PART FOUR
HARDSHIP AND DEPENDENCIES

Eleven
Strategies Used by Chinese Families Coping with Schizophrenia

Michael R. Phillips

The author thanks the leaders and the collaborators from Shashi Psychiatric Hospital, the Department of Psychiatry of Hunan Medical University, Huilong Guan Hospital (Beijing), Jilin Neuropsychiatric Hospital, and Nanjing Neuropsychiatric Hospital for their assistance in collection of the data discussed in this chapter. This research was funded in part by a grant from the Rockefeller Foundation for collaborative research between the Shashi Psychiatric Hospital and the Department of Social Medicine and Health Policy of Harvard University.

The acute or chronic inability of individuals to fulfil their expected functional roles because of age, illness, or injury is a universal phenomenon. A primary function of the family cross-culturally is to provide for the short-term and long-term care of disabled family members while minimizing the effect of the disability on the overall success of the family. The strategy a family adopts to achieve this goal is influenced by a number of factors: the severity of the disability; the family's beliefs about the cause, appropriate management, and likely outcome of the disability; the stage in the life cycle that the individual is disabled (i.e., at birth, as a young adult, in mid-life, or in old age); the cultural ideology about desirable family outcomes and about expected intrafamilial rights and obligations; the availability of extrafamilial social support services; and the socioeconomic resources of the family. Strategies used to cope with disability are highly dynamic; changes in any of these factors—such as a decrease or increase in severity of the disability or a change in the family's beliefs about the disability—result in modifications in the family strategy. Thus analysis of the strategies families adopt to cope with the disability of a family member provides a unique perspective on the constraints that cultural ideology and socioeconomic conditions place on family choices.

Schizophrenia is one of several illnesses that are frequently associated with serious and chronic social dysfunction, so it is a suitable index condi-

tion for assessment of the strategies that families use to cope with disability. It is a universally prevalent disorder of unknown etiology,^[1] which usually starts during early adulthood. It typically has a fluctuating course characterized by relatively short episodes of florid symptoms—hallucinations, delusions, bizarre behavior, and disorganized thinking—followed by much-longer quiescent periods during which sufferers manifest varying degrees of residual symptoms: affective flattening, poverty of thought, and lack of motivation. The most commonly used treatments (antipsychotic drugs) can usually decrease the severity and frequency of relapses of florid symptoms, but they have limited effectiveness in treating the more chronic residual symptoms. Schizophrenia affects young adults in whom the hopes of future family success reside, so it is a severe blow to the morale of family members. In societies such as China where there are few social support services for the mentally ill and where mental illness is highly stigmatized, families are the primary care-givers for schizophrenic patients; they adopt a wide variety of structural and functional strategies with greater or lesser success. This chapter discusses the effect that schizophrenia has on family strategies in China and looks at the influence recent socioeconomic changes have had on these strategies.

The difficult choices facing families with a schizophrenic member are poignant examples of the dilemma that faces all families in post-Mao China. The rapid ideological and socioeconomic changes are transforming the opportunity structure and, I contend, the ideal paradigms of family behavior; so families must now try to select strategies that satisfy the dictates of both the hierarchical, family-centered Confucian paradigms and those of the egalitarian, individual-centered paradigms seen in Western cultures. Most families are only partially aware of the dilemma; their methods of family decision making and the strategies they adopt to achieve family success are unstable amalgams of elements from these two contradictory worldviews. But for families of the chronically disabled the choices are starker and the decisions are more conscious. In an era when the authority of urban parents over adult children is rapidly diminishing and "free choice" marriages are becoming the norm, parents of schizophrenic adults closely supervise the lives of their disabled children and arrange their marriages. In an era when economic well-being is an increasingly important indicator of social status, and when the reduction in state-sponsored social welfare is

[1] There are, of course, a wide range of theories about the cause of schizophrenia. The most radical position is that schizophrenia and all other mental illnesses do not exist: T. S. Szasz, The Myth of Mental Illness (New York: Harper and Row, 1961). The position taken in this chapter is that biological factors are the primary cause of schizophrenia in most instances of the disorder, but that sociocultural factors strongly modulate the age of onset, severity of symptoms, frequency of relapse, and degree of social dysfunction. Treatment should, therefore, combine biological (medication) and psychosocial interventions.

increasing the economic burden of chronic illness, these families usually follow the ethical dictates of Confucianism and continue to provide for schizophrenic family members despite the detrimental effect this has on the economic and social status of the family. Thus Chinese families respond to the catastrophe of having a chronically disabled member by adopting more traditional patterns of family behavior even though they realize that their behavior is out of step with the trends of the times. They are acutely aware of the contradictions that all families in post-Mao China must resolve, contradictions that will intensify as the reform process proceeds.

Method

This chapter includes data collected from three separate studies that I conducted during my stay in China from 1985 through 1990. The first study (hereafter, Changsha study) was a collaborative project between the Department of Psychiatry at the University of Washington in Seattle and the Department of Psychiatry of the Hunan Medical University in Changsha, which ran from December 1985 until June 1987.^[2] Patients who were officially resident in Changsha (population: 1.3 million) and who met the American Psychiatric Association criteria for schizophrenia were recruited from the outpatient psychiatric clinic at Hunan Medical University.^[3] The patient and one or more family members were seen on a monthly basis at the clinic for six to eighteen months.

The second study (hereafter, multicenter study)^[4] enrolled a random

[2] M. R. Phillips, Q. J. Shen, Y. P. Zheng, et al., "Zai Zhongguo dui 'Jiating Qinmidu he Shiyingxing Liangbiao (FACES II)' he 'Jiating Huanjing Liangbiao (FES)' de chubu pingjia" (Preliminary evaluation of the Family Adaptability and Cohesion Scale [FACES II] and the Family Environment Scale [FES]), Zhongguo xinli weisheng zazhi (Chinese Mental Health Journal) forthcoming.

[3] The first study (in Changsha) used the diagnostic criteria for schizophrenia from American Psychiatric Association, DSM-III: Diagnostic and Statistical Manual of Mental Disorders (3d ed.) (Washington, D.C.: American Psychiatric Association, 1980), 181-93. The second and third studies (the multicenter study and the study in Shashi) used the criteria from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (3d ed. rev.): DSM-III-R (Washington, D.C.: American Psychiatric Association, 1987), 187-98. The official Chinese diagnostic criteria for schizophrenia were in a state of flux at the time I conducted these studies, so I decided that using the American criteria would be more appropriate. The Chinese criteria are quite similar to American criteria except that in the Chinese criteria the minimum duration of symptoms needed is three months, whereas the duration required by the American criteria is six months. Thus the American criteria are somewhat more stringent; had I used the Chinese criteria, the sample would have included more patients who had one brief psychotic episode that subsequently resolved completely.

[4] M. R. Phillips, W. Xiong and Z. A. Zhao, Jingshenbing yinxing yangxing zhengzhuang liangbiao shiyong youguan wenti (Issues involved in the use of scales for the assessment of negative and positive symptoms in psychiatric patients) (Wuhan: Hubei Science and Technology Publishing House, 1990).

selection of schizophrenic patients admitted to four large psychiatric hospitals (in Beijing; Nanjing; Siping, Jilin; and Shashi, Hubei) from July 15, 1988, to November 30, 1988. On the day of admission the patient and a family member were administered a one-hour structured interview that collected extensive social and demographic information about the patient and about the household in which the patient lived.

The third study (hereafter, Shashi study) is an ongoing collaborative study between the Shashi Psychiatric Hospital and the Department of Social Medicine of Harvard University, which started in May 1988. At the time of admission to hospital, schizophrenic patients who are urban residents of Shashi or Jingzhou (approximate populations: 270,000 and 100,000, respectively) are enrolled in the study. Extensive clinical, demographic, and social data are obtained, and the one and one-half hour Camberwell Family Interview is administered to family members.^[5] Families are then randomly assigned to treatment and control groups. After discharge from hospital, patients assigned to the treatment group attend the outpatient clinic with one or more family members on a monthly basis. Control subjects receive no special intervention. This chapter utilizes data on thirty-three treatment-group families and thirty-two control-group families that were followed for six to twenty-four months.

The three studies collected data on 428 Chinese families with a schizophrenic member. The characteristics of the patients are presented in table 11.1. (In table 11.1 and in subsequent tables the total number of cases reported may be smaller than the sample size because some cases have missing data.) Collectively, these studies provide extensive quantitative and qualitative data about the strategies used by Chinese families who have a schizophrenic family member. All of the families in these studies, however, come from clinical sources, and so families that do not bring their ill family member to see a psychiatrist are not represented. This sample, then, over-represents patients with more severe symptoms and patients that have state-sponsored health insurance.

The other major methodological issue is that the data for the Changsha study and for the treatment-group families in the Shashi study were

[5] J. Leff and C. Vaughn, Expressed Emotion in Families: Its Significance for Mental Illness (London: Guilford Press, 1985). The Camberwell Family Interview is an extensive semistructured interview that uses family members' descriptions of their interactions with the patient over the course of the illness to determine the degree of "expressed emotion" family members have toward the patient. Several replicated studies in Britain and the United States have shown that patients from families with high expressed emotion (as assessed by the scale) are significantly more likely to relapse than patients from families with low expressed emotion. Since families are such an important part of the care-delivery system for schizophrenic patients in China, I expect that after suitable revisions of the instrument it will be possible to replicate these findings in China.

obtained in the context of a long-term clinical relationship.^[6] All subjects were fully informed of the nature of the research study, but they had to overcome both their discomfort in talking with a Chinese-speaking Cauca-

[6] The complex epistemological issues of the clinician-ethnographer are discussed at length in E. B. Brody, "The Clinician as Ethnographer: A Psychoanalytic Perspective on the Epistemology of Fieldwork," Culture Medicine and Psychiatry 5 (1981): 273-301.

sian physician and their unfamiliarity with talking about family issues in a clinical setting. In most cases I did not find these problems major obstacles. In contrast to previous reports about the emotional reserve of Chinese subjects,^[7] I found that most family members would openly express their anguish and frustration when given an opportunity to do so. The family strategies discussed in this chapter are those adopted by families prior to my clinical intervention.

Schizophrenic Disability and its Effect on Household Functioning

Case 1 . Mrs. Ma is a twenty-seven-year-old woman whose problems started five years ago when her angry interactions with other employees and episodes of "talking crazy" led to dismissal from her job as a cashier and, eventually, to psychiatric hospitalization. One year after the onset of these problems, her parents, who were eager to find her a spouse, located an army sergeant who wished to leave the army and move to the city. There was a two-month "courtship" during which Mrs. Ma's father composed love letters, which she copied and sent to the man. They then met briefly five times and were married. She became pregnant two years later. As the pregnancy progressed she started wandering in the streets, shouting her husband's name and stopping cars to see if he was driving; she had an abortion and was readmitted to the psychiatric hospital. One year later she again became pregnant; during the pregnancy she became progressively more irritable and had to be rehospitalized after an episode in which, according to her mother, "she smashed a TV and other household goods, stabbed her husband in the arm, and struck her father on the head with an iron bar so severely that he needed ten sutures to close the wound." After her discharge from hospital, her husband went to court to apply for a divorce. Her parents tried to prevent the divorce, but her husband won the case on the grounds that he had been tricked into the marriage.

One and one-half years after her third hospitalization Mrs. Ma remains on medication and has not had any further outbursts of violence, but she is unwilling to participate in social activities or to consider resuming employment. She continues to sleep alone in her conjugal apartment but spends her days in the nearby apartment of her parents. Her father still has poor sleep and a poor appetite because of his concern about his daughter. Her mother complains about Mrs. Ma's laziness and unwillingness to help with the housework and about the financial burden of caring for her. Mrs. Ma's

[7] T. Y. Lin, "Mental Disorders and Psychiatry in Chinese Culture: Characteristic Features and Major Issues," in Chinese Culture and Mental Health , ed. W. S. Tseng and D. Y. H. Wu, 369-93 (London: Academic Press, 1985).

illness has profoundly changed her parents' household: "Every evening we are tense and cannot relax until she has taken her medicine and returned to her apartment to sleep—we are afraid that she may explode again and kill us. We had hoped for a peaceful retirement but now that's not possible."

The most authoritative figures available report the point prevalence of schizophrenia as 6.06 per 1,000 in urban China and 3.42 per 1,000 in rural China.^[8] Given a population of 1.1 billion and an urban:rural population split of 25:75, there are 4.5 million persons with schizophrenia in China at any given time. Less than 3 percent of these patients are hospitalized in the nation's 803 psychiatric institutions,^[9] approximately 3.4 percent live on their own, and I estimate that no more than 3 percent reside in prisons, nursing homes, or on the streets. The remainder, over 90 percent, live with their families. By contrast, only 40 percent of the 1.2 million schizophrenic patients in the United States live with their families.^[10] Thus in China, as in other countries with underdeveloped services for the mentally ill, families are the primary care-givers for schizophrenic patients.

Providing care for schizophrenic family members when they have acute symptoms is only one of the burdens of illness for the family. As the illness progresses, the chronic inability of affected family members to perform expected functional roles has an even greater effect on the household. Every aspect of patients' social functioning is severely affected. Many are unable to sustain gainful employment or to get married. For those who do marry and have children, their ability to adequately perform marital and parent-

[8] Coordinating Epidemiological Group for Twelve Regions, "Duo lei jingshenbing, yaowu yilai, ji renge zhangai de diaocha ziliao fenxi" (Analysis of survey results of all types of psychiatric illnesses, drug and alcohol dependence, and personality disorders), Zhongguo shenjing jingshen ke zazhi (Chinese Journal of Neurology and Psychiatry) 19, no. 2 (1986): 70-72. This is by far the largest and most rigorous epidemiologic study of psychiatric disorders yet done in China. Nevertheless, the unexpectedly large difference in urban and rural prevalences casts doubt on the thoroughness of case-finding in the countryside.

[9] State Statistical Bureau, Zhongguo Tongji Nianjian 1989 (1989 Statistical Yearbook of China) (Beijing: Chinese Statistical Publishing House, 1989), 889. Psychological Medicine Research Center of West China Medical University, Quanguo Jingshen Weisheng Yiliao, Jiaoyu, Keyan Jigou: Minglu (National registry of psychiatric treatment, educational, and research institutions) (Sichuan Psychology Association, 1990). In total, there are about 127,000 psychiatric beds in Chinese institutions. The Ministry of Public Health operates 414 acute-care psychiatric hospitals with 81,000 beds. The Ministry of Civil Affairs operates 190 chronic-care psychiatric hospitals with about 35,000 beds. The Ministry of Public Security operates 23 forensic psychiatric hospitals with about 6,000 beds. And there are an estimated 5,000 beds in psychiatric research centers, in psychiatric wards in general or military hospitals, and in hospitals operated by other ministries or collectives. Approximately 80 percent of the psychiatric beds in the country are occupied by schizophrenic patients.

