Growing Old in a New China: Transitions in Elder Care 9781978813953

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Growing Old in a New China

Global Perspectives on Aging Series editor, Sarah Lamb This series publishes books that w ­ ill 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 ­w ill be aimed at students, scholars, and occasionally the general public. Jason Danely, Aging and Loss: Mourning and Maturity in Con­ temporary Japan Parin Dossa and Cati Coe, eds., Transnational Aging and Recon­ figurations 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 ­r ose k. keimig

Rutgers University Press New Brunswick, Camden, and Newark, New Jersey, and London

 Library of Congress Cataloging-­in-­P ublication 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 p ­ eople—­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​.g­ ov​/2­ 020019304 A British Cataloging-­in-­P ublication 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​.­r utgersuniversitypress​.­org Manufactured in the United States of Amer ­i­ca

 For my parents, Kay and Ed, the prophet and the professor

Contents

Introduction

1

1. Filial ­Children, Benevolent Parents

21

2. Bodies in History, Embodied Histories

44

3. Place and Space, Rhythm and Routine

68

4. Entanglements of Care

90

5. Care Work

108

6. Chronic Living, Delayed Death

129

Conclusion

150

Acknowl­edgments

161

Glossary 163 Notes 165 References 169 Index 189

vii

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 m ­ other—­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 a­ fter 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 b ­ ecause of the stroke, she said. Before the stroke, she was so capable. She could do every­thing. Now she ­can’t do

1

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 w ­ ere ­going to come visit her ­today, but it was too hot, so she had told them not to come. “Chinese p ­ eople are very good to their c­ hildren, ­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 other­w ise 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 2  Growing Old in a New China

lady” outcome the social worker had advised my f­ amily to prepare for. ­A fter 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 p ­ eople 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, Introduction 3

t­ here was a saying that it was rare to live to seventy. ­There ­were very few p ­ eople in their seventies—­very few. But now, seventy-­year-­olds are still considered ‘­little b ­ rothers.’ ” As Grandpa Zhou states, a primary driving force in the changing elder care situation is the sheer number of aging p ­ eople. 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 w ­ ill 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 ser­ vices (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 p ­ eople 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 4  Growing Old in a New China

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 r­ ose, 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 pro­ cesses 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 Introduction 5

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 house­­ holds 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 c­ hildren 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 ser­v ices offered by community organ­ izations 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 ser­v ices (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 6  Growing Old in a New China

to equip all community health centers with small wards to provide palliative and hospice care. Th ­ ese 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, t­ here ­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 t­ hese institutions (S. Chen 1996). In the late 1990s, following the decentralization of China’s welfare ser­ vices, 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). Introduction 7

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 ser­v ices (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 ser­ v ices, 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 8  Growing Old in a New China

hybrid facilities that provide both medical and residential care, within t­ hese 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 is the fact that many elders do not have savings, due to the low wages they received ­under the socialist economy. Some cities—­ including Qingdao, Nanjing, and Shanghai—­have experimented with long-­term care insurance and waiver programs, but all of ­these have been ­limited in depth and effectiveness (W. Yang et al. 2016; Y. Zhang 2020). At the time of my research in Kunming, all institutional fees ­were paid out of pocket. To meet residential care fees and medical expenses, many institutionalized elders ­were forced to rely on other sources of income. Data from China’s 2010 national census show that one-­fourth of urban elders over sixty-­ five relied primarily on f­ amily members for financial support, while the rest relied on their pensions (Q. Jiang, Yang, and Sanchez-­ Barricarte 2016). As stated above, ­after the centrally planned economy and social safety nets ­were dismantled in 1978, social security emerged as a major social challenge. In 2014, when my research was taking place, a national universal pension plan was put in place for rural and nonemployed urban residents that provided a minimum benefit of RMB 55 ($9) per month. The amount varies by region. The average was RMB 81 ($13); in Shanghai it was RMB 540 ($90), and in Kunming it was RMB 84 ($14) (T. Liu and Sun 2016). Employed urban residents receive pensions through their employers (S. Li and Lin 2016). In 2014, the average pension in Kunming was RMB 1,955 ($326), and it was increasing at a rate of about 10 ­percent a year (Du 2015). Due to the amount of flux and uncertainty surrounding economic and social support in old age, con­temporary elders’ aging experiences are often unpredictable and complex. In approaching this tough topic, I follow the lead of con­temporary China medical anthropologists such as Arthur Kleinman, who challenges us to Introduction 9

take seriously the affective and emotional experiences of aging and caregiving: “Faced with the dangers and uncertainties of their own embodied suffering and the insecurities and seemingly endless changes in their cultural worlds, how do ordinary Chinese make sense of their experiences? Or do they make sense? What kinds of quests for meaning do they embark on? And where do ­those inner journeys lead them? Furthermore, what do quests for meaning have to tell us, beyond personal biographies, of what is happening to Chinese culture? And how is that connection between the person and the context, the emotional and the moral, best studied?” (Kleinman 2011, 263). Over the course of thirteen months of research in Kunming, I  took ­these questions into hospitals, elder care homes, living rooms, and bars, exploring the universal facts of aging, caring, and ­dying in the context of Chinese society and individual lives. It was difficult research. Although I had worked as a paid caregiver for developmentally disabled adults in the United States, the intensity of smells, sounds, stories, and suffering in ­these facilities could be overwhelming at times. But generosity, wisdom, and kindness ­were ­there in equal mea­sure. In this book, I hope to communicate the richness of ­ these very ­ human experiences through my exploration of emerging elder care formations and new ways of being an el­derly person, a filial child, and a caregiver in con­temporary China.

Institutional Care Research While a number of China anthropologists have studied elders and elder care within the context of the ­family, most work has focused on rural areas (Davis 1991; Freedman 1966; Parish and Whyte 1978; R. Watson 1991; Wolf 1978). Other studies in the social sciences have used surveys and semi­structured interviews in urban elder care institutions to get a sense of how elders and families are reacting to increasing rates of institutionalized care (L. Chen 2016). Overall, the results have been quite positive. Most studies report that the majority of elders show physical 10  Growing Old in a New China

and m ­ ental improvements ­after entering an institution (Cheng, Rosenberg, Wang, Yang, and Li 2011), and that they prefer living in an institution compared to their previous living arrangements (Guan, Zhan, and Liu 2007) even if they are still physically in­de­ pen­dent (Zhan, Liu, and Guan 2006). Elders also tend to be more positive and open-­minded about the transition than their c­ hildren (Zhan, Feng, Chen, and Feng 2011). However, no long-­term ethnographic fieldwork had been conducted in Chinese elder care institutions at the time I conducted this research. Outside of China, Lawrence Cohen (1998), Sarah Lamb (2000 and 2009), and Margaret Lock (1993), among ­others, have provided rich accounts of the aging experiences in non-­Western contexts. In his complex ethnography, No Aging in India, Cohen critiques common assumptions about dependence being an unwelcome aspect of aging and deconstructs the automatic association between modernization and changing f­amily structures. In one example, he describes a group of elders who manage and reside in an old-­age community—­yet who are pitied by the larger community despite the smooth functioning of the institution, due to their apparent lack of f­ amily support. In line with his conclusions, ­others have also noted that de­pen­dency is pre­sent across the life course, and the value placed on dif­fer­ent forms of dependence is a reflection and creation of active social pro­cesses (Bateson 2010; Buch 2018; Chi 2011). Anthropologists have also determined that experiences of aging and elder care are further mediated by gender (Lamb 2000; Lock 1993; Wentzell 2013), migration (Ikels 1983), and globalization (Lamb 2009). In Aging and the Indian Diaspora, Sarah Lamb takes a nuanced look at the way Indian elders and their communities reconceptualize Indian modernity as they explore new ways of aging and new possibilities for personhood in l­ater life. Similar to the elders in my study, Indian elders have traditionally received care within intergenerational families. The pre­sent research builds on Lamb’s call to pay more attention to elder agency, and I agree with her observation that “even though they tend to be viewed by ­others and to view themselves as in many ways emblematic of ‘tradition,’ Introduction 11

­those of the se­nior generation are at the same time very actively involved in fashioning new modes of life for themselves and their descendants” (2009, 17). While Lamb analyzes the rise of old age homes in the context of modernity and globalization, this book focuses on elder care experiences in the face of ceaseless, historical change. In the more general field of caregiving research, a number of ethnographies have focused on ­people on the margins of life and death—­whether due to illness, aging, or neglect—to examine how personhood is constructed, contested, denied, and claimed (Biehl 2005; Kaufman 2005; McLean 2007). For some, as medicalization splits the social category of old age into a multitude of discrete diseases, new forms of subjectivity become available, and individuals can use t­ hese diagnoses to claim identity and personhood (Liebing and Cohen 2006; Rabinow 1999). Yet for most, aging and de­pen­dency are feared forms of social death: once unable to be active producers or reproducers, the old and dependent join the ranks of eco­nom­ically unproductive bodies, which have no value in a market-­based society (Biehl 2005). Chinese elders face similar challenges, and therefore this research is not just about living in old age but also about ­dying. As death increasingly moves out of private homes and into public spaces, issues surrounding ­dying push the frontiers of medicine and challenge the reach of state control over the body (Agamben 1998; Biehl 2005; Das and Poole 2004; Hyde 2007; Kohrman 2005). As caregivers, patients, and families grapple with shifting meanings and patterns of death, ­there is a growing recognition of the complexities surrounding the ­dying pro­cess in con­temporary institutional settings (Chapple 2010; Kaufman 2005 and 2015; Lock 1996 and 2002; Spiro, Curnen, and Wandel 1996). A theme that emerges to dif­fer­ent degrees in both João Biehl’s evocative ethnography of death on the margins of society, Vita (2005), and Kaufman’s account of ­dying in modern hospitals, . . . ​And a Time to Die (2005), is that when it comes to end-­of-­life care, ­there is a constant slippage between the concepts of letting die, hastening death, and killing—­ especially for the socially unwanted and eco­nom­ically unproductive. 12  Growing Old in a New China

In addition, as Lock (2002) makes explicit in her ethnography on organ donation in Japan, w ­ hether death is seen as a moment or a pro­cess, and as an individual experience or a social event, is entirely dependent on the cultural context. Kaufman’s take on the moral dimension of the modern prob­ lem of ­dying in Amer­i­ca is that “when nature is no longer viewed as natu­ral, when it is known to be socially and culturally constructed, it can no longer provide the moral foundation for the good and correct life” (2005, 325). As life-­saving technologies become more advanced, this foundation is fatally destabilized by the ever-­shifting boundary between life and death and by “a popu­lar culture that is enamored with the biology of hope” (Good 2007, 377). Although ­these technologies can save and extend lives, once they are widely available, the “choice” to use them becomes an illusion, since not choosing to do so (and thus allowing death) seems like a crueler option than extending life, even if the ultimate effect is the prolongation of suffering (Kaufman 2005 and 2015; Krakauer 2007). ­These power­ful institutional caregiving and end-­of-­life ethnographies demonstrate the value of bringing all ele­ments—­however unsavory or painful—of a field site into view and recognizing that moments of beauty and life coexist si­mul­ta­neously with intense suffering (Biehl 2013). The stories I heard in Chinese institutions ­were emotionally rich and complex, as w ­ ere the p ­ eople who shared ­those stories. I strive to portray this “depth of personhood” in my accounts of their lived—­and living—­experiences, showing that at any age and in any place, ­people are always “vulnerable, failing, and aspiring ­human beings” (Biehl, Good, and Kleinman 2007, 14).

Theoretical Considerations The ultimate goal of this book is to shine a spotlight on the everyday experience of aging and caregiving, primarily from the perspectives of elders. In line with the anthropological call “to attribute to the ­people we study the kinds of complexities we acknowledge in ourselves” (Biehl and Locke 2010, 317), I allowed Introduction 13

in­for­mants’ accounts to inform my theory rather than the other way around. The themes that emerged pushed me ­toward theoretical orientations that emphasize the embodied, temporal, relational, and affective dimensions of the lived experience. As the title of this book suggests, this proj­ect explores the juxtaposition of “new” and “old” in Chinese elder care institutions and the ways the tension between old and new ideas, desires, and understandings shapes the experience of caring and being cared for. Furthermore, it examines how changes within elder care institutions reflect, respond, and contribute to broader changes in the social fabric. ­Because t­hese ele­ments are complexly interwoven, untangling them requires flexible, responsive theories. My observations in China’s “new” elder care homes and other medical institutions reveal the messy and uneven development of China’s nascent elder care industry, and supporting theories must account for the power of the unexpected and unintentional. Of special concern is the issue of bodies and embodiment. Aging and caregiving are intrinsically oriented ­toward the body. Throughout this book, I draw on Maurice Merleau-­Ponty’s phenomenological notion of the body as our way of being in and of the world, from which, in which, and through which we experience time, history, and change (1945/1962, 85). ­ Because bodies are embedded in larger social and cultural milieus, the treatment of bodies draws attention to moral issues and broader social concerns about f­amily formations, communities, and nations (L. Cohen 1998; Scheper-­Hughes and Lock 1987; Wilkinson and Kleinman 2016). In my analy­sis of aging Chinese bodies, I follow the lead of Susan Brownell (1995), who adapted Thomas Laqueur’s (1990) Western categories of physiology for the Chinese context. Brownell describes three key features of Chinese conceptions about the body. The first, the “cosmic hierarchical mode,” describes the way the body is seen as “intimately connected with the world around it” by the circulation of essences throughout the cosmos, and as sensitive to the balance of yin and yang energies (Brownell 1995, 241). The second concerns the “economy of fluids” that circulates within 14  Growing Old in a New China

­ uman bodies and places an emphasis on regulating internal balh ances. The third feature is the “one-­sex model,” in which “both sexes w ­ ere believed to share the same essential physiology” (ibid., 242). Throughout this book, I explore how ­these embodied understandings of harmony, balance, and complementarity permeate all levels of experience. To understand the broader context within which ­these embodied experiences of aging and caregiving are occurring, I draw on theories of power and subjectivity. New forms of institutional care bring to the fore issues of state control over bodies and populations. Most theories that address ­these forms of “biopower” employ Foucault’s notion of “biopolitics,” which includes both biopo­liti­cal aspects (such as the state’s power to provide—or not provide—­ welfare ser­vices and officially mandated caregiving practices) and anatamopo­liti­cal aspects (which include the creation of modern subjects who act in accordance with t­ hose ser­vices and policies by seeking out certain forms of care, providing care, or engaging in self-­regulating be­hav­iors) (Foucault 1976/1990, 141, 142). However, rather than taking a Foucauldian stance, I take the position that although many of ­these biopo­liti­cal proj­ects begin with clear, specific objectives, the final outcome is rarely what was originally intended (Ferguson 1994; Greenhalgh 2008; Scott 1998). This I attribute to the fact that many modern subjects do not ultimately “do as they ­ought” (Redfield 2005, 65). Instead, seeds of change germinate at the juncture between the intention and unexpected consequences of both individual and social proj­ects. To dig deeper into the ­human significance of ­these changes, I seek to uncover the ways in which old age m ­ atters to old p ­ eople. I draw on the concept of “emergent subjectivities” to understand changing perceptions, expectations, and desires and to describe elders’ evolving relationships with themselves, o­ thers, and larger historical and social pro­cesses (Inhorn 2012, 34). I also highlight the emotional, physical, and social suffering experienced by many elders t­ oday. In line with recent work by Ian Wilkinson and Arthur Kleinman, I approach this suffering as an ele­ment that flows within larger social and cultural pro­cesses of change (Wilkinson and Introduction 15

Kleinman 2016). By bearing witness to the suffering, I hope to emphasize the moral and ethical significance of care and care practices in society t­ oday.

Methodology The data for this book w ­ ere collected during thirteen months of fieldwork in Kunming between 2013 and 2015. Kunming, with a population of 6.7 million, is the capital of Yunnan Province in southwest China. Bordering on Vietnam, Laos, Myanmar, and Tibet, Yunnan is known for its scenic landscape; temperate climate; and rich natu­ral resources, including tea, tobacco, and rubber (Harrell 2001). Officially home to twenty-­five of China’s fifty-­five minority nationalities, Yunnan is also one of ­those most ethnically diverse provinces in China. Despite its distance from the po­liti­cal and ­economic centers of the country, Yunnan’s weather and landscape make it a top tourist and elder care destination. This research proj­ect began during a preliminary visit to the region in 2011, when I contacted local elder care researchers and providers and received written permission to conduct research in a palliative care ward and elder care fa­cil­i­ty. Yale University’s institutional review board approved the research, and a local hospital director supervised the proj­ect. Prior experience as a paid caregiver for developmentally disabled adults in the United States had prepared me for the rhythms of institutional caregiving. In total, I conducted seventy-­t wo recorded interviews and surveys in Mandarin with ­family members, elders, and caregivers from a wide range of social and economic backgrounds. ­A fter a de­cade of formal language training and a prior year-­long research proj­ect on sports in Beijing, I was able to communicate comfortably in standard Mandarin. While it took several months before I picked up the local dialect, most of my in­for­mants ­were able to speak standard Mandarin. For three early interviews with staff members who spoke only the local dialect, a local research assistant joined the interviews to help translate. However, the remaining interviews ­were conducted one-­on-­one. 16  Growing Old in a New China

In addition to assisting with early interviews, my research assistant helped transcribe interviews into Chinese characters and translate written materials, which ­were reviewed and revised by me and a local doctor. While the transcriptions ­were helpful guides in reviewing interviews, direct quotes are drawn from audio recordings, with transcriptions used for support and clarification. Pseudonyms ­were assigned to participants and institutions. During the first phase of the research, from October  2013 through May  2014, I collected data primarily in hospital-­based geriatric and palliative care wards. I lived on-­site at a busy city-­ level hospital and spent nearly ­every day in the palliative care unit. ­Because most patients in this unit w ­ ere too ill to be interviewed, data ­were derived primarily from observations and interviews with caregiving staff. Twenty staff members ­were interviewed at this hospital. Of ­those, eigh­teen ­were female, and nineteen ­were originally from Yunnan. Their average age was 36.7 years. Observations ­were collected while shadowing doctors and nurses on rounds, during staff meetings, and at palliative care conferences in Shanghai and Beijing. In the second phase of research, from May through November  2014, I continued to visit the palliative care ward regularly, but I shifted my data collection efforts from hospitals to elder care facilities. Before I began my fieldwork, I had secured written permission to conduct research in what was considered to be a model public elder care institution, but bureaucratic complications compromised this access early in the proj­ect. However, through the connections of hospital contacts, I gained access to a number of local elder care facilities that ­were, according to my in­for­mants, more au­then­tic than my original field site. My primary institutional site, Jade Hills Elder Care Home, was a private institution that had about three hundred beds and that usually operated at full capacity. Compared to other institutions in Kunming, it was average in terms of cost, size, and the level of care provided. Jade Hills charged a flat fee of about $350 per month—­comparable to the average monthly pension in the city at the time. In terms of care needs, the residents ranged from Introduction 17

being completely in­de­pen­dent to requiring twenty-­four-­hour assistance. Jade Hills was older and shabbier than other institutions I visited, and it attracted a larger proportion of high-­need residents ­because of the lower flat fee. During the day, Jade Hills was staffed with a single doctor, and it was not equipped to provide any m ­ ental health ser­v ices. Care workers, who w ­ ere typically middle-­aged female mi­grants from surrounding villages, lived on-­site and provided the bulk of care. I documented sixty visits to Jade Hills during the second phase of my research, averaging three per week. I supplemented ­these visits with visits to other elder care facilities in the region—­ high-­and low-­end, public and private, and urban and rural—­for a total of over seventy-­five visits to eight dif­fer­ent facilities.7 I visited on both weekends and weekdays during visiting hours, which ­were usually 8:00 a.m. to 8:00 p.m., arriving a­ fter or leaving before the after­noon rest period. I was allowed to come and go freely and interact with residents in­de­pen­dently. Like the first phase of my research, this phase relied heavi­ly on participant observation and open-­ended interviews. I conducted formal one-­on-­one interviews with fifteen el­derly men and eigh­teen el­derly w ­ omen. Interviews ­were recorded with permission. The average age of the institutionalized elders was seventy-­four years, and all in­for­mants had at least one child. I used a set of verbal questions to determine ­mental capacity, and I read aloud informed consent information for participants who ­were illiterate. While ­these recorded interviews are the sources of all direct quotes in this book, an estimated 250 hours of participant observation in elder care facilities provided the foundational data in the research. Many Chinese elders are wary of signing documents, and some of my closest in­for­mants would not or could not participate in a formal interview. However, through my participant observation they w ­ ere still able to contribute to my understanding of the everyday experience of elder care. On an average day I interacted with ten to fifteen residents and staff members. We occasionally shared snacks, played mahjong, gossiped, or sang songs, but most days we sat quietly and watched the shadows stretch. I took notes in a small 18  Growing Old in a New China

notebook during t­hese interactions, which ­were typed up as field notes at the end of each day, stored on a password-­protected computer, and transcribed and coded using Dedoose software. Additionally, I returned to Kunming in September 2015 for a final phase of the research. During this brief visit, I recorded a second set of interviews with key in­for­mants, including Zhang Wei, Ma Meili, and Wang Hua, who appear frequently throughout this book. I asked them to elaborate on some of the themes that had emerged during data analy­sis and compared t­hese conversations to my initial findings.

Structure of the Book Chapter 1 begins with an analy­sis of China’s emerging elder care situation through the lens of the parent-­child relationship. Confucian f­ amily ethics have s­ haped the collective consciousness and social structures in China for millennia. In terms of elder care, the concept of xiao (孝)—­fi lial piety or filial reverence—is invoked as the defining moral ele­ment of the parent-­child relationship. In this chapter, I demonstrate the strong tendency within the existing lit­er­a­ture to focus on the child’s perspective, often overlooking parents’ continuing contributions and active roles as morally creative agents. In an attempt to recapture the parental perspective, I look at filial piety as part of a larger system of ­family ethics based on balance and harmony. I suggest that although filial piety is a key moral ele­ ment, the concepts of kindness, love, and benevolence are equally impor­tant for understanding ­today’s elder care transitions in relation to China’s family-­centric ethical foundation. In chapter  2, I examine ­today’s elder care transitions within their larger historical contexts. Keeping the focus on the elders and their personal histories, I show how old age and elder care are being experienced ­today—in the living pre­sent—in completely new ways. Using notions of embodiment, I trace the complex ways in which historical events in China over the past c­ entury ­were experienced by dif­fer­ent generations, and through specific stories, I show how t­ hese pro­cesses continue to shape present-­day Introduction 19

aging and caregiving experiences. I look at how past and ­future challenges have created cohorts of moral pioneers who must navigate an unfamiliar elder care landscape, explore new forms of se­nior subjectivity, and reimagine ways of growing old in China. Chapter 3 takes a deeper look at this emerging elder care landscape through an analy­sis of the tension between place and space, the i­magined and lived, and the concrete and abstract. Through detailed descriptions of elder care facilities, I demonstrate the wide variety of forms ­these institutions take and the complex dynamics of place making. I also explore how t­ hese newly formed places attract diverse groups of p ­ eople with individual understandings of the nursing home as place. I use notions of rhythm and routine to examine the biological, natu­ral, and social temporalities that shape the institution as both space and place, and I look at how residents and caregivers understand, contest, resist, create, and define multiple spaces through direct experiences. In chapters 4 and 5, I explore the entanglements of care in China. By analyzing definitions of and expectations for both family-­based and institutional care in China, I ask who should care, in what way, and why? Through examples of everyday care practices, I show how multiple dimensions of care operate in homes, communities, and elder care institutions. While chapter  4 examines informal and unpaid care, chapter 5 focuses on how care operates and circulates in institutions in the form of paid care. Treating care as a form of “attentional energy” within ­these institutions, I look at how caregivers and residents attempt to allocate, circulate, economize, and stimulate this “potentially scarce social resource” (Buch 2015, 279). Chapter 6 examines the darker side of institutional care and the ways end-­of-­life interventions complicate both living and ­dying for ­today’s institutionalized elders. I demonstrate how the intersection of medical technologies, demographic shifts, and caregiving shifts turns ­dying into a diagnosis, complicated by insurance regulations, local bioethics, and ­limited resources. For ­those cut off from both curative and palliative care, life itself becomes pathological, and many find themselves in prolonged states of chronic living and delayed death. 20  Growing Old in a New China

1 Filial ­Children, Benevolent Parents Profound was King Wen. With how bright and unceasing reverence did he regard his resting places! As a sovereign, he rested in benevolence. As a minister, he rested in reverence. As a son, he rested in filial piety. As a ­father, he rested in kindness. —­James Legge (Trans.), G ­ reat Learning

At Jade Hills, an elder care home I visited several days a week for nearly seven months, staff members typically greeted me with a shake of the head or a sigh and a scolding: “­You’re ­here again.” I seemed to always arrive too early or too late, on a day that was too hot, cold, windy, rainy, or sunny. A well-­connected local doctor had introduced me to the home’s director, Lu Wei, who seemed pleased by the prospect of f­uture reciprocated ­favors. However, the overworked staff members strug­gled to understand why I kept showing up to just “hang out,” as they put it. During an early attempt to explain the purpose of my research, I invited Director Lu to review my interview schedule. Frowning and shaking his head, he pointed out a number of what he called “meaningless” questions, such as ­those about marriage (“every­one is married!”) or urban migration (“not in­ter­est­ing!”). I was surprised, however, when he dismissed the ­whole section on filial piety. He estimated that only three out of ten p ­ eople would have any idea what filial piety was. I told him that I had not yet encountered that prob­lem,

21

and he replied that I must have been talking to old p ­ eople. While he did have a point, I also interviewed dozens of younger p ­ eople and found that middle-­aged ­people w ­ ere actually more interested in the topic of filial piety than elders w ­ ere. Zhang Li, a thirty-­ one-­year-­old female doctor, said: “Is t­ here anything more impor­ tant than filial piety? As I see it, filial piety includes many, many ­things. I should say many ­things are contained in it, so it is relatively complete. Nothing is more impor­tant than it.” The contradiction between the opinions of the director and the physician, both of whom worked in elder care institutions, highlighted an issue that nagged at me throughout this research. When I set out to study China’s “new” elder care homes, my theoretical orientation was similar to Dr.  Zhang’s. Knowing that proper ­family relationships, which include younger generations’ care of their elders, formed the bedrock of Chinese ethics and traditional practice, it seemed to me that the recent phenomenon of middle-­class elders living in elder care homes rather than with their healthy, adult ­children was in conflict with core values. Although I could understand the social, demographic, and economic ­factors driving ­these new elder care arrangements, the question remained: what are the moral implications for individuals, families, and society? According to Yan Yunxiang, an eminent China anthropologist, “the most significant change with re­spect to el­derly support, in my opinion, is the disintegration and ultimate collapse of the notion of filial piety” (2003, 289). In his analy­sis, he systematically showed how de­cades of socialist revolutions undermined filial piety’s institutional support in the mid-­t wentieth ­century and led to the “demystification of parenthood and filial piety” (ibid., 189). He pointed to marketization and individualization as the ultimate culprits in the destruction of filial piety. Yet despite the accuracy of Yan’s observations and the sound logic of his argument, filial piety stubbornly persists in very real ways at the social level. It is the foundation of new policies, including the Law on Protection of the Rights and Interests of the El­derly (Shum et al. 2015), and makes an appearance in e­ very academic and popu­lar 22  Growing Old in a New China

conversation about elder care. Of course, one does not have to practice a tradition to make use of it. The early Chinese social scientist Fei Xiaotong, writing in the 1940s, observed that ­people tend to “justify social change by reinterpreting the old authorities,” which eventually leads to “a widening separation between the names of phenomena and their real­ity.” He goes on to assert that as long as ­people “pay lip ser­v ice to the form, they may reinterpret and thereby change the content” (X. Fei 1948/1992, 89). In agreement with Fei’s account, recent empirical research suggests that filial piety has survived social upheavals, but not without considerable effort from both ­children and parents to negotiate, interpret, and reimagine filial expectations and practices (D. Wang 2004; Whyte 2004; Zhan, Feng, and Luo 2008). However, most of ­these studies have focused on younger adults or in­de­pen­dent elders. For example, one study, which analyzed survey results from 19,415 adults over sixty—95 ­percent of whom did not require instrumental support from their ­children—­found that only 1.5 ­percent considered their ­children unfilial (Mao and Chi 2011). In Shanghai, Jeanne Shea and Yan Zhang found that even elders who did require care but ­weren’t receiving it from their own ­children felt not that their ­children ­were unfilial but that they w ­ ere understandably “busy with their own lives” (2016, 375). Heying Jenny Zhan, who has spent several years collecting qualitative data in urban elder care institutions, has also reported high levels of el­derly satisfaction regarding adult ­children’s filiality (Zhan, Liu, and Guan 2006; Zhan, Feng, and Luo 2008). Similarly, in my research, all the elders I interviewed had adult ­children yet received paid caregiving ser­v ices, ­whether at home or in an elder care institution. Some situations, from an outsider’s perspective, bordered on abandonment: a c­ ouple of elders reported seeing ­family members less than once a year. Nonetheless, while elders described varying levels of closeness with their f­amily members, of the thirty-­three who completed formal interviews, only one claimed that a child was unfilial. On one level, ­these unexpectedly positive reports prob­ably stem from a disinclination to acknowledge or share feelings of Filial ­Children, Benevolent Parents  23

dissatisfaction and disappointment about one’s own ­ family members with an outsider. For example, in a qualitative survey of 265  elders and 114 ­family members, Zhan and colleagues found that 49 ­percent of el­derly respondents claimed to have initiated the move to an institution themselves, while only 28 ­percent of relatives reported that the elders actually wanted to make that move (Zhan, Liu, and Guan 2006). The authors question ­whether this discrepancy is the result of ­children’s guilt or parents’ retroactive face-­saving responses to unfilial be­hav­ior. It is impossible to know with certainty the thoughts and feelings of other ­people, which they may conceal even from themselves. However, throughout my fieldwork, I was surprised to find very l­ittle verbalized discontent about c­ hildren. Although institutionalized elders frequently reported missing their families and wishing they could spend more time with them, they did not articulate ­these desires in terms of filiality, nor did they demonstrate the “strong entitlement to support” that Yan observed among rural el­derly (2003, 178). Based on the lit­er­a­ture I read before conducting my fieldwork, the experience of el­derly institutionalization should be saturated with concerns about the breakdown of filial piety. However, according to my observations of and conversations with elders, this did not seem to be the case. How and why do ­these elders still view, or profess to view, their ­children as filial? Furthermore, considering that elders ultimately have the most at stake if filiality lapses, why do they seem less concerned about it than younger generations and social scientists are? And if elders do not see an association between filiality and institutionalization, then what moral dimension is involved in their experiences of major elder care transitions? Fi­nally, how might ­these questions make sense of the contradiction between Director Lu’s assertion that filiality is no longer understood and Dr. Zhang’s belief that that nothing supersedes it? In this chapter, I attempt to answer ­those questions by first describing the foundations of Confucian f­amily ethics and how they have s­ haped collective consciousness and social structures in China for millennia. I then review existing perspectives on filial piety, both historical and modern, to demonstrate that although 24  Growing Old in a New China

the lit­er­a­ture is theoretically rich, discussions of filial piety tend to focus on the child’s role in the parent-­child relationship. Scholars have explored the creative, flexible, agentive aspects of filiality, but often in the context of static, constraining structures of parental expectation and traditional obligations. The result has been an overlooking of parents’ continuing contributions and their active roles as morally creative agents. With this in mind, in the second half of the chapter, I zoom out and look at filial piety as one part of a larger system of ethics centered on balance and harmony. Examining the roles of obligation, expectation, and reciprocity, I shift the lens to focus on intergenerational exchange from the parents’ perspectives. Rather than looking at duties and obligations, I emphasize the role of parental expectations, contributions, and understandings, especially as related to considerations of balanced reciprocity. I argue that for elders, the concepts of kindness, love, and benevolence might provide a more complete picture of the intergenerational relationship in practice. Fi­nally, I demonstrate how a focus on younger generations’ moral shortcomings tends to overshadow elders’ individual experiences with aging and institutionalization and distract from the broader social pro­cesses involved in their physical, financial, or emotional strug­gles.

Filial Piety In the introduction to their edited volume on the topic of filial piety, or xiao (孝), Alan Chan and Sor-­hoon Tan argue that “it would not be an exaggeration to say that the concern with xiao pervades all aspects of Chinese culture, both past and pre­sent” (2004, 1). While this is no doubt true, I have found that using “filial piety” as shorthand for the value system it represents prevents many En­glish speakers from truly understanding the moral and affective significance of the term—­especially the deeper way it operates in the Chinese psyche. When I talked with my dad about this topic, he asked how filial piety in China was any dif­ fer­ent from what he witnessed growing up on a farm in rural Filial ­Children, Benevolent Parents  25

Minnesota. He could recall many families, including his, living in multigenerational ­house­holds and caring for their elders at home. In the United States, too, only the most destitute elders spend their final years in welfare homes, and ­factors like economic necessity, geographic mobility, and concern and affection for one’s blood relatives drive many caregiving decisions. However, the way filial piety shapes Chinese ethics and, by extension, all realms of individual and social life, is much more apparent and articulated than in Western cultures. B ­ ecause of this uniqueness, following other scholars, I ­will use the transliteration xiao throughout this chapter rather than an En­glish translation (X. Feng 2008a). In the Analects, an anthology of Confucius’ words collected by his disciples shortly ­after his death in 479 bce, xiao is described as the “root of all benevolent actions” (Legge 1861, 2). This centrality is “one of the most distinctive characteristics of Confucian ethics” and extends into all areas of life (Wong 2008). In fact, re­spect for elders is a defining characteristic not just of China, but of East Asia in general. In Filial Piety (2004a), Charlotte Ikels and contributors provide a comprehensive analy­sis of the historical and cultural context of this virtue. In the introduction (2004b), Ikels describes the structure of the character for xiao, which is the symbol for “old” above the symbol for “child” or “son.” As with many Chinese characters, this ideogram is at once obvious and ambiguous. From one perspective, the child below supports and holds up the old. Looked at another way, the old’s position above the young reflects generational hierarchy or lineage. Alternatively, the old and young are depicted in xiao as bound, interconnected and interdependent. In line with ­these multiple interpretations, most studies of xiao emphasize the variety of forms it can take as a practice, belief system, historical ideal, form of reciprocity, and more (W. Li, Hodgetts, Ho, and Stolte 2010). In the introduction to his translation of a foundational Confucian text, the Classic of Filial Piety, Feng Xin-­ ming (2008a) describes xiao not as simply a guide for individual be­hav­ior but as the blueprint for the entire social order. He explains that the virtue, in its classical sense, is the very foundation of civil society 26  Growing Old in a New China

and takes the place often reserved for religious mandates in other cultures (X. Feng 2008a). As Zhang Wei, an elder care home resident in his late eighties, explained to me: “You Americans say that God gives life. We say that parents give life. We must show them due gratitude.” Xiao’s ubiquitous influence is also evident in the fact that few of my respondents could pinpoint how, when, or where they learned about it. “It has been passed down from ancient times,” one twenty-­four-­year-­old nurse explained. “Every­one knows it from the time they are young.” Another female respondent, a twenty-­ nine-­year-­old Buddhist palliative care doctor, explained it this way: “I feel that xiao is not something that exists in ‘knowing’; it is one of China’s traditions. You see how past generations did it, and you know you should do it, and you know how you should do it. Just like: ‘what one generation does, the next generation sees.’ ” While respondents ­were not able to recall their personal introduction to the concept, most historical evidence dates the emergence of xiao to the Western Zhou period (1045–771 bce). By the Han period (206–220 bce), it had become a focus of intellectual and po­liti­cal elites (Chan and Tan 2004). Along with other core concepts of Confucian ethics, including ren (仁), compassion or benevolence, and li (礼), ritual or etiquette, xiao emphasizes one’s moral interdependence with o­ thers, contributing to Confucianism’s categorization as a relational rather than individualistic ethical system (Wong 2008). While the earliest understandings of filial piety are attributed to Confucian classics such as the Classic of Filial Piety, the ­Great Learning, and the Analects, the concept has also had an impact on Chinese Buddhism and Daoism (Chan and Tan 2004). However, the far-­reaching influence of ­these Confucian classics, and the virtues they expound, is largely due to the fact that for centuries—­ until the early 1900s—­ a ll male children with educational aspirations had to memorize them ­ (Eno 2016). But xiao is not simply an ideology or intellectual exercise; it is the paragon of ethics, the core of selfhood. According to the Classic of Filial Piety, xiao begins in self-­care in the most bodily Filial ­Children, Benevolent Parents  27

sense and ends in establishing oneself in the Way and honoring parents by passing one’s name to posterity. ­Because of the natu­ral love between parents and ­children, “the teaching is not stern and yet it is successful” (X. Feng 2008b, 11). The teachings include provisions for bodily health, conflict management, ­family life, sickness and death, and mourning and sacrifices. However, they emphasize attitude over actions. As stated in the Analects, “it is the expression on the face that is difficult. That the young should shoulder the hardest chores or that the eldest are served food and wine first at meals—­whenever was that what filiality meant?” (Eno 2015, 36). ­These Confucian classics, geared ­toward scholars and other members of the intellectual classes, also inspired more popu­lar images of be­hav­ior, such as t­hose found in The 24 Filial Exemplars (Jordan 1986). Research participants in my study ­frequently referred to this short, twelfth-­century text, which describes extreme examples of conducted characterized by xiao. Since I am a native Minnesotan, I find the story of Wu Meng particularly exemplary: “When Wu Meng of the Jin dynasty was eight years old, he was very filial t­owards his parents. The ­family was poor, and the bed had no mosquito net. ­Every night in summer mosquitoes in droves nibbled at their skin and sucked their blood without restraint. Although ­there ­were many, Meng did not drive them away, lest in leaving him they bite his parents. So ­great was his love of his parents!” (ibid., 90).

