Wuhan – lessons from burn rehabilitation in China 

 by David R Schieffelers

To most people, Wuhan carries rather negative connotations. Known as the origin of a devastating pandemic, Wuhan is also home to one of China’s largest burn centres, the Wuhan Institute of Burns, where patients with burn injuries receive specialised care. Since 2019 our research group MOVANT has been involved in a collaborative research project with the Wuhan Institute of Burns with the goal to improve burn rehabilitation – an emerging field that is still underutilised in many parts of the world.

This research collaboration has allowed me, as a physiotherapy researcher, to look at Wuhan through a very different lens – one that I believe can be applied to the larger context of international collaboration and development between East and West. It is my hope that by sharing some of the following lessons clinicians and researchers might approach working with the East in ways that do not further global inequities.

Lesson 1: The victim

It is estimated that 95% of all worldwide burn injuries occur in low-/middle income countries (LMICs) .  Irrespective of country, burn injuries also disproportionally affect the lowest socio-economic spectrum in each society. The root cause for this gap in burn injury incidence between rich and poor is the same between countries as within countries: inequality. It is inequalities in income, education, work safety, living conditions, population density that increase the risk of sustaining a burn injury.

In the context of Wuhan, a mega-city with a population of 15 million, burns can often be explained by the rapid industrialisation and urbanisation that China has undergone over the past few decades. The lowest socio-economic spectrum in China is largely made up by non-resident economic migrants who have migrated from surrounding rural places to Wuhan in the hope of ending cycles of poverty. Migrants predominantly work in manual labour, large factories, and live in areas of high population density with rarely enforced fire safety standards - all of which make burns all the more likely. The costs of specialised burn care come with high out-of-pocket expenses which burn victims often struggle to afford. They regularly rely on relatives (or an insured employer in case of a work accident) to cover life-saving medical expenses. Rehabilitation is then often seen as an optional luxury which most patients prefer not to pay for.

At the Wuhan Institute of Burns, rehabilitation staff spend much of their daily rounds trying to convince patients to agree to receive rehabilitation treatments, only to be rejected more often than not. It is only once patients have developed severe long-term impairments that rehabilitation treatment is considered a necessity – a point in time at which many existing impairments are difficult to reverse. The end result is that burn survivors are often left with preventable long-term disability which perpetuates if not reinforces cycles of health inequity.

Patients participating in our ongoing research project in Wuhan benefit by receiving rehabilitation treatments free of charge. Although this is not a sustainable solution for those unable to afford rehabilitation, both patients and clinicians get to experience how valuable rehabilitation can be. The hope is that these positive experiences may change perceptions and show that burn rehabilitation is worth investing resources into.

Lesson 2: The perpetrator

In the majority of cases burn injuries are considered accidental, and the simple answer to who is to blame would be that no single clear perpetrator exists. The more complex answer however sees burns as a product of social and global injustice to which all of us contribute to by being part of systems that perpetuate inequalities. The supply chain of the garment industry is a good example. 97% of worldwide clothing is produced in LMICs, of which 40% in China. The retailer’s incentive of larger profit margins coupled with the consumer’s desire to buy cheap clothing puts pressure on supplying countries to keep manufacturing costs as low as possible. This is often made possible by the persistent exploitation of human capital, including underpaid labour, violating worker’s rights, and ultimately compromising on work and burn safety, as shown in this analysis of fires in garment factories in Asia. The same holds true for many other industries, and it shows how much consumerism and capitalism can contribute to the increased burn incidence across countries, primarily affecting LMIC regions.

Understanding the collective complicity changes the dynamic of who the perpetrators of burn injuries in LMICs are, but it can also transform our idea where burn prevention should start.

Lesson 3: The helper:

Burn rehabilitation is still an emerging field in China, with most burn centres employing only between 1-3 full time rehabilitation staff (despite ±1000 admission/year).

Besides the financial difficulties of the patients, self-reported barriers to rehabilitation across Chinese burn centres are staff shortages, limited space for rehabilitation treatments, lack of interdisciplinary team work systems, and limited professional knowledge about rehabilitation. Considering these barriers, it would not seem too far-fetched to label Chinese rehabilitation workers as less competent than their Western counterparts. Conversely, the Wuhan Institute of Burns is a front runner of burn rehabilitation in China. Despite high workloads, rehabilitation staff work tirelessly to see patients improve and regain independence. They have built up far more expertise in treating severe burns and working with limited human and material resources than most rehabilitation workers in HICs.

Nevertheless, research collaboration between HICs and LMICs often assumes Western knowledge superiority. Accordingly, in most cases funding is unilateral and research design and protocols are predetermined with little input by the LMIC partner. The collaboration between our research group and the Wuhan Institute of Burns is an example of mutual ownership and funding. The goal of the collaborative research project is to study the effects of early exercise following severe burns - a population far more prevalent in China than in Belgium.

While Western burn rehabilitation is by default regarded as ‘state-of-the-art’, many of the rehabilitation methods are not feasible in LMICs. In Wuhan, for instance, exercises based on out-of-bed mobility were often impossible due to the lack of height-adjustable bed frames or the absence of hoist systems transferring patients into chairs. Hence, more than just an effort to copy the ‘state-of-the-art’ methods, innovation and creativity is needed to address barriers to inpatient rehabilitation in China, and other LMICs. Often the real barriers are more systemic than they seem at first sight. Health efficacy/effectiveness research has an important role to play in changing some of these systemic barriers through innovative techniques informed by the local context and needs. It is our hope that the results of our ongoing trial in Wuhan might encourage all stakeholders to make early exercise rehabilitation a more mainstream part of essential burn care.


The victim - perpetrator - helper narrative of burns is not black and white, but understanding its complexity is instrumental in approaching burns as a matter of global and social justice. Systemic barriers to burn rehabilitation in China need to be addressed, but should not take away from the role that efficacy / effectiveness research can play in promoting quality improvement. Mutual ownership, knowledge exchange, and a deep awareness of the historical dynamics at play form the basis of equitable research collaboration between East and West.

David Schieffelers is a FWO funded PhD researcher in burn rehabilitation with a particular interest in international cooperation and development. His research aims to lay clinical foundations for the role of early exercise in the prevention of long-term disability of burn survivors. As part of his teaching duties, David is a lecturer in the course “International and Global Development and Health Care” at the Global Health Institute. David is also part of the working group ‘Research and societal service delivery’ at the University of Antwerp to develop a new strategy on decolonisation, global engagement, global diversity and solidarity.

2021 MOVANTresearch