[10] E. F. Torrey, Surviving Schizophrenia: A Training Manual (rev. ed.) (New York: Harper and Row, 1988), 8.

ing functions is severely reduced. Affected family members are often socially isolated, have difficulty in performing routine household chores, and, in extreme cases, are unable to care for their own personal hygiene.

The ability of schizophrenic patients to obtain and sustain employment is significantly impaired. Overall, 18.8 percent of the patients in this sample have never been engaged in productive labor, 40.0 percent are unable to sustain their previous employment, and 41.2 percent are currently employed. Currently employed patients include cadres (9 percent), technical-professional workers (9 percent), industrial workers (73 percent), urban agricultural workers (3 percent), and businessmen or service-trades workers (3 percent). The rate of employment is significantly less than expected: Pasternak found that 87 percent of male urban residents between sixteen and fifty-nine years of age are gainfully employed, and 80 percent of female urban residents sixteen to fifty-four are gainfully employed^[11] —the corresponding rates in this sample are 40.7 percent and 36.7 percent, respectively. There are no significant differences in the employment status between male and female patients. Of the 341 currently or previously employed patients, 301 (88.3 percent) are in state-sector jobs that provide medical insurance.

The employment rate of Chinese schizophrenic patients is, however, probably higher than that of schizophrenic patients in the West. Accurate data on employment of schizophrenic patients in the West are not available, but the most optimistic experts believe that under ideal conditions 20 percent of American schizophrenic patients could hold full-time jobs and a further 20 percent could maintain part-time jobs; the actual rates are certainly much lower than these ideal rates.^[12]

Table 11.2 shows that the marital competency of these subjects is also seriously impaired. Of the 423 patients, 49.6 percent have never married. This rate is much higher than expected: according to the national rates of marriage by age the expected never-married rate in these subjects is 28 percent.^[13] Of the 188 currently married patients in this sample, 78.2 percent live in neolocal households, 17.0 percent live with the patient's parents (11.7 percent patrilocal and 5.3 percent uxorilocal), and 4.8 percent live in the household of the patient's sibling. In circumstances where the patient

[11] B. Pasternak, Marriage and Fertility in Tianjin, China: Fifty Years of Transition (Honolulu: East-West Population Institute, 1986), 15.

[12] Torrey, Surviving Schizophrenia , 252-53.

[13] State Statistical Bureau, Statistical Yearbook of China 1986 (Hong Kong: Economic Information and Agency, 1986), 80. The expected rate of never-married persons in the sample is calculated by multiplying the number of persons at each age by the proportion of the general population at that age who have never married, summing these products, and then dividing by the sample size (423) to obtain an overall expected rate for the sample. The expected rate of divorce for once-married persons is calculated in a similar fashion. Unfortunately, the census data do not separately report age-specific marital status for males and females, so it was only possible to adjust the expected rates for age and not for sex.

fell ill before marriage, couples that do not establish their own household inevitably live with the patient's family regardless of the sex of the patient.

The rate of divorce among once-married schizophrenic patients—8.0 percent (15/213)—is almost tenfold the expected rate of 0.81 percent. Male patients are significantly less likely to get married than female patients (43.3 percent versus 60.8 percent), and if they do get married they are significantly more likely to get divorced (11.0 percent versus 4.8 percent). Of the twelve male and five female divorced patients in this sample, four men live on their own, eight men and four women live with their parents, and one woman lives with a married sibling.

What effect does a family member with such disabilities have on the functioning of a household? Table 11.3 shows the opinions of family members from 293 urban Chinese households with a schizophrenic member (data from the multicenter study). It demonstrates that the schizophrenic illness of a family member has a profound effect on the economic, social, and emotional well-being of the household. Economically, the illness limits the productive labor of the ill family member, interferes with the work of other family members who must care for the ill person, and often results in considerable treatment costs. In urban households (where most patients have state-sponsored health insurance) the major economic effect is on the earning potential of the household: the per capita yearly income of urban households with a schizophrenic member is significantly lower than the national average (860 yuan versus 1,192 yuan).^[14]

The functional disability of a schizophrenic family member often requires structural and functional modifications in the household. The household

[14] State Statistical Bureau, 1989 Statistical Yearbook of China , 729.

types of 420 Chinese families with a schizophrenic member are presented in table 11.4, and the status of the affected family member in these households is presented in table 11.5. Both the census data and Pasternak's work^[15] suggest that this sample has a lower than expected rate of single-person households (4.3 percent) and a higher than expected rate of "other" types of households (4.0 percent). In the West, socially isolated schizophrenic patients often use welfare payments to live on their own in single-person households,^[16] but in China single patients rarely receive housing from their workplaces, so they are required to live with relatives. Families with a schizophrenic member may be more likely than other families to resort to relatively unconventional household arrangements: in seven households unmarried adult patients are living with their elderly grandparents, and in twenty-four households adult patients live in their siblings' homes. Compared with female patients, male patients were more likely to live alone, more likely to live in their parental household, and, if they live in their own conjugal household, more likely to be the head of their own household.

Family Strategies Used to Cope with Schizophrenia

Case 2 . Mr. Cai is a twenty-three-year-old man who first developed problems five years ago when he became fearful that others were out to harm him, cursed the national leaders, and wandered away from home for days at a time. His mother thought that "it was something to do with spirits," and so she took him to a shamanistic healer. When this intervention was in-effective, his father, who thought Mr. Cai had a "psychological problem," had him admitted to the psychiatric hospital. Mr. Cai's unusual beliefs and behavior resolved quickly with antipsychotic medication, but he refused to take medication after discharge; he has been hospitalized with the same pattern of symptoms six times in the last five years. In the intervals between hospitalizations he is socially isolated and unable to function well enough to obtain regular employment.

Mr. Cai's mother is a fifty-five-year-old woman who recently retired from a responsible position "because I need to take care of him [Mr. Cai] at home." She desperately seeks out shamans and others who claim that they can cure her son; her husband has criticized her for this on several occasions. She is an important member of their local residents committee and has used this position to obtain 50 percent coverage of her son's drug costs from her former employers and to guarantee an urban residence permit to a young woman from the countryside who has agreed to marry her

[15] State Statistical Bureau, Statistical Yearbook of China 1986 , 83; Pasternak, Marriage and Fertility in Tianjin, China , 36.

[16] Torrey, Surviving Schizophrenia , 8.

son. Five years after the onset of the illness she remains distraught: (sobbing) "This is the biggest trouble of my life. I have no hope. Whatever we can do, we will do for him. I can't die now because I need to take care of him."

Mr. Cai's father is a fifty-eight-year-old worker who is even more severely affected by his son's illness: "When he gets ill my heart breaks. I sleep poorly because of his illness. Whenever he is not at home, I can't eat and I lose weight. Sometimes I get so upset about him I cry." After Mr. Cai's first hospitalization his father quit his job as a state worker and opened a bicycle-repair shop where he works twelve hours a day seven days a week to make enough money to pay for his son's multiple hospitalizations: "All the money I make is organized for his use." When Mr. Cai is reasonably well, his father arranges part-time work for him at the bicycle-repair shop. To guarantee Mr. Cai's long-term security, his father has decided to rent out two flats in their privately owned home and to give this income to his son rather than selling the flats and dividing the proceeds equally among his three children; his wife and two older children are strongly opposed to this plan.

Confronted with the disability of a family member, families first try to resolve the problem by accessing a care-delivery network that includes extended family, friends, folk healers, and professional health-care providers. If the care-delivery system is unable to "cure" the disability, and the individual is permanently unable to perform expected social roles, the family must then develop strategies that provide for the long-term security of its ill family member while protecting the interests of the family as a whole. The strategies developed to achieve these goals are the product of a dynamic interaction of patient, family, and social factors. What follows is a partial list of these factors and how they influence the strategies Chinese families utilize in the management of schizophrenia.

Family, Folk, and Professional Explanatory Models of Disability

In the early stages of a disability family strategies aim to cure the disability, return ill family members to their normal functional roles as soon as possible, and resume interrupted long-term plans for family advancement. The steps the family follows to achieve these goals are strongly determined by the meanings it attaches to the dysfunctional behavior of its disabled family member. The idiosyncratic and polysemous meanings attributed to the behavior by individual family members are condensed into the family's "explanatory model,"^[17] which provides a tentative explanation of the behavior

[17] A. Kleinman, Patients and Healers in the Context of Culture (Berkeley: University of California Press, 1980), 83-118.

and a potential course of action. The family initially attempts to deal with the problem within the family, but if the disability is serious, it may seek the advice and assistance of an expanding circle of informants and care providers.

In China the family, not the affected individual, plays the dominant role in the selection of treatment choices; if family members have varying views, it is usually the view of the household head that prevails. The hierarchy of resort to care providers is determined by the family's explanatory model and by the relative availability of different types of providers in the community. Exposure to the wider cultural conceptions of the causes, appropriate treatment, and likely outcome for the disability—the folk and professional explanatory models—influences the family's explanatory model and leads to alternative family strategies for the management of the disabled person. Chinese families are very pragmatic in their utilization of healthcare providers: they often try a variety of modalities (either sequentially or concurrently) to find the method that generates the most desirable outcome.

Chinese folk models ascribe mental illnesses to imbalances in the supernatural, physiological, or psychosocial environment of the ill person.^[18] In rural areas supernatural explanations such as spirit possession, wrath of ancestors, and imbalances of cosmological forces are seen as important causes of mental disturbances: 70 percent of the families with a mentally ill member in the countryside consult native shamans at some point during the illness.^[19] In both rural and urban areas many families have assimilated traditional medical concepts that consider mental aberrations the result of either an excess or a deficiency of physiological functions (e.g., eating, bowel movements, sexual activity) that disrupts the yin-yang balance; families that subscribe to such organic causes try dietary measures, take vitamins, or seek treatment by herbalists or physicians of traditional Chinese medicine.

Psychological factors (e.g., excessive introversion, laziness, a "strong" personality) and psychosocial stressors (e.g., pressure of studies, failure in love affairs, conflicts at work, family tensions, being sent down to the countryside) are common explanatory models used by urban families. Families with such beliefs first try to reduce the stressors by manipulating the social environment of the affected person. My clinical cases include families in which (1) parents exhort their children to be less "lazy"; (2) a parent took

[18] K. M. Lin, "Traditional Chinese Medical Beliefs and Their Relevance for Mental Illness and Psychiatry," in Normal and Abnormal Behavior in Chinese Culture , ed. A. Kleinman and T. Y. Lin, 95-111 (Dordrecht, Holland: Reidel, 1981).

[19] S. X. Li and M. R. Phillips, "Witch Doctors and Mental Illness in Mainland China: A Preliminary Report," American Journal of Psychiatry 147 (1990): 221-24.

an ill child on a two-month sight-seeing trip around the country to relieve the stress of school; (3) parents arranged alternative employment for a child who felt workmates were plotting against him; (4) parents arranged a rapid marriage to resolve the symptoms that occurred "because of a failed love affair"; and (5) parents had the patient live with a distant relative to reduce exposure to intrafamilial stresses in the natal household.

If these cosmological, physiological, and psychosocial interventions fail, the family may suspect that the problem is a "mental illness"; but the intense stigmatization of mental illnesses in China inhibits most families from seeking professional psychiatric care. If, however, the ill person manifests socially disruptive behavior, the family is obligated by neighbors, school administrators, work leaders, or the police to seek immediate treatment.^[20]

The professional psychiatric explanatory model of mental illnesses currently in vogue in China is an amalgam of American biological psychiatry (which attributes most mental aberrations to alterations in the structure or function of the brain) and of the more holistic approach of traditional Chinese medicine (which ascribes mental illness to physiological or psychosocial disharmonies). Recommended treatments for serious mental disorders are almost invariably somatic, such as antipsychotic drugs, electroconvulsive shock therapy, herbs, acupuncture. I find that families usually accept Western drugs but are unlikely to accept the professional Western explanatory model of brain dysfunction unless it is couched in the more familiar terms of physiological imbalances.

At first families tend to see every remission of symptoms as the hoped-for cure, but when it becomes evident that a particular treatment is only palliative and not curative, they may become angry with the care providers and seek out alternative forms of treatment. They are often willing to make almost any sacrifice or to try the most unlikely methods if there is hope of a cure. Cases from my clinical practice include several such families: families that have exhausted their savings to pay the exorbitant fees of itinerant healers who claim they can cure the disorder; intellectuals or high-level cadres who, despite considering shamanistic practices superstitious charlatanism, seek out native shamans for their ill family members when more conventional methods fail; families who accept the extravagant claims of qi gong "masters" (who have recently had a dramatic increase in popularity) until their recommendations to stop medication and to practice physical

[20] In some situations it is not the family but other social authorities who decide about the treatment of a mentally ill person. Students living away from home may, in emergency cases, be sent directly to a psychiatric hospital; mentally ill persons who have committed serious crimes may be remanded to a forensic psychiatric hospital without the consent of family members; and persons living on the streets who are obviously mentally ill and who have no known family may be treated in a chronic-care psychiatric hospital.

disciplines lead to the patient's relapse; and one family with two children that emigrated to a distant province in the unshakable belief that the changed environment would cure their son.

Social Services for the Disabled and Social Attitutes about Disability

Family choices for the treatment and long-term care of their disabled members are constrained by the availability of treatment and social service options in the community and by the social rules that define access to the available facilities. Underdeveloped countries such as China have limited health and social services, particularly in the countryside, and so families must often try to maintain the disabled person within the household. This pattern of family-based care for the disabled is reinforced by the social ethic that families "care for their own,"^[21] and by the legal requirements of family members stipulated in the Marriage Law (Ikels, chapter 12, this volume).