Filial Piety and Power Social scientists have long posited that the ­family, as the primary locus of socialization, plants the seeds of collective consciousness in individuals that both reflect and establish the social and moral order (Durkheim 1893/1960). However, long before social scientists began theorizing, this inextricable individual-­family-­society relationship was explic­itly stated and cultivated in Confucian classics, primarily through the virtues of xiao, ren, and li. As a directive to ­f uture leaders, the ­Great Learning, states: “Wishing to order well their states, they first regulated their families. Wishing 28  Growing Old in a New China

to regulate their families, they first cultivated their persons” (Legge 1861, 221). This ordering follows the dictates of four relationships: father-­son, husband-­w ife, mother-­in-­law–­daughter-­in-­ law, and brother-­brother. While morality governed by xiao may have provided stability and order, scholars—­especially feminists—­observed that it also institutionalized hierarchical relationships and social inequalities, such as t­ hose of the patriarchal ­family and the imperial state (Ebrey 2004; Sangren 2017). Since Confucian ideology explicated the value of authority within and beyond the ­house­hold, it served state interests to promote a belief system that valorized obedience among subordinates (Sangren 2017, 227). Although some aspects of xiao have been at odds with ruling interests throughout history, particularly during Maoist revolutions, they could still be used to promote devotion, selflessness, and responsibility in cadres, contributing to the enduring influence of xiao (Davis 1991; Ebrey 2004) Ultimately, the justification for institutionalized hierarchies is the fact that they are based on the original relationship—­the parent-­child dyad—­which is inherently unequal (Ivanhoe 2004). In his most recent work, Filial Obsessions, Steven Sangren explores this in­equality as it operates in the father-­son relationship, viewing it as “an instituted fantasy in which subjectivity is defined as the self-­producing action of the filial son” (2017, 294). The father-­ son dyad is of par­tic­u­lar interest ­because, traditionally, Chinese family structures ­ ­ were patriarchal, patrilineal, and patrilocal, meaning authority, inheritance, and place of residence followed the male line (Parish and Whyte 1978). In Sangren’s analy­sis, the father-­ son relationship is marked by an “antinomy” between patriarchal authority and the “ego ideal” that is at the core of filial piety in the Chinese context (ibid., 135). This antinomy creates tension between the authoritative power of the f­ather and the desires of the son. Ethnographic examples describe cases in which conflicts arose between elders’ “wishes to retain their authority and to refuse to hand it over” and “descendants desires to acquire the authority possessed by their parents” (ibid., 151). Deborah Davis (1991) notes that before the collectivization of agriculture Filial ­Children, Benevolent Parents  29

­ nder Mao Zedong, older generations, especially in rural areas, u could maintain control over their younger generations ­until death. While this was not the typical situation, rural elders could choose to assert their authority by delaying transfers of property or capital. Urban parents with strong po­liti­cal or professional networks could also use their connections to exert control over their c­ hildren throughout their lives. However, Sangren ultimately trou­bles this notion of absolute parental power. ­Because the princi­ples of filial piety extend beyond the grave, all men are always already sons and ultimately draw their power from this original identity. Following Angela Zito (1997), Sangren explains: “The agents of ritual constitute themselves as patriarchs by representing themselves as sons. In other words, among ‘filial action’s’ most remarkable effects is that, by representing themselves as filial sons subordinate to transcendent powers/ father figures, sons both legitimize and exercise their own social authority.” In this analy­sis, which prioritizes both the son’s position and his perspective, the f­ather is treated as “an imaginary, transcendental projection” (2017, 226). While Sangren’s analy­sis provides a fresh take on this power dynamic, his son-­ centric focus eclipses the lived experience of ­fathers as ­fathers and the real­ity of parental life that extends beyond the imaginaries of their c­ hildren. This is not to criticize his proj­ect, but to highlight a lacuna in the lit­er­a­ture on Chinese parent-­child ethics. In part, the tendency t­oward child-­oriented approaches is due to the fact that even within the Confucian classics, the parental perspective is nearly absent. As one scholar noted: If we consult the Analects and the Mencius, the central question with re­spect to intimate relationships is how to express love and re­spect for one’s parents. In contrast to the almost complete silence with re­spect to parents’ obligations ­toward ­children, the constant demand for filial piety seems almost bizarre. . . . ​Some Confucianists contend that the reason for such a dearth of discussion of parental obligation might be that the care that parents express ­toward their own ­children flows so 30  Growing Old in a New China

effortlessly and naturally that it does not deserve a separate discussion; on the other hand, according to this line of reasoning, since ­children obviously have a harder time expressing care and love for their parents, filial piety needs to be emphasized. (Herr 2003, 481)

In line with Sangren’s reasoning, the historical emphasis on c­ hildren’s obligations in parent-­child relationships could also be explained by the fact that, of all family-­based virtues, xiao may be the most universal: ­every person was once a child, but not all become parents. But once again, this does ­little to acknowledge the real existence of parental morality and the fact that ­every child is only a child in relation to a parent. Therefore, I propose that rather than trying to stretch or invert filial piety to accommodate the moral experiences of elders, it may be more productive to widen the lens and approach the parent-­child relationship, and xiao itself, in terms of harmony, balance, and unity.

Reciprocity and Obligation Although xiao is often described as a root, according to the Confucian Doctrine of the Mean, equilibrium is the “­great root from which grow all the ­human actings in the world,” and “harmony is the universal path which they all should pursue” (Legge 1861, 248). This concern with balance and harmony permeates all aspects of Chinese cosmology, shaping understandings of health and illness, natu­ral events, and ­human relationships. In his study of residents in the Chinese village of Xiajia, Yan described how the basic Chinese concept of reciprocity, or bao (报), was reflected in four general rules of gift giving. The first rule is that a good person practices reciprocal relationships; the second is that one should make gifts properly, according to social and kin hierarchies; the third is that gifts should be given based on situational considerations; and the fourth is that counter-­gifts (that is, reciprocal gifts) should be dif­fer­ent, delayed, and slightly greater than the original gift (Y. Yan 1996, 125). Filial ­Children, Benevolent Parents  31

Social and kin hierarchies are based on the five relationships of “universal obligation” described in the Doctrine of the Mean: ­those between sovereigns and ministers, ­fathers and sons, husbands and wives, ­brothers, and friends (Legge 1861, 273). Though ancient in origin, t­hese reciprocal relationships continue to have ­great significance for con­temporary Chinese society. For example, Andrew Kipnis observed that among nonrelatives, networks of reciprocal exchange, or guanxi (关系), determine one’s identity. When the villa­gers in his research “re-­create their networks of relationships, they also re-­create themselves” (Kipnis 1997, 8). Similarly, Davis described Chinese personal relationships as “saturated with the obligation to reciprocate” (1991, 10). ­Because of the high value placed on maintaining balanced networks, the breach of reciprocal rules could result in the loss of face, which has both social (mianzi, 面子) and moral (lian, 脸) repercussions (Y. Yan 1996, 137). While the rules of reciprocity ­were intended to strengthen relationships, they also cause some p ­ eople “to curtail meaningful social contracts for fear that participation in joint activity w ­ ill eventually impose obligations that they are unable or unwilling to pay” (Davis 1991, 10). But no person, however isolated, can completely avoid obligation; each person is born with original debt. Sangren describes the debt that accompanies the parental gift of life as “intrinsically fraught with ambivalence.” ­Because it can never be fully reciprocated, it creates a bond that is unbreakable yet inescapable (Sangren 2017, 263 and 229). However, in Yan’s analy­sis of the gift, he noted that the greatest f­avors, or enqing (恩情)—­those that could not possibly be repaid—­were not expected to leave one with a lifetime of anxious obligation. Instead, they w ­ ere intended to cultivate gratitude (Y. Yan 1996, 144). The gift of life is one such example of enqing, and the weight of this original gift is such that even when ­children give gifts to their parents, the “recipient always remains superior to the giver” (ibid., 63). Placed in the context of the larger pursuit of harmony, this original imbalance creates a tension that generates moral activity associated with xiao. It is ­here that many analyses about parental 32  Growing Old in a New China

contributions begin and end. Though they may acknowledge lifelong exchanges of child care or resources, most accounts place elders firmly on the receiving end of parent-­c hild exchanges: “Fundamental to ­these values is the assumption that through the gift of life and early nurturing, parents become eligible for a lifelong claim on their ­children’s resources. ­Children provide for el­derly parents, and parents turn to adult ­children without guilt, ­because both generations believe that the creation of the ­children’s physical existence and the care given them in childhood require ­children to reciprocate in their parents’ old age” (Davis 1991, 53). However, all of the elders in my study had provided their ­children’s life and early nurturing, but not one expressed a feeling of entitlement ­toward their ­children’s resources. In contrast, even ­t hose residing alone or in elder care homes expressed concerns about burdening their c­ hildren and guilt over feelings of neediness. In ­t hese situations, the original gift—­l ife and early nurturing—­ had not changed, and yet the end-­of-­life counter-­gift had. Nonetheless, they maintained that their ­children ­were filial. Obligation and indebtedness, as expressions of imbalance in a harmony-­ oriented ethical system, explain the original energetic drive of filial reciprocity. However, they fail to account for its endurance in the face of ­these changes. My argument is that it is not in spite of, but ­because of, the ongoing moral activity of parents that xiao endures even in ­these situations. As stated above, xiao is not an end in and of itself but a root. Out of experiences of dependence, duty, and obligation grows benevolence. In the transition from child to parent, filial piety matures into generous kindness. The words of one twenty-­nine-­year-­old doctor, who had recently become a ­mother, reflect this development: I ­don’t expect my son to take care of me or anything. I think I ­w ill just go to an elder care home. I d ­ on’t want to add to his burden, but in terms of taking care of my own parents, I definitely would still take care of them. ­Because since I’ve gotten married I’ve thought about it—as soon as my parents get old, I want to bring them ­here and take care of them. I feel our Filial ­Children, Benevolent Parents  33

generation and the generation below us are not the same. We ­won’t expect as much from the younger generation. ­Because parents—in China it is this way—­don’t demand reciprocation from their ­children. Every­one is like this. I think ­people like me all think this way. My child is my absolute duty and commitment. I take care of him, provide for his education, raise him to maturity, including ­later buying him a h ­ ouse, ­etc. In China it seems like every­one is like this, every­one feels this is my personal responsibility, it d ­ oesn’t seem like anyone expects their ­children w ­ ill pay them back. Every­one is like this, including myself right now. I also think this way—­I d ­ on’t count on my child’s reciprocation. I just hope he grows up healthy and happy, and that’s enough.

This complementary moral virtue of parental kindness, both the source and fruit of xiao, works in tandem with it to maintain the harmony of the parent-­child relationship, yet it is often unarticulated in discussions of elder care. In the following sections of this chapter, I attempt to add to understandings of emerging elder care formations by privileging the parental perspective. I pre­sent benevolence as a decisive moral ele­ment in the parent-­child relationship. I see this relationship not as based on obligation or duty, but as a mutual striving for balance and harmony in the face of life’s ceaseless changes.

Exchange and Balance The elders in my study reported that, for the most part, their ­children are now living lives that are significantly better than their own had been in terms of material comforts. Nonetheless, many of the elders felt that their aging and caregiving needs w ­ ere a burden on their c­ hildren. Part of this perception can be traced to larger historical pro­ cesses that have severed the traditional routes ­Chinese parents used to participate in lifelong intergenerational exchanges with their ­children. For example, Zhang Wei, a resident in his late eighties, had been imprisoned as an anti-­rightist 34  Growing Old in a New China

when his c­ hildren ­were young, and they w ­ ere ­later relocated to the countryside as sent-­down youth. Th ­ ese events compromised his ability to provide for his ­children in their youth, and as a result, he did not feel entitled to their resources in his old age. During one of our conversations, Grandpa Zhang reminisced about his childhood more than eighty years e­ arlier, when he lived in an extended f­amily with cousins and grandparents—­ w ith every­one taking care of each other. ­Things had changed, though, and now he wanted to “liberate his ­children.” He told the story of how he ended up in the elder care home: he had lived with his ­daughter, who had been a sent-­down youth. Occasionally ­those who had been sent down to the same village would have a reunion. For the days she was away for the reunion, she would arrange for a restaurant near their apartment to deliver three meals a day for him. However, one time she and her husband ­were ­going to be away for two weeks. They ­ were discussing what to do, and although they ­ didn’t bring up their concerns with Grandpa Zhang, he overheard the conversation. He came to them and said that he thought it would be a good idea if they looked for an elder care home for him. They objected, but he insisted. Now they are retired themselves and have grandchildren. They come to visit him ­every Sunday for an hour or less. He wishes they would stay longer—­the ­whole day—­but he “­doesn’t dare” ask them to. He just “puts himself second” and knows that no m ­ atter how often they come or ­don’t come, families always keep old ­people in their hearts: “I have no complaints. I cannot complain about them.” Researchers note that parent-­ child power dynamics began shifting as early as the Maoist era as a result of attacks on the f­ amily and the abolition of private-­property, which weakened the ideological and economic foundations of intergenerational exchange (Newendorp 2017; Y. Yan 2003). More recently, market-­economy ethics have reframed notions of reciprocity in terms of the “rationally calculated princi­ple of balanced exchange,” but t­oday’s elders, who earned very low wages u ­ nder the socialist economy, have no way of participating in this type of exchange (Y. Yan 2003, 189). Furthermore, smaller living spaces, fewer grandchildren, and higher Filial ­Children, Benevolent Parents  35

incomes have discouraged intergenerational living, cutting off a key ave­nue for alternative forms of parental contribution. In par­tic­ u­lar, disabled and dependent parents have no way to continue engaging in intergenerational exchange except as recipients, which increases their feelings of guilt and indebtedness. While ­these oft-­cited ­factors help explain why many el­derly in­for­mants felt like a burden to society and their families, I would argue that material imbalances ­were not the primary driving force in their elder care decisions or experiences. For one ­thing, institutionalization often increased, rather than decreased, the financial burden on an elder’s f­ amily.1 For another, most elders accepted that their economic situations w ­ ere, for the most part, not of their making and beyond their control. Yet as the Analects emphasize, the parent-­child exchange should operate beyond the material level: “The filial piety of now-­a-­days means the support of one’s parents. But dogs and h ­ orses likewise are able to do something in the way of support; without reverence, what is ­there to distinguish the one support given from the other?” (Legge 1861, 12). Even when they could not participate effectively in material exchanges, parents still had considerable power over the dynamics of the affective parent-­ child exchange. It is on this more abstract level that one can better understand why el­ derly parents make the choice, despite their ­children’s objections, to move into an institution. Institutionalized elders frequently expressed with pride how ­little they demanded from their c­ hildren. “I d ­ on’t demand any sort of filial piety. . . . ​As for me, I’m just satisfied. Any requests I do make they satisfy. That’s enough for me,” reported one sixty-­ seven-­year-­old resident. Minimizing their needs and desires was one strategy that elders employed to respond to imbalances in the parent-­child relationship. Another strategy was to provide their ­children with intangible resources in place of material ones. For example, by choosing to move into an elder care home, Grandpa Zhang felt that he was giving his ­ daughter gifts she truly desired—­time, money, space, and freedom. He did what was in his power to maintain the harmony, or at least the perception of harmony, in the parent-­child relationship. 36  Growing Old in a New China

Based on Grandpa Zhang’s account, his choice to move into the elder care home had nothing to do with his ­daughter’s filiality and every­ thing to do with parental benevolence. Making the choice himself was a twofold act of generosity. In the first place, he could give her the ultimate gift of liberation. In the second place, ­because he firmly insisted on the move, her ac­cep­tance of his institutionalization did not threaten her filial piety but was instead a filial act of submission. Few elders ­were able to articulate the pro­cess and motivations b ­ ehind their institutionalization as clearly as Grandpa Zhang, but most demonstrated this type of understanding kindness in their attitudes ­toward their ­children. One example is Song Xin, a nurse from a small village on Yunnan’s western border. She had come to Kunming and worked tirelessly to transform a derelict hospital into a geriatric hospital known for its exceptional quality of care. Her ­daughter insisted she would take care of Song Xin in old age, but Song Xin had witnessed the burden of daily caregiving and knew her d ­ aughter did not understand the true magnitude of the responsibility. Although she was only in her fifties, she began making plans to establish an elder care home where she could spend her final years. How ­great was her love for her ­daughter!

Expectations and Understanding While the benevolent actions of the elders above play a major role in maintaining harmonious parent-­child relationships, one can also see how their benevolent orientation t­oward c­ hildren—­especially regarding expectations for filial be­hav­ior—­are shaping ­today’s elder care experiences, both inside and outside of institutions. Many respondents of all ages expressed expectations about intergenerational coresidence that agreed with ­those presented by this ­couple in their seventies who live separately from their two adult ­children: husband: As long as I can still take care of myself, I would not be willing to live with [my c­ hildren]. ­Because we older ­people—­our diet, our lifestyles, the t­ hings we eat— Filial ­Children, Benevolent Parents  37

wife: In the ­things we eat, in ­these daily habits, between the older generations and younger generations t­ here are—­there are differences. It is very difficult, very difficult to integrate harmoniously. husband: In addition, ­there is a generation gap between ways of thinking. wife: If you ­aren’t able to negotiate ­these differences, a­ fter some time, it’s very—­very easy for conflicts to arise. They are distressed, we are distressed. Is t­ here any need for this? As long as I can still move, I w ­ ill take care of myself. In contrast to the images of parents demanding obedience and expecting reciprocity, the accounts above suggest that parents of all ages tended to suppress their own needs as much as pos­si­ble. Most parents genuinely just want to see their c­ hildren happy. If a child’s pursuit of happiness made their parents happy, then ultimately this fulfilled the requirements of filial piety (Y. Yan 2011). A thirty-­six-­year-­old nurse said: “In fact, parents’ desires ­aren’t that their ­children give them so many ­things and that is filial piety. They just want most of all to see you safe and sound, living a happy life. If you are happy, that is good enough.” For many parents, seeing their ­children happy and fulfilled gives meaning to the past suffering they endured (Kleinman 2011). Parents are not simply changing their own expectations for filial actions. As Grandpa Zhang demonstrates, they are also encouraging their ­ children to be more understanding ­ toward themselves: “I have also talked [with my ­children] about this prob­lem. In the same way that you must transform the ­family members’ thinking, you also must not think, ‘How does this look? Does this look bad? Am I not filial to my elders?’ Young ­people should change this thinking. Older p ­ eople and younger ­people both. My c­ hildren ­aren’t just relying on the government for elder care ­because it is con­ve­nient, right? It is in order to collectively transform and provide for the needs of ­today’s elders: food, clothing, and housing—­these ­things. A solution to a difficult situation. It is not out of con­ve­nience.” 38  Growing Old in a New China

While ­these attitudes ­were common among the institutionalized elders I spoke with, not all Chinese parents want to liberate their c­ hildren from their filial duties. Many Chinese parents still have high expectations of care and obedience from their c­ hildren. Liu Ling, a well-­off forty-­five-­year-­old in­for­mant, who took care of her ­ father at home, complained bitterly about her el­ derly ­father’s lack of benevolent understanding. Liu lived with her el­derly ­father in a large ­house in the suburbs of Kunming. She had two b ­ rothers, but according to her, they ­were not filial at all. She recounted how once their f­ ather got sick and c­ ouldn’t take care of himself, and he asked his younger son to come and give him a bath. The younger son said absolutely not, he could not wash his f­ ather. The older son, a well-­off businessman, said that he would come over. He brought along one of his employees and sat in the living room, smoking and drinking tea, while the worker bathed his ­father. When the worker was finished, the son gave him RMB 50 ($8) and told him to leave. A fter this incident Liu’s parents de­ ­ cided that they could depend only on their d ­ aughter for elder care, as they had never considered any option besides ­family care. Since she took care of them, she got the ­house. This made her younger ­brother and his wife very angry, b ­ ecause they w ­ ere hoping to rent it out for profit. Despite gaining control over the massive ­house, Liu found taking care of her ­father extremely tiresome. He wanted her to be home with him all the time. He said it was not enough for him just to be clothed and fed, b ­ ecause he felt that she w ­ asn’t good to him. If she put on a nice outfit, he interrogated her about where she was ­going. If she said she was ­going out with friends, he closed his eyes and ­wouldn’t look at her. He was constantly calling her to find out where she was. She would lie and say she was g­ oing to meetings just so she could go hang out with friends. She felt that she could never travel or have any freedom ­because of her f­ather, and she would happily have given her b ­ rother the h ­ ouse if she thought that he would take good care of their dad.

Filial ­Children, Benevolent Parents  39

Burden of Love While some elders, like Grandpa Zhang, worry that their requests for time and affection are a burden on their ­children, ­others—​ especially ­those from younger generations—­worry that the overabundance of parental contributions in the form of kindness and love is inadvertently having a negative effect on t­oday’s c­ hildren. Steven Harrell has noted a frequent comment among urbanites that “China has moved from a society in which ­children are filial to their parents to one in which parents serve their ­children” (2001, 149). One thirty-­one-­year-­old palliative care doctor described her experience with her own parents in terms of this inverted parent-­ child relationship: “In fact, ­there i­sn’t too much I can do for them. The main t­ hing is to keep them com­pany. Then, if at the very least they have their ­children by their side, I feel they ­will, without a doubt, be very happy. Then, especially since I am the one who lives furthest away, whenever I am with them, they ­will think you—­ even though you have plenty of food and clothes, they ­will give you all kinds of ­things. Like my mom seems to think I c­ an’t [afford to] eat meat. When I go home, she makes me so much meat and has to buy me this and buy me that.” Coming from the other side of the parent-­child relationship, another physician in her forties described her strug­gle with an overabundance of understanding and sympathy ­toward her child: “I feel so sorry for kids ­today. Like my ­daughter, ­every night she ­doesn’t get to bed ­until ­after midnight or one. Often she goes to bed a­ fter me. Then she gets up early, very early, and goes to school. She ­doesn’t even have time for a midday nap. I feel she suffers much more than me. Sometimes I think, I just ­can’t bear to make her do too much more, at the most I’ll sometimes have her do something like washing dishes.” One w ­ oman, whom I met while she was visiting her m ­ other at Jade Hills, explained that ­because ­children ­today are the focus of too much and too intense love from their grandparents and parents, they are abnormally naïve for their age. Parents shelter them from any ­actual challenges. At the same time, she ­doesn’t want 40  Growing Old in a New China

her d ­ aughter to be burdened by her, the way she is by her own parents. Her ­daughter, who was busy upending broken bricks in the bushes near a dripping w ­ ater spout and dropping black snails and gray pill bugs into a paper cup, looked old enough to be in school. She was six already, her m ­ other confirmed, but she ­wasn’t ready to send the girl to school yet—­maybe next year. The mom, who appeared to be in her forties, was talking with a friend and his el­derly f­ather, who had lately begun refusing to talk or eat. ­Behind them, in one of the dim rooms lining the courtyard, was the l­ittle girl’s maternal grand­mother, who was bedridden. The ­little girl’s m ­ other was certain that she herself would one day live in an elder care fa­cil­i­t y. She explained that parents from her generation do not want to burden their c­ hildren. Her ­mother was in an elder care home, and she “hated to do it,” but her “abilities ­were ­limited.” Her m ­ other’s pension was enough to cover the fees, so her main contribution was buying fruit or personal items when she visited. She and her friend agreed that if they tried to take care of their parents at home, “they could not have a normal life.” She said that her d ­ aughter sees how she treats her ­mother, and she expects that her ­daughter ­w ill treat her the same way. Accordingly, she “had no expectations, absolutely no expectations” that her d ­ aughter would play a role in her ­f uture elder care.

Conclusion As I have argued throughout this chapter, the child-­centric filial crisis narrative that dominates elder care analyses fails to provide a complete picture of the current elder care situation. This is not because the narrative is inaccurate. Many scholars, including ­ Davis (1991) and Yan (1996), have identified the pro­cesses contributing to intergenerational imbalances—­ including migration, individualization, and decreased fertility—­from their roots in Maoist era revolutions through post-­Mao reforms. ­There is no doubt that ­these ­factors have made it increasingly difficult for ­children to realize filial ideals of elder support. However, ­these explanations do not line up with elders’ reports, particularly those Filial ­Children, Benevolent Parents  41

of the institutionalized elders, who experience the most unfilial of elder care arrangements. In part, this is likely due to protective strategies employed by elders to reduce cognitive dissonance and avoid hurting or embarrassing their ­children. Nonetheless, even this contribution by elders is often discounted as a reaction to a child’s unfilial action. However, as I asserted in my analy­sis of Sangren’s (2017) work, parents are not passive responders—­they are also active contributors. Decisions about and experiences with elder care emerge from efforts to restore harmony in the face of larger imbalances. All too often xiao is used interchangeably with the parent-­child relationship. As a result, parents have no role apart from accepting what is given (or not) or pursuing strategies to try to encourage their c­ hildren’s filiality. Accounts from elders like Grandpa Zhang demonstrate the value of expanding the conversation about elder care decisionmaking beyond filiality. While he may not have wanted to move into the institution, he initiated the move. ­Children might still feel anxiety, as Grandpa Zhang’s d ­ aughter did, that institutionalization might appear unfilial, but this resulted from, not in, the move. Similarly, Director Lu’s belief that filiality is unimportant and Dr.  Zhang’s view that nothing supersedes it can coexist in this framework. Grandpa Zhang and many of the other parents quoted in this chapter did not link their c­hildren’s filiality with elder care provision. Nonetheless, it was through their own experiences as filial ­children that they developed a sympathetic understanding of the obstacles that their own care needs put in the path of their c­ hildren’s advancements. Yet, as the previous section cautions, this lowering of expectations might be counterproductive. Through parents’ benevolent attempts to liberate their c­ hildren from the growing burdens of filial responsibilities and themselves from the burdens of indebtedness, they eliminate a critical part of their ­children’s (and their own) moral development. As the Confucianist phi­los­o­pher Ranjoo Seodu Herr states, “not only is our embeddedness in h ­ uman relationships ‘the point of departure’ for becoming truly h ­ uman, but maintaining harmonious relationships 42  Growing Old in a New China

is itself a goal of life” (2003, 472). While filial piety operates as a first step t­ oward that harmony, it is not in relationship with itself, but rather with the equally active, creative ethic of parental benevolence. It is the continuous interaction of benevolence and filial piety that maintains the ­family as an “immortal vehicle” (Kleinman 1980, 133). This is not to say that all parent-­child relationships are harmonious. Some ­children place parents in institutions against their wishes, and some parents consider their ­children unfilial. As David Graeber observed in his analy­sis of debt, “­There is no area of ­human life, anywhere, where one cannot find self-­interested calculation” (2001, 29). This also holds true in the Confucian parent-­child relationship. Sangren and ­others have demonstrated the charged nature of parent-­son ambivalence. However, Graeber goes on to point out that ­there all areas of life also contain acts of kindness. The question he poses is “why one, and not the other, is posed as ‘objective’ real­ity” (Graeber 2001, 29). Xiao does not exist in a vacuum but in a system of dynamic balance. Similarly, the stories of increasing desires for individuality, freedom, and self-­ realization among adult ­children provide only half the story. ­Filial piety—­w ith its association with indebtedness, active reciprocity, and the strug­gle for power and self-­realization—­often takes center stage instead of the subtle workings of parental benevolence in accounts of agency and change. Reintroducing the parental perspective allows for a deeper historical analy­sis of the parent-­c hild dynamic and a wider view of the elder care transition that captures the ways parents are reducing their own needs, choosing to move to institutions, and increasing self-­care strategies to maintain parent-­child harmony.

Filial ­Children, Benevolent Parents  43

2 Bodies in History, Embodied Histories Men make their own history, but they do not make it as they please; they do not make it ­under self-­selected circumstances, but u­ nder circumstances existing already, given and transmitted from the past. The tradition of all dead generations weighs like a nightmare on the brains of the living. —­Karl Marx, The Eigh­teenth Brumaire of Louis Napoleon

Li Ming brought my hand to the top of her head and moved my fin­gers along the part in her salt-­and-­pepper hair to where it thinned on the crown. “­There,” she said. “Can you feel it?” She had just finished telling me about her childhood in Kunming during the 1940s. In one harrowing tale, she had described fleeing the Japa­nese bombers that threatened the city. The Li f­ amily, like many ­others, had prepared a bomb shelter in nearby hills. During one raid, she and her parents ran to their shelter, while her older ­sister escaped to a classmate’s shelter. A ­ fter the threat had passed, the f­ amily learned that the classmate’s shelter had collapsed u ­ nder a rock slide. When they w ­ ere fi­nally able to retrieve the bodies, Grandma Li saw that her ­sister’s fingertips w ­ ere shredded from clawing at the suffocating earth. A ­ fter that, she resolved to live her life in happiness. Death spared no one. Speaking of her ­sister, Grandma Li said: “­A fter she died, I thought: if a person is only able to live one day, that is still a day. As long as I’m living, I should be happy, right? I worked hard 44

and did my job well. If I was able to help p ­ eople, I helped them. That’s the way I thought. That’s the way I acted.” However, in 1956, the revolutionary fervor that had been building in China descended upon Grandma Li’s work unit, and her cheerful countenance was deemed antirevolutionary: “Two of my workmates said I was too lighthearted, too open-­minded . . . ​they grabbed a metal pole and beat me. My bones broke, and still they hit me and hit me!” Over half a c­ entury l­ater, I could still feel the dent in her skull. Although Grandma Li’s youthful spirit transcended many of our differences, the stories she shared over a bag of steamed pork buns reminded me that the knowledge of Chinese history I held in my mind she carried in and on her body. For her and other elders, the histories they embodied played a crucial role in their present-­day experiences with aging and caregiving. As one resident reminded me: “Although you studied Chinese culture and language in Amer­i­ca, you ­haven’t lived through the ­actual situation ­here. Your knowledge comes from written words. You ­don’t have an understanding of the true real­ity of ­things. When it is all said and done, we have been ­here nearly ninety years.” Con­temporary Chinese elders have arguably lived through one of the richest shared histories of any generational cohort on earth. They witnessed international and civil wars, famine and revolution, and nation building and economic development—­ nearly a c­ entury of rapid, ceaseless change. However, as Grandma Li’s story demonstrates, history is not simply lived through and experienced as memories; it is also incorporated into minds and bodies and continues to unfold in the pre­sent. Like Grandma Li, many of the elders I spoke with had experienced severe personal traumas. As a generation, they had seen millions of ­people die of starvation and war and millions more be lifted out of poverty: their nation’s incredible advancements had come at a cost. Arthur Kleinman, who has spent de­cades writing about the somatization of psychological distress in China, and his colleagues have observed: “How ­these emotions of hurt and resentment affect their current lives is not so clear . . . ​­there must be, especially Bodies in History, Embodied Histories  45

among the el­derly, a large reservoir of bitterness, sadness, and anger” (Kleinman et al. 2011, 7; see also Kleinman 1980). It is unpredictable how past events ­w ill manifest themselves in the pre­sent. In many cases, especially with the old and aging, the body carries the weight of history and “secretes time” (Merleau-­ Ponty 1945/1962, 278). Scars, wears and tears, and aches and pains can thus be significant parts of an individual’s pre­sent experience as well as lasting connections between the individual experience and the collective past and pre­sent, representing “the way the past is taken up and lived in the pre­sent” (Ram and Houston 2015, 18). Beyond the body, present-­day economic and interpersonal situations also take on greater significance when considered in their larger historical contexts. As discussed in chapter  1, one of the driving forces of this research is the fact that an elder with a ­family and financial resources choosing to live in an elder care institution is a novel concept, one that would have been unthinkable a generation ago. In this chapter, I aim to answer the question: Who are t­ hese ideological pioneers, ­today’s Chinese elders? The majority of their lives has already been lived, so answering that question requires attending first to historical contexts, both individual and group. With a focus on attitudes t­ oward care, aging, and de­pen­dency, this chapter w ­ ill describe some of the major historical transformations in China over the past c­entury and, through specific stories, show how ­these pro­cesses continue to shape present-­day aging and caregiving experiences. Through this consideration of the past, I w ­ ill show how old age and elder care are being experienced t­oday—in the living ­pre­sent—in completely new ways. Similar to the situation that Marcia Inhorn observed among M ­ iddle Eastern men navigating new fertility technologies, Chinese elders are experiencing “double forms of emergence” as new medical technologies and caregiving arrangements create and react to new possibilities and desires for personhood in old age (2012, 269). As I demonstrated in chapter 1, for some elders, especially older ones, ­these ideological and technological changes are reshaping their expectations for f­amily 46  Growing Old in a New China

care and their decisions about institutionalization. In this chapter, I explore how ­these changes are paving the way for new se­nior subjectivities—­ones that look beyond family-­based roles and reimagine se­niorhood as a time of leisure, self-­realization, and travel.

The Scope of Change In 1950, when Grandma Li was just entering adulthood, China had a population of 565 million. Eighty-­seven ­percent of the population lived in rural areas, and life expectancy at birth was 40.1 years. W ­ omen had an average of 6.2 c­ hildren (Riley 2004). Since then, Grandma Li has witnessed China’s population more than double, reaching 1.4 billion. In response to new ­family planning policies and w ­ omen’s entering the workforce in greater numbers, fertility rates have plummeted to 1.6 ­children. Meanwhile, health care improvements have helped life expectancy surge from 49.6 years in 1965 to 76.5 years in 2017 (World Bank Group 2019a). In terms of aging and elder care, this convergence of decreasing fertility, increasing life expectancy, and changing f­amily structures means that a growing number of elders are reliant on support from a shrinking base. China’s old-­age de­pen­dency ratio, which is the number of dependents (over sixty-­five) per 100 persons of working age (fifteen to sixty-­four), was on par with the world’s at 11 ­percent in 2010, but is expected to rise to 24 ­percent in 2030 and potentially as high as 60 by 2060—­nearly double the global projected el­derly de­pen­dency ratio of 34  ­percent (United Nations 2013). Although China’s one-­child policy was recently abolished, allowing all ­couples to have a second child, the share of the Chinese population sixty and older is expected to more than double from 15.2  ­percent in 2015 to 36.5  ­percent in 2050 (Global Age Watch Index 2015). The social and economic developments of the past c­entury have brought wealth and opportunities to huge portions of the Chinese population. The effects on f­amily life, especially as it pertains to elder care, are complex and paradoxical at times. During the Maoist revolutions of the 1960s and 1970s, many of the Bodies in History, Embodied Histories  47

economic and social mechanisms that encouraged strong f­amily bonds w ­ ere destroyed by land and wealth re­distribution, yet forces of collectivization kept families intact, especially in rural areas (Davis and Harrell 1993). Although the ­family continued to be the primary source of care, the state encouraged devotion to the “socialist big ­family” and promised ­f uture security for all (Y. Yan 2009, 280). However, ­after the reform period began in 1978, this new “­family” gave way to the market, leading to a “drastically altered environment” for families and caregiving (Davis and Harrell 1993, 2).

