In Depth: Understaffed, Under-resourced and Overwhelmed — Coronavirus Early Response
(Wuhan) — Wang Jianjun, a community manager of the Jianghan District in Wuhan, let out a deep breath Thursday afternoon when he learned that the last confirmed coronavirus patient in his community was admitted to a hospital.
It meant Wang and his community were finally in compliance with city officials’ Feb. 9 order that all confirmed patients be hospitalized, a key step in the city’s fight against the deadly Covid-19 virus.
It has been more than 20 days since Jan. 23 when Wuhan, a metropolis of 11 million people at the epicenter of the epidemic, was locked down to curb the spread of the disease. Even after imposing such an unprecedented quarantine, officials moved too slowly and missed key windows to control the spread of the virus within the giant city, experts said. Infected people traveled freely seeking treatment, becoming mobile sources of contagion.
“The epidemic is explosive, and the only way to prevent its spread is to cut the infection sources,” said Chen Bo, a professor at Huazhong University of Science and Technology in Wuhan. He urged as early as Jan. 25 that the city use civic facilities as quarantine sites for suspected patients, but officials declined, citing concerns over inadequate medical supplies and risk of contagion, Chen said.
Between Jan. 22 and Feb. 1, the government focused most on adding fever clinics and hospital beds but failed to properly quarantine and care for suspected patients, Chen said. Most such patients couldn’t be confirmed with the infection for lack of testing kits and had to return home. Many of them deteriorated into severe condition or spread the virus, Chen said.
This put Wuhan community managers like Wang under tremendous pressure to fight the epidemic without medical training or facilities. These neighborhood officials were effectively drafted for the front lines to screen people in their communities who were suspected of having the infection, and obtain treatment for those with confirmed cases. Most of the time, they found themselves powerless to carry out their duties.
A review of the past 20 days in Wuhan shows how the city was slow to live up to its promise to contain the epidemic, shifting from allowing most suspected patients to stay home or move around the city to requiring centralized quarantine for all of them. Not until Feb. 2 did Wuhan officials realize the extent of the danger and impose tougher quarantine measures, further strengthening them on Feb. 8.
Those lost days led to enormous waste of medical resources and human lives, experts said. Stories from frontline community managers piece together a vivid account of the overdue policy change’s heavy human cost.
In Wang’s 4,000-person community, nine people were diagnosed with the virus as of Thursday. One of them died after waiting 10 days in vain for hospital admission, according to Wang.
In another part of the city, manager Li Dong of the Baibuting community in Jiang’an District stayed up several nights trying to find hospital beds for patients in his neighborhood. As the last patient was hospitalized Feb. 11, Li had his first shower in 10 days.
His relief didn’t last long. The next morning, two new confirmed cases were reported.
On Feb. 13, the Hubei provincial health authority reported a stunning increase of 14,840 new confirmed cases in one day, including 13,436 in Wuhan. The sudden jump was because of a revision to diagnosis criteria under which patients’ conditions can be determined based on clinical symptoms rather than waiting for laboratory tests.
Li said he wasn’t surprised as his daily struggle gave him a sense of the outbreak’s severity. But as the number of confirmed patients spiked, the burden on community workers also mounted.
“(We) have to find hospital beds for more patients,” Li said with a sigh. “When this will come to an end?”
Jan. 23: Community paralyzed after city lockdown
Just 20 days ago, the Baibuting neighborhood was cheerfully celebrating a massive Lunar New Year event.
“It is like 20 years have passed in 20 days, and so many things happened,” Li said.
It has been a tradition since 2000 that the 130,000-resident neighborhood holds a banquet similar to a Western potluck before the Lunar New Year. About 40,000 families brought meals to share. Li was busy organizing the event on Jan. 18 even though word was circulating of a mysterious disease.
“There was reportedly no human-to-human transmission, but many of us were concerned,” Li said. “We suggested canceling the event, but officials rejected.”
Two days after the Baibuting banquet, renowned epidemiologist Zhong Nanshan disclosed that 14 medical staff had been infected, evidence that the disease was transmitting between people.
“We were stunned,” Li said.
On Jan. 23, the Wuhan government ordered to close off the city of 11 million residents from the outside world, a measure soon followed by other cities in Hubei Province that evolved into the largest quarantine in human history.
