Shangxule is a hardscrabble farming village in the mountains of the northern Chinese province of Hebei. The elevation is too high for cash crops like strawberries, so locals plant corn, wheat, peanuts, and sweet potatoes, mainly for their own consumption. In recent years, most of the young people have left for jobs in coastal factories or on construction sites. “Who lives here now? Other than the kids, it is just us elderly folk trying to not get sick so we can keep on farming,” says 69-year-old Dong Xiangju, sitting in the small courtyard of her rundown brick and cement farmhouse on a cold December afternoon. Her two sons and a daughter work in the provincial capital of Shijiazhuang and only rarely have time to return home, she says.
As her 70-year-old husband, Gao Chouni, wields a big stick to drive their pig back into its pen and chickens roam about, Dong talks about her biggest worry: the cost of seeing a doctor. “Life isn’t easy at all, and my health keeps getting worse,” she says, slapping her arthritic knee for emphasis. The tab for an overnight hospitalization last year to treat her heart disease and high blood pressure came to 8,000 yuan ($1,154), more than a year of the household’s income, she says. “If we can stand the pain, we don’t go to the hospital—it’s just too expensive.” Their children don’t usually send money home but will occasionally pitch in on medical costs, say the couple.
The outlines of China’s demographic challenge are well-known: By 2050 almost 27 percent of the population will be 65 or older, up from around 10 percent in 2015, according to projections by the United Nations and the China Research Center on Aging. Less recognized is that the crisis will hit hardest in villages like Shangxule, which are suffering the twin effects of China’s one-child policy and decades of migration to the cities.
Already, some 80 million elderly, or 60 percent of all of the country’s senior citizens, live outside cities and far from the better health-care facilities. One-fifth of rural elderly have incomes that fall below the official poverty line, in many cases because the cost of treating an illness plunged the household into debt, according to Su Guoxia, a director in the State Council Leading Group of Poverty Alleviation and Development. And the suicide rate for older Chinese living in the countryside is more than three times that of urban peers, says Xiangming Fang, an economist at Georgia State University’s School of Public Health. Addressing members of the Communist Party’s Politburo in May of last year, President Xi Jinping noted “there is a quite big gap between reality and elderly people’s expectation of happy twilight years.”
Chinese farmers typically toil in the fields past 70, says John Giles, lead economist in the Development Research Group at the World Bank and an expert on aging in China. “This isn’t just puttering around in the garden,” he says. “This is arduous work. And if the elderly have children who have migrated, then they are more likely to be working longer and for more hours.”
The rural elderly have higher rates of physical disabilities than urbanites. Many have difficulty performing basic tasks such as dressing, eating, and bathing. They’re also increasingly afflicted by chronic ailments such as hypertension, heart disease, respiratory problems, and diabetes, in part because of high rates of smoking and drinking, along with, crucially, inadequate health care. Unlike people in much of the rest of the world, China’s citizens spend less on their health as they grow older, not more, says Albert Park, an economist at the Hong Kong University of Science and Technology. “So even though older people are getting less healthy in rural China, they are getting less health care,” Park says.
Mao’s legions of barefoot doctors—villagers with basic health training who charged minimal fees for service—brought about huge improvements in health care in the countryside. But many of those gains began dissipating with the onset of market reforms in the late 1970s. Today, China’s cities attract a disproportionate share of government health spending, along with the best doctors, so rural residents must put up with care that is expensive but shoddy. The average cost of a hospital visit is 50 percent of the annual income of a city dweller; for rural residents it’s 1.3 times annual income, according to Gerard La Forgia, the lead author of Healthy China: Deepening Health Reform in China, a joint report by the World Bank, the World Health Organization, China’s finance ministry, and other government agencies. Meanwhile, a 2014 survey by Stanford’s Rural Education Action Program found that patients at village health clinics received an accurate diagnosis only about one-quarter of the time. Overprescription of drugs is rampant. “Sometimes they give you the wrong medicine,” says Dong, the farmer from Shangxule. Last year she suffered an allergic reaction to a drug she says was incorrectly prescribed.
China’s policymakers are aware that the problems of the left-behind rural elderly could become a financial and social time bomb if ignored. Tax breaks are being used to encourage more hospitals to enter underserved rural areas, according to Mao Qunan, a spokesman for the National Health and Family Planning Commission. And while senior living facilities have only recently started cropping up in some cities (in Confucian China, traditionally children are supposed to take care of their elderly parents), authorities are encouraging them to expand into rural areas. A pilot rural pension program introduced in 2009 has been expanded and currently covers most people over 60 (previously, no one in the countryside had any retirement benefits).
Similarly, most village elderly now have access to a rural medical insurance scheme that was introduced more than a decade ago. Both programs provide limited protections, though; rural pensions amount to about 80 yuan a month (less than $12), far lower than average urban payments, while insurance copayments and out-of-pocket payments are high. “On paper it looks great—90-some percent of the rural population is covered, and that is probably true,” says La Forgia. “But what does it cover you for is the question.”
China’s restrictive residency permit system makes it difficult for the rural elderly to join their children in cities, and their insurance usually doesn’t cover treatment at urban hospitals. Some children are returning home to care for their parents, a move that could hurt economic growth as younger Chinese take less productive work or even leave the workforce, says the World Bank’s Giles. “Later I will have to return to my hometown because my parents are getting older,” says 25-year-old Zhang Chi, who works at a toy factory in Dongguan more than 825 miles from his hometown of Xi’an, in central China. “Working far away, you can only see them infrequently, which isn’t good.”
Others don’t think returning to the countryside is feasible or even desirable. Some migrants fear that they won’t make enough to support their families. And while life in China’s industrial cities has its own hardships, factory workers generally enjoy comforts unknown to their rural brethren. “Of course, having our children live far away is not easy,” says Dong. “But there is little work for them here, so they all must go out to find work—that is the way it is. If I miss them, what use is that?”
The bottom line: About 60 percent of China’s senior citizens live in rural areas, where poverty is widespread and health care is poor.