by Mei Fong
“The idea that human reproduction is sacred is no longer accepted by younger villagers,” he wrote.
Probably the strongest reason for today’s erosion of parental power is economic. The prospect of inheritance has always been powerful protection against elder mistreatment. But land reform and collectivization mean rural elders today have little to pass on to their children economically.
Xiao said the elders in Panshi who felt the most secure were those caring for grandchildren. “That’s how they feel useful. They know as long as they’re doing that, their children will continue to send money home,” she said. She’s also known cases where grandparents have been summoned to cities to take care of their grandchildren. “Those people have an awful time. They don’t know anyone and the cities are so dirty,” she said. “Nowadays our children have become rulers; we just don’t dare say anything to make them angry. Not like the past, when your children obeyed you until you died.”
Suddenly, a bell rang. A young boy dashed into the clinic.
“Popo, popo, open the cupboard,” he gasped.
Xiao opened a padlocked drawer.
I wondered why this sense of urgency. A cut? Diarrhea?
Rummaging inside, he pulled out a lollipop. He handed her a grubby note. Other children followed, and Xiao was soon kept busy collecting money. Unlike the medicine cabinet, the candy cupboard, I noticed, was locked.
“Wow, you do so many things, treating sick people and running a sweetshop, too,” I exclaimed. I meant it as praise, but Xiao glanced away, embarrassed.
“I heal people,” she said softly.
V
Why do I see such a bleak picture of aging in China? After all, aside from loosening the one-child policy, there are other steps that China can take to ameliorate a graying transition, including raising the retirement age and reforming a clunky pension system. Some of these measures have already happened, or are likely to happen soon.
There’s also no doubt that China’s social safety net is growing quickly. In 2011, rural pension schemes covered only a quarter of the rural population. In 2013, this expanded to half, then three-quarters in 2015. China began health-care reforms in earnest only in 2009, but yibao has swiftly evolved; premiums have risen quickly in the past five years, significantly reducing out-of-pocket expenses.
Despite this, there’s little to celebrate. There are two things that help make old age more tolerable: money to pay for comforts, medical treatments, and necessities at a time when you can no longer work; and family, or family substitutes, for emotional support and care. Neither resource is solid in today’s rural China.
For China’s elderly to have a secure and pleasant old age, its economic engine must continue to chug on, making enough to service eldercare and pension demands. But China’s economy is slowing down, and an aging demographic will add significant headwinds. This situation is likened to a “speeding bicycle that has to keep going just to keep from falling over,” according to a report by the Center for Strategic and International Studies. China’s aging issue makes economic growth more essential but more difficult to achieve. In over three decades of China’s economic reform era, the expansion of its working-age population has on average added 1.8 percentage points per year to its GDP growth rate, CSIS reported. By the 2030s, the contraction of its working-age population will be subtracting 0.7 percentage points per year.
As for family, China has done too little, too late. The one-child policy has been loosened to a two-child policy. But babies take time to mature and become workers. Even that major shift will do nothing to smooth over the problems of the next two decades in this area.
The one-child policy significantly reduced the number of caregivers for China’s elderly, not just in quantity alone, but also in quality. There are fewer women in China now—and by extension, fewer daughters-in-law, and they’re the ones who really take care of the elderly.
VI
The city of Kunming is possibly one of the most pleasant places in China in which to live and die. It is located in the south near Vietnam and Myanmar but lacks the muggy heat of those places, for it is on an elevated plain six thousand feet above sea level, similar to Tahoe. That height also serves to keep away the pollution that clogs almost every other provincial capital in China. Kunming is the only major city in China I’ve been in recent years where blue skies are the norm.
Ma Ke’s No. 3 People’s Hospital’s Section on Palliative Care in Kunming is renowned by nature of its age—it is the oldest—and size—it is one of the biggest. China’s most famous hospice opened in 1986 with just six beds, two doctors, and a nurse. Now it has seventy beds and will more than quadruple that in 2015 with a new wing. Those are pretty outsize numbers even by China’s standards, where ten beds for palliative care is more the norm.
Still, to be the top hospice provider in China is to be a giant among pygmies. In an index created by the Economist Intelligence Unit that ranked the quality of care for the dying, China came in close to the bottom on almost every metric: quality, affordability, availability.
The hospice is a unit inconspicuously tucked within a general hospital, which is handy camouflage. In a culture that venerates luck and fortune—good old Lu and Fu—talk of death has the opposite effect, leading to Chinese abhorrence of things that even hint at this: the number 4, for instance, whose name sounds like the word for “death.” Neighborhoods around hospices have been known to raise vehement protests. In the late 1990s, for example, residents living near Beijing’s Songtang hospice smashed its windows and forced nearly a hundred dying patients into the streets in the middle of the night.
Ma is slight and energetic, a member of the Hui minority. (The Huis, one of China’s largest ethnic minorities, are Muslims. Kunming, being on the old Silk Road, has a sizable number of Hui folk. Most are no longer strict Muslim practitioners, which may be just as well, since practices like observing Ramadan have been recently banned by Xi Jinping’s government.) Ma originally trained as a neurosurgeon, but “China has so many surgeons, it’s hard to distinguish yourself.” Sensing a pioneering opportunity, he turned to hospice care. Having made a name for himself, he intends to publish the diary he keeps, with the title “At the Gate of Heaven.”
