Migrant Workers

Clinical Decision Making in Rural China

September 25, 2020 by Hanna Pickwell

Society for East Asian Anthropology
By Xisai Song
September 16, 2020

This piece is part of an SEAA series on “An Anthropology of Ethics in East Asia.” The articles examine how individuals cope with societal changes such as environmental crises, nationalism, economic development, and mobility through a lens of everyday ethics.

As a life-sustaining treatment for patients suffering from kidney failure, hemodialysis has been ridden with controversies since its emergence. It is a “half-way technology” that can neither cure the disease nor provide a sense of comfort, but jams patients into a long and torturing status between life and death (see for example, Fox and Swazey 2001; Kaufman 2015). The life quality for patients on hemodialysis is extremely low: they have to constantly practice self-discipline in food and water consumption (only one small cup of water a day) and chronically experience a long list of complications such as itchy skin, sleeping problems, and bone diseases. Unless acquiring kidney transplants, patients have to depend on hemodialysis until death.

In 2019, I conducted fieldwork in the hemodialysis ward of a public hospital in Qiushui, a poor, mountainous county in northeastern Sichuan, China. There were 95 patients suffering from kidney failure who regularly visited the ward for a four-hour hemodialysis treatment two to three times a week. The majority of them were from the county’s rural areas, among whom most were former migrant workers. They used to work as laborers such as factory workers, construction workers, and truck drivers in coastal provinces in China, but returned to their hometown to receive hemodialysis treatments. Half of these patients were under 45 and 10 of them were in their twenties. In spite of their young age, only six patients in this ward were waiting to receive a kidney transplant. Why do so many patients choose the arduous hemodialysis treatment instead of kidney transplant? How is their clinical decision making formulated in the social-historical and political context of China today?

Photograph of the interior of a hemodialysis ward — Image description: There are about half a dozen beds in this corner of the ward, all accompanied by hemodialysis equipment. The ward is clean and well-lit. There is a large, partially opaque window stretching across one wall of the ward letting in a small amount of light.
Caption: A corner of the hemodialysis ward. Xisai Song

What shocked me when doing fieldwork in the hemodialysis ward was how grateful those patients were to the state, in sharp contrast to what has been documented in anthropological studies in other contexts where poor patients attributed their reluctance to receive kidney transplants to social and structural problems (for example, Hamdy 2012). Coexistent with their indebtedness to the state was patients’ intensive moral anxiety and self-blame. State-sponsored insurance schemes and the “Targeted Measures in Poverty Alleviation” (jing zhun fu pin) program cover 75 to 90 percent of patients’ medical expenses, making hemodialysis financially accessible. These state welfare programs made patients feel included into the political order. At the same time, although migrant workers are constitutive of creating the new socioeconomic landscape of reform-era China (Zhang 2001), they are displaced from it immediately as they lose their ability to work. Unemployment is common among these former migrant workers on hemodialysis because their bodies can no longer handle the heavy labor required to keep their jobs as blue-collar workers. As a result, families, both as a cultural source of support (Kleinman 1980; Yan 2017) and an agent of the biopolitical state (Ma 2020), become the default safety net that patients depend on for financial support and for care. Caring for a sick family member is a long-standing moral norm in China. In poor rural households, however, caring involves meticulous calculations and moral tensions; families strain to coordinate their limited resources including labor, money, opportunities, and life prospects. Consequently, clinical decision making, discursively framed as a private act of family responsibility, is in fact a dilemma of survival. Deciding on treatment options like kidney transplantation entails moral struggles of evaluating and comparing life values among family members.

