Growing Old in a New China: Transitions in Elder Care

By Rose K. Keimig

Growing Old in a New China: Transitions in Elder Care is an accessible exploration of changing care arrangements in China. Combining anthropological theory, ethnographic vignettes, and cultural and social history, it sheds light on the growing movement from home-based to institutional elder care in urban China. The book examines how tensions between old and new ideas, desires, and social structures are reshaping the experience of caring and being cared for. Weaving together discussions of family ethics, care work, bioethics, aging, and quality of life, this book puts older adults at the center of the story. It explores changing relationships between elders and themselves, their family members, caregivers, society, and the state, and the attempts made within and across these relational webs to find balance and harmony. The book invites readers to ponder the deep implications of how and why we care and the ways end-of-life care arrangements complicate both living and dying for many elders.
 

• Language: English
• Publisher: Rutgers University Press
• Release date: Feb 12, 2021
• ISBN: 9781978813939

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Growing Old in a New China

Global Perspectives on Aging

Series editor, Sarah Lamb

This series publishes books that will deepen and expand our understanding of age, aging, ageism, and late life in the United States and beyond. The series focuses on anthropology while being open to ethnographically vivid and theoretically rich scholarship in related fields, including sociology, religion, cultural studies, social medicine, medical humanities, gender and sexuality studies, human development, critical and cultural gerontology, and age studies. Books will be aimed at students, scholars, and occasionally the general public.

Jason Danely, Aging and Loss: Mourning and Maturity in Contemporary Japan

Parin Dossa and Cati Coe, eds., Transnational Aging and Reconfigurations of Kin Work

Sarah Lamb, ed., Successful Aging as a Contemporary Obsession: Global Perspectives

Margaret Morganroth Gullette, Ending Ageism, or How Not to Shoot Old People

Ellyn Lem, Gray Matters: Finding Meaning in the Stories of Later Life

Michele Ruth Gamburd, Linked Lives: Elder Care, Migration, and Kinship in Sri Lanka

Yohko Tsuji, Through Japanese Eyes: Thirty Years of Studying Aging in America

Jessica C. Robbins, Aging Nationally in Contemporary Poland: Memory, Kinship, and Personhood

Rose K. Keimig, Growing Old in a New China: Transitions in Elder Care

Growing Old in a New China

Transitions in Elder Care

ROSE K. KEIMIG

Rutgers University Press

New Brunswick, Camden, and Newark, New Jersey, and London

Library of Congress Cataloging-in-Publication Data

Names: Keimig, Rose K., author.

Title: Growing old in a new China: transitions in elder care / Rose K. Keimig.

Description: New Brunswick, New Jersey: Rutgers University Press, 2021. |

Series: Global perspectives on aging | Includes bibliographical references and index.

Identifiers: LCCN 2020019304 | ISBN 9781978813915 (paperback) | ISBN 9781978813922 (hardcover) | ISBN 9781978813939 (epub) | ISBN 9781978813946 (mobi) | ISBN 9781978813953 (pdf)

Subjects: LCSH: Older people—Care—China. | Older people—Services for—China. | Aging parents—Care—China. | Geriatrics—Social aspects—China. | Aging—Social aspects—China. | Intergenerational relations—China. | Social change—China.

Classification: LCC HV1484.C62 K44 2021 | DDC 362.60951—dc23

LC record available at https://lccn.loc.gov/2020019304

A British Cataloging-in-Publication record for this book is available from the British Library.

Copyright © 2021 by Rose K. Keimig

All rights reserved

No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is fair use as defined by U.S. copyright law.

The paper used in this publication meets the requirements of the American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992.

www.rutgersuniversitypress.org

Manufactured in the United States of America

For my parents,

Kay and Ed,

the prophet and the professor

Contents

Introduction

1. Filial Children, Benevolent Parents

2. Bodies in History, Embodied Histories

3. Place and Space, Rhythm and Routine

4. Entanglements of Care

5. Care Work

6. Chronic Living, Delayed Death

Conclusion

Acknowledgments

Glossary

Notes

References

Index

Growing Old in a New China

Introduction

We therefore recognize, around our initiatives and around that strictly individual project which is oneself, a zone of generalized existence and of projects already formed, significances which trail between ourselves and things.

