These disputes can take various forms, including the display of corpses at a hospital, the blockade of a hospital entrance, the destruction of property, attacks against health professionals, and in some cases, the employment of gangs by patients’ families in order to pressure medical institutions for more compensation in instances of malpractice. China’s CCTV reported that in 2010 alone there were 17,243 cases of yinao, an increase of almost 7,000 incidents from five years earlier.^[1] The official People’s Net claims that over 10,000 Chinese health professionals are attacked or injured every year.^[2] A ten-province survey in China finds that more than half of health professionals had been verbally abused, nearly a third had been threatened, and 3.9% had been physically assaulted by patients or their relatives.^[3] Research in a three-tiered hospital in Shanghai found that there were 577 cases of medical violence between 2000 and 2006, comprising 61.5% of all medical disputes that took place in the hospital during this period. ^[4]

Chinese domestic media, international media, and leading journals such as the Lancet,^[5] the Economist,^[6] and British Medical Journal^[7] have widely discussed patients’ violent attacks against doctors. These various media outlets have accused the attackers of disturbing hospital order and of using indiscriminate violence, and they have called on the government to protect health professionals. In these reports, the blame is placed on the deepening miscommunication between patients and doctors, inflammatory reporting, the absence of formal institutional mechanisms for dealing with medical disputes, and problems related to the health system more generally. But social scientists have not looked at the use of nao in medical disputes with much seriousness. Why do people engage in nao and what does it tell us about Chinese society?

From forgiveness to revenge: The commercialization of the Chinese health sector and the demonization of doctors

In March 2012, a young man in the city of Harbin in northern China stabbed four members of the hospital staff; one of the victims, a junior doctor, died soon afterwards. The attacker complained that he had been refused treatment by the doctors, while the hospital staff explained that the patient had a particular illness which required treatment in another hospital first.^[8]

How could so many people feel “happy” after hearing about a doctor who had been violently killed?

Although the media had long been reporting on cases of doctors being killed by angry patients and their families since the 2000s, the Harbin case generated more controversy. Not only was it extremely violent in nature, but the reactions the incident garnered were extraordinary. In an internet survey that was conducted after the killing, survey participants were asked how they felt about the incident. The four answers that respondents could chose from were: “happy,” “angry,” “sad,” and “sympathetic.” Among the 6,161 people who responded to the survey, 4,018 indicated that they were “happy” while only 879 felt “angry,” 410 “sad” and 258 “sympathetic.”^[9] The results beg the question: How could so many people feel “happy” after hearing about a doctor who had been violently killed?

When the incident took place, I was doing fieldwork about health care transformation in a county in Southwestern China. Intrigued by the survey’s findings, I began to incorporate the case into my interviews. I asked my respondents to react to the incident. The question always evoked emotional responses from local residents. While many people showed their sympathy toward the deceased physician, stating that it was wrong to kill, they also expressed a high degree of understanding toward the extreme behavior of the patient. “There must be something wrong with the doctors or the hospital, or else how could the patient come to attack you [the doctors]!” an interviewee speculated. Indeed, for many interviewees, their first reaction was to suspect the doctors and the hospital involved of wrongdoing. My respondents recalled their own unhappy encounters with doctors and hospitals or recounted stories of others’ experiences that they had heard about: instances where patients were overcharged, rejected from a hospital for not having sufficient money, mistreated by health professionals, or ignored, sometimes literally, to death. This elderly couple that I interviewed expressed a typical commentary:

Grandpa Xu: I reckon the doctor might have done something bad, caused great resentment. You [the health professional who was killed] were a doctor, how could he [the patient] kill you [without a reason]? …

Grandma Xu: In the past, it was less typical. He [the patient] could forgive you [the doctor]. Honestly, in the past, how did you [the doctor] behave towards patients? Your primary concern was to save him, your professional responsibility was to save the patient. Thus, the patient’s family could forgive you. Now, even for a minor illness, your main focus is to make money, therefore if something goes wrong, they [the patient’s family] would certainly argue with you until they took back more money from you.

