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Minding China's Elders

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“With passive urbanization, people are not choosing to move to the city, but the city is moving to them.”

THE WORLD’S MOST POPULOUS NATION IS GETTING OLD, and fast. In 2000, one in seven people living in China was older than 60; by mid-century, the World Health Organization projects that nearly one in three will be. This trend is occurring against the backdrop of equally dramatic urbanization. In 1978, only 18 percent of China’s population lived in urban areas; by 2020, roughly 60 percent of the population will be urbanized.

Di Liang with her mother and grandmother in Dujiangyan, near their home in Chengdu.

Di Liang, a Fielding School Department of Health Policy and Management PhD candidate from China, is concerned about how this seismic demographic shift will affect the health and well-being of Chinese elders. Will expanded opportunities associated with urbanization translate to better mental and physical health outcomes for the older population? Or will any economic benefits be offset by lower levels of family support?

It’s a concern rooted in the experience of Liang’s own family. She grew up in Chengdu, the capital of Sichuan Province in southwest China. “The place where my parents live was rural 10-15 years ago, and now there is no farmland left,” Liang says. “The lives of the people in the community have changed so much, and yet the effects have not been well studied.”

Liang notes that urbanization has major implications on the way older people live. That is especially relevant in China, where elders residing with their adult children and other family members is common, and where rural elders have relied on their family, rather than the government, for financial and social support. “The question is how this urbanization will influence elders’ family support, mental well-being, and health care,” Liang says.

Researchers interested in examining the impact of urbanization on the lives of the affected populations traditionally have faced the challenge of self-selection bias – those who decide to move to urban areas may have different demographic, personality, or other characteristics from those who choose to remain in their rural environment, making it difficult to know to what extent the new environment is responsible for the outcomes. The urbanization movement in China, though, is distinct in a way that affords Liang a rare opportunity to learn about its effects on rural elders’ health and well-being: It is being fueled to a considerable extent, she explains, not by people’s decisions to move, but by a state-led, economically motivated effort to urbanize rural communities through compulsory land acquisition and development of villages.

A 2014 report by the World Bank found that among the 100 million people who became urban residents in China between 2000 and 2010, for 42 percent it came as a result of this urban land expansion effort, a phenomenon known as passive urbanization. “Normally with urbanization we think about people migrating to the cities,” Liang explains. “With passive urbanization, people are not choosing to move to the city, but the city is moving to them.”

Using data from the China Health and Retirement Longitudinal Study, a Peking University-led survey that collects demographic and health information from a representative sample of China’s 45-and-older population every two years, Liang in her doctoral dissertation compares rural elders who have experienced passive urbanization (passively urbanized elders) with those who have not (long-term rural elders). She is particularly interested in the impact on elders’ mental health. “The mental health issues among Chinese elders are really striking to me,” Liang says. “Depression rates are high, and although the overall suicide rate has significantly declined in China over the past decade, it has been increasing among elders.” Given the cultural importance of family in China, one of the key questions for Liang is how family support is affected by urbanization, and how that bears on elders’ mental well-being along with other issues, including informal caregiving, chronic disease management, and financial support.

Liang notes that passive urbanization is controversial in China, sparking land disputes and concerns about the lack of involvement of urbanized former rural residents in decisions about their community’s development. But her ongoing analysis suggests that compared to long-term rural elders, those who live in the newly urbanized communities receive more financial support and are less likely to experience symptoms of depression. She has found no significant differences between the two groups in levels of informal caregiving of the elders by their children. “The explanation is that urbanization, in whatever form, can reduce the amount of poverty, and in my study higher income levels are closely associated with better access to health care along with lower levels of depression,” Liang says.

That isn’t to say that there aren’t other concerns about the effects of passive urbanization on Chinese elders. Liang believes her findings underscore the imperative for policies that target the very different needs of the population groups she has studied. In the case of rural elders, she argues for higher public pensions to protect them from extreme poverty, along with efforts to train village health workers for the aging population. In the newly urbanized communities, Liang says, services can be provided for rural elders who were previously more difficult to reach. For all urban elders, Liang adds, more professional long-term care services are needed to relieve the burden of family members.

Liang hopes her work will help to inform polices on behalf of Chinese elders amid the ongoing state-led urbanization efforts. “As an only child, I am particularly motivated to focus on how these demographic changes are affecting elders,” she says. “I want to make sure my parents and grandparents are going to be supported and happy.”