Generational Cohorts In China, as elsewhere, the definition of “old” is subjective. The retirement age has been set at sixty for men and fifty-­five or fifty for ­women since the 1950s. For practical purposes, adults can start enjoying se­nior benefits—­free bus fares and entrance fees, access to what are known as se­nior colleges, and protection ­under the aged-­care law—at sixty. However, many of my research participants did not think that every­one over sixty should be in the same group of “old.” Their feelings agree with Mary Catherine Bateson’s (2013) view that increasing life expectancies and decreasing morbidities are reshaping the ­human life course and necessitate a reimagining of late adulthood. Based on her ethnographic research with older Americans, Bateson postulates that the extension of healthy postreproductive years of life has given rise to a new life stage, which she calls “Adulthood II.” Building on Erik Erikson’s “Eight Stages of Man” (Erikson 1950, 247) Bateson locates this stage between “Adulthood” and “Old Age” and characterizes it as marked by higher levels of health and energy than expected, identity reevaluation, and the potential for developing “active wisdom” (2013, 79). Another cause of the perceived differences between older and younger elders may be their age-­related experiences with the radical changes that occurred in China during their lifetimes. More specifically, life-­course theory suggests that significant historical 48  Growing Old in a New China

events occurring during an age cohort’s formative late adolescent years have lasting effects that shape the generation’s beliefs, values, and be­hav­iors (Egri and Ralston 2004; Inglehart 1997). For example, the oldest elders in my study w ­ ere born in the 1930s and early 1940s ­under a Nationalist government. Referred to as the “Republican” or “Pre-­Consolidation” generation, they came of age during the “Nanjing Period,” which was punctuated by the Sino-­Japanese War (1937–1945) and World War II (1939–1945). This was also a time of social and economic modernization efforts that often embraced both Western and Confucian values (Egri and Ralston 2004; Harmel and Yeh 2015). During my research, Pre-­Consolidation elders w ­ ere in their eighties and nineties and accounted for a l­ittle less than half of my formal interviews. The remaining interviewees, in their sixties and seventies, spanned two age cohorts: the “Consolidation” and “Cultural Revolution” generations. The older respondents in the younger group—­the Consolidation elders—­had experienced the rising power of the Communist party and Maoist ideology as youths in the 1950s and 1960s, a decrease in Western influence, and an atmosphere of idealistic enthusiasm (Harmel and Yeh 2015; Sun and Wang 2010). The younger “Cultural Revolution” generation (or “Lost Generation”) is the focus of most scholarly research on age cohorts in China (Harmel and Yeh 2015; Hung and Chiu 2003; Egri and Ralston 2004). Born in the late 1940s to 1960s, this cohort came of age during a period of conflict and upheaval (Zhou 2016). In my research, most respondents from this generation ­were still in the workforce or had recently retired, participating as doctors, nurses, ­family workers, or caregivers.1 Many ­were sent-­down youth, who ­were separated from their families and dispatched to rural areas during the Cultural Revolution to do manual l­abor (Hung and Chiu 2003; Zhou 2016). Experts note that this group—­whose education, ­family life, and employment opportunities ­were continually disrupted by reforms and revolutions—­was disproportionately disadvantaged when compared to other age cohorts (Hung and Chiu 2003). Bodies in History, Embodied Histories  49

­A fter the Lost Generation is the “Social Reform” generation. This cohort came of age in the late 1970s through the late 1980s and was socialized during a post-­Mao era of economic and social reform. Often described as materialistic and hedonistic, this cohort represented the majority of working-­age respondents in my research (Egri and Ralston 2004). Fi­nally, the “One Child” generation, socialized in the era of the one-­child policy, has been described as “markedly dif­fer­ent from its pre­de­ces­sors” (Harmel and Yeh 2015, 215). Also known as the wo yi dai (我一代), or “me generation,” the cohort of only c­ hildren (often referred to as ­little emperors) is portrayed as coddled and self-­centered, but more open to change and outside ideas (Y. Yan 2009). Due to the unending waves of reform and the radically dif­fer­ ent historical circumstances that colored the coming-­of-­age experiences for all generational cohorts in this research, many of my respondents did not identify with the cohorts that came before or are coming ­after them (Rofel 1999). For example, one study found that Pre-­Consolidation elders w ­ ere more likely to have a conservative viewpoint and value the good of the group over the good of the self, compared to the Consolidation or Cultural Revolution cohorts (Egri and Ralston 2004). Grandma Li, a Pre-­Consolidation elder, seemed to express some frustration with this “generation gap” among elders during one of our conversations: “Older ­people should try to do some ­little ­things—­whatever they are capable of—­without needing to get paid for it. Then they w ­ ill not add to the country’s trou­bles. This is my way of thinking. I personally go out and do ­things that are within my abilities, and I d ­ on’t want any reward from my country. But my opinion w ­ ill prob­ably be completely rejected by many in younger generations who are not willing to go out and do this type of volunteer work, like t­ hose sixty-­year-­olds who just retired and spend ­every day riding the buses. One day someone told me of this one person who took forty bus rides in one day!” By this point in the story, Grandma Li’s normally calm, mea­ sured tone had nearly become a shriek. I could understand her passionate response to the bus situation. Kunming’s subway 50  Growing Old in a New China

system was quite ­limited at that time, and most ­people relied on public buses for all travel. Grandma Li and I took the same crowded bus route to Jade Hills Elder Care Home, where ­every other day she visited her husband, a resident t­here. A r­ide cost RMB 1–2 ($0.17 or $0.33) depending on w ­ hether the bus was air-­ conditioned, but it was f­ ree for t­ hose over sixty. Grandma Li felt strongly that younger elders, especially recently retired ­women, ­were exploiting this benefit: “Ai-­yo! Is ­there any need for this? You tell me. Ah! About t­hese t­hings . . . ​my older generation prob­ably has some—­still has some ideas and opinions from many years ago. ­These—­these—­these—­these barely sixty-­year-­olds get a bus card and just go to this place, then that place, then this place! Ai-­ya! So unnecessary! D ­ on’t you think? How much does this add to ­those buses? Nothing but trou­ble.” While ­these generational divisions are not cut-­and-­dried, they serve to bring multiple timescales into view at once, incorporating the relational dimension of individual and macrohistorical timelines. They also help us resist the tendency to see elders as a monolithic group of old ­people by keeping distinctive early life events in view. This provides another dimension for thinking about individuals’ experiences of and reactions to the historical pro­cesses described below.

Before 1949 Prior to the 1940s, the typical Chinese citizen was a rural peasant who lived in a village differentiated from ­others by language, geography, and culture. Despite t­ hese local affinities, the typical citizen would also have strongly identified with a centralized state and would have been integrated into the larger Chinese society through market exchanges and larger cultural princi­ples governing lineage, kinship, and rituals (Freedman 1966; Siu 1990; Skinner 1971). Considering the size and diversity of China’s populace, ­these cultural princi­ples ­were remarkably widely accepted. Part of this was due to the state’s utilization of a cultural nexus of power that “imposed a structure but not the content” (J. Watson 1985, 323; Bodies in History, Embodied Histories  51

see also Siu 1990). The structure was centered on Confucian princi­ples and practices that had been a part of state orthodoxy since the Qin dynasty (221–207 b.c.). Yet it was not ­until the Song period (920–1200)—­when China’s government officials became concerned about differentiating so-­called civilized Chinese culture from that of their allegedly barbaric northern neighbors—­ that the state started to concern itself with the ­family and religious practices of peasants (Ebrey 1990). To reach such a geo­graph­i­cally extensive and culturally differentiated populace, state-­sanctioned morality and ideology w ­ ere promoted through popu­lar entertainment like puppet shows, religious festivals, and ritual ceremonies (D. Wang 2003; J. Watson 1985). All the possibilities for maneuvering and serving individual interests made this nexus particularly durable and effective in promoting and sustaining the cultural values surrounding f­ amily dynamics and kinship princi­ples. ­These cultural princi­ples encouraged the formation of four key dyads in the typical Chinese ­family, mentioned in chapter  1: father-­son, husband-­w ife, mother-­in-­law–­daughter-­in-­law, and brother-­brother. Although ­there was regional and historical variation in the dynamics of ­these dyads, the general tenor of ­these relationships showed considerable durability before 1949. Due to both the importance of land and settlement rights and the common practices of patriarchy and patrilineality, the father-­son link was often considered the most impor­tant of the four dyads, while the mother-­in-­law–­daughter-­in-­law relationship was considered the most contentious (Parish and Whyte 1978; Wolf 1978). With inheritance flowing through the male line, reciprocity was expected from sons: the parents provided a wife and inheritance for the son, and the son reciprocated by showing his parents re­spect in life and death—­demonstrating filial piety, providing old age support, and continuing the ­family line by producing male descendants. It was into this atmosphere that my oldest in­for­mants w ­ ere born.

52  Growing Old in a New China

The Reform Period Although concerns about modernization predated the rise to power of the Chinese Communist Party (CCP), sweeping reforms ­were pursued with unpre­ce­dented speed and enthusiasm beginning in the 1950s (Rofel 1999). ­Under CCP rule, the ways in which culture and tradition could be constructed, performed, and remembered—or forgotten—in the ser­vice of modernization and development took on added significance (Rofel 1999; Siu 1989). Especially in the early years of reform, once “purged of its ‘feudal superstitions,’ ” traditional Chinese culture was an invaluable asset to the modern nation-­building proj­ect, supporting a narrative of unity, continuity, and the uniqueness of the Chinese race (Ong 1999, 37). During this time, the three key princi­ples of Chinese f­amily formation mentioned above—­patrilineality, patriarchy, and filial piety—­came ­under attack as feudalist thought and thus ­were considered counterrevolutionary. This period also saw the beginnings of an emphasis on the conjugal bond over the intergenerational bond, as young ­people resisted arranged marriages with government support and parental authority was dismantled (Siu 2006; Whyte 1992). Yet paradoxically, while the state was promoting absolute reliance on collectives on the one hand, on the other hand, it was still relying on the moral systems of parent-­child obligations to provide caregiving support, especially for elders (Harper 1992). This was not merely in practice, but also in policy: the 1950 Marriage Law made it a child’s duty to support their parents (Harper 1992). However, even without the law and propaganda, in real­ity ­family members ­were still deeply committed to one another, and feelings of filial obligation seemed to have survived the revolutionary fervor (Davis and Harrell 1993; Parish and Whyte 1978). This period, when the Pre-­Consolidation generation of elders was nearing adulthood, was difficult but hopeful for many Chinese people. Grandma Xu, a Jade Hills resident in her nineties,

Bodies in History, Embodied Histories  53

who grew up in a large multigenerational ­house­hold in a small city not far from Kunming remembered the period this way: ­ ose years ­after my mom died ­were the most difficult. I had to Th manage the h ­ ouse­hold, buy food, and take care of the ­children. My dad’s eyes w ­ ere bad—he ­couldn’t see—so I had to take care of him, too. It was so difficult. I had to work during the day to earn money. We needed food, clothes, but I d ­ idn’t have the money to buy them. They gave out rations for cloth. This was in the forties or fifties—­I think the rations ­were in the fifties ­There ­were tofu rations, meat rations, rations for this, rations for that—­ah! ­These ­things in the past seem like a dream when I think of them now! During the hard times, we ate a l­ittle less than during the not hard times. During the harder times, we ­didn’t eat. I—­I just ­didn’t have any way to get a l­ittle more food. Ah! It was so difficult. Like a dream, r­ eally. Remembering it . . . ​ ah . . . ​it’s quite difficult. ­A fter that period, life slowly improved. My wages went up, life was good.

In the early years of CCP rule, land reforms and peasant cooperatives succeeded in increasing the quality of life in both rural and urban areas. Across the country, p ­ eople like Grandma Xu enjoyed higher incomes and improved infrastructures. Although urban areas received larger investments and experienced greater benefits, both urban and rural residents gained access to new schools and clinics (Davis and Harrell 1993). However, this period of stability was short-­ lived, as Mao Zedong pushed ­these smaller cooperatives to form larger collectives and abolished privatization in the mid-­to late-1950s in an effort to spur faster economic and industrial growth. At the same time, ideological campaigns ­were becoming more radical. China entered an era of revolutionary fervor that lasted from the ­Great Leap Forward (1957–1959) through the Cultural Revolution (1966–1976). Resource mismanagement led to widespread famine from 1959 to 1962 that hit rural areas especially hard, contributing to an estimated thirty million deaths (Ebrey 1996). Life was 54  Growing Old in a New China

strictly regimented, and ­family ties came second to party loyalties. Schools and universities w ­ ere closed, and ­children w ­ ere placed in communal nurseries as the entire population turned its full energy ­toward communal steel and agricultural production (Ebrey 1996). Just as ­tables, chairs, and coffins w ­ ere equally valued insofar as they w ­ ere fuel for the ever-­burning steel furnaces, individual identities as man, w ­ oman, parent, and child w ­ ere subordinated to one’s role in building a new country. ­Here we can see the origins and effects of generational differences. While all three of ­today’s el­derly cohorts w ­ ere alive and experiencing the same waves of reform at this time, the Consolidation and Cultural Revolution cohorts ­were being socialized in this atmosphere as young adults and ­children. Older Pre-­Consolidation adults, with roots in pre-­CCP times and more to lose, ­were more likely to be responding to, coping with, or defending themselves against t­ hese changes. Zhang Wei, an eighty-­ eight-­ year-­ old resident of Singing Meadows, is one example of a Pre-­Consolidation elder. With brown eyes that have faded to blue with age, he lives in a single room on the second floor of the home. He spends his days reading alone in his room, fearing that contact with the other residents w ­ ill make his brain soft. Indeed, his mind is still piercingly sharp. As a precocious youth, he had earned a master’s degree in astrophysics at a young age and intended to find work in a research laboratory. Instead, he was aggressively recruited to teach science at a private m ­ iddle school. Accepting the job turned out to be a fateful decision: “When the Hundred Flowers Campaign began, we ­were told to put forth our suggestions to help the government. I was not clear what the campaign was actually trying to do. From 1950 onward I could not tell if what was being said was po­liti­cally motivated or ­actual truth. Would I dare make a statement? One day, a school official came to me and said, ‘You ­haven’t yet issued a statement. You must have many ideas about ways to help the party. What­ever you wish to say, just say it!’ I said, ‘I have no exceptional ideas, I only wish the government was less controlling of us teachers.’ . . . ​­Later he said, based on their evaluation, I was Bodies in History, Embodied Histories  55

antiparty and antisocialist from top to bottom.” Grandpa Zhang was publicly criticized and spent the next twenty-­t wo years in a forced ­labor camp. ­A fter his release, he returned home to his wife and three ­children and took up work in a factory. Grandpa Zhang was not alone. More than three million p ­ eople ­were labeled antirightists, and approximately 500,000 of them ­were sent to ­labor reform camps in the wake of the Hundred Flowers Campaign (Dikötter 2013; Ebrey 1996). Although they knew the accusations and punishments w ­ ere unjust, they also knew re­sis­tance was futile. For Pre-­Consolidation and Consolidation elders, the effects of this powerlessness—in the face of a complete rearrangement of truth, as well as the uncertain and mercurial meanings of good and bad and of friend and e­ nemy—­linger. In my research, elders who ­were other­wise happy to speak informally often hesitated, or refused, to participate in a formal interview ­because of the required signed consent. Meanwhile, the younger Cultural Revolution generation, which included Grandpa Zhang’s former students, was called upon to join Mao’s attack on intellectuals and other authority figures. Mao believed that communism required continual revolution and strug­gle. Schools ­were shut down as traditional power structures ­were dismantled. This was a dark period for the aged and the status of the el­derly. The army of young p ­ eople—­the Red Guards—­needed an outlet for their passion, and in 1968, Mao began the sent-­down youth program. Many, including Grandpa Zhang’s ­children, left their homes to work in rural areas across the country. One hospital patient in her sixties described her and her close friends’ experiences as sent-­down youth: You went to school from when you w ­ ere small, regardless of ­whether your ­family was rich or poor, but no one had ever worked in the fields. Your responsibility was to “study hard and strive to improve.” Even the very young ones—­fourteen, fifteen years old—­had to leave their families. Besides working in the fields, growing rice and corn, you had to go into the mountains to chop your own wood, cook your own food, raise pigs, raise 56  Growing Old in a New China

chickens—­a ll ­these ­things you had never done before. So a­ fter working, the farmers could go home to their families, and someone would be preparing them food. But a­ fter you came home from a painstaking day of l­abor, the peasants ­were eating and your stomach was growling, but you still had to make your own food and do every­thing yourself.

­ ntil Mao’s death in 1976, the Cultural Revolution left no part U of China untouched. In 1978, Deng Xiaoping outplayed Mao’s successor, Hua Guofeng, to become the de facto leader of the country, ushering in a new era in China’s history. It is against, and within, this historical landscape that t­oday’s elders developed their ideas about what it means to grow old and on what one can and should depend. De­cades of forced forgetting, physical vio­ lence, emotional suppression, and the submission of one’s desires to the greater good have had lasting physical and psychological effects on many Chinese cohorts (Kleinman 1980; Kleinman and Kleinman 1994; Rofel 2007). While the historical events described above are receding into the past, they still cling to the bodies moving forward.

Embodied History History is not simply stored in memories and archives. It is also embedded in cells, skin, ligaments, and bones. We experience the world through, in, and as our bodies. It is the physical form alone that binds us to time, places us in specific historical moments, and mediates our encounters with the wider world (Merleau-­Ponty 1945/1962). It is our “surface in contact with the world,” that part of us that is not simply in the world but also of the world (ibid., 240). For elders, especially, bodies remember and remind through aches and pains, as well as scars and hollows, regardless of the mind’s attempts to forget or suppress. ­Because the corporeal self is inseparable from the historical, po­liti­cal, and social pro­cesses in which it is imbedded, medical anthropologists have explored it as a multidimensional site of Bodies in History, Embodied Histories  57

analy­sis (Biehl, Good, and Kleinman 2007). As a point of departure, the body holds significance as both a “physical and symbolic artifact,” rooted in time, and a product of nature and culture (Scheper-­Hughes and Lock 1987, 7). The stories that follow reverse the lens on the individual-­historical nexus presented in the preceding section of this chapter. Instead of showing individual bodies in history, they reveal the histories in bodies. Many of ­these histories—­those that are relatively more local and specific—­ might other­ w ise be lost or overlooked, but b ­ecause they are embedded in bodies, they persist in shaping the pre­sent and ­f uture. The case of ­Uncle Tang is one such example. Tang Bai, age sixty-­nine, had moved into Jade Hills Elder Care Home about eight years e­ arlier from a scenic city a c­ ouple of hours south of Kunming. His wife had died several years ago, and his only d ­ aughter had arranged for him to come to Jade Hills to be closer to her. Compared to the other residents, he was energetic and chatty. He was always ­eager to introduce me to new respondents in exchange for a small finder’s fee of one Yale ballpoint pen (the token of appreciation I gave all participants), explaining that the previous one had mysteriously dis­appeared. He was the first resident to welcome me into the community, so I was happy to oblige. During our formal interview, ­Uncle Tang wanted to show me a card he had tucked inside his jacket pocket. ­A fter fumbling with the button for a few moments, he apologized for being so slow. “A train,” he explained, referring to the years he had spent working on a railroad. He held his hand up so I could see the deep hollow in his palm and the way his fin­gers curled inward like the toes of a bird. Roads and railways have long s­ haped Yunnan Province, just as they did U ­ ncle Tang’s hand. Locals often attribute the province’s laid-­back atmosphere to its geo­graph­i­cal remoteness. The proverb “Tian gao, huangdi yuan” (天高皇帝远), or “Heaven is high, and the emperor is far,” expressed an “out-­of-­sight, out-­of-­mind” relationship between the region and China’s east coast centers of po­liti­cal power.2 However, the province has been an impor­tant national and inter­ national exchange hub since the second ­century bce (B. Yang 2009). 58  Growing Old in a New China

The most famous route, the Tea and Horse Road, played a major role in the cross-­regional exchange of goods, ideas, and combat supplies up through the end of World War II (ibid.). As Erik Harms (2011) observed in Vietnam, roads are geo­graph­i­cal manifestations of social relations, both past and ­future, and they emerge from and produce social exchanges in messy, unpredictable ways. In the case of Yunnan, ancient trade routes brought foreign ideas and p ­ eople to the province, and ­those ­people in turn brought new roads and railroads to it (B. Yang 2009). Road and railway construction accelerated rapidly in Yunnan during the Sino-­Japanese War. The juxtaposition of being far inland and accessible through multiple means—­land, rail, ­water, or air—­made Yunnan and the neighboring provinces of Sichuan and Guizhou ideal sites for relocating the nationalist government away from Japa­nese pressure on the coast (B. Yang 2009). Masses of civilians, including ­Uncle Tang, w ­ ere recruited to build railroad lines and highways through some of China’s most challenging terrain. The line that ­Uncle Tang worked on, the Dongchuan Railway Extension, was an overly ambitious proj­ect that enlisted tens of thousands of workers. In this “confrontation of perfect visions of pro­gress with the messy realities of development in practice,” the messy realities prevailed (Harms 2011, 157). Beset by floods, landslides, earthquakes, and erosion, developers fi­nally abandoned the Dongchuan proj­ect in the 1960s. Most of the tracks w ­ ere pulled up or repurposed, and ­today the remnants of the proj­ect are found in the minds and bodies of workers like ­Uncle Tang. In one of our conversations, he said: “Let me tell you about that time [1960s]. I had fifty jin [25 kilograms] of food [a month]—­not enough to eat. At that time, we w ­ ere still using ration coupons. ­Later they added thirty jin [15 kilograms]—­even eighty jin [40  kilograms] was not enough. That work was so difficult.” He traced his index fin­ger along the groove that began near his right thumb and curved up ­toward his ring fin­ger, moving his fin­gers slightly to demonstrate their l­imited range of motion: “­After the train crushed my hand, it was very weak. I could not work anymore. They gave me a disability card, so I can r­ ide the bus for ­free.” Bodies in History, Embodied Histories  59

In her account of the Chernobyl disaster, Adriana Petryna (2002) describes how Ukrainian citizens, many of whom w ­ ere struggling with increasing poverty and insecurity, sought to be recognized as legitimate sufferers from radiation by the state to gain access to scarce economic and social resources. For medical anthropologists working in postsocialist contexts, the concept “biological citizenship” provides a useful model for analyzing the ways suffering, illness, and disease can become cultural resources in the face of weakening social protections and increasing medical and economic inequalities that often accompany transitions to a market economy (Rose and Novas 2005, 439). Illness can become social capital, and damaged bodies can become “the ground for staking citizenship claims” in contexts where other forms of capital are devalued or inaccessible (Petryna 2002, 5). Similarly, U ­ ncle Tang’s mangled hand, which he referred to whenever he strug­gled to complete a ­simple manual task, was still able to open many doors. A ­ fter fi­nally extricating the object from his pocket, he showed me a state-­issued disability card that was securely fastened to his jacket with a long piece of yarn. He pointed out the characters for “disabled” and his name beneath a photo of his younger self. With this card, his biological citizenship—­his status as a disabled Chinese citizen—­was officially recognized. The card confirmed that he was a legitimately deserving citizen who could claim access to state-­sponsored resources and rights. According to ­Uncle Tang, one of the key privileges was that he could r­ ide the bus for f­ ree. However, as his fellow residents ­were quick to point out, this was meaningless, since he was unable to leave the institution to ­ride ­those ­free buses. Although the long-­ abandoned railway was now buried in overgrowth and footnotes, it continued to shape ­Uncle Tang’s pre­sent circumstances and ­future possibilities—­both opening and closing off his potential movement through the world. For some elders, past actions influenced their pre­sent in exceptionally positive ways and provided much more than ­free bus rides. For example, lixiu ganbu (离休干部), retired cadres who had joined the CCP before 1949, w ­ ere rewarded for their loyalty with 60  Growing Old in a New China

higher pensions, based on their years of party membership. In addition to higher pensions, ­these elders received preferential hospital treatment, better medical insurance (in many cases, covering up to 100  ­percent of inpatient costs), and stipends for in-­ home health care. However, enduring party loyalty had its dark side as well. One after­noon, while I was sitting with a group of care workers in Dragon Pool Elder Care Home’s sunny atrium, an older ­woman with short gray curls approached. Smiling widely, she introduced herself as Yang Ling. She was very pleased to speak with a foreigner, she explained, ­because we seemed so courteous—­ always giving up our seats to elders on buses. She asked about my research and then pointed to her husband, who was sitting on a nearby bench. Auntie Yang began telling me about his difficult life. He was originally from Henan, but a­ fter his f­ ather died during the Sino-­Japanese war, he moved south and joined the CCP as a young man. Although it was hard work, his long-­standing party membership gave him lixiu ganbu status and benefits, and they w ­ ere therefore able to afford this high-­end institution. Suddenly, noticing that her husband’s perch was now an empty seat, she took off down the hall, moving in a quite sprightly fashion for a seventy-­eight-­year-­old. Following b ­ ehind at a more leisurely pace, I caught up with the ­couple near their room at the end of the hallway. Auntie Yang gave me a quick tour of the spacious room with private bath, and then her husband, speaking for the first time, asked us to talk outside so he could take a nap. While we sat in the after­noon sun eating sunflower seeds and drinking tea out of flimsy paper cups, Auntie Yang explained that her husband had developed dementia two years ago and it was progressing quickly, which was why they had de­cided to move to Dragon Pool. In a low voice Auntie Yang confided that she believed the dementia had been caused by all of her husband’s years of not being able to “speak truth” during the Cultural Revolution. Forgetfulness and disengagement, especially when associated with Alzheimer’s disease or other forms of dementia, are considered the biggest threats to one’s personhood in old age in the Bodies in History, Embodied Histories  61

West. Pia Kontos described Alzheimer’s disease as “a much feared stigmatizing label that carries with it the force of a sentence of social death” (2006, 195). Alternatively, Margaret Lock, Stephanie Lloyd, and Janalyn Prest (2006) argued that medical recognition, especially for diseases that involve behavioral changes, could reduce social stigma. In ­those instances, cognitive decline creates the potential for a new personhood rather than simply the negation of personhood. More recently, scholars have been expanding ­these conversations beyond fear and stigma to explore how love and friendship can provide lenses for understanding the mutual transformations that dementia care relationships can inspire (Brijnath 2014; Taylor 2017) In China, medical knowledge about dementia is ­limited, as are associated caregiving resources (Z. Chen et al. 2017). Insurance does not always cover treatment or medi­cation for it and, as mentioned in the introduction, rarely covers long-­ term care. China launched a national five-­year plan for ­mental health in 2015, whose priorities for improved education and training included dementia. However, being diagnosed with dementia was difficult and provided few benefits (ibid.). In recent years, orga­ nizational advocacy for ­people with dementia and their caregivers has increased measurably, but at the time of my research, ­there ­were no specialized facilities for ­people with dementia in China, and public understanding of their specialized care needs was ­limited (Shea and Zhang 2016; Y. Zhang 2020). In the case of Auntie Yang and her husband, dementia provided an explanatory model that made sense of the unpredictable manifestations of both neurological aging and psychological suffering. This resonates with Kleinman’s (1980) analy­sis of neurasthenia and other psychiatric diseases as explanatory models for understanding how Maoist and post-­Mao changes are experienced through the mind and body. Ji Chun employed a similar strategy in explaining her ­father’s aging experience. I met Ji in the cadre unit on the top floor of a large provincial hospital. I was following a nurse on rounds when Ji came over to apologize for her ­father, who was yelling incoherently on the 62  Growing Old in a New China

other side of the room’s partition. As a retired cadre, his inpatient stay was fully covered by insurance, so she brought him to the hospital as often as she could. On this day, he was receiving treatment for a minor respiratory infection. Ji explained that he was dissatisfied with his morning nurse assignment and had threatened to continue yelling and refusing treatment ­until a younger, prettier nurse could be found. His ­daughter, accustomed to ­these outbursts, believed that his formerly high status in the party led him to expect a certain level of re­spect and privilege. Now that he was old and retired, she felt, he strug­gled with more psychological burdens than a person from a lower social class would have. However, my experiences with elders from a range of backgrounds suggested that the loss of social roles is psychologically difficult regardless of class. As the historical analy­ sis above recounts, ­today’s Chinese elders entered the workforce during a period of socialist reform, and many still have a deep belief that their worth is bound up with notions of contribution and productivity (Y. Li, Xu, Chi, and Guo 2014; Mjelde-­Mossey, Chin, Lubben, and Lou 2009; Z. Zhang and Zhang 2015). Everett Zhang has convincingly argued that the con­temporary social situation has changed drastically and that as a result, t­ here has been “an abandonment of the ethos of sacrificing life for the revolutionary cause, and an emerging appeal for valuing life” (2011, 1). However, this sacrificial attitude still lingers in elders like Auntie Ma, whom I introduced in this book’s opening pages: “I am not selfish. I want every­one to be better than me. Get along better than me. I am willing to dress shabbily and let ­others buy clothes, eat less, and let o­ thers get full.” Despite her desire to give, Auntie Ma felt that she was now capable only of receiving. Her embodied experience of aging was deeply affected by this dissonance. Furthermore, she was quite aware of society’s perception of elders as burdens, and as a result, she saw herself as only a drain on a system where value is mea­sured with dollar signs: “What do p ­ eople ­today believe in? They believe in money! This is social pro­gress.” Although she had savings and a small pension, “How could it ever be enough?” Bodies in History, Embodied Histories  63

The examples above demonstrate that elders’ past traumas affect the pre­sent and ­f uture and often intensify the challenges of old age. Grandma Li, introduced at the beginning of this chapter, did not receive proper medical care following her violent beating. The enduring hip and back pain from that incident made it impossible for her to care for her husband, who was injured by a hit-­and-­run driver while working as a doorman. As a result, he had to move into Jade Hills Elder Care Home, where Grandma Li, with her indomitable optimism, visited him e­ very other day. For most p ­ eople—­like U ­ ncle Tang, Ji’s f­ather, and Auntie Yang’s husband—­the past both increased and impeded access to resources, experiences, and subjectivities. Grandpa Zhang, who had spent most of his adult life in a forced ­labor camp, observed that history’s influence on the f­ uture body is ultimately unpredictable: “My only request [in the ­labor camp] was that what­ever job was most difficult, they assign me to that one. In my ­family, not one person has lived past sixty-­five. So when ­people ask me, ‘How have you lived to ninety?’ I tell them, ‘­because I labored for twenty-­t wo years in that prison.’ ”

New Se­nior Selves Mao’s death in 1976 was a watershed moment for Chinese society. To pull China out of de­cades of stagnant economic growth, the Chinese state promoted the loosening of the bond between individuals and their collectives. This untying was expected to spark initiative and creativity, encourage entrepreneurialism, and propel China into the global market as a fierce competitor. In this atmosphere, individuals w ­ ere strongly encouraged to take risks, but they ­were required to face the consequences of failure on their own. This caused a major transformation in the understandings of care and dependence, which in only a few de­cades shifted from total reliance on the state to total reliance on the self (Ong and Zhang 2008). This heightened focus on self-­cultivation and self-­sufficiency permeates all layers of Chinese society. Scholars studying f­amily and private life in China describe the post-­Mao period as one 64  Growing Old in a New China

marked by an increase in individualization, privatization, and self-­responsibility (Y. Yan 2011). For elders, the result has been that many traditional forms of se­nior subjectivity, such as living in an extended ­family and raising grandchildren, are becoming less available. In my research, respondents across age groups viewed this as a natu­ral, positive change. One recent retiree, who had no plans of ever living with her adult son, described it this way: “In the past, families lived together b ­ ecause they could not afford to split up. It is good that now economic conditions have improved for every­one and families can afford to live separately, ­because each generation’s way of living is dif­fer­ent. It ­doesn’t ­matter if they live separately—­family is still ­family.” In response to t­hese changes, new ways of aging and new forms of se­nior subjectivity have emerged. To understand the emergence of ­these new subjectivities, one must also give proper weight to the larger historical, social, and cultural formations that shape and are s­haped by them (Ortner 2005). For current and soon-­to-be elders, the historical pro­cesses of the past c­ entury in China ­were not erased by new policies or possibilities. Mediated by p ­ eople’s developmental age, class, and individual circumstances, ­these histories linger in both minds and bodies. For example, one nursing director from the Cultural Revolution generation, wary of depending on social institutions, had begun making plans with three of her friends to rent an apartment and hire a caregiver, creating their own mini-­facility for elder care. Members of the Social Reform generation, who have more time and money to invest, are imagining completely new realities. Some, like the Shanghai investor introduced in chapter 3, are investing in huge 10,000-­bed retirement estates featuring five-­star h ­ otels and travel perks. O ­ thers are not planning for old age care but are making lifestyle choices to forestall dependency—­from self-­care practices to religious devotion (Shea 2014). Ji, whose cantankerous ­father was introduced above, is from the Social Reform generation and explained her personal approach to aging to me. The first part of her plan is to “take care of myself, maintain my health, and enrich myself.” In addition to staying in Bodies in History, Embodied Histories  65

shape physically and mentally, she had recently become a Christian. She firmly believed that God would not let her get dementia, which was the greatest of her many age-­related fears. She hoped that by taking good care of herself, she would be able to be in­de­pen­dent well into her seventies.3 However, as a backup plan, she took comfort in the idea that if her quality of life became too diminished, she would be prepared to take her own life. She told a story of two old doctors who had washed themselves, put on beautiful clothes, and took some pills—­the end. She and her husband agreed that such an exit was very dignified, and she would like to be able to make that choice as well.

Conclusion Although younger generations of elders have the advantage of time and resources, older generations are also actively engaged with, and at the forefront of, ­these transformations. As the other chapters in this book explore in detail, many of ­today’s oldest elders are choosing elder care institutions over traditional ­family care, acting as moral pioneers in this emerging institutional landscape. While older generations may have childhood memories of large intergenerational families and in-­home elder care, the alleged tradition that Pre-­Revolution and Revolution elders have actually experienced has been one of ceaseless change. As Grandma Hua, an eighty-­nine-­year-­old Singing Meadows resident, told me, “Our generation of elders is truly pitiable. We have had to be at the forefront of every­thing. During the nation’s most difficult times, we raced to catch up; we raced to keep pace with revolution, to keep up during the Cultural Revolution. Now we are still racing to keep up.” For ­today’s elders, “catching up” with the new ideals of individualization is especially difficult due to their disadvantaged starting point. Their lifetime investments in the collective have small payouts in the private market. Increases in mobility, freedom, and choices have ­little value to ­people entering a period of deceleration and de­pen­dency. Nonetheless, even institutionalized 66  Growing Old in a New China

elders are actively engaged in new forms of sociality as they interact with strangers in the most intimate settings. ­These words from Grandma Hua, show that even a­ fter nearly ninety years, adaptability persists: “If you d ­ on’t change, then what? We cannot change the world; we must change ourselves.”

Bodies in History, Embodied Histories  67

3 Place and Space, Rhythm and Routine Impor­tant tensions may arise when places that have been ­imagined at a distance must become lived spaces. —­Akhil Gupta and James Ferguson, “Beyond ‘Culture’ ”

Sitting in the ­silent atrium of an elder care fa­cil­i­ty, just ­after lunch, it is difficult to discern the original purpose of this building. Paper cutouts and colorful drawings are pasted randomly along the wide white hallways, and bunches of bright red knots and peppers hang in corners and doorways. From above, yellow light filters through a dusty glass dome and strands of faded multicolor flags, adding a dreamy quality to the open common area. The air is too still, though, and the midday sun’s sharp rays turn the plastic scoop chairs and vinyl couches sticky, driving inhabitants to cooler corners. Looking down over the railings that circle the center of the main floor, one can feel cool air rise from a dim cafeteria lined with a dozen smooth brown ­tables. The food ­here is cooked soft and bland, as evidenced by the lack of odors ­after lunch. Surprisingly, the ­whole building is almost odorless, which the director points out repeatedly during tours: “You would never know this is an elder care home!” In fact, less than two years ago this building was not an elder care fa­cil­i­t y but a summer boarding school for Korean exchange students. Shortly before that it was a museum, which explains 68

why many of its features—­from the uneven stone garden paths to the steamy common area—­are more decorative than accessible. Throughout my tours of elder care facilities in China, I frequently encountered this mismatch between form and function. One of the main barriers to establishing an elder care institution in con­temporary China is finding the physical space in which to operate it. Land owner­ship is a complex affair in China, as the government strug­gles to balance total state owner­ship of land with private property rights (L. Zhang 2015b). In her ethnography on the emerging ­middle class in Kunming, Li Zhang (2010) describes how the privatization of real estate has been a core post-­Mao strategy to spur economic growth. In Kunming especially, city planners’ desires to keep pace with the rest of the country’s rapid modernization has pushed many ordinary residents out of prime commercial districts (ibid.). Elder care facilities have also felt the squeeze. While the government has enthusiastically encouraged private investment in elder care, without concomitant financial support or land subsidies, developers of elder care facilities have ­little chance of being competitive in a still-­hot housing market (Dai 2014). Aware that they cannot expect the same type of profit margins that developers of apartment complexes or shopping malls can, elder care fa­cil­i­t y developers rarely win bids for new forty-­to seventy-­year land leases and instead repurpose buildings that w ­ ere originally intended for factory workers or c­ hildren (L. Zhang 2015). Despite ­ these challenges, institutional elder care is still attracting interest and investors. Based on the official “9073” elder care model explained in the introduction (of elders, 90 ­percent are cared for at home, 7 ­percent in the community, and 3 ­percent in institutions) and projected demographic estimates (the numbers of Chinese older than sixty-­five are expected to reach 300 million by 2025 and 487 million by 2053), the institutional elder care demand w ­ ill be nearly 15 million beds by midcentury (Lei 2020). Other surveys suggest an even higher demand: one report found that 11.3 ­percent of urban elders and 12.5 ­percent of rural elders are willing to live in elder care institutions, driving potential demand Place and Space, Rhythm and Routine   69

closer to 58 million beds in the next thirty years (Chang 2012). As of 2020, ­there ­were approximately 7.6 million elder care beds available in 200,000 facilities in China (Lei 2020). To get a sense of the incredible speed of development, in 1988, t­here ­were fewer than 50,000 elders living in China’s 870 welfare homes (Chen 1996). However, t­ hese numbers are rough estimates at best. Residential elder care facilities in China are categorized as state-­run, community, enterprise, and privately owned, but the distinctions are not clear-­cut, and ­there is no precise differentiation in name or function between what in the West are known separately as nursing homes, assisted living facilities, and retirement communities (Saiquan 2002; Zhan, Liu, and Guan 2006). For a person engaged in the everyday activity of caring for elders, a more accurate and relevant indicator of the rapidly developing elder care institution situation might be a quick internet search. The one I conducted at the conclusion of my fieldwork, in November 2015, listed 23,606 facilities in China and 92 in Kunming (“Kunming nursing home list” 2015). I visited eight of ­those 23,606 facilities and encountered a wide range of elder care arrangements, from a no-­fee welfare home tucked into the mountains of rural Yunnan to a luxury retirement estate in Shanghai whose monthly fees exceeded $3,000. I also spent time in geriatric and palliative care wards, private homes, and community care centers, all of which are also significant sources of Chinese elder care. While models, projections, and statistics might describe, however hazily, what is happening, they say ­little about why it is happening at all or why it is happening in this way. Deep historical analyses, such as ­those presented in chapter  2, contribute to our understanding by attending to the dynamics of time. The goal of this chapter is to add to that an analy­sis of space and the relationship between ­those dimensions. Truly appreciating the con­temporary development of elder care institutions in China and the rich potential for ­f uture forms requires attending to the tension between place and space, the ­imagined and lived, and the concrete and abstract (Gupta and Ferguson 1992). However, space and place are slippery concepts, 70  Growing Old in a New China

morph­ing in and out of each other as perspectives and scales shift. In his examination of the ­human experience of place and space, Yi-­Fu Tuan (1977) provides some observations on how one might begin to make sense of the ceaseless dynamism of this relationship in terms of h ­ uman experience. As Tuan sees it, space is that which allows movement and freedom. Place is the pause in ­those movements—­the “concretion of value”—­w ithin which new spaces can unfold (ibid., 12). Space contains constellations of places and networks of pauses of varying durations. Space is both inside and outside t­hese pauses, and ­ these pauses are deeply ­human. Spatial organ­ization reflects, shapes, and instructs bodies and social relationships. Using Tuan as a guide, this chapter dives into the complexity of place and space making in Chinese elder care institutions. First, I describe five elder care facilities that I visited and demonstrate the wide variety of forms ­these institutions take. Next, I highlight the dynamic pro­cesses and movements that animate elder care spaces in China and how they collide and congeal in surprising ways to create new elder care places with par­tic­u­lar forms, definitions, and understandings. Since “the experience of space is always socially constructed,” the second half of the chapter focuses on how ­these newly formed places attract diverse groups of p ­ eople with individual understandings of elder care home as place (Gupta and Ferguson 1992, 11). Paying special attention to the embodied experience, I explore how undifferentiated spaces become meaningful places and how, as soon as ­these new places are formed, they bring to life new spaces ready to be claimed (Tuan 1977). To illustrate this ceaseless dynamism, I draw on Henri Lefebvre’s (1992/2004) notions of rhythms and routine and trace the biological, natu­ral, and social temporalities that establish elder care institutions as both space and place. I pay ­special attention to the pauses in movement—­t he gates, locks, bound­aries, settlings, and dwellings—­that indicate the formation of new places. Using ethnographic examples, I explore how residents and caregivers understand, contest, resist, create, and define spaces for themselves, and how they engage with the bound­aries Place and Space, Rhythm and Routine   71

and intersections where t­ hese “entangled horizons of transformation” become most vis­i­ble (Danely and Lynch 2013, 4).