“It was a mess that day,” Li said. “Residents were calling for inquiries, and the district authority ordered us to send a print notice to every family in one day.”
The following days meant more challenges as the community management team was assigned to screen and register all patients with fever in the neighborhood and arrange for medical checks or home quarantine for suspected patients. Meanwhile, they had to work on the supply of necessities and basic services to ensure livability in the community.
Since then, Li and his team have been overwhelmed with the work of asking residents about their health conditions, registering those with symptoms and contacting hospitals of behalf of suspected patients.
As the city suspended all public transit and restricted private cars, Li found it was difficult to manage transportation of residents to hospitals. It was even harder to find hospital beds when most of the city’s hospitals were swamped.
“I called hospitals every day searching for beds, and our supervisors also begged for help everywhere, but there was little help,” Li said. “Patients couldn’t understand and were always angry with us.”
Little had Li known that an even tougher time was about to come.
Jan. 23 – Feb. 1: Brutal natural selection
Since the lockdown began, there have been two key battlegrounds. The first is the city’s medical system, which has been completely swamped. The second, less visible battleground is residential communities, which have been charged with making sure essential supplies are available, and identifying and quarantining potentially infected people as early as possible.
But this massive community management system is being given inadequate official support, with workers lacking the necessary training, protective gear and other resources they require.
Wuhan’s core urban area is divided into 1,159 communities. Each has its own community workers who cover hundreds of households. A total of 6,000 cars were assigned to these communities after the lockdown and following ban on intra-city transportation. The cars were meant to deliver food and other essential supplies and transport people to medical facilities – that is, to serve the remaining 9 million people in Wuhan, including a fast-growing number of coronavirus patients.
Despite the massive workload, many community managers including Jianghan District’s Wang said the help they could provide to patients and their families was very limited during the first 12 days after the lockdown.
“There was no concrete support from higher authorities, and communities had no medical resources,” Wang said. “All we could do was file forms and repeatedly report patients’ conditions.”
Some emergency contacts were handed out to the community managers, but many turned out to be a dead-end. Wang once called the district emergency contact number to help a patient in critical condition arrange a ride to a hospital. Half a day later, he received a call from the district head, requiring the community to provide its own transportation.
Wang ended up using his private car to bring patients to the hospital, despite the transportation ban. But that was not the end of the ordeal.
On the first day of Chinese Lunar New Year, Wang chauffeured a patient from his community in critical condition to the hospital in his own car, after repeated failed attempts to get help from the district. Both him and the patient waited at the hospital for five hours, only to receive some medicine — the hospital was running out of beds.
Wang didn’t give up. The hospital reception desk told him that he could dial a hospital complaint number and try a city-wide emergency hotline by dialing 12345. He did both, and both times reached the same nurse with the same answer.
“There was nothing we could do to help patients with hospital admission,” Wang said. “They had to rely on themselves.” Many patients were in despair as they couldn’t be hospitalized but were afraid to stay home and risk infecting their families, Wang said.
State and local health authorities repeatedly emphasized the role of communities in disease control.
“We must rely on the mobilization power of residential communities, including in rural areas, to conduct a blanket search. Make sure that protective control systems reach every household and every person,” said He Qinghua, an official with the National Health Commission at a news conference on Jan. 27.
Zhong Nanshan, a leading Chinese respiratory disease expert and the head of a specialist team at the National Health Commission, also said that early identification and quarantine is the most primitive, but most effective, measure in containing the spread of the virus.
“Governments told the public to seek help from communities, but without enough resources and manpower, we were helpless,” said Zheng Ling, a community leader in the Jiang’an District.
Also under pressure were community health-care centers. The facilities, which have long provided only basic health-care services and common illness treatments, were assigned to do preliminary screening and distinguish among fever patients, according to a Jan. 24 Wuhan city government order.
Most community clinics were underequipped for the task of dealing with highly infectious patients. Caixin found in a Jan. 27 interview with a health-care center at the Baofeng community that the 60-staff clinic had only one protective suit and a limited stock of single-use masks. Yang Qinghong, a doctor at the clinic, said he interviewed 100 patients that day, including more than 30 with fevers and two with severe symptoms.
Official data released Feb. 3 showed that the fatality rate of the new coronavirus was as high as 4.9% in Wuhan and 3.1% in Hubei, compared with 0.16% in the rest of the country.