One room in Ma’s hospice comes closest to representing this putative gate, the room where they lay out the dead. Prominently located in a highly trafficked section of the building, the room is christened “Mount Penglai,” after a mountain that holds a place in Chinese mythology roughly equivalent to Olympus. Penglai is a fabled dwelling place of the immortals with no pain, no disease, and bountiful food, wine, and peach blossoms.
The hospice’s Penglai, however, holds little suggestion of the divine. There is an altarlike niche with a picture of an unidentified deity that could represent almost any religion. It is flanked on each side by a lugubrious couplet:
Where is the moon and the spring breeze? I don’t know.
The peach blossom falls in the river and is gone.
I peer in and see a body in white. Staffers tell me the deceased is Muslim and is being wrapped in a ceremonial white shroud. On other occasions, Mount Penglai might be used for Taoist rituals, or Buddhist prayers.
There is no real reason for this room to exist. The hospital already has a mortuary, where dead bodies can be laid out before being claimed by relatives. Ma says the Penglai room fulfills a need. “Sometimes, we have a death a day, and relatives don’t know what to do,” said Ma. “We don’t have systematic religion in our country, but we do have many burial customs which bring peace to the living.”
There is also, of course, another, more prosaic reason for the room’s existence: it is leased to a local funeral home and is an important revenue source for the department. Most hospital departments—oncology, pediatrics, and so forth—in China are run as profit-making entities, whose revenue in part depends on the number of treatments prescribed. Staff are paid a bonus on this, which can frequently match or surpass their base pay. Such avenues are, o
f course, limited for hospice staff, who can prescribe little in the way of curative treatments for the terminally ill. This is one reason why they have difficulty luring medical personnel, said an administrator. The Penglai room therefore helps replenish coffers.
But the Penglai room also has another effect. Death, instead of being tucked away and hushed out of sight, is given a prominent space.
One of the things I discovered while talking to Ma, other doctors, and patients was how small a part the elderly play in making decisions about their own health care. Doctors usually relay news of the patient’s conditions to the family, leaving them to disseminate the news to the patient. Or not. In cases where the patient’s family wishes to hide or conceal details, doctors usually comply, sometimes reluctantly. “We only tell white lies,” one doctor told me.
Offspring can and often do induce doctors to perform futile medical procedures and surgeries that the patient doesn’t want or need. UK-based public health scholar Chen Hong found in her study of end-of-life China cancer patients that doctors are “overly aggressive” in their treatments, with measures that tend to prolong the suffering of patients.
“I had a patient with rectal cancer,” Ma told me once. “He himself was aware there was blood in his bowel movements. The daughter wouldn’t let us tell him he had cancer. She would rather her father remain unaware, and she told us to tell her father it was simply hemorrhoids.
“Months passed, but the patient did not feel he was getting better. He still found blood in his stool. He was not happy with me. He thought he wasn’t getting proper treatment and refused to cooperate anymore.”
Ma finally persuaded the daughter to allow him to let the patient know the truth of his condition. According to Ma, he tried to break it gently.
“I tried talking to the patient, to see if he was strong enough to accept the truth. I told him, ‘Look, you’re already seventy, at this age lots of people get sickness, like cancer. My previous diagnosis might be wrong. It is possible you might have cancer. Have you thought about that?’ He replied, ‘It’s all right. I have two children; one of them is in Hong Kong, the other in Kunming. They both have jobs and families, they’re very happy. I am well prepared for this.’
“I did not believe he was prepared. So the second day, I came to his room and said I would reexamine him. I waited until the third day to tell him it was actually cancer. I thought he might be able to accept it. But after half an hour, he passed out. He only awoke fifteen days later. A week later, he died.”
I asked Ma if this really happened in such a dramatic fashion. He insisted it was so. It is not one of his proudest moments, he said.
“We failed in this case,” he said.
There are several reasons for this peculiar state of affairs in China, where family takes precedence over patient. Economics is one: doctors defer to the adult children of patients, because they’re the ones paying the bills. This generation of Chinese elderly are relatively impoverished next to their children, who’ve been able to enjoy the fruits of China’s economic boom.
The more unfortunate explanation is that the deathbed is where the all-but-gone filial piety rears its head. “It’s all about mianzi, ‘face,’” said a Beijing hospital administrator. “Children have to show that they really tried, and so they insist on doctors doing everything at the end, even if it means a whole lot of unnecessary and painful treatments.”
Ma has another theory: the past thirty-plus years of China’s experiments in capitalism have created a culture of materialism. “In recent China, we have turned into materialists; not me, but the other people. Thereafter we didn’t have an education about death. Materialists only believe in what they see with their eyes and deny what could not be observed with eyes. They are not religious.”