Diversity of Forms In China, public images of elder care homes generally feature smiling wheelchair-­bound elders singing and clapping to Maoist-­ era songs while attentive, uniformed care workers crouch at their side, laughing encouragingly. However, in real­ity, elder care facilities, and the quality of care in them, vary widely due to the lack of regulation and standardization (H. Zhang 2007). While public elder care institutions receive government support and are generally well staffed and well regarded, they are accessible only to ­those without ­children or with good connections (Shum et  al. 2015).1 However, due to bureaucratic control, they also tend to be the most accessible for researchers, which could skew study results. A number of survey-­based research studies have described high levels of satisfaction with institutional life, self-­reported physical and m ­ ental improvements of residents a­ fter entering an institution, and a preference for institutional life over previous living arrangements (Y. Cheng et al. 2011; Guan et al. 2007; Zhan, Liu, and Guan 2006), but other studies have found depression rates of 38–46 ­percent among institutionalized elders in mainland China (H. Wang, Shi, and Gao 2007; Ouyang, Chong, Ng, and Liu 2015) and as high as 81.8  ­percent in Taiwan (Lin, Wang, and Huang 2007). The mixed results are likely due to the aforementioned differences in institutional quality. Although China’s Ministry of Civil Affairs released a document titled “Basic Regulations for Social Ser­vice Organ­ization for Elders” in 2001 and vowed to develop a unified rating system for elder care institutions by 2022, researchers agree that wide discrepancies still exist with regard to the regulations’ implementation and regulation (Zhan, Liu, and Guan 2006; Xin­hua 2020; Y. Zhang 2020). While quality is difficult to mea­ sure, Athena McLean (2007)—­who conducted research in U.S. nursing homes—­analyzed institutional settings based on physical space, environmental 72  Growing Old in a New China

aspects, and experiential aspects and noted that the lighting and layout of a space contribute heavi­ly to the experiences of both residents and visitors. João Biehl—­working in a Brazilian “zone of social abandonment” (2005)—­provided readers with a more visceral introduction to the sights and smells of institutional neglect and bodily decay. While none of the elder care institutions I visited compared to ­those in Biehl’s Vita, in the analy­sis that follows, I combine ­these two approaches, describing the physical places alongside the sensory environments of five facilities to give readers a glimpse of the diversity of forms that Chinese elder care institutions take.

Jade Hills, a Private Elder Care Home The doors of the crowded bus jerk open onto a sidewalk crowded with vendors selling cell phone accessories and grilled snacks. Down a narrow side road that is deeply pitted and dusty from a nearby construction site is a sign for Jade Hills Elder Care Home. The arrow points past a flowing open sewer and three rotting couches to a red metal door, whose placard states that visiting hours are from 8:00 a.m. to 6:00 p.m. Through the bars in the door, I can see a doorman sitting before a small tele­vi­sion in a small room, and I wave to get his attention. ­After a few moments, he comes over and wordlessly jangles his key in the heavy lock, swings the wide gate open, and promptly returns to his show. The smells hit me before the picture comes into focus. The ubiquitous scent of stale urine mixes with a bouquet of odors that vary depending on the time of day and year: congealing milk, cement dust, paint, flowers, car exhaust, unwashed bodies, and soiled clothing. Just inside the door is a cluttered office building flanked by a small parking lot with room for six cars. Ten buildings, each 1–3 stories high, ­house the approximately three hundred residents, with separate spaces for the kitchen, laundry, and bathrooms. ­There are no elevators or ramps, and the win­dows and hallways on the upper floors are secured with bars and locks.2 The residential buildings surround an open courtyard containing a small pond, a patch of unruly bamboo, and a garden that is tended by Place and Space, Rhythm and Routine   73

care attendants and fenced off from residents for their safety. A six-­foot-­w ide concrete path bordering the courtyard is lined with built-in tile benches and trellises that offer support for climbing vines and shade for residents. ­There are no recreational or rehabilitation facilities, so this path is a multipurpose activity space that bustles with bodies and noise. When it is cold or rainy, residents retreat to their modest rooms. A typical room sleeps two to four elders in bunk beds—­ the upper bunks are for storage only—­around the perimeter. Occasionally a care worker sleeps on a cot in the ­middle of the room. The rooms are furnished with wooden chairs and ­tables, which are usually topped with electric ­kettles and jars of hot sauce. The larger buildings also have common rooms, with couches against the walls surrounding small tele­vi­sion sets. The rooms are cramped and dim, but the floors are well swept, and the doors and win­dows are often left open to allow air to circulate. The bottom bunks are residents’ only private spaces, and pushed against the walls, they have a cave-­like feel. Tucked in corners or hung from bedposts are ­family photo­graphs and small baskets or bags of tissues and snacks.

Singing Meadows, a Private Elder Care Home Singing Meadows, less than three kilo­meters from Jade Hills, is on a main road lined with wide sidewalks and stops for several major bus routes. The locked entrance, also guarded by an uninterested doorman, is only chest high, as are the silver fences and thick bushes that surround the complex. From the rows of shaded plastic chairs in the front common area, one can look out at the passing traffic and catch a whiff of the neighboring spice market. Broad walkways, with room for round t­ables, chairs, and large planters, separate the two-­story residential buildings that ­house approximately five hundred residents in three hundred rooms. High overhead, translucent panels keep rain out and soften the high-­a ltitude sunshine. Beyond the residential buildings, the sounds of ping-­pong balls and piano m ­ usic drift through the doorway of a recreation room. 74  Growing Old in a New China

Residents and staff members relax in gazebos, chatting, knitting, and playing mahjong. A small t­ emple, massage room, and exercise area are tucked among garden spaces planted by residents with flowers and broad-­leaved plants. Canopied walkways and ramps ensure that even on the rainiest days all residents can easily get from their rooms to the cafeteria without getting wet. The rooms are bright and spacious. Each contains 1–4 full-­size beds with nightstands, chairs, a t­ able, tele­vi­sion set, and small bathroom.

A Rural Public Welfare Home On a good day, the trip to the small mountain town along Yunnan’s northwest border with Tibet, requires a harrowing overnight bus ­ride and multiple minibus transfers, followed by a long walk, or, if you are lucky enough to snag a r­ ide with a passing car, a short r­ ide to town. On a bad day, if the single road is washed out or blocked by a landslide, more walking is involved. Once t­ here, the welfare home is easily located on the far edge of town. Old-­ style calligraphy paintings of el­derly men and w ­ omen cover the plaster walls leading to the fa­cil­i­t y, where the unguarded red doors of the pagoda-­style entrance stand open. Three-­story buildings with upturned roofs, their paint faded to a dusty yellow, surround a courtyard with t­ables and benches nearly hidden u ­ nder knee-­ high grasses and lush bougainvilleas. Residents gather in the shade of the veranda-­like lower level, leaning against scuffed cement walls and smudged red columns. Some sit on low stools or directly on the laminated wood floor, sharing a b ­ ottle of baijiu (白酒), a caustic clear rice wine liquor, though it is not yet noon. Fire extinguishers and handrails hung with mops and articles of clothing line the hallways. Short cement ramps from the ground lead to the first-­floor rooms, which are all sparsely furnished but spacious. The fa­cil­i­t y ­houses ­people of all ages, including a twelve-­year-­old orphan, but most residents are poor and disabled elders without families. Fewer than twenty residents live ­there, so most of the second-­floor rooms are empty.3 The win­ dows have metal bars, but open doors reveal ­simple beds, ­tables, and chairs for furniture. No tele­v i­sions or radios can be heard, but Place and Space, Rhythm and Routine   75

residents entertain themselves by passing around a docile bunny and watery-­eyed puppy or sending someone into town to buy another b ­ ottle of rice wine liquor.

A Geriatric Unit at a Large Public Hospital Arriving at the hospital just before a shift change is an exercise in patience and trust. With only four elevators servicing seventeen floors, a throng of doctors, nurses, and patients rush ­toward each elevator as soon as its door opens, stopping only when the car’s weight alarm begins its harsh dinging. Then, one by one, ­people step out ­until the alarm falls ­silent and the elevator can begin its shaky ascent. This is a general hospital, and the elder care units are on the uppermost floors. With each passing floor, the load lightens, and few passengers are left when the doors open on the sixteenth floor. Following a standard hospital design, the two floors of this geriatric unit feature a central nurses’ station surrounded by patients’ rooms. This floor was originally reserved for lixiu ganbu, or high-­ranking party members, so the rooms ­here—­each of which has only one or two beds—­are larger than ­those on the floor below. However, the smaller rooms are still spacious by Chinese standards. Most of them have three beds, each with a bedside ­table and large dresser. The unit is quiet, decorated in sterile whites and creams. Hallway activity consists primarily of the quiet movement of nurses and doctors. Some patients walk laps with care attendants or ­family members, but most lie in their rooms watching tele­v i­sion or resting. Periodically, the cheery bars of “Oh, Susannah” begin playing over the intercom, and the nurses check the numbers on an overhead electronic board to see which patient has just pushed their call button. As in many Chinese hospitals I visited, a slight scent of cigarette smoke wafts out of the stairwell and mixes with the usual aromas of bodily fluids and disinfectants.

A Shanghai Private Retirement Estate The high-­end retirement complex in Shanghai was still ­under construction when I visited in the fall of 2015, but an illuminated 76  Growing Old in a New China

scale model in the foyer of the main building provided a glimpse into the ­f uture of elite aging in China. A smiling, smartly dressed guide gave a tour of the rehabilitation and recreation spaces, which w ­ ere filled with natu­ral light and state-­of-­the-­art equipment. She s­topped at a large video screen to demonstrate how residents could use this to virtually connect with their doctors at any time of day. The tour also included a look at model rooms equipped with sleek appliances, modern furniture, and sunny decks. Residents could choose from a range of layouts and sizes, customizable based on one’s preferences and care needs. The guide highlighted integrated bed alarms and motion detectors, which would allow f­ amily members to receive virtual updates on the residents’ movements throughout the day. ­A fter each interaction with a care worker, residents would have the option to rate the interaction using electronic buttons located near the doorway, ensuring a controlled care environment for residents and their f­ amily members.

Spaces Becoming Places As the examples above demonstrate, Chinese elder care institutions have a wide variety of forms. My fieldwork observations agree with reports that describe an elder care situation fraught with an uneven distribution of resources, lack of standardization, and insufficient oversight, especially in private institutions (Feng et al. 2011; Zhan, Luo, and Chen 2012). The descriptions above are included to illustrate that China’s elder care institutions do not point to a single ­thing but rather to a shifting situation: the simultaneous emergence of new places and new identities at the nexus of larger and longer pro­cesses. However, in this analy­sis I treat space not as a bounded emptiness but as an opening capacity, a potentiality generated by both tangible and intangible forces: “Space is not the setting (real or logical) in which ­things are arranged, but the means whereby the positing of ­things becomes pos­si­ble. This means that instead of imagining it as a sort of ether in which all t­hings float, or Place and Space, Rhythm and Routine   77

conceiving it abstractly as a characteristic that they have in common, we must think of it as the universal power enabling them to be connected” (Merleau-­Ponty 1945/1962, 243). Furthermore, in my descriptions of ­these “clusters of interaction” (Gupta and Ferguson 1992, 8), I focus less on the systematic and hierarchical aspects and more on the unlikely connections and awkward interactions that create and obstruct ­these potential places (Tsing 2005).

Imagining Spaces Hundreds of dollars’ worth of seafood congealed on the ­table while Xiang Fu picked at a bowl of plain white rice. The waiter had been instructed to hold the spice for the guest of honor, but as she reminded us repeatedly, her Shanghai palate simply w ­ asn’t accustomed to such strong flavors. Out of courtesy, the other diners checked their appetites and scoured the menu for a bland vegetable dish. Xiang, in her forties, was a tuhao (土豪)—­part of China’s growing nouveau riche class. Her bright pantsuit and permed hair hinted at the fashion degree she had pursued before becoming wealthy in the wake of China’s market reforms. The conversation turned to the reason for her visit to our provincial town: her insurance com­pany, with funds flowing in from the mainland, Taiwan, and Hong Kong, was investing in a massive elder care fa­ cil­ i­ t y just west of Kunming. She explained that although she had no interest in elders or medicine, her com­pany saw elder care as a potentially lucrative investment. The building site was still an overgrown patch of land, but Xiang was already certain of its success. Based on a preliminary survey the com­pany had done, ­great numbers of ­people w ­ ere ready to pay RMB 5,000 ($833) per month to secure one of the 10,000 beds in the ­future full-­service community, which would feature a h ­ otel, hospital, education center, garden, restaurants, stores, and even a kindergarten. Excitedly, Xiang explained that eventually the com­pany hoped to connect multiple elder care communities into a network that spanned across Asia and even reached into Eu­rope and North Amer­i­ca. Although not a single 78  Growing Old in a New China

community was yet in existence, she described the membership card that would allow all elders (of a certain class) to travel freely within this international network. Her fellow diners listened politely as they handed their full plates back to the server. No one objected when she called for the check. Much can be gleaned from the answer to the ­simple question: “Who has the power to make places of spaces?” (Gupta and Ferguson 1992, 11). In the past twenty years, the forces of privatization and marketization, growing wealth of private investors like Xiang, shrinking f­amily sizes, and contraction of the welfare state have opened spaces in China in which new elder care facilities can and do take shape. In and across t­hese spaces, unlikely relationships form, awkward dinners lead to business contracts, and money from Hong Kong pays a bulldozer operator in rural Yunnan to clear a rusty patch of soil in an overgrown field. Many of the investments fueling ­these developments are coming from within China, but—as in the case of Xiang—­money also flows across borders. For example, just outside of Kunming, I met a Muslim businessman from China’s Hui ethnic group who was building a Muslim elder care fa­cil­i­ty in Kunming with money from across the M ­ iddle East. Eventually countless interactions and transactions generate places whose emergence creates new opportunities for more unlikely connections. ­These unlikely connections w ­ ere on full display during an after­noon visit I made to Singing Meadows, in the southern district of Kunming. The ­people in the room I was observing had ­little in common apart from the space they shared, which less than five years before had echoed with the footfalls of tired leather workers. Dr. Wang Lu—­from Anhui Province, two thousand kilo­meters to the northeast—­had come to Singing Meadows on the recommendation of a friend. This par­tic­u­lar after­noon, he was ­doing his after­noon rounds and had been held up for nearly twenty minutes by Auntie Zhou, a chatty former teacher in her late sixties. Auntie Zhou’s husband, also a retired teacher, was in the corner, ­doing his best to block out the conversation with the thin pages of a newspaper. Place and Space, Rhythm and Routine   79

Auntie Zhou and her husband w ­ ere from Chongqing, nine hundred kilo­meters to the north, and ­after they retired with sizable pensions in the previous year, they immediately made plans to escape Chongqing’s gray winters and oppressively humid summers. Neither suffered from any major medical issues or disabilities, but the wide range of ser­v ices and socializing opportunities convinced them that an elder care home would be a smarter retirement investment than similarly priced apartments. Auntie Zhou, extremely enthusiastic about the fa­cil­i­t y, explained that its excellent management style is modeled on a Japanese-­ owned institution in Shanghai. A soft knock at the door interrupted Auntie Zhou just as she launched into a descriptive account of her son’s new girlfriend. Wei Qing—­a hugong (护工), or care worker—­walked in with a tray and set down two yogurt cups and straws. Wei explained that she had arrived two weeks ago from a farming village near Chuxiong, a small city 120 kilo­meters west of Kunming. A ­ fter multiple years of drought, her aunt—­who had been a hugong at Singing Meadows for a year, convinced her to take the three-­hour bus ­ride to the city and apply for a job at the institution. Dr. Wang, Auntie Zhou, and Wei are all part of the massive displacement of bodies that has been accelerating in China, flowing primarily from rural to urban areas. The national proportion of urban residents increased from 43 ­percent in 2005 to 56 ­percent in 2015  in China, and from 30  ­percent to 43  ­percent in Yunnan (China Statistical Yearbook 2019). Dr.  Zhang and Auntie Zhou, whose urban registration and wealth shield them from many of the difficulties experienced by rural mi­grant workers like Wei Qing, are not counted among the so-­called floating population, which has more than doubled from 121 million in 2000 to 253 million in 2014 (ibid.). Instead, they are part of a new elder care flow, which in recent years has brought millions of elders into southern provinces like Hainan and Yunnan to escape northern winters (Sina 2016). In the past de­cade this flow has accelerated, moving in multiple dimensions and directions, and the resultant frictions have 80  Growing Old in a New China

created new formations. As Anna Tsing observed, “rubbing two sticks together produces heat and light; one stick alone is just a stick. As a meta­phorical image, friction reminds us that heterogeneous and unequal encounters can lead to new arrangements of culture and power” (2005, 5). In the case of elder care, encounters between doctors and retirees from the north, young ­women and men from the fields, money from the ­Middle East, and technologies from the south and west rearrange former boarding schools, fields, and leather factories to construct elder care institutions as places. But once ­imagined and constructed, how—as space—­are ­these places lived and contested?

Making Space While I sit on one of the benches along the long side of the courtyard path at Jade Hills, my senses are assaulted by a cacophony of shouts, honks, and coughs. Staff members move quickly, delivering laundry, food, and medicine stacked on trays and carts. Supported by ­family members or care workers, residents slowly walk laps, feet shuffling. A ­silent old ­woman in an orange safety vest comes past, sweeping up a handful of stray leaves. She is followed by another resident, Tang Bai, with his flyswatter at the ready. The director, pants cinched high on his round belly, rushes by on flat feet b ­ ehind the small supply van his son is driving. He shouts at a t­able of residents shuffling mahjong tiles. As the van comes t­oward them, honking impatiently, they edge their ­table and wheelchairs closer to the wall to make room. In the garden area ­behind me, hugong pour the contents of stinking black buckets onto the newly turned soil. To my left and right, residents gather in small groups and press tinny radios to their ears; pass snacks around; chat with visitors; or simply sit hunched on benches or in wheelchairs, drifting in and out of consciousness, shifting slowly with the sun. ­These unique tangles of lived spaces, each with its own movements and rhythms, as well as sounds and smells, exist within each elder care institution. McLean, during her work in U.S. Place and Space, Rhythm and Routine   81

nursing homes, observed that the elder care institution “is at once a home, an institution, workplace, a regulated industry, and most often a business . . . ​ each with dif­fer­ ent and often conflicting demands and expectations” (2007, 62). As demonstrated in the description of Jade Hills, each of ­these dif­fer­ent functions also requires its own space. Edward Hall, in an early ethnographic study of space, observed that the experience of space is dependent on “selective attention and inattention to specific aspects of the environment,” so that “what crowds one ­people does not necessarily crowd another” (1968, 84). As any visitor to China learns, tolerance for crowding is higher t­here than in the average country. Crowding, insofar as it is an “awareness that one is being observed,” can be a source of caring closeness or claustrophobic surveillance (Tuan 1977, 60). Space is a l­ imited resource that must be constantly claimed and defended, ­whether on the bus or sidewalk or standing in line. In the caregiving world, many of the usual means of space making are controlled resources. One can slightly modify the question posed above—­“ Who has the power to make places of spaces?”—­asking, “Who has the power to make spaces within places?” If space is the freedom to move and act, to what extent can one move and control other p ­ eople’s movement in turn (Tuan 1977)? At Jade Hills, where space is tight, the first sound you hear when you arrive is the jangle of keys on a heavy ring. In this crowded place, much of the space has already been partitioned. Each upper floor has a locked gate to prevent vulnerable residents from wandering. The courtyard garden has a lock to keep residents from hurting themselves. Meanwhile, the doors to residents’ shared rooms are open at all times during the day. In contrast, at Singing Meadows, a high proportion of residents live in single rooms or with their spouses, and they have the option to shut their doors when they wish. Gardens, recreation rooms, and even the front office, are open to residents and staff members alike. Apart from the front gate, which is a guarded electric door, the only ­thing residents reported being locked was the medicine cabinet that held the sleeping pills. 82  Growing Old in a New China

Private Places In institutions like Jade Hills, where residents share bedrooms and bathrooms and are not able to erect physical barriers like doors or gates, how is space claimed and defended? In an effort to understand the interconnection between a physical body and the space it inhabits, Setha Low theorized that a “person makes space by moving through it” (2003, 16). She used this conception to argue for an expanded notion of the body that extends beyond its material form. She also said that “the space occupied by the body, and the perception and experience of that space, contracts and expands in relationship to a person’s emotions and state of mind, sense of self, social relations, and cultural predispositions” (ibid., 10). While Low emphasized the intersubjective nature of space making, her in­for­mants ­were relatively active and ­free in their movements. However, in caregiving situations, the body might be subsumed into another’s work space, and control of one’s own movement might be severely compromised. I observed a situation like this during one of my first visits to the second floor at Jade Hills. The gate at the top of the stairs was locked, so ­there was l­ittle foot traffic from other residents or visitors. The residents all sat in the hall, facing their rooms, with their backs against the gates that overlooked the courtyard. No one was talking, so I sat quietly, listening to the sounds from below. A ­woman appeared in the doorway of one of the rooms, frowning and looking left, then right. She patted her head, checking that the pins ­were still holding her hair tightly in place. A square black purse was looped over her forearm. Without looking down and still frowning, she reached in and pulled out a black umbrella. She checked her watch and sighed. Ignoring the eyes that followed her quick strides ­toward the exit, she reached the gate and tried to turn the knob. Confused, she asked p ­ eople sitting nearby if they could help her open it, growing more agitated with each “no.” Noticing the growing commotion, a hugong called out, “Grandma, your ­daughter’s on the phone. Answer it quick before she hangs up!” Even though ­there was no ringing, no missed Place and Space, Rhythm and Routine   83

messages, and no phone, the resident hurried back to her room. A few minutes l­ater, she reappeared in the doorway with her purse on her arm, looking side to side, smoothing her hair, and checking her watch. Susan Brownell observed that “where alliance relationships are more impor­tant, we might find that greater symbolic importance is placed on substances that link bodies” (1995, 243). Similarly, in elder care homes, though alliances ­ were not always desired or even voluntary, the flow of substances linked residents and caregivers in the shared work of caregiving. For example, one after­noon a male resident who was sitting on a commode chair had a bowel movement. A ­ fter a few long minutes, a hugong noticed the smell and came over with a mask and gloves. The man was a head taller than the hugong, so it took considerable effort by both parties to keep him balanced against the wall while she removed and replaced the commode tray. Judging by the deepening creases on his face, it was clear that he was distressed by the incident. He apologized and thanked her profusely, and she chastised him for thanking her, saying it was her job. Afterwards she retied his chair to the bars with a cloth strap so he ­wouldn’t fall over. Both resident and caregiver tried to control the body’s “dangerous” margins and the fluids that passed through and over them, but bodies are notoriously leaky (Douglas 1966). In this example and the one above, regardless of ­whether the desire was to hold in (like the man on the commode) or get out (like the w ­ oman with the purse), the inability to define and control the margins of one’s own body space was a source of discomfort for both residents and caregivers. Residents who did have control over their body spaces ­were constantly competing with other residents and caregivers engaged in their own space-­making endeavors. B ­ ecause t­hese personal spaces ­were subjective and fluid, they w ­ ere most vis­i­ble at the margins, where bound­aries—­once threatened, defended, or transgressed—­ must be defined. But as the following observations of Grandma Lan’s space-­claiming experience reveal, residents’ power to defend ­these spaces was often ­limited. 84  Growing Old in a New China

During an after­noon visit to Auntie Ma’s room in Building 1, I was surprised to find Grandma Lan, a resident of Building 9, whose eyebrows ­were penciled a dazzling blue, sitting on the couch. Auntie Ma’s building was small, so residents from other buildings rarely came inside. Grandma Lan explained that she was feeling dizzy, so Auntie Ma had gone to find a doctor for her. I sat down next to her to chat, but Auntie Ma’s hugong immediately shooed us away, saying that one of the residents from Building 1 wanted to come inside and sit down. The hugong tried to show Grandma Lan back to her room, but she ­didn’t want to bother the hugong, so I walked her back instead. When we arrived at her room, she sat down on her bed and showed me a large doll with a hat, a friendly face in her other­w ise sparse corner of the room. She told me about her college years and how she ­hadn’t slept in a bunk bed since ­middle school. Then she leaned back on her elbows and admitted that she was feeling very angry ­today. A hugong had been giving a bath to the resident in the bed across from her and had shaken the bedding out inside the room and piled the dirty linens on Grandma Lan’s bed. Grandma Lan said that she just got up and walked out. She d ­ idn’t want to make any trou­ble, but she was very angry. The anger Grandma Lan experienced over the violation of her bed demonstrates the significance of this personal space. In many ways, institutionalized elders face many of the same challenges that have been identified among mi­grant workers in urban China, including hugong—­who often find themselves sharing intimate spaces with strangers when they relocate. A general discomfort and lack of trust makes it difficult to ­settle in one’s body and environment and leads to a sense of placelessness (Sun 2009). In her work with Aboriginals, Nancy Munn describes features of the Aboriginal landscape “which are concentrated loci of a place’s authoritative power” but “do not define its spatial bound­ aries. Rather, they are the identifying centers from which a space with uncertain or ambiguously defined limits stretches out” (1996, 453). Like Munn’s Aboriginals, the elders at Jade Hills had certain identifying space markers that w ­ ere respected extensions of Place and Space, Rhythm and Routine   85

the body. Most common was a padded cushion, which residents would carry in a plastic bag and use to mark their seats on the benches. ­Those without cushions carried pieces of newspaper or cardboard or sat directly on their plastic bags. Even papers and bags, once used, w ­ ere not shared between residents. If they left to go to the bathroom or to walk a lap around the courtyard, t­ hese items secured their spot ­until they returned. ­Those who did not venture outside had regular seats on couches and chairs within their buildings. Once, while I was sitting on the couch in Building 8, sandwiched between Grandma Lao (a cheerful resident in her nineties) and Grandma Min (an eighty-­year-­old w ­ oman who was only ­there for a short stay), ­Uncle Tang—­a resident who normally sat on the benches along the courtyard—­walked into the room. For a moment he stood in the doorway, sizing up the situation, while residents eyed him warily. Grandma Min asked me in a low voice if he was looking for me, which he confirmed by trying to squeeze onto our couch. Grandma Lao, generous as always, scooted further down so ­Uncle Tang could have more space, while every­one ­else on the couch grumbled. ­A fter a few minutes of small talk, ­Uncle Tang asked, as he often did, if I had any more Yale pens, explaining that he had lost the one I gave him last time. I handed him one, and, satisfied, he headed back out to the benches, which was a relief for every­one. The discomfort caused by U ­ ncle Tang’s sudden appearance in Building 8 illustrated how, in addition to movement and bodies, time and routine shape spaces. The delineation of couch spaces was not simply the result of someone claiming them, but by the same someone claiming them day ­after day. ­Uncle Tang’s appearance was not only a violation of bound­aries but also an arrhythmia in the normal routine of that space (Lefebvre 1992/2004).

Space and Time, Rhythm and Routine An elder care home is not a physical entity so much as it is the rhythms and flows with, within, and across its doors, walls, 86  Growing Old in a New China

walkways, and other physical bound­aries. In his work on the transformation of space on Ho Chi Minh City’s outskirts, Erik Harms shows how one’s sense of time reveals the multiple ­systems of power at work within interpersonal relationships (2011, 102). ­There is an overlap ­here between who controls the space and who sets the time. According to Lefebvre, “everywhere where ­there is interaction between a place, a time, and an expenditure of energy, ­there is rhythm” (1992/2004,15). For many elders the institutional rhythm was that of a droning monotony. “­Every day is the same,” one resident said. Asked about what she does during the day, another replied: “The day is just eat, eat, eat; sleep, sleep, sleep.” The tedium of institutional life is impossible to deny. Time is meaningless, yet every­one is waiting—­ for the sun, meals, visitors, and death. Meanwhile, the overworked staff members move to a much faster rhythm, resulting in temporal dissonance and disharmony. Staff members are often telling residents to “hurry up” or “just wait.” As staff members also determine the timing for meals and ­going to bed, ­these are often out of synch with elders’ internal rhythms of hunger and sleepiness. One morning, while I was sitting with a group of ­women at Jade Hills, the lunch bell sounded. All of the w ­ omen got up to go back to their buildings, except one, a newly arrived resident. She flagged down a hugong who was walking by and asked her, “Where are they ­going?” The hugong replied, “To eat!” “I’ve already eaten,” the new resident replied, confused. The hugong laughed and slowly led the ­woman ­toward her building, saying, “That was breakfast, now it is lunch!” The new resident’s confusion was understandable. Lunch was served at the early hour of 11:00 a.m. to give hugong time to clean up before the after­noon rest period. Eventually, most residents took Lefebvre’s advice “to let oneself go, give oneself over, abandon oneself to its duration” (1992/2004, 27). They ate when they ­were not hungry and slept when they ­were not tired. ­Uncle Tang, one of the few residents with a watch, did not give himself over to the institutional rhythms; rather, he diligently attended to them. Having morning conversations with him was difficult a­ fter 10:30 a.m., as Place and Space, Rhythm and Routine   87

he would check his watch ­every ­couple minutes, despite the loudness of the lunch bell. Once I asked him if the food was good. “No,” he replied, checking his watch. Then I asked if he was hungry. “No,” he replied, checking his watch again. Although ideally his body would “serve him as a metronome” (ibid., 19), only ­Uncle Tang’s wrist gave him a grasp on the rhythm of institutional life.

Conclusion Through attention to “infrastructures in the making,” this chapter highlighted the institutional diversity within China’s current elder care landscape (Biehl and Locke 2010, 318). If one takes seriously the idea that a place is a “concretion of value,” the huge disparity in quality among institutions, especially within the private sector, might give one pause (Tuan 1977, 12). Although ­these institutions, and the hugong within them, provide essential ser­ vices that allow ­family members to devote their energy to jobs and other personal pursuits, the value of ­these ser­v ices is often understated, concealed, or hidden (Buch 2018). In general, discussions of institutional elder care investments calculate only the profit margins between operating costs and residents’ fees. This fails to include the value of increased economic productivity by the f­ amily members, who would other­w ise be providing the caregiving ser­v ices. From an economic standpoint, that is actually the primary value of institutional care, and without appropriate social and po­ liti­ cal acknowl­ edgment and investment, elder care institutions ­w ill continue to be plagued by paper-­thin profit margins and compromised quality of care. Even within institutions, the wide variety of experiences reflects the uneven distribution of wealth and opportunities in many Chinese institutions and society at large—­disparities that could be reduced with state-­level standardization policies and consistent oversight. Despite the best intentions, not all i­magined spaces become real places within the everyday happenings of elder care. Last I heard, the Shanghai investor was in a contract dispute over clearing the land, and the deal was at risk of falling through. However, 88  Growing Old in a New China

t­ here ­w ill be more investors ­after her who ­w ill imagine new places into existence. At that point, caregivers and residents ­w ill take over the construction of the elder care home as place, their coexistence creating and created by shared spaces and times. Yet despite engaging in this cocreation, many residents ­today feel alienated and estranged from both their bodies and environments as they share intimate spaces with strangers and strug­gle with sleep, privacy, and trust. In the following chapters I explore ­these intimate caregiving relationships by tracing the va­ri­e­ties of forms that care takes in historical and con­temporary elder care formations in China.

Place and Space, Rhythm and Routine   89

4 Entanglements of Care The most difficult aspect of writing about care is not finding which words to use, but dealing with the limits of using words at all. —­Annemarie Mol, Ingunn Moser, and Jeanette Pols, Care in Practice

A nurse and a hugong are bent over the bed of a ninety-­year-­old ­woman, trying to insert a nasogastric tube into her nostril. The patient’s d ­ aughter, nearly seventy, is sitting on a low stool, turned away from her m ­ other’s twisting, painful grimaces. The hugong holds the patient firmly and re­adjusts her oxygen mask as the nurse snakes the tube in and down. Once the insertion is complete, the ­daughter approaches, rubbing her ­mother’s feet and legs as she strug­gles to fill her lungs: “­Don’t be afraid, Mom. ­Don’t worry. Take a deep breath.” The hugong holds the patient’s hand and places a few tissues u ­ nder her oxygen mask where it presses against the skin. The d ­ aughter accepts one to wipe away her own tears. When the nurse returns fifteen minutes ­later, the ­daughter is still crying, but the hugong is on the other side of the room, chatting and laughing with another patient’s ­family members. The ­daughter calls the hugong over to help her clean up her ­mother’s stool. The nurse closes the door and attends to another patient, while the hugong gets a bedpan and some warm ­water. The hugong

90

wipes and rinses the ­woman, checking her skin for bedsores and dabbing on red liquid where it looks raw. The nurse looks on and brings a pillow for extra padding. The ­daughter holds her m ­ other on her side and comforts her in a soft voice. When the hugong finishes cleaning the ­woman up, her ­daughter unfolds a well-­worn piece of paper and rec­ords the date and time. ­There is another person in the room, of course—­the observer (in this case, me). She is taking her own notes based on the ­things she can and cannot see. She can see that folded piece of paper quite clearly b ­ ecause it reminds her of an application on her phone where, months before, she recorded her own informal daily pro­ gress report: “Sep. 23, 2013: Mom wrote letters S, T, O; breathed on her own for an hour.” Trying to make sense of the new real­ity, to mea­sure change in the timeless space of illness, she—­I—­clung to absurdly small details. “Sep. 30, 2013: Mom swallowed pudding, was able to move her tongue all around. Overall, a ­really ­great day.” While I observed o­ thers caring for the m ­ other whose body was slowly slipping out of control, my mom was back home trying to regain control of her own. I caught only a glimpse of the void of the loss of the ­mother, but it was dizzying. Now, years ­later, I can see how my own experiences colored my observations of ­family care in China. While I have tried to separate the two situations, it is like trying to remove the dye from a piece of cloth. In the pages that follow, I highlight the relational bonds and exchanges I witnessed in elder care settings, not to disentangle them but to illuminate the complexity of the connections that bind us to each other and explore the relational perspectives that shape the caring experience. At the heart of this story, what draws disparate groups of elders, ­family members, and caregivers together and defines the spaces they share is care. The elder care homes, hospitals, and palliative care wards described in this book are new care arrangements that, as the previous chapters demonstrated, are “embedded within forms of governance and global po­liti­cal economic transformation” (Buch 2015, 287). Despite care’s centrality to this proj­ect and o­ thers

Entanglements of Care  91

like it, conceptualizing care is a challenge. It is familiar and ubiquitous, yet if we try to define it, it proves elusive. Care, a­ fter all, “is not necessarily verbal” (Mol, Moser, and Pols 2010, 10). Like our homes or innermost thoughts, many forms of care are almost “too close to be seen,” and invisibility and discretion are often highly valued, especially for recipients of care (Tuan 1977, 144; see also Sadruddin 2020). Care has been described as a “cognitive and emotional orientation ­toward the other” (Rummery and Fine 2012, 323), a “defining moral practice” (Kleinman 2009, 293), and a “form of ­labour” (Rummery and Fine 2012, 323), as well as a “gift exchange” and an “embodied experience” (Kleinman 2015, 240) that ultimately “seeks to improve life” (Mol et al. 2010, 13). In their recent work on social suffering, Iain Wilkinson and Arthur Kleinman describe care practices in a way that deserves quoting at length. They argue that in acts of care real t­ hings are at stake, including life itself: “In relationships of care we are made pre­sent to each other and are ­there for each other. Emotions are invested and worked through and become the grounds of interpersonal solidarity. . . . ​A focus on care involves us in attending to relationships of vulnerability in which social values are dramatically exposed in terms of their h ­ uman consequences and effects. Care settings engage ­people in social relationships that are saturated with moral meaning as well as material practices and symbolic acts central to lived moral experience” (2016, 161). In this chapter and chapter 5, I examine ­these “relationships of vulnerability” in the elder care context and the values and practices that accompany them. I begin by analyzing the definitions and expectations of care in China and how they have evolved over the past c­ entury. I ask who should care, in what way, and why. Next, I look more specifically at elder care. Through descriptions of everyday care practices, I attempt to illustrate how multiple dimensions of care operate in elder care formations t­oday. I also highlight the affective qualities of care, and through reflections on my own experiences, I try to provide glimpses of ­these ­things that are too deep to be mea­sured, too close to be seen.

