by Mei Fong
It was clear that Nurse Gao had a good bedside manner, chatting breezily as she helped Chen through a series of hand exercises. She massaged his upper torso while he remained in his wheelchair. Later, they moved to his bed, where she had him perform a series of leg and hand lifts. He was breathing heavily and sweating by the end of it. “Work harder, you can do this!” encouraged Nurse Gao.
It didn’t look like a bad way to grow old. Chen’s wife was still in good health and able to help take care of him. Their children and grandchildren lived nearby. The stairs were an inconvenience, but otherwise the apartment was handily located in central Beijing, near several hospitals, shops, and the subway. More importantly, the entire apartment block was assigned housing under Chen’s previous work unit, so they knew all their neighbors. It was a village within a city. Everybody knew each other’s business so well, when Nurse Gao entered the building, a passing neighbor hailed her. “Here for a massage again?”
We hopped on the bus to the next client. Along the way, Nurse Gao filled me in on her job. Before, she worked in a hospital, attending to hundreds of patients daily. “It was hard. I became a nurse because I wanted to help, but after a while, they just become so many bodies.” (Long lines at China’s big hospitals are so endemic, it’s common practice to hire people to stand in line for you.)
Now she saw no more than six patients a day. Many, like Chen, whom she’d been treating for eight months, were regulars. She got to know their families, their little idiosyncrasies, and took pride in being able to see some heal and progress. They invited her to their grandchildren’s weddings, gifted her with little red packets at Spring Festival. Night shifts and working during holidays were things of the past. She can’t imagine returning to hospital work, she said. “I like being able to see my clients regularly. I can tell I make a difference,” she said, beaming.
My initial forays with Nurse Gao appeared to reinforce the general feeling I had of retirement in urban China. Stroll through any park on any given weekday between the hours of 10:00 a.m. and noon, and you’ll come away feeling like life post-retirement in China’s cities is a pretty decent affair. With such early mandatory retirement comes plenty of leisure time, and so the parks are filled with pensioners engaged in picturesque activities: dancing, tai chi, sword fighting, kite flying, and, my particular favorite, a form of geriatric graffiti that involves tracing out Chinese calligraphy on pavements using brushes and water, which dries and leaves no trace.
A friend’s father once took me to see him play Rouliqiu in the park, a favorite game among retirees using principles of tai chi and lacrosse. Using a paddle with a rubber center, he flipped a weighted ball to his partner, who caught the ball, twirled like a Sufi mystic, and tossed it back. More like a dance than a ball game, the sport was invented by a university professor in the 1990s and now has hundreds of thousands of adherents, not just in China.
So many retirees are practicing public dancing that municipal governments sought to place curbs on the noise emitted by their huge boom boxes. Affected residents have hurled abuse, water balloons, and in some cases excrement at these irrepressible “dancing grannies,” as they are dubbed by local media, to little avail. “Granny square dancing” has even become a competitive sport. In Jiamusi, not far from the Korean peninsula, locals have created a style—lots of coordinated hand and hip movements, performed in white Minnie Mouse gloves—widely imitated in elderly cheerleading competitions across China.
Parks and IKEA cafeterias have also become a hot singles scene for retirees. At Beijing’s Tiantan Park, not only are parents posting singles ads seeking mates for their grown children; now the elderly are doing it for themselves. Teng De’En, one of the organizers, shows me a fat folder of ads he brings to the park every Sunday. For 5 yuan—about 80 cents—subscribers between the ages of sixty and eighty-five place lonely-hearts ads. They typically list things like age, blood type (thought to predict personality), horoscope, and whether or not they have that all-important Beijing household registration.
This emphasis on what kind of household registration you have is quite common in the young singles scene. I hadn’t thought it would be such a big deal for the elderly, who’d already raised their families. Of course, I hadn’t thought it through: health benefits are tied to your registration status, and city dwellers get better coverage than those with rural residency permits.
Matchmaker Teng, a crusty divorcé, was himself in search of a new mate. His only daughter lived in the United States, and remarriage after sixty was becoming more socially acceptable, he said. “Who wants to die alone?”