In the first 10 days after Wuhan’s lockdown, the city’s supply of medical resources, especially testing kits and hospital beds, largely fell short of demand. Many suspected patients were instructed by hospitals and the local government to stay home and quarantine themselves. “But how should they do that at home? How to manage this? The government didn’t give any training to frontline communities, let alone provide the necessary support measures,” Huazhong University of Science and Technology’s Chen said.
Chen listed three severe consequences of the early lax response to suspected cases: lack of medical care resulted in deterioration of patients’ condition, with many falling quickly into critical condition, increasing the death rate; the policy of staying home caused more cross-family and community cluster infections, spreading the virus at a much larger scale; once those patients reached critical condition, they needed to seek professional medical help, including rescue efforts, but to do so had to travel back and forth for multiple times between their homes and various hospitals, waiting in long queues for registration, treatment and hospitalization, causing more cross-infection in hospitals.
Cross-infection resulting from the massive population of un-hospitalized patients jeopardized the effectiveness of the city lockdown, and created enormous difficulties for those patients and their families.
“During that period (before Feb. 2), suspected patients left at home in Wuhan and their families went through a brutal process of natural selection,” Chen said.
Feb. 2 – Feb. 8: Back on track, slowly
Almost two months into the outbreak, the city of Wuhan announced on Feb. 2 that it would sort patients into four groups and treat them accordingly. The city decided to isolate and independently treat confirmed cases, suspected cases, patients with fevers (one of the most common coronavirus symptoms, but a common symptom of many ailments) and those who have been in close contact with coronavirus patients but who do not yet show symptoms.
Wang said things seemed to start getting back on track after Feb. 2, when the Wuhan government ordered that all confirmed patients be hospitalized and suspected patients be moved to designated quarantine sites rather than staying at home.
Since Feb. 2, local authorities converted a number of hotels into quarantine centers under a plan to accommodate all suspected patients. Meanwhile, a makeshift hospital called Huoshenshan went into operation.
“There was finally a decision that confirmed patients must be hospitalized, and suspected patients would be put in isolation to cut the infection paths, although it was late,” Wang said.
The opening of quarantine centers and more makeshift hospitals has offered relief to Wuhan’s overcrowded hospitals. The Wuhan city health authority said Feb. 2 that the city would add 12,000 beds in existing hospitals to accept coronavirus patients. The next day, three new makeshift hospitals opened with nearly 4,000 beds to receive mild patients.
But the expansion of medical facilities could hardly keep up with the accelerating rate of infections in the city. Several community workers said they are still struggling to find beds for patients or help them get timely medical care.
As patients had to wait for laboratory tests to confirm infection before they could be admitted to hospitals, a large number of suspected patients remained in quarantine sites with limited medical treatment, according to Li.
The space in quarantine sites ran out quickly, and many suspected patients still remained at home.
Feb. 9 – Feb. 13: Race for hospital beds
Since Feb. 9, authorities in Wuhan have started a campaign to ensure that all confirmed patients be hospitalized. The central and provincial government called Feb. 9 a “hard deadline”.
That added to pressure on community workers to send patients from their neighborhoods to hospitals. Not a single confirmed patient should be left at home every day, according to the order. Although community offices could provide transport and refer patients to hospitals, it was up to the hospitals to decide on admissions, Wang said.
It was common for patients to travel back and forth or wait hours for a bed. The last two confirmed patients from Wang’s community to be received by a hospital were a 71-year-old couple. They queued for a whole day in the hospital waiting for space even when they were exhausted.
“I had to persuade them to stay there,” Wang said. “Otherwise they would have to start all over again.”
“As long as they are admitted by the hospital, not staying home, (I) complete my task,” Wang said in a guilty tone.
Some people suffered more. Ren Shanyou, 63, moved into a quarantine hotel Feb. 11, but his condition deteriorated quickly to include high fever and difficulty breathing. As of Feb. 13, Ren was still waiting in the hotel for space in a hospital, despite limited medical treatment available at the site.
As the number of confirmed patients jumped Feb. 13, Wang said his fight for hospital beds will continue.
“I don’t care if it is tiresome, but I really hope there are more considerations for patients so that they will suffer less,” Wang said.
Contact reporter Han Wei (email@example.com) and editor Bob Simison (firstname.lastname@example.org)
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