The institutional attitudes of workplaces and other social agencies and the personal attitudes of employers and other influential social actors can either restrict or expand the options available to families. In societies such as China where there are no professional social workers who can act as intermediaries for the disabled, family members must negotiate for the patient in order to obtain desired changes in the patient's social environment. They negotiate with the patient's workplace about medical coverage, disability payments, return to employment after hospitalization, and changes in the patient's responsibilities at work. Parents of ill students negotiate with school administrators about temporary leaves of absence, reenrollment after treatment, changes in the patient's course of study, and premature graduation. Family members must also negotiate with their own employers to get temporary leaves of absence or early retirement so they can care for the patient at home. To achieve a favorable outcome in these negotiations, family members of disabled persons must become adept at the "strategies of supplication" described by Davis (chapter 3, this volume).

Another determinant of the family's strategy is the stigmatization of the disability in the society. The willingness of families to use the available health care and social service options and to negotiate on the patient's behalf depends on the degree of stigma attached to the disability. The family must decide if the potential benefits of enlisting aid from the health-care delivery system and negotiating with the official representatives of social institutions are worth more than the loss of family status that occurs when they admit to having a disabled member. In China, as in many other countries, mental illnesses are more heavily stigmatized than other disabilities

[21] J. Hsu, "The Chinese Family: Relations, Problems, and Theory," in Chinese Culture and Mental Health , ed. W. S. Tseng and D. Y. H. Wu, 95-112 (London: Academic Press, 1985).

because they are often viewed as the results of the social or moral errors of the family.^[22] Popular press reports about the numbers of murders and other crimes committed by the mentally ill magnify the public's fear of mental illness and perpetuate this social stigmatization.^[23] Persons with mental illnesses can be refused a marriage certificate, and the siblings of a mentally ill person will have difficulty finding a spouse because of fears that they are genetically tainted. In many academic centers and industries those who have received treatment for mental illness must undergo a formal (and occasionally demeaning) evaluation process before they can be accepted back at school or on the job. It is little wonder that Chinese families with mentally ill patients want to keep it secret.

Case 3 . Mr. Zhou is a twenty-seven-year-old single cadre with eleven years of schooling who first fell ill seven years ago. His parents report that at that time "he felt others were following him and that his teacher wanted to harm him," so they decided to have him hospitalized. He never returned to school; after ten months of resting at home he took up employment as an administrative cadre in a factory. Over the next five years he had three more episodes and a second hospitalization. His problems included extreme anxiety, fear about going out on the street because "strangers may harm me," discomfort in listening to music "because it gives me bad thoughts," repetitive thoughts about meaningless numbers, strange eating habits ("I won't eat eggs because they are bad for the intelligence"), and extremely uncomfortable interactions with females because of "my excessive preoccupations with finding a wife." He frequently had to ask leave from work to "rest at home."

The parents, particularly Mr. Zhou's mother, have been extremely anxious that no one find out about their son's illness, both for his sake and for the sake of the family's stature in the community. They paid the high cost of his hospitalizations themselves rather than have the money reimbursed by the health insurance scheme at his workplace (filing a claim would require disclosing his illness). Despite my recommendations, they are reluctant to reduce his medication for fear that he will have a relapse that will expose his illness to others. Mr. Zhou's twenty-two-year-old sister, who has lived in the same household over the last seven years, does not, as yet, know that he has a mental illness, "because she would be upset if we told her." Over the last two years I have seen Mr. Zhou and his parents more than twenty times; I have never been told their real names, the names of their workplaces, or the location of their residence.

[22] T. Y. Lin and M. C. Lin, "Love, Denial and Rejection: Responses of Chinese Families to Mental Illness," in Normal and Abnormal Behavior in Chinese Culture , ed. A. Kleinman and T. Y. Lin, 387-401.

[23] See, e.g., "Schizophrenic Criminals Face Police Action," China Daily , 23 June 1988, 3.

Characteristics of the Patient

The long-term security needs of disabled persons vary depending on the severity of the disorder and on the marital and employment status of the person at the time of onset of the disability. The family strategy for management of the disability must, therefore, be tailored to the specific circumstances and characteristics of the patient.

Sex . Acceptable functional roles vary by sex, thus the options available to families are different for male and female disabled persons. In China the role of housewife or housekeeper is an acceptable social position for females, so there is less pressure on females with mental illnesses to obtain regular employment than on males. The generally better social outcome for female schizophrenic patients (a higher proportion are married and independent of their natal families) is partially due to the wider range of acceptable functional roles available to females.

Marital status . In China, the parents of persons who are unmarried dependents at the time of onset of a disability assume almost total control over the disabled person's life and may prolong this expanded parental role much longer than is customary. Once parents accept the chronicity of the disability, one of the most urgent agendas is to find a spouse who will care for the ill person after the parents' death. Schizophrenic patients usually lack the social skills and social networks needed to find a spouse for themselves, so in virtually all instances parents make the selection for their child and undertake the marital negotiations. The extended parental authority and arranged marriages seen in these families goes against the current of social change in China, which is leading to decreased parental authority and to more "free choice" marriages.^[24]

Typically, urban families attract women from the countryside or men from the army by offers of urban residence registration and employment in enterprises where the patient's parents have some influence. This practice of finding mates of lower status is a departure from the traditional ideal marriage between "matching doorways"—dangmen hudui ²⁵ —and from the current pattern of high status homogamy in Chinese marriages described by Whyte (chapter 8, this volume). The engagement period is short, with few face-to-face meetings, and the married couple is encouraged to have a child immediately, as this will cement the marriage. It is usually understood that the patient's family will continue to assume partial responsibility for the care and maintenance of the patient after marriage. The higher

[24] Martin Whyte and William Parish, Urban Life in Contemporary China (Chicago: University of Chicago Press, 1984), 117-24.

[25] Pasternak, Marriage and Fertility in Tianjin , China , 26-27.

proportion of patrilocal versus uxorilocal residence among married schizophrenic patients (11.7 percent versus 5.3 percent) supports Lin and Lin's contention that Chinese families marry off their mentally ill daughters to get rid of the responsibility but marry their mentally ill sons to produce male grandchildren.^[26] My clinical work with these families, however, indicates that the need to terminate responsibility to dependents by making them jural adults through marriage is the overriding motivation of parents for both male and female schizophrenic patients.

Case 4 . Mr. Tuan is a thirty-eight-year-old man whose first hospitalization occurred fifteen years ago when he believed that people were following him and that strange voices were talking to him; he has been rehospitalized seven times over the subsequent years. Three years after the onset of his problems, he made inappropriate advances to his younger brother's fiancée; his parents decided that this proved his problems "were due to unreleased sexual energy," and so they arranged for him to marry a woman from the countryside (whom they did not inform about his psychiatric hospitalizations). His parents obtained an urban residence permit for the woman, organized a job for her as a maintenance worker in a technical college, and arranged for the couple to get housing at the college. After eleven years of marriage, Mr. Tuan's wife continues to be dominated by and beholden to her father-in-law. Neither she nor Mr. Tuan had the courage to voice any disagreement when his father decided to move their ten-year-old son to Mr. Tuan's sister's household.

In some cases patients refuse to marry, either because they have unrealistic expectations for a spouse or because they have no interest in any form of social interaction; the parents then try to convince the patient's sibling(s) to assume responsibility for the patient when they (the parents) die. When there are no siblings or when the siblings refuse (they are not, by law, required to assume this responsibility), the parents may try to convince more distant relatives to assume responsibility for the patient or apply for placement of the patient in one of the few welfare institutions for the chronically mentally ill.

If the patient is married and has established his or her own household at the time of onset of the illness, the spouse is usually the primary decisionmaker in the care of the ill person. This is a more difficult responsibility than in the parental case because the spouse must assume a new and often unwelcomed role. In China, patients' spouses actively seek the assistance of their natal family and of their in-laws in making decisions about the management of the patient, but over time these extended family members tend

[26] Lin and Lin, "Love, Denial and Rejection."

to be less and less willing to assist the beleaguered spouse. After division of the natal household (fen jia ) the responsibilities of kinship become contingent on reciprocal benefit;^[27] since there are considerable social disadvantages and no benefits in being associated with a mentally ill person, many family members distance themselves from the patient and his or her spouse.

Families of disabled persons are particularly eager to avoid the divorce of the ill person because divorce usually means that the responsibility for the patient will revert to the natal family. Spouses recruited by the patient's parents may divorce the patient because the reality proves much worse than what was portrayed to them before the marriage or because they have already achieved their goal of urban residence and employment. In cases where the patient falls ill after marriage, divorce is more likely if the marriage has been a short and unhappy one; if the marriage had been satisfactory prior to the onset of illness, the spouse is much more willing to make the continuing sacrifices necessary to sustain the marriage.

Employment status . In China the employment status at the time of onset of a disability is crucial because individuals who are employed in state-sector jobs have guaranteed health insurance coverage and disability payments, usually for life. Without such security, the economic pressures on the family caused by the disability are considerable, and the family's strategy must first aim to provide economic security for the patient. If the disability is so severe that employment, even partial employment, will never be possible, the family assigns the ill person to a nonproductive role in the household and provides for him or her with the productive labor of other household members. For most disabilities, however, ill persons retain some degree of employability despite their disability. In urban areas persons with limited abilities have great difficulty entering and remaining in the wage-oriented labor market; family members must often expend considerable resources to help the disabled person overcome barriers to employment.

In the past parents in state-sector jobs were able to retire early and give their jobs to their disabled children (the dingti option), but this privilege was rescinded in 1983. Parents who have relatively high status in their workplaces are still able to arrange for the employment of their disabled child at their unit; this arrangement has the advantage that the parents are in a good position to negotiate any needed changes in the patient's work environment. If unable to place the patient at their own unit, parents may trick other units into accepting their child without informing the unit about

[27] M. Cohen, House United, House Divided: The Chinese Family in Taiwan (New York: Columbia University Press, 1976), 57-85.

the illness, or they may pay high fees to send their disabled child to a private training college to get a technical diploma that can be used to obtain a job. When the patient is unable to perform a regular job, families try to organize part-time or temporary work. Occasionally, families open small shops with the express purpose of providing employment for their disabled family members.

If the patient is working at the time of onset of the mental illness or obtains a job subsequent to the onset of illness, the family's strategy focuses on helping the patient sustain the job and on ensuring that the patient receives health and disability benefits. Once the work unit is aware of the patient's mental illness, family members negotiate with workplace leaders about hospitalization and about returning to work after hospital discharge. If the patient has difficulties completing expected tasks, family members try to have the patient assigned duties that are more compatible with his or her abilities.

The extent the disability interferes with performance of functional roles . The family strategy must assign the functional roles that the patient is unable to perform (e.g., wage earner, housekeeper, childcare provider, supporter for elderly adults) to other family members. In households where there are many duties and few persons who can assume these duties (e.g., a stem family with one frail elderly grandparent and preschool-age children), the disability of one person will put a heavy burden on the others. Sometimes the disability of a key family member results in temporary or permanent structural changes in the family. In nuclear families with small children, for example, the psychiatric hospitalization of one parent often results in the transfer of the patient's children to a grandparent's home or the recruitment of a grandparent or other retired family member into the nuclear household.

The long-term dependence of the patient necessitates the creation of a new family role: the "patient care-giver." If the patient is relatively independent, the major responsibilities of this role will be to help the patient make important decisions and to assist the patient to achieve desired goals by serving as an interlocutor between the patient and relevant social actors. If the patient needs extensive direct supervision of his or her daily activities, the time and effort needed to perform this care-giver role may dictate changes in the functional roles of family members or recruitment of new family members. In 20 percent of the families in this study, for example, family members (usually the patient's mother) retired prematurely from work to assume the care-giver role. Occasionally more distant relatives are temporarily or permanently recruited to the household to supervise the daily life of the patient. If the family cannot find the personnel to perform this function, it may seek long-term hospitalization for the patient.

Protection of the Interests of Other Family Members

In selecting strategies for the management of chronic disability within the family, Chinese families must compromise two competing cultural values: self-sacrifice to provide for dependents; and judicious investment of family resources in the careers of family members who are most likely to increase the social status of the family. Chinese families often go to extremes of self-sacrifice to assist their disabled members to achieve and sustain the socially desirable goals of education, employment, and marriage; but when it becomes evident that the effort is wasted, the family is faced with a dilemma. Should they reduce their support for the disabled person and use the family resources in ways that are more likely to produce beneficial effects for the family as a whole, or should they sacrifice the goals of the family to the needs of the disabled person? In the urban families I have treated, parents usually conclude (after much soul-searching) that they must do whatever is possible for the disabled child and leave the capable children to fend for themselves. If family members have different views on the issue, arguments about the distribution of family resources may lead to serious and long-standing family conflict.

Families must also protect healthy family members from the direct and indirect harm caused by the disabled person. A few schizophrenic patients are violent toward their family members; if the episodes of violence are severe or frequent, the family may decide to transfer the patient to another household or, if possible, to get the patient hospitalized in a long-term facility. A patient's children, another major source of concern for family members, are often cared for by grandparents because the family does not believe that the patient is an adequate parent. Families also adopt strategies that minimize the effect of the stigma of mental illness on the family: they may restrict the social activity of the patient to decrease the likelihood that he or she will shame the family, and they may move the patient's siblings to live with distant relatives to increase the siblings' chances of finding suitable spouses.

The Effect of Recent Socioeconomic Changes

The socioeconomic changes in China since 1978 have had a major effect on every aspect of life. Strategies used by families to manage disability have had to adapt to this new socioeconomic environment. Overall, the decreased availability of free health care, the increased competitiveness of employment, and the trend toward increased personal autonomy have made it more difficult for families to adjust successfully to the disability of a family member. But the large urban areas have seen some developments that, if extended to the rest of the country, will lighten the burden for the families of the disabled.