92  Growing Old in a New China

Traditional Chinese Conceptions of and Expectations for Care Although t­ here is no term in Confucian texts that directly translates to “care,” scholars have suggested that the virtue ren, (translated as “compassion,” “benevolence,” and “kindness”) contains many of the same ­human relationship princi­ples as the term “care” (Pang-­ White 2011, 376). Composed of the characters for person (人) and two (二), ren is intrinsically relational (ibid.). Ren and xiao (filial piety) form the core of Confucian ethics, and their interpersonal other-­oriented emphases are why Confucianism is considered a relational rather than an individualistic ethical system (Pang-­ White 2011; Wong 2008). However, Confucian ethics support “care with distinctions” (Wong 2008) or “gradation of love” (Pang-­W hite 2011, 382), meaning that although “all ­people are owed moral concern, some are owed more than o­ thers, according to the agent’s relationship to them” (Wong 2008). Based on ­these concepts, the highest moral concern, or care, is owed to one’s immediate ­family and extends outward from ­there. While the instructions for general care might be subjective and relativistic, expectations for elder care are explicit in Confucian texts. As described in chapter 1, Chinese traditional society was patrilineal and patrilocal. Confucian princi­ples dictated that sons should remain in the same ­house­hold as their parents and provide them with physical, economic, and emotional care. Although caregiving was provided through the male line, daughters-­in-­law, as ­house­hold man­ag­ers involved in daily caregiving practices, ­were the traditional caregivers for dependent elders (Wolf 1972; Zhan, Liu, and Guan 2006). Margery Wolf (1972), a pioneer in research on Chinese w ­ omen, noted that although some daughters-­in-­law and mothers-­in-­law found common ground in child raising and sharing h ­ ouse­hold duties, for most w ­ omen this relationship was notoriously contentious. The land reform and collectivization policies that marked the 1950s through the 1970s in China reduced much of the economic

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power that older generations had over younger ones. However, it did not immediately change the caregiving structure of ­family life (Parish and Whyte 1978). Grandparents ­were still encouraged to take care of grandchildren so that both working-­ age parents could work, and geographic mobility was highly restricted. As a result, many families continued to live in multigenerational ­house­holds (Shea 2019). Although ­women ­were active in the workforce, they continued to shoulder a disproportionate amount of caregiving tasks in the home, and relationships between mothers-­ in-­law and daughters-­in-­law ­were a source of friction through the years of reform (Parish and Whyte 1978). As fertility rates declined and residential patterns shifted in response to economic opportunities and work demands in the 1980s and 1990s, elder care expectations—­especially for daughters-­in-­law—­began to change (Shea 2019). ­Today, especially in urban areas, fewer families are choosing to live in multigenerational homes. As a result, caregiving expectations for daughters-­in-­law have under­gone a major shift. In a mixed-­methods study in Shanghai, Jeanne Shea and Yan Zhang (2016) found that daughters-­in-­law accounted for 5.9 ­percent of the community’s primary caregivers, making them only slightly more likely than neighbors (4.3 ­percent) to serve as primary caregivers for elders in the community. Changing co-­residence patterns have also altered the dynamics of the daughter-­in-­law–­mother-­in-­law relationship. One of my respondents, a spirited Jade Hills resident in her eighties, described how t­ hese changes played out in her own ­family: “When China was a feudal society, daughters-­in-­law lived with their mothers-­in-­law, and daughters-­in-­law ­were scared of their mothers-­in-­law. But times have changed. Now some mothers-­ in-­law are afraid of their daughters-­in-­law! Can you believe it? Last week my daughter-­in-­law bought me some new clothes. I ­didn’t need them, but I pretended to be happy anyway.” While her response may not have been motivated by fear, this degree of courtesy shown to a daughter-­in-­law certainly did not follow traditional expectations of deference.

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Elder Care Law and Policy As the structure undergirding the traditional elder care model has eroded, new formal policies have been put in place to clarify responsibilities for elder care provision. A number of policies addressing aging and elder care provision, beginning with the 1996 Law on Protection of the Rights and Interests of the El­derly, have tried to address the gap between care needs and care provision (Shea 2019). This law, in addition to other formal policies, requires ­children (including sons-­and daughters-­in-­law) to provide “economic support, housing and housing repair, payment of medical expenses, instrumental help, taking care of the ‘special needs of the el­derly,’ emotional support, re­spect, attention, and frequent visits” (Shea 2019, 339). Unlike the Confucian doctrine on which they base their authority, con­temporary elder care laws and policies are gender-­neutral in assigning responsibility for caregiving. Considering the huge number of single c­ hildren born under the one-­ ­ child policy, this gender-­ neutral stance makes sense and aligns with reports on current urban in-­home care practices. For example, among the 240 caregiver respondents in their community-­based quantitative survey in Shanghai, Shea and Zhang (2016) found nearly even shares of sons (26.5 ­percent) and d ­ aughters (24.7 ­percent) who ­were providing primary care to elders in their home. However, gendering is multidimensional. While sons and d ­ aughters w ­ ere about equally represented, wives far outnumbered husbands, and overall 63  ­percent of primary caregivers in the study ­were female (ibid.).

Parent-­Child Care In chapter 1 I highlighted the complex dynamics shaping parent-­ child relationships in con­temporary China, showing how the ways c­ hildren demonstrate filial reverence for their parents are mediated by geographic distance, work schedules, economic situations, and competing care demands. As described in the preceding section of this chapter, in social imaginaries and po­liti­cal Entanglements of Care  95

policies, c­ hildren are expected to be primary caregivers for their parents—­but in real­ity, they represent only about half of in-­home primary caregivers (Shea and Zhang 2016). Furthermore, by the time aging parents require intensive caregiving, their ­children are often quite old themselves. Many of the adult “­children” I met in hospitals w ­ ere retired, and their grandchildren w ­ ere in school. For them, parent-­child caregiving responsibilities—­such as making visits to elder care institutions—­did not take away from other obligations or cause economic strain, apart from the medical and transportation fees associated with the visits. Of greater concern ­were the physical demands of caregiving on their own bodies and their inability to address elders’ medical needs at home. For respondents who did fit the description of the so-­called sandwich generation—­working-­age adults concerned with the care needs of both their c­ hildren and their parents—­caregiving was often an anticipatory activity. Dr. Wu, a well-­connected physician at a mid-­size city hospital, was a thoughtful but impatient man. When I waited in his smoke-­fi lled office while he barked ­orders into the phone, I would examine the pile of gifts that ­were constantly arriving: a box of Chu oranges, cartons of cigarettes, and Tang dynasty vases. He was discreet about w ­ hether they ­were for past or ­f uture ­favors, and even I, a not-­so-­well-­connected foreigner, knew how difficult it was to refuse a gift. Unlike most of my other in­for­mants, Dr. Wu was a practicing Muslim. He felt that the lack of religion among many Chinese ­people ­today is at the root of fears about being alone or lonely in old age. According to him, religious ­people are so busy praying and working on self-­ cultivation that they d ­ on’t have time to be lonely. “Loneliness is a state-­of-­mind prob­lem,” he explained to me. Dr. Wu was well respected in the community for his compassion and skills as a physician. When we went out to eat with other physicians and the topic of caregiving came up, they would often comment that the way Dr.  Wu took care of his parents was a model of how a good son behaves. I was interested to observe his par­tic­u­lar model of in-­home elder care, as most of my research had been with elders in institutions, and I was happy to accept a 96  Growing Old in a New China

New Year’s invitation to Dr. Wu’s for dinner. It was too complicated to explain how to get to his home by bus, so Dr. Wu picked me up in his modest sedan. He worked for a public hospital, he reminded me, so it was best not to have a flashy car. As we drove past block a­ fter block of flattened concrete and metal rubble, he explained that he had purchased this h ­ ouse for his parents a l­ittle over a de­cade ago. At that time the surrounding area had been filled with small shops, but every­thing had been razed for new developments. He believed that in the next five years the neighborhood would be rebuilt and bustling again. We continued past some napping dogs and went through a secured entrance that led to a small, gated community of single-­family homes. Dr.  Wu parked in the short driveway and gave me a tour of a fenced yard with persimmon trees in two corners, a small garden, and a patio overhung with gourds. Inside the home, he showed me photos of his d ­ aughter, who was studying business abroad, that sat on a shiny ­grand piano. His m ­ other was in the kitchen, making beef dumplings, while his f­ather read the newspaper. When I asked Dr. Wu ­later about elder care plans for his parents and himself, he explained that he often visits his parents on the weekends and over the holidays, but they are able to take care of themselves. If they developed more intensive care needs, he had money set aside for an in-­home caregiver. As for himself, he did not expect his ­daughter to return from abroad and take care of him. He planned to live at home as long as pos­si­ble and was considering reserving a spot in a retirement community in case he needed more intensive care. According to Dr.  Wu and many of the elders and ­family members I spoke with, as long as a person has zili (自理), or the ability to take care of themselves, they would not choose to enter an elder care institution. In t­ hose cases, the most valuable forms of care an adult child can offer their parents are maintaining relationships through visits and phone calls and preparing for ­f uture needs. One forty-­five-­year-­old physician, who lives several hours from her parents, said that she cared for her parents by encouraging them to do what they want: go on trips, eat out, and spend money buying ­things that made them happy. Another physician, Entanglements of Care  97

a thirty-­five-­year-­old palliative care doctor with no siblings, had already prepared a room in her apartment for her parents, even though her parents have made it clear that they ­don’t want to move to the city u ­ nless they have no other option. Yet despite the soundest plans, many p ­ eople eventually find themselves unable to care for themselves or their ­family members at home and decide to turn to an institution for care. For institutionalized ­people, ­family members continue to be an impor­tant part of the care landscape. During my visits to Kunming hospitals, relatives w ­ ere a constant presence, and as illustrated in the opening vignette, they provided a large amount of instrumental care. In residential facilities, ­family visits tended to follow regular schedules, with traffic peaking on the weekends. In t­hese settings, f­ amily members prepared food; helped wash and dress residents; and provided material items such as pillows, clothing, and cushions to augment what was supplied by the institutions. ­Family members ­were also nearly the only source of affectionate care. While guan’ai (关爱), or showing care and concern for someone, is commonly associated with elder care, the term that elders used more frequently was guanxin (关心). In addition to meaning care and concern, guanxin also includes “expressing interest in.” Once, when I asked a group of residents at Jade Hills what elders need most, one lady laughingly exclaimed, “Guanxin me!” Every­one ­else enthusiastically agreed. That is all elders want, they said: to receive a phone call or visit, to feel cared about as well as cared for. Although residents stated that p ­ eople other than ­family members could also provide guanxin, relatives ­were the preferred source of this type of emotional attention. At all the elder care facilities I visited, f­ amily members visited throughout the week, but on weekends the walkways and rooms would be filled with adult c­ hildren and spouses carry­ing bags of fruit and cookies, pushing wheelchairs, holding residents’ hands, smoothing their hair, and unpacking clean laundry and new clothes. As the opening vignette demonstrated, their attention was oriented t­oward dif­fer­ent parts of the body and mind than ­those that paid caregivers focused on. F ­ amily members typically 98  Growing Old in a New China

attended to the outside parts of residents’ bodies: their hands, ­faces, heads, and clothing, along with their stomachs. ­Family members brought food and snacks to residents e­ very time they visited. In some hospitals I visited, food ser­v ice was not available, or the food was considered too poor-­quality for a sick patient, and families therefore had to be highly involved in this type of care. In residential facilities where elders’ health conditions w ­ ere more stable and their lives monotonous, ­there was often ­little to do during the visits, so adult c­ hildren would sit quietly on the couches in front of the tele­v i­sion set, knitting and sharing snacks or taking slow laps around the courtyard with their parents. ­Family members’ visits w ­ ere often used as a mea­sure­ment of time. Days w ­ ere mea­sured by their distance from the last or next visit. How often ­family members came to visit and how long they stayed w ­ ere signs of their guanxin. However, t­ here was also some ambivalence with regard to visits. For example, Auntie Ma would tell me how much she enjoyed her sons’ visits and would bring up their once-­a-­week routine as a sign of their close relationship. But once, when I inquired about an upcoming visit, she demanded, “What is the point of [him] coming (Lai kan you shenme yong? 来 看有什么用)?” One adult ­daughter, ­a fter visiting with her ­mother, ­stopped on her way out to chat with some other residents, who complimented her on what a filial ­daughter she was for visiting as often as she did. She laughed and said, “Tell that to my mom!” She explained that her mom was constantly text­ing and calling her to ask when she was ­going to visit, even if she had already visited that day. One female resident noted that this tension between the ideal and real­ity of f­ amily care in the context of the institution reflected a deeper h ­ uman desire: “The heart simply longs for love and affection. In real­ity, even at home, t­ here remains this longing for love and affection.” I hear echoes of this truth even ­today when I drive away from a Sunday visit to my childhood home. As the sky turns pink over the fields, I won­der: Was I pre­sent enough? W ­ ere the conversations au­then­tic enough? Did I connect enough to feel satisfied, if that turns out to be our last time together? Entanglements of Care  99

Spousal Care While c­ hildren receive most of the focus in discussions of f­ amily elder care, the real­ity is that over half of Chinese se­niors ­today live in empty-­nest ­house­holds, and in some of China’s larger urban areas that share is closer to 70  ­percent (Q. Li 2017). In a recent article, Shea notes that, despite its being a major source of elder care, spousal care is overlooked and undervalued in dominant Chinese national policies on aging and caregiving: “It is as if it is not r­eally elder care ­until c­hildren need to get involved. Before that, it is just life as usual” (2019, 343). As in other contexts, spousal care in China is highly gendered (Buch 2018). ­Because wives tend to be younger than their husbands, spousal caregiving is primarily performed by w ­ omen (Shea and Zhang 2016). Grandma Li, whose husband was a resident at Jade Hills, had been caring for him at their home a­ fter a poorly treated broken hip left him disabled. Eventually her own back prob­lems made it impossible for them to safely maneuver his body, which was nearly twice as large as her own, and they made the decision for him to enter an elder care fa­cil­i­t y. I heard similar stories from a number of other ­couples: when they could no longer take care of each other, it was not uncommon for both to move into an institution, even if only one required specialized care. For this reason, spouses—­especially wives—­were a major form of care within elder care institutions. At Singing Meadows, Grandma Hua, an eighty-­nine-­year-­old resident who assisted with the m ­ usic program, devoted most of her remaining energy to keeping an eye on her husband, who was always trying to sneak out the front gate. “I feel like I’m getting so old!” She told me, “I’m still alive, but life is so tiring. Even though my financial situation is good and I’m well taken care of, still ­there are ­things I need to put effort into ­doing.” Grandma Hua’s husband’s dementia had progressed rapidly, and although Singing Meadows was thoughtfully designed, it was not yet equipped to provide specialized memory care ser­vices. In the two years they had lived at the elder care home, Grandma Hua’s husband had managed to sneak past the guards 100  Growing Old in a New China

and through the locked gates three times, once taking a bus across town. Sighing as she recounted her long hours of searching and endless vigilance, she explained, “I just feel a l­ittle bit tired.” Grandma Hua’s experience is increasingly common in China. An estimated 96 ­percent of ­people with dementia receive care at home rather than in institutions, with spouses providing the vast majority of that care in urban areas (Z. Chen et al. 2017; C. Wang, Chan, and Yip 2014). ­Because few elder care homes have the training or resources to provide skilled dementia care, many do not admit ­those with serious cognitive decline or other behavioral issues1 (Z. Chen et al. 2017). When exceptions are made, as in the case of Grandma Hua’s husband, spouses are responsible for ­taking on the extra care burden. I met several spouses who, like Grandma Hua, had chosen to move into an elder care home to provide additional care for their partners even though they ­were capable of living in­de­pen­dently. ­Others, like Grandma Li, lived apart from their partners but still continued to provide care through frequent visits. Grandma Li took an hour-­long ­ride on a crowded bus to Jade Hills ­every other day, bringing her husband food and social and emotional support. As has been documented in other research on the topic, t­hese spouses did not bemoan or resent their caregiving responsibilities and instead expressed satisfaction that they w ­ ere still able to contribute (Shea and Zhang 2016).

Self-­Care Outside the back gate of my residential community, part of the sidewalk was replaced by a long strip of egg-­size river stones set on end, so they protruded from the concrete a few inches. A local friend explained that standing or walking on the stones could activate pressure points in the feet for treating vari­ous ailments. When this part of the sidewalk w ­ asn’t occupied, I would walk over it and feel the stones through my thin-­ soled shoes, like knuckles pushing into the ­soles of my feet. Most mornings and eve­nings, one or two elders in socks or bare feet would be slowly Entanglements of Care  101

making their way across the rocky path. Across China’s urban landscape, elders engage in a wide variety of self-­care practices. In open squares, ­people of all ages—­but especially retirees—­gather in the mornings and eve­nings for dancing, qigong, and tai chi practice (Shea 2014). They also use the adult exercise equipment that is common in residential complexes to stretch, strengthen, and massage their bodies. In terms of psychological care and m ­ ental health, many attend classes at what are known as retirement universities or spend time in parks reading newspapers and playing games with their peers. Others, like Grandpa Zhou, pride themselves on their self-­ ­ sufficiency. I met Grandpa Zhou while he was receiving treatment for chronic heart disease at one of Kunming’s provincial hospitals. He was a former teacher, and his only child lived in California. His wife had passed away a l­ittle over a year before, and now, at ninety-­two, he lived alone, apart from part-­time caregiving support from a paid caregiver called Auntie Wei. When I asked him about his experience with aging, he replied: “My belief is that come what may, you live in this world, and you need happiness in life. However, this happiness needs to be based on an inner balance. D ­ on’t envy p ­ eople who are richer than you, ­don’t look down on p ­ eople who are poorer than you. Every­one’s situation is dif­fer­ent, life circumstances are dif­fer­ent—­that’s the way it is. In China we have a saying, ‘Neither intimidated by force nor corrupted by wealth.’ In any case, while you are in this world if you can happily live a common life, that is enough. Happiness consists in contentment.” Indeed, it seemed that Grandpa Zhou lived a common, content, and happy life. I visited him twice at his s­ imple apartment, following him as he carefully made his way up the stairs—­there ­were fifty-­t wo, he informed me—to the fourth floor. His building, like many of its era, had no elevators. When we arrived, Auntie Wei started lunch as Grandpa Zhou prepared coffee for me and Pu-­erh tea for himself. He had a huge collection of tea packages stacked on the ­table, a big flat-­screen tele­v i­sion placed against the wall, and pictures of himself and his late wife 102  Growing Old in a New China

prominently displayed on shelves around the room. He showed me pictures of his d ­ aughter, son-­in-­law, and grand­son. He told me that in his spare time he usually played on his computer, chatted with friends and ­family members on WeChat and QQ , read the news, and watched foreign films. He shared memories of wars and food rations ­until it was time to eat. When we sat down, Grandpa Zhou drew my attention to the balanced meal of braised pork, eggs with tomato, greens, fish, and soup. ­A fter eating, three of his friends, all in their eighties, climbed the fifty-­t wo steps to join Grandpa Zhou for a game of mahjong. They talked briefly about their spouses who had passed away and the En­glish words they knew—­but just as when we ate, we talked about eating, while they played mahjong, they talked about mahjong. Eventually the conversation gave way to the rhythmic clacks and thumps of mahjong tiles on the felt ­table.

Community Care Some cities in China, such as Shanghai, have been investing heavi­ly in community care programs (Y. Zhang 2020). Harnessing the power of strong community networks, ­these community-­ based elder care ser­vices, including small clinics and in-­home visits, are intended to help se­niors stay in their homes as long as pos­si­ble. However, in Kunming, many of the older communities, especially in the inner city, have been demolished to make way for new developments (L. Zhang 2010). Where community networks have weakened, volunteer groups have started to take on some caregiving responsibilities. On one occasion, I joined a Buddhist volunteer group whose members made regular visits to a low-­ income elder care community in Kunming to provide food, medicine, and entertainment to residents. When we arrived, a group of forty or so p ­ eople w ­ ere already gathered in a large community room eating seeds, nuts, and other snacks. For this visit, the volunteers—­ who included adult ­ women and ­ children ranging from toddlers to high schoolers—­had put together a variety show. While the audience remained subdued through most of the Entanglements of Care  103

per­for­mance, a partner yoga per­for­mance elicited excited gasps and loud applause. Afterward, I joined the volunteers for lunch at a vegetarian tea h ­ ouse, where they discussed the pros and cons of bringing medicine instead of snacks to the next visit and possibly incorporating the national anthem into the program to encourage feelings of gratitude for the state-­sponsored housing the residents ­were receiving. To foster greater feelings of community connection, schools have also been encouraging volunteerism among students. One after­ noon, I arrived at Jade Hills to find six middle-­ school ­children and their parent chaperones gathered in front of a small group of residents. They explained that they ­were completing an assignment for school. ­Every semester they ­were given an exercise to increase their empathy for ­those in more difficult situations. This semester they had to visit an orphanage, elder care fa­cil­i­t y, or mi­grant laborer community. The following semester they would have to spend one week ­running a ­house­hold. I followed them as they moved from building to building, dancing and singing to ­music barely audible through their cell phone speakers. Some residents paid no attention to their presence, while o­ thers joyfully bustled around to make room for the guests. Residents marveled over the smooth skin of the students’ hands and arms and laughed in response to questions they ­couldn’t quite hear. ­After an hour or so, the students brought their paperwork to the office to be signed before piling in the van and waving goodbye. As I watched their parents hand them packages of cookies and biscuits, I remembered similar visits to nursing homes in my small hometown, the off-­key songs we sang, the strained conversations that lasted for only one or two questions, and the feeling of relief when I was back in the car driving away—­ grabbing for a snack with my smooth-­ skinned hands, laughing easily with my friends, having already forgotten the visit in anticipation of the day’s next adventure. Within institutions, which are often gated and disconnected from surrounding communities except for rare visits from schoolchildren or charity groups, fellow residents filled the roles of community members and provided an impor­tant source of care. 104  Growing Old in a New China

For example, at Jade Hills, residents would assist with a number of caregiving tasks. One resident, a ­silent man who appeared to be in his early eighties, would take several laps around the walkway, picking up small pieces of debris with a long pincher tool. Younger and more able-­bodied residents would help feed older and disabled residents during meals and clean them up afterward. One resident, Auntie Xiao, told me that she kept an eye on her fellow residents and would occasionally ask her ­children to bring extra clothes and food for residents whose ­children ­didn’t visit them. Although residents often complained that every­one ­else was fengzi (疯子), or crazy, their peers also provided valuable com­ pany, entertainment, and emotional support. At Jade Hills, one of the oldest residents t­ here, Grandma Lao, was especially attentive to her fellow residents. One chilly September morning, I was sitting on one of the benches across from Building 8 with U ­ ncle Gua, who was describing a recent bout of migraines, when Grandma Lao came out of the building, pushing Auntie Xiao in her wheelchair. Old enough that other residents also called her “Grandma,” Grandma Lao was generous and cheerful. This day she was wearing a thick embroidered jacket over her plump frame and an orange knit hat with large puff balls over the ears, which she had pulled low on her head. As soon as she had parked Auntie Xiao’s wheelchair next to us, she knelt down on her ninety-­seven-­year-­old knees and rolled up the cuffs of U ­ ncle Gua’s sweatpants so they w ­ ere no longer dragging along the ground. A few minutes ­later, Auntie Zhong walked ­toward our group. She was crying and wiping her nose on her sleeve, singing a sad refrain about how beautiful we ­were and how her husband d ­ idn’t want her anymore. Auntie Zhong was often lost in sorrow, and Auntie Xiao whispered to me that she was fengzi ­because she had lost all the ­family’s money to a mahjong addiction. However, Grandma Lao listened patiently to Auntie Zhong, saying, “­Don’t cry, ­don’t cry,” and she peeled off thin pieces of carefully folded tissues to give her. It was only 10:30 in the morning, but Grandma Lao convinced Auntie Zhong to go back to her room and rest before lunch. Entanglements of Care  105

Conclusion On New Year’s Eve, a­ fter one too many meals of pork belly and dumplings, I met up with some nurse friends who had stayed in the city for the holiday due to work. They wanted to go out, so we headed to the bar district. Although the rest of the city was quiet, the bar district’s narrow alleys ­were alive with neon lights and club m ­ usic. I was one of the few Westerners inside the crowded club and decidedly underdressed. Businessmen with stomachs bulging against their button-­down shirts insisted on buying us warm beer in exchange for lukewarm conversation. Eventually every­one grew bored, and we moved to the dance floor. Looking around at the crowd, I could see that most of the p ­ eople ­were in their twenties, members of the one-­child generation. Many w ­ ere prob­ably like my friends, mi­grant workers whose line of work did not allow them to return home for the holidays. Yet how strange, I thought, that all ­these potential singletons, ­these ­little emperors, w ­ ere away from their families on this most family-­focused of holidays. A few weeks ­earlier, I had asked Dr. Wu if the hospital cleared out for the holidays, thinking that families would want to bring elders home to celebrate New Year’s. He said no, quite the opposite—­beds ­were fuller than ever. If ­people brought their sick relatives home, he told me, they ­wouldn’t be able to enjoy the holidays. Back in the throbbing club, an emcee decked out in a red silk jacket came on stage and began singing a popu­lar song about f­amily and homecoming. The glittering crowd, with their glasses of champagne and imported beer, earnestly sang along. The year before, while I was traveling in the United States and unable to make it home for Thanksgiving, I had gone to a local pub for turkey and stuffing. I overheard the conversations of other ­people at the bar talking about what a relief it was to be f­ ree, to be out with their friends and done with the suffocating obligation of not-­quite-­satisfying ­family gatherings. As ­people in the Kunming crowd swelled with emotion, singing earnestly of love and ­family, I was reminded of the relief that comes with voluntary separation from the ­things you can never get close enough to. 106  Growing Old in a New China

Increasing work responsibilities and improving economic conditions are reshaping intergenerational residential patterns and social life for Chinese families ­today. More elders are taking care of themselves and each other, freeing their c­hildren to pursue their own happiness and live their own lives. As entanglements of care evolve in urban China, it may be that daughters-­in-­law, as a social unit, are the real beneficiaries of China’s demographic shifts. However, the roles they vacate are quickly being filled by a new, mostly female, class of paid caregivers. In chapter 5, I focus on care that extends beyond the f­amily into the realm of care work, to explore how paid care work is creating new forms of sociality and the limits of ­these relationships.

Entanglements of Care  107

5 Care Work In questioning what care involves ­people ­doing, the conditions ­under which care is practiced, who does the care work, and how well par­tic­u­lar individuals and groups are cared for, we are set to examine the most elemental conditions of ­human sociality. —­Iain Wilkinson and Arthur Kleinman, A Passion for Society

Wealthy Chinese families have long had domestic helpers, but the practice of hiring baomu (保姆), or live-in or hourly wage domestic helpers, did not become a common urban practice ­until ­after the 1980s (H. Yan 2008). Similar to the Filipino domestic workers whom Nicole Constable studied in Hong Kong, baomu are primarily middle-­ aged rural ­ women and are tasked with cleaning; cooking; and caring for ­children, ­house­holds, and elders while middle-­and upper-­class w ­ omen shift their energies from ­house­hold chores to activities that are “more in­ter­est­ing, entertaining, or lucrative” (2007, 22). In New Masters, New Servants, Hairong Yan (2008) notes that in­for­mants often complained that it was harder to find a good baomu than a wife. I heard similar comments from my own in­for­ mants. One well-­off in­for­mant said that her f­amily had gone through over a dozen baomu. Some left ­because they missed home, while o­ thers ­were caught stealing. She recalled one time when they had hired a young man and a young w ­ oman who eventually

108

fell in love and left.1 Another had an infectious skin disease and had to be asked to leave. Echoing many of Yan’s findings, my in­for­ mants mentioned the difficulty of finding h ­ ouse­hold help that was heshide (合适的), or appropriate—­noting that many baomu lacked ­either suzhi (素质), or quality, or wenhua (文化), or culture, or ­were simply guanbuliao (管不了), or unmanageable (H. Yan 2008). ­Because of this, ­there is a growing preference in China’s elder care sector to receive care from hugong rather than baomu. Similar to personal care attendants in the United States, hugong are a ubiquitous presence in all Chinese elder care institutions. Due to the high workload of nurses in Chinese hospitals, many of which have a ratio of one nurse to eight patients, hugong provide a significant portion of care and are primarily responsible for helping residents perform activities of daily living. A four-­week study of direct nursing care delivery in a Shanghai neurological ward revealed that nurses performed only 25.6  ­percent of the total patient care, while the other 74.4  ­percent of direct patient care was provided by relatives, hugong, and nursing students (H. Jiang, Li, Ma, and Gu 2015). Although some might argue that the transition to outsider care is a significant break from Confucian ­family care, a case could be made that the tradition of daughter-­in-­law caregiving was also a form of outsider care. Margery Wolf observed many a mother-­in-­law who felt ambivalent t­oward her son’s wife, seeing her as “a member of her f­amily at times and merely a member of the ­house­hold at o­ thers” (1972, 35). Rubie Watson (1991) also found that during the historical period when marriage was considered an economic transaction for families, a wife’s position was not much dif­fer­ent from the unfree status of concubines and domestic servants. Given ­those findings from Wolf and Watson, one of my original questions was w ­ hether or not paid caregivers and elders would form kin-­like bonds. Occasionally elders would say that a caregiver was like a child to them—­a remark usually made within earshot of that caregiver. More often caregivers would say that

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they treated the elders “as their own ­family members,” but this was usually in the context of actions rather than affect. Indeed, it seemed that although l­ater influential intellectuals, such as Mozi, advocated impartial care for all p ­ eople, the Confucian idea of care with distinction colored relationships between elders and paid caregivers. Part of this was due to the unbridgeable social and cultural gaps between urban elders and their mostly rural caregivers. For example, Grandpa Zhang’s paid caregiver, Guo Xi, was a rural mi­grant in his thirties who had been with Grandpa Zhang since he entered the institution three years ago. Mr. Guo was attentive and friendly, walking arm in arm with Grandpa Zhang whenever he left the room, checking on him throughout the day, and ensuring that he always had a light for his cigarettes. Grandpa Zhang was completely satisfied with the quality of care he received from Mr. Guo, but their relationship was ­limited: “It’s not that I look down on him. Why d ­ on’t I discuss t­ hings with him more often? ­Because some t­ hings he simply c­ an’t understand.” Mr. Guo, who was sitting beside us during the conversation, agreed. Although his hometown was less than two hours from Kunming, he had not finished ­middle school. To Grandpa Zhang, the intellectual distance made true emotional closeness impossible. In addition, many elders expressed concerns about being taken advantage of by caregivers. Profit-­oriented scams—­from fake food scandals and investment cons to feigned traffic accident injuries—­have eroded social trust in China (Y. Yan 2009). News reports and tele­vi­sion dramas often depict elders as especially vulnerable victims of ­these pianzi (骗子), or scams. Once, while visiting Jade Hills, I helped an el­derly resident back to her room when she was feeling light-­headed. When I returned, Auntie Ma, another resident, was sitting outside waiting for me. She chastised me for helping the ­woman back to her room. I was confused, ­because I had assumed that they w ­ ere friends. Auntie Ma told me that I needed to be more careful: t­here ­were bad p ­ eople in the world who would try to take advantage of me or try to steal my money. I told her not to worry, since I d ­ idn’t have any money, but 110  Growing Old in a New China

my levity only annoyed her further. “What if she had fallen and hurt herself?” she asked me. “You would be to blame,” she warned. While elders and ­family members worry about being victimized, paid caregivers also experience work-­ related anx­ i­ eties. Nurses and doctors often shared stories of patient-­perpetrated vio­lence in hospitals. According to one report, more than half of medical staff members reported having experienced verbal abuse from patients or, more often, patients’ f­ amily members, and more than 13  ­percent reported having been assaulted (Buckley 2016). Known as yinao (医闹), this type of hospital vio­lence often results from dissatisfaction with care, disputes regarding negligence, or conflicts over compensation and fees (Yu 2016). Th ­ ose working most closely with patients and families often felt that they disproportionately took the blame in patient-­hospital disputes. Similar to what Elana Buch (2018) observed in the home care industry in the United States, t­ here was a general expectation that care workers would naturally imbue their caregiving practices with empathy, warmth, and kindness. However, this empathetic concern was not expected to flow both ways: the exhaustion and exploitation that care workers experienced ­were often ignored or dismissed as just part of the job they had chosen to do (Buch 2018). One thirty-­year-­old female hugong, who worked overnight shifts in a palliative care unit, explained: “We also sleep h ­ ere, and we cannot go out. [When ­there is a conflict] . . . ​the secret is it is their fault, but they w ­ ill say it is ours. They look down on us as hugong, so we are the bad guys and you can criticize and look down on us. ­Things like this happen sometimes. So working ­here for us . . . ​w ith ­family members and such, is a ­little hard. Some ­w ill say to us, ‘Thank you!’ Some w ­ ill not.” In t­hese intimate, emotionally charged settings, relationships between paid caregivers and ­those receiving care are often fraught with conflicts regarding trust, bound­aries, roles, and expectations, and the historical tensions between mothers-­in-­law and daughters-­ in-­law suggest that this may not be new. Similarly, despite—or perhaps ­because of—­their status as outsiders, both the daughters-­ in-­law of yesterday and the hugong of ­today are charged with Care Work  111

performing the most intimate caregiving tasks, while often receiving ­little recognition for their ser­vices. However, hugong are not ­family members, and as one hospital hugong explained, their care must be motivated by other ethical princi­ples: “Compassion is very impor­tant ­because sometimes the residents get mad and hit you, but you c­ an’t hit back. It is also up to the hugong to know when residents are cold, hungry, [or] sick and take care of ­those needs for them. Even if they wrong us, yell at us, we are still good to the patients ­because they are patients, ­because they ­were brought to our department. We treat them as our own selves b ­ ecause eventually we ­will be old ­people. This is the way I think.” In the section that follows, I explore in more detail the emergence of hugong as a primary source of elder care and their roles in elder care institutions from their own perspectives.

