HENGYANG, China – Dr. Chen Yuna had just eaten her lunch and was seated at her desk updating patients' medical records when a masked man entered her office. He pulled out a dagger and stabbed her 28 times in her neck, chest, stomach and elsewhere. Then he left her to die in a pool of blood.
He knew the hospital well enough to slip out easily: Before he became Chen's killer, the man had been her patient.
Chen's murder in central Hunan province is one of thousands of violent attacks in recent years by patients that have crystallized public discontent with China's health care system, the largest in the world.
Despite an injection of more than $240 billion in government funding into health care over the past three years, the doctor-patient relationship has continued to break down. Doctors are overworked and underpaid, and many push drug sales or charge extra for services such as deliveries to make more money. Patients are faced with high medical expenses, brief consultations and often poor quality care.
The government's attempts to fix the system may even have made some things worse. Its rapid expansion of insurance coverage means that more patients can pay for health services, which are mostly provided by public hospitals. But even as demand has gone up, doctors and funding are still in short supply. Hospitals are often scenes of disarray, with beds overflowing out of wards into corridors and shouting matches between patients and medical staff.
The anger built up over years is now exploding into violence, with doctors, nurses and interns around the country stabbed, punched or otherwise assaulted by patients or their relatives over the past year. A few have died. Although official data is unavailable, state media reports say there were more than 17,000 "violent incidents" at health care facilities nationwide in 2010, a 70 percent increase from 2004.
In a top Beijing hospital in September last year, a 54-year-old cancer patient stabbed a doctor 17 times after a dispute. In the northeastern city of Harbin in March, a 17-year-old patient with a spinal disease attacked doctors with a fruit knife, leading to the death of an intern. One month later in Beijing, a man identified as a patient stabbed two doctors.
"China's doctors are in crisis," the British medical journal Lancet said in a May editorial urging a government inquiry into the spate of violence and solutions to ending it.
The story of Chen's murder is told through interviews with Chen's husband, her co-workers, a patient and police, and supported by photos and reports from the local health bureau and state media. The alleged assailant's family could not be reached despite numerous attempts; very little is publicly known about him. He has been charged with murder.
Chen grew up surrounded by the medical profession. As a child in the late 1970s, she lived on a hospital compound with her parents, who both worked as doctors. Many of her relatives were also doctors.
Around her, however, the world of Chinese health care was changing.
When the Communist Party took control in 1949, it created a centrally planned medical system that ran large facilities in cities and deployed barefoot doctors into the countryside to vaccinate children and promote hygiene. But by the early 1980s, free-market reforms were virtually dismantling the health care system.
The government cut funding to hospitals. They were allowed to make hefty profits from new drugs and technologies instead, and doctors' bonuses were tied to these revenues. So doctors had an incentive to sell more drugs and tests even if they weren't needed, and expenses skyrocketed.
Chen graduated in medicine from a local university in 2001 and joined her father at the Hengyang No. 3 People's Hospital. She kept journals with detailed medical notes about her patients and a Chinese-to-English glossary of medication names in the back.
Chen specialized in tuberculosis because most of her patients suffered from it — including the man who would later kill her.
By many accounts, Chen, 34, loved her profession and worked hard. "She was very warm, very caring," said Jian Hongjiang, who was Chen's patient when he was hospitalized in June for TB. "She came to see me every day and always asked me if I was feeling better. I was shocked when I heard what happened to her."
Chen, like most doctors, rarely had public holidays off and worked many weekends. Her phone rang daily with calls from patients with questions and requests.
One of the last text messages she sent was to her department head on April 21, when she was out of town with her husband. "I've already accounted for my patients, their conditions are all stable," she wrote. Some days she came home from work and remarked: "Today was such a hard day."
Chen's workload was not unusual. In a survey released February of more than 10,000 doctors by the online medical network Dingxiangyuan, a third said they saw more than 50 patients a day, some more than 100.
Hard work and low government-set salaries have made the medical profession one of the least popular in China. Entry-level doctors in major cities earn about 3,000 yuan ($500) a month, doctors say, about the average income of university graduates despite more work and more risk. In grassroots facilities like the hospital Chen worked in, salaries are even lower. After 11 years, Chen was earning only around 3,500 yuan ($550) a month, more if she saw more patients.
The low wages have led to widespread and well-known corruption, which fuels hatred of doctors. Many users of popular online microblogs have cheered the attacks on doctors as rightful punishment for corrupting the health care system.
The April stabbing was not Chen's first encounter with violence. In September, a patient threatened her with a knife over a dispute about him cuddling with his girlfriend in front of other patients in the ward.
Terrified, she called her husband, Liao Chongzhou, who rushed to the hospital. Police took statements but the patient was discharged without incident.
Liao did not think too much of it. "This kind of thing happens all the time in grassroots hospitals," said Liao, who used to be a doctor too until he quit last year, fed up with what he described as overly demanding patients.
It was only after reports of doctors being severely attacked elsewhere earlier this year that he called his wife's hospital and suggested they beef up security. Liao told a hospital official: "If something happens, it will be too late for regrets."