Grandpa Xu: The people [patients and their families] are just too resentful. His [the doctor’s] attitude is really bad… Some [doctors] are too arrogant, they [the patient’s families] killed you then, anyway, one life redeems another life…^[10]

Grandpa and Grandma Xu’s comments were informed by memories of an earlier era. During the Maoist period, the socialist system provided almost universal, albeit very basic, healthcare to Chinese citizens. Doctors were encouraged to selflessly “serve the people.” Patients recognized that doctors were dedicated to saving lives, which enabled patients to be more “forgiving” when medical mishaps occurred.

However, since the 1980s, as China began adopting market reforms, its healthcare system transitioned from being a fully state-run and state-financed to more privately financed and privately-delivered. These changes have led to soaring medical fees, lower medical insurance coverage, and poor access to affordable medical services. Reduced state investment has forced hospitals to become financially self-sufficient. Hospitals are regarded as profit-motivated rather than patient-centered. Indeed, patients are required by the hospital to pay money up-front; without money, some patients are even rejected by the hospital. These changes are reflected in doctors’ demeanors towards their profession. Underpaid doctors often turn to morally “grey” sources of income, such as drug kickbacks, bribery, and over-prescription. Patients often depict doctors as insensitive and profit-driven. And indeed, the commercialized healthcare sector opens patients up to an unparalleled regime of exploitation. In response, patients cannot hold lenient attitudes toward doctors and hospitals. When medical accidents occur or misfortune strikes, angry patients and their families often target doctors as well as other health professionals, including nurses and administrators, for revenge. Doctors, whose work involves more uncertainty, such as inpatient doctors, surgeons, and emergency room doctors, are especially vulnerable to attack.

Grandpa Xu’s words epitomized many locals’ explanations of the violence: patients or their families “intentionally ignored the law, because by using the law [the doctor escaped punishment or only received a prison sentence], you [the doctor] would continue harming others [after being released from prison]…they just killed you, that’s all.” Killing the “bad doctor” is understood as a preemptive act, a way to prevent future medical accidents. According to this logic, not only does the demonized doctor not merit a patient’s trust, but it is even acceptable for the doctor to experience violent forms of retribution, including murder.

Nao: A Weapon of the Weak?^[11]

In the municipality in which my field site is located, there were 550 recorded medical disputes that took place between 2008 and 2011, or approximately one medical dispute every two days. Medical conflicts and disputes erupted in the county hospitals every month. Rising numbers of health professionals have experienced verbal or physical violence from patients. The medical dispute that took place in one county hospital in 2011 was especially controversial. It was widely discussed by locals and repeatedly mentioned by health professionals that I interviewed. The patient had been diagnosed with terminal cancer and was hospitalized. Overwhelmed by pain, she jumped off the hospital building one night and died. After the incident, the patient’s relatives gathered in the hospital, placed the coffin at the hospital entrance hall, and asked for compensation. The family also employed gangs to nao in the hospital. Fights broke out between the patient’s family and the hospital, resulting in the injury of several members of the hospital staff, including the hospital director.

Drawing from archival and online sources, I found many cases of patient suicide that led to violent disputes between hospitals and patients’ families. These cases aroused intense discussions about hospital responsibility. When the overcrowded public hospital attributed some daily care responsibility to the patient’s family, the family responded by demanding that the hospital take full responsibility if accident happened during the patient’s hospitalization. Further complicating this matter, was the fact that existing laws did not specify the distribution of responsibility in cases of suicide in medical facilities. When these disputes went to court, the adjudications varied from case to case. Many families thus relied on themselves to nao in order to seek just compensation.

I found a long complaint posted on a local internet forum that had been written by the patient’s husband soon after the suicide. From the post, I learned that the patient was left unattended by hospital staff even though they had been informed about the patient’s unstable emotional state and suicidal tendencies. Additionally, the corpse was transferred to another mortuary outside the hospital before the family had been informed. In order to “seek justice” (tao gongdao), the family used the internet as a way to air their complaints. The post was filled with grievances. In the forum discussion, others expressed sympathy toward the family and criticized the hospital.

The practice of nao in medical dispute is infused with local social and cultural meanings. Crying out loud, acting emotionally, displaying funeral equipment, and broadcasting funeral music are common practices in conventional mourning. When a patient dies, the family is justified to engage in these mourning rituals even at the hospital or clinic. Most of the practices of nao, albeit controversial, do not directly violate the law. Moreover, the public tends to sympathize with the weak, in this case, the mourning family. The long list of grievances the public has about profit-driven hospitals and “irresponsible” health professionals also increases their tolerance towards nao, which is thought to target those in power.