—Maurice Merleau-Ponty,

Phenomenology of Perception

Ma Meili¹ was the informal spokeswoman of Jade Hills Elder Care Home.² Her close proximity to the front gate and clarity of mind made her the obvious choice when staff members needed a firsthand account of institutional life for visitors, reporters, or anthropologists. At seventy-eight, she had lived at Jade Hills for nearly three years. Before retiring, she had worked in a watch factory alongside her husband, whom she deeply admired for his skilled craftsmanship. She also prided herself on being extremely capable, both as a worker and mother—having raised three successful sons, one of whom coached Olympic athletes. Six years earlier she had suffered a stroke, and when her husband died three years after that, she had discharged their in-home caregiver and moved to Jade Hills.

Auntie Ma was feeling very sad today. In fact, she was sad every day. It was because of the stroke, she said. Before the stroke, she was so capable. She could do everything. Now she can’t do anything. She lifted her affected left wrist with her opposite hand and let it drop in her lap. She began to cry. If the stroke hadn’t happened, she would still be able to do so much. I asked her if she talked to her children about how sad she was, but she said no. She didn’t want to make them sad. They were going to come visit her today, but it was too hot, so she had told them not to come. Chinese people are very good to their children, aren’t they? she asked.

When Auntie Ma spoke these words on a sunny Kunming afternoon in May 2014, as we sat side by side in a small patch of shade bordering the institution’s makeshift parking lot, they held a special pathos for me. On September 17, 2013, less than a month before I was scheduled to depart to conduct research on aging and caregiving in China, my mom, an otherwise healthy, fifty-five-year-old nurse practitioner, had suffered a hemorrhagic brainstem stroke. Leaving my caregiving ethnographies and research materials in New Haven, Connecticut, I took the first flight home to Minnesota and spent the next two weeks navigating the intensive care unit gray zone of impossible choice making and uncertain outcomes that I had read so much about (Kaufman 2005).

Anthropologists strive to immerse themselves deeply in other worlds, to set preconditions aside and explore the unknown through practices of discovery and inquiry, and then to describe that experience in a way that makes the strange familiar and the familiar strange.³ Indeed, thanks to Sharon Kaufman and other ethnographers of end-of-life caregiving (see Biehl 2005; L. Cohen 1998; Lock 2002; McLean 2007) who have beautifully captured the formless time, the desperate search for meaning (I think she moved her toes!), and the exchanges of care within medical institutions, I did find the hospital experience strangely familiar. However, those accounts are drawn from the far side of the participant-observer’s lens and within the bounds of the academic’s research schedule. Eventually even Bronisław Malinowski’s boat returned. Meanwhile, just beyond the observational space and time, the institutional experience continues to unfold.

Defying the odds, my mom slowly regained consciousness—a new kind of consciousness, to be sure, but far beyond the blinky lady outcome the social worker had advised my family to prepare for. After my mom was moved down to the neuro-progressive ward, my dad and I had a conversation about care plans. He was still working full-time, as were both of my sisters, so I expected to postpone my fieldwork indefinitely. He rejected my plan. I would go to China. They would figure it out. This was not up for discussion, so I left my parents at the inpatient rehabilitation facility and flew to China to spend a year interviewing parents whose children had left them in institutions.

I begin with this account to admit up front that this project became, in many ways, a personal act of filial piety (or parental benevolence, depending on how you look at it). Like Auntie Ma, many of the institutionalized elders I worked with had suffered strokes. Even today, despite the frustrations and pains of poststroke living, my mom turns her smiling side toward me. So when Auntie Ma cried on my shoulder instead of her sons’, the exchange was more than just data for my research. Now that the passing of time has given me a wider perspective, I see the ways that my own uncertainties informed the kinds of questions I asked (or didn’t ask) and may have made me overly sympathetic or generous in my treatment of the parent-child relationship.

Background

Despite the parallels between my and my subjects’ experiences, this project is ultimately about the elders and caregivers who are navigating the rapidly changing elder care situation in urban China. One of these elders, Grandpa Zhou, an eighty-seven-year-old former teacher, shared his views on the current situation over a game of mahjong: The reasons for it are very simple: life has improved, conditions have improved, and medical technologies have advanced. You see, in the 1930s, the average life expectancy for Chinese people was only about thirty. In the [19]50s, the average life expectancy was still only in the forties. Over the past thirty years, life improved, conditions improved, and life expectancy reached over seventy years. I don’t even know how high it is today. In ancient China, there was a saying that it was rare to live to seventy. There were very few people in their seventies—very few. But now, seventy-year-olds are still considered ‘little brothers.’

