadn’t receded completely and that Remicade treatment would have to be delayed for three more months was crushing. The doctor didn’t tell Li the bad news directly; instead, he made him stand outside his office while he talked to Li’s grandfather. According to Wei, it was at this moment that his client felt most insulted. “Li’s mind-set was now ‘Are the doctors tricking me?’ ” he told me. “All he knows is he’s been there many times, and each time it’s ‘No, no, no.’ ”
One of China’s first doctors was Bian Que, a semi-mythical figure of the fifth century B.C., remembered for his ability to see through the human body and to raise the dead. But he seems to have been underappreciated in his own time: when he told the king of Qi that he looked sick, the king dismissed him, suspecting that the doctor was trying to cheat him out of his money. Days later, the king died. Hua Tuo, a famous surgeon in the second century A.D., recommended removing a tumor from the brain of a general, who, suspecting a murder plot, had him executed—an early instance of patient-on-doctor violence.
Modern medical techniques, which evolved in Europe and North America in the nineteenth century, were slower to take hold in China. Well into the twentieth century, doctors continued to practice a mixture of traditional healing and modern medicine, and it wasn’t until the Communist takeover, in 1949, that the Chinese government assumed any responsibility for health care. Vaccination drives, improved sanitation, and a campaign to eradicate the “four pests”—rats, flies, mosquitoes, and sparrows—curbed disease and reduced child mortality. In 1965, on the brink of the Cultural Revolution, the Party announced an initiative to provide every production brigade with “trained medical personnel who are practitioners part time and do physical work.” These “barefoot doctors,” as they became known, were typically peasants, along with a few urban youths. By Western standards, they were amateurs, but the system at least provided rural Chinese with access to very basic treatment. Ten years after the start of the program, life expectancy in China had increased from fifty-one to sixty-five years.
Some barefoot doctors went on to have significant careers in medicine. One is Gordon Liu, whom I met at his office at Peking University, where he is the director of the China Center for Health Economics Research. His office is in a resplendent Qing-dynasty building, overlooking a courtyard on one side and a river on the other. “I got the best spot,” he said, with a grin. Liu, who has spent most of his career in the United States, was wearing Nike sweatpants and a casual Boss shirt. He spoke with the offhand confidence of a professor in permanent lecture mode. Whenever I asked a question, he’d pause and say “O.K.” before starting again, as if I’d interrupted his flow.
Liu grew up in rural Sichuan, and, like most young people during the Cultural Revolution, was sent to work on a collective farm as soon as he finished high school. He remembers waking up at 6 A.M. to plant corn in soil that wasn’t suitable for corn. “Every day, we had to do that kind of meaningless work,” he said. One day, the village leader called him in and told him that he would be the village doctor. His qualifications: he had a high-school diploma.
“I knew nothing about medicine,” Liu told me. “I just began to treat people. I don’t even know how many people got worse after my treatment, how many people died. I have no clue.” Still, barefoot doctors were respected and patients didn’t complain about the standard of care. “People were fighting for a cup of water, a bowl of rice,” Liu said. “Health care was not even on their agenda.”
After Mao died, in 1976, China reopened its universities, and Liu attended college in Chengdu. In 1986, he went to the City University of New York’s Graduate Center, to study health economics, and stayed on in the United States, teaching. China’s medical system, meanwhile, fell apart. Deng Xiaoping instituted a program of economic liberalization, which dismantled the system of co-operatives that many had relied on for medical care. While the hands-off approach boosted certain sectors of the economy, like manufacturing and real estate, it crippled the health system. The state was no longer responsible for providing health care, and public hospitals, in charge of their own financing, went after profits. Doctors were poorly paid and many of them started taking bribes, the money typically stuffed in a “red envelope.” Under the old system, teams of educated city doctors had travelled to rural areas to supplement the service of the barefoot doctors; now sick farmers had to come to the provincial capitals for the best treatment, and big urban hospitals became overburdened. “The government basically considered health care a back-burner issue,” Liu said.