Availability of Health Care

The significantly reduced numbers of urban residents entering state-sector jobs has resulted in a decrease in the proportion of the urban population that receive free health care.^[28] Moreover, my own data show that many state firms are decreasing their expenditures for health care by tightening eligibility criteria for health benefits or by increasing the proportion of copayment by the user. With the economic retrenchment of the last two years some smaller firms have been unable to pay for the health care of their employees, who must now cover these expenses themselves. At the same time the pressure for health institutions to become efficient and profitable has resulted in a rapid increase in the costs of treatment^[29] —over the last two years the average cost of a two- to three-month psychiatric hospitalization has increased from 500 yuan to 1,000 yuan. The overall effect of these changes is to make health care less available and less equitable. Since disabled persons are high utilizers of health services who are unlikely to have state-sponsored health insurance, they are severely affected by these changes.^[30]

The decreased accessibility to health care is changing families' strategies for the management of disabled family members. Families in which the patient nominally has full medical benefits must be more active in dealing with the patients' workplace to overcome the bureaucratic barriers that enterprises are erecting to limit their health care expenditures. An increasing proportion of families with uninsured, disabled family members are simply unable to afford medical care, so they try to maintain the patient in the home or seek out other, less expensive, interventions. In the case of uninsured schizophrenic patients, most families pay for the first hospitalization in the hope that this will lead to a full remission; but when they realize that hospital treatment is palliative not curative, they are less likely to have the patient hospitalized a second time or, if the patient is rehospitalized, may demand the earliest possible discharge. Some psychiatric hospitals have recently opened "observation wards" where family members provide all the nursing care for the patient during a brief seven- to ten-day admission; this

[28] My own data show that 25 percent of urban residents who get admitted to a psychiatric hospital have no medical insurance. The central government is aware of the magnitude of the problem, but there are, at present, no visible changes at the grass-roots level: "All Chinese to Enjoy Health Care by the Year 2000," China Daily , 8 September, 1990, 1.

[29] G. E. Hendersen, E. A. Murphy, S. T. Sockwell, J. L. Zhou, Q. R. Shen, and Z. M. Li, "High-technology Medicine in China: The Case of Chronic Renal Failure and Hemodialysis," New England Journal of Medicine 318, no. 15 (1988): 1000-1004.

[30] The government is aware of these problems and has allocated 30 million yuan per year (for the five-year period starting in 1989) to provide treatment for various disabilities: "Major Programme to Aid the Disabled," China Daily , 1 December 1988, 3. This degree of support will have little effect on the problem.

is a less-expensive option, which economically limited families with severely disturbed patients may be obliged to select.

Employment

Economic retrenchment and unemployment have resulted in an increasingly competitive job market that tends to exclude those with marginal employability—the disabled. It is now much more difficult for urban families to obtain a secure state-sector job for their disabled family member. Lacking the connections to arrange such a position, many families must either settle for jobs in collective or private enterprises that provide limited (if any) social security benefits or give up entirely on trying to find employment for their disabled family member.^[31]

For disabled persons who have obtained employment or who were employed at the time of onset of their disability, the new responsibility system has increased the pressure to perform up to expected standards. Several of my patients who have regained their work skills following a psychiatric hospitalization are unable to return to work because their fellow workers do not want to accept someone whose inferior performance might affect the productivity bonuses of all. Many firms now require persons who take leave for psychiatric treatment to undergo a complicated evaluation process before returning to work. Economic pressures have caused some enterprises to decrease the time ill workers are paid 100 percent of their salary (usually six months) and to reduce the amount of disability payments (usually 60 to 80 percent of the previous salary) paid to workers who become officially "disabled." Thus the right to continued employment and social welfare benefits is no longer guaranteed; to safeguard these rights, families with a disabled member must now be much more active in their negotiations with the leaders of the patient's workplace.

One positive change has been the development of welfare enterprises and factories that employ varying numbers of disabled persons. These enterprises are either fully under the supervision of the Ministry of Civil Affairs (which administers most of the state welfare programs) or are state or collective enterprises that are given tax incentives if 30 to 50 percent of their workers are disabled persons. As of March 1988 there were 24,000 such enterprises that hired 395,000 disabled persons;^[32] but demands for increased economic efficiency have threatened many of these sheltered workshops with closure.^[33] Unfortunately, very few of these enterprises are willing to hire persons with mental disorders.

[31] A draft law on the protection of the handicapped that is currently under consideration by the State Council should, eventually, make it easier for families to obtain employment for their disabled members: "Law for Handicapped Ready for Discussion," China Daily , 4 September 1990, 3.

[32] "Rural Handicapped Need Special Help," China Daily , 17 March 1988, 3.

[33] "Deng Pufang Appeals for Help," China Daily , 22 March, 1989, 3.

Changes in Social Values

The increased cost of health care and the decreased ability of the disabled to obtain employment with social security benefits is increasing the economic burden of disability for the family. At the same time, the reforms have enhanced the importance of economic factors in the determination of social status in Chinese society, and so families with disabled members now find it more difficult to improve or even maintain their social status. Several of the families I treat have not bought such items as televisions, refrigerators, or washing machines, because of the expenses incurred for treatment of their ill family member or because they feel that they must save for the economic security of the patient.

Exposure to the West is slowly enhancing the value placed on independence and personal autonomy and diminishing the value placed on responsibilities within the extended family;^[34] as these new values become more firmly established, adult disabled persons will be less willing to be chronically dependent on their family, and family members will feel less morally obligated to provide lifelong support for the disabled individual. In my own clinical work there are several cases in which patients have been divorced by dissatisfied spouses or chronically hospitalized by families; it is my impression that such cases, though still uncommon, are on the increase. Lin and Lin report that rejection of seriously mentally ill family members is a common final outcome in Chinese families living in Westernized societies.^[35] The socioeconomic changes currently in progress in mainland China may produce a similar outcome; if this occurs, there will be increasing pressure on the state to build more chronic-care facilities for the mentally ill.

Destigmatization

One change that may decrease the rate of rejection of disabled members from households is the official recognition and destigmatization of disabilities. The election of Deng Xiaoping's paralyzed eldest son, Deng Pufang, as chairman of the Disabled Persons' Federation of China and his frequent efforts to publicize the plight of the disabled and to change government policy on their behalf have helped to demystify disabilities, to focus public attention and resources, and, most important, to lighten the burden of guilt and shame that the families with disabled members bear.

Progress in decreasing the stigmatization of mental illnesses has been slower than with other disabilities, but there has been some progress. The most visible sign that psychiatry has finally moved out from the shadows was that the opening banquet of the 1988 meeting between the American

[34] A. Y. King and M. H. Bond, "The Confucian Paradigm of Man: A Sociological Perspective," in Chinese Culture and Mental Health , ed. W. S. Tseng and D. Y. H. Wu, 29-45 (London: Academic Press, 1985).

[35] Lin and Lin, "Love, Denial and Rejection."

Psychiatric Association and the Chinese Psychiatric Association was held in the Great Hall of the People. The recent development of counseling centers, crisis intervention centers, child behavior clinics, telephone hot lines, parenting training classes, and so forth in the large urban areas indicates an increased awareness of the importance of psychological factors.^[36] A spin-off effect of this psychologization of the urban intellectuals is that mental illnesses are demystified; they are seen as extreme manifestations of the psychosocial stressors that are experienced by all. It is unclear how quickly and how extensively this new "popular" view of mental illness will infiltrate the public consciousness, but as it does it will relieve some of the guilt and shame experienced by the families of the mentally ill, who will then be more willing, presumably, to utilize available services. In my own clinical work with urban families, an increasing proportion of families identify social stressors as the primary etiology of schizophrenia; this may be an early indicator of the "psychologization" of mental illnesses in China.

Demographic Transition

One other factor that is affecting the strategies of families with disabled members is the decrease in family size. With smaller families more functional roles must be assigned to each individual, and so the loss of one family member through disability has a greater effect on the family. Single-child families in which an unmarried child develops a serious disability are particularly hard-pressed: there is no one who can assure the security of the parents in their old age, and there is no sibling who can assume responsibility for the disabled child when the parents die. If the parents are unable to find a spouse for their disabled child, they may seek the assistance of their extended families in providing for their own and their child's future, but in most cases the child will become a ward of the state when they die. The numbers of such cases will inevitably increase as the family size decreases.

Discussion

This chapter discusses the results of a series of studies that collected extensive quantitative and qualitative data on 428 urban families of schizophrenic

[36] A long list of articles in the China Daily from 1985 onwards chronicle the burgeoning of psychological training and counseling in China: "Parents Study Art of Child-rearing," 21 October 1985, 1; "Volunteer Helpers Flock to Counselling Course," 11 February 1987, 3; "Family Advice," 2 October 1987, 3; "China's Suicide Prevention Center," 25 February 1988, 3; "Campus Kids Get a Weight off Their Minds," 22 September 1988, 1; "China's Mediation System Unique," 10 October 1989, 4; "Intimate Elder Sisters Allay Teenagers' Worries," 25 October 1989, 3; "Tianjin Has Now Got a Hot Line to a Shrink," 25 December 1989, 1; "Some Behavior Problems Solved at Children's Clinic," 14 February 1990, 5.

patients in China; 331 of the families were interviewed for one hour at the time the patient was admitted to hospital, and 97 families were seen monthly in an outpatient clinic over a period of six months to two years. The data were collected from clinical sources and so they cannot be considered representative of families with schizophrenic members who do not utilize psychiatric services. Nor can the results for these urban families be considered representative of rural Chinese families.^[37] Given these qualifications, the data justify several conclusions about families with schizophrenic members in China:

1. The schizophrenic illness of a family member has a severe effect on the functioning of a household.

2. Families with schizophrenic members must undertake a difficult revision in the family's strategy for success. Some or all of the functional roles of the patient devolve to other family members, and the family must assume the additional function of caring for the patient. If the personnel and resources of the household are insufficient to meet these unexpected demands, families resort to structural changes.

3. In China, family members closely supervise the lives of relatives with schizophrenia: they determine the pattern of health-care seeking; they undertake necessary negotiations with schools and workplaces; they find a spouse for the patient (if the patient is not married at the time of onset of the illness); and, when necessary, they assume responsibility for the care of the patient's children.

4. The socioeconomic resources of the family are a major determinant of the strategies adopted to manage disabled family members. Families with limited resources are less able to obtain treatment for the patient, less able to recruit a spouse to their family to care for the patient, and less able to obtain employment for the patient.

5. The recent socioeconomic changes in China are, in sum, making it increasingly difficult for families to cope with the schizophrenic illness

[37] The multicenter study also collected data on 164 rural families, but space limitations prevented me from presenting them here. The findings were broadly similar for urban and rural families except that (1) a much higher proportion of rural families do not have health insurance; and (2) rural schizophrenic patients have better outcomes than urban schizophrenic patients because the social and intellectual demands of agricultural labor are lower than those of industrial labor and because the heads of autonomous rural households have the flexibility to define roles that maximally utilize a disabled person's productive ability. These findings suggest that the lower chronicity of schizophrenia found in underdeveloped countries by the International Pilot Study of Schizophrenia may also be found within a single country where there are underdeveloped and developed subpopulations: World Health Organization, Schizophrenia: An International Follow-up Study (New York: Wiley, 1979). A detailed comparison of the differences between hospitalized rural and urban schizophrenic patients is presented in W. Xiong and M. R. Phillips, "Chengxiang zhu yuan jingshenfenliezheng bingren de bijiao" (Comparison of urban and rural hospitalized schizophrenic patients), submitted manuscript.

of a family member. If current trends continue, there may be more schizophrenic patients who are ejected from households.

The Role of Traditionalism and Modernism in Chinese Family Strategies

One of the most consistent findings in these families is that if a patient gets married after the onset of illness, the introductions and marriage arrangements are almost always orchestrated by the patient's parents. This is in dramatic contrast to the findings of the five-cities study (Unger, chapter 2, this volume), which found that 0.94 percent of marriages are arranged and 15.79 percent of marriages are initiated by introductions from relatives. Parents of schizophrenic patients in Western societies do not commonly arrange marriages for their ill children (this is my clinical impression; I am unaware of any statistics on this issue). Why, then, do Chinese parents of schizophrenic patients act in this way? I suggest that the traditional Chinese practice of arranged marriages, though rapidly being replaced by "free choice" marriages, is still a paradigm in Chinese culture that, given the situation of a child who lacks the social skills needed to find his or her own spouse, can be utilized as a blueprint for action by Chinese parents. The paradigm is, however, transformed in the new social context: in most circumstances the parents of adult schizophrenic children negotiate directly with the prospective spouse rather than with the prospective spouse's relatives.

Contemporary Chinese culture provides a wide palette of different paradigms for social behavior that could be placed on a traditionalism-modernism continuum: one pole includes the most traditional Confucian models of social behavior, which emphasize the social interdependence of individuals and the subjugation of the self to promote social harmony, and the other pole includes the most modern "Western" models, which emphasize independence, assertiveness, and individualism. K. S. Yang has developed this traditionalism-modernism concept in a series of studies in Taiwan covering a span of over twenty years.^[38] His results suggest separate traditionalism-modernism continua for different types of social behavior (e.g., child rearing, marital relationships, professional relationships); and he hypothesizes that the behavior of Chinese individuals and families is strongly influenced by where their particular beliefs place them on these continua. This is a useful heuristic model that enhances understanding of Chinese social behavior, but it does not give sufficient weight to the role of particularistic factors in determining the strategies of social actors.

At any point in time a specific Chinese community—such as urban PRC, rural PRC, Hong Kong, Taiwan, Overseas Chinese communities—

[38] K. S. Yang, "Chinese Personality and Its Change," in The Psychology of the Chinese People , ed. M. H. Bond, 106-70 (Hong Kong: Oxford University Press, 1986), 106-70.

has modal paradigms for different types of social behavior (i.e., the behaviors that are most frequently observed), and the members of the community have a range of ideal paradigms of behavior that they consciously or unconsciously try to emulate. When selecting a strategy for action in a specific situation, however, a variety of particularistic factors incline social actors to act in ways that diverge from the ideal and modal paradigms; the disability of an adult child, for example, induces parents to adopt more traditional paradigms of parent-child relationships. In different circumstances these same actors may make different choices: for example, the parents of the schizophrenic patients in this study did not arrange the marriages of their nonschizophrenic children. Thus analysis of family strategies must simultaneously consider at least four dimensions: (1) the range of paradigms of family behavior available in the culture; (2) the modal paradigms of family behavior in the community; (3) the internalized ideal paradigms of family behavior held by the social actors involved; and (4) the status of particularistic factors that are known to affect the family behavior under consideration.

Ethical Considerations Inform the Strategies of Chinese Families

In case after case I found that parents chose to expend all their resources on the treatment and long-term care of their schizophrenic child. Even when it became clear that the child would be chronically disabled, they continued to sacrifice the economic and social status of the family to assist their ill child. Why were these families consciously diverging from the strategies predicted by economic determinism? One father gave a representative response: (plaintively) "We've spent everything we saved for our retirement and for the marriages of our other children on her. But what else could we do? She's our daughter."

