On Sunday morning, hundreds of doctors gathered in Beijing to attend the funeral of their former colleague Yang Wen, who was reportedly killed by the relative of one of her patients on Dec. 24. Mourners expressed sorrow over the loss of a fellow physician and fury toward the killer.

As the week has progressed, however, many medical professionals’ focus has shifted toward preventing similar tragedies from happening in the future. A growing number of doctors have come forward to demand further action be taken to protect hospital staff, including tighter security checks and tougher sentences for violent patients.

Yang’s death was not an isolated incident. Patient-on-doctor violence has been a serious problem in China’s health system for years, with 85% of doctors stating they had experienced a violent incident at work in a recent survey by Dingxiang Yuan, an online platform for health professionals. 

Though the number of fatal attacks has declined since a peak in 2012, they have not stopped. On Oct. 22, just two months prior to the incident in Beijing, Feng Lili, a surgeon from the northwestern city of Lanzhou, was also killed by a cancer patient.

Chinese health professionals blame the violence on a number of underlying factors, from widespread patient mistrust of doctors, to stretched resources at hospitals amid a rapidly aging society. But for many, the most immediate causes are lax security standards at health centers and the light punishments handed to many offenders.

Zhao Lizhong, a doctor at the Beijing Aerospace General Hospital, one of the capital’s leading institutions, tells Sixth Tone that new security measures in particular are urgently needed. He has personal experience of violence: While on duty in the emergency room in 2012, a patient approached him from behind and stabbed him in the neck — an eerily similar attack to the one that killed Yang.

“I’ve been hoping my blood could serve to wake people up and make them understand that the relationship between doctors and patients should be complementary — we should be struggling side by side,” says Zhao.

Zhao is calling for mandatory security checks at hospitals and the establishment of an accountability system for hospital assaults similar to the one China previously introduced to deal with mining accidents. 

“If hospital management is made accountable and relevant officials held responsible for negligence after such violent attacks, things will definitely improve,” says Zhao.

Experts agree that tightening safety measures can play a significant role in reducing hospital violence. The level of security in Chinese health institutions varies widely. While some high-profile hospitals in major cities have imposed security checks and are regularly inspected by police, many smaller centers make do with only a few security guards. Only 29% of doctors believe their hospitals take sufficient measures to protect their staff, according to the Dingxiang Yuan survey.

Li Huijuan, a Beijing-based lawyer who has represented the families of several murdered doctors in court, points to the southern city of Zhongshan, Guangdong province, as a model for others to follow. After hospitals nationwide suffered a string of deadly attacks in early 2012, Zhongshan’s medical institutions took several precautions: establishing drunk tanks for intoxicated patients, equipping security guards with pronged batons, stationing police officers on-site year-round, and installing alarms in doctors’ offices.

“No major conflicts have been recorded since the reforms were made in 2012,” says Li. “I would highly recommend the Zhongshan approach.”

On Wednesday, the health authority in the southwestern city of Nanning issued a notice, urging all local tier-three hospitals to introduce mandatory security checks.

According to Zhao, hospitals in China are responsible for their own security arrangements. After his stabbing in 2012, Beijing Aerospace General Hospital responded by employing more security guards, but even today there are no police officers positioned inside its grounds.

“Police are law enforcement agents,” he says. “The deterrence they can bring is completely different from what security guards can offer.”

Other medical professionals, meanwhile, want authorities to deter future attacks by increasing the penalties for crimes committed inside hospitals. 

Though patients who kill or severely injure medical workers can face death sentences or long prison sentences, patients who assault and threaten hospital staff often receive little more than a fine or even a mere warning.

In 2014, a woman was released from detention after just a few days, after beating a nurse with an umbrella inside a hospital in the eastern city of Nanjing. The defendant, the wife of a civil servant working with the local procuratorate, was accused of intentional injury but received a light punishment because the nurse’s injuries were judged to be minor.

On Dec. 28, four days after Yang’s death, China’s leaders approved a new health care and health promotion law, which will come into effect in June. The law has been presented as a move to strengthen punishments for violence against health-sector staff, but opinions are divided over how effective it will be in practice.

The new law clearly defines hospitals as public venues — a move that some legal experts consider significant, since China’s criminal law states that those disturbing the order of a public place can be sentenced to up to five years in prison. “The law will mean a lot for law enforcement bodies,” says Li, the Beijing-based lawyer.

Li, however, cautions that the reform is not a game-changer, as previous regulations and court documents indicated that hospitals were already classified as public places. In previous cases, such as the 2014 incident in Nanjing, prosecutors and judges had the legal tools available to press for a tough sentence, but chose not to do so, she suggests.

“The actual conclusions of high-profile cases didn’t live up to our expectations,” says Li. “Law enforcement should have taken full advantage of such cases to highlight the severe consequences of violence in hospitals … If the attacker (in the Nanjing case) had been given a sentence of two years, or even just six months, the educational effect would have been huge.”

