• One-third of China's population will be over the age of 60 by 2050.
  • This means the pressure on healthcare for the older generations is growing - something that is being felt now.
  • Care pressures that are usually shared between children will be even harder when a generation of single children will have to cover these costs.

Huang Ernan knows the live-in caretaker she hires to look after her elderly mother isn’t really up to the job.

At 73 years old, the woman is only a few years younger than Huang’s mother, who is 85. And she often lacks the focus required to provide good care to a patient who has suffered multiple strokes over recent years.

On one occasion, the caretaker left the house without locking the door, allowing Huang’s mother to wander off down the street. Other times, she failed to help her client after she’d wet the bed — an issue that became so common, Huang eventually started buying her mother adult diapers.

Huang, however, has no intention of firing the woman. In her home city of Shanghai, finding a replacement would be far from easy.

The eastern metropolis is ground zero for China’s elder care crisis, offering a glimpse into the pressures that could impact other cities as the country’s population rapidly ages.

By 2050, one-third of China’s citizens will be aged 60 or over — a demographic transformation that threatens to create deep social and economic challenges.

But in Shanghai, the future has already arrived: The country’s most elderly megacity has 5.2 million residents aged over 60 — over 35% of the registered population.

An elderly woman pushes a man in a wheelchair down a street in Shanghai, March 5, 2020.
Day care can cost around 4,000 yuan ($580) a month.
Image: Jin Xiaoxin/People Visual

Access to elder care services has become a hot-button issue for Shanghainese.Demand has far outstripped supply over recent years, leaving families like Huang’s with few good options.

In 2012, there were fewer than three nursing home beds for every 100 elderly residents in Shanghai. And despite government pledges to provide thousands of extra beds by 2022, the problem remains equally acute today. Many downtown facilities have waiting lists stretching well over a year.

Shortages of in-home caretakers — who do the vast majority of care work in the city — are even more severe. A decade ago, surveys suggested Shanghai needed an extra 550,000 domestic workers to meet its elder care needs. Since then, wages for caretakers have more than tripled, but the problem has only worsened.

For many families, hiring a low-skilled domestic helper through the informal economy is the only affordable solution. But there are drawbacks: Most of the caretakers have received little formal training, and they aren’t vetted or regulated by any professional organizations.

Older people don’t have as many choices in the domestic help market.

—Huang Ernan, Shanghai resident

What’s more, the city’s in-home caretakers increasingly tend to be elderly themselves. According to Huang, a 59-year-old Shanghai native, it’s now common for senior citizens to be hired as care workers in the city.

Many end up in elder care because it’s less competitive. When recruiting for higher-paying babysitting jobs, families tend to favor younger workers who are often more highly educated, Huang says.

“Older people don’t have as many choices in the domestic help market,” says Huang. “Though looking after the elderly is more physically demanding … the wages aren’t competitive compared with babysitting jobs.”

While being of an advanced age isn’t a disadvantage in itself, Huang says the influx of retirees into Shanghai’s elder care system may pose potential problems. For one thing, care work is sometimes exhausting and can exacerbate caretakers’ preexisting health conditions.

Huang’s family has first-hand experience of this. The previous care worker Huang hired to look after her mother was 65 years old — quite young by Shanghai standards, she says. The woman worked with the family for three years, until one day she suddenly collapsed while on duty and fell into a coma.

“She had diabetes but didn’t know it,” says Huang.

After the accident, Huang’s family paid the elderly care worker an extra month’s salary as compensation and parted ways. But finding a new caretaker proved to be challenging.

A domestic worker competes in an elder care contest in Xining, Qinghai province, Aug. 13, 2020.
A domestic worker competes in an elder care contest in Xining, Qinghai province.
Image: Lu Danyang/CNS/People Visual

Concerned about the potential health risks associated with hiring an elderly care worker, the family prioritized finding a younger replacement. But months of searching proved fruitless, and eventually they hired their 73-year-old helper. This time, however, the family insisted the woman complete a physical checkup before starting work, Huang says.

Despite these problems, Huang says her family still considers in-home care their best option. Like many in Shanghai, they have little regard for the city’s care homes.

When it first became clear her mother needed full-time care five years ago, Huang and her two sisters went to visit several nursing homes. But they were unimpressed by what they saw, according to Huang.

Though the centers were equipped with professionally trained medical staff, the residents had to share bedrooms, and the general atmosphere in the centers was depressing, Huang says.