At the same time, the visible, public, and persistent nao is disastrous for health professionals and hospitals. While the position of patient’s family as victims affords them moral capital in countering health professionals and hospitals, health professionals who hold less moral capital have limited resources. They generally do not respond to verbal attacks until the situation escalates. In addition, the crying and the display of funeral equipment and corpses meet with Chinese people’s fear and avoidance of things related to death. These funeral performances at the hospital are thought to bring “mei” (bad luck) to the people who encounter them. These intentional actions by the patient’s family are meant to drive patients away, causing the hospital and doctors bad luck in their business. Also, these striking and noisy displays put hospital and doctors in an awkward, humiliating position, and threaten their “face” (mianzi), or the reputations of individual doctors as well as of that of the clinic or hospital. Many medical institutions and doctors cannot survive these troubles. In order to save their business and their “face,” hospital administrators and doctors are pressured to meet the family’s requests.

Moreover, the ritualized gathering together of the patient’s family, kin, and in some cases, hired gangs has symbolic power. In an era of “harmonious society”—the political agenda promoted by the Hu-Wen leadership since 2004 to reduce social conflicts—the government feels increasingly insecure in the presence of large group gatherings and demonstrations. For this reason, the government frequently pressures hospitals to solve disputes as soon as possible and meet patients’ demands. Ironically, the government effort to build a harmonious society, to some extent, empowers patients

The Limits of ‘Preserving Stability’

In the case of the suicide I mentioned earlier, the hospital later initiated efforts to negotiate with the family. But no agreement had yet been reached when I conducted research in the county hospital in 2012; “the amount asked by the family was too much” and the family’s attacks on hospital staff effectively suspended the negotiation. The hospital director was furious about being attacked and revealed the bind he found himself in, with the family demanding compensation, on the one hand, and the government demanding that the hospital maintain stability, on the other:

At the mediation scene, there were the personnel from health bureau and government office, even two members of the police. I bent down to talk with him [the dead patient’s husband]. Suddenly he took a tea cup from the table and hit me with it on my head. It hit the corner of my eye, caused the rise of the intraocular pressure, the brain blood pressure increased too, it may have potential risk for my brain… What can I do? I had to be there, to weiwen [preserve stability]. The hospital head should not be at the mediation scene. Without the hospital head at the site, the conflict could be eased a little. But the government leader did not understand this. He only wanted to reduce his pressure [in preserving stability]. There isn’t any cooperation [between the hospital and the government].^[12]

As the hospital director explained, the patient’s family would wait for an “influential” person to show up, then act strongly and even violently to show their determination. The hospital director was aware of the importance of avoiding direct confrontation. “Instead of forcing the hospital head to go [to meet with the family], it should be the staff specialized in solving disputes who conduct the negotiations,” the director commented. However, the local government’s pressure to maintain stability forced him to meet with the family, which incited the conflict, leading to the attack even in the presence of police and government personnel. The hospital director further complained about the government’s irresponsibility:

When there is a conflict, the police come to tour the hospital then leave… The court just moxini [literally, mix the mud], and even if we win the lawsuit, we still lose. We win the lawsuit but lose the money… Now the state promotes the ‘harmonious society,’ it pursues harmony without the premise of the legal system, this is stupid. It’s the government’s irresponsibility… The effort to conceal conflict cannot really solve the problem… I feel that our society is headed towards a crisis. The crisis is waiting to happen. That’s why our government is so nervous, focusing on maintaining stability which outweighs all other concerns, even pursues stability without principle. They are scared that they cannot control the situation if the fire starts and spreads.

According to my respondents, when medical disputes erupted, the police usually arrived, watched, and then left without doing anything. The police’s main concern was to preserve social order at the site. As a result, they were often reluctant to interfere for fear of further escalating the conflict. Given police inaction, the conflict dragged on. Under pressure from the patient’s family and their loud supporters, the local government, in turn, pressed the hospital to solve the dispute at any cost. The hospital then became the sole target of the medical dispute and the only entity negotiating with the patient’s family. The hospital director explained that even if the hospital won the lawsuit, they still needed to pay the patient’s family in order to “buy peace.” The government, it seems, pursued social order no matter what the cost; and in doing so, it failed to address the root of the conflict. When stability trumps all other goals, a bigger crisis ensues.

