Editor's note: How come the metropolises around the world with concentrated medical resources are so vulnerable to the COVID-19 outbreak? What is the future of globalization and international metropolises? As the Cloud River Urban Research Institute releases the 2019 ranking on medical care radiation of Chinese cities, Professor Zhou Muzhi gives his perspective on the health care system in major cities in the coronavirus crisis.

2019 ranking on health care radiation in Chinese cities

As part of the China Integrated City Index, the Cloud River Urban Research Institute has released the 2019 ranking on health care radiation based on a research of 297 cities above prefecture-level across China. The top 10 are Beijing, Shanghai, Guangzhou, Chengdu, Hangzhou, Wuhan, Jinan, Zhengzhou, Nanjing and Taiyuan. The following top 20 are Tianjin, Shenyang, Changsha, Xi'an, Kunming, Qingdao, Nanning, Changchun, Chongqing, and Shijiazhuang. And the following top 30 are Urumqi, Shenzhen, Dalian, Fuzhou, Lanzhou, Nanchang, Guiyang, Suzhou, Ningbo and Wenzhou.

Evaluating a city's medical care radiation mainly focuses on the number of physicians and the 3A-grade hospitals. The top 30 cities account for 15% of the certified physicians, 30% of hospital beds and 45% of 3A-grade hospitals in the country. China's medical resources, especially the best hospitals, are mainly concentrated in cities higher in the ranking, which serve local residents as well as people from all around China.

One would doubt why cities like Wuhan, with one of the top medical resources, can be so vulnerable to the COVID-19 outbreak and even overwhelmed by the influx of patients？How cities should do to prepare for future epidemics?

A test for the health care system

Wuhan was the first to confront the COVID-19 outbreak. The city climbed one place to the sixth in the 2019 medical care radiation ranking, as it boasts 27 3A-grade hospitals, nearly 40,000 physicians, 54,000 nurses and 95,000 beds. It is hard to expect that a city with such strong health care capacity could be overwhelmed by the coronavirus epidemic.

Other metropolises like New York and Tokyo are equally vulnerable to the pandemic. It seems that the novel coronavirus is testing the medical capability of all global cities.

There are three reasons for the breakdown of the medical care system.

First, overloaded hospitals.

One feature of the COVID-19 epidemic is the exponential growth of infections. Especially during the early stage of the outbreak, the surge in infections and social panic have driven a lot of people, whether they were infected or not, to seek testing and treatment in hospitals. This has caused disorder, leaving those who are critically ill unable to receive efficient and quality care. It is also a reason for its high fatality rate. Moreover, the overcrowded emergency rooms, with confirmed cases, suspected patients as well as their families, can also lead to many hospital-acquired infections (HAI).

Italy, one of the hardest-hit countries in the pandemic, has a relatively high density of physicians, counting 4 per 1,000 people, but the country still suffers a breakdown in its health care system. In the Lombardy region, the number of infections has quickly risen from 1,000 on March 2, to over 10,000 on March 14, and to over 40,000 by the end of March. As many patients with critical conditions could not be treated in time, the fatality rate in Italy is as high as 13%. By April 15, there had been 160,000 confirmed coronavirus cases in Italy, and the death toll was 21,000.

The density of physicians in the U.S., Japan and China was only 2.6, 2.4 and 2 per 1,000 people respectively, much lower than that in Italy.

Wuhan has 4.9 physicians per 1,000 people, while the number in the New York state is 4.6 per 1,000, both higher than their national average. However, the medical care system in both places was still overstretched by the outbreak. By April 16, 83.5% of the COVID-19 deaths in China had happened in Wuhan.

Japan's capital Tokyo has 3.3 physicians per 1,000 people, lower than the level in Wuhan and the New York State. Therefore, the Japanese government has been trying to avoid overcrowded emergency rooms as a key part of its response to COVID-19. The government advises the residents not to go to the hospital and even strictly limits testing to reduce hospitalization. Japan's measures are so far effective to reduce the number of hospital-acquired infections and lower the fatality rate as the medical resources are mostly given to those with critical conditions. By April 15, Japans' fatality rate had been around 2%. By April 10, deaths per 100,000 in Japan had been only 0.07, compared to 33.06 in Spain, 30.25 in Italy, 18.25 in France and 5.04 in the U.S. So far, it is fair to say that Japan has avoided collapse in the medical care system through controlling hospital visits.

However, due to the limit on testing, asymptomatic and mild cases could not be quickly identified, isolated and treated, which brings an underlying problem and casts a shadow to Japan’s COVID-19 response. After the announcement of the state of emergency, Japan adjusted its strategy and started to expand testing.

Second, a drop in the number of medical staff.

A drop in the number of medical staff caused by infections also features in the pandemic outbreaks.

In the early stage of the outbreaks, the countries lacked knowledge of the coronavirus transmission, and medical staff faced a huge risk of infection due to the shortage of protective resources such as masks, protective clothing, and negative pressure wards. Those factors made testing, sampling, intubation, and other medical practices that are inherently at risk of exposure even more dangerous. As a result, the countries have seen a significant decrease in the number of medical staff caused by infections, which exacerbated the shortage of medical staff amid the outbreaks and the scramble for medical resources.

According to the information released by the World Health Organization, data reported by 52 countries showed that 22,073 medical workers had been diagnosed with COVID-19 as of April 8. The situation turned out to be even worse. As of April 15, Spain and Italy alone saw 26,672 and 15,000 medical workers infected respectively.

Apart from the risks during the treatment, the extensive isolation and infection resulted from a dinner party of trainee doctors from Keio University Hospital dealt another major blow to the already scarce medical workforce in Tokyo.

The super-transmissible coronavirus has severely threatened the safety of medical staff and weakened medical capabilities, resulting in the collapse of the medical system.

Therefore, it is critical to protect the safety of medical workers during the fight against COVID-19.

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