In recent weeks, Chinese health authorities have reported new outbreaks of COVID-19 in major cities in the eastern and central parts of the country, including Nanjing, Yangzhou, and Zhengzhou. The news of cases in flood-stricken Zhengzhou was particularly worrying. The city’s Sixth People’s Hospital became the center of a major outbreak in which one confirmed case quickly became 128.

The first cases were confirmed not in patients, or even doctors, but two members of the hospital’s cleaning staff. Of the 128 people who fell ill, 23 were caregivers, including family caregivers and nursing assistants, and three were janitors. This is not the first time nursing assistants and other caregivers have borne the brunt of new outbreaks in China: new COVID cases at two separate hospitals in Shanghai earlier this year were traced back to two nursing assistants who lived in the same neighborhood.

Doctors and medical professionals are often the focus of public and policymaker attention during outbreaks, but other hospital staff, including care workers and cleaners, are also at high risk of exposure to infected patients and contaminated waste. But their marginal status within hospitals — many institutions have outsourced these positions to agencies — has made them a weak link in the country’s epidemic prevention and control system.

There is an element of mismanagement here, in that hospitals failed to stringently screen support staff and protect patients, but it is also the natural outcome of the recent trend toward outsourcing non-clinical tasks to third party contractors. Chinese hospitals started to outsource this work in the 1990s, during a wave of expansion and market reform in which institutions struggled to hire enough staff to keep up with patients’ needs. The resulting worker shortage is most obvious in the country’s nursing sector. According to statistics from the World Bank, China had 2.66 nurses and midwives per 1,000 people in 2017, compared to 14.55 in the US and 8.54 in Russia.

In some major cities, the shortage of trained nurses has fueled demand nursing assistants and caregivers. In 1997, the then-Ministry of Health specified that hospitals could hire nursing assistants as needed and allocate some nursing tasks to them, like feeding patients, removing sputum, and massaging sore body parts.

Meanwhile, in order to focus on their core business of providing clinical services, improve efficiency, and reduce operating costs, many hospitals have thrown open their doors to outsourced labor in other sectors. It has become common for institutions to package a host of jobs — including cleaning, security, food preparation, lab specimen delivery, maintenance, and patient sitting — and outsource them to specialized agencies. Those companies assign and base dedicated management personnel in hospitals, who in turn work under specific hospital departments.

This model of outsourcing seemingly allows hospitals to focus on improving the quality of medical care. In practice, however, management has proved a problem. Nursing assistants are temporary workers, rather than incorporated as part of the nursing staff, and outsourced assistants and cleaning staff have no legal labor relationship with the hospital at all. In other words, neither are technically considered “hospital staff,” even though they work on-site and play an essential role keeping the hospital running.

Given their informal status, nursing assistants’ labor rights are often compromised. They can earn more as personal caregivers — as much as 150 to 200 yuan ($23 to $30) per day in Shanghai — but doing so requires them to stay on call 24 hours a day.

The long work hours, high intensity, and poor protections make it difficult to attract high-quality workers. While nursing assistants play an important role in caring for patients, the majority are older women with low levels of education whose knowledge and practice of hospital regulations and personal protection leave much to be desired. One recent study found that just 22% of patient sitters at a top hospital performed proper hand hygiene during last year’s outbreak.

Moreover, the outsourcing model — paired with nursing assistants’ incomplete understanding of their labor rights — has led to high turnover among nursing assistants, which in turn further discourages hospitals from investing in their training and development. Indeed, being a nursing assistant offers little in the way of income, benefits, job security, or dignity. In my research, I found that it is difficult even for formal nurses to earn their patients’ respect, and this issue is exacerbated for nursing assistants. The lack of a direct employer-employee relationship also erodes their sense of identity and belonging in the workplace.

From the hospitals’ side, the question of how best to manage these external contractors is a thorny one. Theoretically, nursing assistants and other staff are managed by both their contracting company and the hospital, but all too often they fall through the cracks. For example, some hospitals will clean and disinfect their doctors and nurses’ uniforms, but nursing assistants and cleaning staff are left to take care of their own uniforms — a move that heightens the risk of viral transmission.

Hospitals are not the only institutions to profit from a wave of outsourcing in recent decades. However, unlike food delivery platforms, practices at healthcare facilities have largely flown under the radar. That is no longer possible. Repeated COVID-19 outbreaks linked to contractors over the last two years have made it clear that current outsourcing and management norms are a ticking time bomb. It’s time for agencies and hospitals alike to stop shifting the blame for these outbreaks and accept responsibility for the protection of this vulnerable group.

Translator: Katherine Tse; editors: Cai Yiwen and Kilian O’Donnell; portrait artist: Wang Zhenhao.

(Header image: A care worker cleans a bathroom at an ICU ward in Guangzhou, Guangdong province, 2014. Xiao Xiong/People Visual)