CRITICAL LACK OF CARE

Long considered to have a high standard of medical care among central regions of China, Wuhan has 27 top-tier hospitals, ranking fifth on the Chinese mainland after Beijing, Shanghai, Chongqing, and Guangzhou, capital of Guangdong Province. Patients come from surrounding regions as well as across Hubei Province to consult the city’s healthcare professionals. 　

So few people expected that Wuhan’s medical system would be overwhelmed so quickly by the Covid-19 outbreak that it would drive many medical workers to make fraught online appeals for help. Now the epidemic is largely under control in the province, a feat achieved due to assistance from other parts of the country, it is time for Wuhan to reassess and fix its medical system. 　

A professor at Huazhong University’s Tongji Medical College, who refused to reveal his name, told NewsChina that Wuhan’s top-tier hospitals pushed to expand and the number of beds contributed much to the city’s reputation of having abundant medical resources. By 2018, Wuhan had on average 8.6 beds per 1,000 people, much higher than the State’s average level (six beds) and that of Beijing and Shanghai (5.74 beds). 　

In 2015, China’s State Council issued a document forbidding public hospitals from increasing the number of beds for no good reason. But in Wuhan, the top hospitals dodged the ban by establishing branch hospitals instead. 　

This expansion in physical resources was not backed by a similar increase in human resources, according to Liu Zhiyong, another professor at Tongji Medical College. In 2018, Wuhan had 3.57 doctors and 4.91 nurses per 1,000 people, while in Beijing, there were 5.1 doctors and 5.7 nurses per 1,000 people. It indicates, Liu said, that Wuhan’s medical workers had heavier workloads. 　

As health authorities are inclined to distribute resources to top hospitals, their expansion curbed the development of hospitals lower down the pecking order. Ruan Xiaoming, a former official at the Hubei provincial healthcare bureau and former deputy director of the Hubei Province Hospital Association, told NewsChina that second-tier hospitals in Wuhan were in a Catch-22. To get more resources, they had to either climb the rankings or risk being downgraded to district hospital level whose budget is covered by the local government. 　

At the beginning of the Covid-19 outbreak, Wuhan requisitioned seven municipal second-tier hospitals, only to find they were incapable of battling a disease which was much more infectious than SARS. 　

According to Zheng Xian’nian, director of the emergency department at the municipal Fifth Hospital of Wuhan, his hospital did not set up a fever clinic until January 22 and before that, all patients with Covid-19 symptoms went to the emergency room. 　

“The number of patients admitted to our emergency department surged in early January and exceeded 400 per day by mid-January, more than three times the usual,” he told NewsChina. 

　

Zheng said the infectious disease department at his hospital only had three doctors, 10 less than the emergency department. To respond to the Covid-19 epidemic, the Fifth Hospital was transformed into an infectious disease hospital, with its whole medical staff, around 1,000 people, deployed to treat Covid-19 patients after rapid training. 　

Respiratory departments were the next line of defense. Zhang Jixian, a respiratory and ICU physician at the Hubei Provincial Hospital of Integrated Traditional Chinese and Western Medicine, was the first doctor to officially report cases of the novel coronavirus. He told NewsChina that his respiratory department treated 230 patients in the week following the New Year holiday (January 1-3). 　

“As the infectious disease department had neither people nor space, patients were transferred to the respiratory and gastroenterology wards, the former for fever patients whose numbers always peak in winter, and the latter for intestinal diseases that are more communicable in summer,” he said. 　

Gong Zuojiong, director of the infectious disease department at the Renmin Hospital of Wuhan University, told NewsChina that most municipal hospitals in Wuhan have no infectious disease department. 　

Guo Wei, deputy director of the infectious disease department at Tongji Hospital, also told NewsChina that in many municipal hospitals, the infectious disease department and emergency department are joined and share the same senior staff, with the fever and intestinal clinics, if any, performing practically no function.　

“There’s a saying among infectious disease doctors – ‘the infectiousdisease department is like a bedpan - no one takes it out until they need it,’ ” he said. 　

As a provincial hospital, the Renmin Hospital of Wuhan University where Gong works had isolation wards before the epidemic, but they did not have negative pressure chambers, where air pressure is lower than outside, to prevent cross-infection. “We dealt with few respiratory diseases,” Gong said, revealing that the infectious disease department in his hospital focused on intestinal diseases which are not communicable via aerosol droplets and thus have lower requirements for isolation conditions. 　

Ruan told NewsChina that most municipal-run hospitals in Wuhan did not set up an infectious disease department because they could transfer patients to Wuhan Jinyintan Hospital, the only provincial medical emergency center in Wuhan. Built following the 2003 SARS epidemic, Jinyintan was responsible for patients suffering from more common infectious diseases, such as tuberculosis, AIDS and avian flu. According to Ruan, it provided around 700 beds by the time it was put into use in 2008, a size similar to those built for the SARS epidemic. 　

Yet Guo argued that one infectious hospital like Jinyintan might be fine for when there is no epidemic, but it is definitely not enough to handle the situation when a new infectious disease breaks out and spreads quickly. He suggested each hospital set up a number of negative-pressure isolation wards.　

