Side Effect Of China's One Child Policy: Who Will Care For Aging Parents?

Chen Zhaowei woke up on a cot in a hallway of Shenyang Sheng Jing Hospital, one of the largest hospitals in Northeast China. The rooms on the surgical wing are so packed with patients that caretakers like Chen sleep in the hallways to be close to their family members at night.

It has been five weeks since Chen found out about his father’s liver cancer and checked him into the hospital. Chen stays at the hospital 24 hours a day.

“The last time I took a bath was more than a month ago,” Chen said. “I have no place, no time, no energy, no mood to take a bath.”

Chen is an only child. He was born in 1982, two years after the start of the One Child Policy. While he helps his father in Shenyang, the capital city of Liaoning Province, Chen’s mother remains in their hometown. She was diagnosed with depression, so Chen spared her the news of his father’s cancer. Chen also has a family of his own. His wife and 3-year-old son stayed in Dalian, the city where he lives and works, 250 miles away from Shenyang.

 Chen is one of an estimated 176 million children born during the One Child social experiment, which started in the late 1970s and early '80. His struggles caring for his ailing father portend dramatic changes in China's care for its senior citizens as parents of the only child generation reach old age. The parents who raised children under the One Child Policy are reaching 65, facing high risks for health issues and needing care from their only kids.

“In the next 20 years to 30 years, the senior population in China is going to explode to the point where, by 2050, 1-in-4 Chinese will be retirees,” says journalist and author of *One Child*, Mei Fong, who has been covering China and Hong Kong issues since 2003. “The problem is there isn't enough of a young working population to sustain that aging population.”

“Every major developed country is experiencing population aging. What distinguishes China is the fact that the scale is so large and the population aging has happened so rapid,” says Aaron Hagedorn, instructional assistant professor at University of Southern California's Leonard Davis School of Gerontology. “I believe any decision that isn't made quickly will be a very expensive mistake down the road.”

For now, the one child generation will be facing the elderly support issue without help. Reversing China’s shortage in medical resource and elderly support services will be a long-term project. Complicating matters is the long-held filial piety culture, which adds an extra psychological burden to the one child generation, if families turn to professional senior care organizations.

Wen Chang’s Classic of Filial Piety teaches that one must take care of their unwell parents alone: “Taste the medicine before you feed it to your parents; restlessly take care of your parents day and night; do whatever you can to make them comfortable.”

 Chen's plight shows the consequences of the 35-year-old One Child Policy. The most common and traditional Chinese support system for the elderly is stretched too thin. There are simply too few young to support the old. And even if every single child could care for his parents, needs for more sophisticated care would go unmet.

China's health-care professionals are aware of the burgeoning crisis and are looking globally for possible solutions.  Japan, for example, uses older people in their 50s and 60s to provide a level of care. The United States' well-established care systems for the elderly can be expensive, but could offer models for China.

China's two-child policy shows that the government is rethinking the long-term effects of its previous restrictive birth planning policy.

The nationwide campaign to instill respect and responsibility for caring for the elderly intensified last year.  ShanDong province Dr. Tang Xu, who specializes in treating senior citizens, believes it is a sign the government is starting to take the aging problem seriously.

“The clock is ticking,”  Tang Xu said, “Well-trained community nursing workers, senior care knowledge education — the country can’t get these ready in three or even five years. But the earliest one child generation and their parents can’t wait that long. I believe that there will be a chaotic process in between.”

Even if the only child generation and their parents could abandon their cultural beliefs and seek institutional care, too few professional organizations and skilled health-care workers exist in China to treat the huge aging population.

Consider the daily demands at Workers’ Senior Home in LiaoNing Province, which is a public senior care organization founded in 1984. Vice Director Song Yang said the home’s capacity is 300. “We are always full house. To make sure that the ones in most urgent need can get in, applicants are thoroughly filtered based on their health condition and other factors.”

A shortage of nurses forced Workers’ Senior Home to reduce the number of seniors it can accommodate.

“To take care of seniors who can’t carry out daily tasks on their own, the ratio of nursing workers to seniors should be more than 1-to-1.” Tang Xu said. By 2016, according to  Song Yang, the home’s ratio of nursing workers to seniors reached as high as 1-to-6.

 “Senior homes have been in urgent need of regular nursing workers. But no one wants the job. We have to crew from the countrysides and the rural areas,” Song Yang said. “The workers lack professional skills and are hard to find. Because the qualified workers haven’t been treated as they should’ve been.”

Workers’ Senior Home employs 60 nurses, all on a temporary basis. Day-time workers care for five or six patients. Their job is to fulfill basic caring needs like feeding. These workers earn 3000 yuan a month, equal to $460. Night-time workers take care of 20 to 30 seniors. Their job is to help seniors roll over in bed and to use the bathroom. They earn 3500 to 3600 yuan, or $540 to $555.

