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The Challenges from the Chinese “421 Family”

Entering the era of the first generation (those born in the 1980s) of the “one-child policy” parents, “421” has become the typical family structure and challenge for Chinese society.

What is a “421” family structure? It is an inverted pyramid family structure, composed of 4 grandparents, 2 parents, and 1 kid in a closely bonded Chinese family.19300000312288133370361297173

Those who were born in the 1980s were once seen as the happiest generation since they were the only kids in the family and were raised and perhaps spoiled as princes and princesses in the family by parents. It was easier for these children to enter colleges than their parents’ generation since the expansion of universities across the county occurred during that time. However, these “princes” or “princesses” also felt an increasingly unprecedented pressure by the time they grew up. The universities did expand and allowed more students than before, while job openings didn’t increase accordingly by the time they graduated. In recent years, when these children started to build up their own families, they found it even more difficult to get an economical apartment, raise a kid, or support their parents who were getting old. Most of the children of the 80s thus came to call themselves “slaves to housing, kids, credit cards, and elderly parents.” This was due to the national situation as well, as housing is extremely expensive in the most populous cities such as Shanghai or Beijing. Education for kids is costly. When the “grandparents” would get old enough, the “parents” would have to be ready to take care of the elderly both financially and in terms of physical and mental health — due to the Chinese culture, as well as limited pension funds from the government.

Elderly homes are not welcomed by the elderly in China. One of the main reasons for this is due to their unsatisfying service and high prices. In addition, according to the traditional Chinese culture (bringing up children for the purpose of being looked after in old age), being delivered to the elderly home has made the elderly people feel they are left out or ditched by the family. On the other hand, the “empty nest elderly” has reached over 30% on average in big cities, or even more than 50% in some individual cities.

As the most populous country in the world, the number of elderly people has reached over 141 million, which makes it the country with the most elderly people in the world as well. It accounts for ⅕th of the global elderly population, and half of the Asian elderly population. Generally, the reasons of the trend of elderly society are: the extension of life expectancy, the decrease of the birth rate, and the decrease of the mortality rate. However, for China, the three main causes are happening all together and on extreme levels. The “one child policy” since 1978 was a sudden change for China after the populous number of births during Mao’s era.  Together with the decrease of mortality which was brought by the development of the economy, it took only 18 years for China to change into an “elderly country” from an “adult country,” which was an extremely fast transition when compared with high-income countries. China is facing a severe challenge with the aging society.

In most high-income countries, urbanization and industrialization come together with the aging situation. When the seniors (people aged over 60) reached 10% of the total population, their GDP per capita generally reached 10,000 USD or more. They became rich before they grew old. Unfortunately, for China, it is the other way around.

As recognized in international standards, an aging society is defined as the following: over 7% of the total population having reached the age of 65, or over 10% of the total population having reached the age of 60. In this case, China has become an aging society since 2000. However, there are only around 40,000 elderly homes with 1.6 million beds, which means there are only less than 9 beds for every 1,000 elderly people who are aged 60 or above.

As for the support from the next generation, as mentioned earlier, there will be a very long time for the country to move forward when “two young people are taking care of four old people.” In addition to young people’s pressure to survive, and the family separation in different cities or countries due to urbanization, traditional family support would be very difficult to implement.

The change of the economic level, population structure, and the traditional concept of family support or traditional elderly life have brought people to start thinking. Nowadays topics like the methods of generating or expending the pension, the extension of the retirement age, etc. were hotly debated in China. People are all aware of the changes. But how much can they accept the changes, especially for the elderly people? Can they be emotionally independent enough from their kids like the westerners? Even if they can, would the society be able to provide the facilities or benefits for the elderly after they’ve contributed to the society for several decades?

Of course, effort from only one side would never be enough for a country like China especially when it comes to such a big change. In the “421” family, the “2” are still trying to support the “4” in every way they can while taking care of the “1.” The “4” are also doing best they can for themselves to be independent and to try to accept all the changes they never thought would happen. There are some 50-60 people initiating online that they could build up a small elderly home to live together and take care of each other. From the society, there are also proposals that “flexible retirement” might work instead of compulsory early/late retirement. People or companies could choose the best for themselves, since each industry is different after all. There is no rule that applies to all.