For Shan, a patient in her early fifties, kidney transplantation was “meaningless.” Instead, her primary concern was her son’s marriage. Shan was from a rural village in Qiushui. She and her husband were factory workers in southern China. In 2013, Shan was suddenly diagnosed with kidney failure and came back to Qiushui to receive hemodialysis treatments. Shan’s husband also quit his job to take care of her, because Shan suffered from serious complications and couldn’t live by herself. Her son, who was 18 then, dropped out of school immediately and started working as a migrant worker to shoulder the financial responsibility of the family. In the past seven years, Shan and her husband had to rely on her son to pay Shan’s medical bills as well as their living expenditures. “I cried every time I received money from my son. I put too much pressure on him,” Shan once said to me. Shan’s son was 25 and remained single, which was absurd in rural areas where the marriage age was early. In Shan’s village, people called her “bottomless pits of trouble” (wu di dong) and no matchmaker ever introduced a girl to her son. Shan’s son also didn’t find a girlfriend in his workplace. Shan was extremely guilty that her son hadn’t finished school and blamed the difficulty of her son getting married on herself. Shan never considered kidney transplantation, refusing to add more burdens to her son. The financial cost of post-transplant medications was comparable to that of hemodialysis, while the possibilities of recurrent hospitalizations and relapse of kidney failure would further their trouble. Shan’s biggest wish was that her son would build a family of his own before her own death. Her family spent a large portion of their savings remodeling their house in 2019. A new house is an important cultural and economic symbol indicating that a family is ready to welcome a daughter-in-law. Bioethical principles of informed consents and patient autonomy have gained plenty of anthropological scrutiny.

In addition to worries over financial and caring burdens, many young patients regarded kidney transplantation as “useless.” The story of Jinwei, a patient in his mid-thirties, is one example. Growing up in a rural village of Qiushui, Jinwei went to Guangdong, a southern province at the age of 16 in 1998. Jinwei aspired to make a fortune and to snatch a good place in China’s emerging market economy. He started as a factory worker, but later became a gang member. Although his income was much higher, he ended up getting imprisoned for three years. After his release, he went back to working in a factory. Jinwei described the 1990s as a golden age of opportunity. Seeing some of his old friends getting rich, Jinwei was determined not to be left behind. He went to Beijing and invested his life savings into running a restaurant. The business failed a few years later, and Jinwei returned to work in a factory. This was where he met his wife, a fellow worker. In 2018, they got married and his wife became pregnant with twin boys. However, in the same year, Jinwei was diagnosed with chronic kidney disease (CKD). His CKD quickly progressed to the end stage and he started hemodialysis in early 2019. His boys were only three months old. Jinwei firmly refused to sign up for a kidney transplant waiting list. People with kidney transplants should still avoid heavy labor. That is to say, transplantation would not change the fact that Jinwei had lost his ability to work. Reflecting on the past 20 years, Jinwei demonstrated a strong sense of regret and failure, thus having no confidence to build a new life with a disabled body if he were to receive a kidney transplant. Jinwei didn’t bother to undertake the risks of a transplantation surgery, but would rather spend the surgery fees on raising his boys. He was immensely remorseful for his inability to provide his boys with an adequate life. Jinwei strictly practiced self-discipline in everyday life in order to maintain his body in a stable condition and to prolong his life, which extended beyond following medical advice to his moral endeavor to be a good father.

Bioethical principles of informed consents and patient autonomy have gained plenty of anthropological scrutiny. Scholars critique bioethics’ underlying liberalism and science-centric frameworks that overlook the complexity of local moral worlds and obscure structural inequalities (see for example, Kleinman 1995; Mol 2008; Pinto 2014; Rapp 2000). For Shan and Jinwei, their treatment choices are neither autonomous nor orient toward themselves. Instead, they gauge the overall well-being of their families and prioritize the benefits of the ones with relatively better life prospects—their children in both cases. Their seemingly intergenerational moral acts such as the sacrifice of Shan’s son, Shan’s motherly love, and Jinwei’s pursuit of good fathering have, however, obscured these poor patients’ predicaments caused by socioeconomic marginalization. For Shan and Jinwei, the chronic effects after transplantation—including the inability to work, long-term medication, and dependence on care—outweigh the benefits that transplantation can bring. Thus, they deem kidney transplantation worthless. Like Shan and Jinwei, most former migrant workers in the hemodialysis ward of the hospital in Qiushui regard kidney transplantation as being of little help to their life hardships, which challenges biomedical standards of medical efficacy. Instead of applying to individual biological bodies, medical efficacy is unevenly distributed to patients of different social statuses.

Xisai Song is a PhD candidate at Cornell University. Her study examines how lower-class patients struggle with chronic kidney disease in China. Her research interests include chronicity, medical ethics, health inequality, and the ways in which biomedicine is contextualized into non-Western contexts.