As Grandpa Zhou states, a primary driving force in the changing elder care situation is the sheer number of aging people. According to the World Bank database, in 2018, 11 percent of China’s population was over sixty-five, and average life expectancy was 76.7 years—an increase of 2.9 years (3.9 percent) in a decade (World Bank Group 2019b). While notable, this increase represents only the early stage of a massive demographic transition. According to a report from the Chinese Academy of Social Sciences (2019), China’s aging population (that is, people over sixty-five), will represent 23.8 percent of the total by 2040, when average life expectancy will reach 80.3 years. In and of itself, this aging boom is not unique to China. In 2018, Japan’s average life expectancy was eighty-four years, and 27.6 percent of the population was over sixty-five, which has necessitated significant investments in long-term care services (Ikegami 2019; World Bank Group 2019c). However, economic and social policies have propelled Chinese society onto the path of growing old before getting rich, which contributes to the uncertainty and urgency surrounding questions of who can and should provide old age care.

Politics and Economics

China’s aging population has been described as a surging grey tsunami (L. Zhang 2015a), but the developing demographic situation is far from a natural disaster. The lives of today’s elders run parallel to the life of the Chinese Communist Party itself. As a result, older generations have suffered many of the nation’s growing pains. Throughout their adult lives, older people endured continual upheavals with the promise that these sacrifices would not be forgotten. They worked for nearly nothing under a socialist economy, and they retired just as the social safety nets they had helped construct were being dismantled to make room for market reforms. When the one-child policy began (1979–1980), a new cohort was asked to sacrifice fertility for the good of the nation—again, with the promise that this sacrifice would be repaid (Greenhalgh 2008). In the decades that followed, China burst onto the international stage as its gross domestic product soared and incomes rose, but the rewards have not been distributed equally (Y. Yan 2009). Today, in the midst of rising inequality and insecurity, elder care provision appears to be one more uncertainty that older—and younger—generations must navigate for the good of the country.

Although the one-child policy was replaced with a two-child policy in 2016, more than thirty-five years of severely restricted fertility have transformed family structures and desires.⁴ One result is a demographic imbalance called the inverted pyramid family structure (Zhan, Liu, and Guan 2006, 280) or the 4:2:1 paradigm, in which adult couples are potentially responsible for supporting four aging parents and one child (Greenhalgh 2008, 182). At the same time, economic and social reforms have led to the increased migration of working-age adults, high rates of women in the workforce, and decreased intergenerational cohabitation (Y. Yan 2009). In combination with the increasing life expectancies described above, these forces have drastically compromised the ability of families to meet elder care needs.

Historically, despite strong state control over many aspects of life in China, caregiving has been one of the few areas where the state has not been expected, and does not desire, to intervene (Fan 2007; Zhao and Sheng 2009). However, in 1996, as the processes of fertility control, economic reform, and migration steadily chipped away at family support structures, China passed the first Law on Protection of the Rights and Interests of the Elderly, which officially mandated child-parent caregiving duties. Since then, elder care provision has continued to be a source of national concern, as evidenced by the special attention given to it in recent five-year plans, ongoing adjustments to the 1996 law, and the recent lifting of the one-child policy (Shum, Lou, He, Chen, and Wang 2015; Xu et al. 2016).

Currently, the government endorses a 9073 model—in which 90 percent of elders receive in-home care, 7 percent receive community care, and 3 percent receive institutional care—and strongly encourages private investment in the latter (Xinhua 2016; T. Zhang 2016). The first of these, in-home care, is the preferred choice of many elders as well. Historically, in-home care was synonymous with family-based care, but residence patterns suggest that this is no longer the norm. Driven largely by rural-to-urban labor migration, intergenerational coresidence in rural areas decreased from 70 percent in 1991 to 40 percent in 2006 (W. Yang, He, Fang, and Mossialos 2016). Surprisingly, data from the China Health and Nutrition Survey, which sampled about 7,200 households in fifteen provinces and municipal cities across China, revealed the opposite trend in urban areas: between 1991 and 2011, urban intergenerational coresidence increased from 35 percent to 48 percent and was positively correlated with city-level housing prices (Li and Wu 2019).

The effect on elder care is that as parents age, many prefer to remain in their own homes rather than move in with their adult children. Accordingly, the share of elderly empty nesters in China is now over 50 percent and is expected to continue to increase (Shea and Zhang 2016). Although residence patterns have shifted, families still account for a major source of elder care. Adult children often reside close to their parents and visit frequently to help with meal preparation or household tasks. When that is not possible, they may help finance paid caregivers to allow their aging adult relatives to remain at home.