The challenge of rational medicine’s journey from patient- to pathogen-specific

Recently, the New England Journal of Medicine (NEJM) released their 200th anniversary article titled, “Therapeutic Evolution and the Challenge of Rational Medicine,” by Greene et al. [1].  This article gives us a walkthrough of how medicine has evolved in the past 200 years: specifically, from patient-centered in approximately the first century and a half, to pathogen-centered in the last fifty or so years. Traditionally, western doctors had an in-depth knowledge of herbs — and a wide range of (often bizarre) treatments, ranging from the application of the “Devil’s dung” plant to the practice of bloodletting, i.e. “breathing a vein,” to assist in the curing of a disease. While some of these treatments are arguably questionable, specifically the well-versed knowledge of traditional western doctors focused more on the human perspective, and, as a result, may have been a vital ingredient to the overall well-being of the patient. This component appears lost today — where our healers are efficaciously oriented toward targeting a specific pathogen, with very specific aims. This compartmentalization of focus (generating doctors with specific knowledge about specific subjects) leaves patients with any other possible ailments or concerns to hang in the dark. While the light of the brilliant doctor who shines in his specific field of focus may isolate and treat the primary cause of a disease, the flashlight he is shining with on the patient may just as well blind the patient to any other factors just as important that could improve general well-being. The flashlight will of course cast shadows of its own. As the article in NEJM subtly points out, there can be no medicine without both therapeutic enthusiasm and therapeutic skepticism, and skepticism has flourished in the rationale of science ever since the chilling specter emerged from medicines such as thalidomide, Diethylstilbestrol, Vioxx, and Avandia [ibid]. These drugs were developed for specific purposes, i.e. to prevent morning tiredness, to act as an antidiabetic, etc., and while the focus of developing these drugs may have been done through well intention, the outcomes clearly revealed something menacing lurking in the shadows.

“As the locus of disease has narrowed from the afflicted person to the molecular mechanism, and the target of magic bullets has followed suit, physicians have faced regular reminders of the limits of the reductionist approach.” [1]

As we have been endlessly discovering smaller and smaller particles; and smaller and smaller actions that lead to larger reactions, one might wonder if this approach is the best to solely focus on. What may be an additional approach more fitting for our new century?  The Shanghai Center for Systems Biomedicine has released an interesting article titled, “Toward new drugs for the human and non-human cells in people,” by Zhao et al. [2]. This explores the realization that the human body is only sparsely comprised of actual “human” cells. There is in fact a multitude of lifeforms that live within us and work in synergy with our body. For example, our metabolism is aided by lifeforms such as veillonella, bifidobacteria, and lactobacilli. Zhao et al. explain that humans are “superorganisms” due to the fact that we are 10% human cells and 90% microbes (primarily in the intestines).

“‘Super'” in that sense means ‘above and beyond.’ Scientists thus are viewing people as vast ecosystems in which human, bacterial, fungal and other cells interact with each another.” [2]

Therefore, when microbes significantly affect our genetic actions and reactions through gene regulation; i.e. on and off switching, this directly affects our immune response — and thus affects how diseases or disorders manifest. Due to this complexity, scientists realize how the reductionist approach can certainly fail — as all individuals will have a different response to treatment. We are complex beings and thus require complex interventions, and that certainly does not mean we should delve further to find even smaller particles or specialize ourselves even more. We should, on the contrary, seek a more holistic approach. For example, our own nutrition, diets, medications, mental state and physical activity (or lack thereof) completely affect the manifestation of our microbe populations within our bodies — and thus completely affect which genes are expressed and which are not. There is nature just as much as there is nurture.  The so called “functional metagenomics” proposed by Zhao et al. [2] for developing new medicines that affect our microbes (and I say “our” for simplicity, because these organisms work together with us) are showing promise through traditional Chinese medicine  (TCM) — an archaic yet thriving art of medicine that continues to prosper and grow in popularity even among the general scientific community as time passes. In the case of gene-environment reactions, most chronic conditions are involved. Here, Zhao et al. claim the gut microbiome is vital and TCM is tailored to target both the host as well as the synergistic microbes — thus being a holistic medicine, as treatments are not specifically tailored such as the conventional drug approach, which targets in an isolated fashion typical receptors within the “druggable genome.”

It appears that for the next age — moving on from an efficacious, isolated approach in primary care — we are not going back to a patient-centered approach which began in traditional western rational science, but rather a “super organismic” track that attempts to integrate as many human and non-human factors as possible.


