Arthur Kleinman on Mental Health and Caregiving in China | HCFocus

Harvard China Focus interview with Professor Kleinman

Dr. Arthur Kleinman is the Esther and Sidney Rabb Professor in the Anthropology Department in the Faculty of Arts and Sciences, a Professor of Medical Anthropology in the Department of Global Health and Social Medicine at Harvard Medical School, and the Victor and William Fung Director of Harvard University’s Asia Center. Dr. Kleinman is a pioneering figure in medical anthropology and the author of numerous influential works. Trained as a psychiatrist, Dr. Kleinman has devoted his life to understanding illness experience, mental health and stigma, and forms of care and caregiving globally with a special focus on China.

Harvard China Focus: Thank you for participating in our Harvard China Focus Interview. To begin with, could you please briefly introduce yourself and your work in medical anthropology?

Professor Kleinman: My name is Arthur Kleinman, and I’m an anthropologist and a psychiatrist. I have been working in these fields for over half a century, and it’s had the following consequences. I helped introduce the modern idea of depression into China, based on research that I did in 1978, 1980, 1981, and 1983 in Changsha, Hunan. It showed that an old diagnosis being used in China at that time called neurasthenia could be re-diagnosed and more effectively treated as depression. That led me to have a close relationship with Chinese academic psychiatry. I was fortunate enough to be able to train some of China’s leading academic psychiatric researchers over many years, funded by different foundations, including the National Institutes of Health. The same with my work with anthropologists in China medical anthropology — I’ve trained China’s leading medical anthropologist Professor Jing Jun of Tsinghua University, for example, and many medical anthropology professors in universities such as Peking University and Fudan University.

Deep China, by Arthur Kleinman

In the anthropological space, I have been interested in a number of issues. One is, how do you describe caregiving in the context of the healthcare system in China? The usual way of thinking about this is to list the names of hospitals, clinics, and pharmacies. But I showed, starting in Taiwan in the 1960s and then going on to China in the late 1970s, that many other aspects of care were not put into the public health model that needed to be. This includes families, because most care turns out is given in families, but also in the traditional Chinese medical system and even in the folk healing system of religious healers or herbalists. There was this panorama of different kinds of practitioners and I showed that you had to rethink what a healthcare system was. After that, I got very interested in the changes that were happening to individuals in China, and with my former students — now all professors in China mainland or Hong Kong — I worked on a book called Deep China, which is also available in Chinese. We looked at how people were people were changing as China was modernizing and globalizing.

Your generation is considerably different than your parents. Part of that change is a deepening of the sense of the individual and a different way of looking at individuals. Some of it is very good, and it shows a concern for the environment and a concern for society. Some of it is not so good, like the thinking of being selfish. Your parents’ generation is not sure they can trust you, your generation, to provide elder care in the way they did for your grandparents. So I’ve been studying that, and right now have a project called social technology for elder care in Nanjing. This project uses technologies for elder care, along with social systems to help people.

Harvard China Focus: Speaking of the eldercare system, a lot of parents born during the 1970s now have the pressure of taking care of four to six elderly people. One trend that we’ve noticed recently in China is that some elderly people tend to seek nursing homes for themselves. However, there aren’t a lot of choices available. What do you think the role of government should be in this situation?

Professor Kleinman: Very good question. First of all, for those who are well to do, or upper middle class, China has built some superb assisted living and nursing home facilities. I’ve seen these in Shanghai, Beijing, and other cities. What’s surprising about them is that they’re not all filled, so they may be 40–50% filled. Even amongst rich families there is a hesitancy for the family to let the elder person go to assisted living or nursing home, because of this is kind of stigma. It goes against filial piety, that you’re not supposed to. But actually, I found some interesting things in China. One is that a lot of the elderly I‘ve spoken to would actually like to go to some of these homes and be with people from their own generation. They often feel more comfortable, as opposed to being at homes in a city where both husband and wife work but no one’s there during the day. The grandchild is out at school, and the husband works and the mother works.

Photo by Chinese Economic Forum

That’s just about rich people. There are facilities available that are really nice, in fact nicer than we have in the United States. But they’re not using them because of the feeling amongst the younger generation of caregivers, the adults caring for their parents, that this is not the way it’s supposed to be.

