Wang Zhenhua, 88, from Wuhan, Hubei province, suffers from pancreatic cancer, chronic obstructive pulmonary disease and other medical complications. He uses a wheelchair and struggles to stand up, but remains fiercely independent.

"I just need to use the bathroom. I can walk there by myself. I don't need anyone's help," he said.

In reality, even a short walk can leave him breathless and exhausted, and getting from his bed to the bathroom requires assistance from family members or caregivers.

He believes that requiring help is a sign of being "disabled", which undermines his dignity. He doesn't want his family to spend too much time and energy caring for him, nor does he want to incur the high cost of hiring a caregiver.

"We don't want aging to be just about survival. We need a life with dignity and fulfillment," said Ye Cuihua, Wang's wife.

The Wang family's situation will become more common as China's population ages and drives reassessment of how healthcare and eldercare are delivered, experts said. Even palliative care in an elderly person's last days will need to be looked at again.

The number of elderly people in China, those aged 60 and above, soared to 297 million, or about 21.1 percent of the population, last year, according to data from the National Bureau of Statistics.

Family burdens

In the past, China's approach to elderly care has been predominantly family-centered, said Winnie Yip, a professor at the Harvard T.H. Chan School of Public Health.

"In China, there's a notable distribution where 90 percent of individuals prefer to receive care at home, 7 percent opt for community-based care, and a mere 3 percent turn to hospitals," she said. "This situation necessitates a comprehensive reform of the long-term care insurance system to ensure the well-being of the elderly, regardless of their financial status."

Yin Shushan, a scholar at the Institute of Population Research of Peking University said the traditional Chinese model of family care, once the cornerstone of elderly support, is under strain.

"The rapid pace of modern life, coupled with economic pressures, has eroded the ability of younger generations to provide the same level of care, leading to a palpable tension between tradition and contemporary realities," Yin said.

"So the country is compelled to re-imagine its approach to eldercare, balancing traditional values with innovations," he added.

Jing Jun, a professor of the Department of Social Science at Tsinghua University, believes that China's approach to elderly care isn't solely based on family values.

"Even those with strained family relationships still come together during the Chinese New Year, as traditional Chinese holidays emphasize family reunions," Jing said.

"However, the well-being of the elderly doesn't solely hinge on family ties. In China, there are numerous elderly communities based on mutual-aid elderly care. Elderly individuals help each other without blood ties, hence forming reciprocal relationships spontaneously," he said.

Professional approach

In the future, hugong, or professional caregivers, will play a greater role, which will require better standards and training. "It's also a matter of human resources, as the qualifications and training programs for caregivers are still being established," Yip said.

Zhang Qiaoqiao, a 39-year-old who works in Beijing, has employed a hugong for more than six years to look after her father who lives in Changsha, Hunan province.

"Seeking help from a hugong is the only way I can keep my life normal. I can't just quit my job and go home. Nursing home care can be rather expensive if you want someone who is a professional," she said.

Zhang's father is paralyzed and his care would be much easier if his home had equipment to help move him. "It is challenging for the nurse to lift my father up from the bed and transfer him to a wheelchair. Transferring him several times a day can be exhausting," she said.

Tan Xiaoyu, a hugong who works at the Wuhan Puren Hospital in Wuhan, Hubei, said mobility is crucial for the elderly.

"They have families and friends they want to spend time with," she said. "Being confined or bedridden can lead to blood clots, and even depression."

The cost of hiring a hugong is generally 200 ($27.6) to 400 yuan per day, Tan said. Long-term care is a significant expense for ordinary families and is not covered by most medical insurances.

"The expenses are manageable for a short duration only if a person has many children, all of whom are working. Even when the expenses are shared, it drains a family's finances in the long run," she said.

The dilemma intensifies if parents require long-term care, compelling their children to either put their careers on hold or abandon them entirely.

"Maybe hiring a nursing assistant is the solution," said Wang Jing, a single mother grappling with her father's lung cancer diagnosis. "They might provide better care for my parents than I'm able to. As it is, my time is stretched thin between a full-time job and taking care of my son who's in elementary school".

Bigger picture

Arthur Kleinman, a professor of psychiatry and medical anthropology at Harvard University, said the emphasis is currently on improving the healthcare system, which includes mental health services, and in this regard, China is actually performing better than many other countries.

