Turning a Blind Eye: Perceptions of Mental Health and Disability in China

Rampant growth has done much to change the quality of life in China. Cities and trade zones have emerged as economic hubs, leaving rural areas in the dust. Modernization has brought great wealth, but by no means universally. Inequality defines many aspects of daily life, and the mental and physical health of the Chinese people is no exception. Chinas citizens face daunting social, financial, and familial pressures, and the stresses of everyday life have not been alleviated by Chinas widespread poverty, overcrowded cities, and the often catastrophic political experiments of the last hundred years.

    A cursory understanding of life in China may make it less surprising then that mental illness is common and disabilities remain prevalent, but the scale of these problems is startling. The Classification of Mental Disorders, published by the Chinese Society of Psychiatry, is the clinical guide used in China to diagnose mental illness. It very closely resembles the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, including a range of illnesses from anxiety to depression but also adding some culturally unique diagnoses.

    By these standards, an estimated “173 million adults have mental health disorders” (1). Of these 173 million, 4.3  million are registered as having severe mental health problems and 55 percent live in poverty (2). These problems must be considered in light of the inequalities between the rich and poor and between those living in urban and rural areas. The suicide rate in rural China is 3 to 4 times higher than in urban areas (3). This disturbing reality demonstrates the divide between those that have access to mental healthcare and can afford it and those that cannot.

    Additionally, more than 60 million people in China have disabilities (4). The scope of these problems has increased in recent years not only in size but in proportion to the population (5). They persist not only as a result of political apathy, but because of deeply ingrained cultural perceptions that render them far more formidable than many of Chinas other problems

Cultural Perceptions

    The Chinese language provides an interesting and valuable lens for viewing the issues of mental health and disability. By considering what terms have been used historically to describe those suffering from various conditions, it is possible to track the evolution of how they are perceived by society. In the past, terms such as 残废 (canfei - crippled and useless), 哑巴 (yaba - mute), 傻子 (shazi - idiot) and 瞎子 (xiazi - a derogatory term for blind people) have been used to refer to those with disabilities. The generally accepted term today is 残疾 (canji - a deficient/deformed person). That advocacy exists on such a nuanced issue is evidence of progress in and of itself, but without institutional reforms, these social changes do little to improve the quality of life of those with disabilities.

The Blind in China

    But it would be unfair not to mention that modernization has brought some positive changes to the lives of people with disabilities. China shows occasional signs of sensitivity, particularly in cities where the government’s reforms are most visible. Shanghais pedestrian sidewalks demonstrate this awareness, where narrow pathways with elevated grooves serve as a walking map for the blind, who use their feet to feel their way through the city. The pathways are pointed in the direction of the walkway and become horizontal at curbs and intersections. Such accommodations, however, do little to make up for Chinas deficiencies in serving the needs of people with disabilities elsewhere, particularly in rural areas.

    The blind population provides an especially interesting group for consideration. According to the World Health Organization (WHO), China has about 5 million blind people, restricting this number to those who are immobile without some form of aid (6). More generally, at least 12 million Chinese people are visually impaired(7). About half of those 5 million blind people are afflicted with cataracts - a condition that can be easily managed through regular eyecare, or eliminated through a very common and effective surgery (8). Since 1949, China has addressed its lack of eyecare, then reneged during the Cultural Revolution in the 1960s before engaging with this problem once again in the 1980s (6).

    Not because they are incapable, but because they are rarely given the resources to do anything else, many blind people in China follow the same trajectory: they become massage therapists. Blind massages, advertised as such, are very common and fairly inexpensive. They are estimated to number around 100,000. In 2013 alone, 20,111 blind health masseurs and 5,694 blind medical masseurs were trained (9). The common adage that those lacking one sense make up for it with another explains the popularity of blind massages. As a result of their disability and enhanced tactile understanding, blind therapists are uniquely equipped for this work. That blind massages are so common reflects a desire to practically apply what skills people with disabilities have, but it simultaneously ignores what other skills may exist, limiting them to the few professions traditionally available to them.

Education for People with Disabilities

    Chinas failure to accommodate the needs of people with disabilities can be best observed in its educational system. When getting a college education, and later a job, salary, and spouse, hinges on ones performance on the 高考 (gaokao - the infamous Chinese university admissions test, similar to the SAT), blind students have faced a significant and all-too-often insurmountable obstacle. Without access to education that is tailored to their needs, whether that means accommodations as simple as electronic textbooks or in other cases specially trained teachers, those with disabilities and the mentally ill either become outcasts or are forced to pick up the trades of massage therapy and street performing.

    China ignores the sick and people with disabilities to its own detriment. WHO estimated that in the United States, if all the avoidable blindness in persons under 20 and working-age adults were prevented, a potential savings of US$1.0 billion per year would accrue to the federal budget(10). Considering the direct and indirect costs and staggering rates of avoidable blindness, addressing the problem would alleviate a significant financial burden - which may be the most persuasive inducement for the Chinese government.