Now if you ask the elderly themselves, they frequently want to go into these facilities. They’re more comfortable with people from their own age category, who went through the same things in life they went through. They know how to talk with them. They’re not so comfortable with your generation, with completely different terms of music, ideas — they feel uncomfortable sometimes. So I’d say this is one problem.

The second problem is that once you get away from the wealthy to those who are not so well to do, there are some good models, but not that many. One of the problems in elder care in institutional settings is that the people who do most of the care regrettably are people whose education is quite low. Their education, their formation, is not as high as the people they’re engaging, so often the elderly feel uncomfortable. They even get angry at caretakers who they feel are not able to take care of them properly. So, one of the issues in China is raising the status and the education of the caretakers, and that also applies to nurses. I think if I were in China today, I would invest in nursing, and try to raise the level of nursing.

Medical workers providing health check for Chinese Elders, by China Daily

There is a second kind of person needed in China today. China today is putting money into healthcare, but you have a complex system. Maybe not as bad as our system, but still very complex. You need social workers, so social work surely goes up. They know how to navigate the system. They know the alternatives. They know the resources available, so I think that again, China investing in and having more social workers is very important. So raising the level of nurses, building a greater social worker community and then I think finding which models of eldercare are the best institutional models.

If you look at most elder care facilities, they look like hospitals. But why do they need to look like hospitals? Why can’t they look more like community apartments or hotels? They don’t have to have the hospital model. I think that needs to change. Having said all that, I think China has got itself into a tremendous problem. In 2050, 30% of your society will be over 65 years of age. At that stage, you’re going to have about two or less than two workers for every retiree, to support every retiree. Now, it is about 5 workers for each retiree. That’s the longterm effect of the one-child policy. So at that stage, China is going to have to have lots of changes. One is going to have to be changing the retirement age. If people are living into their 80s and 90s, you can’t have women retire at 55 years of age, or men retire at 64. A woman retires at 55 and lives still 85, she’s going to spend 30 years without any work. I think that’s not good for her and not good for society. The retirement system has to be rethought and changed. We also all know that as wealthy as China is today, it still is underfunding its social welfare system. So support for those pensions, and those that support Chinese workers is very, very important in the future.

The Soul of Care, by Arthur Kleinman

But I’m most interested in the quality of care and quality of care. My new book, The Soul of Care, is about the fact that in China and the US and around the world, the quality of caregiving is declining. The human quality of caregiving is getting worse. Now, why is that? That’s because technologies that should improve care have actually been used in ways that don’t improve care but make it more difficult. A good example of that is the electronic medical record, in which doctors and nurses spend all their time in front of a computer, looking at the record. That’s not so good because you want the doctor to be talking to the patient and the nurse to be talking to the patient, not just looking at the electronic medical record. The other thing is that increasingly, doctors don’t trust their physical exam skills, their auscultation with a stethoscope, their percussion with their hands off, they’re feeling for your liver or kidneys, etc. They have much better technologies that can pinpoint these problems, but by not doing the physical exam, they lose their physical contact with a patient which has always been critical. Putting on your hands, indicating to the patient that you’re with them, and that you’re there to help them, has huge effects on people’s hope and their sense of that someone’s there to help. So here’s another example of where technology is getting in the way.

This is our problem for the future, of how to rebuild a human system of care. And you have a further problem in China, in that you have more distrust of doctors than we have in America. This is a problem that needs to be solved. I recognize this is basically an ethical problem. You can’t have patients coming to see the doctor who believes the doctor is only interested in making money and not giving them good help. In the same way, you can’t have doctors who feel the patient is going to sue them or attack them. I think this is going to require all kinds of new ways of thinking about things there. China will build in the future, I’m sure, a good legal medicine system, a medical jurisprudence, where if you are a dissatisfied patient, you don’t hit the doctor — you can sue the doctor with a lawyer, and you can have an ombudsman who speaks for you with the medical community. So I think that improving the doctor patient relationship is really important. This means we’re working with the public, and also working with doctors. And it means training doctors differently with an emphasis on caregiving.

I’m very optimistic for China. Why? Because actually, if you look over at the traditional Chinese medicine, they do a pretty good job of this, or at least a better job than biomedicine is doing in terms of the quality of the patient-doctor relationship. So you need to have that transferred into biomedicine. I think that this is a big tension today in terms of ethics. If you think about it, China has the right ethical system to deal with this because China has both high principles for care, like beneficence doing good as we do in America. But China has something else in its historical, ethical system. In the Confucian tradition, for example, it has the idea of the cultivation of the person cultivating a person’s moral values. That’s what has to happen in medicine, cultivating the moral values of doctors, I think. I’m sure that this will happen in China. Have the years go by, and bigger changes will occur.