"It is crucial for medical professionals, scientists and researchers like us to work hand in hand with our counterparts in China because these challenges are universal," Kleinman said.

"The insights we have gained in the United States can be shared with China and vice versa, with the ultimate goal being enhancing the lives of the elderly. This collaboration is at the heart of our commitment to caregiving," he added.

William Hsiao, an emeritus professor of economics at the Harvard T. H. Chan School of Public Health, said China has to invest more in the healthcare and social needs of the elderly. The Chinese government should set priorities and establish a framework to guide the allocation of resources, he added.

Scientists, sociologists and anthropologist are already cooperating with research institutions and industry partners to look at ways to innovate and improve support for the elderly.

Launched in 2018, the Social Technology for Global Aging Project unites various departments at Harvard University with the Jiangsu Industrial Technology Research Institute and Yangtze River Delta National Technology Innovation Center at Zhejiang University.

The project draws on experts from various fields including anthropologists, economists, engineers, medical practitioners and designers, to look at holistic approaches to improving care for the elderly.

"By engaging directly with local communities, the team gathers insights and perspectives from the elderly population, aiming to pinpoint and address their primary concerns, thereby providing valuable suggestions to facilitate governmental actions," said Wang Yuan, the project coordinator.

The project explores issues such as assisting elderly individuals with mobility problems, challenges faced by those without family support, and blending community services with effective management.

Through these collaborative efforts, researchers and government bodies are working together from multiple vantage points to devise practical solutions to the challenges posed by global aging, Wang said.

Many of the obstacles encountered by the elderly do not demand avant-garde technological solutions, but rather thoughtful application of existing technologies.

Wheelchairs, hospital beds and oxygen supplies, for example, might not represent the pinnacle of innovation, but they can greatly enhancing the daily lives of the elderly.

Meanwhile, the combining of social sciences and industrial technologies is helping the elderly in China benefit from a richer variety of care services. Wearable exoskeletons, for example, are helping some elderly people overcome mobility limitations.

On the financial front, developing long-term care insurance that supplements the existing pension insurance model is also being addressed. Since 2016, long-term care insurance policies have been piloted in 15 cities, and were expanded to 49 cities last year, according to the Chinese government website.

Wang, the coordinator of the Social Technology for Global Aging project, said the elderly in many countries spend almost half of their savings on end-of-life care.

"Our project aims to make cost-effective assistance available for the elderly in China. If we succeed, other Global South countries can learn from our experiences," she said.

A 'good death'

Even in death, Chinese culture throws up challenges not seen in other countries.

Ning Xiaohong, director of the Palliative Care Center at Peking Union Medical College Hospital, told thepaper.cn that deaths that do not allow proper goodbyes are always regrettable. "We hope that every family gets enough time to prepare for a final farewell," she said.

End-of-life care in China faces a unique challenge, said Eric Krakauer, a palliative care physician at Massachusetts General Hospital and Harvard Medical School.

"Families may feel obligated, based on filial piety, to insist that modern life-sustaining treatments and machines be used to keep a family member alive even when these machines cause suffering and give the patient no chance to survive outside the hospital, said Krakauer, who runs a palliative care training program in China.

"If a family member recognizes that comfort is the best goal of care, and thus palliative care is the right type of care for a family member, others may criticize this opinion as non-filial or as 'giving up'. It appears to me that the meaning of filial piety needs to be reconsidered in the age of invasive life-sustaining treatments," he added.

Krakauer said palliative care is often misunderstood as a "giving up" treatment, which makes it even more difficult for many families to accept.

Further discussions on life and death are needed for patients, families and healers, especially in China, experts said.

Health education, especially knowledge about palliative care in Chinese hospitals, is a crucial step forward, experts said. Cultivating a psychological acceptance of a "good death" also plays an important role in helping seniors find meaning and fulfillment in their final years.

"The understanding of 'good death' is completely personal, and has no universal standard, varying significantly from people to people," said Su Jing, secretary-general of the Center for Global Development and Health Communication Research in Tsinghua University.

Instead of viewing death as the ultimate endpoint, a "good death "should involve seeking out cultural and moral experiences that go beyond the physical aspect of life as it draws to a close.

"At this final stage, the essence of what is good emerges as a matter of open choice, emphasizing that the freedom, and dignity to make such choices, are fundamental necessities," Su added.

Fa Cuiwen and Xiao Xiangyi contributed to this story.

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