Cite as: Song, Xisai. 2020. “Clinical Decision Making in Rural China.” Anthropology News website, September 16, 2020. DOI: 10.14506/AN.1498

Glimpses into Care Work in Chinese Nursing Homes

June 6, 2020 by Shuang Lu Frost

Society for East Asian Anthropology
Zhe Yan
May 29, 2020

My conversation with care manager Zhang, the woman supervising the care workers among whom I conducted my fieldwork, came to a halt when she said, “Most care workers are here because they have no better options. They could easily be migrant workers shining shoes on the street today, and just as easily come to work in a nursing home tomorrow if they wanted!” Although she was being dramatic, her remark is representative of widely held perceptions of care workers in China. Despite such a demeaning portrayal of care workers as dirty and unskilled laborers, their daily practice of care reveals an agency which empowers their work.

Public policies for eldercare in China have been predicated on the premise that up to 90 percent of older adults will be cared for at home. However, this scenario is challenged when aging people become physically reliant and cognitively dysfunctional. Social attitudes toward institutionalized care are becoming more favorable as it increasingly becomes clear that adult children can no longer provide direct care for their parents. When constant supervision and intensive care are needed, they are increasingly being sought in nursing homes.

The front desk of a nursing home in China — Image description: The picture showcases the front desk of a nursing home in China. The lobby is spacious, clean, and sparse. There is a waiting area in one corner. A receptionist is working at the desk, which has a Chinese character Fu (happiness) decorated on it.
Caption: Care workers have to document their completed care tasks as part of the standardization requirement before finishing their shift, but emotional care is almost impossible to calculate. Zhe Yan

Because of the incongruence between the burgeoning care needs of an aging population and prejudicial attitudes toward care work itself, it becomes necessary to examine how care workers exercise agency in performing their tasks while coping with the social stigma surrounding them. To illustrate care workers’ agency in navigating the demands of care work, I have identified a set of techniques they developed to achieve caring goals and remain committed to the welfare of residents. In short, care workers exercise agency through encounters both with residents and with each other. These include identity work for self-empowerment, emotional labor to engage and detach, and boundary work to categorize residents and their relatives.

Care workers realize self-empowerment by presenting a caring and professional self in order to counterbalance stigmatized portrayals of care work. Most care workers are either rural to urban migrant workers or urban workers who were laid off in the restructuring of state-owned enterprises. In both cases, during the years that China’s economy was rapidly being reformed, there was a lack of reemployment mechanisms to reintegrate these workers into the formal economy. Consequently, many entered the care sector, in which the level of skill necessary for employment was relatively low.

However, by narrating the meticulous and attentive care they deliver to elderly residents, and in contrast to the availability of immediate family members for direct caregiving, care workers are increasingly constructing a moral standing as fictive kin. But as articulated by care worker Lin, having an empathetic relationship with clients is not enough to provide good care: “Compassion alone is inadequate. Not many residents are happy to live here, but they have no other option. We need to understand their psychological state and provide needed comfort for both the elderly and their families so that they can slowly adjust to institutionalized care. It’s not as easy as you think!” Lin’s closing comment reveals the need for professionalism as well as the capacity for empathy in caring for a vulnerable aging population.

To improve the professionalization of care work, national policies encourage the skill advancement of care workers through training programs. Zuo, a certified care worker, said that she is upset to still be called ayi (auntie, a kinship term also used to refer to domestic helpers). She carefully maintains a distinctive boundary between a common helper in a family home and a certified care worker in a care facility. “It feels different when people address me by my professional title, huliyuan (care worker). It’s like we are being formally recognized as professionals, and not everyone can be a qualified and effective care worker!” Care workers’ professional identity and commitment to care processes help them to mitigate low status and navigate the monotony of the many unpleasant and mundane tasks of care work. Exercising autonomy through detachment shields care workers from escalating emotional tensions.