The ethical importance of the mutual rights and obligations in family relationships (particularly the parent-child relationship) is a central tenet of Confucian doctrine, which has been reinforced by the stipulations of China's Marriage Law. For parents with schizophrenic children the moral imperative to provide for their dependent adult child is more compelling than the social imperative to improve (or sustain) the economic and social status of the family. This ethical responsibility continues until the child marries and establishes an independent household; if the child is unable to achieve these goals, parents feel obliged to "take care of him until we [they] die." Spouses of mentally ill patients, especially those who married the patient before the onset of illness, also experience a moral obligation to care for the disabled individual; but they rarely go to the extremes of self-sacrifice seen in parents of the disabled. Siblings of mentally ill persons, though occasionally willing to help in the management of the patient, do not usually feel a strong moral obligation to provide for the patient.

When confronted with the option of either supporting a disabled relative or advancing the economic status of the family, family members must weigh the effect of their decision on the two different aspects of "face" described by Redding and Wang:

Lian is moral worth and contains the idea of being a "decent" human being. It is ascribed rather than achieved and loss of it is serious. Mianzi carries with it the idea of reputation based on one's own efforts. It is more achieved than ascribed and, although useful in life, it is not essential. Its absence is not a cause for condemnation.^[39] (P. 286)

If the family's actions contravene the ethical expectations of society, the damage to lian will far outweigh any possible gain in mianzi ; and so strong ethical imperatives often result in choices that are not in the best economic interests of the family. A society's ethical standards, however, change over time. It is probable that the slow but definite erosion of the Confucian family system by Western individualistic values, industrialization, and urbanization will result in a weakening of the moral imperative to care for disabled family members.

[39] G. Redding and G. Y. Y. Wong, "The Psychology of Chinese Organizational Behavior," in The Psychology of the Chinese People , ed. M. H. Bond, 267-95.

Twelve
Settling Accounts: The Intergenerational Contract in an Age of Reform

Charlotte Ikels

One of the major problems facing people in any society is how to act while still vigorous and capable so as to ensure support and care in old age. While the means used to achieve these goals are many and diverse, in essence they generally involve both economic and social strategies. In particular, older people, by providing economic and other supports to the young (and middle-aged), hope thereby to be laying the foundation for their own support in later life. Social scientists have analyzed this intergenerational dynamic extensively in terms of exchange theory or reciprocity;^[1] in this chapter the concept of an "intergenerational contract" is used to highlight the binding nature of such exchanges.

The Intergenerational Contract

Both the Chinese constitution and the Chinese government have made abundantly clear that care of the aged in China is primarily a family responsibility, an unavoidable part of a contract between the generations. In

[1] See, for example, Steven M. Albert, "Caregiving as a Cultural System: Conceptions of Filial Obligation and Parental Dependency in Urban America," American Anthropologist 92, no. 2 (1990): 319-31; Toni C. Antonucci, Rebecca Fuhrer, and James S. Jackson, "Social Support and Reciprocity: A Cross-Ethnic and Cross-National Perspective," Journal of Social and Personal Relationships 7 (1990): 519-30; J. Dowd, "Aging as Exchange: A Preface to Theory," Journal of Gerontology 30 (1975): 584-95; Nancy J. Finley, M. Diane Roberts, and Benjamin F. Banahan III, "Motivators and Inhibitors of Attitudes of Filial Obligations Toward Aging Parents," Gerontologist 28, no. 1 (1988): 73-78; Paula Hancock, David J. Mangen, and Kay Young McChesney, "The Exchange Dimension of Solidarity: Measuring Intergenerational Exchange and Functional Solidarity," in Measurement of Intergenerational Relations , ed. David J. Mangen, Vern L. Bengtson, and Pierre H. Landry, Jr., 156-86 (Newbury Park, Calif.: Sage Publications, 1988); Charlotte Ikels, "Delayed Reciprocity and the Support Networks of the Childless Elderly," Journal of Comparative Family Studies 19 (1988): 99-112; Alice James, William L. James, and Howard L. Smith, "Reciprocity as a Coping Strategy of the Elderly: A Rural Irish Perspective," Gerontologist 24, no. 5 (1984): 483-89; and Jeffrey P. Rosenfeld, "Disinheritance and Will Contests," in Family Systems and Inheritance Patterns , ed. Judith N. Cates and Marvin B. Sussman, a special issue of Marriage and Family Review 5, no. 3 (1982): 75-86.

this respect neither the Communist Revolution nor the post-1978 reforms represents any significant break from what traditional Chinese have always regarded as the surest route to a secure old age, namely, that "rearing a son for old age is like storing grain for a famine" (yang er fang lao, ji gu fang ji ). For centuries filial piety was extolled as the highest virtue, and caring for elderly parents was regarded as a key form of its expression.

The traditional Chinese family system ideally rewarded filial sons by providing them access to the resources of the senior generation. In rural areas the primary resource was land; in urban areas it might have been the family business. In the absence of adequate material resources the senior generation might have provided in their place social resources in the form of personal contacts useful for negotiating for temporary employment or for an apprenticeship. Calculations of financial and social gains were, of course, not the only factors expected to motivate filial care. As elsewhere, a sense of obligation for all that parents had already done for one, as well as ties of affection, was expected to make the care of parents seem "natural," an inescapable aspect of the parent-child bond.

Even parents without resources or without the affection of their children were not entirely powerless. In a small village or a tightly knit community any child known to be unfilial risked public censure and jeopardized his other social relationships. Thus, harmony in the family (or at least the appearance of harmony) was an indicator of how well family members conformed to social ideals and served to enhance the relative standing of all its members. Ikels found that a concern for "face" or family reputation continues to be an important consideration in the resolution of intergenerational conflict even in urban areas.^[2] (See also Phillips, chapter 11, in this volume.) Traditionally, supernatural sanctions also played a role in encouraging correct familial behavior. Neglected ancestors made their displeasure with their treatment known by causing illness or misfortune in the families of their descendants.^[3] Similarly, powerless individuals with griev-

[2] See Charlotte Ikels, "The Resolution of Intergenerational Conflict: Perspectives of Elders and Their Family Members," Modern China 16, no. 4 (1990): 379-406. This article reports the responses of 200 urban elders and their family members to five vignettes describing problematic family situations. The elders and a younger family member were asked separately to propose "workable" solutions to the dilemmas depicted. In many cases informants proposed solutions with an eye to "what the neighbors would think" about a particular course of action or the family's inability to resolve the problem.

[3] Emily Ahern, The Cult of the Dead in a Chinese Village (Stanford: Stanford University Press, 1973).

ances in this life were known to commit suicide so that as supernaturals they could seek revenge on their persecutors.^[4] Although the significance of the supernatural realm was officially denigrated for three decades of Communist rule, the resurgence of temple festivals in the last decade suggests that for many Chinese the supernatural remains a power to be reckoned with. Perhaps most important of all in inspiring filial behavior was the child's knowledge of the power of the example he set for his own children. In the absence of any alternative to family care in old age, a man who neglected his parents risked experiencing similar treatment in his own old age.

Historically, the inheritance of property and the care of parents were primarily the concerns of sons. As Greenhalgh points out in the case of Taiwan, the intergenerational contract for daughters was (and continues to be) both more short-term and more overtly economic.^[5] Daughters are required to make contributions to their natal families only so long as they remain unmarried. Parents with limited resources view every expenditure on daughters, who will marry into other families, as losses, but they view those on sons, who will remain members of their natal families throughout their lives, as investments. Greenhalgh argues that given sexual inequality in wages and occupations (a situation that admittedly is at least partially a consequence of parental decisions to restrict the educational opportunities of girls), parental strategies of underinvestment in daughters compared with sons is rational. A study in urban Hong Kong also found that despite the frequency with which Chinese parents state that daughters are emotionally closer than sons (to say nothing of daughters-in-law) and despite the fact that in urban areas a move into a married daughter's home is socially less disruptive to the parents than in the countryside, the great majority of elderly parents were living with sons and not with daughters, and for the same reasons cited by Greenhalgh: the economic potential of sons is generally greater than that of daughters.^[6]

Deborah Davis has investigated the issue of parental preferences for living arrangements in urban families in Wuhan and Shanghai and notes an interesting trend.^[7] In the decade prior to the introduction of the Deng reforms parents seemed almost equally concerned with daughters' as with sons' prospects. Thus married daughters (including those with brothers) were frequently found living with their husbands in their own natal households. Similarly, parents were nearly as likely to exercise the dingti option of

[4] Charlotte Ikels, Aging and Adaptation: Chinese in Hong Kong and the United States (Hamden, Conn.: Archon Books, 1983).

[5] Susan Greenhalgh, "Sexual Stratification: The Other Side of 'Growth with Equity' in East Asia," Population and Development Review 11, no. 2 (1985): 265-314.

[6] Ikels, Aging and Adaptation .

[7] Deborah Davis, Long Lives: Chinese Elderly and the Communist Revolution , rev. ed. (Stanford: Stanford University Press, 1990). See also Deborah Davis, chapter 3 in this volume.

retirement in favor of a child on a daughter's behalf as on a son's. Davis argues that these deviations from traditional practices were less a reflection of an increased preference for daughters than of the involvement of the state in hampering parental strategizing for old age. For example, during the decade of the Cultural Revolution parents had little control over the fates of their children—sons and daughters were sent to the countryside or assigned urban jobs on the basis of current policies regardless of parental plans. Similarly, when the dingti option was liberalized in the late 1970s, parents, knowing that the policy was not likely to be permanent, brought back as quickly as possible whichever child was still living in the countryside. By the late 1980s, however, Davis noticed that married daughters were no longer such frequent members of their natal households and concluded that in China, as in Taiwan and Hong Kong, greater economic opportunities for males meant that greater investment in sons was again a rational parental strategy.

Post-Mao Reforms and the Elderly

The significance of the post-Mao reforms for the elderly and their family members has been to raise the stakes involved in the intergenerational contract; that is, both parties have more to gain or lose now than they had prior to the reforms. For example, changes in housing policy have converted privately owned housing from an inconsequential asset to one of great value,^[8] while wage reform, mandatory retirement, and increasingly restrictive health-care coverage have lowered the relative economic position of the elderly and made them more dependent on the young and middle-aged.

Housing Reform

In the late 1970s the quantity and quality of housing stock in China's older cities were appalling, and by 1980 the national and local governments, as well as individual work units, made the improvement of housing a priority. Urban housing reforms include restoring the property rights of private owners, increasing the amount of housing stock, and encouraging private, rather than work-unit, ownership of new housing. In Guangzhou (Canton), the site of the research on which this study is based, about one-third of the

[8] In 1985 the Chinese government felt compelled to promulgate the first inheritance law since the founding of the PRC precisely because of the increasing frequency of disputes involving property distributions. The inheritance law guarantees the right of a decedent to bequeath property as he or she sees fit and in the absence of a will spells out clearly who has rights in a decedent's property. For the text of the law and its interpretation, see Liu Shuzhen, Jicheng fa bai ti wenda (One hundred questions and answers about the inheritance law) (Beijing: Beijing shifan chubanshe, 1986).

housing is privately owned, much of it in the names of Overseas Chinese. During the Cultural Revolution, however, these owners or their agents lost the right to occupy or sell their property, to set rents, and to choose their tenants. To restore the confidence of Overseas Chinese and thereby to induce them to invest in the homeland, these policies were overturned, and owners were allowed to reoccupy or sell their housing, set rents, and even evict tenants.^[9] All of these measures served to heighten the interest of the younger generation in the senior generation's property.

In October 1989 another wave of housing reforms was officially introduced in Guangzhou. One of the aims of these reforms is to facilitate the withdrawal of work units from the responsibility of providing and maintaining housing for their workers. Implementation has been gradual, but by the spring of 1991 many occupants of old work-unit-provided housing were facing the decision whether to buy their apartments at greatly subsidized prices or to accept substantial rent increases. The privatization of this housing means that even more families will control assets worth fighting about.

Initially, the construction of new housing was largely by work units but was increasingly by "companies" for sale to work units and individual buyers. Because of the high costs of land acquisition and resettlement in the oldest three districts of the city, most of the new housing has been going up in areas that had until recently been primarily agricultural. From the point of view of the elderly, with their limited mobility, such locations can be very unattractive, for they are often too far from medical facilities and not convenient to shops or markets. Thus, some elderly are forced to ponder the question whether it is more desirable to follow one's son to new housing or to remain behind in their familiar and accessible neighborhoods.

Workplace Reforms

The elderly have been particularly affected by changes in the wage system and in the enforcement of retirement. The introduction of bonuses to encourage greater worker productivity has increased the gap between a worker's pre- and postretirement incomes, since retirement income is based on a fixed percentage of the basic wage and does not include the bonus. Despite high rates of pension receipt by urban dwellers, as Unger points out in chapter 2 in this volume, many elderly, especially women, receive quite modest monthly amounts. Despite concerns about reduced incomes, many elderly were essentially forced to retire in the early 1980s. The implementation of mandatory retirement was intended both to provide employment

[9] The actual implementation of these reversals proved to be a decade-long process because tenants could not be evicted unless they had somewhere else to go, and rents of long-term tenants could be raised only incrementally. New tenants (often those without urban household registration) could be charged whatever the market would bear.

opportunities for newly returned "sent-down" youths and current school-leavers and to remove elders who might be inclined to resist the liberalizing policies that Deng was pushing. While middle- and lower-level workers in state enterprises with ample retirement benefits are often happy to retire as soon as eligible, top-level personnel are frequently reluctant to give up the perquisites and powers associated with their positions.^[10] Retirees from impoverished units, who cannot tolerate any reduction in their already minimal incomes, frequently supplement their pensions with earnings from the reform-legitimated private sector as shoe repairers, barbers, or petty entrepreneurs.

Health care costs have become an issue for many elderly and their families, less because of reforms in the health care system itself than because of cost-consciousness on the part of work units, which are responsible for providing coverage to workers. In an effort to reduce costs, work units have been pushing for more cost-sharing by the individual. Thus, some enterprises have set ceilings on the amount they will pay per outpatient visit for medication or have excluded certain high-cost diagnostic tests or treatments. Long-term care requiring the hiring of private attendants is rarely covered at all. The minority of elderly without any coverage is, of course, in an even more difficult situation.