1. Jeremy A. Greene, M.D., Ph.D., David S. Jones, M.D., Ph.D., and Scott H. Podolsky. M.D. Therapeutic Evolution and the Challenge of Rational Medicine. N Engl J Med 2012; 367:1077-1082. September 20, 2012. DOI: 10.1056/NEJMp1113570

2. Zhao L, Nicholson JK, Lu A, Wang Z, Tang H, Holmes E, Shen J, Zhang X, Li JV,  Lindon JC. Targeting the human genome-microbiome axis for drug discovery: inspirations from global systems biology and traditional Chinese medicine. J Proteome Res. 2012 Jul 6;11(7):3509-19. Epub 2012 Jun 5.

Elderly in China

In China, the population over age 60 has reached 180 million. It is predicted that the number will be increasing every year by 5-8 million. Beijing, for example, has the number of elderly people accounting for more than 15% of the city population. In the meantime, due to birth control (one child policy) starting in 1978 – together with the fact that more and more young people are going abroad for work or studies – the number of households with only elderly people is increasing. Senior citizens living alone have become the main characteristic of the aging situation in cities such as Beijing and Shanghai.

The retirement age normally is 50 (for women) or 55 (for men) in China, which is relatively young comparing to the western countries. What do they do after they retire? Most elderly have to provide day care for their grandchildren since maternal leave is only 3-4 months, while kids could only start going to day care at the age of three. In fact, the elderly are taking care of their grandchildren day and night during working days and the kids only stay with their parents during weekends. So when the elderly are enjoying the company of grandchildren, they have to make efforts to take care of them too.

The neighborhood community plays a key role in daily life for the elderly, especially in urban areas. The community center is an ideal place for elderly living in the same neighborhood to gather together and play chess, exercise, etc. Recently, these communities would also be responsible for the day care services (i.e. meal delivery) for the elderly who lose self-care abilities and ensure health checkups of the elderly in the neighborhood.

Transportation is a dilemma, as it is both easy and hard for the elderly. Starting with Shanghai, several other regions such as Sichuan, Lanzhou, Hangzhou, etc. allow elderly people aged above 70 to take public transportation for free. However, if they wish to take a flight, a health certificate is required by most aviation companies.

Monthly pension is normally 1000-2000 CNY (157-315 USD). However, elderly people feel insecure due to low coverage of public medical insurance (from the government). So Chinese people generally save for retirement, meanwhile support from the family is also expected especially when they are sick in the hospital – since usually medical insurance is not enough to cover the costs. Furthermore, nursing service is normally expected from family members due to Chinese tradition and unsatisfying nursing services provided by public hospitals/nursing homes.

Nursing homes are more acceptable by the elderly now than they used to be. In the past, elderly going to nursing homes has been looked down upon, since normally only solitary aged individuals would have to go there and the service from nursing homes was poor. However, due to the trend of an oncoming inverted pyramid within the population – and the improvement of service – going to nursing homes is more acceptable by the elderly nowadays. By interviewing one private nursing home owner, it was observed that compensation on the nursing homes for the elderly requires several criteria. Non-profit nursing homes are either hard to get in or equipped with poor service – with 6-8 beds in one room and one nurse for 15-20 people, while private nursing homes would have rooms with single bed available. There are also newly built public nursing homes these years with better conditions, but it could take the elderly years in the queue system to get a spot. Another issue mentioned by the interviewee was the labor system. Running nursing homes needs employees take night shifts. However, the nursing home labor system doesn’t share the same one as the hospital’s, which has made the management of employees difficult.

The Fifth Social Welfare Institute is one of the best nursing homes in Beijing. It has 230 beds in total and the normal price is 1800 CNY per month per bed. It is equipped with designated medical care (which could be reimbursed), as well as different kinds of activity rooms for dancing, playing pingpong, calligraphy, reading, etc. The reasonable price and complete setting of the nursing home attracts lots of elderly people, however, the waiting time to get in could be years.

In short, after early retirement, the elderly in China rely on pension for the expenses on daily life. While when they get sick or more senior, support from the family will be needed. They enjoy having fun with the people at the same age in the neighborhood or in nursing homes. The number of nursing homes in China is far from enough due to the rapid aging population. Though, the bed occupancy rate might be low in private nursing homes. More affordable nursing homes with upgraded and reimbursable medical services are definitely required for the elderly population in China.