By the beginning of this century, everyone from patients to doctors and government leaders agreed that the system was broken, and the SARS epidemic, which started in southern China in 2002, added to the sense of crisis. In 2003, the government created a medical-insurance system for people living in rural areas, and in 2007 it added a plan for urban residents. In 2002, Liu, who was teaching at the University of North Carolina Chapel Hill, got a call inviting him to Beijing to help establish the department of Health Economics and Management at Peking University. He accepted. “It was my dream,” he said.
In Beijing, Liu began to advise the State Council, China’s top administrative body, which drafts legislation and generally decides the direction of national policy. In 2009, the council announced a reform package with five components: the government would get the entire population insured by 2020; it would bring down the cost of basic drugs; it would boost public-health services, like education and immunization, especially in the poorest regions; it would invest in hospitals in rural areas, to reduce the pressure on urban hospitals; and it would restructure big public hospitals so that they focussed on emergency care and specialist services. This last item has been the trickiest part, Liu said, because it entails taking customers away from the big hospitals. “Hospitals will never do that themselves, unless you surgically conduct the reform,” he said.
The reforms have had mixed success. Officials declare proudly that ninety-five per cent of the Chinese population now has some form of basic medical insurance, up from thirty per cent in 2003, but, over the same period, the cost of medical care has risen, so that, in practice, many patients are paying as much as they were before. Furthermore—as Li Mengnan discovered—the amount of care covered by government insurance plans varies widely depending on where you live. And the pressure on big urban hospitals has increased, because the recently insured have flocked to them faster than new rural facilities can be built. Huang Yanzhong, a professor at Seton Hall University who studies Chinese health care, told me that the spate of violent incidents reflects the failure of the reforms to solve the problem of affordability and access. Patients still expect the best care from big urban hospitals, he said. “When that turns out not to be the case, they get very upset.”
I first saw the inside of a Chinese hospital last summer, during a trip to Yunnan province, in southwestern China, when I contracted a mysterious full-body rash. The doctor, a friendly man in his fifties, saw me right away. As several other patients and a janitor gathered around, I lifted up my shirt so he could see the discoloration. He asked where I lived, and I said Beijing. Of course, he said—the air in Yunnan is different. That was most likely causing the rash. I told him I’d been to Yunnan before and hadn’t had a problem. “What about the food?” he said. “It’s very spicy here.” I was used to spicy food, I said. The water might be having an effect, he suggested. I told him I hadn’t been drinking the water. He looked perplexed and, when I asked what he would recommend, he suggested leaving Yunnan.
“It’s been a long time!” Meng said as an old woman came in. She’d been having stomach pains and had come by to go over some test results. Everything looked O.K., Meng said, holding up her CT scans. He speculated that her stomach ache might be constipation-related. “I poop every three days if I’m lucky,” she said. “See, that’s not enough,” Meng said. “You have to poop every day. What do you eat mostly?” “Steamed buns, rice, porridge,” she said. Meng suggested more vegetables. He offered to order a sonogram from the urology department, but she decided against it.
As a specialist, Meng has the time to get to know his patients and hear their concerns, but, in this sense, he is in a minority. After clocking out, he took me across the hall to the office of a regular resident physician. The man was scribbling a prescription for a nervous-looking woman. When I asked him how many patients he’d seen that day, he silently collected the dozens of receipts scattered across his desk and piled them under my nose.
I heard countless tales of overwork among Chinese doctors. A leading radiologist in Shanghai told me he’d heard that the record number of patients seen in a day is three hundred and fourteen. “That was at the Shanghai Children’s Hospital,” he said. “One doctor, 8 A.M. to 6 P.M., ten hours, two minutes per patient.” According to a study conducted in Shaanxi province, the average visit to a doctor’s office lasts seven minutes, and physicians spend only one and a half minutes of that time talking to the patient. As a result, patients tend to be pushy, crowding in doorways and entering without knocking. Joe Passanante, a doctor from Chicago who did a stint at Beijing United Family Hospital, told me that he was once performing CPR on a woman when the parents of a girl with a fever walked into the room. “Here I am pushing on a dead person’s chest, trying to revive her, and they’re asking me to see their daughter,” he recalled.