Meanwhile, Wang Yunsheng was growing more frustrated by the day.
A decade ago, Wang left his rural home in Hunan at 15 for the prosperous south to work to help support his family. Last year, while doing construction in Guangdong province, he started coughing incessantly. Several hospital trips later, he was diagnosed with tuberculosis.
The 25-year-old migrant worker took two courses of medication and showed signs of improvement, but suffered from insomnia and a rash on his arms, possibly as side effects.
In July last year, Wang went home to Hengyang and turned to the No. 3 hospital for help. He spent 28 days in the hospital and at least 8,600 yuan ($1,350) — about one and a half times the annual income of a farmer. He was told that he had drug-resistant TB that is hard to cure.
About half his hospital expenses were covered by insurance, one report says, but drug-resistant TB is expensive to treat and would have cost him tens of thousands of yuan over the next few years. With a family to feed, medical bills were the last things he needed.
In general, the government's expansion of health insurance coverage — from 30 percent of the population in 2003 to 96 percent last year — has made it more affordable for people to seek health care. As one result, hospital admissions have surged by two and a half times over the same period. At many top city hospitals, patients line up overnight for consultation tickets or are gouged by scalpers for them.
"The supply cannot catch up with demand, you have long waiting times, doctors on average spend five minutes with patients and don't have time to communicate well with their patients and that creates problems," said Yanzhong Huang, an expert on China's health reforms at the Council on Foreign Relations.
At the same time, insurance benefits are still too shallow to cover major illnesses such as cancer, HIV/AIDS or TB, described by health economists as "catastrophic" because treatment often wipes out family savings. Spending on health care as a share of household expenditure in China has gone up by 2.3 percent a year in the past few years, according to a Lancet study in March.
Because patients are spending a lot, their expectations increase, doctors say.
"Part of the violence against health workers is because people don't know the limitations of medicine and medical care and they expect that if they pay, the cure will come," said Sarah Barber, a health expert at the World Health Organization's office in China. "I think you have a gap between the expectations and what can realistically be achieved."
Wang believed that doctors were lying to him when they called his condition hard to treat, and that he developed drug resistance due to bad treatment.
He grew despondent. His anger zeroed in on his main physician: Chen.
April 28 began like any other day. Chen started a 24-hour shift at 8 a.m. by checking on her patients at the decades-old, rundown hospital, in a forested area in the rural outskirts of Hengyang. The three nurses on duty on her floor left to check on patients. Chen was alone.
Wang walked into her office unnoticed around midday.
Ten minutes later, nurses found Chen lying on the floor bleeding to death. Bloody footprints marked the corridor and a staircase leading to the ground floor.
Liao, her husband, was returning to his office from lunch when his in-laws tried to reach him. He rushed to the hospital, but police would not let him near the crime scene. Finally, they told him she was in a morgue.
There, Liao stroked his wife's face and thought how she looked like she was just asleep. Then he examined the wounds on her neck, heart, liver, back, chest and left arm. He fell to the floor.
"At that time, I lost control, I could not feel my limbs," Liao said. "I studied medicine and so I'm used to seeing things like this, but this is a person I loved... I could not take it."
The next day, several dozen former schoolmates joined him in a protest at the hospital over the safety of medical staff. They blocked the entrance, strung up a banner across the gate and set up a picture of the slain doctor.
A passing taxi driver had seen a man with bloodied hands outside the hospital, and helped police identify Wang from a list of Chen's patients. They arrested Wang near a train station with a dagger in his possession. Police said he was angry and asked why they did not take his side against the doctor.
Now the hospital has set up a security post in the middle of the sprawling compound, though three guards on duty were napping or otherwise not watching during a recent visit by The Associated Press.
"It can be said that my wife's life has been given up in exchange for a security post," Liao remarked.
Hospital officials reached by phone said they had no comment on the attack on Chen or the state of security at the facility.
A few days after Chen was murdered, the Health Ministry and Public Security Ministry issued a joint notice saying people who threaten, insult or injure medical staff or who bring flammable or explosive materials into hospitals will be held criminally responsible. People are also barred from setting up mourning halls or burning funeral money in these facilities — common methods of protest. Police posts have been set up in hospitals across the country, while doctors in some cities have been trained in self-defense.
The government has also announced a code of conduct barring doctors from seeking bribes and accepting kickbacks from medical companies. It is also testing different models of funding at many hospitals to reduce reliance on drug profits, but the situation is not expected to improve soon.
For Liao, the death of his wife was "like the sky had fallen." He tells their 6-year-old daughter that her mother is in heaven getting treatment for an illness; one day when she is older, he says, he will tell her the truth.
He waits for the day the killer is put on trial and expects the maximum sentence.
"For the murderer, he should repay the life he has taken with his own life, and that should serve as a lesson for others," Liao said. "It should serve as a wake-up call for patients and doctors... Because if this kind of thing happens again, it will mean that my wife died in vain."
Associated Press researchers Yu Bing and Flora Ji contributed to this report from Beijing.
Follow Gillian Wong on Twitter: http://twitter.com/gillianwong