    It is important to note that Chinese society presents unique difficulties for the blind. The nature of Mandarin Chinese, the dialect spoken by over one billion people (11), makes communication difficult. It is a tonal language. To understand the implications of this, consider that a word spelled the same way in pinyin may have up to four different meanings depending on how it is pronounced. The Chinese vocabularys many homophones only complicate things further for someone who cannot use character or context to elucidate wordsmeanings.

    Braille is the most common tactile writing system used by the blind. Braille, however, makes use of an alphabet, and so Chinese characters are not naturally suited for braille transcription. With the advent of pinyin in the late 1950s (the system used to transform Chinese characters into words using the Roman alphabet), braille has become more applicable, but the unique challenges of translating Chinese remain.

    In 2014, the Ministry of Education made significant progress in this field by offering the gaokao in electronic and braille forms. While there were no laws in the past that explicitly barred the blind and people with other disabilities from higher education, health exams and a general stigma among administrators almost always prevented them from being admitted (12). The administration of the gaokao in more accessible formats has been hailed as an important step, but by no means the last, in attaining educational equality.

    Much of what the Ministry of Education has guaranteed in the past went unenforced and lacked the weight of genuine policy, but recent announcements seem to suggest real progress. Along with offering the gaokao in 2014, the ministry also announced plans to ensure that at least 90 percent of children with visual, hearing, and intellectual disabilities receive primary- and middle-school education by the end of 2016. The plan calls for more investment in infrastructure, teacher training, and curriculum reform(13). Should these reforms be carried out efficiently and universally, those with disabilities, particularly the blind, may soon see a world of opportunity beyond that of the massage parlor

A Brief History of Mental Health in Modern China

    Beyond the physically disabled, China faces a serious mental health issue that continues to grow in proportion to its population, reflecting Beijings failure to address the problem (14). It stems from a range of factors, notably the stresses of modern society, the weight of Confucian principles on the individual, and the gross inequalities that make ones studies, work, and home life a constant source of pressure. Such problems persist in part because China lacks the resources needed to address them. As of 2012, a commentary in the The Lancet points out, [China] has only about 20,000 psychiatrists, just 4,000 of whom are adequately trained and qualified(15). In proportion to the population, this represents about one-tenth the number of psychiatrists in other developed countries (16). For comparison, the United States, with a population less than a quarter the size of Chinas, has over 25,000 psychiatrists (17). While not necessarily an indicator of general mental welfare, this discrepancy is provocative, and the greater presence of psychiatrists suggests a more developed mental healthcare system.

    Training professionals, building facilities, and offering more comprehensive insurance that can properly treat the sick are important but insufficient steps toward treating mental illness. Even where adequate healthcare is currently available, such a negative perception of psychiatric care exists that people are afraid to seek treatment or therapy. When these perceptions are considered in light of Chinas altogether lack of psychiatric professionals, it seems one suffering from depression, schizophrenia, or one of many other possible ailments has nowhere to turn. To properly address issues of mental health and disability in China, certain stigmas must be shed. Additionally, an effort by Western nations to recognize more sincerely the virtues of traditional Chinese medicine would be a welcome supplement to Chinas modernization efforts. Such a combination can prove invaluable, as demonstrated by Tu Youyous 2015 Nobel Prize in Medicine (Chinas first in a scientific field) for her discovery of Artemisinin, a malaria-fighting compound that was discovered only after a study of ancient Chinese texts(18). While the Nobel Committee plainly states it was not honoring traditional Chinese medicine, it is hard to ignore the role it played in Dr. Tu’s discovery.

Current Status of Mental Health

    These problems are by no means new, and fortunately, activists are beginning to see the light. In 2013, Chinas first mental health law took effect (19) after 27 years of debate. If its objectives are carried out, the law has the potential to erode the stigma against mental healthcare, while providing  necessary privacy and protections for those that seek it. While the law bears unique marks of Chinese culture, it provides a framework for more resources and greater accessibility. For instance, mental healthcare has traditionally been sought out by family members of the patient, but this law requires voluntary admission except in specific cases, such as when an individual poses a danger to himself or society. Exceptions to voluntary admission become alarming, however, when one considers the specifics of the law.

    For example, part of the stigma against mental healthcare stems from the government’s record of using it for political gains, often holding dissidents under the pretense that they posed a threat to the security of the state.  At times, the 2013 law conjures up hints of this vile history. For example, the duration of involuntary admission in China is not specified and there are no set intervals for reevaluation(19). In other words, a patient admitted to a facility involuntarily may be held indefinitely without necessarily being reevaluated. But as the American Journal of Psychiatry notes, it will probably take several years of trial and error before the intent of the law is fully realized(19).