“Nursing workers are required to obtain basic trainings or degrees before they get to practice,” Tang Xu said, “However, people with trained skills or related degrees would want a career that is more stable, more decent, and with more income. ”

For example, Yue Sao nannies who take care of newborn babies and their mothers can earn 8000-10,000 yuan monthly, or up to $1,500. Compared to senior care, the work is  easier for triple the pay.

Song Yang feels strongly about how seniors are afraid of moving into nursing homes because of unmet needs.

“The ratio of nursing workers to seniors we have now is barely enough to fulfill seniors’ physical needs, like feeding, night watching or basic medical cares, it’s very hard to take care of the seniors psychologically.” Song Yang said.

University of Southern California Professor Iris Qi, whose specialty is gerontology, believes more people would be drawn to the jobs if they could see a “career ladder” for advancement. “Nursing worker’s salary and social class should match with their working experience and professional skills,” Qi said. “Who’d want to work in a profession where you can’t see the next level?”

China finds itself in a quandary: Although nursing workers are considered low-paid, the cost is still huge for many seniors. Will  the only child be able to afford that cost without a sibling to share the bills?

China can learn from many elderly support models from around the world. The most promising solutions will respect the filial piety virtue and accommodate the demographic structure shaped by One Child Policy. Government guidance is essential to taming the chaos and uncertainty that could prevail once the senior care organizations and workers are pushed to their limits. In fact, seniors might be part of the solution.

“The senior supporting model that China should learn from is a model that combines support from organization, family and community,” said Gerontology professor Jia Suping of Dalian Jiaotong University. “Seniors don’t want to move out from home, we should respect that. We should offer community senior service, day care and short-term living facilities.”

Through Japan’s golden plan, a government-funded home care program, experts found out that by using people in their 50s and 60s to care for people in their 70s and 80s, the quality of care tends to be better. The workers themselves feel more fulfilled by what they are doing.

  “Because they can relate to people their own age, they can understand the issues and they tend to be more patient,” USC's Hagedorn said. “They feel like by helping this person today, they are earning Karma that they can cash in later when they need the support.”

 China's early retirement age, 55 for women and 60 for men, makes it possible for retirees to contribute and boost their income as well. Nursing jobs might be a suitable career role for older adults in a community.

 ShanDong province Dr. Tang Xu believes the Chinese government should build the cost of nursing workers into the social insurance system. “The costs of hiring nursing workers is not covered at all,” Tang Xu said. “But it will be the part where help is most needed.”

 The state of California, for example, offers government-paid nursing workers to low- income seniors, who can hire their favorite person to take care of them. The caregiver is paid minimum wage.

Welfare systems in developed countries are more established, but maintaining the system is not cheap.

Professor Hagedorn estimates American’s old age programs tap 24% of the federal budget; by 2050, they'll account for more than 70% of the budget, if no changes are made.

“We are really generous with our Medicare, Medicaid and Social Security. The U.S. has been running a deficit since 2000, so it's obvious that we can't sustain what we have,” Hagedorn said. “China's done a good thing by making not too many promises so far. But as economies grow, and as people become more wealthy, they tend to expect more and more.”

 Advocates for the aging populations around the world are seeking a cost-effective model that offers seniors the care that they need, and that they want.

In China, the demands are the same.

“They don't want their health to decline, they don't want to change their environment,” Hagedorn said.  “They want to be surrounded by the people that they like, the people that they know, the people that they are related to.”

Many Chinese seniors dislike nursing homes. They don't like the constant exposure to change and are stressed by many factors, from ignored needs and the food to the environment and companions they cannot choose for themselves.

“Once you are in a nursing home,” 68-year-old Chinese-American Winnie Feng said, “you can only accept whatever is offered. Don’t think too much, you’ll die soon.”

 The mental health needs of seniors must be addressed in any long-term care plan.

 “When people come to a certain age, their personalities change dramatically,” said Li Yan, a social worker intern at Golden Age Village, a Los Angeles-area senior apartment complex. “They need guiding and consulting to overcome the psychological change. In the U.S., every senior care organization has social workers to connect the seniors with social resources, or to care about seniors’ mental health. I haven’t seen anything like this in China.”

Social workers can help ease seniors’ anxiety against nursing homes. However, no new nursing homes have opened  in California since 1994. The United States has shifted to the model of assisted-living.

Professor Hagedorn said people tend to stay longer in assisted-living facilities, which offer more social support in a home-like environment. However, assisted-living facilities cannot replace the sense of security that home can bring. They are middle-ground solutions.

What Professor Jia described as community senior service, is very similar to a California senior program, called multi-purpose senior services program. It provides extra services at low cost to  people who qualify for nursing home care but choose to stay at home with their families.

It offers adult day care services  at about 10 percent of the price of a nursing home.

“The American model depends on wealth and depends on people having saved a lot of money,” Hagedorn said. “Chinese culture is different than American culture, much more collectivist in nature. People feel more sense of filial piety in obligation towards their family, and if you are able to tap into that, that can lead to many more sustainable model.”

 The key is finding a program that will work in China. Said Hagedorn: “The good thing for China, when it comes to preparing for aging society, is that the government sets rules and people respond fast.”