I’m not sure I agree with Ma. Chinese culture does abhor anything close to talk of death. We don’t have fourth floors, or fourteenth floors—and sometimes, as a nod to Western superstition, thirteenth floors either—which can make elevator rides bewildering. We don’t like vintage clothes, white flowers, or giving clocks, all things that are associated with death and bad luck. These practices do impede our “education about death,” as Ma put it. In my family, any talk of death would always be punctuated with a pithy “Choi!”—the Cantonese equivalent of “Bite your tongue.”
But I think the reason for this abhorrence stretches beyond materialistic culture and has its roots in the Chinese system of beliefs around what happens after death. Broadly speaking, most Han Chinese hold beliefs that are an amalgamation of Taoism, Buddhism, and Confucianism, with a good dollop of folk religion and ancestor worship sprinkled in. In general, it results in a vision of the afterlife similar to this one: you still need money and creature comforts, you still have bureaucracy and hierarchy, and you must slog on in a more-or-less eternal cycle of rebirth. Unlike the Muslim and Christian creed, there is very little vision of a soothing Eternal Rest.
One of the best places in Beijing to glimpse the Taoist view of the afterlife is at the Dongyue Miao. Dongyue has stood in the same location for over eight hundred years, even as hutong alleys around it have crumbled before the onslaught of skyscrapers.
In Dongyue, there are various chambers, each holding plaster-of-Paris tableaux depicting the afterlife. Each chamber represents an office in the afterlife, and overall they add up to a grim vision of unending bureaucracy, where the dead are judged for past deeds and have to appease numerous supernatural deities.
In the underworld, there is a department of signatures, as well as a department of signing documents. There is a department of recording merits, of determining individual destiny; departments for confiscation of property, examining false accusations, controlling theft, wilderness preservation—who knew that would be important in the afterlife?—and, my personal favorite, the department for implementing “fifteen kinds of violent death” (though the finer points of postmortem death elude me), all laid out in as much gory detail as red paint and plaster will permit.
With this less-than-enchanting view of what is to come, no wonder Chinese abhor talk of death and take heroic measures to prolong life. As a popular Chinese saying goes, Hao si buru tousheng. “Better to struggle to live on, than die a good death.”
When my father died, we laid him out in state on the veranda, his coffin packed in dry ice. The visitors’ first stop was the reception desk, where relatives sat with a giant book, recording contributions of “white gold”—gifts of money in white envelopes to help pay for the funeral. We, the daughters and wife of the deceased, pinned scratchy sackcloth hoods on our heads and burned joss paper to pay for his comforts in the afterworld.
Every year at Qingming and Double Nine Festivals, we would visit the columbarium where we kept his ashes. There, we’d make more ashes, burning “Hell Money”—sheets of paper purchased at religious stores. These literally had the words “Bank of Hell” and “Legal Tender” printed on them, as well as a picture of the Jade Emperor, the emperor of heaven in Taoist mythology.
Aside from festivals to honor ancestors, we also celebrated Ghost Month, where offerings were made not just for our own clan, but for all spirits. During this month, it is believed that the gates of hell open and ghosts are free to roam the Earth seeking food. These unfortunate ghosts are ones who no longer have people paying tribute to them.
Ghost Month is therefore rife with superstition, a month when nobody gets married or starts a business. As a child, I loved to wander with my mother into the religious shops in the weeks ahead of Ghost Month, for they had paper models of houses, cars, and people, looking exactly like toys. I longed to touch and play with them but was never allowed to, of course, for this would have been extremely bad luck.
These offerings have kept up with the times: I’ve seen paper Louis Vuitton handbags, paper iPhones, and, of course, the all-purpose afterlife accessory, a paper Amex Black card. In 2006, China’s Ministry of Civil Affairs even went to the trouble of imposing a ban on the burning of “messy sacrifi
cial items” such as paper replicas of Viagra, luxury villas, and karaoke hostesses.
All this shows that, while most religious and cultural systems stress that you can’t take it with you, the Chinese eminently believe you can, as long as you have descendants, the more the better. To die without issue is to duanzi, juesun—one of the worst curses you can visit upon someone Chinese, for it means an eternity as a Hungry Ghost.
VII
The Kunming hospice has a smell I’ve come to associate with institutional life in China: pork bone soup and instant noodles mingled with the occasional waft of urine from the toilets and a fug of cigarette smoke.
Patients sleep two to a room. There are no showers, so residents have to make do with sponge baths or, if they are able-bodied, go home to bathe. There is just a narrow space between beds, enough for a person to sidle through sideways. To compensate for the rooms’ lack of space, large communal seating areas dot the floor, with raftlike wooden chairs and couches in peeling vinyl. Small food tins, scrubbed clean of their labels, serve as ashtrays. Here, residents and visitors linger, smoking, sewing, chatting on the phone.
In one of the sitting rooms, I met Li Jiayi placidly embroidering flowers on shoe soles. Li’s mother had been an inmate for the past seven months, hit with both Alzheimer’s and Parkinson’s.
Jiayi was thirty-five, with a cloud of long, dark hair and a serene face without a speck of makeup. With her was her five-year-old daughter, Qingxue—“Little Stream”—an engaging sprite with a gappy smile. A tiny tiara was perched on her braids. They were the hospice’s youngest regulars.