Care Workers: Hugong The residents of Building 8 w ­ ere still slurping down the last of their soup when the hugong began efficiently stacking the metal bowls and plates, wiping mouths, and removing bibs. One ­woman had nodded off, her thick chin resting against her chest. A hugong slapped her cheek ­gently, yelling loudly in her ear, “Grandma! Are you finished eating?” Taking her grunt as an affirmative response, the hugong dumped the contents of her bowl into a waste pan. Two other hugong chatted excitedly about the new shirt one of them had just bought for RMB 35 ($6). She pulled it out of a bag, showing off the lace and sequins and mulling over potential alterations. Their voices drowned out the tele­v i­sion, but the residents seemed unbothered. Once the dishes w ­ ere stacked and ready, each hugong grabbed a tray and headed for the kitchen. The room was suddenly quiet, save for the low drone of the tele­ vi­sion, gurgly breaths, and an occasional cough. Then, just as suddenly, the hugong ­were back, filling the room with loud laughter and clean steaming dishes. Although hugong do the bulk of intimate caregiving tasks and animate the caregiving environment, they are often invisible in 112  Growing Old in a New China

accounts of elder care. Part of the reason is that they are very difficult to interview. In my research I was able to conduct recorded interviews with only eight hugong and informal surveys with five more. At first, most would decline to do an interview, stating that ­either I would not be able to understand their accents or they would not be able to understand my questions. However, ­after I spent more time in institutions, my informal conversations with hugong revealed other reasons for the refusals. In one conversation with a hugong who had been working at Jade Hills for ten years, she explained that it was just too easy to lose her job. She had no insurance, no pension, and no job security. If the ­people in the office heard that she had said anything negative to a foreign researcher, her livelihood, as well as her ­family’s, could be at stake. As is the case for many ­people who engage in paid and unpaid caregiving work around the world—­“the work that makes all other work pos­si­ble” (Buch 2018, 202)—­most hugong I interviewed worked and lived in precarious situations. As part of the massive population of rural mi­grants who account for much of China’s formal and informal ­labor force, most remain in ­these difficult jobs to provide for their families, building webs or chains of care that stretch emotional and economic resources to their very limits (Buch 2018; Hochschild 2000; Heinemann 2013). Research results from hospital-­based studies in Shanghai and Chengdu show that poor living conditions, minimal training, job instability, separation from families, low income, high turnover rates, and physical and time-­related burdens contribute to increased levels of depression among paid caregivers (Hui, Wenqin, and Yan 2013; Liang et al. 2018). Wu Ga, forty-­t wo years old, was originally from Luquan, an ethnically diverse region a ­couple hours northwest of Kunming. Like many of the hugong working in the city hospital’s palliative care ward, her journey to the city was determined by economic necessity and personal connections. She had found the job through her mother-­in-­law’s younger ­sister’s d ­ aughter. Ms. Wu’s ­mother and f­ather w ­ ere in their seventies and eighties and living with her siblings, but she and her husband w ­ ere responsible for Care Work  113

the care of his older relatives. Although her two ­children w ­ ere grown, the ­house­hold still needed to support five ­family members: herself, her husband, his parents—­both in their sixties—­ and his eighty-­three-­year-­old grand­father. She explained: “Who can work? Three are unable to work, so I went out to find a job. Our ­family needed money, so I went to earn some.” She works twelve hours a day, with a half day off ­every two days, and describes her primary job responsibilities as “washing f­aces, washing butts, washing feet.” She also cleans rooms, feeds patients and turns them to prevent bedsores, and chats with the few who are coherent. However, she admits that her favorites are t­ hose who cannot talk and never pepper her with requests. Like nearly all of the hugong I interviewed, Ms. Wu came to do the work on the recommendation of ­ family members or friends. And like her, many of ­those left the countryside to care for urban elders as a way to support their own aging f­ amily members back home. Other hugong—­like Min Zhang, a long-­time city hospital employee—­were part of a group more akin to environmental refugees, who had migrated ­after their villages w ­ ere bulldozed for development proj­ects, poisoned by reckless farming practices, or sucked dry by recent droughts and overuse of ­water. Ms. Min, forty-­one years old, had been working in the palliative care ward for about seven years, ­after being referred by a friend from her hometown. She had been warned that it was a dirty job, but she needed to make money for her ­family, and her son wanted to go to school in Kunming. Her own schooling had been cut short b ­ ecause her ­family was so poor: “That time was so difficult, so difficult. At that time, you had to pay a small school fee, and we ­couldn’t afford even a few dollars. [They told us,] ‘If you d ­ on’t bring the money tomorrow, you cannot be in school.’ We ­were so afraid, so we ­stopped ­going.” Instead she married, farmed, and had two ­children. Per­sis­tent droughts eventually made it impossible for the f­ amily to continue farming, so she and her husband left for work in the city. She had only worked at this one hospital, and according to her, “­every day is the same.” Indeed, when I asked her how many days a week she worked, she replied, 114  Growing Old in a New China

“Eight.” She worked the night shift (from 2:00 p.m. to 8:00 a.m.) ­every other day, earning about RMB 1,400 ($233) a month, and her job was far from stable. “Anyway, I just take it day by day,” she told me. Many hugong had similar complaints about the monotony of the job. In hospitals, they usually worked in shifts, but in some institutions, they worked twenty-­four hours a day. Despite the low pay and long hours, few felt that the job was more difficult than their lives in the countryside had been or the other types of mi­grant ­labor jobs available to them would be. Ji Du’s two c­ hildren ­were already grown and had ­children of their own, but she remembered the time when her ­children w ­ ere young as the most difficult period of her life. The f­amily had no money. If the c­ hildren fell sick, the ­family would not be able to pay hospital bills u ­ ntil ­after the harvest. She knew that her job as a hugong was also difficult and the wages w ­ ere too low, but it ­wasn’t the worst job she had had. She had worked at many jobs—­ cooking at a school in Chuxiong; working as a farmer; opening a kuaican (快餐), or fast-­food stall; ­r unning a shaokao (烧烤), or barbeque; selling clothes; and working construction. According to Ms. Ji, of all t­ hese jobs, the hardest was being a farmer. Even though she was only forty, having basically lived half a lifetime, she felt that some ­people in their ­whole lives never experience such heartache as she had already known. She explained that many younger ­people could not ­handle ­doing the job of a hugong ­because they ­were too accustomed to better conditions. In contrast, her generation had strug­gled more and was better able to endure hardships. For her, the most difficult parts of the job w ­ ere having to take care of men who weighed eighty kilograms or more, being fined if residents fell, not getting paid consistently, and being bored. She made RMB 2,450 ($408) a month and received f­ree room and board, but she worked twenty-­four hours a day. Ms. Ji explained that she had chosen this job over ­others ­because it seemed like a more Christian ­thing to do.2 Even though it was dirty, tiring work and the salary was low, she was still willing to do it b ­ ecause she believed it was what God wanted her to Care Work  115

do. She recalled the first elder care fa­cil­i­t y she worked at, where hugong ­were required to work for one month in the institution’s garden plot, growing crops, before they could start caregiving. ­A fter one day, Ms. Ji de­cided to quit: it was too hot, and she had not moved to the city to work in a field. The second institution was too dirty and unsanitary, so she left and took a job at the elder care home where she currently works. Originally, she thought that this job would entail spending time with elders and helping with cooking and ­house­work, but when she arrived she discovered it was mostly cleaning up urine and feces and lifting residents larger than herself. She often thinks about quitting, but she ­doesn’t want to go back to her hometown and have every­one think that she could not h ­ andle the work. Ms. Wu, Ms. Min, and Ms. Ji are demographically representative of the hugong in the institutions I visited, and their histories are in line with research reports on caregivers in Shanghai and Chengdu (Hui et al. 2013; Liang et al. 2018). All thirteen of the hugong I interviewed or surveyed had migrated from surrounding suburbs or villages. The average age of the twelve w ­ omen and one man was forty-­five, and the ages ranged from thirty to fifty-­three. Similarly, results from one Shanghai tertiary hospital reported an average age of forty-­three for their all-­female sample (Hui et al. 2013). In a tertiary hospital in Chengdu, the reported average age was forty-­eight, but male hugong accounted for 32 ­percent of that sample (Liang et al. 2018). Although retirement age in China is between fifty and fifty-five for ­women and sixty for men, when I asked hugong how long they planned to work as care workers, most gave responses along the lines of “as long as I am able to” or “as long as they want me.” As ­these results demonstrate, in cities across China, the typical hugong is a middle-­aged w ­ oman, yet institutions often sought out younger workers and male hugong who ­were better suited to the physical demands of the job. For example, one institution had an age cap of fifty for female hugong and fifty-­five for males and paid male workers RMB 100 ($17) more than females per month. However, as Ms. Ji noted, younger workers w ­ ere not considered as 116  Growing Old in a New China

reliable as older workers, and both man­ag­ers and elders complained about the high turnover rates at this institution. High turnover rates ­were also reported in Shanghai to be a significant threat to the quality of care (Hui et al. 2013). Although I observed and spoke informally with male hugong in both hospitals and elder care homes, I was able to formally interview only one male hugong. Like many of the other male hugong I met, forty-­eight-­year-­old Wang Hong was married. His wife, also in her forties, worked as a hugong at the same hospital. I interviewed Mr. Wang in the long, wide hallway of a well-­respected geriatric hospital in Kunming. He was cracking pumpkin seeds open and passing the kernels to an el­derly male patient seated beside him. Originally from a copper mining region on the outskirts of Kunming, Mr. Wang and his wife had come to this hospital eleven years before, ­after hearing about the job from a niece. He worked seven days a week and slept on a cot in a hospital room with three to four patients. On a good night he got about four solid hours of sleep. For him, the job was more psychologically challenging than it was physically difficult. He had worked at other jobs in the city, like construction, and he thought that they ­were more difficult than this. His most impor­tant responsibility was turning patients to prevent them from getting bedsores, and the most difficult part of his job was cleaning up feces and urine. He explained that this was mostly b ­ ecause some patients, like the one sitting next to him, had dementia and could be uncooperative when they did not understand why he was performing ­those tasks. Despite the difficulties, Mr. Wang was very satisfied with his job: “Even though the work is pretty hard, nurses and doctors treat us well. Upper management is also very good to us, so I’m very satisfied.” It is hard to say how long he ­w ill stay at this job: “If my health remains good, I’ll continue for a while.” This per­sis­ tence was one of the most impor­tant qualities for a good c­ aregiver, he explained, in addition to “compassion, a balanced temperament, the ability to suffer hardship, and no fear of dirty work.” He believed that d ­ oing his job was a kind of filial piety, and he saw the patients as part of his own ­family. He attributed this Care Work  117

attitude to an awareness that “every­one w ­ ill get older. At the very least, they need to feel cared for.” As Mr.  Wang noted, the hospital he worked at valued its hugong and prided itself on the quality of its caregiving staff. My ­later conversations with the hospital’s nursing director, Song Xin, confirmed Mr. Wang’s statements. Director Song, in her fifties, had been recruited from a small city on Yunnan’s western border about a de­cade ­earlier to try to revive the then-­failing hospital. She was passionate about elder care and worked tirelessly to develop training programs for caregivers and improve institutional care. Director Song believed that the key to an institution’s financial success was providing high-­quality care, and that this was accomplished by ensuring that caregivers ­were happy and well taken care of. Hugong at her hospital received higher wages than average—­for example, Mr. Wang made RMB 3,000 ($500) a month, more than any other hugong I interviewed. The nursing director also reported that the hospital would make ­every attempt to address any personal issues that might interfere with work or increase turnover rates, such as by paying a hugong’s ­children’s school fees or hiring multiple ­family members—­like Mr. Wang and his wife. In addition to higher pay and job security, the hugong at this institution received exceptional training. Mr.  Wang remarked that b ­ ecause of this, ­family members of patients often tried to recruit them to take care of their relatives at home or in other institutions.3 The training and professionalization of hugong are crucial concerns in the nascent paid care worker industry. At the time of my research, regulations and standardization ­were lacking, so each institution developed its own standards for training. In agreement with the majority of institutions I observed, data from the abovementioned Shanghai hospital revealed that although 98  ­percent of hugong ­were trained, the training lasted only one or two days (Hui et  al. 2013). In contrast, Mr.  Wang reported that hugong at the geriatric hospital received anywhere from one to three weeks of formal and on-­ the-­ job training, depending on how quick a learner one was. 118  Growing Old in a New China

It appeared that Director Song’s philosophy had produced the desired results. A ­little over a de­cade ­after her arrival, the formerly decrepit clinic had become a well-­regarded hospital that was filled beyond capacity. I spoke with one eighty-­five-­year-­old male patient, who had mobility prob­lems related to diabetes. Friendly and intelligent, he was a lixiu ganbu (see chapter 2), and therefore he had enough money to pay for long-­term care at any number of Kunming’s elder care institutions. He told me he was very satisfied with the care he received at the geriatric hospital and c­ ouldn’t think of a better place for elder care. Although Director Song’s geriatric hospital pre­sents a strong case for how to improve quality of care, some questions remain: What is quality care? How is it mea­sured? Exploring ­these issues not only elucidates the range of elders’ experiences but also “brings a spotlight to con­temporary power relations” as it “sets in bold relief the asymmetry between ­those who are most valued and ­those who are hardly valued at all” (Wilkinson and Kleinman 2016, 161).

Quality of Care I was sitting at a ­table with Ms. Ji, an elder care hugong introduced above; an eighty-­year-­old male resident; and his wife, who was visiting for the after­noon. The wife had brought a few pears, and we w ­ ere all happily crunching away as she deftly carved the fruit and handed out slices. The husband sat quietly, occasionally removing his dentures to shake pear remnants into a wastebasket, while his wife described the stroke and broken hip that had led him to this elder care home. It was a higher-­end institution, so they could not both afford to live t­here. Instead, she continued living at home and came to visit him once a week. “The quality ­here used to be much better,” she sighed. Curious, I inquired further. I had heard similar sentiments from care workers and other residents. I asked what had changed and why, but my questions brought the conversation to a halt. The wife shrugged. Ms. Ji, who had recently complained about not getting paid in months Care Work  119

and was considering leaving, was equally reticent. Neither could explain what had changed, and they eventually tried to end the line of questioning by explaining that actually t­ hings ­were “okay.” Seeing that I was at a loss, the husband fi­nally chimed in: “They used to have five dif­fer­ent dishes, but now ­there are only three.” This comment opened the floodgates, and soon even ­people at nearby t­ables w ­ ere adding to a chorus of complaints related to every­thing ranging from meat quantity to improper seasoning and overcooked rice. That interaction demonstrated the difficulty I often experienced when trying to elicit candid opinions about the quality of care in Chinese elder care institutions. Often t­ here was a lingering concern that a conversation might be overheard or misconstrued. One resident in her seventies, who usually refused to discuss her feelings about the quality of her elder care home, the management, or the caregivers, fi­nally agreed to an interview during my follow-up visit in 2015. ­A fter checking to see that no one e­ lse was within earshot, she lowered her voice and said, “This place is ­really terrible, but ­don’t single out this one place specifically. It is representative of the ­whole situation. . . . ​Government officials might treat me badly and say, ‘Why are you talking with her like this?’ Right?” In addition to fears of retribution from power­f ul outsiders, the intimacy of caregiving relationships puts elders—­and, as hugong reports show, caregivers—in a vulnerable position. ­These ­factors all contribute to the challenge of discussing quality of care. Furthermore, both care and quality are subjective, complex concepts. In her work on care practices, Annemarie Mol acknowledges this inherent difficulty: “It is that somehow writing about the goods of care is just too nice. Too cosy [sic]. Th ­ ere are also bads to address, but how to do so? In the pre­sent context, engaging in criticism would be gratuitous. I would risk nothing by passing moral judgments. So what I seek, instead, but cannot quite find, is a good tone for writing about care practices that do not live up to the ideals of ­those who do the care work. How, while telling stories, to address the ever pressing scarcity of time to care, or the just not 120  Growing Old in a New China

good enough taste of the food?” (2010, 229). Taking that line of questioning further, what of the care workers who are also engaged in the caregiving relationship? How can we account for the pain, suffering, and vio­lence they experience (Buch 2018)? Rather than trying to identify good or bad care, my approach is to follow the footprints of care in everyday practices: tracking it through food, in words, over bodies, in clothes, and on surfaces. Mary Douglas observed that the main function of cleanliness norms is “to impose system on an inherently untidy experience” (1966, 4). In elder care institutions, everyday care practices fulfill a similar purpose. Signs of disorder often indicate a lack of attention or an unfulfilled care need. Inattention can lead to disorder in overabundance (full commodes, crowded rooms, and unpaid bills) as well as in deficiency (underseasoned food, empty w ­ ater ­bottles, and understaffed facilities). In caregiving institutions, this often results from staff members’ being overextended and competing demands for their attention, which is ­limited. Therefore, I see care not as a ­thing, but as the energy that is activated by and transferred through attention, which I call “attentional energy.” As with other forms of energy, attentional energy is ­limited and dependent on its source (attention). In this chapter, I look for how it is manifested in accordance with specific caregiving roles and relationships, and how this energy is distributed, transferred, blocked, and augmented.

Management—­C are through Guanli According to staff members and residents at Singing Meadows, one of the nicest elder care facilities I visited during my fieldwork, the institution’s success could be attributed to good guanli (管理), or management. U ­ ncle Bo, a Singing Meadows resident in his late seventies, pointed out the signs of this good guanli during an impromptu tour of the fa­cil­i­t y. When I first met U ­ ncle Bo, he was sitting in the lobby of the office, wearing blue-­striped pajamas on his tall, thin frame. He looked up from his newspaper as I walked past to check in with the worker at the front desk and gave me a friendly, sparse-­toothed smile. He seemed ­eager to Care Work  121

chat, so I sat down and asked him about his life. He asked if I could tell that he was not native to Kunming and was actually a northerner. He had moved to Chongqing from Henan with his ­family when he was nine years old. He clarified the point: “We did not ‘move.’ We escaped a famine.” The country was in chaos, and his f­amily had no food to eat and no clothes to wear. He did not receive much of an education, but he eventually got married and had five ­daughters. ­Uncle Bo explained that he had come to Singing Meadows the previous August ­ after an intestinal operation. Uncertain about the extent of my medical vocabulary, he lifted his pajama top to show me a small piece of intestine poking through his skin that was attached to a yellowed ostomy bag. He had spent forty-­ seven days in the hospital before coming to Singing Meadows. Although the fees w ­ ere a l­ittle higher than what he received for a pension, his c­ hildren helped cover the remaining cost, and he was very satisfied with the institution. He described the variety of food in detail: t­ here ­were six dif­ fer­ent dishes at dinner, and the breakfast menu changed ­every day. He detailed the dif­fer­ent fees for each level of care and the wide range of activities offered. Then, folding up his newspaper, he offered to show me what he was talking about. As we walked, he pointed out garden spaces, activity rooms, electric heaters, no-­ smoking signs, and a suggestion box. I asked if he had put any suggestions in the box, and he laughed and said no: “If I had any suggestions, I would just tell them!” He explained that on occasion the residents received haircuts and basic checkups for f­ree. We also talked about how strict and good the guanli was, and he walked me over to a large poster board hanging in the hall that listed the institution’s rules. A list of infractions and fees for all staff members was also prominently displayed in the office. He recounted that once a resident was not reminded to refill their prescription and ran out of medi­cation. Even the doctors ­were fined RMB 100 ($17) for the incident. This responsibility for guanli lies in the hands of directors and is their primary way of attending to and caring about the 122  Growing Old in a New China

institution as a w ­ hole. While residents expressed appreciation whenever management staff members spent time talking to them, they did not expect this or highlight it as the sign of a caring man­ag­er. Instead, indicators of guanli ­were manifested primarily in rules, food se­ lection, and money-­ related concerns. When attentional energy was directed at the first two, that was a sign of good guanli, while too much attention to the third usually indicated poor management. For example, at Singing Meadows, residents would often complain that the man­ag­ers ­were “just in it to make money.” Similarly, f­ amily members, who w ­ ere usually reluctant to criticize the management outright, would say that the “fees ­were too high”—or, as one resident commented, “the fees are too high for how bad the food is.”

Hugong—­C are through Zhaogu Caregivers ­were expected to provide zhaogu (照顾). This type of caring for, attending to, or looking a­ fter, was related to everyday needs. As the section above on hugong demonstrated, zhaogu centered around tasks related to bodies, food, and cleanliness. Ms. Ji, the Christian hugong introduced above in this chapter, took g­ reat pride in her attention to the care needs of the residents. This attention was vis­i­ble on the skin and clothes of the men she cared for. For example, one of her residents, who was in his eighties, was a former army officer. Although his dementia had progressed to the point where he could no longer speak, his skin and eyes w ­ ere clean and clear, and he wore a dark blue suit without a wrinkle or stain. The hugong’s most l­imited resource was time. At Jade Hills, this was the primary form of energetic exchange and attention. One hospital hugong described her approach to the job: “What­ ever way the old person does t­ hings, I do it the same way. If she is slow, I also move slow.” For hugong, higher inputs of time-­related attentional energy ­were evidenced not by fast-­paced work but by slower speeds, pauses, and stopping. For example, in preparation for meals, some hugong would push wheelchair-­bound residents back to their room very quickly, ignoring requests to slow down, Care Work  123

while ­others would go slowly, allowing residents to stop as they wished. In other instances this was manifested in the hugong’s level of willingness to give or take time. I observed this rationing of time by Auntie Ma’s hugong, Zhi Chun, which intensified during meals. Ms. Zhi, a stocky, middle-­aged ­woman u ­ nder five feet tall whose hair was pulled back in a tight bun, rarely smiled or spoke. She was responsible for two adjoining rooms of elders, with four men in one room and four ­women in the other. The residents ­were aware of Ms. Zhi’s heavy workload and rarely seemed offended by her brusque manner. For example, during an after­noon milk break, I observed Ms. Zhi telling Auntie Ma to hurry up and drink her milk so she could wash the dish. Auntie Ma drained her bowl immediately and handed it to Ms. Zhi, who left for the kitchen. When Ms. Zhi returned, Grandma Ma asked if she could fill her ­water b ­ ottle. Ms. Zhi was tidying the room and told her to wait. ­After she had finished sweeping, she left the room without a glance in Auntie Ma’s direction. In U.S. nursing homes, Athena McLean observed that a “premium on time” has led to the prioritization of “body task-­centered care over person centered care” (2007, 34). However, in lower-­end elder care institutions like Jade Hills, hugong ­were also responsible for ­house­keeping tasks, which forced them to spread their attentional energy even thinner.

A Circulating Resource In caregiving institutions, staff members, families, and residents are all aware that care, in the form of attentional energy, is a “circulating and potentially scarce social resource” (Buch 2015, 279). For the energy of care practices to circulate through a caregiving institution, established pathways are needed. This usually begins with man­ag­ers and supervisors establishing clear standards and paying close attention to any signs of blocks or leakages. At Singing Meadows, the twenty-­five-­year-­old vice director explained how her institution maintains a healthy system: “­Every day, a few of us go around and ask the elders, ‘How was the food t­oday?’ 124  Growing Old in a New China

Then t­ hey’ll say, ‘This food was such-­and-­such a way.’ Then they ­w ill tell us which foods w ­ eren’t good. Then the next time we visit we ­w ill pay attention to their physical appearance or, for example, the hot ­water—­these very ­simple t­ hings.” However, even in well-­managed institutions, care demands are high and care resources are ­limited. As stated above, the quality of care is directly related to the levels of attentional energy. To maximize that energy, residents employ a number of techniques that give them some control over the quality of care. The first is conservation. For example, Grandpa Zhang, who was unfailingly matter-­ of-­fact and modest, said this about his relationship with the hugong at Singing Meadows: “Of all the residents ­here, I have the best attitude t­ oward the hugong. I’m not trying to flatter myself. I have never required hugong to do anything. I d ­ on’t make any requests. I have never had a single issue with any hugong. For example, e­ very day they clean my room, and sometimes they might not do something quite right. I ­don’t say anything. . . . ​Many old ­people are not like this. They want this, they want that. Even though the hugong ­don’t dare refuse, they ­won’t work as earnestly.” In addition to conservation, man­ag­ers, residents, and f­amily members add their own energy to the system in an effort to augment that of the caregivers. For example, the nursing director at the geriatric hospital, Director Song, based her management style on the belief that the more care that is shown to hugong, the better their caregiving ­will be. This management-­level care is manifested through re­spect, higher wages, job stability, and even involvement in hugong’s private lives—­for example, helping to pay ­children’s school fees or offering jobs or lodging to relatives. Similarly, hugong like Ms. Ji expect that the efforts they put into caring for the residents w ­ ill improve management’s treatment of them, increasing the likelihood that supervisors w ­ ill side with them during patient disputes and raise their wages. F ­ amily members also make attempts to enhance their relatives’ care by being very friendly to management and hugong, paying fees on time, and bringing hugong small gifts of food or money. Similar to practices in other postsocialist contexts, t­ hese exchanges provided f­ amily members with a sense of Care Work  125

productive agency and a sense of connection to or control over their relatives’ pre­sent and ­future well-­being (Praspaliauskiene 2016). I met Mr. Chu and his wife one weekday morning while they ­were at Jade Hills visiting Mr. Chu’s m ­ other. They w ­ ere retired, and their c­ hildren ­were living on their own—­one in Shanghai and the other in the United States. A former musician, Mr. Chu was soft-­spoken and had an easy laugh. He had four siblings, and they all had dif­fer­ent ideas of what to do about their ­mother’s care. She had lived at Jade Hills for six years, and Mr. Chu felt that the conditions w ­ ere not good. He suspected the fa­cil­i­ty’s owner was just in the business to make money. He said that he had talked to the director and threatened to move his m ­ other to another nursing home, but the director had told them that the homes the Chus could afford ­were all the same. Mr. Chu admitted that it was difficult to know the truth. Adding to the difficulties of assessing the quality of care, in China ­today t­here is an “increasing anxiety about the quality, authenticity and value of ­people, goods and words” (Bregnbaek and Bunkenborg 2017, 1). De­cades of slogans and propaganda followed by a new era of advertisements and futuristic billboards have engendered “doubts about the interior make-up of ­things” (ibid.). Mr. Chu was concerned about the quality of care his ­mother was receiving at Jade Hills, but he did not know how to find out if another place would be better. He thought that her hugong ­were not intentionally providing poor care but ­were simply stretched too thin. He had begun giving his ­ mother’s hugong a ­ little extra money ­ every month, and that seemed to have improved her care somewhat. Most residents had ­limited access to money in the institutions, so they had to find creative ways to add to the system. One of the most commonly employed techniques was flattery. Although Auntie Ma rarely spoke about her short-­tempered hugong, introduced above, when she did, she made sure that Ms. Zhi was within hearing distance. On one occasion, Auntie Ma’s son had brought her a bag of spicy fried potatoes. Auntie Ma repeatedly tried to give some to Ms. Zhi, but she refused. I was happy to help her eat them, so we sat on the couch passing the bag back and forth while 126  Growing Old in a New China

Ms. Zhi sat at the t­able watching the tele­vi­sion, her back to us. Unprompted, Auntie Ma said to me: “She is like my ­daughter. She is so hardworking, so g­ reat. ­Every morning she wakes up at 6:30 and helps the residents get dressed, wash[es] our f­aces, brush[es] our teeth. E ­ very day she has to clean butts. Then ‘my d ­ aughter’ gets breakfast, washes dishes, helps with medicines . . . ​it is very difficult. I am willing to live with ­these hugong instead of my own ­children b ­ ecause the hugong take better care of me.” Despite ­these efforts, sometimes the flow of attentional energy was blocked or sapped. This occurred in the case of Ms. Ji, the hard-­working Christian hugong. Ms. Ji put a ­great deal of effort into maintaining a high level of care for her residents. She made beds, or­ga­nized rooms, and saved food from breakfast to prepare as snacks ­later in the day. When the quality of food in the cafeteria began to decline, she would share the meals she had prepared secretly in the room on a small electric cooktop, with vegetables purchased at a nearby market. However, a few weeks ­after I met her, she began asking if I knew of any other elder care institutions that ­were hiring. She confided that she had not been paid in two months. As a result, she began decreasing the amount of food she cooked for o­ thers and began devoting more attention to caring for her grand­daughter, whom she had brought to stay with her.4 When I spoke with the man­ag­er at Jade Hills, he explained that ­these types of situations arose from a host of complex forces affecting the circulation of resources within an institution: “­Every year we are required to increase the hugong’s [monthly] wages by about RMB 100 [$17]. It is required by the government, but where does this money come from? From the elders’ fees. But then elders say to us, ‘If your fees get any higher, we c­ an’t afford them.’ . . . ​ Right now the quality of nursing care h ­ ere is very low. B ­ ecause if you want to raise it, you have to raise fees, but the fees ­can’t get any higher than they are now. This contradiction has resulted in our inability to raise the quality of care.” Just as Buch (2018) observed in the U.S. home care system, poverty and in­equality are inextricably linked with caregiving practices, and it is often the p ­ eople who most need care who are least able to afford it. Care Work  127

Conclusion It is difficult to talk about the quality of paid care in Chinese institutions. Caregivers are too busy, residents are too reticent, and my own observations are mere snapshots of practices that may or may not represent the lived experience of caring or being cared for. Nonetheless, care is everywhere in ­these institutions and serves as both their foundation and their purpose. In this chapter, I tried to capture this ubiquitous, elusive attentional energy as it is manifested by vari­ous elder care actors through a variety of forms and practices. While it is a renewable resource, the energy required for care is variable, unwieldy, and in high demand. To maximize it, caregivers, elders, and their ­family members employed strategies of conservation and augmentation. Using concepts of energy, augmentation, and blockages to speak about care illustrates the draining effects of long-­term care and the fact that bad care is often the result of the misallocation or depletion of resources—­attentional, emotional, financial, or other­wise. As care increasingly moves out of the home and into the public sphere, liberating daughters-­in-­law and employing hugong, ­there is an ongoing effort to increase levels of social care. Within the caregiving sector, nurses are opening training centers for the burgeoning hugong industry. Schools are encouraging students to volunteer in elder care institutions and orphanages. From self-­help movements to disaster relief volunteering, t­hese and other examples of “per­sis­tent tinkering in a world full of complex ambivalence and shifting tensions” represent the shared h ­ uman effort to improve the quality of life for oneself and ­others (Mol, Moser and Pols 2010, 14).

128  Growing Old in a New China

6 Chronic Living, Delayed Death How do I know that delight in life is not a confusion? How do I know that in hating death we are not ­little ones who have lost our way home? —­Robert Eno (Trans.), Zhuangzi

The parade of ­people began filing into Jade Hills’ Building 8 around 2:30 p.m., shortly a­ fter hugong passed around the after­ noon milk. I was one of five p ­ eople squeezed onto a long couch in the small common area between the main entrance and the residents’ rooms. The residents w ­ ere all bent over metal bowls of steaming milk, sipping noisily, while I—­unable to refuse the insistent generosity of Grandma Li on my right—­nibbled at a stale biscuit. At first the ­people walking past seemed to be on a routine visit to a bedridden patient in the dim corner room, but as young m ­ others with toddlers on their hips, businessmen on cell phones, and teen­ agers in bedazzled T-­shirts dis­appeared into the room, it became clear this was not a normal visit. A man yelled. Unfazed, my couchmates fished for soaked biscuit chunks and strings of congealed milk that had sunk to the bottom of their bowls. ­A fter a few minutes, the visitors walked out, wearing expressions ranging from anger to impatience or boredom. Residents slid their empty bowls onto low wooden t­ ables. A group of hugong pulled on blue gloves and entered the corner room, while ­others wheeled a metal t­ able into the open space directly in front of our

129

couch. One hugong emerged from the room carry­ing a large black garbage bag, followed by two more hugong—­each barely five feet tall—­clutching opposite ends of a faded pink sheet that had been loosely wrapped around the body of the deceased resident. They shuffled out of the room and heaved their swaying bundle onto the wheeled t­able with a plop, rattling the empty milk bowls. A few residents watched, expressionless, as the gurney bumped around t­ables and over the uneven floor, its unsecured cargo jouncing unceremoniously on the journey to the van waiting outside. In the quiet that followed, I expected some response to the incident, but the only utterances w ­ ere the usual burps and sighs of a drowsy after­noon. When I asked a resident ­later how she felt about the death of the resident, she replied, “I envy her.” In the beginning, according to the Book of Genesis, death and decline slithered onto the scene as punishment for wickedness and moral weakness, establishing a separation between God and ­humans, good and evil. The implications of this narrative have influenced Western thought on aging and d ­ ying for millennia and continue to shape con­temporary bioethics, health initiatives, and global aging models. In social gerontology, ­there is a recognized tension between conceptions of aging as a lifelong pro­cess and old age as a separate, distinct period of life—­a tension that informs and is informed by policies and eligibility criteria for age-­ based ser­v ices (Grenier 2012). On a societal level, chronological age has an assumed significance for dividing the life course into distinct stages, while at the same time t­ here is a pervasive belief that the “aging self is, ideally, an ageless self ” (Lamb 2014, 46; see also Marshall and Katz 2012). “Healthy” aging is “active” and “in­de­pen­dent” (World Health Organ­ization 2016), and the body’s decline is fought, delayed, or avoided in ­favor of youthful immortality (Rowe and Kahn 1987; Wade 2016). While curative, life-­ promoting ideals encourage positive visions of lifelong potentiality, they also generate dissonance in the face of a­ ctual experiences with incurable conditions and failing minds and bodies. In her research in U.S. medical institutions, Sharon Kaufman described the “zone of indistinction” that 130  Growing Old in a New China

is characteristic of end-­of-­life medical encounters, where diverse understandings and expectations about aging and ­dying converge with institutional practices that are in constant flux (2005, 273). A so-­called good death is often at odds with the curative goals of medicine or stymied by ­limited physical, economic, or ­human resources. Bioethics, medical interventions, and technological advancements work together to defeat aging and delay death, but they offer l­ittle guidance for ­people who are saved but not cured and suddenly are thrust into a “gray zone” between life and death (Kaufman 2005, 62; see also Kaufman 2015). In con­temporary urban China, ­these end-­of-­life encounters are unfolding within a larger caregiving landscape that is itself in transition. Increased migration, urbanization, w ­ omen’s employment rates, and access to medical ser­v ices are radically altering caregiving arrangements (Broad et  al. 2013). Sharp declines in fertility have sapped family-­based caregiving resources and put enormous pressure on medical institutions (Yeoh and Huang 2014). Although many countries, including China, are just beginning to feel the effects of rapid population aging, demand for end-­of-­life institutional care has already outstripped supply. The few palliative care wards that exist routinely turn patients away, admitting only t­hose whose end is predictably soon. In the pro­ cess, ­dying becomes a diagnosis, complicated by insurance regulations, local bioethics, and ­limited resources. For ­people cut off from both curative and palliative care, life itself becomes pathological, and they find themselves suspended in a state of what might be called chronic living. Like other chronic illnesses, chronic living is characterized by the excess of an other­w ise benign condition that becomes pathological when it crosses the subjective boundary of too much or, more often, too long. Life lingers, intractable and incurable. This attention to chronic living is in line with a growing focus within the social sciences on the practices and experiences of “morbid living” (living with a disease), as opposed to “healthy living” (Wahlberg 2018, 743). As I use the term ­here, “chronic living” refers not simply to the undesirable state of living with a disease Chronic Living, Delayed Death  131

but also to what happens when living itself becomes undesirable. While this condition is not unique to con­temporary China, the speed and magnitude of medical advances and caregiving shifts have made it increasingly vis­i­ble ­there. In this chapter, I examine the ways that end-­of-­life interventions complicate both living and ­dying for ­today’s institutionalized elders.

A Good Death Death is one of the few certainties in life. Its finality gives existence meaning and form, and it shapes the contours of the ­human experience. It is an inescapable fate yet is “irrevocably interwoven” with freedom in life (Mbembe 2008, 175). Historians such as Philippe Aries (1981) have traced past socie­ties’ reactions to death and d ­ ying, and psychologists like Elisabeth Kübler-­Ross (1969)—­ who developed the five stages of grief—­continue to influence con­temporary experiences and clinical encounters with death. ­W hether feared, tamed, denied, or named, death is treated across Western sources as something deeply meaningful and potentially redemptive (Green 2012). In his anthropological study of death and d ­ ying, James Green attributes this to an “enduring salvational ethos” (ibid., 25), which Marshall Sahlins (1996) observed in Christianized cultures sharing the same “peculiar Adamic inheritance” (quoted in Green 2012, 24). Despite anthropological accounts demonstrating the relativity of death, ­there is an enduring belief that the dead and the living, the body and the spirit, and the past and the ­f uture are separate (Lock 2002). However, t­hese epistemological models are not easily applied to the Chinese context. Classical Chinese thought on death and ­dying, drawn primarily from early Confucian and Daoist texts, does not emphasize individual salvation or redemptive themes. “Based neither on God nor the death of God,” death is often meaningless, abrupt, and absurd, guided by the same disinterested forces of fate as the weather (Perkins 2015). Chinese philosophies on death also lack the radical life-­death dualism found in many Western traditions. Instead, they stress relationality, reciprocity, 132  Growing Old in a New China

equilibrium, and harmony with natu­ral rhythms. Death is life’s complement—­the states are differentiated, but “a difference is not yet a conflict” (Sahlins 1996, 402). Rather, death is one half of an unending circle and the fertile soil from which life emerges (C. Li 2013; Perkins 2015; Qin and Xia 2015; J. Watson 1988). While complexly interwoven and mutually transformative, Daoist, Confucian, and Buddhist approaches each speak to dif­ fer­ent facets of death and d ­ ying. In line with yin-­yang princi­ples, Daoism portrays death and life as the shaded and sunny sides of a mountain, which are not in opposition and cannot be separated. In the Zhuangzi, a central Daoist text, the sage claims that “whoever knows that life and death, existence and annihilation are all a single body, I ­w ill be his friend” (Eno 2019, chap. 6, ver. 4). Confucius also saw death and life as intimately connected but prioritized the practical here-­ and-­ now concerns of right living. When asked to speak on death in the Analects, he replied with a question: “When you do not yet understand life, how could you understand death?” (Eno 2015, 53). The centrality of Confucian thought in Chinese social life has contributed to the observation that Chinese ­people rarely discuss the afterlife or other metaphysical mysteries (Guang 2013). However, death is a concern even within Confucianism, but it is approached from the perspective of ­those still alive, who are expected to maintain proper relationships and continued reciprocity even ­after death (Perkins 2015). Buddhism, which has been highly influential in China since the third ­century, does attend to metaphysical concerns through its teachings on karma and rebirth (Guang 2013; C. Li 2013). While regional, local, and individual religious beliefs demonstrate g­ reat diversity, the widespread similarity of funeral rites across China in the nineteenth and early twentieth centuries indicate that t­hese shared philosophies have contributed to a standardized “Chinese way of death” (Whyte 1988, 289; see also C. Li 2013; J. Watson 1988). Prior to 1949, most Chinese died and performed funeral rituals at home to help ease spirits out of their bodies and into the afterlife (M. Cohen 1988; Whyte 1988). A ­ fter funeral rites ­were completed, ghosts, ancestral tablets, and tombs Chronic Living, Delayed Death  133

continued to have a place in the daily lives of the living, since death did not sever the bonds of kinship, reciprocity, community, or exchange (M. Cohen 1988). More recently, pressures of urbanization and bureaucratization have encouraged the use of cremation over burial, imbued elaborate funerals with meeting-­like efficiency, and moved death out of the home and into institutions, but a good death still adheres to the abovementioned values of balance, harmony, and reciprocity (Ikels 2004b). For the living, this means attending to the proper rites and ceremonies to ensure the continuation of kinship bonds and exchanges between the living and the dead (J. Watson 1988; Whyte 1988). For the dead and ­dying, a good death is a timely one, in which a person has reached their pinnacle of self-­ cultivation and, surrounded by ­ family members, leaves ­behind a web of social relationships spun so carefully that even death does not disrupt its balance (Hsu, O’Connor, and Lee 2009). Evidence from my thirteen months of ethnographic fieldwork indicates that ­these ideas about a good death continue to hold true for many Chinese elders and their families t­oday. In formal interviews and casual conversations, participants expressed a deep and enduring need for familial connection and balance regardless of their end-­of-­life care setting. However, reports from palliative care wards, elder care homes, and other elder care settings also revealed that obstacles to achieving a good death—­including ­family disharmony, economic concerns, and disease and disability—­are increasing as ­dying moves out of the home and into institutions.