This self-sufficient, vigorous vision of China aging is its most public, most engaging face. But there’s a side to aging in China that is easily hidden. On one of my forays with Pinetree’s Nurse Gao, we visited a woman in her eighties, living alone with severe diabetes and early-onset dementia. Almost all of Nurse Gao’s clients paid for treatment, but this woman’s once-weekly Pinetree tab was paid for by the local municipality.
We heard the TV blasting as soon as we entered the building. Nurse Gao banged on the door, yelling, “Granny, Granny, it’s me, Little Gao!”
There was no answer.
Nurse Gao then fished out her phone and called her, whispering, “She’s a little deaf.” Finally the door opened. An old lady, her bleached face emerging from the darkness, eyed me incuriously. She turned around and shuffled back to the TV set. For the rest of the time, her eyes never left the set.
It was playing a Thai soap opera, her favorite, said Nurse Gao. A miscarriage, an awakening coma patient, and a bankruptcy erupted in swift succession across the screen. Nurse Gao kneaded the old lady’s arms and legs, keeping up a patter that petered out. Questions on her diet, her daily habits, her exercise patterns, her bowel movements all died on the vine.
In between, the commercials that flittered across appeared aimed at a younger set: milk powder, candy, cell phones, cars. Sadly, the aged appear to be a dead demographic for China’s marketers; I didn’t see so much as an adult diaper ad, although China is on track to overtake Japan and the United States as the world’s largest adult diaper market.
The apartment was on the ground floor. It looked like a cavern, the TV its campfire, light bouncing off this woman’s immobile face. The air reeked of stale cigarette smoke, and the walls were brown and water stained. There was no artwork, only a calendar that was two years out of date and a framed studio portrait. It was one of those glossy jobs with an artificial blue sky and airbrushed expressions. Two middle-aged women, a man, all neat hair and neutral smiles. I thought it must be her family. In a whisper, Nurse Gao told me not to ask. “They don’t visit,” she said.
There were the remains of a meal on the kitchen table, biscuits and oranges. The orange peel was neatly quartered. The biscuit packet had been folded into a Rubik’s Cube of squares, as small as it could go, each fold as sharp as if she’d ironed it. I pictured this woman sitting, folding and refolding for hours in the dark.
The visit was an hour, but it seemed an eon. When we emerged from the building, I felt like Plato’s caveman, blinded by an unaccustomed sun.
Even Nurse Gao’s cheery demeanor was dimmed.
“Do you think you’re the only person she sees all week?” I ventured.
“No, but it’s the only time she gets touched,” she said sadly.
III
In his book Being Mortal, American physician Atul Gawande writes about end-of-life care in America. Most want to avoid the indignities and loss of control that come with institutionalized care, he says. Despite the portraits of sprightly independent life we’ve seen in sitcoms like The Golden Girls, despite the plethora of eldercare services from retirement communities to assisted living, Gawande concludes, “Your chances of avoiding the nursing home are directly related to the number of children you have.” Which is bad news for China.
One of the biggest ravages committed by the Communists was its assault on China’s family structure. Mao realized revolutio
n was impossible until he could get people to put the interests of the state above family. Over fifty years, Communism sawed away at the underpinnings of the famously clannish Chinese society, encouraging the young to turn on their parents during the Cultural Revolution and stifling ancestor worship. When the Communists rolled out the one-child policy in the 1980s, it was the coup de grâce.
Now, faced with rising divorce rates and the coming explosion in retiree ranks, China’s leaders realize it must rebuild some of the familial institutions it tried to tear down. In 1996, the National People’s Congress passed a law requiring children to support their aged parents. In 2013, Beijing followed up with a law requiring children of elderly parents to visit frequently. Such laws are difficult to enforce, but passing them sent a clear message: what the state cannot do, the family must.
