Mao's Last Nursing Home

The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of communism is the equal sharing of miseries - Churchill

There is a nursing home in Wuxi called Liang Xiao (name changed). It is located down a side alley off a busy street not far from the central train station. Like most acute care facilities in China, it is a grey and depressing place with little apparent security and wholly inadequate patient supervision. I don't know when Liang Xiao was built and the distressed nature of the buildings offer little clue; most public facilities (with the notable exception of important government offices) are poorly constructed, it could just as easily be 10 years old as it could 30 years old. In all, Liang Xiao seems as hopeless and miserable a place as are its despondent and forlorn patients; fragility seems the least of their ailments as patient quality of life is non-existent. To be fair though, Liang Xiao did have an uncommon amount of activity and the type of motion that suggests design; but it wasn't clear at the time just what it was all about.

I was invited to visit Liang Xiao as a result of one of their nurses having read contacted me via Weibo, the Chinese Twitter. We arranged our visit and scheduled the trip for an early afternoon arrival. Our hosts were the doctors and nurses who run the facility and we were told, the "Chairman" of the company. This last bit of information was curious as I was under the impression that all nursing homes were owned by the state. The purpose of our invitation was to learn if there was any opportunity for us to consult and assist Liang Xiao with their interest in upgrading their geriatric care program.

Shortly after our arrival and once done with the ceremonial exchange of business cards, fanfare of good wishes, obligatory sip of tea and taste of fruit, we were offered a tour of Liang Xiao which we graciously accepted and were told that Mr. Chang would be slightly delayed. Twenty minutes into our tour the Chairman arrived with an entourage of 6 men attending to his calls, carrying his 3 briefcases and just generally making a scene about his arrival. Clearly, the intended impression to be conveyed by this activity was that Mr. Chang was exceedingly important and a much too busy person with whom to be trifled. Our tour guide noticed Mr. Chang's entrance and nervously diverted us from our route to the courtyard in the center of Liang Xiao where a brief introduction was to be made and photos taken. Mr. Chang was given our brochure by one of his assistants and as he read it out loud, he shook each of our hands. Once the introduction was complete, Mr Chang insisted that our tour be postponed until later that afternoon and we should all, at once, retire to the luncheon which had been especially prepared for us.

Our lunch cleared up the mystery of the "Chairman" as well as Liang Xiao's noticeable bustle and opened a door into what might well be the future of nursing homes in China. Calling Mr. Chang a businessman is a profound understatement, as he is more aptly described as one of China's new generation of ravenous entrepreneurs, a new breed of savvy and sharp-eyed capitalists who can spot opportunity a mile away. Mr. Chang's story begins a couple of years ago when the 12th 5 year plan was being written and the government began to allocate funds for the development of senior living facilities. Through what I can only imagine is a carefully constructed and meticulously maintained, salubrious network of political and business contacts (the guangxi must be legendary!) in Wuxi, Mr. Chang crafted himself an opportunity from the ruins of Liang Xiao. And while Mr. Chang doesn't know a thing about nursing care or even the management of such a facility, we must always remember the 4th philosophy of the Joy Longevity Club....General Tsao's copycat chicken with tasty sauce.

Through grants available via the Ministry of Civil Affairs and more importantly private investment, Mr. Chang is slowly turning Liang Xiao around, and even though it may not look like that today, having been to many other nursing homes in China over the past two years, Mr. Chang is clearly on the power curve of his industry. What is even more curious is that Mr. Chang has also "purchased" shares in Liang Xiao and through his private company "owns" a substantial minority stake. I use the quotations for effect here as I have no idea the inner machinations of how he managed this or the details of the structure; like many things in China the means justify the end and it is likely all informally arranged between him and his local government friends. These particulars notwithstanding, it is the big picture that is the point here: Mr. Chang is moving an industry that has long been mired in the stone age of China's dismal legacy of anemic public healthcare. Mr. Chang and those who come after him in Wuxi (not to mention the 39,545 other public nursing homes in China) will no doubt profit handsomely from their efforts and they should; theirs is truly a herculean task.

