Myth of Filial Piety:The Reality of Long-term Care in China

Today’s guest post was written by Ninie Wang and translated by Ashton Liu.

Ninie Wang is founder and CEO of Pinetree Senior Care Services as well as the International Director of the GSC (Gerontological Society of China).  She has been involved in the field of population ageing issues for years and writes extensively about the status of elderly care in China on her excellent Chinese language healthcare blog, here.

Ashton Liu works in Research and Development at Pinetree Senior Care Services.  He has studied at both Carleton College in the US and Tsinghua University in Beijing.  His background includes consulting and business facilitation, and has worked in Asia focused research institutions in the region.

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The concept of ‘filial piety’ is one of those things that is often employed to make blanket generalizations about the Chinese.  For example, “China’s traditional values of filial piety ensure that the elderly are well taken care of by the state.”  But, as past article on this blog have made clear (see four part series by Samuel Green, here) China’s transformation of economy has resulted in a concurrent transformation of traditional family structures.  The extended family is increasingly becoming geographically distant, and the elderly are getting left behind.

In this piece, Ninie argues that in-home care for the elderly is the inevitable future of the Chinese market.  I agree in so far as the short-term future is concerned, though I’ve said before that long-term care facilities will have a brighter future once real estate prices go down.  Whatever happens, this article does a fantastic job describing developing attitudes towards the elderly in China today.  Enjoy.

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When speaking to friends abroad about the situation of China’s ageing population, they often talk about how Chinese senior citizens must be well taken care of given China’s traditional values of filial piety which emphasizes respect and care for one’s elders.  However, when one takes a careful look, this is not the case.  Many of the young think only of pursuing a comfortable lifestyle.  That their parents devoted so much in raising them as children does not register with them, and the youth tend to grow impatient as their parents become slower both mentally and physically.  Examples like Zhou Yang, the Chinese gold medalist in speed skating, who said that she hoped she could make her parents live more comfortably are increasingly rare in China today.  Society is encouraging people to both respect and take care of the elderly, but in reality people keep them at a distance.

Recently, I was visited by a friend’s mother.  I had told her before that I work in the elderly care industry, and when I saw her this time she had prepared a number of questions.  She told me that her father (my friend’s grandfather) had been in good health for years, and while he is 90 years old now he looks only 70.  However, in the past two years he seemed to have aged considerably.  His movement had slowed and he seldom spoke; his family did not know what to do.

I asked in detail about his situation and found out that in the past two years he started to have problems walking, and was sometimes unstable when he would go for walks.  Concerned that he would fall and hurt himself, his family made him stop his daily morning exercise.  The family hadn’t expected that later he just stayed at home, and became less and less active. His body seemed more and more stiff, and he eventually spent most of his time lying in bed.

In addition, because occasionally the grandfather would sometimes ask about things that seemed too obvious or “silly,” his loved ones felt that listening to him was a waste of time and in time simply stopped responding.  The lack of social engagement has its effect on the elderly, and they become increasingly reluctant to engage others. It is only when the entire family gathered together and relatives were speaking amongst themselves do they take notice and ask the grandfather, “Why aren’t you saying anything?”

My friend’s mother also tried to take the grandfather on a bus ride, pointing out to him the new buildings that were being constructed and the landscape that had changed since he had last worked. She kept explaining things to him but found that he had no reaction or wouldn’t even bother to look.  He had already lost most of his curiosity and ability to perceive the world around him.

This story tells the tale of too many families in China. The myth of filial piety has long been a luxury for most families as most people do not understand the elderly, do not understand the process of ageing, and as a result neglect the needs of their loved ones.

In the abovementioned example, because the grandfather’s movement began to show irregularities, the family stopped him from exercising simply for the convenience of the family and children.  The importance of exercise is widely accepted, but there is little public knowledge of its importance for the elderly.  The intensity, type and location of exercise all must be suited and adapted to senior citizens and their individual health needs.  Often in old age as one’s nerves degenerate, seniors might appear to have uneven walking patterns or muscle spasm.  When looking at an elderly with motor system disorders, how many of us would pay extra attention and consider the possibility of Parkinson’s disease?

As seniors start having slow or slurred speech and ask questions that are deemed uninteresting, they become more and more “invisible;” others are no longer willing to engage them in conversations.  There is no myth here about the disappearance of the basic respect for the elderly.  There are some who will naturally have trouble speaking as they age, and others might be suffering from an early form of dementia. Constant language training mixed with speaking exercises can significantly help the elderly maintain their mental capacity.  Engagement with the elderly can also help avoid major speaking problems, including loss of speech, and defer or alleviate dementia.