In a sense, all of the reforms described above can be viewed as reductions or withdrawals of state subsidies from urban dwellers and their replacement by greater financial responsibility on the part of the individual family. In this context younger family members are likely to be more alert to the costs of fulfilling the terms of the intergenerational contract and more sensitive to perceived inequities in parental distributions of property. This chapter explores the functioning of the intergenerational contract during the late 1980s and early 1990s by examining family organization in two hundred urban households. The focus is on aid flows between the generations, with particular emphasis on the ways families manage the long-term health problems so frequently associated with old age. I first examine the characteristic living arrangements of the elderly and the factors that contribute to them. I then consider the nature of the needs of the elderly, in terms of housing, income, health care, and assistance in daily living, and the impact of living arrangements on the meeting of these needs. Last, I speculate on how increases in the value and availability of housing and changes in employment opportunities are likely to affect the operation of the intergenerational contract.

[10] For example, one of my high cadre informants died in late 1989 at the age of ninety. He had never officially left work even though he showed clear signs of cognitive impairment as early as 1987.

The Study Population and Setting

The data on which this chapter is based were gathered in two phases: the first covered a seven-month period beginning in June 1987, the second a five-month period beginning in February 1991. One hundred households in each of two neighborhoods of Guangzhou, the capital of Guangdong province, make up the sample. To assure a range of educational and occupational backgrounds, two urban districts known to differ in these respects were chosen as the initial sampling frame. Yuexiu district was selected as an area representative of commercial, service, and industrial workers, while Dongshan district was selected as an area representative of technical, administrative, and professional workers. In actuality there is, of course, considerable overlap in the occupational categories of the residents of the two districts.

Each of the street committees (jiedao ) within the two city districts was assigned a number, and three street committees within each district were randomly selected and proposed to the respective City District Offices as possible sites for the research. Each of the City District Offices, together with representatives from the Guangdong Academy of Social Sciences (the researcher's host institution), then selected one street committee from among the three as the target neighborhood within its jurisdiction. Three residents committees within each of the chosen street committees were then randomly selected by the researcher, and a total listing of all households containing at least one member seventy years of age or older was obtained from the local police station. Since a final sample of one hundred households from each of the two districts was desired, a proportional quota of households was randomly selected from each residents committee.

In the course of interviewing, it became clear that residents of the two neighborhoods differed not only in occupation but also in place of origin. Compared with Yuexiu, Dongshan had more older residents who came from outside the immediate environs of Guangzhou and its surrounding countryside. Specifically, Dongshan was home to more families of Overseas Chinese from the Taishan county area of Guangdong, as well as to more Mandarin-speaking "northerners" from outside the province. Most of these older people had been living in Guangzhou since at least the mid-1950s and were thoroughly familiar with the local context.

Informants lived in a wide range of housing types: old, privately owned two- and three-story buildings, free-standing single-family buildings best described as cottages, and most frequently, old (or new) work-unit-owned multistory apartment buildings. Regardless of building type, nearly all accommodations were run-down and overcrowded, the combined result of years of scanty investment in housing stock and the gradual growth of the

urban population.^[11] The resulting housing shortage has led to high rates of doubling up by families regardless of preferences for intergenerational living.^[12]

Households selected for inclusion in the study were visited a day in advance by a person from the local residents committee, who presented them with a letter explaining the nature of the research and encouraged them to participate. Although the household registration lists contained many inaccuracies, the overall response rate (percentage of those invited to participate who agreed to do so) was 99 percent. In the case of elders too impaired to be interviewed, another person in the household was asked to provide the necessary information.

The high response rate can be attributed to several factors. First, the topic of caring for the aged has been given high priority and much publicity in China since the mid-1980s when population projections revealed that the number of elderly was increasing rapidly. According to Tian,^[13] in 1982 China had 49.7 million people aged sixty-five or over; by the year 2000 this figure is expected to reach 86.5 million. Thus, participating in the study could be viewed as a patriotic duty. Second, the households in the study could all be expected to be particularly interested in the topic, since they already contained an elderly member. Third, in terms of logistics the elderly are easier to contact than younger informants. They are less likely to be employed, to have competing demands on their time, and to be mobile. Fourth, the two neighborhood samples were geographically compact. Prospective informants had already seen us about the neighborhood, could discuss the experience with others already interviewed, and could verify that the interview was likely to be tolerable—so tolerable, in fact, that all the (surviving) households interviewed in 1987 agreed to be reinterviewed in 1991.

All interviews took place in the informants' homes, usually with at least one other family member present. In addition, the interviewer was usually accompanied by a representative of the Guangdong Academy of Social Sciences as well as a member of the local residents committee or of the street committee. Under these circumstances only the most basic data could be easily collected, although many families went into considerable detail about their own experiences attempting to cope with the health problems of elderly family members. In the course of the one- to two-hour interview in

[11] Much of the new affluence in Guangzhou has been used to improve the material quality of life. During the 1987 interviews families were busy amassing household appliances, but by 1991 they were turning directly to home improvements, that is, laying tiles over bare concrete floors and installing lighting fixtures.

[12] Davis (chapter 3) and Jonathan Unger (chapter 2) in this volume.

[13] Tian Xueyuan, "China's Elderly Surveyed," Beijing Review , November 14-20, 1988, 26-28.

1987, data on the following topics were gathered: residential history, marital history, work history, current income sources, health and functional status, household composition and organization, location of and contact with close kin, leisure activities, and perceptions of intergenerational conflicts. At the close of the interview or on a separate occasion a younger family member was also interviewed on the last topic. In the second phase of data collection the interviewing format and content were similar to the first except that the topics of death and death ritual were added and there was no separate interview with a younger family member.

Because this is a study of an urban population, its findings cannot be generalized to the entire Chinese population. Urban elders, who make up about 20 percent of the elderly population, are a privileged group in terms of resources. Compared with the rural aged, they are more highly educated, more likely to be receiving pensions, more likely to have subsidized medical care, and more likely to have access to a wide range of medical facilities. In short, from the point of view of their families, urban elderly probably remain net producers to their households longer than the rural elderly.

The extension of the findings of this study to other urban populations within China should also be qualified, because Guangzhou itself has some unusual characteristics, the most important of which are its long tradition of overseas contacts and its proximity to Hong Kong. Many residents of Guangzhou have relatives living abroad who, over the course of the years, have sent remittances back to be used for the purchase of private housing or for the support of the elderly. Thus, a substantial minority of the elderly with no visible means of support in fact receives some financial assistance directly or indirectly from these overseas sources. Of perhaps greater significance for the well-being of the elderly is the presence of Hong Kong some ninety miles away. A substantial proportion of the elderly have at least one child living and working in Hong Kong. On the one hand, the lure of the Hong Kong economy means that some elderly have had their local support networks compromised by the emigration (both illegal and legal) of their children. On the other hand, the Hong Kong economy puts extra cash into the hands of the emigrants, which, in turn, frequently finds its way back to their elderly parents. Furthermore, some elderly are themselves former residents of Hong Kong and as such may move freely back and forth across the border.

Another feature to be considered is the current high standard of living now possible in the Pearl River delta.^[14] Much of coastal Guangdong province serves as a magnet for migrants from poorer areas of the province as well as for residents of less prosperous provinces. Thus, for example,

[14] Ezra F. Vogel, One Step Ahead in China: Guangdong under Reform (Cambridger: Harvard University Press, 1989).

Guangzhou currently attracts young women from neighboring Human and Guangxi, who will work for less money than the local residents. These young women are eagerly sought after as baomu for the impaired elderly. At the same time, now that the standard of living in the countryside is so much higher, a significant proportion of the elderly are themselves leaving Guangzhou to live in their native villages.^[15] Do these out-movers differ in some special way from the elderly who choose to remain in the city? One hypothesis is that people return to the countryside to assure themselves a burial rather than a cremation—their almost certain fate if they die in the city. Are these people in fact nearing death? If so, presumably they are already in ill health, and their relocation removes them from the urban health care system as well as from their families. Is the burden of providing care to the urban elderly being shifted onto the rural population? At this point I have insufficient data to answer this question, but it is certainly worth pursuing.

Living Arrangements

The two most important conditions governing the provision of family care to the elderly are the existence and proximity of appropriate family members. For these reasons almost any study attempting to assess the likely impact of an aging population on a nation's resources will include statistics on marital status or living arrangements or both.^[16] In the United States, given American preferences for neolocal residence, the first-choice care-giver of an elder is normally that elder's spouse. While adult children may offer supplementary care, the bulk of care-giving is provided by a spouse, since she (or he) is likely to be the only person other than the elder present in the household. In the absence of a spouse, an adult child assumes responsibility.

In some societies a particular child is clearly designated in advance as the likely care-giver. In prewar Japan, for example, this was normally part of the role of the firstborn son, who would succeed to headship of the house-

[15] I was unable to contact 156 of the original 359 elderly drawn from the household registration lists because they were no longer living at their official residence. Residents committee personnel generally had a pretty good idea of the missing elders' whereabouts, and they reported that 31 percent of these elders (or 13 percent of the total sample) had returned to live long-term or permanently in the countryside. Most of the other missing elderly were living elsewhere in Guangzhou.

[16] See, for example: Gary Andrews, Adrian J. Esterman, Annette J. Braunack-Mayer, and Cam M. Rungie, Aging in the Western Pacific (Manila: World Health Organization, 1986); Chen Ai Ju and Gavin Jones, Aging in ASEAN: Its Socio-Economic Consequences (Singapore: Institute of Southeast Asian Studies, 1989); and E. Heikkinen, W. E. Waters, and Z. J. Brzezinski, The Elderly in Eleven Countries: A Sociomedical Survey (Copenhagen: World Health Organization, 1983).

hold while his younger brothers set up branch households nearby or migrated. In the United States, there are no culturally prescribed rules for assigning care-giving responsibilities other than the vague sentiment that daughters are more likely to be care-givers than sons. In China, Confucian norms prescribed that adult sons remain members of their parents' household and contribute their labor and wages to the household as a whole so long as the parents remained alive. In actuality the idea of "dividing" the family budget was likely to be raised as soon as the sons began marrying. As Cohen and Harrell point out in the case of Taiwan, timing of division is based primarily on economic considerations, specifically on whether the constituent subunits (fang ) believe they are better off apart rather than together.^[17] One of the key issues to be negotiated during the process of division is the nature of the sons' responsibilities for care of their elderly parents.

While brothers may select from a wide range of alternative patterns of care, the guiding principle is that all other things being equal, sons should share equally in the care. If they do not share equally, they usually do not benefit equally in the division of household resources—for example, the son who takes on a disproportionate share of responsibility will acquire more property (land, housing, or other resources) than his brothers. Alternatively, if division precedes the need for care, sons who feel they have been dealt with unfairly by their parents (or their own brothers) might refuse to help out.^[18]

A study of the elderly conducted in urban Hong Kong in the mid-1970s found that a majority of the elderly were "living with adult children."^[19] This simple phrase, however, masks three distinctive living arrangements: (1) Parents living with unmarried children, twenty-one cases; (2) parents living with a married child as well as unmarried children or additional married children, thirteen cases; and (3) parents living with one married child,

[17] Myron Cohen, "Developmental Process in the Chinese Domestic Group," in Family and Kinship in Chinese Society , ed. Maurice Freedman, 21-36 (Stanford: Stanford University Press, 1970); Myron Cohen, House United House Divided: The Chinese Family in Taiwan (New York: Columbia University Press, 1976); Stevan Harrell, Ploughshare Village: Culture and Context in Taiwan (Seattle: University of Washington Press, 1982).

[18] Because of frequent complaints of elder abuse and elder neglect, by the late 1980s some provinces were passing laws to protect the rights of the elderly including their right to care from their adult children. Guangdong province instituted its own such law in February 1991. Article 6 of the law spells out adult children's obligations to provide for their parents, and Article 7 guarantees the rights of the elderly to remarriage and to freedom from interference by their children. The text of the law appears in Lao Ren Bao , no. 3, 1991. Children's concerns about the disposition of parental property and the possible claims of stepchildren to such property are thought to be major reasons for their interference in remarriage plans. The juxtaposition of these two articles suggests the significance of the link between care provision and property provision.

[19] Ikels, Aging and Adaptation .

thirty-seven cases. These three ways of living with adult children are essentially sequential in nature and have different implications for the balance of power between the generations. In the first two instances the housing is that of the senior generation, and the children are still living in the households in which they were raised. In the third instance, of the thirty-seven families, fourteen had lived together continuously and twenty-three had not. All cases of discontinuous residence ended with the moving of the elderly into the household of the married child, and all of these moves came about primarily as the result of the needs (e.g., poverty, ill health, loss of previous residence, loneliness) of the senior generation (though in three cases the in-moving elder was also seen as a source of household help). Clearly, in this last living arrangement, the balance of power favors the younger generation.

There are three major reasons for the high rates of coresidence of the elderly and their unmarried children in Hong Kong. First, this particular cohort of elders was not raised with the small-family ideal but produced offspring into its forties. Second, leaving one's natal family to establish one's own household was frowned upon for any reason other than matrimony or to pursue higher education. Third, housing costs in Hong Kong were high, and most young people were unlikely to have the incomes necessary to live on their own. Thus, many couples in their sixties still had children in their homes, though as these married out or found satisfactory housing, they would eventually leave their parents behind.

The situation for widowed parents, especially for those who had been widowed for many years, was somewhat different. While some of their children could marry out, secure in the knowledge that others were still living with the widowed parent, an only child or the last child left at home seems to have found it very difficult to move out of the nest, viewing such a move as a form of abandonment. If the widowed parent was also in poor health, emotionally frail, or incapable of self-support, residential separation of the generations was nearly impossible. Given high rates of early widowhood and associated discouragement of remarriage, many elderly women in this cohort have always lived with their children. Generally, only intact couples were likely to experience some period of single-generation living in old age.

In Guangzhou the same demographic principles, childbearing into the forties and high rates of widowhood, apply. Similarly, the moving out of a child for reasons other than matrimony or higher education is frowned upon, and given the housing shortage that prevailed until very recently, young people have found it very difficult to establish their own households, less for financial reasons than for rules governing priority of access. Thus, as in Hong Kong, the great majority of elderly Cantonese (68 percent in this study) reside with adult children, and even more than in Hong Kong, this coresidence occurs in the household of the senior generation. Table

12.1 summarizes the living arrangements of the two hundred elders in the study.

