(to No. 57 An Ding Men Wai Da Jie, Dong Cheng District, Beijing)
Dear Ms Sun:
I am writing to advocate more concern for long-term caregivers, whose labour has been undervalued and underpaid in and out of the family in today’s rapidly ageing China. I hope you can take some action as the head of The National Working Commission on Aging.
Long-term care in present China: Policy design and urgent requisite
Long-term care “refers to a broad set of paid and unpaid services for persons who need assistance because of a chronic illness or physical or mental disability” . Consisting of instrumental activities of daily living (LADLs), activities of daily living (ADLs), and therapeutic care for chronic conditions (Feder et al., 2000, p. 42), it serves the group without or losing mobility, the old adults primarily included (Yang, 2016). Firstly came into the policy sight in the 12th Five-Year Plan for National and Economic and Social Development (2011-2015) (Ministry of Civil Affairs of the People’s Republic of China, 2011), the long-term care provisions in China were designed as three-tiered with home-based care as the foundation and community-based services and institutional care as support. (Feng et al., 2020) This care system has been maintained and reinforced till now.
The requisite for long-term care in China is predictably progressively urgent. Referring to The seventh National Census (performed in 2020), the population ageing above 65 was 190.64 million, constituting 13.50% (National Bureau of Statistics, 2021). The “Fourth survey of the living status of the old rural and urban population” (2015) shows that there were more than 40.63 million elderly people in a state of disability or half-disability who required long-term care in 2015 (CNR News, 2016). It is estimated that there will be up to 61.68 million and 97.50 million disabled old in China by 2030 and 2050 (The Drafting Group of General Report, 2015).
Little attention paid on caregivers: Reasons and resulting problems
However, despite the enormous need for long-term care, little concern has been paid to caregivers in today’s China for many reasons. First, lacked existence of “long-term care” in policy and public discourse has caused ignorance and undervalue towards the long-term caregiver group. In the 14th (2021-2025) Five-Year Plan (Ministry of Civil Affairs of the People’s Republic of China, 2021), “long-term care” remains to be constrained in the long-existing traditional category of “yanglao” (养老). It is believed to conclude the general requirement for all older people (rather than noticing the demands of the disabled old). While stressing feeding and handling funeral affairs, the role of care is marginalised in this dominant expression, causing the same problem in public awareness (Yang, 2016). Therefore, long-term care has been undervalued as a career. Moreover, the 2,500 years of cultural contexts in which the Confucian doctrine of filial piety (xiao), family cohesion and intergenerational responsibility emphasises family as the principal living conditions contributor for the old (Cheung, 2019) has primarily moralised and rationalised the domestic long-term care work and even promoted its legislation (Zhan, Feng & Luo, 2008). As a result, inadequate attention is paid to family members as unpaid long-term caregivers and their labour and situation, for caring for parents primarily within the family is culturally natural and obligatory for Chinese adult children. At the same time, formal long-term care has been marginalised in policy design, especially from 1949 to the 1980s when the community-based and institutional elderly care services were provided only non-profitably and only for the “Three-No Elders”- elders with no income, no children, and no relatives as public welfare (Yan, 2016, p.1). Thus, receiving institutional care has long been stigmatised in China as the symbol of miserable ageing life without acceptable living conditions and family company (Yan, 2022). Despite the historical contexts, formal long-term care suffers from more stigma as dirty work (Jervis, 2001) of low status (Yan, 2022). All those factors have caused insufficient attention to paid long-term caregivers.
The undervalued and underpaid situation towards long-term caregivers has brought significant problems. Most directly, many paid long-term caregivers are discouraged from stable work by the unattractive career prospects, including low salaries, shortage of career development opportunities, excessive workload, adverse social attitudes, limited job satisfaction (Feng et al., 2020), and potential trouble dealing the relationship with the elderly and their relatives and ethical dilemmas (Yan, 2020). Currently, middle-aged female migrant workers from the countryside and laid-off workers with limited education dominate the direct care workers in urban nursing homes (Yan, 2020), deteriorating the public impression of the quality of paid long-term care work and restricting its development.