At the end of my day with Meng Hua, I noted that I hadn’t seen any red envelopes changing hands. He explained that extra cash tends to be offered for serious operations, not for the kind of routine visits I’d been seeing. But he said that bribes have become so common in hospitals that they’re barely even frowned on. Physicians’ salaries are low but are typically supplemented with bonuses, kickbacks from drug sales, and bribes. Meng said, “My whole salary for one month is ten thousand yuan,” which is about sixteen hundred dollars. “I want to drive a car, have a house. I need the extra income. If a patient gives a red envelope after a surgery, I might not refuse.”
It’s not too surprising that doctors face significant public hostility. After the killing in Harbin, there were almost as many expressions of sympathy for the killer as for the victim. When People’s Daily, a newspaper that acts as a Chinese government mouthpiece, posted an online questionnaire asking readers to rate their reaction to the murder, as a smiley face, a sad face, or an angry face, sixty-five per cent of readers chose the smiley face. The survey was taken down, but CCTV aired a segment about it: a commentator mused, “Is it possible that we are all the killers?”
If the official channels yield nothing, patients will often stage protests. In 2013, a thirty-four-year-old mother alleging malpractice after a Cesarean section rallied a dozen friends and relatives to storm Beijing’s No. 6 Hospital. She ended up winning about ten thousand dollars in compensation. In May this year, in Kunming, a man whose wife and baby had died during a Cesarean section climbed onto the roof of the hospital carrying his other child in his arms. He threatened to jump while a crowd of relatives below brought traffic to a standstill. When a patient dies and family members blame the doctors, they sometimes lay the corpse in front of the hospital entrance until they are paid off.
In Beijing, I met Benjamin Liebman, a professor at Columbia Law School, who has published a study on “malpractice mobs” in China. He told me that protests consistently extract more money from hospitals than legal proceedings do. Family members can even hire professional protesters. One report in Shenzhen mentioned an average price of fifty yuan a day for the service of a protester. The radiologist in Shanghai told me, “If your mother dies in the hospital, there will be an agency that comes to you and says, ‘We can help you. We can have twenty guys who can come to the hospital, blackmail them, and share fifty per cent of the profits.’ They’re very professional.”
Surprisingly, in a country where even a small public gathering can spark a government response, malpractice mobs often proceed without intervention. It’s possible that the authorities see them as justified or simply as an efficient method for negotiating compensation. Some scholars even argue that the Chinese government tacitly welcomes such protests, considering them to be a relatively harmless outlet for discontent and an early-warning signal of more serious social unrest—a phenomenon that the Berkeley political scientist Peter Lorentzen, in a study of authoritarian regimes, has called “regularizing rioting.” Liebman told me, “Protest becomes the mechanism for providing social security and for distinguishing people who need help.” The problem is, he said, “everyone knows the government has funds to pay people who petition or protest, and that incentivizes more protest.”
At Li Mengnan’s trial, his lawyers’ attempt to get his sentence reduced on the ground of shoddy treatment failed. Li made a poor impression in court and seemed incapable of expressing remorse. During the judge’s interrogation, he answered in monosyllables. “Are you sorry?” the judge asked. “Uh-huh.” “Then apologize to Wang Hao’s parents and the doctors.” “O.K.” The family refused to accept the apology. “I didn’t believe him,” Wang’s father told me later. “Those words were not from the bottom of his heart.” The trial lasted a day; three months later, the judge sentenced Li to life in prison.