    Two years later, the government seems to be following through in implementing these reforms. In June of 2015, China released its National Mental Health Working Plan (20152020), which sets more specific goals that help clarify the 2013 law. It seeks to double the number of registered psychiatrists, provide financial support to those that need it, and address the prevalence of severe mental illnesses such as schizophrenia (1). Other key targets such as autism, depression, and control of the high suicide rate are identified. These are refreshingly specific goals. Unfortunately, they do not make up for what the Plan lacks. No explicit budget has been allocated for the plan,The Lancet explains, and suicide prevention as well as strategies to tackle stigma and discrimination against people with mental illnessgo unmentioned (1).

Threats to Recent Progress

    All changes in China must be considered in the context of how they affect the Partys monopoly on power. A significant threat to Chinas recent momentum comes in the form of a proposed law that regulates foreign NGOs hoping to be recognized by the Chinese government. Under the proposed law, officials proclaim that more NGOs will be registered and could open bank accounts. The unambiguous intention of the legislation, however, is to further restrict the operations of NGOs in China. It bans foreign funding, and requires that all organizations find an official sponsor - one already recognized by the Chinese government. Additionally, all organizations will be forced to register with the Public Security Bureau, as if somehow all foreign-backed NGOs threaten state security (20).

    Another lens for analyzing the problems of modern China is an ancient one, that of its founding philosophy: Confucianism. Confucianism emphasizes duty, social status, and ones ability to support their family. These responsibilities can be seen as constant stresses for the unemployed and neglected. Failure to fulfill ones obligations to family and society may create serious psychological burdens for the individual, pushing them toward the fringes of Chinese life. But Confucianisms emphasis on providing for ones family can be interpreted alternatively: as an incentive to take care of these hitherto ostracized members of society. The often ignored virtues of a family-oriented approach to caring for the mentally ill and those with disabilities can yield valuable results. General welfare is progressing for many in China, and now more than any time in modern Chinese history, people have the opportunity to focus on personal well-being, happiness, and quality of life instead of mere survival

China’s Potential Future

    Chinas one-party system is a double-edged sword, helping to deliver unprecedented growth and increasing the welfare of many, but at a significant cost. As China continues to develop, it must be wary of the economic and social costs of limiting the potential of people that bear unique skills and the ability to be productive. Balancing Party control, Confucian ideology, and modernization is no simple task, and while increasing the amount of money and resources being put towards these issues is necessary, it is insufficient. Chinas problems will persist, if not worsen, until it eliminates the lingering prejudices and stigmas against seeking treatment for mental illness.

    Recently, the China Disabled Person's Federation, an NGO that would fall under the newly proposed law, has advocated using 残障 (canzhang) to refer to people with disabilities. 残障 (canzhang) means handicapped or obstructed, a term which reflects how people with disabilities and mental illnesses ought to be perceived. Obstructed represents the profound notion these people are not incapable of work and success, but that the way society is organized creates obstacles for them, and with reasonable accommodations, they are as well-suited as anyone else to be productive, engaged members of society (4). It remains to be seen how these stigmas and Party control will be affected by the force of changing perceptions and new policies. However, their resilience or eventual erosion in the face of increasing sensitivity and modernization will determine the plight of millions.

Citations:

 

  1. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61146-1/fulltext?rss=yes

  2. http://news.xinhuanet.com/english/2015-06/18/c_134338552.htm

  3. http://www.who.int/mental_health/resources/suicide_prevention_asia.pdf

  4. http://www.bbc.co.uk/ouch/features/one-eye-on-china-challenging.shtml

  5. http://www.cdpf.org.cn/english/events1views/200804/t20080413_267433.html

  6. http://www.who.int/mediacentre/factsheets/fs230/en/

  7. http://usa.chinadaily.com.cn/china/2015-08/03/content_21491079.htm

  8. https://nei.nih.gov/health/cataract/cataract_facts

  9. http://www.cdpf.org.cn/english/statistics/201404/t20140421_267458.html

  10. http://www.who.int/mediacentre/factsheets/fs230/en/

  11. http://www.bloomberg.com/bw/articles/2014-09-23/say-that-in-mandarin-please

  12. http://blogs.wsj.com/chinarealtime/2014/04/17/the-gaokao-now-available-in-braille/

  13. http://www.nytimes.com/2014/05/19/world/asia/in-chinese-schools-disabled-get-shortchanged.html?_r=0

  14. http://www.theatlantic.com/china/archive/2013/07/unable-to-cope-chinas-inadequate-care-of-the-mentally-ill/278170/

  15. http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60893-3.pdf

  16. http://www.economist.com/node/9657086

  17. http://www.bls.gov/oes/current/oes291066.htm

  18. http://www.nytimes.com/2015/10/11/world/asia/nobel-renews-debate-on-chinese-medicine.html

  19. http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2013.12121559

  20. http://www.economist.com/news/china/21661819-new-draft-law-spooks-foreign-not-profit-groups-working-china-uncivil-society

 

The opinions expressed in this article are the author's own, and do not represent the views of the Review at NYU, aside from its belief that the free exchange of ideas is crucial to university discourse.