As table 12.1 clearly indicates, there are major sex differences in living arrangements, with males five times more likely than females (76 over 15 percent) to still be living with a spouse (with or without others). There are three main reasons for this disparity. First, women tend to marry men who are several years older than they, and, thus, women are more likely than men to experience the death of their spouse. Second, age-specific mortality rates are higher for men than for women. Third, traditionally it was culturally acceptable for widowed men to remarry, but not for widowed women. Legally there are no restrictions on the remarriage of the elderly of either sex, and, in fact, official policy is attempting with limited success to popularize remarriage in old age.^[20]

[20] Charlotte Ikels, "New Options for the Urban Elderly," in Chinese Society on the Eve of Tiananmen , ed. Deborah Davis and Ezra F. Vogel, 215-42 (Cambridge: Harvard University Press, 1990).

In terms of a balance of power, the great majority of living arrangements involving an elderly married couple (in contrast to an elderly widowed person) enhance the position of the senior generation because (1) they are associated with residence in housing allocated to the senior generation; (2) decades of continued residence mean that the neighbors are generally familiar with the family's history and circumstances; (3) the man nearly always has his own pension, as do nearly half the women; and (4) the senior female nearly always controls the common budget.

It is important to note, however, that the common budget is likely to represent less than half of the incomes and expenditures of the younger family members. Coresident married children retain most of their wages for their own use—for example, to pay for clothing, transport, educational fees for their own children, recreation, gifts, meals outside the home, and new appliances such as televisions and washing machines, that are generally made available to other family members for the duration of the coresidence. The money that adult children turn over to their mother or mother-in-law is generally regarded as their contribution to the food that the senior female purchases and prepares for the household as a whole, and according to most of the informants, the younger generation itself determines what constitutes an appropriate sum. Some children who live elsewhere nevertheless take their evening meal with their parents or board one or more of their school-age children with their parents, and they too contribute the cost of their meals. Interestingly, some of the unmarried sons in this study were exempted from making any contributions to the family budget on the grounds that they were saving up for their marriage expenses. As Davis points out, failure to assist a son in meeting his marriage expenses is viewed by both old and young as a violation of the terms of the intergenerational contract and might be seen as releasing the son from his obligation to look after his parents.^[21]

What does household division mean in the context of these urban families? If the families remain under the same roof, division means little more than that the younger generation ceases to contribute to the common food budget and begins to prepare and take its meals separately. Division is most likely to occur when there are other married children in the household or when the senior female dies and a member of the younger generation takes over her responsibilities. Depending on the circumstances, the senior generation either chooses to cook and eat on its own or joins one of the junior households (or, less frequently, one parent joins one and the other another). When a member of the junior generation controls the common budget, the elder usually does not contribute to it. To some extent the lack of a contribution is an artifact of the composition of the household; that is, a

[21] Davis, chapter 3 in this volume.

younger person is likely to control the budget only when the senior female is extremely disabled. In such cases the senior women are predominantly in their eighties or nineties and not receiving pensions.

Whether households divide or not, one interesting aspect of the financial arrangements between the generations is that direct cash transfers (apart from contributions for meals) are neither regular nor frequent. Parents without pensions have almost no discretionary funds, inasmuch as coresident children seldom provide any kind of allowance. It is as if the unwritten contract states that each generation must allow the other to share accommodations if there are no alternatives, that the senior generation is entitled to free board and care (including the costs of medical care), and that the junior generation is responsible for its own expenses. Although urban men are only infrequently in this situation, the absence of discretionary funds seems to disturb them more than women because of their sense of entitlement; that is, they expect in their old age to be able to go to the teahouse, smoke cigarettes, and have an occasional drink. Without cash of their own they are effectively cut off from normal peer activities.

Elders who do receive cash for their own use from children are usually not living with them. These are parents who have one or more children living in Hong Kong or overseas. Hong Kong children come back several times a year, bring modern household appliances, take their parents to eat in fancy hotels, and give them gifts of money. Overseas children send remittances several times a year, enabling their parents to live independently, to hire outside helpers, or to spend as they see fit if they are already living with other children. Yang observed a similar phenomenon in rural areas of Zhejiang where parents lamented that rural sons supplied them with grain (and services) but not with cash, whereas sons who worked in towns sent back cash.^[22]

The nearest urban equivalent to inheriting land from one's parents is inheriting one's job. As Davis points out, many former sent-down youth benefited greatly from the expansion of this policy (dingti ) in the late 1970s and early 1980s when the Chinese government encouraged older workers to retire in favor of the young.^[23] Unlike land, however, a job is not divisible, and a parent could pass it on to only one of his or her children. Furthermore, the dingti option was likely to be acted on independently of the issue of household division.

[22] Yang Haiou, "The Future Family Support System for the Rural Elderly: The Consequences of the One-Child Policy and the Latent Impacts of the Current Economic Reform." Paper presented at the 41st Annual Meeting of the Association for Asian Studies, Washington, D.C., 1989.

[23] Deborah Davis, "Unequal Chances, Unequal Outcomes: Pension Reform and Urban Inequality," China Quarterly , no. 114:223-42, 1988. Also Deborah Davis, "Urban Job Mobility," in Chinese Society on the Eve of Tiananmen , ed. Deborah Davis and Ezra F. Vogel, 85-108.

Nevertheless, it is tempting to speculate that parents might choose to link the passing on of a job to filial obligations, that is, to retire in favor of a son who would subsequently be perceived as more obligated than his brothers to look after them. Elsewhere Ikels found that an important "historical" variable affecting care-giver selection was the shared belief that a particular child "owed" the parents more than his or her siblings did;^[24] in the Chinese context job inheritance might be viewed as incurring a greater debt to repay. At this point it is difficult to discern such a pattern in the Guangzhou data. Of the forty cases (in thirty-five households) in which parents retired so that their children could inherit their position, nineteen beneficiaries were sons and twenty-one were daughters. (My data almost certainly understate the frequency with which the dingti option was exercised, for I only gradually became aware of its possible importance and did not systematically ask about it while interviewing.) Given that Cantonese elderly still rely primarily on their sons for support (table 12.2), passing a job on to a daughter does not seem to reflect strategic thinking. However, as Davis indicates, during most of the 1970s parents' strategies were subject to state policies hampering predictability.^[25] Parents themselves indicated that their reason for retiring in favor of a particular child was to bring him or her back from the countryside (it is not clear whether any of their other children were still in the countryside at the time).

As can be seen from table 12.2, preference is definitely given to coresidence with sons. Parents having both sons and daughters were living with sons eight times as often as with daughters (56.4 percent to 6.8 percent). But the mere fact of having sons did not automatically mean living with them. Of 156 elders having at least one son, 8 lived with daughters only, 9 lived with spouses only, 9 lived alone, and 20 lived with others (grandchildren, other relatives, former employers, etc.).

Rather than detail the circumstances that led to each and every alternative living arrangement, I want to make a cautionary statement about the limitations of viewing living arrangements as predictors of family care. While they certainly do tell us something about the proximity of relevant categories of kin, they tell us little about family dynamics and nothing about the availability of kin who do not share the household. In times of need most Chinese elderly, whether they live with children or not, do have resources on which they may draw for support. In the following section I introduce several illustrative cases that demonstrate how families mobilize (or fail to mobilize) to meet their elders' needs.

[24] Charlotte Ikels, "The Process of Caretaker Selection," Research on Aging 5, no. 4 (1983): 491-509.

[25] Davis, chapter 3 in this volume.

The Needs of the Elderly

The minimal needs of the elderly include housing, income, health care, and managing the activities of daily living. As is indicated above, housing in the strict sense of having a roof over one's head is not a problem for the elderly. Most were assigned housing many years ago and have simply continued to live in it. It may be overcrowded, run-down, and lacking in amenities, but it is cheap, and every older person has shelter of some sort. The predominance of pensions means that nearly all men and nearly half of the women in the study have independent sources of income. Those who do not have pensions still do not, so long as they remain healthy, constitute much of a financial drain on their families, since their requirements are few. As we saw above, the family really only has to cover the costs of their meals. Elders for their part, especially elderly women, provide many services for the young and are generally viewed as earning their keep.

Nevertheless, we observed a number of cases in which financial issues were clearly a source of tension between the generations. For example, one seventy-three-year-old widow living with her older married son and his family (in housing assigned by his unit) receives no financial assistance from them, although they do eat together. According to residents committee personnel, the family has had a bad relationship for the duration of the seven years it has lived in the neighborhood. During the interview the son many times corrected his mother rudely while she sat stoically on the edge of the bed. Her daughter-in-law declined to greet us or to say anything throughout the interview, though she remained a hostile presence, determinedly clipping her toenails and pacing back and forth to the balcony. On

being asked to comment on a story about a case of suspected elder abuse, the old woman related her own bad relationship with her daughter-in-law, stating that the young woman never so much as says hello or good-bye when passing her while she is on security duty at the entrance of the building. Her six-hour tour of duty provides her with thirty yuan a month, her only source of income. Apparently, several years ago the residents committee invited her to do this work in an effort to alleviate the tension in the family by providing her with an independent source of funds.

Another older woman's independent source of income and her reluctance to share it with her children has caused at least one child to express disgruntlement about the situation. Four years ago, after having been retired for three years, Mrs. Tai, now seventy-five years old, started her own cooked-food business because she was dependent on her children and did not feel she had enough money. Since she was still able to work, she hired a young woman to prepare food in her home, which she herself sells at a stall. None of her eight children is involved in the business, nor do any of them even live in her house—a cottage-type structure which she had built over ten years ago with funds supplied by a son in the air force—though two live very close by. One evening we stopped by the nearby daughter's house to ask her opinions about stories depicting intergenerational conflict. One of the stories dealt with an old man who was unwilling to turn over to his son the management of the cash box in his small business. In the presence of her mother, the daughter commented: "He doesn't trust the son. Coax him [to turn over control of the cash box]. Help him until he collapses or dies—then he'll give it over to the son. Like my mother—we'll still get the money [when she dies]. She won't even let anyone live over there."

An elder is most likely to need care when he or she becomes ill or so impaired that he or she can no longer manage the daily routine and requires that someone else take up the slack and provide special personal services to the elder—for example, supervision, help with dressing, accompaniment on outings. In terms of financing, medical coverage in the urban areas is quite generous (particularly in comparison with rural areas where the family generally is responsible for all medical costs), though the extent of coverage is dependent on the nature of one's work unit. Among the study population 55 percent had between 90 and 100 percent of normal medical costs covered by their unit; 23 percent had between 50 and 89 percent covered, and only 13 percent had no medical coverage. The remaining 9 percent either received a fixed monthly sum (usually quite small) to cover medical care costs, whether they were ill or not, or were covered on a sliding scale with a fixed monthly maximum.

More important than health per se is the issue of functionality—for example, the degree to which a health problem or a combination of health problems hamper an individual's ability to manage daily life. Liang and Gu

reviewed seven regional studies carried out in China and concluded that between 11 and 15 percent of Chinese aged sixty and over suffer some degree of physical disability, with 10 percent being moderately disabled and 3 to 5 percent being severely disabled or bedridden.^[26] Of the two hundred elders in this study 30 percent experienced moderate or major disabilities in walking, 19 percent in seeing, and 16 percent in hearing. Fourteen percent showed evidence of substantially impaired cognitive functioning, but this figure almost certainly understates the proportion of the sample with moderate to major mental impairments inasmuch as twelve elders could not be rated with confidence because of their deafness or language difficulties. These rates are higher than those found by Liang and Gu, primarily because the population studied is older—with a minimum age of seventy rather than sixty.

The impairments listed have diverse consequences for the affected individuals. Deafness, for example, obviously hampers conversation, but it does not affect one's ability to go out, run a household, or look after oneself. Similarly, mobility problems need not have great significance if neither the affected individual nor his family members consider it necessary or desirable for the older person to go out. Table 12.3 presents the impact of these various disabilities in terms of the kind of assistance the affected elder requires.

As Liang and Gu point out, institutional long-term care is almost exclusively reserved for the childless elderly, whereas those elderly with families must rely almost entirely upon them for support in daily living.^[27] In many

[26] Jersey Liang and Gu Shengzu, "Long-term Care for the Elderly in China," in Caring for an Aging World: International Models for Long-term Care, Financing, and Delivery , ed. Teresa Schwab, 265-87 (New York: McGraw-Hill, 1989).

[27] Liang and Gu, "Long-term Care."

cases several individuals work together to provide care to an affected family member, but more often a single person emerges as the primary care-giver. Among the households in this study 63 percent of the care provided to disabled elderly family members is provided primarily by a single individual with minor contributions from others. In only 37 percent of the cases was care so equally shared that it was not possible to identify a primary caregiver.

To illustrate the nature of the demands placed on the family and to provide some sense of the complexity of the care-giving situations encountered in Guangzhou, four cases are described below.

Case 1 . Mr. and Mrs. Jeung were both originally Cantonese, but most of their working life was spent in Tianjin at a music college. When Mr. Jeung retired in 1965, the couple and the younger of their two sons (they have no daughters) returned to Guangzhou where they rented half an apartment in a two-story house owned by an old friend. At the time of the first interview their older son was living in Beijing; their younger son had since married and lived with his wife and daughter very nearby. The Jeungs' combined pensions amounted to about 230 yuan a month. In addition, seventy-nine-year-old Mrs. Jeung earned an occasional 5 yuan for teaching piano classes at kindergartens or churches. As former employees of a state unit, their normal medical costs (excluding hospital meals) were completely covered.

Despite their seeming affluence, however, the Jeungs' monthly medical expenses were more than double their monthly income. Three months prior to the first interview eighty-one-year-old Mr. Jeung suffered a stroke that left him bedridden and in need of twenty-four-hour care in the local district hospital. Mrs. Jeung herself could not provide this care easily because she has arthritis in her knees and shoulders as well as bone spurs. Consequently, she hired a sixty-seven-year-old woman for more than 17 yuan a day to stay at the hospital twenty-four hours a day looking after Mr. Jeung. Fifteen yuan were paid directly to the woman while over two were paid to the hospital to cover the cost of her meals. Mrs. Jeung said several times that the only way they could manage this sum was through the help of friends.

Before his illness Mr. Jeung had done most of the food shopping and sometimes helped with the cooking. Following his hospitalization their son brought his mother breakfast every morning. After breakfast nearly every day Mrs. Jeung boiled a traditional restorative tonic for her husband and brought it to the hospital. The day preceding the interview her daughter-in-law had taken the tonic to the hospital during her lunch hour because Mrs. Jeung had gone to a hospital specializing in the treatment of high blood pressure to get expert advice on her husband's prognosis. She returned from that visit feeling glum. The costs of staying at the special facility ex-

ceeded what Mr. Jeung's medical plan would cover. Furthermore, she had observed that one of the patients who had already been there for several years had yet to regain the ability to speak, and she doubted the value of moving her husband there. Because her son and daughter-in-law were both employed, they could not easily participate in caring for Mr. Jeung.