The Deterioration of Nao

In medical disputes, existing legal and administrative forms of mediation are usually considered to be expensive, complicated, unreliable, and unjust. For this reason, many prefer to take matters into their own hands, through nao. Unlike official institutional procedures, the practice of nao is a more familiar, straightforward, and less costly way to present a medical grievance. According to one report, there were approximately 200 cases in the Guangdong Province, between January and July 2006, where patients’ families used violence to demand compensation, ranging in amount from 1,500 Yuan to 15 million Yuan (about 244 to 2.44 million US dollars). Of these, 129 were privately resolved before September 2006 and patients’ families received compensation from the hospitals directly.^[13] The apparent effectiveness of nao encourages its wide use. When hospitals are forced to compromise with those who engage in nao, it reinforces the sense that more violence begets more compensation.

Many [doctors] employ a “scalpel versus dagger” metaphor, protesting that they use a scalpel to save patients only to be “repaid” by the dagger.

Doctors, for their part, bear great uncertainty in their daily work. Many employ a “scalpel versus dagger” metaphor, protesting that they use a scalpel to save patients only to be “repaid” by the dagger. Medical practices are increasingly constrained by the boundaries of “safe practice,” limiting doctors’ efforts to save patients. At the same time, hospitals pay large amounts of money annually to solve disputes and expand their security forces. Lacking government and police protection, some hospitals even employ thugs to counter yinao groups. These conflicts sometimes deteriorate to scuffles between the hospital (comprised of hospital professionals and hospital security guards) and a patient’s family, friends and hired thugs. Without enforcement agencies, patients and health professionals are forced to take disputes into their own hands.

The health professionals that I interviewed generally expressed a sense of anger and powerlessness. As one hospital staff member put it, “now the social atmosphere and medical environment are like this [antagonistic toward health professionals], if the state does not create a policy to address these conflicts, we health professionals have no rights, no power, and no way to negotiate with patients at all.” Doctors regarded themselves as the scapegoats of the health system and blamed the government for minimizing its involvement in conflict mediation and in the protection of health professionals. In retaliation, health professionals began to publicly express their grievances and called for more government intervention. They, too, employed nao by taking to the streets, protesting in front of government buildings, and asking for “respect and dignity” (huanwozunyan), for “justice”, and for “punishment of the murder”—referring to the patients who killed doctors (yanchengxiongshou).^[14] These tactics finally forced the government to respond.

Discussion and Conclusion

Since 2012, Chinese central and local governments have implemented a series of new regulations and decrees to contain yinao.^[15] Patients and their families began to be forcefully detained or punished for disruption of hospital order and any acts of violence, including attacks on hospital staff.^[16] In December of 2013, 11 central government departments released a joint Action Plan to Fight Medically-related Illegal and Criminal Actions to Preserve Health Care Order. This special task force began to target yinao as “illegal and criminal actions.”^[17] In April 2014, two patients who had killed doctors were given the death penalty,^[18] the most serious sentence to date. At the same time, the media and official discourses began to link yinao with criminal gangs, even though the involvement of gangs in medical disputes is not common in small counties like my field site. These new measures effectively criminalize people who engage in violent nao and collective contestation that may “disturb social order.”

In addition, the official decrees and the media form a dominant discourse that frames nao as an uncivilized, backward, and irrational form of behavior carried out by people with low suzhi (social merit and quality), while suggesting that the educated, civilized, and modern citizens use legal means to protect their interests. However, the situation is not that people of “low suzhi” actively choose nao. Rather, it is that their relatively powerlessness puts them in a structural position where nao is their only option. Thus, the government’s efforts to contain nao effectively threaten marginalized groups’ very means to defend themselves.

Yet, at the same time, it is a mistake to think that the violence facilitates genuine participation and control. Although, nao allows the relatively weaker party to reverse the power relations, it is only a momentary reversal. Bryan Turner suggests that in Western history, “the critical factor in the emergence of citizenship is violence, that is, the overt and conscious struggle of social groups to achieve social participation.”^[19] But the result of employing nao is often uncertain and arbitrary—hardly a guarantee that the basic rights of citizenship are restored. Nonetheless, these outbursts of violence are a daily reminder that something is very wrong. And I doubt that yinao will disappear as long as the Chinese health sector stays commercialized.