Most of us living in cities would take baby-care lessons or at least read a lot of books when it comes to raising a child.  Few would consider learning about how to take care of the elderly when we have to care for aging members of the family.  Take measuring blood pressure for an example, the ability to correctly measure blood pressure is a specialized skill that requires careful attention to many important details.  In most homes that we have visited, neither the seniors nor the family members who had bought them the devices have the necessary knowledge about the proper timing, cuff size, position and other techniques involved.  Another example relates to diabetes patients.  Chinese seniors love foot massage and spa service.  Those who would insist on adding more hot water are rarely stopped by their family members, causing injuries that often led to diabetic foot.

We have talked to so many young people who believed that their parents were in good health.  However in almost 100% of the case, we later found that the seniors had been suffering from chronic or geriatric diseases for decades.

Many families would reduce or stop proper care when they bring seniors back home after hospitalization, having little idea about the consequences to the elderly without proper rehabilitation. When fading filial piety is accompanied by geriatric health illiteracy, China’s population aging might be facing much more severe social implications.

Some people feel that simply spending time with the elderly or hiring a 24 hour nanny to look after them can solve the problem.  In addressing the problems the elderly face expressing themselves, it is not enough to simply talk or read to them.  One must interact with them and get them to actively participate in a conversation, a practice which requires both careful and technical planning. For specific examples see The Roles of Speech-Language Pathologists Working With Individuals With Dementia-Based Communication Disorders: Position Statement.

This type of professional care designed especially for the elderly is in great demand in China.

Nursing homes have grown rapidly in China, yet the national capacity of less than 3 million beds only serves a small share of the potential demand of about 8 million.  With its significant capital requirement and unclear return on investment, government and private investors alike are reluctant to push for its development.

(For more on elderly population and status of nursing homes see: 国养老遇尴尬: 一床难求和养 老院空置现象并存, and 北 京市2008年老年人口信息和老龄事业发展状况报告 )

For example, to build a large nursing home with 1,000 beds, initial investment can already range from 30 to 150 million yuan.  Even with up to 10% initial investment and annual subsidy of 300 to 1200 yuan from the local government, nursing homes struggle to break even.  A national survey revealed rather low willingness to pay – urban seniors are willing to pay 710 yuan per month for living at a nursing home, while rural ones only 121 yuan per month.  In addition, challenges such as attracting and retaining professional care staff, managing risk and even meeting safety standards are issues of great concern for many veteran managers of nursing homes.

Some people prefer to hire companies that send nannies or care-workers.  Unlike in the US or many other developed countries, these groups in China often lack a basic education, and are assigned into customers’ homes with a limited number of hours’ training (if any).  Although many of them can do a good job at house-keeping and/or cooking, few are equipped with elderly care knowledge.

Increasingly, community hospitals are extending their medical services to homes in their neighborhoods.  What prevent them from providing nursing services are the lack of nurses and the unwillingness to manage the low-margin troublesome service model.  The doctor/nurse ratio in China today reflects the hospitals’ emphasis on revenues and profit, with less than one nurse per doctor.

There is a need for an alternative service.  Pinetree’s professional home care has the potential to be the most cutting-edge solution to the care needs of millions of families with seniors.  Focusing on delivering nurse visits to seniors living near each of its local service units, Pinetree’s asset-light business model with a strong emphasis on quality control and personnel development has started bringing hope to many. If there was any way to re-promote traditional filial piety in the modern China context, Pinetree can actually help make a difference.

China is now struggling with how to deal with the often competing forces of modernity and tradition.  Arguably, China has stronger social structures than other countries to encourage elderly support, but these are under great pressure.  The relocation of career opportunities and urban sprawl have spread families across the country and have raised new questions and challenges.  China will be looking to more developed nations as examples.  Systems like America’s where there exist nursing homes, elderly communities, Social Security, Medicaid that all enhance family support will be models that China will emulate and adapt.

China’s development of elderly care will undoubtedly be based upon in-home care.  In addition to the overwhelming percentage of elderly who prefer to be in their own home rather than a nursing home, the government has already begun to dedicate its attention and resources to developing this industry.

The benefits to an individual’s physical and psychological health when ageing in the home are clear. Economically, in-home care is less of a financial burden as living full time in a hospital or nursing home.  This is a field that other countries are increasingly emphasizing, whether one is making decisions such as how to reform a nation’s healthcare system or how to care for one’s own ageing parents.  In time, it is quite feasible that China may in turn be the model that other countries study.

Today, we are faced with questions such as: has the myth of filial piety already become a burden for China?  What type of treatment can we expect in our own old age? Confronted with the shattered myth of filial piety and the dissolution of family support structures, all societies must now decide whether they are content to let these values dissolve into nothing or whether they are able to rebuild the social and medical infrastructure to allow the elderly to enjoy the comfort and dignity they deserve.