Unfortunately, some of the damage may be difficult to repair. Take nursing homes. In Gawande’s America, having children may help you stay out of the nursing home. In China, not having children could shut you out, a double pain that shidu couples—those who lose their only child—are discovering. Many nursing homes will not admit shidu couples because they have no progeny to authorize treatments or act as payment guarantors. This form of discrimination appears to extend beyond the grave: some shidu parents complain that cemeteries won’t sell them burial plots—not for them, not even for their deceased children—concerned there will be nobody to pay for future upkeep.
Shidu parents—and there are currently a million of them, and growing—petitioned Beijing with a laundry list of demands: higher compensation, priority in adoptions, as well as plans that reflect their pension, medical, and burial requirements. They argued—with some justification—that since Beijing has made money off fines from one-child violators, it should compensate families who observed the laws, only to lose significant financial security with the death of their sole progeny. The argument is Solomonic and heartbreaking in its logic.
Beijing responded by raising compensation slightly, but other requests haven’t gotten much traction. (The shidu compensation scheme was started relatively late, in 2007. Currently, shidu parents receive reimbursement of between $16 and $50 monthly.)
Shidu parents, for example, have requested nursing homes that cater to their specialized needs. One reason: visiting days. “Seeing other people with their families . . . it’s just unbearable,” said one shidu parent.
A 2014 proposal by a local Guangzhou legislator to use social compensation fees, collected from one-child fines, for this purpose went nowhere. Authorities said the fees were needed for existing government expenses.
IV
People like Matchmaker Teng and Nurse Gao gave me some idea of what aging in urban China is like. But that is only half the story. Strictly speaking, 60 percent of the story. The rest of China lives in rural areas where the picture is decidedly more depressing, for the gap between rural and urban China is like the gulf between London and Lhasa.
On every measure, elderly rural folk in China are less well educated and less financially well-off. What’s more, they are also more likely to be cut off from family support, for at no other time in China has there been such a form of age apartheid, where the old are immured in villages and the able-bodied in cities.
It is in the countryside that you are most likely to hear woeful tales of elder abuse, such as the case of farmer Chen Shoutian, who kept his hundred-year-old mother in a pigpen. Chen, who lives in a six-bedroom house, told a local TV station that his mother preferred living in a separate cinder-block structure, sharing her quarters with a huge sow. Then there’s Zhang Zhefang, the ninety-four-year-old who made history by suing her children for abuse. The villager claimed she was locked in a dark room, pinched, and slapped and forced to empty her own slops. What makes her story sad is how unremarkable it is for rural China: she was undernourished, married at a young age, with offspring who are senior citizens themselves and in similar dire situations, depending in turn on their children’s largess.
It is perhaps not surprising, then, that incidences of suicide among rural elders are rising, at a time when China’s overall suicide rate is falling sharply.
While most city residents are covered by pension plans, only about a quarter of rural residents are covered. Many must work until they can’t. Medical treatment is scarce and rudimentary. Nobody knows this better than Xiao Hebi, a “barefoot doctor” in her late sixties. Barefoot doctors were a 1970s phenomenon—semitrained medics in rural areas who played a significant role in reducing infant mortality and the spread of contagious diseases. They helped China become one of the first countries to eradicate smallpox and polio. But when China launched its market reforms in the 1980s, many public health services were defunded—including barefoot doctors. Health costs soared, and many village medics quit. Xiao is the last of a dying breed, and she plans to stay in the harness until she drops.
Xiao’s reasoning is straightforward: despite serving her community for over four decades, she is not eligible for a pension. More importantly, she knows if she quits, her small community in the mountainous Sichuan area is unlikely to get a replacement.
“After me, I don’t know if anyone else will come,” she said.
I met Xiao in her clinic in Panshi, which means “Circle of Stone.” It is near a quarry full of cliffs teetering down to paddy fields. For the past forty years, Xiao has trudged up and down these steep areas in the dark, making night house calls for less than a dollar per visit.