For the civil suit, the family hired a lawyer named Li Huijuan, an energetic woman who also took on the roles of spokeswoman, P.R. agent, and therapist. When I met her recently, at a bookstore café in Beijing, she was wearing an enormous purple coat, and carried a blue Prada purse. She spoke smoothly, often throwing in obscure Chinese idioms, which, upon seeing my blank expression, she would jot down and explain. Li is in her fifties, and went to medical school before becoming a lawyer. Before that, she taught middle school, and she still has a way of turning everything into a teachable moment. Since the trial, she has become the closest thing China has to an activist against patient-doctor violence, flying around the country to lecture doctors and hospital directors on how to prevent conflict with patients. She took out a MacBook Air and showed me a PowerPoint presentation that featured bloody crime-scene photographs, images of protests, and quotations from, among others, Hippocrates, Einstein, Marx, and Peter Drucker. Each victim had his or her own memorial slide: a head shot floating above icons of flowers and candles and a banner detailing the perpetrator’s eventual punishment.
Li is despondent about the state of medicine in China. “The reforms have all failed,” she said. Her view is that it is up to doctors and hospitals to change what they can. In her presentations, she recommends that doctors keep careful records, and make sure that patients understand their diagnosis. Medical schools, too, have begun emphasizing the doctor-patient relationship. Peking University Medical School now offers a course called “Introduction to Medical Humanities,” in which future doctors are taught to empathize with patients.
If China’s medical reforms fail, the cost will be high. As the population ages, families are spending a growing portion of their income on medical care, and an increase in the rates of obesity and smoking means that a younger generation also faces high medical bills. This isn’t just a personal problem—it could drag down the whole economy. For the past few decades, China has prospered by exporting goods to the rest of the world. But, as global demand slows, it will have to rely increasingly on domestic consumption for its growth. The Chinese, who currently have the world’s highest household savings rate (about fifty per cent of income), have to start buying more. But, unless insurance plans offer better coverage for the average family, people will continue to save in order to cover potentially ruinous health-care costs.
Li Huijuan said that when she was studying to become a doctor medicine was a respectable profession. Now, she said, “our friends’ children aren’t going into medicine.” A shortage of doctors, combined with rising costs, could hurt more than just the medical industry, she said: “It will weaken the country’s power.”
On April 1st, the second lunar anniversary of Wang Hao’s death, his family gathered at his grave, on the outskirts of their home town, Chifeng, in Inner Mongolia. Wang Dongqing, Wang Hao’s father, picked up Li Huijuan and me at the airport. “All this architecture is from the past ten years,” Li explained as we drove through the city. “Originally, Chifeng was poor, remote, desolate—now it’s thriving.” Wang nodded in agreement. He grew up in the countryside, but after a stint in the Army went to work at a bank in the city. His car was a luxury Roewe sedan. I asked where he lived. “He lives in the old town,” Li interjected. She was dressed in a black trenchcoat, black leather pants, and big black sunglasses, like a celebrity hiding from the paparazzi. I noticed a miniature prayer wheel on the dashboard, and asked if Wang was a Buddhist. He said no.
The group went to have lunch in a private room in a nearby hotel, where Li continued to comfort Zhao. The men sat at one circular banquet table, the women at another. I took a spot next to Wang Dongqing, whose dark suit had somehow accumulated a few patches of dirt. Between sips of gullet-searing baijiu, the local grain alcohol, I asked him about his son. “He was incredibly steady,” he said, and “very diligent.” The last time they’d seen each other, during the Spring Festival holiday, the young man spent all his time studying.
“He loved medicine,” his sister-in-law said. “He loved it crazily. He told his mom that he’d definitely get the Nobel Prize.” He had just been accepted into a Ph.D. program in Hong Kong—the letter arrived five days after his death—and, whenever a friend or family member got sick, he’d help out, so they never had to go to the hospital. His father and others kept returning to the fact that Wang Hao and Li Mengnan didn’t even know each other. Wang’s death seemed random, the result of unseen forces, “like lightning out of the blue sky,” Wang Dongqing said. There were a billion things that one of the two men could have done differently that day.
I asked Wang Dongqing whom he blamed for his son’s death. “I blame the health-care system,” he said. “Li Mengnan was just a representative of this conflict. Incidents like this have happened many times. How could we just blame Li?”
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