In addition to identity work for self-empowerment, care workers calibrate their emotional labor. While care workers must observe mandates of care, ethics, and moral guidelines in ensuring basic needs are met, they remain autonomous in emotional attachment. For example, care workers are more willing to work with residents who show gratitude and respect for their work. The rewarding aspects of care promote the formation of relationships and allow care workers to find meaning in their work (see Stacey 2005). Care workers also detach emotionally from care delivery when residents only consider them to be servants. Exercising autonomy through detachment shields care workers from escalating emotional tensions. Migrant care worker Xu explains, “I do what I can to help them with feeding, bathing, and toileting; all the basics. But if the relatives or the elderly residents are mean to me, I won’t spend extra time on them. If they don’t respect me and my work, why should I care?” In the daily practice of care, cultivating authentic emotions with residents can be challenging due to heavy workloads and chronic understaffing. Care is routinized and standardized, often dictating that care workers care for instead of care about their elderly clients. In this pressurized environment, care workers’ use of emotions individualizes routine care for elderly residents. By calibrating their emotional attachment in their caring processes, care workers are able to both maintain the energy needed to provide quality care and harness those energies to balance the competing interest of residents, their relatives, and the nursing home.

Emotional labor can also promote processes beyond the simple dyad of care worker and care recipient. It creates the space for care workers to reflect on their own impending need for eldercare and to renew their determination to remain in the eldercare sector. “Their today is our tomorrow!” is a saying reiterated many times by care workers as they think of what awaits them in old age. There is widespread concern about both the mushrooming cost of care and the ability of their own family to later provide care for them, as many care workers belong to the one-child generation. Catalyzed by these concerns, care workers can be more accepting and tolerant of the demanding aspects of care work because they hope that their current commitment to care will be rewarded in part by others caring for them in the future.

Photo of the interior of Chinese care facility — Image description: This room is the social space in a Chinese nursing home, including long tables and chairs. Some elderly residents are watching a Chinese period TV show on the projected screen. Some are sitting across from each other, chatting. Three care workers in blue suits are helping the elderly residents.
Caption: Care workers prepare the elderly residents for supper before dusk. Zhe Yan

Care workers also sometimes categorize residents and their relatives as possessing high or low suzhi (quality) (Yan 2003, Kipnis 2006). Care workers use this term to illustrate the degree of respect received from their clients. Through the boundary work of categorization, care workers create a buffer to counterbalance negative encounters with some residents who are demanding and unreasonable. This phenomenon is also reinforced by nursing homes’ organization of care work, which rotationally assigns residents and working shifts to care workers so that they interact with a large pool of residents over time. Care workers’ strategy to distinguish between high and low suzhi groups helps to ameliorate the impact of unpleasant individual encounters. With the construction of this agency, care workers regulate the environment for the performance of ongoing quality care.

Care workers apply a similar strategy to deal with residents’ relatives. Care workers consider some relatives’ visits to be sporadic and not very interactive, and so the emotional needs of their elderly residents are left unmet. In one extreme case, care worker Wang disdained the utilitarian intention of some relatives’ visits, claiming that they came only to reach the required number of visits to earn them a discount for care expenses from the nursing home. Combined with the disrespect they sometimes receive from relatives, care workers categorize some of these families as being of “low quality” and insulate themselves from unpleasant encounters without blaming themselves, the elderly, or the institution. Exercising agency through categorization is a viable strategy for care workers in some situations, but it also can mask deeper structural problems that need to be addressed. These include an absence of codes of conduct for families, codes of behavior for residents, and formal mechanisms for care workers to voice their concerns to management.

The many and sometimes competing demands of care work make it necessary for care workers to actively exercise agency to achieve caring goals and to guarantee care quality. The three modes of agency developed by care workers and identified in this essay—cultivating self-empowerment, calibrating emotional labor, and categorizing clients and relatives based on suzhi—sustain care workers’ agency in the performance of the full range of tasks required by the elderly in long-term care.

Zhe Yan is a doctoral candidate at University of Würzburg. His research delves into the experiences and social organization of care work in China, focusing on long-term care residential facilities. His research interests include aging and eldercare, and how processes of aging and care are shaped by socio-political conditions.

Cite as: Yan, Zhe. 2020. “Glimpses into Care Work in Chinese Nursing Homes.” Anthropology News website, May 29, 2020. DOI: 10.1111/AN.1409