This all reminds me in a way of Li Cunxin's gripping autobiography Mao's Last Dancer (and subsequent film adaptation by Bruce Beresford in 2009). In his book, Li Cunxin is born into a poor family commune in a small rural village in Shandong Province, where he is destined to work in the fields as a laborer. At first overlooked but eventually selected after suggestion by his teacher during a school visit, Li seems bewildered by the gruff preliminary inspection screening at the province capitol city of Qingdao. He is selected to travel to Beijing to audition for a place in Madame Mao's Dance Academy, and is admitted to its ballet school after passing a series of physical examinations. Years of arduous training follow, until his initial mediocre performance is finally overcome due to inspiration from a teacher's devotion to classical ballet as opposed to the politically motivated, strident form favored by Madame Mao. His determination and courage leads to him being grudgingly permitted by the Academy to travel abroad to Ben Stevenson's Houston Ballet company as a visiting student for three months. In the United States, he begins to question the Chinese Communist Party dictates upon which he has been raised, detaches himself from his political past, defects and flourishes as a dancer.

I see Mr. Chang as China's healthcare Li Cunxin; a charismatic, determined soul who sees more and desires a better circumstance for himself and his business and is frustrated with the status quo. The big difference between Li Cunxin and Mr. Chang is that Mr. Chang no longer has to defect to realize his ambition; China has learned to provide opportunities for those who are motivated enough.

A short injection of China's nursing home history

In 2000, China's Ministry of Civil Affairs announced the "Star Light (Xing Guang) Program" whereby the Ministry allocated 20% of the social welfare lottery fund to build community welfare facilities for seniors. From 2001 to 2004, the Chinese government invested a total of 13.4 billion yuan in this program and built 32,000 "Star Light Centers for Seniors." I want to thank Leung-Wing Chu, FRCP, and Iris Chi for this information as they did a great deal of research in this respect. The services of these centers are overly broad with multiple functions and cover family visits, emergency aid, day care, health care services, and recreational activities to over 30 million elders. At the same time, the government also increased its investment in building nursing homes to provide institutional care for older people in the "Star Light Program". Another program, the "Beloved Care Engineering" program began in 2005 and is aimed at increasing the number of nursing homes and encouraging good nursing home care quality through a government-sponsored Elder Care Foundation. These facilities range from senior citizens' lodging houses (apartments), older people homes, and nursing homes for the aged, which serve to meet elders with different functional abilities and financial backgrounds. The building of older people homes in rural areas was also encouraged for persons who can avail themselves of the "5 guarantees" which, when translated, are the basic needs of "food," "clothing," "accommodation," "health care," and "burial service". Those who can usually find their way into such accommodations are usually former revolutionary guards, government employees or other "proud" occupation. By the end of 2005, there were 39,546 institutions providing vastly different types of services for seniors with most providing subpar care, when compared with their Western counterparts (an admittedly unfair comparison). In total these institutions provided 1.497 million beds.

If providing nursing homes was the only issue then China would be well on her way, however that is the least of concerns. As with most endeavors on the mainland, human resources or lack thereof is usually the issue that trumps the best laid plans. The major source of healthcare workers are (often called "bao mu" in Chinese) laid-off workers in previously state-run factories, migrant workers from rural villages or unemployed ethnic minorities. They often do not have any training in elder care or nursing home care before they start working in the nursing homes for older adults. For laid-off workers, 1 to 2 days of short training in basic personal care is provided free of charge by some local government agencies, for example the Labor, Social Security Bureau, China Committee on Aging, and Women's Federation. However, none of these workers are required to have formal training in geriatric care before they enter into their work. As a result, the quality of care is grim and dangerously low. These workers are often required to pay a fee for these training courses and as this imposes a great financial difficulty, they usually do not enroll before they commence working. Such labor also presents other issues for working in nursing homes; different language or dialect, customs from those of urban cities' older people and cultural prejudices of patients who often dislike their care being given by "bao mu".

We haven't yet begun our work with Mr. Chang, although I am confident we will do a great deal with him. And as you can imagine, the benefits of working with such a person extend far beyond simple contract remuneration. His highly choreographed performance to date in raising Liang Xiao from little more than a living graveyard to real, albeit spartan, nursing home is nothing short of virtuosic.