On a list of status symbols that people instinctively trust, ambulances would likely be near the top. Sadly, in major Chinese cities, even this hallowed representation of the medical profession can no longer be relied on.

A growing number of unauthorized, privately run ambulances have been doing great business picking up vulnerable patients and conning them out of their money. Few of these unauthorized ambulances carry proper equipment or trained medical workers, posing a real threat to the patients' safety.

In April 2012, Liu Jing, owner of a privately run ambulance, was sentenced to pay compensation of 180,000 yuan ($28,900) for contributing to the death of a patient who underwent a heart surgery in Wuhan. Liu locked the door of the ambulance and turned off the air-conditioner when having a dispute with the patient's relatives, which has accelerated the death of the patient, the court said.

There have been numerous cases reported, including some in which patients were detoured hundreds of kilometers away to ill-equipped private clinics and lost precious time for treatment.

"We've known for years that many patients die in these 'black ambulances,' or soon afterwards, because of the lack of proper care and equipment," Ma Yanming, a publicity official from Beijing Health Bureau, told the Global Times.

Even though the city has cracked down on unauthorized ambulances in the past decade, Ma said, their numbers are still growing.

These unauthorized ambulances, active in areas around hospitals, look almost identical to official ambulances, with alarm lights on their roofs and bearing the logos of the 120 Emergency Medical Center or the 999 Emergency Center, the only two organizations in China authorized to pick up emergency patients.

The operators of the unauthorized ambulances attract potential customers by handing out business cards in hospital wards or hanging around the entrances looking for customers. They often offer a cheaper price than official ambulances.

Rampant business

China bans individuals or non-medical agencies from buying or running ambulances. However, a lot of people seized on legal loopholes and colluded with the hospitals to buy or run ambulances to reap a profit.

Black ambulances have become a plague in many cities, including Beijing, Shenzhen, Guangzhou, and Shanghai.

A Baidu search for "ambulance rental companies" will net 2 million search results.

The Global Times contacted three companies in Guangzhou and Beijing, who all claimed that they would charge 10 yuan per kilometer to transport a patient although the price was negotiable for long distances. 

The safety risks brought about by unauthorized ambulances are worrisome, as patients are essentially placing their lives in the hands of untrained personnel.

"We cannot ensure the safety of the patient. Even top-notch doctors cannot guarantee the safety of a patient during a long-distance transport," Zhou, an employee of Mingsheng Car Rental Company in Guangzhou, Guangdong Province, told the Global Times.

Zhou also claimed that patients should sign a disclaimer before being transported.

Claiming to have been in the industry since 2008, Zhou boasted that his company had a wealth of experience in transporting patients.

"We cannot carry out emergency medical services if the patient's condition becomes critical. But we would bring the patient to the nearest hospital as soon as possible," Zhou said.

Illegal price list

Normally, the transportation fee for black ambulances is much lower than the price for official ambulances as these normally charge 30 yuan for the first five kilometers and 1.5 yuan for every additional kilometer.

However, black ambulances seek to gouge patients by charging extra fees for treatment or for on-board attendants.

For example, Zhou said it costs 1,000 yuan extra if the patient requires the use of medical equipment such as an electrocardiogram monitor, blood pressure monitor or respirator. It also costs 5,000 yuan to invite a doctor from a local hospital on board although Zhou refused to say which hospital these doctors would come from.

The fare can be cheaper if the patient employs unlicensed nurses, which are trained by the company, Zhou suggested.

If the patient dies on the way of transporting, then extra fees apply again. "We transport the living, not the dead. We normally charge thousands of yuan if the patient dies on the way," Zhou said.

Li Jianren, a publicity officer from 120 Medical Emergency Center, said the main customers of black ambulances are non-local patients who are in critical condition, as there will be a profitable long-distance transport home after the patients die.

"Black ambulances focus on picking up terminally ill, non-local patients who want to be buried in their hometowns. But the relatives of critically ill patients might be unwilling to pay the high costs needed to send them home through traditional channels," Li told the Global Times.