The second option for elder care, community care, refers to the wide variety of elder care services offered by community organizations to help elders remain in their homes. These include regular home visits from community clinic staff members and neighborhood volunteers, day care centers where adult children can leave their parents while they work, and other health and wellness services (H. Chen, Yang, Song, and Wang 2017; Shea 2017; Y. Zhang 2020). For example, Shanghai, which has been the oldest city in China since 1979, has been investing heavily in community care (Y. Zhang 2020). When I attended a palliative care conference there in November 2013, officials unveiled plans to equip all community health centers with small wards to provide palliative and hospice care. These efforts have continued to expand. During her fieldwork on dementia care in Shanghai in 2017, Yan Zhang (2020) reported that there were 560 senior centers and 127 mini-nursing homes (small community-based elder care institutions with 10–49 beds) operating in the city.

Although considered the last resort for elder care, institutional care—the focus of my research—is developing rapidly in China. In the past decade, residential care beds have increased at a rate of about 10 percent per year, and in 2020, there were approximately 7.6 million elder care beds in 200,000 facilities (Lei 2020). Institutional elder care can be roughly divided into three categories. The first, social welfare homes, are public institutions financed through taxes and welfare lottery funds. Historically, only elders with no living relatives, no income, and no ability to work (called the three nos) lived in these institutions (S. Chen 1996). In the late 1990s, following the decentralization of China’s welfare services, many public facilities began accepting private payers and are now a popular option for institutional care (W. Yang et al. 2016). One newspaper article reported a 100-year waiting list for Beijing’s most popular public welfare home, which had 10,000 applicants for its 1,100 beds (Moore 2013).

Public elder care institutions are often favored over the second type of institutional elder care—private elder care facilities—because they are perceived as providing higher quality care and being more affordable. This is owing to the fact that while government funding for public institutions decreased significantly after market reforms, the state continues to manage and regulate these organizations (G. Liu, Vortherms, and Hong 2017). In contrast, private institutions are often underregulated and, despite government subsidies and incentives, vulnerable to market shifts.⁵ To increase profitability, private facilities often attract more residents by having lower admission standards than public institutions. While this fills beds, the higher demands for care ultimately impact profitability and lower the institution’s quality of care (Shum et al. 2015).

Concerns about quality and cost drive many elders and their families to use hospitals, the third source of institutional elder care. As with public welfare homes, public hospitals have better management, stricter regulations, and more resources than privately run institutions and therefore garner greater public trust (W. Yang et al. 2016; A. Zhang, Nikoloski, and Mossialos 2017). This has led to massive overcrowding, as public hospitals provide an estimated 90 percent of both inpatient and outpatient services (Liu, Vortherms, and Hong 2017). In terms of elder care, public hospitals are especially attractive because inpatient hospital stays are the only form of institutional elder care covered by insurance. Increasingly, efforts are being made to diversify elder care offerings. Newer medical facilities in larger cities such as Shanghai often provide both residential and medical care or long-term graduated care, and in 2019 there were approximately 4,000 of these hybrid facilities across China (Y. Zhang 2020; Lei 2019).

As might be expected, health care costs are a major factor in decisions about where to get elder care. China’s opening up in the 1980s precipitated the breakdown of social welfare services, including public-funded health care. In the meantime, although wages have risen, health care costs have risen even more quickly. In response, the government has implemented numerous health care reforms, and today there is near-universal coverage in both urban and rural areas. However, critics note that there is a wide discrepancy between the insurance for employed urban residents and that for rural and unemployed urban residents (X. Liu, Wong, and Liu 2016).⁶ Specifically, they point to the shallow depth of the insurance plan for the latter group, which has reimbursement rates of 44–68 percent for inpatient costs, and little to no reimbursement for outpatient treatment (Liu, Vortherms, and Hong 2017). They also observe that pharmaceutical costs account for over two-thirds of outpatient out-of-pocket and about one-half of inpatient spending, which disproportionately affects people with chronic conditions (A. Zhang, Nikoloski, and Mossialos 2017). Furthermore, despite government efforts to simplify insurance reimbursement by supporting the development of hybrid facilities that provide both medical and residential care, within these facilities insurance remains divided, covering medical costs but not spending on care (Lei 2019).

In light of the current insurance system, elders, many of whom have chronic conditions and need long-term care, often struggle to afford caregiving costs. An additional hurdle to financing old age care