Health care workers argue the new law is still too weak, especially in terms of protecting hospital staff from intimidation. While it states that demeaning, threatening, or endangering the personal safety of medical staff is illegal, it stipulates that such actions should only be treated as violations of public security regulations, rather than criminal acts. As a result, offenders are likely to continue receiving fines or warnings, rather than face jail time.

“Punishing them according to the public security regulation — a fine of 500 yuan ($70) — is far from enough,” says Li.

In the days following the law’s approval, a group has formed of Beijing-based medical practitioners and policy advisors — many of whom knew Yang personally — calling for the passage of a so-called Yang Wen Act. At time of writing, details on the group’s specific policy proposals remain hazy, but the act would be based on the principle of zero tolerance toward hospital violence. 

The Yang Wen Act takes inspiration from Taiwan’s introduction of the “Wang Kui-fen Article” amending its Medical Care Act following a major scandal in November 2013. Wang Kui-fen, a municipal official, slapped a nurse in public, after the nurse had previously refused to reveal details of her father’s condition over the phone. The new article declared that anyone who threatens or harms a medical worker in any way will be jailed for up to five years and fined up to 500,000 new Taiwan dollars ($16,700). Wang was later given a five-month sentence.

Ma Guangyuan, a high-profile Chinese economist and member of the Beijing Municipal Committee of the Chinese People’s Political Consultative Conference, tells Sixth Tone he plans to raise the Yang Wen Act during the annual meeting of the capital’s legislative advisory body, which begins Friday.

The economist has also proposed the creation of a national Anti-Medical Violence Day on Dec. 24 — the date of Yang’s death — as well as a move to recognize the murdered doctors as martyrs.

Whether the reforms would be enough to heal the divide between China’s patients and doctors remains to be seen. Zhao, the doctor stabbed by a patient in 2012, says the atmosphere in China’s health system is almost unrecognizable from when he started practicing medicine in the 1990s.

“Doctors were well-respected,” he says. “If I’d known then it (working in medicine) would mean risking my own life, I would never have considered the job. It’s not worth it.”

Health experts trace the change in attitudes to the early 2000s, when a key legal change and the rapid introduction of modern medical technologies such as CT scanners led to doctors running more tests on patients. The tests helped doctors make more precise diagnoses, but raised medical costs.

“As a result, patients’ distrust of doctors began to grow exponentially,” says Li. “They assumed doctors were simply trying to make money off of them.”

Wang, a Shanghai-based doctor with 30 years of frontline experience who declined to reveal her full name due to the sensitivity of the topic, agrees that the rise in the number of tests during the 2000s was decisive.

“Conflicts in hospitals have been rising ever since,” says Wang. “It definitely has a lot to do with the wider social environment.”

The growing financial strain China’s public medical insurance funds are experiencing is also creating tensions between patients and medical staff, as hospitals seek to keep their budgets under control. The Chinese funds’ costs have been rising faster than revenues since 2015, as the aging population outpaces investment in health care, according to state media.

In a Dec. 30 interview with China Newsweek, the director of an intensive care unit at a leading Beijing hospital revealed that most hospitals have to restrict their usage of public medical insurance funds toward the end of the year.

“The inpatient department will accept a limited number of patients,” said the doctor, who was not named in the report.

Instead, patients are sent to the emergency room, where they don’t have as many reimbursement entitlements on their treatment costs. 

“For inpatients, reimbursement limits are set at over 100,000 yuan, but for emergency room patients, the number will be much lower,” a doctor at the Beijing Civil Aviation General Hospital, the facility where Yang worked, told the medical news platform Yixuejie. “This means patients have to pay a significant percentage of their medical bills out of their own pockets.”

Finding solutions to these structural issues will be a long-term challenge, which is why Zhao and others are focusing their energies on promoting reforms that can make an immediate difference.

“An accountability system, mandatory security checks, blacklisting people with records of assaulting medical workers, building up quick response teams to intervene once there’s a potential conflict — these are all feasible measures that can get done,” says Zhao. “We can’t turn around the wider (social) environment, but these steps can help significantly reduce the occurrence of intentional harm in hospitals.”

If hospitals are unable to protect their doctors, health professionals worry that the health system’s staffing issues will become increasingly severe. China already faces a shortage of young doctors and is struggling to recruit medical students.

In the past week, there have been several resignations and staffing adjustments at the Beijing Aerospace General Hospital, according to Zhao. An anesthetist applied to join the physiotherapy department, a neurosurgeon decided to move to a community health service center, and others simply handed in their notice.

“What happened has chilled doctors’ passion for their job,” says Zhao. “But who will be the ultimate victims of such losses?”

The doctor, however, understands his colleagues’ decisions. Since his attack, he has also transferred away from frontline duty and is now the director of the hospital’s health management center. “It’s much safer here,” he says.

As physicians attempt to avoid patient-facing roles, the Beijing hospital has been forced to shut down its inpatient pediatric department, according to Zhao. But he refuses to give up hope.

“I still have confidence — with the right measures, the situation will change,” says Zhao. 

Editor: Dominic Morgan.

(Header image: A doctor takes a break at a hospital in Rizhao, Shandong province, Jan. 27, 2017. Tuchong)