People consult a staff member at the inquiry desk of a nursing home in Shanghai, July 9, 2020.
Cost for a care home can be in excess of double the average monthly pension of retired workers in Shanghai.
Image: Wu Ziyi for Sixth Tone

“What worried me the most was whether my mom would be treated well and given her medication on time,” says Huang. “There’s no dedicated caretaker in a nursing home for you.”

Huang, who works as an accountant, shares the cost of the care worker’s 4,000 yuan ($580) monthly wage with her two sisters. They consider this good value, especially as it allows them to keep their mother close by — all three of them live within a few blocks of her apartment in northern Shanghai.

“It’s much cheaper than what nursing homes ask for — you won’t pay less than 5,000 yuan a month for a bed there,” says Huang.

If you get along well with your children … few will consider a nursing home.

—Zhou Ying, care center director

Even the recent killing of an 83-year-old woman by her 67-year-old caretaker in the eastern Jiangsu province hasn’t shaken Huang’s preference for in-home care.

The incident occurred just eight days after the Jiangsu caretaker, surnamed Yu, started work in May. Yu was arrested and charged with homicide three months later, the killing having been caught on her client’s in-home security camera.

According to police officers involved in the investigation, the caretaker’s motive for killing the elderly woman was simple: She wanted to finish the job and get paid as quickly as possible.

“In our interrogations, the woman (Yu) didn’t even agree that her behavior constituted homicide — as she put it, she just ended the life of a dying woman,” a police officer surnamed Zhang at the Liyang Public Security Bureau tells Sixth Tone. “She complained about the physically demanding job, as the elderly lady was heavy.”

According to Zhang, such cases are rare in Liyang — a small, county-level city of less than 1 million people. But murders by live-in caretakers are not unheard-of in China.

In 2014, a caretaker was found to have poisoned and hanged her 70-year-old client in the southern city of Guangzhou. Again, she reportedly did so in order to get paid her 2,500 yuan wage more quickly.

Later, police discovered the caretaker, surnamed He, had used similar methods to attack another nine elderly people, seven of whom died. The care worker received thedeath sentence in 2016.

Elderly residents chat at a nursing home in Shanghai, July 9, 2020.
Elderly residents chat at a nursing home in Shanghai.
Image: Wu Ziyi for Sixth Tone

The Yu and He cases both caused a sensation in Chinese media, but most Shanghai residents who speak with Sixth Tone say the stories haven’t affected their thoughts regarding elder care. Though rare, stories of abuse inside Chinese care homes have also emerged over recent years.

Huang says she has no plans to move her mother to a nursing home or to install security cameras in her mother’s house, dismissing the recent killing as an isolated incident. “It’s a rare and extreme case,” she says.

Because they live so close to their mother, the three daughters are able to check on her every evening after work, Huang says. This wouldn’t be as easy to do if her mother was in a nursing home, she adds.

According to Zhou Ying, director of a senior care center at a residential community in central Shanghai, most people in the city still have a strong preference for in-home care over nursing homes.

“The overwhelming majority of elderly residents come to us to inquire about home-based care services,” says Zhou. “If you get along well with your children … few will consider a nursing home.”

Elderly people sit in a nursing home in Shanghai, July 9, 2020.
Elderly people sit in a nursing home in Shanghai.
Image: Wu Ziyi for Sixth Tone

Liu Aiying, however, is one of the few Shanghai residents who voices support for care homes. The woman, who is in her 70s, has been living in a downtown nursing home since her husband developed symptoms of Alzheimer’s disease six years ago. She says it’s been a smart decision.

“They have professional medical services — they have doctors and nurses,” says Liu. “They provide good catering services to save us from worrying about what to eat on a given day.”

My child’s generation is the country’s first generation of single children. They’re going to deal with huge pressure

—Huang Ernan, Shanghai resident

The center isn’t cheap: Liu and her husband pay 10,000 yuan per month for a one-bedroom apartment inside the nursing home, which is more than double the average monthly pensionretired workers in Shanghai receive. But Liu says it’s worth it. Before, the elderly couple shared a two-bedroom apartment with Liu’s son and daughter-in-law, and they often felt constricted.

“Honestly, we couldn’t hire a home-based caretaker for that already cramped apartment,” says Liu. “And I don’t want to live too close to my child’s family, as we have very different habits.”

But not everyone can afford the luxury of renting a private apartment in a care facility. Huang worries above all about what will happen when her generation starts to require full-time care. She plans to retire next year, she says.

“My mother has three children and the three of us shared the responsibility of providing for her,” says Huang. “I can’t imagine what things will be like when I get too old to take care of myself. My child’s generation is the country’s first generation of single children. They’re going to deal with huge pressure.”