In the day she is usually found at her clinic. The day I met her, dressed in a silver-sprinkled floral blouse and polished leather shoes, Xiao was hooking up a flu patient to an IV. On the walls, the pictures of two Chinese medicine sages looked on: Sun Simiao, author of the first encyclopedia of Chinese medicine, and Li Shizhen, who wrote the first definitive work on Chinese medicinal herbs.
Xiao, however, had little truck with traditional Chinese medicine. In a corner of her dispensary, empty and dusty from disuse, was an antique-looking cabinet with over a hundred small drawers used to store Chinese herbs. It was too complicated, costly, and ineffective for modern-day needs, said Xiao. Instead, she dispensed vitamin C injections, paracetamol, penicillin, and amoxicillin from a glass-fronted cabinet. She did so with a new patient who wandered in, waving her straw hat and complaining of the heat.
“It’s too hot here! At least get a fan!” she exclaimed.
She sat on the end of the couch. “What’s the matter with you?” she cozily asked the patient hooked up to the IV.
The flu patient opened her eyes. “Flu,” she mumbled.
Xiao gave the second patient two days’ worth of painkillers, neatly wrapping each pill in white paper. The woman handed her a 5 kwai note, about 80 cents. Xiao made change.
In her heyday Xiao delivered babies, set bones, and gave vaccinations. But Xiao hadn’t done an inoculation in over a decade, and the only babies she delivered now were livestock. Almost all her human clientele were over sixty, with typical ailments such as hypertension, diabetes, and dementia. She had little in the way of training or medication to help such ailments.
In 2008, one of Xiao’s relatives contracted cancer. He was admitted to the hospital, stayed a week, and didn’t die as expected. When medical expenses grew too high for his family to cover, he came home. With her oil-covered paper umbrella in one hand and flashlight in the other, Xiao climbed a steep mountain path twice daily to visit him, slithering up paths made slick by the summer rains. She kept him on a regimen of IV drips that included a mixture of painkillers and antibiotics. To hydrate him, she dabbed moist cotton balls on his lips. This patient, she said proudly, was still alive.
Rural residents have in recent years been able to get medical coverage, though it is still very limited. China was slow to adopt universal medical coverage, but it has been growing by leaps and bounds. Yibao, its version of Medicare, was rolled out in 2008, as well as an equivalent medical insurance scheme for rural dwellers. Every individual in Panshi pays 70 yuan—a little
over $10—yearly under the plan. Many Panshi dwellers complain, however, that reimbursement rates are low, and out-of-pocket expenses high.
Still, it’s a vast improvement after the past twenty years, when the dismantling of socialist infrastructure led to a rampantly capitalistic, for-profit health-care system. Now, Panshi’s residents have coverage for major health-care crises, but it’s tied to their household registration, making it difficult for elders to move in with their children in distant cities and still retain coverage. Also, there are simple logistical issues that become insurmountable when you are old, and poor, and live in a remote area. For example, doctors won’t prescribe more than a week or two’s worth of pain medication at a time. So Panshi’s sick elderly have to make frequent trips to the nearest big city, Dazhou, two hours away by bus, a costly and tiring business, said Xiao.
Xiao opens her clinic doors every day at 5:00 a.m. She starts making her house calls at nightfall. Midnight is reserved for paperwork, and she goes to bed at 2:00 a.m., in a room attached to the clinic. Her three children have asked her to retire, or at least ease up on her punishing schedule. “But what is there left for me to do?” she said matter-of-factly, perched on a table. She swung her legs, drawing attention to her shiny leather shoes, as if to say, “What, me, barefoot?”
You might imagine that concepts such as filial piety, the backbone of old-age security, would be stronger among supposedly more traditional rural dwellers. But anthropologist Yan Yunxiang says filial piety has essentially collapsed.
Yan spent more than a decade doing fieldwork in a small village in northern China. As he explains it, the basis for parental power was the concept of enqing—that children owe their parents a debt that can never be repaid because their parents gave them life. Parenthood also had an elevated status because of village kinship systems and religious rituals like ancestor worship. Communism and 1980s materialism basically eroded these beliefs, leading to what Yan calls the “demystification of parenthood.”