Lonely no more in Shanghai

L is for the way you look at me,
O is for the only one I see,
V is very, very extraordinary,
E is even more than anyone that you adore can..

Love, is what today’s post is about. We have had so many songs of romance since the birth of music and L-O-V-E was the final album released by Nat King Cole before he died in 1965. But what is the connection then between today’s special focus on love, the elderly and (to spice things up) Swedish furniture manufacturer IKEA?

In Shanghai, the IKEA in Xuhui district is quickly becoming a mecca for dating seniors. According to an expert from a U.S.-based management consulting company, this is because of the casual atmosphere that acts more as a place of leisure than a place to buy furniture. At a weekly session of romance in IKEA’s cafeteria outlet, the seniors would gather in a group of 70 to 700 to chat over a cup of free coffee offered to holders of the IKEA Family membership card. Staffs can expect to hand out as many as 500 cups of coffee every time the group meets up. When quizzed on why IKEA was chosen as a matchmaking location, some seniors pointed out to the availability of similar lonely hearts that throngs the outlet looking for either friendships or relationships.

You can find a boyfriend or girlfriend, or just make friends and chat. It makes you a little bit happier,” says Ge, a smartly dressed 50-year-old woman who retired not long ago.

Ge’s friend, with the surname Han, is a retired bus-ticket seller also explains, “If I meet a guy and he’s appropriate for me, we can call each other. But if he finds someone more suitable for me, he’ll help and introduce me to the other guy.”

This phenomenon can be traced to China’s soaring divorce rate, shifting demographics and the relaxing atmosphere of the stores themselves. Shanghai is fast becoming an ageing society and as early as three years ago, retirees have started to frequent the IKEA in Shanghai. Some such as Ge however, understand that they are living off the goodwill of the company through their extended ‘coffee dates.’ They believe that an ideal solution would be the establishment of a similar setting in their communities, a suggestion worthy of consideration for the government.

Social support is important, especially for the elderly who are living at a fragile age. In Singapore, social support services and programmes in the communities not only cater to the lonely and vulnerable elderly, but also seek to encourage active lifestyles among the seniors. The Chinese government could perhaps adopt such concepts as they plan the blueprint towards elderly-friendly communities in the city.

Meanwhile, for the divorced and lonely seniors in Shanghai, where do broken hearts go, can they find their way home?

They certainly will, in IKEA , as love will keep us alive.

(Source: NPR)

(Image source: Whats on Xiamen, Mark Ralston)

Exploring TCM in elderly care

Quite recently, I was following a particular drama series that was airing every weekday nights. A Mediacorp (Singapore) production titled “The Oath”, the story revolves around the rivalry between a Traditional Chinese Medicine (TCM) practitioner and a doctor skilled in western medicine. With a common aim to save lives, both individuals ironically were also in love with the same woman. Eventually, the former may have won her heart, but honours were even in the duel between Chinese and Western medicine.

This is because both methods are effective in their own right and in certain instances, have a complementary effect on each other. In the case of elderly care, various aspects of TCM are used to promote longevity and wellness. The Chinese believed that Qi (Chi) or vital energy flows throughout the body. It is essential to regulate the Qi within as an interruption of energy flow would indicate body aches. Chinese herbs such as aloeswood, costus root, ginseng, persimmon calyx and tangerine peel help facilitate the flow of Qi in vital organs, alleviating pain. Food remedies like scallion, garlic, ginger and peach also provide health and longevity benefits.

For pain relief in bones and joints, acupuncture, a proven effective treatment against arthritis and osteoporosis may be an option for the elderly in pain management. Mind-body exercises such as Qi Gong and Tai Chi also boast the benefits of strengthening immune systems, preventing falls, decreasing chronic ailments and mitigating symptoms of depression among the elderly.

To sum it up really, TCM and western medicine practices may differ in many ways, yet it is important to note that both medical cultures have the best of intentions for the general health and wellness of their people. As both sides continue to discover new and innovative routes towards longevity and good health, the standards of elderly care can only improve. But for now, it is all hands on deck as we brace for impact from the imminent silver tsunami.

(Source: Vitality-After-60, Yin-Yang House, Chinese Food Therapy, NHS UKBastyr Centre For Natural Health)

(Image Source: Jimmie)

(Video Source: MyPathTV)