As the joint result of the underdevelopment of long-term care services and the old’s choices due to cultural and historical contexts in China, family members are the principal long-term caregivers for more than 95% of elderly people, according to the “Fourth survey of the living status of the old rural and urban population” (2015) (CNR News, 2016). Crises exist although “ageing in place”, which means remaining older people in their own homes for as long as possible according to their preference (Lewis & Buffel, 2020, p.1), is widely believed to be a rational policy design (Yang, 2016). Due to the marked social transformation, Chinese families gradually lose the capacity and willingness to provide such heavy labour. The family planning policy, the increased labour mobility boomed by rapid urbanization and industrialization (Yan, 2022), and the transforming social values such as individuality, privacy, autonomy and responsibility have significantly shifted families into smaller and more dispersed forms and challenged the previous norms of relying on family members, especially the younger generation to care for the old (Cheung, 2019). Besides, domestic long-term care has to be supported by professional workers out of the family to provide appropriate medical care. The undervalued and underpaid situation towards long-term caregivers also brings potential risks for care receivers.
Solving the problems: Paying more attention to long-term caregivers from various aspects
To tackle the severe challenge brought on by rapid ageing, to improve the long-term care situation and to secure a better living quality for the disabled old in contemporary China, we should pay more attention to long-term caregivers both in and outside of the family.
Firstly, the unpaid long-term caregivers in the family should be socially valued and compensated. From the 1970s, some reconsideration about the production-reproduction relationship has emerged in Western academic contexts. Reproductive activities such as care work and unpaid domestic (which are mainly conducted by women) are argued to be viewed as productive labour which generates value (Costa & James, 1972; Mies, 2012 ). The hardship of domestic long-term care workers and the sacrifice of family caregivers should be comprehensively admitted even in the filial piety propaganda cultural surroundings. Besides, the value generated by those unpaid caregivers should be socially recognised by compensating them. More care holidays and financial support should be provided for working family caregivers to relieve their stress materially and spiritually.
Additionally, paid long-term caregivers should be treated more appropriately. Their career prospects should be improved by raising wages, providing more professional training opportunities, avoiding overwhelming workloads with adequate staffing, enhancing the working environment with more investment, and promoting a positive career image.
Besides these general strategies, I want to stress two current-politically overlooked points based on recent anthropological studies. Initially, long-term caregivers could be vulnerable without the necessary regulation protection when working in older people’s houses. Recent research conducted in Beijing has demonstrated the worries of medical caregivers about home healthcare services for disabled older adults. The limited advocacy for their rights and the shortage of laws and regulations ruling home healthcare services make them face potential personal safety risks, including verbal abuse, over-duty tasks and even sexual harassment in the old’s home, diminishing their working motivation to an excessive extent (Xu et al., 2021). Moreover, the dimension of emotional labour, which means “the requirement for workers to orient their inner emotions and outer emotional displays in alignment with a set of occupational requirements” (Yan, 2022, p. 3), should be emphasised in their work. It is invisible in the Chinese context, although crucial to both the old and the caregivers (Yan, 2022). In Yan’s research, long-term caregivers working in central China nursing homes toughly constructed and maintained three moral buffers to self-manage feelings and handle mental health issues without specialised emotional support provided (Yan, 2022). Social protection should be supplied, such as emotional burdens relief training.
Everybody gets old one day, and vulnerability and dependency are inevitable and inherent within the human condition, requiring care (Held, 2006). Given the rapid ageing situation, the urgent requisite for long-term care combined, and the devaluation towards informal and formal long-term care work in contemporary China, more attention should be paid to long-term caregivers working in families, communities and institutions. By socially recognising and compensating unpaid caregivers and enhancing the career prospects of paid caregivers, those crucial to the life quality of disabled elderly could be supported materially and spiritually. Starting by paying attention to long-term caregivers in many aspects, we could promote the advancement of long-term care in contemporary China and meet the need of massively increasing ageing populations.
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