End of the road

The unbalanced distribution of medical resources in first-tier cities, like Beijing, Shanghai, and Guangzhou, draws in these many non-local patients, sparking a shortage of official ambulances and creating an opportunity for black ambulances to reap the profits.

 Hu Tiansheng, 25, spotted a money-making opportunity and began running unauthorized ambulances since 2008. Hu was arrested for beating other ambulance operators when fighting over customers in 2010 but went on trial again for another offence in January 17 this year. 

 On May 4, 2012, Hu arrived in a Beijing hospital to pick up a patient. When he drove into the hospital, he found another ambulance had already arrived and picked up his client. Hu blocked the hospital entrance, brandished a knife and slashed two of the rival operators,

Back in 2010, Hu was sentenced to six months behind bars for beating his competitors while he ran a black ambulance. He returned to the business for its lucrative profits after being released.

"Usually, an ambulance earns more than 100,000 yuan a month," Hu told the Beijing Youth Daily after his latest trial began.

They prefer transporting long-distance patients. "We could earn around 100,000 yuan if we transported a patient from Beijing to Tibet," Hu told reporters.

Usually, black ambulances charge between 5 to 10 yuan per kilometer, although the price is negotiable for long distances.

According to the law, only hospitals that have over 300 beds qualify to be equipped with at least one ambulance.

But Hu elaborated on how he obtained the qualification to buy and operate ambulances.

"By bribing officials in local hospitals, they prepare the formalities and help an individual get the qualification to purchase an ambulance, or we buy old ambulances from the hospitals," Hu said.

By colluding with doctors and nurses, Hu easily found patients. "Doctors and nurses would help introduce patients to me, and in return, I would pay them a commission," Hu said.

Cases of black ambulance drivers coming to blows over clients are not uncommon. Last year in Guangzhou, Meng Shuyun, a woman in her 60s, was sentenced to 12 years in prison and a fine of 60,000 yuan for making profits from black ambulances.

The case aroused public outcry for a crackdown on unauthorized ambulances as even official ambulance drivers were not safe from these gangs. One licensed driver, working for the Beijing Emergency Ambulance Center, was beaten last November by drivers of unlicensed ambulances while trying to pick up a patient at a local hospital.

No real solutions

"The short supply of official ambulances has resulted in a growing number of black ambulances," Ma Yanming said.

There are around 400 ambulances in Beijing, with half belonging to the 120 Beijing Medical Emergency Center and the rest being operated by district hospitals.

"We don't directly manage the other half of the ambulances, which means that when we are in great need of ambulances from district hospitals to help pick up patients, they might not be available," Li Jianren, told the Global Times.

The misuses of ambulances have caused trouble before. Last year, fury was sparked when a hospital in the Haidian district of Beijing used an ambulance to ferry medical personnel to a restaurant.

In order to satisfy the greater demand of patients, 120 Beijing Emergency Medical Center allocated five ambulances to serve long-distance transportation. However, Han Chao, the group leader for these long-distance journeys, complains that five ambulances are far from enough. Han explained his team was exhausted. "We have worked around the clock many times. Sometimes, you might have to turn around to transport a patient to a third city when you are already on the way back to Beijing from another transport," Han said.

Han said, they transported more than 40 patients a month on average before 2010, but the number declined to 20 patients a month in the last two years, because of the expanding number of unauthorized ambulances.

  "There is a strong demand for ambulances. However, the official ambulances cannot fulfill the need, and the market is not totally open, so unlicensed ambulances seize the opportunity to pounce," Han said.

In January, the Beijing Health Bureau issued a new regulation on ambulances, initiated on February 1, imposing a ban on non-local ambulances picking up patients in the city.

"Curbing the rampant black ambulances relies greatly on the unified supervision and management between different departments, including the traffic police," Ma said.

But once proving vague, the new regulation did not specify what penalties the violators would face.