“An infectious disease department will not play any role until it is equipped with enough [isolation] wards,” he said. 　

“The ICUs in Wuhan differ sharply between hospitals, and their general quality cannot rival those in big cities like Beijing, Shanghai and Guangzhou,” Li Jianguo, a chief expert at the ICU department, Zhongnan Hospital of Wuhan University and a former senior member of the China Society of Critical Care Medicine (CSCCM) Hubei Branch, told NewsChina.　

At a press conference held by China’s National Health Commission on February 4, health official Jiao Yahui ascribed Wuhan’s higher rate of Covid-19 deaths to the lack of ICU beds, only 110 at the preliminary phase of the outbreak. He said that the rest of the inpatients were taken care of by non-ICU medical workers which crippled Wuhan’s medical care service. On April 17, Chinese health authorities revised upward the death toll for Covid-19 cases in Wuhan from 2,579 to 3,869, a 50 percent increase.　

At Wuhan Jinyintan Hospital for example, its ICU department only had five doctors with less than 20 instruments for oxygen treatment. The hospital transformed three floors into ICUs and sought assistance from three other top hospitals. 　

“We found there was a massive lack of medical staff, especially ICU doctors and nurses,” said Tong Zhaohui, deputy president of Beijing Chaoyang Hospital who was part of the first specialist team to go to Wuhan from Beijing. 　

“We later asked five hospitals in Beijing, Shanghai and Guangzhou to send a number of experienced ICU doctors to assist... And by Spring Festival Eve (January 24), Jinyintan’s ICU department only had two doctors left, with the other three all on sick leave,” he added. 　

Li Shusheng, the ICU director at Tongji Hospital, blamed a shortage of young specialists for Wuhan’s weak ICU care. He told NewsChina that medical graduates in China cannot become a specialized physician until they complete a State-defined resident training for the target department. ICU care, however, is not listed as part of the State training program. This means ICUs have to attract doctors from other departments who might feel reluctant to spend additional time on ICU training with little return. 　

“Intensive care is the only Class-2 subject in clinical medicine that isn’t covered in the State’s training program for residents, which is the first step to train young specialists,” he said. 　

His opinion was shared by another expert who has been working in an ICU department for over 20 years. “How could a department not be in chaos if it has no [talent] base. It can’t be a permanent plan that we have to depend on nationwide assistance under State orders tobattle a big epidemic,” he told NewsChina on condition of anonymity. 　

To prevent cross-infection in hospitals, the municipal government quickly established a hierarchical system, defining district hospitals as the first site for people to check if they were infected with Covid-19, and no upper-tier hospital would admit any Covid-19 patient without a transfer letter from a district hospital. Yet, as district hospitals were not skilled at distinguishing and treating infectious diseases, the system caused many patients to be left unchecked and untreated at home. The situation did not turn around until teams of medical workers and experts were sent to Wuhan. 　

“We saw 200 fever patients per day at the peak (January 25 to February 14), since our hospital was the only one in the neighborhood that was able to admit fever patients and do CT tests,” an insider at the district-level Wuhan Chang Dong Hospital told NewsChina.　

Wuhan started a dual-transfer system in 2006 which encouraged big hospitals to transfer patients with chronic or common diseases to district hospitals and district hospitals to transfer patients with rare and serious diseases to big hospitals. In 2008, big hospitals began to connect to district hospitals for the convenience of the transfer, and in 2015 and 2016, Wuhan issued two documents promoting and improving the hierarchical system.　

But the system did not work as well as expected. According to Xiong Nian, president of Wuhan Red Cross Hospital, district hospitals actually focused on public health services, such as vaccination, instead of medical diagnosis and treatment. He revealed that among 12 district hospitals in Hankou District, at least half did not even set up a ward, and among the remaining ones with wards, half used the wards as nursing homes for seniors.　

“Compared to upper-tier hospitals, district hospitals lag behind in the quality of treatment and even the varieties of medicines,” Xiong told NewsChina. “Supposing my hospital provides 1,000 kinds of medication, the number of those available in a district hospital will not exceed 100,” he added. 　

In Xiong’s opinion, the hierarchical system just served to “pump” patients from district hospitals to big ones. “When providing medical services at a [connected] district hospital, doctors from a municipal hospital would transfer all the patients to their hospitals... The district hospital’s 3 million yuan (US$426,372) social medical insurance quota would be counted in the municipal hospital’s account,” he said.　

“The connection between big hospitals and district hospitals is too loose. It should have been a win-win model where doctors from big hospitals bring technologies to district hospitals and help improve the skills of the grass-roots medical workers,” said Ruan Xiaoming. 　

Wang Guiqiang, a chief member of the China Society of Infectious Disease, observed that Singapore’s 800 district clinics played a big role in preventing hospitals from becoming overwhelmed during the pandemic. 　

He suggested that China train more general practitioners for district hospitals and put the fever clinic system established following the SARS epidemic under the charge of those district GP physicians. 　

“District hospitals should focus more on doing preliminary tests for common diseases and take over the fever clinics from second-tier hospitals, so the second-tier ones can take charge of common infectious diseases. Top-tier hospitals will be for rare and incurable diseases. This is the [right] hierarchical system for the future,” he said.