Photo / U.S. — China Health Summit

Harvard China Focus: Do you have any specific messages about family care you would like to convey to the audience?

Professor Kleinman:I think the family caregiver is tremendously important. I took care of my wife with her early onset Alzheimer’s for 10 years, and what helped me greatly was a home health aide. This is like a care worker, who works in the family, and I had a wonderful person who helped me with this. So this is a problem for China because they have traditionally used for home health aides, mostly housemaids. But now today, there aren’t enough housemaids because who wants to be one? China will need to figure out how to replace the bottom. Are we going to invite people from Southeast Asia to China to play this role? Or are we going to increase the financial support for housemaids so more people would like to do that? That will all be part of the policies in China’s future. The centerpiece of domestic policy in China is going to be dealing with aging. And you know what? It’s going to be the centerpiece of American policy, and the centerpiece of Japanese policy, and the second centerpiece of European policy. This means we’ve never taken aging seriously, but we’re going to take it seriously. Right now. This is going to come. This is a huge issue for all of us.

Harvard China Focus: We’ve noticed recently that other countries like France and Brazil are going through pension reform. By delaying retirement years, a huge amount of government spending is reduced. In France, for example, people oppose, while in Switzerland, people appreciate the pension model. What is your take on these different systems?

Professor Kleinman: First of all, China and the United States are too big as societies so they can’t follow the Switzerland model. Switzerland is tiny, it’s too small. So we have to have bigger models. I would say that Germany is a good model, Holland is a good model, and Japan is a good model for China. But Japan is going to have trouble now, because in Japan by 2050, 40% of the society will be over 65 years of age. They’re going to have trouble keeping the current system going, but right now it’s wonderful. If you’re in Japan right now and you’re an ordinary person, if you need a home health aide to help with the elderly, the government will provide. That’s free as part of the national system. But in 2050, I don’t think Japan can afford that. I don’t know what’s ahead for them. China and the US share the same problem, hence the solution in the United States is a win in China. A win in China is a win in the United States. We should all be learning from each other. This is one area that we can learn from each other because we’re facing the same problem.

Photo / Karen L. Ding, Harvard Crimson

Harvard China Focus: Alzheimer’s is a problem in countries around the world. There’s an ongoing project by Biogen that says there are making a cure for Alzheimer’s — what are your thoughts about this?

Professor Kleinman:I don’t know about Biogen or what they’re doing, but I can tell you right now, this is not a good area. Regarding Alzheimer’s, we don’t know the cause. We’re even unsure of whether it’s one disease or multiple diseases. We have no treatment. So, therefore, everything is caregiving. It’s not the discovery of new drugs, though hopefully, that’ll happen sometime. But that’s going to be years off because we don’t even have the slightest idea about what the causes are, and every idea we’ve had has proved to be wrong. We’re not going to be easily able to rationally plan new drugs — we’re going to have to face the fact that for Alzheimer’s, the biggest problem is caregiving.

This is not just true of Alzheimer’s. You should remember dementia is not equal to Alzheimer’s. Alzheimer’s is only one cause of dementia. In China, you have dementia associated with high blood pressure, so multi infarct dementia is also very common. You also have various kinds of frontal-temporal dementia as we do in the US. Dementia is a mixed bag. It’s not just one disease, but this is going to be extraordinarily important for the future. I personally don’t like the claims that are made by drug companies that they have a substance to cure Alzheimer’s. There’s no evidence of that today.

Harvard China Focus: Do you think it’s a good time for us to reconsider how the elderly should be perceived in society? They’re often more energetic than the social stereotype would think.

Professor Kleinman:Absolutely. I’m with you entirely. Look at me — I’m seventy-eight years old. I don’t regard myself as elderly. I regard myself as active. I’ve got a lot of things I’m doing, I’m traveling all over doing things. Teaching, doing research. I think the whole idea of the elderly is changing. What is the elderly? What does it actually mean? The identity should be much more positive.