Modern ­Dying in Urban China Sitting in his modest single room at Singing Meadows, Grandpa Zhang describes the incident six years ago that triggered his heath decline and inspired a recent discussion with staff members about end-­of-­life care directives: “Just ­after dinner I was helping [my wife] use the commode when she suddenly collapsed on the bed. I yelled for help, and the nurses and doctors rushed in to revive her. The doctor ­doing CPR asked me, ‘Should I save her?’ At that time

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my mind was racing. What I thought was this: It is useless to try to save her in this situation. But how did I answer the doctor? I said, ‘Save her!’ Immediately he sent her down to the ICU, where she was hooked up to a ventilator and other machines. Why did I think ‘­Don’t save her’ and yet tell the doctor ‘Save her!’? I knew trying to save her was futile, but if I d ­ idn’t save her, if I d ­ idn’t say ‘Save her!,’ she would have died. My ­children, my sons and ­daughters, would not have understood my decision. They could not have possibly understood. They would only demand: ‘Why d ­ idn’t you save our mom?!’ Right? How could I explain myself to them?” Although Grandpa Zhang’s wife survived the incident, she never recovered consciousness and passed away a few days ­later. Now institutionalized and nearing ninety, Grandpa Zhang has made it clear to ­family and staff members that he does not wish to be “saved” from death: “I have discussed it with my d ­ aughter, as well as with the staff and the doctor. If I fall ill again, it would be best that they d ­ on’t say, ‘Quick! Get him to the hospital!’ If I am admitted to the hospital, I simply cannot afford to pay RMB 100,000 [about $16,600] for fifteen days. . . . ​I am ninety years old. This life is basically finished.” In her work in U.S. medical institutions, Sharon Kaufman described the gaps between expectations and realities of modern ­dying: The most common popu­lar understanding of “the ­dying pro­cess” is that ­there w ­ ill be a relatively long period of stability followed by a short period of physical decline. While this trajectory often characterizes cancers, it does not, in fact, characterize most disease that precedes death. A more common situation is one of long-­term disability, with periods of acute symptom exacerbation that may or may not be accompanied by obvious decline. Patients, families, and sometimes physicians expect that, given the right medical treatment, patients ­will survive each exacerbation, and the patient frequently does survive many flare-­ups or acute episodes. Thus, when death fi­nally occurs, it seems “sudden.” (2005, 33)

Chronic Living, Delayed Death  135

In China, institutions are playing an increasingly larger role in  reshaping the urban experience of aging and d ­ ying. Although national surveys show considerable discrepancies in rates of home and institutional deaths, they agree that education level, urban residence, and social position are all strongly correlated with higher rates of institutional death (Jing and Yuan 2016). In wealthier nations an opposite trend is observed, but the same princi­ple is at work—­ those with better resources die wherever they feel they ­will receive the best end-­of-­life care (Gu, Liu, Vlosky, and Li 2007). In the Chinese context, the demand for institutional care is also being fueled by rising rates of insurance coverage, access to specialized medical ser­ vices, and bureaucratic pressures (Jing and Yuan 2016). For example, in 2014 the Ministry of Public Safety issued new end-­of-­life protocols that mandate signed death certificates even for in-­home deaths, encouraging some families to transport their imminently d ­ ying relatives to hospitals to avoid the hassle of the paperwork (ibid.). While demand is clearly increasing for institutional end-­of-­ life care ser­v ices, it is unclear who should or can provide and receive them. China’s official hospice and palliative care institutions are in a comparably early stage of development. The first hospice care institution opened in 1988, and by 2011, ­there ­were approximately two hundred palliative and hospice care facilities serving an estimated 1 ­percent of the p ­ eople in need of palliative care in mainland China (J. Li, Davis, and Gamier 2011, 292). Due to a lack of national-­level organ­ization, t­ hese ser­v ices are inconsistently regulated and funded and disproportionately located in larger cities. The imbalances cause such divergent priorities within the practitioner community that one local palliative care doctor, who is a pioneer in the field, described the situation to me as a “gang war.” At all levels, from policy to training and practice, ­there is clear disagreement about the goals and scope of palliative care, who should be providing it, and even what it should be called (O’Connor, Poon, and Hsu 2015). Despite ­these inconsistencies, palliative and hospice ser­v ices are in high demand among patients and families seeking end-­ of-­life care. All of my respondents expressed high satisfaction with 136  Growing Old in a New China

the care their relatives received while in ­these units. Compared to other hospital wards, palliative care wards tend to be less crowded and exempt from insurance-­based limits on inpatient stays. Furthermore, hospice and palliative care departments are among the few departments where morphine is used regularly and pain control is prioritized (Gao 2012). However, providing t­hese ser­vices requires first determining that a patient is, in fact, ­dying—­a pro­ cess complicated by local bioethics, family-­based decision-making, and taboos that discourage openly speaking about death. In Grandpa Zhang’s account above, one can see how the pressures of family-­ based decision-making converge with available technologies to complicate end-­of-­life choices in the face of sudden decline. His is not a unique case. Survey response data from 315 critical care doctors across China showed that only 47 ­percent of doctors report ever applying do-­not-­resuscitate ­orders—­compared to 95  ­percent of doctors in Eu­rope and Hong Kong—­and more than 70 ­percent claim to not feel comfortable discussing limiting life-­sustaining therapies with relatives (Weng et  al. 2011). This is significant ­because, in line with Chinese bioethics, doctors first discuss medical situations with families before revealing diagnoses to patients. Although policies are changing with regard to informed consent, it is a common practice for physicians to withhold fatal prognoses from patients per the f­amily’s request, as ­family members fear that speaking about death may cause it to arrive unnaturally soon (Bian 2015; Fan and Li 2004; O’Connor et al. 2015). While it is unclear ­whether or not avoiding the topic actually staves off death, ­there is no doubt that it interrupts the ­dying pro­ cess. As Barney Glaser and Anselm Strauss (1968) noted in their seminal work, Time for D ­ ying, one must be recognized as d ­ ying to be treated as ­dying. Within institutions, death must be “named and expected” before ­dying can commence (Kaufman 2005, 201). Death’s timing is especially complicated with older patients. As new medical technologies extend life spans, common old age disease trajectories become even harder to predict. This also holds true in Chinese institutions. The vast majority of palliative care departments are located within oncology units, and cancer—­w ith its relatively Chronic Living, Delayed Death  137

predictable timeline—is almost synonymous with death (Dong et al. 2016). Yet, as the following exchange with a thirty-­year-­old palliative care doctor shows, even within ­these units, good care is pro-­life. Dr. Ming: Once we had this stroke patient, he was completely unable to take care of himself. A ­ fter that, he—­you could say he was living in extreme suffering. The ­family members requested [us] to stop all treatment, including tube feeding. So the patient ultimately, to speak frankly, starved to death. Author: Starved to death? Dr. Ming: We ­were unwilling to let this situation happen, but the ­family members said, “If you want to keep feeding him, then take the patient home with you.” This is what they said to us. Our nurses and hugong did not have the heart to do it, and they secretly fed him. The f­ amily members got very angry and said, in the end, our d ­ oing this just added to his suffering. As a result of ­these complex institutional pro­cesses, while many Chinese elders are frail, declining, and dependent, ­unless they have a determinable end date or predictable trajectory, few are recognized as ­dying. Some, like Grandpa Zhang’s wife, die suddenly in intensive care units. Many ­others, who have surpassed the inpatient stay limit but do not qualify for hospice care, spend their final years in long-­term care institutions that are not equipped to provide palliative care. In t­ hese institutions, death is ever pre­sent, but few ­people are recognized as ­dying. In this tenuous, ill-­defined space carved out by and for the not-­quite-­living and the not-­quite-­dying, many p ­ eople strug­gle to maintain the familial and social balances necessary for a good death. As one elder care home resident observed, “for t­ hose who cannot live and cannot die, life is extremely painful.”

Chronic Living The Gale Encyclopedia of Medicine describes “chronic” as “of long duration and slow progression. Illnesses that are chronic develop 138  Growing Old in a New China

slowly over time and do not end. Symptoms may be continual or intermittent, but the patient usually has the condition for life.” One of my closest in­for­mants at Jade Hills, Wan Long, understood the feelings of helplessness and hopelessness that often accompany such a bleak prognosis. At sixty-­two, he was a relatively younger resident, and he often passed the slow after­noons retelling stories of the path that had led him to his current state. When did his sickness begin? The first answer that comes to mind is the day he had his stroke, fourteen years ago, at the age of forty-­eight. But as he sifts through layers of memories, ­Uncle Wan traces the symptoms further back. His ­mother had also suffered a stroke. She was in her seventies, and afterward she lived happily at home in the care of her two sons ­until she died at eighty-­nine. Or it could have been when his wife left him and their one-­year-­old d ­ aughter. But no—­even ­after that he was still living well, still healthy, still working. He got into construction at the very beginning of China’s financial boom in the 1980s. The money poured in. He was strong, capable, smart. He could see something once and be able to do it. His ­father had been a soldier; his m ­ other was in the Chinese Communist Party. ­Things had changed. He took care of his ­daughter, gave her every­thing—­ prob­ably too much, he admits now, with a shake of his head. The money was good, but he worked in the early years of privatization—­ though he had no pension, no insurance, and no security. He took care of his m ­ other ­after her stroke, but it ­didn’t feel like a burden: “It was what I was supposed to do. I was her son, right? If I d ­ idn’t do it, who would?” His ­daughter is very smart but immature. He pulls himself back into the pre­sent moment, shaking his head and using a stained handkerchief to wipe the saliva that leaks incessantly from the loose corner of his mouth. It ­isn’t her fault. He d ­ oesn’t blame her. “Yes, yes, forget it, just forget it,” Auntie Xiao, another resident, consoles U ­ ncle Wan, edging her wheelchair closer a­ fter a few minutes of tsk-­tsking in the background. “­Don’t blame her, blame . . . ​the government—” “Blame this illness!” Chronic Living, Delayed Death  139

Even ­Uncle Wan is surprised by his angry outburst. He rarely shouts or complains. He sits quietly in the shade and naps in his broken wheelchair. He sits quietly in his stinking, unwashed clothes and does not make a fuss even when he has to go to the bathroom and the plastic jug he uses as a makeshift commode is full. Once, the director clipped U ­ ncle Wan’s wheelchair with the supply van while making deliveries along the narrow walkway. ­Uncle Wan did not say a word, just grunted and glared while a fellow resident helped him straighten his chair. He walks one lap around the courtyard e­ very morning and after­noon, his right arm drawn in like an insect leg and his dropped foot rasping in time to the clack of his metal cane. During our visits, he lights up as he vividly recounts all-­night mahjong games and exotic travels, but when the conversation circles back to his pre­sent condition, he has ­little to say: “Nothing changes.” “­There is nothing I can do.” “This illness ­w ill last ­until death.” He admits it has gotten much harder to motivate himself, especially now that his headaches have gotten worse. It was not always this bad. The first nursing home was good, but one day his ­daughter came and told him he had to move. The fees w ­ ere too high. The government had razed the home he had built, and the money was gone. She packed up his few possessions, and they drove away. He tells me, “I thought we ­were ­going home!” He laughs now at his own naïveté, which triggers violent wet coughs and wheezy gasps. When he catches his breath again, he wipes his mouth and continues. He has not seen his ­daughter in two years. He understands, though. One day she said to him, “Dad, when you had your stroke, the hospital fees ­were over RMB 100,000 [about $16,600]. What could I do?” She left him at Jade Hills and dis­appeared. ­A fter she s­ topped paying, the management moved him from his first-­floor room to one on the third floor. Th ­ ere are no elevators or ramps at the fa­cil­i­t y, so e­ very morning the nursing assistant maneuvers his wheelchair and ninety-­k ilogram body down the stairs, and ­every eve­ning she pulls him back up. He s­ topped reporting his falls to the office once he realized it made no 140  Growing Old in a New China

difference. One day I arrived at the institution to find him with a ban­dage wrapped around his forehead. He had tipped forward out of his wheelchair while napping and hit his head on the concrete. “I think it would be much better if I could die, but that is not my decision,” he explained. Although the staff had refused to fix his wheelchair’s flat tire for weeks, they did take him to a doctor to patch up his head. The case of U ­ ncle Wan is an extreme example of chronic living. Like other chronic illnesses, his did not have a clear cause, but all signs indicated that he could expect no relief or improvement. As Auntie Xiao, the resident who had joined our conversation, ­later explained: “­There is nothing you can do, nothing you can do, nothing you can do. This is just the situation. The circumstances have led to this place, and you can only obey the circumstances. Th ­ ere is nothing you can do.” As a fundamental component of the h ­ uman condition, pain is pre­sent across the life course. However, the physical, cognitive, psychological, and social losses associated with late life can be a deep source of suffering for many elders (Attig 2015). In ­Uncle Wan’s case, his personal losses w ­ ere exacerbated by the larger social and historical context he inhabited. His changing body was inextricably rooted in a world that “ceaselessly assails and beleaguers subjectivity as waves wash round a wreck on the shore” (Merleau-­ Ponty 1945/1962, 241). ­These waves included the privatization and rising costs of health care, life-­extending technological advances, changing f­amily dynamics, and the increasing individualization of risk (Y. Yan 2009). The disruptions caused by t­hese larger forces made his end-­of-­life experiences, both in terms of disease and treatment, painful to a pathological degree (Cassell 1991). The subjective nature of pain makes it difficult to mea­sure, but research suggests that nursing home residents report higher levels of pain than their community-­dwelling peers (Abdulla et al. 2013). However, the typical treatments for pain—­opioids and adjuvant drugs like antidepressants—­are tightly regulated in Chinese hospitals and virtually non­ex­is­tent in nursing home settings (D. Wang 2004). Without hope for relief, pain and life merge for many Chronic Living, Delayed Death  141

residents. “Now every­one says a long life is long suffering,” reported one elder in her eighties. She was relatively healthy, but she had witnessed the lingering lives of ­those around her, including her husband—­whose dementia was rapidly advancing. “I am not afraid of death,” she told me. “I am only afraid of being unable to die.” However, it is not simply untreated pain that differentiates ­these cases of chronic living from nonpathological aging in China. Pain is a symptom of deeper disorder. According to the princi­ples of Chinese medicine, pathology arises out of disharmony or imbalanced energy. When in proper balance, even disability, de­pen­ dency, pain, and death have a place in the flow of existence. For example, ­Uncle Wan’s ­mother had also suffered a debilitating stroke, but according to his account, she had had a positive end-­of-­ life experience and a good death. What differentiated ­Uncle Wan’s case from his m ­ other’s ­were the series of familial disruptions he experienced and the corresponding dismantling of his family-­ based safety net. It is this deeper relational disharmony that gives rise to the pathological pain of chronic living. It is difficult to overstate the importance of f­amily bonds to the Chinese psyche. As described in chapter 1, the character for filial piety, xiao, is the symbol for “old” above the symbol for “young.” Although this can be interpreted in multiple ways, the two parts are clearly arranged in a relationship of balance. If the top becomes too heavy or the bottom too weak, the structure ­w ill be compromised. Increasingly, this is indeed becoming the new image of elder care in con­temporary China: an upside-­down ­pyramid with aging baby boomers at the top and de­cades of only ­children making up the tapering bottom. This imbalance emerges at the intersection of larger social forces and shifting interpersonal relationships, and it is a key concern in elder care discussions in China. While many discussions focus on the burden this imbalance puts on younger generations, few recognize the disorienting effects it is having on older generations. One Jade Hills resident in her eighties echoed many of her peers when she asserted, “Life is meaningless!” As fertility rates have declined, elders—­especially w ­ omen—­have had fewer 142  Growing Old in a New China

opportunities to contribute informal l­abor to the f­ amily economy. Adult ­children have also become less dependent on their parents for formal economic support as China’s economy has developed, further eroding elders’ sense of purpose. ­These f­actors have also contributed to an ideological shift related to intergenerational coresidence. This shift is not simply happening among younger ­people. The majority of my older respondents, both t­ hose living at home and ­those in elder care institutions, said that they ­were not willing to live with their adult ­children. According to one hospital patient in her seventies, “We older p ­ eople are accustomed to certain foods and ways of living that are dif­fer­ent from [­those of] younger generations. It is very difficult to bring ­these into harmony. ­There is also a generation gap between ways of thinking.” Although fewer families are living in intergenerational house­ holds, f­ amily bonds still persist. For ­people suffering from chronic living, both the withholding and the demonstration of filial piety have contributed to their condition. For example, ­Uncle Wan suffers now ­because his ­daughter has ­stopped paying for his care and visiting him, but the thousands of dollars she did pay for life-­saving procedures over the years also contribute greatly to his current state. Combined with the rising costs of medical care and caregiving ser­vices, elders who suffer from disabling illnesses—­and even ­those who do not—­recognize that they are not needed, only needy. As one elder care home resident in her eighties explained, “If I could die now, it would be a relief. No regrets. ­Because now each generation is better off than the one before. Seeing they have good lives, good jobs, is ­great. I ­don’t worry.” Although very few elders I spoke to ­were living in institutions against their w ­ ill, for many it was exceedingly difficult to maintain the health of relationships that distinguish a good life—­and death—­when physically dislocated from ­family members. Even when the decision to move to an institution was made voluntarily and out of love for ­family members, it is true that “the most grievous components of h ­ uman suffering take place in the experience of broken relationships and lost connections to t­ hose individuals and contexts that bestow on our lives positive meaning” (Wilkinson Chronic Living, Delayed Death  143

and Kleinman 2016, 9). So it was for Grandpa Zhang. Although he enjoyed keeping up with current events and suffered only minor physical aches and pains, he spoke often about the ache of this separation from ­family members: “At this [institution], what weighs most on my mind? Th ­ ere is just one t­ hing: the absence of ­family. For ­people like me, whose minds ­aren’t yet confused, the biggest lack is ­family. For example, on Saturdays and Sundays, kids, grandkids, great-­grandkids all come to see you. But they stay for about a half hour and then leave. . . . ​I never ask them to come. I never make any request like that. But in my heart, the ­thing I lack most is ­family.” Despite sharing ­every meal with hundreds of residents and caregivers, Grandpa Zhang felt emotionally isolated. As mentioned above, he was stunningly intelligent, and he feared too much contact with other residents would make his brain soft. For Grandpa Zhang and many other institutionalized elders, the physical separation from ­family members weakened their connections to their social worlds. For the individual, t­ hese interpersonal relationships and social ties constitute the self, and their disappearance amounts to a social death (Kipnis 1997). Although weekly visits fulfilled an emotional need, they ­were not enough to maintain the strong reciprocal bonds necessary to establish one’s place in the social fabric. As Grandpa Zhang’s links to the wider world withered and fell away, his chronic living became chronic ­dying. He expected to live out the rest of his life in the elder care home, but ­whether that would be days or years, no one could say. “So now I’m ­here just, as I like to say, just ‘waiting,’ ” he explained. “Waiting for what? Waiting to die.” Resigned to the pain and intractability of their condition of chronic living and chronic ­dying, many institutionalized elders are nonetheless impatient for a cure: “Death hurry up! Now is just suffering—­death would be better.”

Delayed Death In my conversations with the ­children of residents, a main reason cited in the decision to institutionalize parents was that they w ­ ere 144  Growing Old in a New China

safe in the institution. On the one hand, the c­ hildren meant safe from accidental falls and sudden illnesses, but on the other hand, they meant safe from themselves. Much scholarly attention has been given to the high rates of suicide among Chinese elders, which are more than double t­ hose found in the United States (44 ­percent versus 18  ­percent) (C. Wang et  al. 2014). The motivations for el­derly suicide range from poverty and f­ amily conflict to serious illness, and rural ­women are especially at risk (W. Fei 2011). Institutionalized elders may have similar motivations for self-­harm, but they lack the means. Rooms have bars on the win­dows, and sleeping pills are locked up. Residents are supervised at all times. This lack of control, which contributes to chronic living with no access to a cure, weighed on the minds of many of my in­for­mants. On more than one occasion, elders asked me if I could buy sleeping pills and sneak them into the institution. Suicide and euthanasia ­were common conversation topics. For example, as I was leaving Jade Hills one after­noon, I ­stopped to talk to Auntie Ma, who was feeling especially depressed. “Life is meaningless,” she sighed. I asked if she was in pain. She said she had no pain, but “every­thing is uncomfortable.” She had no energy and just wished she could die: “It would be so much better if ­there was euthanasia, just an injection and then ­you’re done.” Life had meaning when she was younger, but now she ­couldn’t do anything. I tried to remind her how much she had helped me with my research, but she was unmoved. Looking out into the overgrown courtyard, she cried, “I wish the w ­ ater in that pond was deeper so I could drown myself in it.” In her work on organ donation in Japan, Margaret Lock describes the emergence of a biomedically informed “new death” that is timed and managed (2002, 103). Most of the elders in my research had also experienced biomedical interventions, but unlike Lock’s comatose patients, my in­for­mants ­were often outside the biomedical sphere as they waited for death, unfit for curative or salvage operations. As Auntie Ma’s story shows, the “new death” they faced was decidedly unmanageable. Auntie Ma, Grandpa Zhang, and ­Uncle Wan all experienced acute pain from being cut off from former social roles and Chronic Living, Delayed Death  145

relationships, an “interpersonal social suffering” characteristic of other chronic illnesses (Kleinman and Hall-­Clifford 2010, 250). In Auntie Ma’s and U ­ ncle Wan’s cases, suffering stemmed from inhabiting unproductive, consuming bodies in a society geared toward economic dominance—­ ­ living too long and d ­ying too slowly in an era that put a high value on efficiency and speed. As with Grandpa Zhang, ­these elders experienced social death long before their unmanageable bodies released them (Biehl 2005; Lock 2002) Even elders who w ­ ere relatively healthy worried about joining the ranks of ­those whose “bodies in time mean far too much” (L. Cohen 1998, 302). One eighty-­seven-­year-­old in­for­mant, who still lived in his own apartment, candidly told me: “I just wish I could go more quickly. I d ­ on’t want to be in pain and suffering. This kind of thinking i­sn’t like that of religious belief. Religions teach that while you are h ­ ere, think about the next life. I just want a quicker death! Ha ha! A sudden one would be best, but that is not good. For ­people who care about you that is not good.” Through death, elders sought to liberate not only themselves but also their loved ones from the burdens of chronic living. Grandma Hua, a former schoolteacher, lived at Singing Meadows with her husband. She was nearing ninety, but her round face was still full and her eyes bright. Warm and gregarious, she played piano for the elder care home’s choir and had written their theme song. Although she was glad to bring happiness to o­ thers, she admitted that she was “very tired.” Her husband’s dementia had progressed quickly over the past year, and she spent most of her time keeping an eye on him. Her one hope for her own f­ uture was that she would go quickly—­that the phone call to her c­ hildren would be, “Your mom is already gone.” She did not want to linger in the hospital and experience all that comes with a prolonged death. She did not want to be saved from death, Grandma Hua told me. She just wanted someone to hold her hand when it hurt.

146  Growing Old in a New China

Resignation: Mei Banfa In the face of their intractable conditions, elders’ most common response was resignation. In fact, all of ­those involved in the caregiving situation frequently expressed feelings of resignation. The phrase mei banfa (没办法), whose literal translation is “­there is no way,” has a meaning closer to “­there is nothing you can do” or “you have no choice.” For example, when I asked hugong if they found their jobs monotonous or residents if they w ­ ere used to living at the elder care home, they would frequently answer, “Mei banfa.” Residents frustrated about their inability to move forward into death or back to healthy life used the same phrase to explain their situations. One resident summed up the ­whole institutional experience as simply a mei banfa de banfa (没办法的办法), or “what you do when ­there is nothing you can do.” In her book Resigned Activism, Anna Lora-­Wainwright noted that mei banfa was also the most common response her respondents gave regarding pollution. She saw it as her respondents’ “way to convey their own feelings of powerlessness” and “a means through which they comfort themselves about the limits of their agency” (2017, xxvii). The phrase functions in a similar way in elder care institutions. Even though Grandpa Zhang told me that “living is a very boring t­ hing,” as with many events in his life—­from his twenty-­t wo years of forced l­abor to his late-­life dependency—­ his power to control or change it was l­imited.

Conclusion Not all residents suffered from chronic living. Some derived ­great joy from the com­pany of their fellow residents and caregivers or busied themselves with games, crafts, and ­music. ­Others found comfort in religious beliefs about heaven or reincarnation. Even ­those who did find themselves suspended between living and ­dying experienced moments of delight, excitement, and laughter. Indeed, Auntie Ma, who often seemed hopelessly hopeless, once surprised me by exclaiming, “What fun this life is! We are Chronic Living, Delayed Death  147

constantly learning.” The point of this chapter is not to create a spectacle of suffering, but rather to portray the full experiences of ­people whose lives are caught in the eddies of change (Kleinman 2010). I share their stories not to evoke pity, but out of “re­spect for ­great misfortune, for ­great ugliness, for ­great failure” (Nietz­sche 1892/1954, 378). Through the narratives in this chapter, one can trace flows of desire—­economic, technological, and individual—­moving ever outward and forward, each driven to expand. New possibilities are celebrated and new forms of living realized. ­Today, huge portions of the Chinese population can travel freely for work and play, adult c­ hildren can afford their own homes, and patients can recover from previously incurable diseases. However, this mountain has a dark side as well. Demographic changes have transformed the shape of families, and increases in both life expectancy and chronic illness have extended the period of decline. Many ­people who are saved from death but not disability or de­pen­dency are left in economic ruin and have to choose from a range of poorly regulated caregiving facilities in which to spend their final days. As a result, growing numbers of elders no longer experience the ­dying pro­cess surrounded by ­family members. Isolated from ­these key sources of meaning making and identity formation, social death occurs long before physical death releases them. As health care prac­ti­tion­ers, policy makers, elders, and ­family members search for new and better ways of extending life, it is necessary to also expand notions of and possibilities for a good death. Recognizing and identifying chronic living brings t­hese lives out of the “zone of indistinction” and into serious discussions about quality of life mea­sures and end-­of-­life care. For Chinese elders in par­tic­u­lar, more attention needs to be paid to the role social isolation plays in end-­of-­life suffering. Strategies to maintain meaningful social connections could go a long way ­toward improving quality of life, especially among institutionalized elders. Many of the elders I spoke with ­were adamant in their belief that ­there should be more public discussions about right-­to-­d ie policies in China, and discussions of suffering and death are 148  Growing Old in a New China

necessary counterweights to reports of institutional elder care investments and life-­extending technological advances. Out of compassion for our current elders and f­ uture selves, our pursuit of life’s creative potential must be balanced with equally brave explorations of aging, ­dying, and death.

Chronic Living, Delayed Death  149

 Conclusion So freedom flounders in the contradictions of commitment, and fails to realize that, without the roots which it thrusts into the world, it would be no freedom at all. —­Maurice Merleau-­Ponty, Phenomenology of Perception

On days when I could not work up the energy to trek to an elder care institution or climb three floors to the palliative care unit, I curled up with an episode of a Chinese tele­v i­sion series called To El­derly with Love (Lao you suo yi [老有所依]). The synopsis reads, in part: “Jiang Mulan and Lu Xi are a married ­couple, working in Beijing, supporting both their parents and their child (shang you lao, xia you xiao [上有老下有小]). B ­ ecause they are both first-­ generation only c­ hildren, elder care is an especially heavy burden to bear” (Baidu 2017). Released in 2012, the series portrayed China’s current elder care situation in the typical style of Chinese dramas: full of sudden, meaningless tragedies; tearful f­amily betrayals and reunions; unpunished bad guys; and dead good guys. In the first episode, Jiang had to rush to her ­father’s side ­after he was injured by a hit-­and-­r un driver, which caused trou­ble at her job and endangered her even more el­derly grand­father, who was in the early stages of Alzheimer’s. On the same day, Lu’s ­father died suddenly, and he was forced to return to the countryside to take care of his m ­ other, who had been para­lyzed by a

150

stroke. ­Things only got worse from ­there. The series explored ­every dark corner of aging, caregiving, and intergenerational living in a modern Chinese city. Against the backdrop of bustling, thriving Beijing, the el­derly protagonists w ­ ere continuously getting lost, confused, scammed, and abused. The final tragedy, however, was that the t­rials of caregiving nearly destroyed Jiang and Lu’s marriage. The online description for the final scene describes a birthday cele­bration at Mulan’s ­father’s elder care home during which the c­ ouple is fi­nally re­united: “Jiang Mulan and Lu Xi started again. It was one big happy ­family reunion” (ibid.). This book explores the same question that animates To El­derly with Love: What is the role of aging ­people in con­temporary Chinese society? In an atmosphere geared ­toward speed, advancement, growth, expansion, and development, the old and dependent and the slow and declining seem to have no place except as burdens or hindrances (H. Yan 2008). Like Jiang’s and Lu’s parents, con­ temporary Chinese elders are a potential danger to themselves—­ but even worse, they are a potential danger to their c­ hildren’s livelihoods and lifestyles, as the energy required to care for them weakens one’s ability to be oneself. However, one of my arguments throughout this book is that the reason for ­these bleak portrayals of the elder care situation is that t­ hese questions are too often asked and answered exclusively from the perspective of younger generations. For example, although To El­derly with Love focused on the plights of its el­derly protagonists, it did so within the framework of their ­children’s established lives. From this perspective, the younger c­ ouple’s lives served as a steady point of reference, existing comfortably in the larger society, while the elders’ lives w ­ ere the source of disorder that threatened ­family harmony. This orientation characterizes many elder care discussions in China t­oday, contributing to perceptions of the el­derly population as an outside force, a so-­called grey tsunami, threatening the stability and trajectory of a rising nation (L. Zhang 2015a).

 Conclusion  151

Change and Imbalance The depiction of elders as a disorderly force is striking, considering the lifelong sacrifices that older generations have made for their country. As Grandma Hua expressed in chapter  2, ­today’s older generation is “truly pitiable” when considered within their historical context. They sacrificed their bodies and ambitions, faced imprisonment, hid from bombers, fought wars, endured famines, and worked for pennies for most of their adult lives. In exchange for their sacrifice and dedication to nation building, they ­were promised lifelong support. For some, especially lixiu ganbu like Ji Chun’s ­father, ­these promises have been kept, and they enjoy excellent medical care and financial support. For the rest, despite assurances that rewards would be shared equally, the income gap continues to widen. Social security and health insurance reforms have helped ease the transition, but elders are most vulnerable to the high costs of aging in a market-­based economy. As a result, a growing portion of the population has to rely on financial and caregiving support from ever-­smaller families. Although f­amily support was once taken for granted, that is no longer the case within many families. Throughout this book I have shown how socioeconomic pressures and shifting demographics are disrupting the channels of reciprocal exchange between parents and ­children. Writing before both Maoist and market reforms, Fei Xiaotong made an observation that continues to resonate in the current climate: “If society changes slowly, paternalistic power is stronger; if it changes rapidly, a dif­fer­ent phenomenon occurs, which is characterized by the saying ‘­Fathers do not act like ­fathers, and sons do not act like sons (fubufu, zibuzi [父不父, 子不子]).’ Therefore, when rapid changes occur, the paternalistic power of f­athers over sons diminishes accordingly” (X. Fei 1948/1992, 97). Following the argument I laid out in chapter  1, I  looked at this power imbalance from the perspective of the elders who are making real efforts to continue to act like f­athers, despite their lack of economic or social capital to do so. 152  Growing Old in a New China

The link between speed of change and imbalance also operated within institutions. In chapter 3, I showed that rhythm and routine w ­ ere ways to order and make sense of the untidy institutional experience, as in the case of ­Uncle Tang and his watch. However, the imbalances between the elders’ overabundance of time and the caregivers’ shortage of it w ­ ere also a source of tension, as seen in the example of Auntie Ma and her hugong, Zhi Chun, in chapter 5. Despite institutionalized elders’ compromised ability to engage in reciprocal relationships, they still found ways to restore balance, often by adjusting their own desires and expectations. Although they may have been tired of change, they could not escape it. As Grandma Hua noted at the end of chapter 2: “If you d ­ on’t change, then what? We cannot change the world; we must change ourselves.”

Se­nior Subjectivities Despite popu­ lar assumptions, elders are also advancing and catching up, growing and developing. One of my main goals throughout this book has been to portray elders in a way that highlighted their rich histories, multidimensional identities, and continual unfolding. In chapters 1 and 5, I showed that elders are not passive receivers but are actively involved in maintaining the balance and harmony of the parent-­child relationship. Their understandings of the weight of elder care burdens and the benevolence they show to their c­ hildren have pushed many parents to give up all expectations of their child’s f­uture support. In chapter  2, I looked at how ­ these changing expectations and desires have engendered new se­nior subjectivities that find meaning in roles outside the context of the ­family. Retirement universities and elder care estates offer opportunities to improve one’s body and mind and develop one’s own interests within a peer-­based social atmosphere. This mirrors the trends observed among younger cohorts that show a rise in individualization and an increase in horizontal relationships (Y. Yan 2009). In chapter 3, I examined how ­these new se­nior subjectivities are both the product and  Conclusion  153

source of newly ­imagined elder care spaces. Some facilities, like Singing Meadows, provide comfort, entertainment, and high-­ quality care and are liberating spaces where se­niors can avoid intergenerational conflict and spend their final years among peers with similar tastes and habits.