Case 2 . The following case provides a clear illustration of how the various parties to the intergenerational contract can interpret the terms differently. In 1986 eighty-five-year-old Mr. Fok and his eighty-three-year-old wife formally divided their property among their three sons and their senior grandson (oldest son of their oldest son); their three daughters waived their rights to any shares. Prior to division the senior Foks owned four dwellings: a village house (given to their oldest son), two small dwellings in Dongshan they had been allocated when their original urban dwelling was taken over by the government (one of these was given to their middle son, the other to the senior grandson), and a three-story house in Dongshan in which they and other family members lived. This house had been built with money provided by the Foks' youngest daughter, a driving instructor in Hong Kong. At division the youngest son was given the third floor and half the first floor, the senior grandson was given the second floor, while the old couple retained half the first floor for their own use.

The division process had not been amicable; in fact, the residents committee had to come in and mediate when two of the brothers actually came to blows. As a condition of division the oldest son (through his oldest son) agreed to provide for old Mrs. Fok, while the youngest son agreed to provide for Mr. Fok. Since neither of the parents had pensions or medical coverage (they had come to Guangzhou in the 1950s when they themselves were already about fifty and thus too old to obtain employment in the state sector), they were totally dependent on their sons for support. Operationally, this support meant primarily meal provision, but eventually in Mrs. Fok's case it meant meeting substantial medical bills. In the winter of 1990-91 Mrs. Fok had surgery for gallstones and spent two months in the district hospital. The costs of her care came to between 5,000 and 6,000 yuan, which the oldest son paid. He felt, however, that this was an exceptionally heavy burden for one son to carry and requested that his two brothers help him with these expenses. At first both brothers argued that this was not their responsibility, but the middle brother eventually yielded to his older brother and sisters' argument that he had received a share of the parental property and surely owed something. The youngest brother, however, refused to pay anything, insisting that he was responsible only for old Mr. Fok.

In an effort to resolve the impasse the youngest daughter returned from Hong Kong. She supported the youngest son in his claim that the middle

son should contribute but that he should not. She herself contributed 1,000 yuan toward her mother's medical bills and redefined the future property division (recall that she was the original source of funds for the building of the three-story residence). Under the terms of the original division the old couple had retained the rear half of the first floor of their dwelling; at their deaths it was expected to go to the youngest son, who already used the front half for his home appliance repair business. Under the redefinition the rear half is now to go to the senior grandson because he and his father paid for the bulk of Mrs. Fok's medical care. In actuality the case is not yet closed as both the parents are outraged that their youngest son will not accept any responsibility for his mother's expenses and have instituted a legal suit to require him to pay.

Case 3 . In contrast to the Fok family, the eight siblings in the Gunn family provide an example of harmonious functioning and shared responsibility in dealing with their mother's housing and health problems. Between the first and second interviews, an interval of less than four years, Mrs. Gunn, a widow in her early eighties, moved six times and lived with five of her eight children. At the time of the first visit Mrs. Gunn had been living with her younger son's family in a building owned by an Overseas Chinese. In 1988 her daughter-in-law, with whom she got along very well, died of stomach cancer. In April of the following year Mrs. Gunn went on a three-month visit to her older son in Hong Kong. When she returned, her younger son and his new wife soon had a child. Mrs. Gunn did not get along with the new daughter-in-law as well as she had with the first and was particularly concerned that her granddaughter (by the first daughter-in-law) was being treated unfairly by her stepmother.

During the 1990 Spring Festival most of Mrs. Gunn's children assembled in Guangzhou; they felt that under the circumstances she was under too much stress in her younger son's household and pressed her to move in with any of them. Although she did not actually want to move, Mrs. Gunn had little choice, for the Overseas Chinese landlord had reclaimed the house in which she lived and was waiting for them to leave. Her younger son was being assigned housing with considerably less space in another part of Dongshan. Consequently, she moved in with her oldest daughter, a widow living in the same old neighborhood. Then, almost immediately, from April to October of 1990, Mrs. Gunn went to Beijing where her third and fourth daughters lived and stayed with one of them.

When she returned to her oldest daughter's house in Guangzhou, both her oldest daughter and her second daughter felt that she had deteriorated physically. They worried that she had circulatory problems, so in the spring of 1991 they sent her to the hospital for a general work-up. While in the

hospital, Mrs. Gunn suddenly had a very severe attack of herpes zoster, which initially threatened her eyesight and required a great deal of care. Although a baomu was hired to look after her, at least two or three children or children-in-law (including those living in Hunan province and in Hong Kong) were usually present also. One day her oldest daughter, who has a heart condition, collapsed at the hospital while trying to look after her. Therefore, to relieve the strain on her oldest daughter, Mrs. Gunn, upon her release from the hospital, went to live with her second daughter in another district of Guangzhou. (This arrangement cannot be long-term, because the second daughter's entire family is about to emigrate to Canada.)

As a retired kindergarten teacher Mrs. Gunn has 100 percent medical coverage and also receives a pension of 180 yuan. Nevertheless, her hospitalization and subsequent care at home cost the family about 4,000 yuan. Part of this sum went for the baomu , part of it for an intravenous medication available only from Hong Kong, and part of it for gifts to doctors who came from specialty clinics to treat Mrs. Gunn at home. Fortunately, these financial obligations were met relatively easily because Mrs. Gunn's children had held a meeting in early 1991 to formalize their contributions to her welfare. Prior to the meeting the various children had contributed as they saw fit, but as a result of the meeting, care and financial obligations were divided up more systematically. The three children in Guangzhou (the two oldest daughters and the younger son) are expected to provide housing and the bulk of daily care. The older son, living in Hong Kong, and the youngest daughter, living in Australia, each contribute HK $500 (a total of approximately US $125) a month to Mrs. Gunn's upkeep. The two daughters in Beijing and the one in Hunan are expected to be available for emergency assistance, such as looking after her in the hospital or providing housing. Interestingly, no property transfers have been involved in these care decisions, for Mrs. Gunn has no property beyond whatever she has been able to save out of her pension.

Case 4 . Ninety-year-old Mrs. Fong is originally from Taishan county. Like many women of that area, she lived with her parents-in-law while her husband worked overseas (in Cuba), where he died in 1954. Because of her husband's absence, Mrs. Fong bore only one child, a daughter, but she had the foresight to purchase a son, who eventually left the village for work. During the 1950s her son's unit was transferred to Shaoguan, a remote part of Guangdong province. In 1956 Mrs. Fong joined her married daughter (who had also married a man working abroad) in Guangzhou and subsequently followed her to Hong Kong, where she stayed until 1984. By that time her daughter was already in her late sixties and in failing health. At the same time Mrs. Fong's son retired and returned to Guangzhou to live.

He moved into his sister's privately owned house (in which his own wife and children had been living all along) and was joined by his elderly mother.

Mrs. Fong has arteriosclerosis, but she does not require any special medical services. This is fortunate, for she has no health coverage at all. Her son retired from a relatively impoverished state enterprise that provides him with a flat payment of eight yuan a month to be used for medical expenses. However, Mrs. Fong does require extensive assistance simply to get through the day. She has a knee problem that dates from her Hong Kong days and cannot get around without a cane; she never leaves the house. More important, she is severely impaired mentally. She has nearly no memory, seldom talks (though when she does, she is extremely repetitive), has a bad temper, and cannot really look after herself. Her sixty-one-year-old retired daughter-in-law related how Mrs. Fong does not even know enough to change her clothes. She will wear the same thing for days and resist all efforts to persuade her to allow them to wash her clothing. They have had to forcibly undress her.

The Future of Family Care-Giving

From the above four cases we can see that proximity of kin is a crucial variable affecting the provision of care to the elderly. During most of the Maoist era and even into the 1980s, the Chinese government has promoted policies that, by constraining opportunities for geographic mobility, have simultaneously promoted the availability of family care-givers.^[28] These policies include deferring the construction of new housing, restricting migration, and discouraging job changing. Furthermore, the one policy that did separate young people from their parents, that of sending urban youth to the countryside, was modified early on so that at least one child could remain in the city. The subsequent broadening of the dingti option enabled hundreds of thousands, if not millions, of those who were "sent down" to return to the city and to their parents' own work units. Not only were potential care-givers in place, but the policy of allowing women to retire at age fifty and fifty-five with full benefits meant that they could provide care to a disabled elder without compromising the financial standing of their families or jeopardizing their own futures.

How are the economic policies that have been developing over the past decade likely to affect the availability of family care-givers and their willingness to provide care? The single most important question now facing Chinese

[28] Charlotte Ikels, "Family Caregivers and the Elderly in China," in Aging and Caregiving: Theory, Research and Policy , ed. David E. Biegel and Arthur Blum, 270-94 (Newbury Park, Calif.: Sage, 1990).

elders, whether to continue sharing dwelling space with the younger generation or to live separately, is a direct consequence of the enormous boom in housing construction that has been under way for nearly a decade. Increased opportunities for job mobility also contribute to the dispersal of children and to the need to make decisions about housing, though, as Davis points out, in the urban areas job mobility is more apparent than real.^[29] As a result of the increasing availability of housing, more and more young couples are able to acquire apartments of their own and no longer need to spend years of their married life in their natal households with their parents. This increased availability of housing means that many older people whose spouses are still alive at the time their youngest child marries are likely to spend some years living only as a couple. One result of this living arrangement will be more situations such as the Jeungs encountered—when one elder becomes ill or disabled, almost all of the care will fall on the coresident spouse. This is especially likely now that much of the new housing is being built on the outskirts of the city far from the natal households of the new occupants. When one of the elderly partners dies, the survivor will have to decide whether to remain in his or her own territory until no longer able to do so or, leaving old friends and neighbors behind, to join a married child in unfamiliar territory. The younger generation for its part will be forced to ponder its own filial obligations in more detail. Instead of assuming that, by default, the last son to marry will simply remain with a widowed parent, brothers (and to a lesser extent sisters) will have to spend more time negotiating parent-care responsibilities, as the Foks and the Gunns have done.

Under the new circumstances proximity will continue to be important, but historical and situational factors will come to play a more important role in determining the distribution of these responsibilities, and the assumptions now implicit in the intergenerational contract may have to be clearly spelled out. Historical factors could include calculations of which child is more obligated by virtue of having received special parental investments by, for example, being the beneficiary of the dingti option or of childcare services. Situational factors, such as who can provide care with the least disruption to their own family when parental needs become apparent, will also necessitate both intragenerational and intergenerational strategy sessions to determine who can best provide the necessary care. Thus, in the absence of any competing family obligations, a retired child or child-in-law is a likely candidate for the role of care-giver.

The provision of care by an elderly spouse, a residentially distant child, or a still working child presents more logistical difficulties than does care provided by someone young and coresident or living just down the street. If

[29] Davis, "Urban Job Mobility."

the Chinese government continues to expect families to provide the bulk of elder care, it will be necessary to develop support services for these families. Homemaker services, respite care services, and mutual aid organizations are all neighborhood-based programs that would allow the elder to remain in his or her own residence and at the same time would lessen the burden taken on by the family. Alternatively, workplace-based programs, such as daycare centers or care-giver leave policies, could alleviate the stress of providing parent care. Some forms of congregate living, such as retirement apartments for the relatively well elderly or nursing homes for those whose children are unable to provide direct care, could be expanded. Currently, most welfare homes for the elderly restrict admission to the childless and needy elderly, but increasingly such homes are beginning to admit elders whose children cannot look after them but are able to pay for care.^[30]

Conclusions

As is indicated in the introduction to this chapter, the traditional intergenerational contract was generally understood to require sons to support their parents in old age. Material and psychological incentives along with the threat of social and supernatural sanctions usually made living up to the contract more attractive to the younger generation than reneging on it. In the reform era the strength of these forces has been weakened as the young take advantage of the new opportunities to live and work in communities other than the ones in which they were raised. Nowhere is this more apparent than in the rural area, where the shift from the collective to the individual household as the unit of production has undermined the power of the village (formerly team or brigade) head to penalize neglectful adult children by witholding their wages.

Great official concern has been expressed recently about both the willingness of adult children to support their parents and how best to take preventive action to avoid abuse. According to a report in the Legal Daily , such abuse and neglect in Zhejiang caused the deaths of at least 187 elderly Chinese between 1988 and 1990.^[31] These "abnormal" deaths, of which many were suicides, were the result of being denied medical treatment, being coerced into turning over property, and being bullied and tortured. Local authorities were accused of not paying much attention to these cases and of failing to prosecute the persons responsible.

Sun reports that some localities are now requiring written contracts of support between elderly parents and their children.^[32] Such contracts are

[30] Liang and Gu, "Long-term Care."

[31] Legal Daily , 1990. Cited in Lena H. Sun, "China Seeks Ways to Protect Elderly," Washington Post , October 23, 1990.

[32] Sun, "China Seeks Ways."

not, of course, a new idea, but requiring them of newlyweds and involving officials rather than relatives to witness them are new. The vice-chairman of the Qindu county (Shaanxi province) committee on aging clarified the need for contracts by pointing out that "it is very common for children, especially sons who are the traditional care-providers, to quarrel among themselves about who will take care of the parents." This issue of conflict among siblings, whose individual resources may now vary substantially compared with the prereform period, is the same phenomenon Cohen discusses in Taiwan.^[33] The sons are so concerned about the exploitation of their conjugal families by one another that determining how to meet the needs of the senior generation becomes one more source of contention.

In the urban areas, as we have seen, elders are less vulnerable to the quarrels among their sons because they normally have their own pensions and subsidized medical care. Nevertheless, it is clear that "serving" the elderly—that is, assisting them in the tasks of daily living—may become a source of contention among their children. Parents now appreciate more than ever the need to think strategically and to nurture a sense of filial obligation in their children. Thus parents sometimes exempt unmarried sons from contributing to the household budget, provide childcare for adult children living elsewhere, and make themselves agreeable coresidents by staying out of young people's affairs. In these ways they hope to lessen the impact on themselves of the new opportunities young people have to seek distant jobs and to move into separate housing.

[33] Cohen, House United .