Now in our society in America, unlike China, we have some problems with the way that young people look at the elderly. In China, young people may fail the elderly in the future, in terms of caregiving, but by and large, you still look at the elderly in positive terms. In America, we’ve always been a youth society. And here, youth do not look kindly on the elderly. They see the elderly as no longer relevant. And I think that’s going to have to change because in my society, the elderly have the money. And on your side, they may not because they lived through poor times in China. In my society, the elderly, they have the money. And so they’re going to change things.

Harvard China Focus: Back to your studies on depression and living environment, could you share some of your findings, particularly in the Chinese context?

Professor Kleinman: Most of my research in China has looked at the social causes of depression. What I’ve shown is that people usually get depressed because of a reason. It’s not just a biological change. Something happens when you break up with a boyfriend. You get depressed. You lose your job, you get depressed. You are a farmer and you have a failure with your crop, or you get sick and you spend all your money on hospitals, you get depressed. To change depression, you can sometimes change it with medication. Often you can change it with psychotherapy, but by and large, elderly people and rural people are not accustomed to psychotherapy, young people are. So what other kinds of things help? Well, China starts with some good ideas. You see the elderly getting together and dancing, or doing actual exercises, or playing mahjong together. I think that that identity is that you’re maybe old physically, but your mind is still okay. Even if your mind is not okay, you want to live a good life.

That’s the question we should be asking — how can we help the elderly live a good life? Part of this is making sure that they have financial security. Part of it is making sure that they have friends and family, they’re not isolated. Part of this is making sure they have a good healthcare system and that they get good healthcare. But part of this is thinking of being elderly as a time of wisdom and a time of being able to bring more purpose and meaning to your life, to cultivate that sort of thing. I think that’s very important. And again, I think this is going to happen. It’s just going to take decades to happen. So we can’t see far enough in advance to know how it would be, but it will happen.

Photo / Harvard China Focus

Harvard China Focus: Biologically, if you feel uncertain or insecure, can that trigger your defense system into depression?

Professor Kleinman:There are some forms of depression that run in families and probably have a biological basis. But we don’t know the biology of depression. Some psychiatrists will claim they know the biology of depression, but they don’t. We don’t know what the biology of depression is. All the theories we have have been proved wrong. The serotonin hypothesis was wrong, the epinephrine hypothesis, wrong. Cortisol hypothesis, wrong. We have no understanding of the biology of any mental illness — not just depression, but anxiety, schizophrenia, and bipolar disease. If you want to see this, a very good book is by Anne Harrington here at Harvard called Mind Fixers. The beginning of that book is a devastating account of the failure of biology in psychiatry. Nonetheless, I’m telling you, that even though we don’t understand the biology, we know that some forms of depression run in families and that they probably have a genetic contribution. We just don’t know what the genetic contribution is. There are people who are more vulnerable to depression. And so you and I might go through the same experience. We lose our job, you get depressed? I don’t. Part of that has to do maybe with your greater vulnerability to depression. But what I’m trying to say is that in the treatment given to you, the treatment takes away your symptoms, but it doesn’t take away the underlying cause of your depression. You get a new job or you have a good relationship, then your life will do better.

Harvard China Focus: So what’s the missing piece between the social cause and depression?

Professor Kleinman:I think the missing piece is that we don’t understand yet how the social becomes the biological. We know what happens. We don’t understand how it happens. And we understand this, that psychotherapy is as effective as medication and more human than medication. So for your generation, many people are turning to psychotherapy for trauma, but your parents’ generation was not socialized like that. That’s not the language they use. So they’re not going to do well in that kind of setting. For them, drugs and other kinds of somatic treatments are more appropriate.

Dr. Arthur Kleinman is the Esther and Sidney Rabb Professor in the Anthropology Department in the Faculty of Arts and Sciences, a Professor of Medical Anthropology in the Department of Global Health and Social Medicine at Harvard Medical School, and the Victor and William Fung Director of Harvard University’s Asia Center. Dr. Kleinman is a pioneering figure in medical anthropology and the author of numerous influential works. Trained as a psychiatrist, Dr. Kleinman has devoted his life to understanding illness experience, mental health and stigma, and forms of care and caregiving globally with a special focus on China.

Interviewer | Lucy He

Editor | Olivia Fu

Typography | Olivia Fu

Founded in 1997, Harvard College China Forum is North America’s leading and longest-running student-run conference on China.