A Moral Crisis? However, this emphasis on expanding the bound­aries of the individual, even among older generations, has a dark side as well. Andrew Kipnis observed that “the liberation of the individual is si­mul­ta­neously her or his enslavement to wider social forces” (2012, 7). This dynamic can be seen in chapter 6’s account of U ­ ncle Wan, who “jumped into the sea”1 and was destroyed by the combined forces of catastrophic illness, medical debt, and the privatization of health care. Saved by medical technologies, he is now locked in an elder care institution with no feasible escape. He and other elders suffering from chronic living are in the uncomfortable position of being f­ ree to keep living but not ­free to die. ­These individual stories can contribute valuable perspectives to ongoing conversations about a con­temporary moral crisis in China. Scholars suggest that the collapse of the collective and the rise of the individual are precipitating forces in the widespread erosion of social trust (Ci 2014). As communities shrink, ­those taking on the roles of protecting families and homes—­such as baomu and hugong—­are distrusted outsiders. Yet at the same time, the collapse of the collective has been a ­great equalizer. Yan Yuxiang (2011) has demonstrated how conjugal and peer relationships have grown closer, strengthening horizontal bonds and weakening vertical ones. Although this may have reduced the power of ­those traditionally at the top of hierarchies, like elders, it has empowered ­those typically on the bottom, such as ­women and young p ­ eople. In trying to make sense of the dual nature of modern Chinese life and its contradictory effects on the individual, Arthur Kleinman (2011) has used the image of Huang Yongyu’s winking owl (2011). The painting—­created in 1973, in the midst of the Cultural 154  Growing Old in a New China

Revolution—­features a round gray owl sitting alone on a branch, one yellow eye open wide and the other closed shut. The original meaning of the owl’s wink is uncertain. Huang claimed he heard that this was the way owls sleep, but most ­people have interpreted the painting as a sly commentary about officials who turned a blind eye to corruption. In t­oday’s hyperconnected world, the wink takes on another meaning, representing “necessary alertness even in periods of quiet rest” (Kleinman 2011, 285). The open eye, according to Kleinman and his co-­authors, is tuned to the activity of modern life and demands, while the closed eye is turned inward t­ oward emotional concerns and issues of care. This “unrelieved and irresolvable” tension between the exterior and interior forces permeates the Chinese elder care situation (Kleinman et  al. 2011, 24). Within elder care homes, this tension was found in descriptions of unsatisfying visits that ­were never enough and the busyness of business that made it impossible for adult c­ hildren to take care of their parents. For modern citizens, especially in China’s urban areas, the speed of change and the uncertainty of the f­ uture make it difficult, even dangerous, to close both eyes. What if one is caught unaware? This is not simply a modern condition, but one that ­today’s elders have inhabited for a lifetime. This was clear in the example of Grandma Li, who spent her early years ­r unning from bombers and getting beaten, and who now spends her l­ater years trying to find hospitals that take her insurance and seats on crowded buses. Even institutionalized elders like Grandpa Zhang and Auntie Ma, who are surrounded by locked gates and have twenty-­four-­hour care, ­were vigilant against potential threats. ­There is much to be gained by opening both eyes and seeing the situation for what it is. Through descriptive accounts of care practices and care institutions, I have tried to pre­sent both the good and the bad, which are ultimately subjective and inseparable. Yet as I showed in the accounts of chronic living in chapter 6, what may be needed more than an opening is a closing of the eyes. With the frantic pace of everyday life, ­there is a thirst for states of deep rest that allow us to withdraw, disconnect, meditate  Conclusion  155

or pray, be quiet and still, ­settle, and die. But to close both eyes, one has to feel the steady safeness that is born of genuine trust and care—­a state that empty nests cannot provide. However, the idea that half-­opened and half-­closed eyes are a contradiction that must be resolved reveals my own binary thought patterns: open or close, make a choice and relieve yourself of the choosing. It reflects an ethnocentric and, I must admit, anthropocentric bias. It turns out that Huang’s belief about owls was accurate. Owls, along with many other birds (and aquatic mammals and reptiles), do sleep with one eye open and the other shut. The technical term is “unihemispheric slow-­wave sleep,” and researchers note that it is “in direct contrast to the typical situation in which sleep and wakefulness are mutually exclusive states of the w ­ hole brain” (Rattenborg, Lima, and Amlaner 1999, 397). As might be ­imagined, sleeping with one eye open is less efficient, in terms of rest, than sleeping with both eyes closed. However, it provides a way to balance the risk of predation with the benefits of rest. The authors suggest that b ­ ecause this is such a common form of sleeping, the more in­ter­est­ing question is: Why ­don’t all animals sleep this way? As a partial reply, the researchers describe a curious observation: when ducks sleep in a group side by side, as they do on a log, the ducks on the edge of a group are 150 ­percent more likely to sleep with one eye open (typically the outside eye), while ­those in the ­middle are more likely to sleep with both eyes closed. This phenomenon is known as the “group edge effect,” b ­ ecause ­those on the “risky edge of a group” are more likely to engage in the one-­eye sleeping be­hav­ior (Rattenborg, Lima, and Amlaner 1999, 397). The researchers go on to suggest our taken-­for-­granted ability to sleep with both eyes closed is intimately linked to the development of social groups among terrestrial mammals (Rattenborg, Amlaner, and Lima 2000).

Why Care? The ducks on the log, though not as sophisticated as the winking owl, help make sense of the relationship between caregiving and 156  Growing Old in a New China

individualization in modern China. In e­ very chapter of this book, the postreform values of individualization, privatization, and self-­ responsibility ­shaped the way elders and f­amily members experienced elder care (Y. Yan 2011). Accordingly, former expectations that one can or should rely on another for care are being replaced by self-­care strategies. From working out to saving money, finding God, and making contingency plans, the se­niors I talked to had found ways to care for themselves. However, self-­care is qualitatively dif­fer­ent from relational care in the same way that five sleeping ducks on five separate logs are qualitatively dif­fer­ent than five sleeping ducks on one log. As group sizes shrink, proportionately more individuals find themselves on the risky edge. But on the level of lived experience, what good comes out of the relationship between the old and the young? Both elders and adult ­children reported that generational gaps and lifestyle differences often made intergenerational living incon­ve­nient, annoying, and stressful. Th ­ ere is no promise that the old w ­ ill offer wisdom and no promise that the young ­w ill provide good care. In the Chinese language, early writers found a way to represent elusive concepts like “size,” “height,” and “everywhere” by combining two contradictory ideas into one character: “size” is made up of “big” and “small,” “height” is “tall” and “short,” and “everywhere” is “inside” and “outside” (M. J. Chen 2002). The tension between the two opposites, when allowed to coexist, could express a higher level of meaning. Similarly, by combining the characters for young and old, xiao came to represent what emerges out of the tension between the parent and the child. As described in chapter 1, the reciprocal efforts to resolve the tension and maintain a dynamic balance are the beginnings of care itself. However, as I argued in the same chapter, xiao is not the only source of care. The self-­other tension of ren, or compassion, also generates genuine care. Accordingly, strategies are being put in place to increase social empathy and levels of ren. Schoolchildren take mandatory field trips to elder care homes and orphanages, and volunteerism is encouraged. However, the impacts of profit making and sloganeering seem to have sharply eroded public  Conclusion  157

trust at the same time that ­family bonds are weakening, suggesting that this may not be a ­v iable source of sincere care on a social level. Similarly, within the caregiving world, it is unclear how to provide long-­lasting, high-­quality care—­the kind that allows for both-­eyes-­c losed sleep—­u nder current economic and social constraints. ­Today, many hugong are performing both the physical and emotional work of caregiving, but they are suspended between the roles of insider and outsider, and they are d ­ oing so primarily to care for their own families. Therefore, ­these care arrangements, like self-­care strategies, are ­limited in depth and duration. During my research, I attended palliative care conferences in Shanghai, Beijing, and Dehong prefecture in western Yunnan Province, and I frequently heard the suggestion that elder care be provided by religious groups rather than the private or public sectors. One physician explained that religious faith helps ­people perform the difficult tasks of caregiving. As the example of the Christian hugong, Ji Du, demonstrates, this is not simply talk. My observations agreed with reports from other staff members that her caregiving was exceptional. The palliative care doctor I worked with, a devout Muslim, credited his faith as the reason he continued to push for palliative care reform in China. I also observed a Buddhist volunteer group’s regular efforts to improve the physical and m ­ ental health of elders in a welfare community. However, religious organ­izations are vulnerable to many of the issues that plague secular society. For example, the pastor of a large state-­licensed Protestant church in Kunming explained that his church had opened a Christian elder care fa­c il­i­ty, but no one would pay any fees ­a fter they heard it was supported by a charity—so the church was forced to close the fa­cil­i­t y.

Dynamic Balance The story of the elder care situation in China is one of deep and complex imbalances, but it is equally about the continual effort to retain—or regain—­harmony. Understanding not only the 158  Growing Old in a New China

significance of balance and harmony in the Chinese context, but also the unique meaning of the terms, is key to understanding how present-­day care imbalances might be resolved. The word for China—­Zhongguo (中国)—­ literally translates to “­ middle kingdom.” In En­ glish, “­ middle” means equidistant between two points. This same idea is built into our notion of balance, often represented by a linear scale with a fixed central point. Balance is achieved by adding to or subtracting from one side ­until both sides are equal. Accordingly, commentators note that “­middle kingdom” is often interpreted to mean “central” kingdom, as in the kingdom at the center of the world (M. J. Chen 2002). However, the character zhong (中), which is the subject of the Doctrine of the Mean (Zhong Yong [中庸]), actually has a dif­fer­ent meaning. The “­middle” in the earliest Chinese writings is not a fixed center point on a line but the axis of a wheel. On a vertical axis, it is the relative point on a long pole that balances the two sides. B ­ ecause the “­middle” is dynamic—­the “mean” in Doctrine of the Mean—­balance is pos­si­ble even between two unequal weights. ­There is no reason to believe that individualization and atomization w ­ ill suddenly reverse course. However, that does not necessarily spell the end for the ­family bond or the caregiving ethic. The lessons of dynamic equilibrium suggest that it is pos­si­ble to achieve the “harmonious integration of opposites rather than a reactive compromise between them” (M. J. Chen 2002, 183). The ­family is the first exchange, providing all h ­ umans with the experience of life-­sustaining care and a practice ground for learning the rules and rhythms of care. However, the final realization of this ethic is caring for another. As caregiving increasingly becomes the responsibility of the self and strangers, it is not clear what ­will replace the moral experience of intergenerational care. What is clear, at least according to Wang Hua, a Singing Meadows resident, is that “­there is no way to go home. The old system, old customs, are gone. Every­thing is new and just beginning. We are all trying to feel our way around.”

 Conclusion  159

A Closing Tale: The Daoist Farmer The changes happening in Chinese elder care t­ oday are indicative of transitions occurring on all levels of society. While they are having a disproportionately negative effect on some parts of the population—­especially the el­derly, the dependent, and the poor—­ they are also providing younger generations with opportunities for freedom and autonomy. To say which is ultimately better for individuals, families, and society is difficult b ­ ecause, as the following Daoist tale illustrates, the story is continually unfolding. A farmer named Sei Weng owned a beautiful mare that was praised far and wide. One day this wonderful ­horse dis­appeared. The p ­ eople of his village offered sympathy to Sei Weng for his ­great misfortune. Sei Weng said simply, “What makes you think this is bad?” A few days ­later the lost mare returned, followed by a ­whole herd of wild h ­ orses that was led by a beautiful wild stallion. The village congratulated Sei Weng on his g­ reat good fortune. He said, “What makes you think this is good?” Some time ­later, Sei Weng’s only son, while riding the stallion, fell off and broke his leg. The village ­people once again expressed their sympathy at Sei Weng’s misfortune. Sei Weng again said, “What makes you think this is bad?” Soon ­after, a war broke out, and all the young men of the village except Sei Weng’s lame son ­were drafted and sent into a horrible b ­ attle. The village p ­ eople ­were amazed at Sei Weng’s good luck. But Sei Weng only replied, “What makes you think this is good?”2

160  Growing Old in a New China

Acknowl­edgments

This book would not have been pos­si­ble without the support of my many teachers, both in and out of the classroom, at Milaca Public School, St.  Olaf College, and Yale University. Special thanks to my dissertation advisor, Marcia Inhorn, who showed me that ethnography could make a real difference in p ­ eople’s lives, helped me stay anchored, and encouraged me to grow. I also had the g­ reat privilege of working with Arthur Kleinman, whose compassionate thinking and writing have allowed me stay open to what ­really ­matters. And I would not be where I am without the guidance of Susan Brownell, who has been a golden thread throughout my intellectual life. I am also indebted to my Kunming advisors, Dr. Ma Ke and Professor Ping Fen Tang, whose guidance and guanxi opened many doors across China; the many residents, families, and health care workers who patiently shared their stories and snacks with me; and my research assistant and friend, Wei Wei. Many thanks to the anonymous reviewers at Rutgers University Press who took the time to read drafts of this book and provide valuable suggestions for revisions. I am also incredibly grateful for the support, guidance, and positive outlook that Sarah Lamb provided during the final writing stages. Thanks also to Jasper Chang and editors at Rutgers University Press for their work in guiding this manuscript through the publication pro­cess. Financial support for this research was provided by the Wenner-­ Gren Foundation, the National Science Foundation, and Yale

161

University’s Whitney and Betty MacMillan Center for International and Area Studies. Fi­nally, thanks to all my friends who kept me healthy and happy during this long journey: Mikaela and Johnny, Amy and D’arcy, Yu, Adrienne, Aalyia, Jess, Gabriela, Mollie, Kat and Nora. Thanks to my f­amily, from roots to shoots, for all the lessons, support, encouragement, and love: Grandma Babe and Grandpa Lou; Grandma Fern and Grandpa DeLloyd; Mom and Dad; Ann, Mark, Riley, and Tom; Rachel, Thad, and Kasey; Zoe and Gail; Zoë, Maiya, and Biscuits. And a heartfelt thank you to Sarah, who has given me a beautiful space to sit and does not complain when the dishes pile up.

162 

Acknowl­edgments

Glossary

Pinyin Definition

bao reciprocity baomu

live-in or hourly wage domestic

Characters 报 保姆

helpers

enqing ­great ­favor, g­ reat kindness fengzi

guan’ai

guanbuliao guanli

guanxi

guanxin

crazy; a lunatic or madman

to show concern and care for

unmanageable, uncontrollable

management, administration

管理

to be concerned about; show

关心

suitable, appropriate

interest in

care worker

home for the el­derly

laonian gongyu

old age home



etiquette, manners

li

管不了

ties and mutual obligation

heshide

jinglaoyuan

关爱

关系

solicitude for; care for; express

hugong

疯子

a social network of reciprocal



恩情

合适的 护工 敬老院 老年公寓

ceremony, rite, ritual; courtesy,

礼

liaoyangyuan

sanitorium; convalescent

疗养院

lixiu ganbu

retired cadre

离休干部



hospital or home

mei banfa ­there is nothing to be done; ­

没办法

pianzi

骗子



there is no way

scam, cheat, trickster, imposter

163

ren

compassion; benevolence;

仁

suzhi

quality, character, disposition

素质

kindness wenhua

education, culture, schooling;

文化

filial piety; filial reverence

孝

literacy xiao

xiuyangsuo

yanglaoyuan

rest home; sanatorium

nursing home

yinao

or­ga­nized disruption of health



abuse of medical staff members



zhaogu zili

164 Glossary

休养所 养老院 医闹

care facilities; verbal or physical to take care of; attend to; look a­ fter

to take care of oneself; provide

for oneself

照顾 自理

Notes

Introduction 1. Pseudonyms are used for all ­people and places throughout this book.

In accordance with Chinese tradition, and in line with the conventions laid out in Shea and Zhang (2016), husbands and wives are assigned

dif­fer­ent surnames, and kinship terms “Auntie” or “­Uncle” are used for ­people sixty to eighty years old and “Grandma” or “Grandpa” for older

­people.

2. ­There is no easy way to translate into En­glish the names of residential care facilities in China. In the current stage of rapid and uneven

growth in the elder care industry, the term “nursing home” or yanglaoyuan

(养老院) is used to describe a wide variety of institutional care settings, including public and private enterprises, welfare homes, community-­ based short-­term care facilities, and day care centers. Other common terms include laonian gongyu (老年公寓), liaoyangyuan (疗养院),

jinglaoyuan (敬老院), and xiuyangsuo (休养所).

3. As Horace Miner demonstrated in his 1956 article “Body Ritual among the Nacirema.”

4. China’s one-­child policy was first relaxed in 2013, allowing ­couples to have a second child if the husband or wife was an only child. In 2015,

the rule was amended so that all c­ ouples could have two ­children, and the new two-­child policy went into effect in January 2016. However,

observers question ­whether or not this ­w ill encourage higher fertility

rates, noting that with the huge investments needed to raise a success-

ful child t­ oday, many Chinese ­couples are unwilling to have a second— or even a first—­child (Greenhalgh 2008; Phillips 2015; Xu et al. 2016).

165

5. One of the greatest sources of financial strain and instability for the operators of private elder care institutions is the ground u ­ nder their

feet. ­Because land in China can only be leased (from the government)

and not owned, private institutions are often forced to relocate by new construction or inflated rent prices.

6. ­People cannot choose their own insurance, since it is based on their residence and occupation.

7. The primary facilities I visited are described in detail in chapter 3. Other facilities I visited include a 200-­bed public-­private hybrid social welfare home with residential and rehabilitation facilities, a 30-­bed private

Muslim elder care fa­cil­i­t y, and a 60-­bed community elder care fa­cil­i­t y.

1. Filial ­Children, Benevolent Parents 1. As discussed in the introduction, in most Chinese cities—­including Kunming—­health insurance does not cover the cost of elder care institutions. Therefore, all fees must be paid out of pocket.

2. Bodies in History, Embodied Histories 1. A few of the residents I interviewed w ­ ere younger than sixty, but they had been disabled by illness.

2. In reference to Yunnan’s geography, many local ­people also use an alternative version of this proverb: “Shan gao, huangdi yuan”

(山高皇帝远)—­“ The mountains are high, and the emperor is far.”

3. In recent years ­there has been a resurgence of religion in China, which is

especially prominent among middle-­and upper-­class ­women. It is linked to reactions to the overcommodification of society (Kleinman 2011).

3. Place and Space, Rhythm and Routine 1. As mentioned in the introduction, public institutions began accepting some private payers in the late 1990s, even if they did not qualify as a

“three-no” (no relatives, no income, and no ability to work). However, high demand has severely restricted access for most private payers (W. Yang et al. 2016). 166 Notes

2. Like all elder care institutions I visited, Jade Hills did not have a

specialized dementia ward, so residents with dementia and o­ thers who ­were at a high risk of escape w ­ ere ­housed on upper floors where the

entrances could be locked. Residents without dementia also lived on

­these floors and would request caregivers to open the doors when they came and went. Races between residents and caregivers to and from the doors provided a fair amount of action and excitement on t­ hese floors.

3. I visited this welfare home in August 2014. Although its director

resides at the complex, he or she was not t­ here at the time of my visit. Another staff member, who was cooking lunch for the residents, said that the number of residents is always in flux.

4. Entanglements of Care 1. For example, Singing Meadows did not grant admission to residents

with severe cognitive or m ­ ental health issues, and the director told me they would discharge residents if they developed ­these issues during

their stay. The director explained that they simply w ­ ere not equipped to provide appropriate ser­v ices for such ­people. For that reason, ­family members whose relatives had more severe dementia often turned to

institutions with lower admission standards, like Jade Hills—­which

admitted ­people of all ages with a range of intellectual and developmental disabilities and m ­ ental illnesses.

5. Care Work 1. In this situation, the baomu had been hired to help take care of the in­for­mant’s el­derly ­father. The female baomu was in charge of

­house­hold tasks, while the male baomu performed physical caregiving

tasks.

2. China’s official ideology is Marxism, but Christians are allowed to worship in official state-­l icensed churches. Since the early 1900s, Yunnan’s proportion of Christians has been unusually high for a

noncoastal province, particularly in its ethnically diverse rural areas

(Ying 2009). Reports suggest that local officials typically tolerate the Notes 167

unregistered “house churches” found in many of ­these rural areas

(Entwistle 2016). However, Ji Du confided in me that she and her

fellow believers still feared and experienced persecution from local authorities.

3. Mr. Wang stated that hugong trained by the geriatric hospital w ­ ere not permitted to work for other hospitals or as private caregivers for

patients. I was not able to confirm this with Song Xin or other staff members, so I am unsure how or if this was enforced as a rule.

4. According to Ms. Ji, the institution allowed c­ hildren ­under five to stay with hugong for short periods of time. Her “five-­and-­a-­half-­year-­old”

grand­daughter (­later revealed to be ten) stayed with her for six weeks.

Conclusion 1. “Jumping into the sea” (xiahai [下海]) is a term commonly used in the

early days of postreform China to describe t­ hose who left secure jobs in an effort to strike it rich in the private sector.

2. Taken from Bradford Hatcher’s (2009) translation in the Book of Changes.

168 Notes

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Index

adaptability, 66–67. See also social and economic changes Aging and the Indian Diaspora (Lamb), 11 aging population, 3–4, 47–51. See also death and d ­ ying; intergenerational relationships; population statistics Alzheimer’s disease, 61–62, 150 Analects (Confucius), 26, 27, 28, 30, 36, 133 . . . ​And a Time to Die (Kaufman), 12 anger, 46, 85, 129. See also psychological distress anthropology: on aging and elder care, 10–11; on death and d ­ ying, 132; as discipline, 2; on embodied history, 57–58, 60 appropriate (合适的), as term, 109 Aries, Philippe, 132 assault, 111 Australian Aboriginals, 85 balance, 14–15, 25, 31, 134, 142, 158–159 bao (报), 31–34 baomu (保姆), 108–109, 154, 167n1 (ch. 5). See also hugong (护工) “Basic Regulations for Social Ser­v ice Organ­ization for Elders” (2001), 72 Bateson, Mary Catherine, 48 benevolence (仁), 27, 28, 93, 157 “Beyond ‘Culture’ ” (Gupta and Ferguson), 68

Biehl, João, 12, 73 biological citizenship, 60 biopolitics, 15 Bo, ­Uncle, 121–122 bodies. See embodiment Brownell, Susan, 14, 84 Buch, Elana, 111, 127 Buddhism, 27, 133 Buddhist volunteer group, 103–104, 158 cancer, 135, 137–138 cap­i­tal­ist economy, 4–5 care: by ­children, 95–99; as circulating resource, 124–128; conceptualization and expectations of, 90–94, 109, 110, 119; quality of, 119–121. See also baomu (保姆); hugong (护工) care facilities. See elder care institutions Care in Practice (Mol, Moser, and Pols), 90 care workers. See hugong (护工) Chan, Alan, 25 China (中国), as term, 159 China Health and Nutrition Survey, 6 Chinese Acad­emy of Social Sciences, 4 Chinese Buddhism. See Buddhism Chinese Communist Party (CCP), 4, 53–57, 60–61. See also Cultural Revolution generation; Maoist revolutions Chris­t ian­ity, 66, 115, 130, 167n2 (ch. 5) chronic, as term, 138–139

189

chronic living, 12, 131–132, 138–144, 147–149, 154. See also death and d ­ ying; depression Classic of Filial Piety (Feng), 26, 27–28 Cohen, Lawrence, 11 community elder care, 5–7, 103–105. See also elder care institutions compassion (仁), 27, 28, 93, 112, 157 Confucian princi­ples and practices, 24, 51–52, 93, 109, 110, 133. See also Analects (Confucius); Doctrine of the Mean (Confucius); filial piety or filial reverence (孝) Consolidation generation, 49, 50 Constable, Nicole, 108 cosmic hierarchical mode, 14. See also embodiment crazy (疯子), 105 Cultural Revolution generation, 49, 50, 66. See also Chinese Communist Party (CCP) culture (文化), as term, 109 Daoism, 27, 133, 160 Davis, Deborah, 29–30, 32, 41 death and d ­ ying, 12–13, 130; chronic living, 12, 62, 131–132, 138–144, 147–149, 154; delay of, 144–146; “good death,” 131, 132–134; in modern, urban China, 134–138; resignation of, 147. See also aging population; suffering dementia, 61–62, 117 dementia care, 62, 100–101, 167n2 (ch. 3), 167n1 (ch. 4) Deng Xiaoping, 57 dependence, 11, 33, 64 depression, 72, 113, 145. See also chronic living; suicide disability, 59–60, 134, 135, 142, 166n1 (ch. 2). See also chronic living Doctrine of the Mean (Confucius), 31, 32, 159 domestic helper (保姆), 108–109, 154, 167n1 (ch. 5) Dongchuan Railway Extension, 59

190 Index

Douglas, Mary, 121 Dragon Pool Elder Care Home, 61 economic changes. See social and economic changes economy of fluids, 14–15. See also embodiment The Eigh­teenth Brumaire of Louis Napoleon (Marx), 44 “Eight Stages of Man” (Erikson), 48 elder care institutions: community-­ based, 5–7, 103–105; description of physical space in, 68–69; ­family involvement in, 98–99; food in, 68, 88, 99, 121, 122, 124–125, 127; geriatric hospital unit, 8, 76, 119; guanli of, 121–123; institutional rhythms of, 86–88; placemaking and, 70–73, 88–89; quality of care in, 119–121, 124–125; regulation of, 72; retirement estate, 76–77; space making in, 77–86; spousal care in, 100–101, 146; statistics on, 7, 8, 69–70; terms for, 165n2; types of, 7–8; welfare homes, 75–76; workplace abuse and anx­i­eties in, 110–112. See also death and d ­ ying; names of specific institutions elder care law and policy, 5, 22, 95 embodiment, 14–16, 19, 44–46, 57–64, 83–86. See also chronic living; suffering emergent subjectivities, 15 enqing (恩情), 32 Erikson, Erik, 48 euthanasia, 145 exchange. See parent-­child exchange exercise, 75, 102, 105 expectations, 37–39. See also obligation ­family elder care, 5–6, 95–99. See also intergenerational relationships ­family structures, 5, 11, 64–65. See also intergenerational relationships Fei Xiaotong, 23, 152 Feng Xin-­ming, 26 fengzi (疯子), 105 fertility control policies, 4–5, 47, 165n4

fertility rates, 47, 94, 131 Filial Obsessions (Sangren), 29 Filial Piety (Ikels), 26 filial piety or filial reverence (孝), 41–43; elder responses on, 23–24; expectations of, 37–39; as foundational Chinese concept, 26–28; love, as burdensome, 40–41; opposing opinions on relevance of, 21–23; as parent-­child exchange, 34–37; power and, 28–31; as reciprocity, 31–34; as term and character, 19, 25, 26, 93, 142, 157. See also intergenerational relationships; reciprocity (报) financial strains, 8–9, 135, 140, 165n4, 166n5. See also health insurance; pensions flattery, 126–127 food in elder care institutions, 68, 88, 99, 121, 122, 124–125, 127 food insecurity, 59–60 food rationing, 59, 103 Foucault, Michel, 15 Gale Encyclopedia of Medicine, 138–139 geriatric hospitals, 8, 76, 119 gift-­g iving, 31–33, 96 “good death,” 131, 132–134. See also death and ­dying Graeber, David, 43 gratitude, 32 ­g reat f­ avor (恩情), 32 ­Great Learning (Legge), 21, 27, 28–29 Green, James, 132 guan’ai (关爱), 98 guanbuliao (管不了), 109 guanli (管理), 121–123 guanxi (关系), 32, 99 guanxin (关心), 98 Guo Xi, 110 Hainan Province, 80 Hall, Edward, 82 happiness, 44–45, 102 harmony, 14–15, 25, 31, 134, 158–159 Harms, Erik, 59, 87

Harrell, Steven, 40 health insurance, 8–9, 61, 152, 166n1 (ch. 1), 166n6. See also financial strains Herr, Ranjoo Seodu, 30–31, 42–43 heshide (合适的), 109 history and embodiment, 44–46, 57–64 hospice care, 7, 136, 137, 138 hospitals, 8, 76, 119. See also elder care institutions hourly domestic helpers (保姆), 108–109, 154, 167n1 (ch. 5) Hua, Grandma, 66, 67, 100–101, 146 Huang Yongyu, 154–156 hugong (护工), 109–119, 158; care through zhaogu, 123–124; ­children of, 168n4; demographics of, 116; mi­grant workers as, 80; quality of care by, 119–121; as term, 80; training of, 118, 168n3; wages of, 115, 116, 118, 126, 127. See also baomu (保姆); care; guanli (管理) Hundred Flowers Campaign, 55–56 hunger, 59–60 hybrid public-­private elder care institutions, 8–9. See also elder care institutions Ikels, Charlotte, 26 India, 11 individual vs. collective life, 64–66, 156–157. See also cap­i­tal ­ist economy in­equality and filial piety, 28–31 Inhorn, Marcia, 46 institutional care. See elder care institutions institutional rhythms, 86–88 insurance. See health insurance intergenerational relationships: chronic living and loss of, 142–144; co-­residence and, 6, 94, 143; elder subjectivities in, 153–154; in India, 11; parent-­child care, 95–99; parent-­child exchange, 34–37; parent-­child relationship, 29–31; reciprocity in, 31–34; tele­v i­sion series on, 150–151. See also filial piety or filial reverence (孝) isolation, 96, 144, 148

Index 191

Jade Hills Elder Care Home: admission standards at, 167n1 (ch. 4); community care in, 105; dementia care in, 167n2 (ch. 3); description of, 17–18, 73–74; space making at, 82, 83 Japan, 4, 13, 145 Japa­nese invasion of China, 44 Ji Chun, 62–63, 65–66 Ji Du, 115, 119–120, 125, 158, 168n2 (ch. 5) jinglaoyuan (敬老院), 165n2. See also elder care institutions jumping into the sea, as phrase (下海), 154, 168n1 Kaufman, Sharon, 2, 12–13, 130–131, 135 kindness (仁), 27, 28, 93, 157 Kipnis, Andrew, 32, 154 Kleinman, Arthur, 9–10, 15, 45–46, 62, 92, 154 knowledge vs. embodiment, 44–46 Kontos, Pia, 62 Kübler-­Ross, Elisabeth, 132 Kunming, overview, 16, 166n1 (ch. 1) l­abor migration, 5, 6, 80 ­labor reform camps, 56, 64 Lamb, Sarah, 11 Lan, Grandma, 84–85 land owner­ship, 69, 166n5 Lao, Grandma, 105 laonian gongyu (老年公寓), 165n2. See also elder care institutions Law on Protection of the Rights and Interests of the El­derly (1996), 5, 22, 95 Lefebvre, Henri, 71, 87 li (礼), 27, 28 liaoyangyuan (疗养院), 165n2. See also elder care institutions life-­course theory, 48–49 life expectancy, 3–4, 47, 148 Li Ming “Grandma Li,” 44–45, 50–51, 64, 100, 101 Liu Ling, 39 live-in domestic helpers (保姆), 108–109, 154, 167n1 (ch. 5)

192 Index

lixiu ganbu (离休干部), 60–61, 76, 119, 152 Li Zhang, 69 Lock, Margaret, 11, 13, 62, 145 loneliness, 96, 144, 148 Lost Generation, 49 love, as burdensome, 40–41 Low, Setha, 83 Lu Wei, 21 Ma Meili “Auntie Ma,” 1–2, 63, 126–127, 147–148 male hugong, 116, 117–118 Malinowski, Bronislaw, 2 management (管理), 121–123 Maoist revolutions, 29, 41, 47–48, 62, 152. See also Chinese Communist Party (CCP); Cultural Revolution generation Mao Zedong, 29–30, 54, 56–57 Marriage Law (1950), 53 Marx, Karl, 44 Marxism, 167n2 (ch. 5) McLean, Athena, 72, 81–82, 124 meal times, 87 medical anthropology, 9–10, 57–58, 60, 132 mei banfa (没办法), 147 ­mental health ser­v ices, 18, 62, 102. See also depression; loneliness; psychological distress; suicide Merleau-­Ponty, Maurice, 14 methodology overview, 16–19 ­middle, as concept, 159 migration of workforce, 5, 6, 80 Min Zhang, 114 Mol, Annemarie, 120 morality: care and, 93; crisis of, 154–155; of death and ­dying, 12–13; filial piety and, 19, 22. See also obligation Munn, Nancy, 85 Muslim faith and medical care, 79, 96, 158, 159, 166n7 New Masters, New Servants (Yan), 108 New Year’s holiday, 106

9073 model of elder care, 5–6, 69 No Aging in India (Cohen), 11 nursing care, 109 nursing home (养老院), as term, 165n2. See also elder care institutions obligation, 31–32, 106. See also expectations; filial piety or filial reverence (孝); reciprocity (报) old age home (老年公寓), as term, 165n2. See also elder care institutions One Child generation, 50 one-­child policy, 4–5, 165n4 one-­sex model, 15. See also embodiment owls, 154–156 paid caregivers. See baomu (保姆); hugong (护工) pain, 141–142. See also suffering palliative care, 7, 16, 17, 131, 134, 136–138, 150 parent-­child care, 95–99 parent-­child exchange, 34–37. See also intergenerational relationships; reciprocal exchange networks (关系); reciprocity (报) parent-­child relationship, 29–31. See also filial piety or filial reverence (孝); intergenerational relationships A Passion for Society (Wilkinson and Kleinman), 108 patriarchy, 28–31 pensions, 9, 17, 41, 61, 63, 80, 122. See also financial strains Petryn, Adriana, 60 Phenomenology of Perception (Merleau-­ Ponty), 150 pianzi (骗子), 110 placemaking, 70–73, 88–89. See also elder care institutions population statistics, 4, 16, 47, 69, 80. See also aging population poverty, 59–60. See also financial strains power: filial piety and, 28–31; migration and, 78–81; space making and, 87

Pre-­Consolidation generation, 49, 50, 53 private elder care facilities, 7, 76–77, 83–86. See also elder care institutions; names of specific facilities private payment for elder care, 7, 9, 166n1 (ch. 1), 166n1 (ch. 3) private property, 69, 166n5 psychological distress, 45–46, 62–63, 72, 96. See also ­mental health ser­v ices quality (素质), as term, 109 quality of care, 119–121, 124–125 railroad, 58–59 reciprocal exchange networks (关系), 32, 98, 99 reciprocity (报), 31–34 Reform period, 53–57 religion: caregiving and volunteerism by groups, 103–104, 158; comfort from, 66, 147; current rise in, 166n3 (ch. 2); lack of, 96; worship of, 167n2 (ch. 5) ren (仁), 27, 28, 93, 157 Republican generation, 49 research overview, 10–19, 166n7 residential care facilities. See elder care institutions resignation, 147 Resigned Activism (Lora-­Wainwright), 147 retired cadres (离休干部), 60–61, 76, 119, 152 retirement estate, 76–77 right-­to-­d ie policies, 148–149. See also euthanasia; suicide ritual or etiquette (礼), 27, 28 Sahlins, Marshall, 132 Sangren, Steven, 29–31, 32 scams (骗子), 110 school-­aged volunteerism with elders, 104, 128, 157 Sei Weng, 160 self-­care, 65–66, 101–103, 158 self-­sufficiency vs. collective life, 64–66, 156–157. See also cap­i­tal ­ist economy

Index 193

sensorial descriptions, 10, 73, 81, 84 sent-­down youth program, 35, 49, 56–57 Shea, Jeanine, 23, 94, 100 show concern and care for (关爱), 98 Singing Meadows: description of, 74–75, 154; living arrangements at, 82; types of care at, 100, 167n1 (ch. 4) social and economic changes, 4–5, 19–20, 46–49, 53–57, 64–67, 151–153 social death, 12, 62, 142–146. See also death and d ­ ying social inequalities and filial piety, 28–31 socialist economy, 4, 9, 48 Social Reform generation, 50, 65 social security, 9, 152 social welfare homes, 7, 75–76. See also elder care institutions societal structures, 51–52 Song Xin, 37, 118, 125, 168n3 space making, 77–86. See also placemaking spousal caregiving, 100–101, 146 stroke, 139–140 suffering, 15–16, 59–60, 141–146. See also death and d ­ ying; embodiment suicide, 66, 145–146. See also depression suzhi (素质), 109 take care of oneself (自理), 97 Tan, Sor-­hoon, 25 Tang Bai “­Uncle Tang,” 58–61, 81, 86 Tea and Horse Road, 59 theoretical orientations of research, 13–16 ­there is no way, as phrase (没办法), 147 “three-no” policy, 7, 166n1 (ch. 3) Time for ­D ying (Glaser and Strauss), 137 To El­derly with Love (tele­v i­sion series), 150–151 to take care of (照顾), 123 trade routes, 58–59 trauma, 44–46 Tsing, Anna, 81 Tuan Yi-­Fu, 71 tuhao (土豪), 78

194 Index

The 24 Filial Exemplars (Jordan), 28 two-­child policy, 5, 47, 165n4 ­Uncle Tang. See Tang Bai “­Uncle Tang” United States: home care industry in, 111, 127; intergenerational relationships in, 25–26, 27; studies on aging population in, 48; studies on nursing homes in, 72–73, 81–82, 130–131 unmanageable (管不了), as term, 109 Vietnam, 87 Vita (Biehl), 12, 73 volunteerism, 103–104, 128 wages, 115, 116, 118, 127 Wang Hong, 117–118, 168n3 Wang Hua, 19, 159 Wang Lu, 79, 80 Wan Long “­Uncle Wan,” 139–141, 143, 154 Watson, Rubie, 109 Wei Qing, 80 welfare homes, 7, 75–76. See also elder care institutions welfare ser­v ices, 7, 26 wenhua (文化), 109 Wilkinson, Ian, 15, 92 winking owl painting (Huang), 154–156 Wolf, Margery, 109 workplace abuse and anx­i­eties, 110–112 World Bank, 4 wo yi dai (我一代), 50 Wu, Dr., 96–97, 106 Wu Ga, 113–114, 116 Wu Meng, 28 xiahai (下海), 168n1 Xiang Fu, 78–79, 88 Xiao, Auntie, 105, 139, 141 xiao (孝), as term and character, 19, 25, 26, 93, 142, 157. See also filial piety or filial reverence (孝)

xiuyangsuo (休养所), 165n2. See also elder care institutions Xu, Grandma, 53–54 Yan, Hairong, 108–109 yanglaoyuan (养老院), 165n2. See also elder care institutions Yang Ling “Auntie Yang,” 61–62 Yan Yunxiang, 22, 24, 31, 41, 154 Yan Zhang, 23, 94 yinao (医闹), 111 Yunnan Province, overview, 16, 58–59, 167n2 (ch. 5) Zhan, Jenny, 23, 24 Zhang, Everett, 63

Zhang Li, 22 Zhang Wei “Grandpa Zhang,” 34–37; care of, 110, 125; early life experiences of, 55–56, 64; on ­family relationships, 27, 38, 144; on health and end-­of-­l ife care, 134–135, 147 zhaogu (照顾), 123–124 Zhi Chun, 124, 126–127, 153 Zhong, Auntie, 105 Zhongguo (中国), 159 Zhou, Auntie, 79–80 Zhou, Grandpa, 3–4, 102–103 Zhuangzi (Eno), 129, 133 zili (自理), 97 Zito, Angela, 30 zone of indistinction, 130–131, 148

Index 195

About the Author

­r ose k. keimig is a medical anthropologist who is interested in the ways h ­ umans experience change across the life course. Her research has taken her from Beijing during the 2008 Olympics to the banks of the Nujiang River. She is attracted to the weird and wild ­things that emerge on the borders of life, nature, technology, and understanding. She currently works as a UX researcher.